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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.  Cerebrospinal fluid leakage from the umbilicus: Case report and literature review 
Highlights
•Numerous abdominal complications have been reported in the literature.•An umbilical cerebrospinal fluid (CSF) fistula following a VP shunt is an extremely rare complication.•The mechanism of CSF leakage from the umbilicus is exactly unknown, we aimed to explain this mechanisms.
Introduction
Shunt catheters within the peritoneal cavity have migrated through and perforated almost all the intra-abdominal hollow viscera. An umbilical cerebrospinal fluid fistula following a ventriculoperitoneal shunt is an extremely rare complication.
CASE PRESENTATION
We report a 8-month-old infant who presented with leak of clear fluid from the umbilicus, seven months after a ventriculoperitoneal shunt operation. We could not see distal tip of the shunt on examination. After the operation, the patient’s follow-up was uneventful.
Discussion
The direct effect of CSF and VP shunt, such as chronic irrigation, silicon allergy, foreign body reaction, may cause sterile inflammation on the abdominal structures and this inflammation may soften tissue and cause CFS leakage and VP shunt extrusion.
Conclusion
If the distal tip detected on umbilical region, these patients should be examined frequently for umbilical shunt pathologies, especially infants.
doi:10.1016/j.ijscr.2015.12.052
PMCID: PMC4818294  PMID: 26814999
Umbilical fistula; Ventriculoperitoneal shunt; Hydrocephalus
4.  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
5.  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
6.  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
7.  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
8.  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
9.  Patent vitellointestinal duct as paraumblical abcess: A rare presentation 
Highlights
•The duct fully obliterates (narrows and disappears) during the 5–6th week of fertilization age (9th week of gestational age), but a failure of the duct to close is termed a vitelline fistula.•We present a case of 1 year male with paraumblical abcess due to patent vitellointestinal duct who underwent incision and drainage twice.•Of all the anomalies of the VID, complete patency of the duct is the rarest.
Introduction
Umbilical and paraumblical abscess can occur in children with presenting complaint of discharge from umbilical region. However, patent vitello intestinal duct presenting as paraumblical abscess is rare phenomenon.
Presentation of case
One year old male child presented with complain of discharge from umbilical region since birth. Incision & drainage done twice thinking it to be paraumblical abscess.
Discussion
Vitellointestinal duct as abscess is rare presentation but it should be considered as a differential diagnosis of discharging umbilicus as management of abscess and patent duct are different.
Conclusion
Patent vitellointestinal duct can present as paraumbilical abscess, and it should be kept in differential diagnosis specifically in children.
doi:10.1016/j.ijscr.2015.07.039
PMCID: PMC4601947  PMID: 26301682
Vitellointestinal duct; Abscess; Fistula
10.  Excision of the urachal remnant using the abdominal wall-lift laparoscopy: A case report 
Highlights
•Abdominal wall-lift technique is a promising surgical option for patients with a symptomatic urachal remnant.•The Pfannenstiel incision provides a good view of the operative field as well as an excellent cosmetic outcome.•Urachal sinus excision using the abdominal wall-lift laparoscopy seems to surpass the previously reported methods in term of safety, cosmetics, and adequacy of surgical procedures.
Introduction
Here, we report the surgical excision of the urachal remnant using the abdominal wall-lift laparoscopy with a camera port in the umbilicus, combined with a small Pfannenstiel incision to optimally treat the bladder apex.
Presentation of case
A 21-year-old woman presented with periumbilical discharge and pain on urination. Contrast enhanced CT and MRI showed an abscess in the umbilical region that was connected to the bladder via a long tube-like structure. It was diagnosed as an infected urachal sinus. Partial excision of the umbilical fossa followed by dissection of the urachal remnant was easily performed using the abdominal wall-lift laparoscopy from the umbilicus down to the bladder without pneumoperitoneum or additional trocar placement. A Pfannenstiel incision was made above the pubis to get access to the junction between the urachal remnant and the bladder. Under direct vision, we succeeded in accurately dividing the remnant tract, and we adequately closed the bladder opening with absorbable sutures. This method has the advantage of easily closing peritoneal defects after excision of the urachal remnant with direct sutures under a laparoscopic view from the umbilicus. Cosmetic satisfaction was obtained postoperatively.
Discussion and conclusion
Urachal sinus excision using the abdominal wall-lift laparoscopy seems to surpass the previously reported methods in term of safety, cosmetics, and adequacy of surgical procedures.
doi:10.1016/j.ijscr.2016.03.037
PMCID: PMC4832082  PMID: 27064744
Urachal remnant; Laparoscopic; Abdominal wall lift
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.  Primary umbilical endometriosis: a cause of a painful umbilical nodule 
Journal of Surgical Case Reports  2015;2015(3):rjv025.
A female patient presented with a painful swelling in the umbilicus. Ultrasonography demonstrated a hypodense nodule of 1.8 cm. Surgical exploration revealed a subcutaneous, dark discoloured, lobulated swelling at the bottom of the umbilicus, which turned out to be primary umbilical endometriosis (PUE). Primary umbilical endometriosis is a rare and benign disorder, caused by the presence of ectopic endometrial tissue in the umbilicus, which can present as a painful, discoloured swelling in the umbilicus. The clinical distinction between primary umbilical endometrioses and other causes of an umbilical nodule is difficult. Additional imaging modalities do not show any pathognomonic signs for establishing this diagnose. Surgical exploration and excision are a safe and definitive treatment of primary umbilical endometrioses. This case highlights the importance of including PUE in the differential diagnosis of women with a painful umbilical nodule.
doi:10.1093/jscr/rjv025
PMCID: PMC4363684  PMID: 25786440
13.  A case of an omphalomesenteric duct remnant in an adult treated with laparoscopic surgery 
Highlights
•An omphalomesenteric duct (OMD) remnant is a rare case in an adult.•A ductal structure was found between the distal ileum and the umbilicus in this case.•Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen.•A good field of view around the umbilicus and adequate working space were provided.•Both diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery.
Introduction
The presence of an omphalomesenteric duct (OMD) remnant is a rare condition that typically affects the pediatric population. This report describes an extremely rare case of an OMD remnant that was diagnosed and resected by laparoscopic surgery in an adult.
Presentation of case
A 52-year-old man underwent a medical examination at our hospital for right lower quadrant pain. Laboratory findings showed slight leukocytosis and an elevated C-reactive protein level. A luminal structure connected to the umbilicus was detected in the right pelvic wall by abdominal computed tomography, and an OMD remnant was suspected. Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen; no trocars were inserted near the umbilicus. This procedure provided both a good field of view around the umbilicus and adequate working space. We definitively diagnosed the structure as an OMD remnant and resected it with minimal invasion. The patient was discharged on postoperative day 7 without complications. Pathologic analysis found the lumen is covered by ileum-like mucosa, and a microabscess is formed in the surrounding fat tissue.
Discussion
OMD remnants are uncommon, and their diagnosis is difficult. Most reports advocate for prompt surgical resection in symptomatic patients.
Conclusion
In the present case, definitive diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery.
doi:10.1016/j.ijscr.2015.01.047
PMCID: PMC4353944  PMID: 25680534
Omphalomesenteric duct remnant; Laparoscopic surgery; Meckel’; s diverticulum
14.  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
15.  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
16.  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
17.  Abdominal tuberculosis manifested as tuberculosis of the urachal sinus in an adolescent and the role of laparoscopy in the management: a rare case report 
Background
Abdominal tuberculosis (TB) is an uncommon affliction in adolescence. It is usually associated with pulmonary tuberculosis. The disease is caused by lymphohaematogenous spread after primary infection in the lung or ingestion of infected sputum and has a typically protean and nonspecific presentation. The occurrence of TB in an urachal remnant is probably from the contiguous spread of an abdominal focus or mesenteric lymph node. Urachal TB is a rare entity, with only two reported cases in the literature. We report here a case of clinically silent pulmonary and abdominal TB that manifested in the infection of an urachal sinus and highlight the role of laparoscopy in its diagnosis and treatment.
Case presentation
A 14-year-old boy presented to our institution with peri-umbilical swelling and purulent discharge from his umbilicus for 2 weeks duration. There were no radiological, microbiological or clinical evidences of TB in the initial presentation, though he had close social contact with someone who had TB. A computed tomography scan of the abdomen confirmed the diagnosis of an urachal abscess. An incision and drainage procedure was performed followed by a course of antibiotics. A scheduled laparoscopic approach later showed that the peritoneum and serosal surface of the small and large intestines were studded with nodules of variable sizes, in addition to the urachal sinus. The histology of the resected tissues (urachal sinus and nodules) was consistent of TB infection. He recovered fully after completing 6 months of anti-tuberculous therapy.
Conclusion
This report highlights a rare case of TB urachal abscess in an adolescent boy, the difficulties in the diagnosis of abdominal tuberculosis, the need to consider TB as a cause of urachal infection in endemic areas and the use of laparoscopy in both diagnosis and treatment.
doi:10.1186/s12879-016-1405-6
PMCID: PMC4744458  PMID: 26850778
Tuberculosis; Urachal sinus; Urachal abscess; Infection; Laparoscopy
18.  Comparative Transcriptomics Reveals Jasmonic Acid-Associated Metabolism Related to Cotton Fiber Initiation 
PLoS ONE  2015;10(6):e0129854.
Analysis of mutants and gene expression patterns provides a powerful approach for investigating genes involved in key stages of plant fiber development. In this study, lintless-fuzzless XinWX and linted-fuzzless XinFLM with a single genetic locus difference for lint were used to identify differentially expressed genes. Scanning electron microscopy showed fiber initiation in XinFLM at 0 days post anthesis (DPA). Fiber transcriptional profiling of the lines at three initiation developmental stages (-1, 0, 1 DPA) was performed using an oligonucleotide microarray. Loop comparisons of the differentially expressed genes within and between the lines was carried out, and functional classification and enrichment analysis showed that gene expression patterns during fiber initiation were heavily associated with hormone metabolism, transcription factor regulation, lipid transport, and asparagine biosynthetic processes, as previously reported. Further, four members of the allene-oxide cyclase (AOC) family that function in jasmonate biosynthesis were parallel up-regulation in fiber initiation, especially at -1 DPA, compared to other tissues and organs in linted-fuzzed TM-1. Real time-quantitative PCR (RT-qPCR) analysis in different fiber mutant lines revealed that AOCs were up-regulated higher at -1 DPA in lintless-fuzzless than that in linted-fuzzless and linted-fuzzed materials, and transcription of the AOCs was increased under jasmonic acid (JA) treatment. Expression analysis of JA biosynthesis-associated genes between XinWX and XinFLM showed that they were up-regulated during fiber initiation in the fuzzless-lintless mutant. Taken together, jasmonic acid-associated metabolism was related to cotton fiber initiation. Parallel up-regulation of AOCs expression may be important for normal fiber initiation development, while overproduction of AOCs might disrupt normal fiber development.
doi:10.1371/journal.pone.0129854
PMCID: PMC4469610  PMID: 26079621
19.  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
20.  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
21.  “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
22.  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
23.  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
24.  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
25.  A necrotic lung ball caused by co-infection with Candida and Streptococcus pneumoniae 
Introduction
A necrotic lung ball is a rare radiological feature that is sometimes seen in cases of pulmonary aspergillosis. This paper reports a rare occurrence of a necrotic lung ball in a young male caused by Candida and Streptococcus pneumoniae.
Case report
A 28-year-old male with pulmonary candidiasis was found to have a lung ball on computed tomography (CT) of the chest. The patient was treated with β-lactams and itraconazole and then fluconazole, which improved his condition (as found on a following chest CT scan) and serum β-D-glucan level. The necrotic lung ball was suspected to have been caused by coinfection with Candida and S. pneumoniae.
Conclusion
A necrotic lung ball can result from infection by Candida and/or S. pneumoniae, indicating that physicians should be aware that patients may still have a fungal infection of the lungs that could result in a lung ball, even when they do not have either Aspergillus antibodies or antigens.
doi:10.2147/IDR.S24269
PMCID: PMC3259690  PMID: 22259251
lung ball; necrotic lung ball; Candida; Streptococcus pneumoniae

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