Contiguous Extension Research Articles

Ruptured mycotic abdominal aortic aneurysm in the setting of an adjacent perinephric abscess

Arterial aneurysms are most commonly present due to progressive vessel wall injury. They may then act as a nidus for bacterial seeding that can lead to the formation of a mycotic aneurysm in 2.5% of all abdominal aneurysms, which is associated with high mortality. Management of mycotic aortic aneurysm has been challenging always. Here we present a rare case of a ruptured mycotic aneurysm secondary to contiguous extension of a perinephric abscess. The patient required emergent surgery and underwent reconstruction of the aorta using a Dacron graft with a good 18 months outcome.

A case of pagetoid spread of urothelial carcinoma with notable reduction achieved through enfortumab vedotin, resulting in complete surgical resection.

Secondary extramammary Paget's disease is a rare condition associated with the contiguous extension of tumor cells from the underlying adnexal structures, genitourinary, or gastrointestinal tracts. We report the case of an 80-year-old female with a 7-year history of urothelial carcinoma who presented with erythema of the labia majora. The diagnosis was pagetoid spread of urothelial carcinoma. The patient declined surgical resection of the lesion. She underwent nine cycles of first-line platinum-based chemotherapy and received one course of pembrolizumab for metastatic urothelial carcinoma. As the lesion progressively enlarged, third-line therapy with enfortumab vedotin was initiated, which resulted in significant tumor reduction. This allowed for a successful surgical complete resection of the tumor. Enfortumab vedotin was highly effective and demonstrated dramatic efficacy for controlling extramammary Paget's disease secondary to urothelial carcinoma.

Fungal Musculoskeletal Infections: Comprehensive Approach to Proper Diagnosis.

Fungal musculoskeletal infections often have subacute or indolent manifestations, making it difficult to distinguish them from other diseases and infections, given that they are relatively uncommon. Fungal infections occur by hematogenous spread, direct inoculation, or contiguous extension and may be related to different risk factors, including immunosuppression and occupational activity. The infection can manifest in isolation in the musculoskeletal system or as part of a systemic process. The fungi may be endemic to certain regions or may be found throughout the world, and this can help to narrow the diagnosis of the etiologic agent. Infections such as candidiasis, cryptococcosis, aspergillosis, and mucormycosis are often related to immunosuppression. On the other hand, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and blastomycosis can occur in healthy patients in geographic areas where these infections are endemic. Furthermore, infections can be classified on the basis of the site of infection in the body. Some subcutaneous infections that can have osteoarticular involvement include mycetoma, sporotrichosis, and phaeohyphomycosis. Different fungi affect specific bones and joints with greater prevalence. Imaging has a critical role in the evaluation of these diseases. Imaging findings include nonspecific features such as osteomyelitis and arthritis, with bone destruction, osseous erosion, mixed lytic and sclerotic lesions, and joint space narrowing. Multifocal osteomyelitis and chronic arthritis with joint effusion and synovial thickening may also occur. Although imaging findings are often nonspecific, some fungal infections may show findings that aid in narrowing the differential diagnosis, especially when they are associated with the patient's clinical condition and history, the site of osteoarticular involvement, and the geographic location. ©RSNA, 2024.

Malignant Portal Vein Thrombosis with No Obvious Liver Parenchymal Mass on Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

The presence of portal vein thrombosis (PVTT) in hepatocellular carcinoma (HCC) is associated with adverse prognosis with dismal survival. Malignant portal vein thrombosis usually develops as a contiguous extension of the liver tumour into portal vein or its branches. Here we present an interesting FDG PET-CT image of a patient with chronic hepatitis B infection having isolated malignant portal vein thrombosis without any obvious liver mass.

Tricuspid valve metastasis in osteosarcoma, paving way through iliofemoral vessels – An unusual presentation of a usual diagnosis

Hematogenous spread of osteosarcoma is a common knowledge, with frequent metastases to lungs and bones. Cardiac involvement is rare finding, most of them depicting contiguous cardiac extension through vessels into the right atrium. Tricuspid metastases are rare. We encountered one such rare case of femur osteosarcoma with multiorgan metastasis including systemic veins, cardiac chambers, and tricuspid valve involvement which presented as diagnostic dilemma. Early detection was crucial for further management and prognostication of patient.

Rates and reasons for reoperation within 30 and 90 days following cervical spine surgery: a retrospective cohort analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry

BACKGROUND CONTEXTReoperation following cervical spinal surgery negatively impacts patient outcomes and increases health care system burden. To date, most studies have evaluated reoperations within 30 days after spine surgery and have been limited in scope and focus. Evaluation within the 90-day period, however, allows a more comprehensive assessment of factors associated with reoperation. PURPOSEThe purpose of this study is to assess the rates and reasons for reoperations after cervical spine surgery within 30 and 90 days. DESIGNWe performed a retrospective analysis of a state-wide prospective, multi-center, spine-specific database of patients surgically treated for degenerative disease. PATIENT SAMPLEPatients 18 years of age or older who underwent cervical spine surgery for degenerative pathologies from February 2014 to May 2019. Operative criteria included all degenerative cervical spine procedures, including those with cervical fusions with contiguous extension down to T3. OUTCOME MEASURESWe determined causes for reoperation and independent surgical and demographic risk factors impacting reoperation. METHODSPatient-specific and surgery-specific data was extracted from the registry using ICD-10-DM codes. Reoperations data was obtained through abstraction of medical records through 90 days. Univariate analysis was done using chi-square tests for categorical variables, t-tests for normally distributed variables, and Wilcoxon rank-sum tests for variables with skewed distributions. Odds ratios for return to the operating room (OR) were evaluated in multivariate analysis. RESULTSA total of 13,435 and 13,440 patients underwent cervical spine surgery and were included in the 30 and 90-day analysis, respectively. The overall reoperation rate was 1.24% and 3.30% within 30 and 90 days, respectively. Multivariate analysis showed within 30 days, procedures involving four or more levels, posterior only approach, and longer length of stay had increased odds of returning to the OR (p<.05), whereas private insurance had a decreased odds of return to OR (p<.05). Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning to the OR (p<.05). Non-white race, independent ambulatory status pre-operatively, and having private insurance had decreased odds of return to the OR (p<.05). The most common specified reasons for return to the OR within 30 days was hematoma (19%), infection (17%), and wound dehiscence (11%). Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%). CONCLUSIONReoperation rates after elective cervical spine surgery are 1.24% and 3.30% within 30 and 90 days, respectively. Within 30 days, four or more levels, posterior approach, and longer length of stay were risk factors for reoperation. Within 90 days, male sex, CAD, four or more levels, and longer length of hospital stay were risk factors for reoperation. Non-white demographic and independent preoperative ambulatory status were associated with decreased reoperation rates.

Prevalence, Predictors, and Oncologic Outcomes of Pelvic Organ Involvement in Women Undergoing Radical Cystectomy.

In women, radical cystectomy includes removal of the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall, yet contiguous extension of urothelial carcinoma to all pelvic organs is rare and routine removal may be unnecessary. To study pelvic organ involvement in women at radical cystectomy and investigate oncologic outcomes. Women with bladder cancer who underwent radical cystectomy at the Mayo Clinic and University of Toronto (1980-2018) were evaluated. Cancer-specific survival (CSS) was estimated with the Kaplan-Meier method; comparisons were made with the log-rank test. Associations with CSS were evaluated with Cox proportional hazard modeling. A total of 70 women with pT4a and 83 with pT3b cancer were studied. Organs involved were vagina (n = 41 of 70; 58.6%), uterus (n = 26 of 54; 48.1%), cervix (n = 15 of 54; 27.8%), fallopian tubes (n = 10 of 58; 17.2%), and ovaries (n = 7 of 58; 12.1%); 22 of 58 patients (37.9%) had >1 organ involved. Of 70 with pT4a cancer, 64 were available for survival analysis by 3 pelvic organ groups: vaginal only, vaginal and/or cervical/uterine, and vaginal and/or cervical/uterine and/or fallopian tubes/ovarian involvement. Three-year CSS for vaginal involvement only was 39%; it was 14% if cervical/uterine involvement, and <1% if fallopian tube/ovarian involvement was included (P = .02). Among 20 women with pT4aN0/Nx and vaginal involvement only, 3-year CSS for vaginal involvement was 50%, whereas among 48 women with pT3bN0/Nx cancer, 3-year CSS was 58%, P = .70. Isolated vaginal involvement should be separated from uterine and/or adnexal extension of urothelial carcinoma at pathologic staging. Direct ovarian extension is rare and routine removal may be unnecessary.

Distal coronary artery abnormalities in Kawasaki disease: experience on CT coronary angiography in 176 children.

Precise evaluation of coronary artery abnormalities (CAAs) in Kawasaki disease (KD) is essential. The aim of this study is to determine role of CT coronary angiography (CTCA) for detection of CAAs in distal segments of coronary arteries in patients with KD. CTCA findings of KD patients with distal coronary artery involvement were compared with those on transthoracic echocardiography (TTE) during the period 2013-21. Among 176 patients with KD who underwent CTCA (128-Slice Dual Source scanner), 23 (13.06%) had distal CAAs (right coronary-15/23; left anterior descending-14/23; left circumflex-4/23 patients). CTCA identified 60 aneurysms-37 proximal (36 fusiform; 1 saccular) and 23 distal (17 fusiform; 6 saccular); 11 patients with proximal aneurysms had distal contiguous extension; 9 patients showed non-contiguous aneurysms in both proximal and distal segments; 4 patients showed distal segment aneurysms in absence of proximal involvement of same coronary artery; 4 patients had isolated distal CAAs. On TTE, only 40 aneurysms could be identified. Further, distal CAAs could not be identified on TTE. CTCA also identified complications (thrombosis, mural calcification and stenosis) that were missed on TTE. CAAs can, at times, occur in distal segments in isolation and also in association with, or extension of, proximal CAAs. CTCA demonstrates CAAs in distal segments of coronary arteries, including branches, in a significant number of children with KD-these cannot be detected on TTE. CTCA may therefore be considered as a complimentary imaging modality in children with KD who have CAAs on TTE.

Hemophagocytic Lymphohistiocytosis and Severe Hypoxemia in a Preterm Infant.

Hemophagocytic Lymphohistiocytosis and Severe Hypoxemia in a Preterm Infant.

There is No "Axillary Tail": Rethinking the Assumption of James Spence.

Summary:Widely quoted, “the axillary tail of Spence” refers to a contiguous extension of adipose angling superolaterally from the primary breast into the axilla. Described anecdotally in 1871, the “tail of Spence” has been considered important to the fields of general surgery, oncology, plastic surgery, and anatomy ever since. Despite the ubiquitous presence of the concept in literature, clinical discussions, and educational settings, we argue against the very existence of Spence’s “tail.” While pinch-testing and topographically mapping 316 consecutive patients in preparation for breast and gynecomastia surgery, we found a consistent pattern of focal fat mounds without continuity between breast and axilla. The absence of an uninterrupted superolateral tail was reaffirmed while analyzing 20 research participants who were pinch-tested with calipers and topographically mapped, specifically to define fat pad anatomy. We documented that the axillary breast mound was always distinct from the primary breast and that all women and many men had an additional “lateral chest wall tail” that never angled toward the axilla. In most, rolling the shoulder girdle anteriorly created a visible groove between the axillary mound and the primary breast, with little or no pinchable fat beneath that crease. With all deference to Spence, we have established that the outer half of the chest is consistently defined by three focal adipose structures—an axillary mound, the primary breast mound, and a previously unnamed “lateral chest wall tail”—with no anatomic evidence of an “axillary tail” of fat extending superolaterally from breast to axilla.

A contiguous extension of Dixon’s theorem for a terminating 4F3(1) series with applications

We derive a summation formula for the terminating hypergeometric series \[{}_4F_3\left[\!\!\begin{array}{c}-m,a,b,1+c\\1+a+m,1+a-b,c\end{array}\!\!;1\right],\] where $m$ denotes a nonnegative integer. Using this summation formula, we establish a reduction formula for the Srivastava-Daoust double hypergeometric function with arguments $z$ and $-z$. Special cases of this reduction formula lead to several reduction formulas for the hypergeometric functions ${}_{p+1}F_p$ with quadratic arguments when $p=2,3$ and 4 by employing series rearrangement techniques. A general double series identity involving a bounded sequence of arbitrary complex numbers is also given.

Imaging Manifestations of Genitourinary Tuberculosis.

The genitourinary region is one of the most common sites of extrapulmonary tuberculosis (TB) involvement. The imaging features of genitourinary TB are protean and can mimic other entities, including malignancy, and pose a diagnostic dilemma. Hematogenous seeding and lymphatic spread of mycobacteria from pulmonary, tonsillar, and nodal TB are implicated in the pathogenesis of genitourinary TB. In addition, contiguous extension from the urinary tract and sexual transmission are described as sources of genital TB. Genitourinary TB can be indolent and results in nonspecific signs and symptoms; thus, imaging has a vital role in the working diagnosis for these cases. Classic uroradiologic signs of genitourinary TB are primarily described from the era of intravenous urography and conventional radiography. Now, CT, CT urography, MRI, and US are used in the diagnosis and management. Familiarity with the imaging features of genitourinary TB may help guide the diagnosis and, in turn, lead to timely management. US has a vital role in the evaluation of scrotal and female genital TB. MRI offers superior soft-tissue contrast resolution and excellent depiction of anatomic detail. The various imaging manifestations of genitourinary TB are highlighted. ©RSNA, 2021.

Cutaneous Aspergilosis Caused by Aspergillus Flavus: A Case Report

Background: Cutaneous aspergillosis occurs relatively less frequent and therefore remains poorly characterized. Cutaneous aspergillosis can be as primary or secondary infection. Primary cutaneous aspergillosis usually involves sites of skin injury, intravenous catheter, traumatic inoculation, and associated with occlusive dressings. Secondary lesions result from contiguous extension from infected underlying structures or from widespread blood-borne seeding of the skin. Purpose: To know the skin manifestation, efflorence, examination and therapy of cutaneous aspergillosis. Case: A man complaint itchy redness macule and pimples on the right arm since 2 weeks. Initially just felt a little then expands. Patients with post operative brachial injury and uses a cast during one month. On examination there are erythematous macule unsharply marginated with papules. Potassium hydroxide examination, shows conidiophores, dichotomously branching and septate hyphae appropriate description with Aspergillosis Sp. Cultures found grow granular colonies, flat often with radial grooves, yellow at first but quickly becoming bright to dark yellow-green with age, For the identification microscope from the culture specimen there was conidia, phialde, conidiophore and vesicle that suitable with Aspergillus flavus. Patients received itraconazole 2 x 200 mg for 6 weeks and obtained satisfactory results. Discussion: Healthy hosts can develop cutaneous aspergillosis in surgical wounds, by traumatic inoculation, at sites associated with occlusive dressings. In some instances, a presumptive diagnosis of primary cutaneous aspergillosis can be made immediately by examining a potassium hydroxide preparation and culture. Conclusion: Diagnose of cutaneous aspergillosis can establish by potassium hydroxide and culture examination, therapy with itraconazole 2x 200mg give satisfactory results.

N-terminal Transmembrane-Helix Epitope Tag for X-ray Crystallography and Electron Microscopy of Small Membrane Proteins

Structural studies of membrane proteins, especially small membrane proteins, are associated with well-known experimental challenges. Complexation with monoclonal antibody fragments is a common strategy to augment such proteins; however, generating antibody fragments that specifically bind a target protein is not trivial. Here we identify a helical epitope, from the membrane-proximal external region (MPER) of the gp41-transmembrane subunit of the HIV envelope protein, that is recognized by several well-characterized antibodies and that can be fused as a contiguous extension of the N-terminal transmembrane helix of a broad range of membrane proteins. To analyze whether this MPER-epitope tag might aid structural studies of small membrane proteins, we determined an X-ray crystal structure of a membrane protein target that does not crystallize without the aid of crystallization chaperones, the Fluc fluoride channel, fused to the MPER epitope and in complex with antibody. We also demonstrate the utility of this approach for single particle electron microscopy with Fluc and two additional small membrane proteins that represent different membrane protein folds, AdiC and GlpF. These studies show that the MPER epitope provides a structurally defined, rigid docking site for antibody fragments that is transferable among diverse membrane proteins and can be engineered without prior structural information. Antibodies that bind to the MPER epitope serve as effective crystallization chaperones and electron microscopy fiducial markers, enabling structural studies of challenging small membrane proteins.

A FAB-Tag for Small Membrane Protein Structure Determination

The “resolution revolution” in electron microscopy left some proteins behind: small helical bundles that are almost entirely membrane embedded. Decorating a target with recombinant antibody fragments (Fab) that bind in a structurally specific and rigid manner can overcome limitations of small particle alignment, but antibody discovery campaigns are expensive, time-consuming, and are not guaranteed to work. Here we identify a helical epitope from the HIV envelope protein (gp41) that can be engineered as a contiguous extension of the first transmembrane helix of diverse membrane proteins. We demonstrate the utility of this maneuver by complexing a single Fab to three unrelated, small membrane proteins. The strategy permitted us to crystallize an otherwise structurally-intractable 30-kDa fluoride channel, as well as visualize Fab fragment decoration by negative stain EM. This 17-amino acid α-helical epitope can be bound by distinct, structurally characterized Fab fragments that can aid in structure determination of the target membrane protein.

Race, Ethnicity, and Socioeconomic Status Are Associated With Prolonged Time to Treatment After a Diagnosis of Colorectal Cancer: A Large Population-Based Study

Race, Ethnicity, and Socioeconomic Status Are Associated With Prolonged Time to Treatment After a Diagnosis of Colorectal Cancer: A Large Population-Based Study

RUPTURED GASTRIC DUODENAL ARTERY FROM MYCOTIC ANEURYSM DUE TO CANDIDA ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycotic aneurysms refers to the irreversible vascular dilations caused by weakening and destruction of the vessel intimal wall by an invasive organism. Due to the advent of early treatment with antibiotics, mycotic aneurysms are quite rare, constituting only about 1-3% of all arterial aneurysms. We present a case of a 64 year old intravenous (IV) drug user who was admitted for candida endocarditis and developed hemorrhagic shock due to a ruptured gastric duodenal artery from a mycotic aneurysm. CASE PRESENTATION: A 64 year old male with a history of IV drug use and chronic steroid use for erythrodermic psoriasis presented with fevers for several days. In the emergency department, he was febrile to 101.9 degrees Fahrenheit, tachycardic to 120 beats per minute, and hypotensive to 88/46 mmHg. Blood cultures were drawn and he was started on IV fluids, broad-spectrum antibiotics, and vasopressor support for septic shock. His cultures were positive for candida fungemia. He had a transthoracic echocardiogram (TTE) which revealed a focal thickening on the anterior mitral valve leaflet which prompted a transesophageal echocardiogram (TEE). TEE confirmed a small, mobile vegetation on the anterior mitral valve leaflet consistent with endocarditis. Furthermore, his hospitalization was complicated by hemorrhagic shock with computed tomography of the abdomen revealing a large hematoma from a ruptured gastric duodenal artery requiring massive transfusion and emergent embolization for resolution of the bleed. The cause of the arterial bleed was found to be due to a mycotic aneurysm. DISCUSSION: Mycotic aneurysm is a rare phenomenon only constituting about 1-3% of all visceral aneurysms. They were first described by Dr. William Osler as aneurysms associated with bacterial or fungal endocarditis which had the appearance of a “fresh fungus vegetation” 2. Although mycotic aneurysms were initially thought to be due only to infective endocarditis, emerging literature revealed that these aneurysms can develop as a result of any hematogenous spread, lymphatic spread, contiguous extension, or direct inoculation. The initial presenting signs and symptoms of mycotic aneurysms constitute a febrile illness that eventually leads to fulminant sepsis. If left untreated, 20% of mycotic aneurysms will rupture leading to massive hemorrhage. Treatment of mycotic aneurysms includes antibiotic therapy, removal of the source of infection, and surgical or endovascular repair of the aneurysm itself. Endovascular intervention has been a successful intervention for mycotic aneurysms with a 2-year survival rate of 75%. CONCLUSIONS: Clinicians should recognize the risk of developing mycotic aneurysms and possible rupture as a complication of infective endocarditis with the mainstay of treatment being early antibiotic administration, removal of the source of infection, and surgical or endovascular repair of the mycotic aneurysm. Reference #1: Parkhurst GF, Dekcer JP. Bacterial aortitis and mycotic aneurysm of the aorta; a report of twelve cases. Am J Pathol. 1955;31(5):821-835. Reference #2: Gomes MN, Choyke PL. Infected aortic aneurysms: CT diagnosis. J Cardiovasc Surg (Torino). 1992;33(6):684-689. Reference #3: Sörelius Karl, Mani Kevin, Björck Martin, et al. Endovascular Treatment of Mycotic Aortic Aneurysms. Circulation. 2014;130(24):2136-2142. doi:10.1161/CIRCULATIONAHA.114.009481 DISCLOSURES: No relevant relationships by Everardo Arias Torres, source=Web Response No relevant relationships by Tim Cheng, source=Web Response No relevant relationships by Richard Lee, source=Web Response No relevant relationships by George Nasr, source=Web Response

En-bloc rectosigmoid and mesorectum resection as part of pelvic cytoreductive surgery in advanced ovarian cancer

Objective:“En-bloc” resection of pelvic tumor in ovarian cancer (OC) is still controversial. The aim was to analyze results in an OC series from a single center, all of whom underwent “en-bloc” resection as part of cytoreductive surgery.Material and Methods:Clinical and surgical records from sixty patients with ovarian carcinoma who underwent “en-bloc” resection surgery were retrospectively analyzed.Results:Patients’ mean age was 56 years; 36 patients had primary disease and 24 had recurrent disease. Carcinomatosis was present in 46.7% of patients. Primary surgery was performed in 49 and interval debulking surgery in eleven. Complete cytoreduction was achieved in 55.0% and optimal in 38.3% of patients. Carcinomatosis significantly decreased the probability of complete cytoreduction [odds ratio (OR): 0.22; p=0.021]. Mesorectal infiltration occurred in 83% of patients. Risk of death was non-significantly higher (hazard ratio: 1.9) in women with mesorectal infiltration. Median overall survival was longer for patients without infiltration (46.1 vs 79.1 months; p=0.15). Eighty-five percent suffered from mild to moderate complications and colorectal anastomosis (CRA) leak occurred in two patients (3.6%) with CRA below 6 cm. Diaphragm resection had >5 times the risk for major complications (OR: 5.35; p=0.014). There was no three month mortality.Conclusion:When contiguous gross extension of disease to pelvic peritoneum and sigmoid colon is found, in patients with advanced OC, microscopic involvement of the mesorectum and intestinal wall is present in most cases making “en-bloc” resection necessary if complete cytoreduction is to be achieved. The associated morbidity is acceptable.

Unusual Skin Metastasis from Gastric Cancer: A Case Report

Background: Skin metastasis from gastric cancer are relatively rare, but they have important clinical significance because they usually indicate a worse prognosis. Skin metastasis from gastric cancer may spread through lymphatic ducts, blood vessels in the ligamentum teres, contiguous extension, or embryologic remnants of the umbilicus. Purpose: To report an unusual skin metastasis from gastric cancer that clinically resembles as a benign lesion of skin papules. Case: A rare metastasis from gastric cancer origin in a 61-year-old male in the abdominal skin. Gastric cancer metastasis in an unusual site such as the abdominal skin often resembles as dermatitis, especially in the early course of metastatic spreading, which looked like common papules on the skin. Discussion: In the beginning, the skin papules were not suspected to be a metastatic process because there was no palpable or no tenderness in the subcutan or fascia underneath. The appearance resembled common dermatitis. However, as papules rapidly spread to the surrounding skin, the malignancy was then suspected. The incisional biopsy from the papules was performed and showed that it was metastatic diffuse-type gastric adenocarcinoma. Conclusion: The skin metastasis was different from general nodules, but rather as skin papules of general dermatitis in initial appearance. The surgeon and dermatologist should be alert if they find any benign appearance of a skin lesion on the abdominal wall in a patient with a history of gastric cancer surgery.

Rapunzel syndrome in an adolescent girl

Bezoars are masses, which are commonly encountered in patients after stomach surgery or in those with psychiatric problems. These are formed by the accumulation of intraluminal non digestible substances that can lead to obstruction of the stomach and the small intestine. Trichobezoars are concretions formed by accumulation of hair in stomach. Usually, trichobezoar is confined to the stomach. However, rarely there is contiguous extension of trichobezoar through the pylorus into jejunum, ileum and even up to the colon. Such a condition is called the Rapunzel syndrome. The term comes from a story written by the Grimm brothers in 1812 about Rapunzel who was a long-haired maiden. Rapunzel syndrome is an extremely rare complication of a gastric trichobezoar. We hereby, present the case of a 13 years old girl with Rapunzel syndrome due to a very large gastric trichobezoar. The patient had trichotillomania and trichophagia for 11 year prior to presentation. An abdominal computed tomography scan showed a heterogeneous mass occupying the whole stomach cavity with extension into the jejunum. She was subjected to an exploratory laparotomy and gastrotomy. A large dense mass of hair extending up to jejunum was removed. Following surgery, psychiatric consultation was sought to prevent recurrence. Cases of trichobezoar have been reported in literature very infrequently but Rapunzel syndrome is extremely rare and less than 50 cases have been reported in medical literature till date. Trichobezoar is a very rare cause of upper abdominal mass and should be considered if there is a history of impulsive hair pulling. A psychiatric assessment and a long-term follow-up are advocated as a regular part of treatment to prevent recurrence. • Trichobezoar leading to Rapunzel syndrome is an extremely rare entity with less than 50 cases been reported in medical literature till date. • It should be considered strongly in a young patient with abdominal pain and non-tender abdominal mass with history of trichotillomania. • The diagnosis is possible on imaging in a proper clinical setting. However, Rapunzel syndrome is most often an intraoperative finding. • Surgical removal is the gold standard treatment of choice. • Parental counselling, neuropsychiatric assessment and treatment, long-term follow-up and behavioural therapy are advocated as a regular part of treatment to prevent recurrence.