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1.  Abscess of urachal remnants presenting with acute abdomen: a case series 
Introduction
Urachal diseases are rare and may develop from a congenital anomaly in which a persistent or partial reopening of the fetal communication between the bladder and the umbilicus persists. The most frequently reported urachal anomalies in adults are infected urachal cyst and urachal carcinoma. The diagnosis of this entity is not always easy because of the rarity of these diseases and the atypical symptoms at presentation. Imaging techniques, such as ultrasonography and computed tomography have a significant role in recognizing the presence of urachus-derived lesions.
Cases presentations
Case presentation 1: A 25-year-old Arab-Berber man presented with a 10-day history of progressive lower abdominal pain accompanied by fever, vomiting, and low urinary tract symptoms to our emergency department. Laboratory data revealed leucocytosis. The diagnosis of an acute peritonitis was made initially. Abdominal ultrasonography revealed a hypoechoic tract from the umbilicus to the abdominal wall, and the diagnosis was rectified (infected urachal remnants). The patient was initially treated with intravenous antibiotics in combination with a percutaneous drainage. Afterwards an extraperitoneal excision of the urachal remnant including a cuff of bladder was performed. The histological analysis did not reveal a tumor of the urachal remnant. Follow-up examinations a few months later showed no abnormality.
Case presentation 2: A 35-year-old Arab-Berber man, without prior medical history with one week of abdominal pain, nausea and vomiting, associated with fever but without lower urinary tract symptoms visited our emergency department. Laboratory data revealed leucocytosis. Abdominal ultrasonography was not conclusive. Computed tomography of the abdomen was the key to the investigation and the diagnosis of an abscess of urachal remnants was made. The patient underwent the same choice of medical-surgical treatment as previously described for case one, with a good follow-up result.
Case presentation 3: A 22-year-old Arab-Berber man, with no relevant past medical history, presented to our emergency department because of suspected acute surgical abdomen. Physical examination revealed umbilical discharge with erythema and a tender umbilical mass. Abdominal ultrasonography and computed tomography scan confirmed the diagnosis of infected urachal sinus. Initial management was intravenous antibiotics associated with a percutaneous drainage with a good post-operative result, but a few days later, he was readmitted with the same complaint and the decision was made for surgical treatment consisting of excision of the infected urachal sinus. The clinical course was uneventful. Histological examination did not reveal any signs of malignancy.
Conclusions
We describe our clinical observations and an analysis of the existing literature to present the various clinical, radiological, pathological and therapeutic aspects of an abscess of urachal remnants. To the best of our knowledge, this manuscript is an original case report because this atypical presentation is rarely reported in the literature and only a few cases have been described.
doi:10.1186/1752-1947-6-226
PMCID: PMC3459711  PMID: 22846644
Urachus; Bladder; Neoplasms; Urachal cyst; Urachal remnant; Urachal sinus; Abcess
2.  A colo-urachal-cutaneous fistula in an 88-year-old male 
Introduction
Urachus anomalies are remnants of the urachus, an embryonic connection between the fetal bladder and umbilicus. These anomalies usually remain asymptomatic but can cause symptoms in case of infection. An extremely rare complication of symptomatic urachal remnants is fistulizing to adjacant viscera. We describe the first case of diverticulitis associated sigmoid-urachal-cutaneous fistula.
Case report
An 88-year-old male visited the outpatient clinic with intermittent bleeding and gassy discharge from his umbilicus. Examination showed a normal looking umbilicus with a small fissure at the bottom in which a 10 cm probe could be inserted. Laparotomy revealed a fistula extending from the umbilicus to a pus filled cyst superior to the bladder. A second fistula between the cyst and a mid-sigmoid diverticulum was identified. The involved sigmoid segment was resected. Pathological examination demonstrated no malignancy.
Discussion
Urachal remnants are extremely rare in adults. They typically present with abdominal pain or palpable masses. Additional imaging can aid the diagnostic process.
Conclusion
Due to the risk of recurrence and malignant transformation complete surgical excision of urachal anomalies is the treatment of choice. This can be done in a 1-step or 2-step procedure.
doi:10.1016/j.ijscr.2011.10.013
PMCID: PMC3267281  PMID: 22288045
Cyst; Diverticulitis; Fistula; Sigmoid; Urachus; Laparatomic surgery
3.  Concurrent appendiceal and umbilical endometriosis: a case report and review of the literature 
Introduction
Endometriosis affects 3 to 10 percent of women of reproductive age. Most of the time it involves the pelvis; however, sites of endometriosis have been reported almost anywhere in the body. Appendiceal and primary umbilical endometriosis are considered rare loci, making accurate diagnosis elusive. Here we present the case of a 46-year-old woman with concurrent appendiceal and umbilical endometriosis.
Case presentation
A 46-year-old Greek woman presented with a large mass in the lower abdomen adhering to the surrounding organs. She reported recurrent lower abdominal and pelvic pain and the presence of a dark-blue hard nodule at the umbilicus. She had no previous medical, surgical or gynecological history. Her physical examination and laboratory test results were without any significant findings. The laparotomy revealed a fibromatose uterus adhering to the rectum and a urinary cyst and a palpable mass in the vermiform appendix. A hysterectomy and an appendectomy were performed. The umbilical mass was also excised. Pathology revealed endometriosis of the umbilicus and the appendix. The postoperative period was uneventful and she was discharged.
Conclusions
Endometriosis, although rare, should always be considered in women of reproductive age, presenting with cyclic pain. The diagnosis is, most of the time, difficult and requires a high degree of clinical suspicion. The clinical doctor should be aware that endometriosis can sometimes be multifocal, thus a thorough investigation is required in all cases.
doi:10.1186/1752-1947-8-258
PMCID: PMC4131801  PMID: 25052818
Endometriosis; Appendiceal endometriosis; Umbilical endometriosis; Concurrent endometriosis; Multifocal endometriosis
4.  Menstruating from the umbilicus as a rare case of primary umbilical endometriosis: a case report 
Introduction
Endometriosis is a common gynecological condition and presents mainly with involvement of the pelvic organs. Extrapelvic presentations in almost all parts of the body have been reported in the literature. However, umbilical endometriosis that is spontaneous or secondary to surgery is uncommon and accounts for only 0.5% to 1% of all endometriosis cases.
Case presentation
A 35-year-old Caucasian woman presented with umbilical bleeding during periods of menstruation. Her umbilicus had a small nodule with bloody discharge. An ultrasound was performed and a diagnosis of possible umbilical endometriosis was thus made. The nodule shrunk in response to gonadotropin-releasing hormone analogues but continued to persist. The patient underwent a wide local excision of the nodule with a corresponding umbilical reconstruction. Histopathology confirmed the diagnosis of umbilical endometriosis. The patient was asymptomatic at follow-up, but nevertheless warned of the risk of recurrence.
Conclusions
Pelvic endometriosis is a common condition, but the diagnosis of primary umbilical endometriosis is difficult and differentials should be considered. This case strongly suggests that a differential diagnosis of endometriosis should be considered when an umbilical swelling presents in a woman of reproductive age.
doi:10.1186/1752-1947-3-9326
PMCID: PMC2803849  PMID: 20062755
5.  Umbilical hernia rupture with evisceration of omentum from massive ascites: a case report 
Introduction
The incidence of hernias is increased in patients with alcoholic liver disease with ascites. To the best of our knowledge, this is the first report of an acute rise in intra-abdominal pressure from straining for stool as the cause of a ruptured umbilical hernia.
Case presentation
An 81-year-old Caucasian man with a history of alcoholic liver disease presented to our emergency department with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed with excision of the umbilicus and devitalized omentum.
Conclusion
We report the case of a patient with a history of alcoholic liver disease with ascites. Ascites causes a chronic increase in intra-abdominal pressure. A sudden increase in intra-abdominal pressure, such as coughing, vomiting, gastroscopy or, as in this case, straining for stool can cause rupture of an umbilical hernia. The presence of discoloration, ulceration or a rapid increase in size of the umbilical hernia signals impending rupture and should prompt the physician to reduce the intra-abdominal pressure.
doi:10.1186/1752-1947-5-170
PMCID: PMC3095553  PMID: 21539740
6.  Primary umbilical endometriosis. Case report and discussion on management options☆ 
INTRODUCTION
We report a recently observed case of primary umbilical endometriosis (UE), with the main aim to discuss the management of this rare condition.
PRESENTATION OF CASE
A 24-year-old woman complained of a painful nodule on her umbilical region, bleeding with her menstrual cycle. Ultrasonography showed a hypoechoic superficial mass in the umbilicus and no signs of intra-abdominal endometriosis. Excision of the nodule under local anesthesia was performed. Histopathological analysis confirmed the diagnosis of umbilical endometriosis. Neither symptoms nor signs of local recurrence have been observed after 24 months.
DISCUSSION
UE should be taken into account in differential diagnosis of umbilical disorders even in young nulliparous women with no typical symptoms of pelvic endometriosis. Although there is a substantial agreement about the necessity of surgery, treatment options are either local excision of the lesion or removal of the whole umbilicus with or without laparoscopic exploration of the peritoneal cavity. The decision should be tailored for the individual patient, taking into consideration the size of the lesion, the duration of symptoms and the presence of possible pelvic endometriosis.
CONCLUSION
Local excision saving the umbilicus may be the treatment of choice in patients with small UE lesions.
doi:10.1016/j.ijscr.2013.11.001
PMCID: PMC3860025  PMID: 24291679
Endometriosis; Umbilicus; Treatment
7.  Spontaneous Discharging Umbilical Sinus Secondary to Infected Cystic Teratoma Ovary: An Atypical Presentation 
Mature cystic teratomas are the most common ovarian neoplasm in patients younger than 20 years. Its complications include torsion, rupture, infection and malignant degeneration. Infection of teratoma is an uncommon event. We are reporting the first ever case of infected mature cystic teratoma presented as a chronic discharging sinus via umbilicus. 30 years old young primipara presented with complaint of seropurulent discharge from umbilicus for 6 months. Ultrasonography showed right sided complex adnexal mass. Umbilical exploration revealed sinus tract travelling deep into the pelvis attached to right ovarian mass. Salpingo- oopherectomy was done on right side and sinus tract excised. Cut-section of specimen showed heterogeneous mass of soft tissue with intact capsule containing hairs, cheesy white purulent material, fat and cartilage. Biopsy was suggestive of mature ovarian cystic teratoma.
doi:10.7860/JCDR/2014/8130.4273
PMCID: PMC4064868  PMID: 24959477
Chronic discharging Sinus; Infected Cystic Teratoma; Umbilical sinus
8.  Umbilical endometriosis mimicking as papilloma to general surgeons: A case report 
The Australasian Medical Journal  2012;5(5):272-274.
Introduction
Cutaneous or umbilical endometriosis is a rare entity that is often overlooked because of chronic abdominal pain. We present a case of umbilical hernia that presented to the general surgeons due to chronic abdominal pain and nodule in the umbilicus, which was clinically diagnosed as umbilical papilloma.
Case presentation
A 48-year old multiparous Caucasian woman presented with painful nodule in the umbilicus for two and half years. The nodule was excised and the histopathological diagnosis was umbilicus endometriosis.
Conclusion
Umbilical endometriosis is a very rare disease but should be considered as a differential diagnosis in women presenting with umbilical swelling.
doi:10.4066/AMJ.2012.1198
PMCID: PMC3395284  PMID: 22848323
Endometriosis; Umbilical endometriosis; Papilloma
9.  Umbilical endosalpingiosis: a case report 
Introduction
Endosalpingiosis describes the ectopic growth of Fallopian tube epithelium. Pathology confirms the presence of a tube-like epithelium containing three types of cells: ciliated, columnar cells; non-ciliated, columnar secretory mucous cells; and intercalary cells.
We report the case of a woman with umbilical endosalpingiosis and examine the nature and characteristics of cutaneous endosalpingiosis by reviewing and combining the other four cases existing in the international literature.
Case presentation
A 50-year-old Caucasian, Greek woman presented with a pale brown nodule in her umbilicus. The nodule was asymptomatic, with no cyclical discomfort or variation in size. Her personal medical, surgical and gynecologic history was uneventful. An excision within healthy margins was performed under local anesthesia. A cystic formation measuring 2.7×1.7×1 cm was removed. Histological examination confirmed umbilical endosalpingiosis.
Conclusions
Umbilical endosalpingiosis is a very rare manifestation of the non-neoplasmatic disorders of the Müllerian system. It appears with cyclic symptoms of pain and swelling of the umbilicus, but not always. The disease is diagnosed using pathologic findings and surgical excision is the definitive treatment.
doi:10.1186/1752-1947-4-287
PMCID: PMC2936926  PMID: 20735830
10.  A Case of Neonatal Neutropenia Due to Anti-Fc Gamma Receptor IIIb Isoantibodies Treated with Recombinant Human Granulocyte Colony Stimulating Factor 
Case Reports in Medicine  2009;2009:717545.
Alloimmunization to granulocyte-specific antigens can occur during pregnancy. Maternal antibodies of IgG class can cross the placenta to result in alloimmune neonatal neutropenia. Antibodies to human neutrophil antigens anti-HNA-1a, HNA-1b, and HNA-2a have been most commonly reported to cause alloimmune neonatal neutropenia. Isoantibodies to Fc gamma RIIIb (CD16) if mother is a HNA-null phenotype are rarely involved in neonatal neutropenia. We report on a case of severe neutropenia (440 neutrophils/μL) due to anti-Fc gamma RIIIb (CD16) isoimmunization. On day 14 severe omphalitis developed, which was treated for 7 days by an antibiotic (ceftriaxone in a dose of 80 mg/kg/d) according to umbilical swab finding. Omphalitis persisted for 10 days in spite of antibiotic therapy and only resolved upon the introduction of rhG-CSF therapy. Therapy with rh-GCSF proved efficient and led to neutrophil count increase to 1970/μL and cure of omphalitis. However, therapeutic effect on granulocyte count was of transient nature, as granulocyte count fell to 760 n/μL on day 4 of therapy discontinuation. Neutropenia persisted for 2 months. The newborn was discharged from the hospital on day 26 with normal clinical status with clinical and laboratory control examinations at 2-week intervals. No additional infections were observed during the course of neutropenia.
doi:10.1155/2009/717545
PMCID: PMC2734935  PMID: 19730745
11.  Omphalolith presented with peritonitis: a case report 
Cases Journal  2009;2:8191.
Omphalolith is a hard, smooth, almost black bolus found in the umbilicus, resembling a malignant melanoma. It is often accompanied by seborrhea which may lead to abscess formation. It may be related to poor hygiene. Patient is usually complaining of umbilical discharge and pain. This report describes a rare case of omphalolith (umbilical stone) induced peritonitis, in a patient who presented as acute appendicitis. In our case the two umbilical stones found their way to the peritoneal cavity and induced peritonitis.
doi:10.4076/1757-1626-2-8191
PMCID: PMC2769553  PMID: 19918359
12.  Acquired Umbilico-Inguinal Fistula with Persistent Discharge due to Suture Reaction: A Case Report and Review of the Literature 
Case Reports in Medicine  2012;2012:216345.
The aim of this paper is to stay a very rare umbilico-inguinal fistula (UIF) resulting from a delayed suture reaction after the use of silk suture to repair an inguinal hernia. A 3-year-old boy presented with persistent umbilical discharge. The initial diagnosis was omphalitis and he was treated with broad-spectrum antibiotics but a UIF was subsequently diagnosed. Surgery was performed to ascertain the cause of the UIF. This case demonstrates that silk suture used in inguinal hernia repair can lead to a UIF, which should be considered in the differential diagnosis of a patient presenting with persistent umbilical discharge.
doi:10.1155/2012/216345
PMCID: PMC3471475  PMID: 23091496
13.  “Cannon Balls or Pus Balls” in Pap Smears: A Case Report 
A 50–year old female presented with the chief complaint of a discharge per vaginum, which was there for the past 15 days. A routine PAP smear was received in the Department of Pathology, Government Medical College, Patiala, India. After its fixation and staining, it was examined under the microscope. It showed the Trichomonas vaginalis infection, with the neutrophils forming cannon balls at places. Neutrophils in the PAP smear are a nonspecific finding, particularly if they are low in numbers or if they are seen in the premenstrual and the menstrual phases. The neutrophils which are adherent to the squamous cells are called “cannon balls” or “pus balls”, which are common in the Chlamydia infection. This case is being presented because of the presence of these rare morphological structures i.e. “cannon balls” or “pus balls”.
doi:10.7860/JCDR/2013/5799.3265
PMCID: PMC3782945  PMID: 24086888
PAP; Cannon ball; Trichomonas vaginalis
14.  Spontaneous Colo-Umbilical Fistula Complicating Diverticulitis of the Sigmoid Colon 
Case Reports in Surgery  2013;2013:925041.
Colocutaneous fistula caused by diverticulitis is relatively uncommon with colo-umbilical fistulas being even rarer. We herein report a rare case of a spontaneous colo-umbilical fistula due to diverticulitis of the sigmoid colon. The fistula developed from a diverticulum of the sigmoid colon that discharged through the umbilicus after two episodes of acute diverticulitis. The condition was successfully treated by resectional surgery.
doi:10.1155/2013/925041
PMCID: PMC3690254  PMID: 23841011
15.  A Case of Trichogerminoma 
Annals of Dermatology  2010;22(4):431-434.
Trichogerminoma is a rare neoplasm which was first described in 1992 and there is still controversy over its inclusion into the spectrum of trichoblastoma. A 79-year-old woman presented with a 5-year history of an asymptomatic nodule on the left posterior neck. Histologically, the lesion revealed a well-demarcated deep dermal nodule surrounded by a pseudocapsule. The tumor was composed of lobules with basophilic cells and some of the lobules displayed a distinctive pattern of densely packed 'cell balls' with peripheral condensation. Immunohistochemically, the tumor cells showed zonal CK5/6 immunoactivity in contrast with the negatively stained 'cell balls'. These characteristics were compatible with the diagnosis of trichogerminoma. We report here on a rare case of a hair germ tumor called trichogerminoma.
doi:10.5021/ad.2010.22.4.431
PMCID: PMC2991721  PMID: 21165214
Cell ball; Hair germ tumor; Trichoblastoma; Trichogerminoma
16.  541 Intravenous Immunoglobulin in Leukocyte Adhesion Deficiency 
Background
Leukocyte adhesion deficiency (LAD) is a primary immunodeficiency disease (PID) caused by a defect in neutrophil adhesion, characterized by skin ulcers, poor wound healing and recurrent bacterial infection. Intravenous immunoglobulin (IVIG) is used to treat patients with PID, but in LAD is not rutinely used. Treatment consists in prompt antibiotic, G-CSF for chronic ulcers and the only definite therapy is bone marrow transplantation (BMT). We present the case of a child with LAD, who was treated with IVIG with a good response before BMT.
Methods
We present a case report of a 2 year-old male, second child of consanguineous parents (cousins 1st grade). His sister had omphalitis and umbilical abscess and died at 6 months with candidiasis and perianal infection. There were 6 episodes of infectious diseases from birth to 6 months: At 11 days of life presented with omphalitis. At 2 months, upper respiratory tract infection with poor response to antibiotics. At 4 months he presented with suppurative otitis media, and was transferred to our hospital with suspected immunodeficiency, with neutrophilia (up to 95900). He was treated with IV antibiotics, and after resolution with prophylactic antibiotics. At 6 months had gastroenteritis and 1 week later septic shock. Treatment with intravenous immunoglobulins (IVIG) was started.
Results
After IVIG was initiated there were only 6 episodes of infectious diseases from 6 months to 2 years, including in the cord blood stem cell transplantation (CBSCT) period: at 9 months, gastroenteritis; at 15 months balanosposthitis (ecthyma gangrenosum), at 17 months had cellulitis in the hand and buttocks and oral candidiasis. CBSCT was performed on February 2011, at 1 year 11 months, but didn't engraft. He was discharged with prophylactic antibiotics and cyclosporine. At 2 years he had catheter associated sepsis. Currently the patient is receiving monthly IVIG, fluconazol, TMP SMX, Acyclovir and in protocol for BMT and has remained stable.
Conclusions
IVIG is not routinely used in LAD. In our case, monthly IVIG resulted in improvement with less infectious episodes. We suggest the use of IVIG as an adjuvant tool for the treatment of patients with LAD before BMT.
doi:10.1097/01.WOX.0000411656.95065.43
PMCID: PMC3512966
17.  Angiomyxoma: a rare tumor of the umbilical cord 
Tumors of the umbilical cord are rare anomalies and should be considered when using prenatal ultrasound for detection of cystic lesions. Differential diagnosis of umbilical cord tumors should comprise umbilical cord teratoma, hemangioma and angiomyxoma. It can also be an umbilical cord polyp, umbilical cord cyst, hernia into the cord and omphalocele, which are mostly isolated findings, except omphalocele. Angiomyxoma is a rare tumor of the umbilical cord and is associated with incresaed perinatal morbidity and mortality. We present a 22-year-old woman with a large umbilical cord tumor who underwent a caesarean section. As in our case, neither chromosomal aberrations nor elevated alphafetoprotein were found after amniocentesis or chordocentesis. Macroscopical and microscopical pathological examinations of the mass after delivery revealed an angiomyxoma with cystic degenerations in myxoid stroma.
PMCID: PMC3939307  PMID: 24591896
Umbilical cord; angiomyxoma
18.  Uneventful Disappearance of a Large Left Atrial Ball Thrombus with Enoxaparin in a Patient with Mitral Stenosis Associated with Pregnancy 
An atrial thrombus is a relatively common echocardiographic finding in patients with mitral valve stenosis (MVS) and atrial fibrillation (AF). However, a “ball thrombus” or floating thrombus in the left atrium is a rare and specific entity associated with MVS. A 24-year-old woman with rheumatic MVS presented with complaints of progressive dyspnea and inferior limbs edema that began 23 days earlier after a caesarean operation for stillbirth carried out at 8 months of pregnancy. At the time of hospitalization, she was in New York Heart Association functional class III and the ECG showed sinus rhythm. Transthoracic color-flow Doppler echocardiography revealed a thick, stenotic mitral valve with a valvular area of 0.9 cm2, and an echogenic large left-atrial mass diagnosed as a free-floating left-atrial thrombus that was corroborated by transesophageal echocardiography. She refused surgery and was treated medically, and low molecular weight heparin (LMWH) (enoxaparin 80 mg/12 h) was given for 14 days and was discharged uneventfully on coumarin. Two days before discharge, a transthoracic and transesophageal ecocardiography showed disappearance of the ball thrombus uneventfully leaving spontaneous echo contrast inside the left atrium. To the best of our knowledge, this is the first case showing disappearance of a giant left atrial ball thrombus with LMWH treatment in a patient with severe MVS during sinus rhythm associated with pregnancy.
doi:10.2174/1874192401105010212
PMCID: PMC3219885  PMID: 22114653
Left atrial ball thrombus; Pregnancy; Mitral stenosis; Enoxaparin.
19.  Termite-egg mimicry by a sclerotium-forming fungus 
Mimicry has evolved in a wide range of organisms and encompasses diverse tactics for defence, foraging, pollination and social parasitism. Here, I report an extraordinary case of egg mimicry by a fungus, whereby the fungus gains competitor-free habitat in termite nests. Brown fungal balls, called ‘termite balls’, are frequently found in egg piles of Reticulitermes termites. Phylogenetic analysis illustrated that termite-ball fungi isolated from different hosts (Reticulitermes speratus, Reticulitermes flavipes and Reticulitermes virginicus) were all very similar, with no significant molecular differences among host species or geographical locations. I found no significant effect of termite balls on egg survivorship. The termite-ball fungus rarely kills termite eggs in natural colonies. Even a termite species (Reticulitermes okinawanus) with no natural association with the fungus tended termite balls along with its eggs when it was experimentally provided with termite balls. Dummy-egg bioassays using glass beads showed that both morphological and chemical camouflage were necessary to induce tending by termites. Termites almost exclusively tended termite balls with diameters that exactly matched their egg size. Moreover, scanning electron microscopic observations revealed sophisticated mimicry of the smooth surface texture of eggs. These results provide clear evidence that this interaction is beneficial only for the fungus, i.e. termite balls parasitically mimic termite eggs.
doi:10.1098/rspb.2005.3434
PMCID: PMC1560272  PMID: 16720392
egg recognition; mimicry; termites; sclerotia; insect–fungus interaction
20.  Giant Ovarian Tumor Presenting as an Incarcerated Umbilical Hernia: A Case Report 
Journal of Korean Medical Science  2009;24(3):539-541.
We report a rare case of a giant ovarian tumor presenting as an incarcerated umbilical hernia. A 61-yr-old woman was admitted to the hospital with severe abdominal pain, an umbilical mass, nausea and vomiting. On examination, a large, irreducible umbilical hernia was found. The woman underwent an urgent operation for a possible strangulated hernia. A large, multilocular tumor was found. The tumor was excised, and a total abdominal hysterectomy and bilateral salphingo-oophorectomy were performed. The woman was discharged 6 days after her admission. This is the first report of incarcerated umbilical hernia containing a giant ovarian tumor within the sac.
doi:10.3346/jkms.2009.24.3.539
PMCID: PMC2698209  PMID: 19543424
Granulosa Cell Tumor; Hernia, Umbilical; Surgery
21.  Maxillary Antrolith: A Rare Cause of the Recurrent Sinusitis 
Case Reports in Otolaryngology  2013;2013:527152.
Introduction. An antrolith is a calcified mass within the maxillary sinus. The origin of the nidus of calcification may be extrinsic (foreign body in sinus) or intrinsic (stagnant mucus and fungal ball). Most antroliths are small and asymptomatic. Larger ones may present as sinusitis with symptoms like pain and discharge. Case Report. We report a case of a 47-year-old lady who presented with heaviness on the left side of the face and loosening of the left 2nd molar tooth since two months. CT scan of the osteomeatal complex and paranasal sinuses showed an opacification of bilateral maxillary sinus and an amorphous area of bone density in the left maxillary sinus. Because of the size of the mass, benign neoplasms were considered in the differential diagnosis. During an endoscopic sinus surgery, it was found to be an antrolith, which was successfully managed by antrostomy and Caldwell-Luc Surgery. Discussion. Antrolith is a rare condition. Rhinoliths are known to invade into the maxillary antrum, but a localised lesion in the antrum is very unusual. A case of an isolated antrolith is presented for its rarity and for differential diagnosis of localised antral disease. Conclusion. Antrolith should be considered as differential diagnosis of unilateral radio-opaque paranasal sinus lesions.
doi:10.1155/2013/527152
PMCID: PMC3580910  PMID: 23476856
22.  Parallel evolution controlled by adaptation and covariation in ammonoid cephalopods 
Background
A major goal in evolutionary biology is to understand the processes that shape the evolutionary trajectory of clades. The repeated and similar large-scale morphological evolutionary trends of distinct lineages suggest that adaptation by means of natural selection (functional constraints) is the major cause of parallel evolution, a very common phenomenon in extinct and extant lineages. However, parallel evolution can result from other processes, which are usually ignored or difficult to identify, such as developmental constraints. Hence, understanding the underlying processes of parallel evolution still requires further research.
Results
Herein, we present a possible case of parallel evolution between two ammonoid lineages (Auguritidae and Pinacitidae) of Early-Middle Devonian age (405-395 Ma), which are extinct cephalopods with an external, chambered shell. In time and through phylogenetic order of appearance, both lineages display a morphological shift toward more involute coiling (i.e. more tightly coiled whorls), larger adult body size, more complex suture line (the folded walls separating the gas-filled buoyancy-chambers), and the development of an umbilical lid (a very peculiar extension of the lateral shell wall covering the umbilicus) in the most derived taxa. Increased involution toward shells with closed umbilicus has been demonstrated to reflect improved hydrodynamic properties of the shell and thus likely results from similar natural selection pressures. The peculiar umbilical lid might have also added to the improvement of the hydrodynamic properties of the shell. Finally, increasing complexity of suture lines likely results from covariation induced by trends of increasing adult size and whorl overlap given the morphogenetic properties of the suture.
Conclusions
The morphological evolution of these two Devonian ammonoid lineages follows a near parallel evolutionary path for some important shell characters during several million years and through their phylogeny. Evolution of some traits (involution, umbilical lid) appears to be mainly driven by adaptation to improve the hydrodynamic properties of the shell, whereas other characters (sutural complexity) evolved due to covariation with features that play a central role in the morphogenesis of mollusc shells. This example provides evidence that parallel evolution can be driven simultaneously by different factors such as covariation (constructional constraints) and adaptation (natural selection).
doi:10.1186/1471-2148-11-115
PMCID: PMC3112087  PMID: 21529353
23.  Patent vitellointestinal duct 
BMJ Case Reports  2010;2010:bcr1220092594.
During the 3rd week of intrauterine life there is a communication between the intraembryonic gut and the yolk sac. As the development proceeds this communication narrows into a tube known as the vitellointestinal duct (VID). With the establishment of placental nutrition this duct usually becomes obliterated by the end of the 7th week of intrauterine life. In about 2% of humans this duct persists and gives rise to a group of anomalies of which Meckel's diverticulum is the commonest and complete patency of the duct is the rarest.1
We report a case of a 4-month-old infant who presented with umbilical polyp, discharge from the umbilicus, significant dehydration and failure to thrive because of complete patency of the VID
doi:10.1136/bcr.12.2009.2594
PMCID: PMC3029414  PMID: 22778111
24.  Pulmonary fungus ball caused by Penicillium capsulatum in a patient with type 2 diabetes: a case report 
BMC Infectious Diseases  2013;13:496.
Background
Following the recent transfer of all accepted species of Penicillium subgenus Biverticillium to Talaromyces (including Talaromyces marneffei, formerly Penicillium marneffei), Penicillium species are becoming increasingly rare causal agents of invasive infections. Herein, we present a report of a type 2 diabetes patient with a fungus ball in the respiratory tract caused by Penicillium capsulatum.
Case presentation
A 56-year-old Chinese female gardener with a 5-year history of type 2 diabetes presented at the Shanghai Changzheng Hospital with fever, a cough producing yellow-white sputum, and fatigue. The therapeutic effect of cefoxitin was poor. An HIV test was negative, but the β-D-glucan test was positive (459.3 pg/ml). Chest radiography revealed a cavitary lesion in the left upper lobe, and a CT scan showed globate cavities with a radiopaque, gravity-dependent ball. The histopathologic features of the tissue after haematoxylin-eosin staining showed septate hyphae. The fungus was isolated from the gravity-dependent ball and identified as Penicillium capsulatum based on the morphological analysis of microscopic and macroscopic features and on ribosomal internal transcribed spacer sequencing. After surgery, the patient was cured with a sequential treatment of fluconazole 400 mg per day for 90 days and caspofungin 70 mg per day for 14 days.
Conclusions
Although the prognosis is often satisfactory, clinicians, mycologists and epidemiologists should be aware of the possibility of infection by this uncommon fungal pathogen in diabetes patients, since it may cause severe invasive infections in immunocompromised hosts such as diabetes and AIDS patients.
doi:10.1186/1471-2334-13-496
PMCID: PMC3819729  PMID: 24152579
Fungal ball; Pulmonary infections; Penicillium capsulatum
25.  Parallel Algorithm for GPU Processing; for use in High Speed Machine Vision Sensing of Cotton Lint Trash 
Sensors (Basel, Switzerland)  2008;8(2):817-829.
One of the main hurdles standing in the way of optimal cleaning of cotton lint is the lack of sensing systems that can react fast enough to provide the control system with real-time information as to the level of trash contamination of the cotton lint. This research examines the use of programmable graphic processing units (GPU) as an alternative to the PC's traditional use of the central processing unit (CPU). The use of the GPU, as an alternative computation platform, allowed for the machine vision system to gain a significant improvement in processing time. By improving the processing time, this research seeks to address the lack of availability of rapid trash sensing systems and thus alleviate a situation in which the current systems view the cotton lint either well before, or after, the cotton is cleaned. This extended lag/lead time that is currently imposed on the cotton trash cleaning control systems, is what is responsible for system operators utilizing a very large dead-band safety buffer in order to ensure that the cotton lint is not under-cleaned. Unfortunately, the utilization of a large dead-band buffer results in the majority of the cotton lint being over-cleaned which in turn causes lint fiber-damage as well as significant losses of the valuable lint due to the excessive use of cleaning machinery. This research estimates that upwards of a 30% reduction in lint loss could be gained through the use of a tightly coupled trash sensor to the cleaning machinery control systems. This research seeks to improve processing times through the development of a new algorithm for cotton trash sensing that allows for implementation on a highly parallel architecture. Additionally, by moving the new parallel algorithm onto an alternative computing platform, the graphic processing unit “GPU”, for processing of the cotton trash images, a speed up of over 6.5 times, over optimized code running on the PC's central processing unit “CPU”, was gained. The new parallel algorithm operating on the GPU was able to process a 1024×1024 image in less than 17ms. At this improved speed, the image processing system's performance should now be sufficient to provide a system that would be capable of real-time feed-back control that is in tight cooperation with the cleaning equipment.
PMCID: PMC3672999
Machine vision; GPU; Image processing; Cotton; Sensing

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