It is very unusual to forget a surgical sponge in an operative wound, but the consequences are severe. Traditionally, textiloma produces a reticulated, textiform mass of mixed pattern, the appearance of which is highly suggestive on both plain abdomen radiograph and computerized tomography (CT) scan. [1][2][3] We report an atypical case of giant abdominal cystic textiloma mimicking a hydatid cyst arising from the spleen with spontaneous rupture into the stomach. Case ReportA 40-year-old male patient was referred to the surgical clinic of King Khalid Military City Hospital with complaints of epigastric swelling and pain of three years' duration, without fever. On inquiry, no other symptoms were noted, but the patient reported a past history of surgical operation for a road traffic accident 9 years previously. Clinical examination revealed a large firm abdominal mass extending from the left to the right hypochondrium. Its lower margin was well-circumscribed, but its upper margin could not be felt. A right upper abdominal paramedian laparotomy scar was noted. Biological tests were unremarkable. Plain abdominal radiographs showed an opacity in the epigastrium and left hypochondrium, displacing the gastric bubble and bowel gas. Ultrasound of the abdomen revealed a huge cyst in the left upper quadrant, measuring 25 cm in its long axis. The cyst was in close contact with the inner surface of the spleen, which showed multiple large calcifications with marked posterior acoustic shadowing (Figure 1). The cyst demonstrated multiple tiny mobile low-level echoes, with the presence of dependent hyperechoic serpiginous structures. These features were suggestive of hydatid cyst of the abdomen complicated by membrane detachment (type 2 of Gharbi). 4 Ultrasound could not confirm the organ of origin of the cyst. Abdominal CT scan with oral and intravenous contrast enhancement disclosed a well-defined encapsulated, non-enhancing cystic mass in the left upper quadrant. The liver, pancreas, stomach and great vessels had been pushed to the right. Inside the cyst, dependent hyperattenuated serpiginous structures were noted (Figure 2). CT scan could not determine whether the mass arose from the spleen, the left lobe of the liver or the peritoneum. Magnetic resonance imaging (MRI) of the abdomen was done in transverse, sagittal and coronal planes by using SE T 1 -weighted sequences in order to detail the location and extent of this mass. On MRI, the lesion appeared isointense to the spleen, suggesting a thick content. Coronal and transverse cuts demonstrated that the cyst was independent of the liver. On sagittal cuts, the mass showed a close relation to the anterior surface of the spleen that was displaced downwards (Figure 3). No intracystic formation was identified on MRI. Although the serological agglutination test for ecchinococcosis was negative, the radiological picture was suggestive of a huge abdominal hydatid cyst with detached membrane, probably arising from the spleen.

Cyst with Fat-Fluid Level and Budd-Chiari Syndrome. 2001; 21(3-4): [225][226][227] Hepatic hydatid cyst is a parasitic infestation due to the development of the larval form of the tapeworm Echinococcus granulosus in the liver.1 Although compression of hepatic veins is commonly noticed on imaging studies, hepatic hydatidosis is a very rare cause of Budd-Chiari syndrome.2 Fat-fluid level in a hepatic hydatid cyst (HHC) was first reported in 1996 by Montero et al., 3 who documented three cases of the condition on CT and MRI, and explained it by its rupture into the biliary tree. Although no other cases have been published in the literature to our knowledge since then, there has been controversy on the significance of the presence of intraparasitic fat. Beric et al. feel that the fat-fluid level in a HHC is related to the degeneration of hydatid membranes rather than to biliocystic communication. 4 The purpose of this study was to report an exceptional case of large fat-fluid level in a hepatic hydatid cyst in the left lobe with no biliocystic communication, but associated with chronic Budd-Chiari syndrome due to compression of hepatic veins by multiple HHC of the right lobe. Case ReportA 55-year-old female patient was admitted for epigastric pain and heartburn of a year's duration. On examination, no jaundice or fever was noted. Abdominal palpation revealed an enlarged liver with a bulging mass in the left lobe. Liver function tests were normal (total bilirubin, 15 μmol/L; unconjugate bilirubin, 8 μmol/L; direct bilirubin, 7 μmol/L, and alkaline phosphatase, 112 IU/L). Serological tests for hepatitis B and C were negative. Test for echinococcosis using IHA was negative. On abdominal ultrasound, the liver was dysmorphic, showing undulating outlines with severe enlargement of the left lobe and caudate lobe, which were suggestive of chronic liver disease. The right lobe of the liver exhibited four masses. A huge multiseptated cystic mass, 12 cm in diameter and suggestive of multivesicular hydatid cyst (type 3 of Gharbi), occupied the whole right lateral sector, encroaching upon the right medial sector and totally compressing the right and middle hepatic veins. Three masses of solid heterogeneous echogenicity were in the segments 5 and 8, showing well-defined outlines with slight enhancement of posterior echoes. These three masses contained long hypoechoic spirals highly suggestive of pseudotumoral hydatid cyst (type 4 of Gharbi). The gallbladder harbored a large stone, whereas the biliary ducts were normal. The left hepatic lobe exhibited two superficial anterior echogenic heterogeneous masses, the largest of which was in segment 2. It was 13 cm in its long axis, and displayed a horizontal level separating a lower hyperechoic layer and an upper hypoechoic layer. The second mass, 5 cm in diameter, was located in segment 3 and showed peripheral calcifications. Also, ultrasound noted mild ascitis as well as splenorenal collateral venous circulation near the lower pole of the spleen denoting portal hypertension. CT wit...

Malignant melanoma (MM) is a malignancy with poor prognosis. Between 25% and 30% of primary cutaneous MM occur in the head and neck, and of these, 5%-10% arise on the external ear. [1][2][3][4] The helix is the most common site, followed by the lobule, the tragus-preauricular skin, and the concha.3 Primary melanoma of the external auditory canal (EAC) is rare. We report a case of a primary malignant melanoma of the external auditory canal and describe its computed tomographic (CT) features. Case ReportA 65-year-old man presented with a two-year history of painful mass in the left ear, with recent increase in size and ipsilateral hearing loss. There was no previous history of ear problem, trauma or surgery. On physical examination, the EAC was obliterated by an ulcerated red brownish mass. The pinna was intact with no evidence of regional lymphnode enlargement. The facial nerve function was normal. The endoscopic biopsy microscopically showed malignant epithelioid melanocytes with pigmented granular cytoplasm, large nuclei and prominent eosinophilic nucleoli expanding in the dermis. Mitoses were present and there was brisk lymphoid infiltrate at the base. On plain skull x-ray, no obvious bony changes were observed. Temporal bone CT scan in transverse and coronal planes demonstrated a soft tissue mass obliterating the EAC and eroding its inferior margin as well as the roof of the temporo-mandibular joint (TMJ). The mass was invading the hypotympanic cavity through the tympanic membrane. The inferior tympanic bony margin was partially eroded. The tumor had involved the ossicular chain with erosion of the malleus and the long process of the uncus. The mass was moderately and homogeneously enhancing after intravenous contrast injection. The epitympanic cavity, the mastoid cells and the internal ear were preserved. No intracranial extensions or metastases were detected. Magnetic resonance imaging (MRI) examination was not done due to lack of facilities. The patient underwent a subtotal tumor excision with regional lymph node dissection. The surgical treatment was followed by multiple sessions of radiotherapy. Six months later, the patient presented with a large local recurrence, intracranial and lymphnode metastases, and died one month later.

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