Multifocal Presentation Research Articles

Extracutaneous sporotrichosis.

SUMMARYSporotrichosis is a subacute-to-chronic infection endemic to tropical and subtropical regions. It usually involves subcutaneous tissue but can occasionally cause extracutaneous infections, especially in hyperendemic areas. Extracutaneous infections are classified based on the anatomic location of the lesion and the route of infection (primary or multifocal). The clinical forms are as follows: (i) pulmonary (primary or multifocal); (ii) osteoarticular (primary or multifocal); (iii) ocular (ocular adnexal lesions including eyelid lesions, conjunctivitis and dacryocystitis, and intraocular infections); (iv) central nervous system; and (v) mucosal (primary or disseminated). Multifocal clinical presentations are observed mainly in immunocompromised individuals. The diagnosis must be confirmed in the laboratory by mycological examination of the clinical samples. Itraconazole and amphotericin B are the most commonly used antifungal agents for treating pulmonary, osteoarticular, ocular, and mucosal forms. Treatment may include surgical excision of the initial lesions in pulmonary and osteoarticular forms. The treatment of neurological involvement is far from optimal and is associated with a high mortality rate despite long treatment periods.

Detection of genetic mutations in 855 cases of papillary thyroid carcinoma by next generation sequencing and its clinicopathological features

ObjectiveTo investigate the genetic mutations in patients with papillary thyroid carcinoma (PTC) and their clinicopathological features by next generation sequencing (NGS).MethodsNGS technology was used to detect genetic mutations in PTC patients, and clinicopathological features were collected.Results①Among 855 PTC patients, 810 patients had genetic mutations, and 45 patients had no genetic mutation. ②BRAF mutation was associated with tumor diameter (P < 0.001) and histological subtypes (P = 0.002). The abundance of V600E mutation was associated with gender (P = 0.004), tumor diameter (P < 0.001), bilateral presentation (P = 0.001), extrathyroidal extension (P < 0.001), lymphatic metastasis (P < 0.001), histological subtypes (P = 0.002) and TNM staging (P = 0.000); The different mutation abundance of V600E was associated with tumor diameter (P < 0.001), multifocal presentation (P = 0.047), bilateral presentation (P = 0.001), extrathyroidal extension (P = 0.001), lymphatic metastasis (P < 0.001), histological subtypes (P = 0.022) and TNM staging (P = 0.000). ③RET fusion was associated with tumor diameter (P < 0.001) and lymphatic metastasis (P = 0.005). ④TERT mutation was associated with gender (P = 0.043), tumor diameter (P < 0.001), extrathyroidal extension (P = 0.028) and TNM staging (P = 0.017). ⑤RAS mutation was associated with histological subtypes (P < 0.001). ⑥NTRK and PIK3CA mutations were not associated with clinicopathological features.ConclusionNGS technology can comprehensively analyze the genetic mutations in PTC patients, which provides important prompts for the occurrence, development, diagnosis and treatment of PTC. In addition, BRAF V600E mutation, RET fusion and TERT mutation are associated with a number of high-risk clinicopathological features. Detection of genetic mutations in PTC patients by NGS is of great significance.

Giant Cell Tumor of Capitate with Secondary Aneurysmal Bone Cyst: A Case Report

Abstract Background Giant cell tumors (GCTs) of the carpal bones are rare. GCTs of the hand tend to be aggressive, could result in multifocal presentation, and have a high rate of recurrence. Case Description We report a rare case of GCT of the capitate with secondary aneurysmal bone cyst (ABC) in a 40-year-old man. The patient presented with complaints of pain and swelling over his right wrist since 6 months. Radiographs showed the presence of a lytic lesion in the capitate. Magnetic resonance imaging scanning revealed a well-defined, lobulated, multiseptate lytic lesion involving the entire capitate, extending into its subarticular regions. Fine-needle aspiration revealed findings suggestive of a GCT. He underwent en-bloc excision of the capitate, bone grafting of the defect using an appropriately sized bicortical iliac crest autograft, and third carpometacarpal and midcarpal fusion. Histopathological examination of the lesion confirmed the presence of a GCT, with a secondary ABC. At 3 years following surgery, he was asymptomatic with no signs of tumor recurrence, radiocarpal arthritis, or instability. He was able to perform 45 and 60 degrees of wrist extension and flexion, respectively. Literature Review To our knowledge, there are no prior reported cases of GCT of the capitate with a secondary ABC. Clinical Relevance GCTs of the hand in general have a high rate of recurrence. The presence of a super-added ABC could further increase this risk. In the authors' opinion, en-bloc excision of the affected bone, reconstruction of the defect, and appropriate fusion is the optimal mode of management of these cases.

Clinical, magnetic resonance imaging, histopathological features, treatment options and outcome of spinal ependymoma in dogs: 8 cases (2011-2022).

This study aims to report on the clinical magnetic resonance imaging, histological features, treatment options and outcomes of spinal ependymomas in dogs. Retrospective evaluation of medical records from dogs histologically confirmed spinal ependymomas with clinical presentations, magnetic resonance imaging findings, histological aspects, treatment options and outcomes. Eight dogs presented with acute to subacute onset of para- or tetraparesis. Magnetic resonance imaging findings included intramedullary oval-shaped space-occupying lesions that appeared hyperintense on T2-weighted images isointense on T1-weighted images and exhibited marked homogeneous or ring contrast enhancement. A peculiar feature, previously described only in human ependymomas, was observed in three patients - a T2-weighted hypointense rim, termed hemosiderin cap sign. Haematomyelia with necrotic foci was observed in one dog. Surgery, when performed, enabling a definitive intra-vitam diagnosis. Histological examination revealed that rosettes and pseudo-rosettes as disposition of neoplastic cells were the most common features reported. Furthermore, cerebrospinal fluid metastases were identified in one case. Clinical and histopathological findings in our case series were consistent with those previously reported in the literature. Magnetic resonance imaging features were fairly typical and highly suggestive of spinal ependymomas. The hemosiderin cap sign may aid in the presumptive intra-vitam diagnosis of these rare spinal tumours. Additionally, we described cerebrospinal fluid spread of neoplastic cells and subsequent multifocal or metastasis presentations. Surgery offered a dual benefit by facilitating intra-vitam diagnosis and, in some cases, extending survival time.

Demographics and Clinical Assessment of Familial Multiple Sclerosis Patients in Ain Shams University Hospitals

Abstract Background Multiple sclerosis (MS) is the most seen demyelinating disease. The exact cause of MS is still uncertain; many genes significantly increase the disease susceptibility along with several well-defined environmental factors. Genetic factors play an important role in the pathogenesis and clinical presentations of MS. Aim of the Work This study aims to detect the prevalence of familial multiple sclerosis among Egyptian patients suffering from MS at Ain Shams University hospitals, to register the demographics and the clinical characteristics of familial multiple sclerosis patients and to demonstrate the effect of inheritance on the severity and progression. Patients and Methods This study aimed to detect the prevalence of familial multiple sclerosis among Egyptian patients suffering from MS at Ain Shams University hospitals, to register the demographics and the clinical characteristics of familial multiple sclerosis patients and to demonstrate the effect of inheritance on the severity and progression. The current study showed that the prevalence of familial multiple sclerosis among MS Egyptian at Ain Shams University hospitals was 6,4%. Female to male percentages were found to be (73.8%) to (26.2%) respectively. Results The mean age of onset among the FMS cases was found to be (26.1±7.8). The mean time elapsed between symptoms onset and diagnosis was found to be (19.9±34.0) months and it was found that time from disease onset to MS diagnosis is significantly shorter in the 2nd and 3rd family-members diagnosed in familial cases compared to 1st family member diagnosed with MS. Regarding focality of presentation at the first attack, in this study there was found that monofocal presentation was more common than multifocal presentation (64.4%). The current study also showed that affection of the pyramidal functional system is significantly the most frequent in cases with an affected relative of first degree while it was least frequent in cases with an affected relative of third-degree consanguinity. Sensory affection in the first attack was the most common functional system affected. Most of the familial MS cases showed relapsing remitting pattern of the disease (76.6%) that was followed by SPMS (20.9%) and the least frequent form was PPMS (2.3%) with no significant relation between the degree of consanguinity between the relatives affected within the same family and the pattern of progression of the disease. Conclusion The number of exacerbations per year in the studied cases was 0.9±0.8 and the mean MSSS of the studied cases was (4.9±2.5) and there were significant agreement between type in cases and relatives indicating that the presence of a family member diagnosed with a certain MS clinical phenotype can be a predictor to the clinical phenotype in the patient calling for special consideration to the choice of treatment for the patient.

Multifocal linear morphea - a rare presentation with rapid progression and deformities in a young adult: a case report

Morphea or localized scleroderma, is an uncommon skin disorder characterized by skin thickening and hardening. This case report describes a late 20s married woman working at a spinning mill, who presented with a unique and rare manifestation of morphea. Over two years, she developed a linear black color thickening of the skin on her right upper limb, left lower limb, and abdomen, accompanied by deformities and functional impairments. The patient reported a rapid progression of hyperpigmented lesions and weakness, prompting medical consultation. Cutaneous examination revealed distinctive hyperpigmented, atrophic plaques with xerotic changes and flexion deformities. A biopsy from the chest confirmed localized scleroderma. Basic investigations were within normal limits. The patient was managed with weekly pulse therapy involving corticosteroids, resulting in some relaxation of skin tightness. This case highlights the importance of recognizing and promptly treating rare multifocal morphea presentations to prevent severe deformities and enhance the patient's quality of life. Long-term follow-up is essential to monitor treatment outcomes and disease progression.

Long-term outcomes of ADEM-like and tumefactive presentations of CNS demyelination: a case-comparison analysis

A minority of initial multiple sclerosis (MS) presentations clinically or radiologically resemble other central nervous system (CNS) pathologies, acute disseminated encephalomyelitis (ADEM) or tumefactive demyelination (atypical demyelination presentations). With the aim of better defining the long-term outcomes of this group we have performed a retrospective cohort comparison of atypical demyelination versus ‘typical’ MS presentations. Twenty-seven cases with atypical presentations (both first and subsequent demyelinating events) were identified and compared with typical MS cases. Disease features analysed included relapse rates, disability severity, whole brain and lesion volumes, lesion number and distribution. Atypical cases represented 3.9% of all MS cases. There was considerable overlap in the magnetic resonance imaging (MRI) features of ADEM-like and tumefactive demyelination cases. ADEM-like cases tended to be younger but not significantly so. Atypical cases showed a trend towards higher peak expanded disability severity score (EDSS) score at the time of their atypical presentation. Motor, cranial nerve, cerebellar, cerebral and multifocal presentations were all more common in atypical cases, and less likely to present with optic neuritis. Cerebrospinal fluid (CSF) white cell counts were higher in atypical cases (p = 0.002). One atypical case was associated with peripheral blood myelin oligodendrocyte glycoprotein (MOG) antibodies, but subsequent clinical and radiological course was in keeping with MS. There was no difference in long-term clinical outcomes including annualised relapse rates (ARR), brain volume, lesion numbers or lesion distributions. Atypical demyelination cases were more likely to receive high potency disease modifying therapy early in the course of their illness. Despite the severity of initial illness, our cohort analysis suggests that atypical demyelination presentations do not confer a higher risk of long-term adverse outcomes.

Different profiles of acute graft pyelonephritis among kidney recipients from standard or elderly donors.

Acute graft pyelonephritis (AGPN) is a relatively common complication in kidney transplants (KTs); however, the effects on allograft function, diagnostic criteria, and risk factors are not well established. Retrospective analysis of all consecutive adult KTs was performed between 01 January 2011 and 31 December 2018 (follow-up ended on 31 December 2019) to examine the association between the diagnosis of AGPN (confirmed with magnetic resonance imaging [MRI]) during the first post-transplantation year and graft outcomes. Among the 939 consecutive KTs (≈50% with donors ≥60 years), we identified 130 MRI-confirmed AGPN episodes, with a documented association with recurrent and multidrug-resistant bacterial urinary tract infections (UTIs) (p < 0.005). Ureteral stenosis was the only risk factor associated with AGPN (OR 2.9 [95% CI, 1.6 to 5.2]). KTs with AGPN had a decreased allograft function at the first year (ΔeGFR 6 mL/min/1.73 m2 [-2-15] in non-AGPN vs. -0.2 [-6.5-8.5] in AGPN, p < 0.001), with similar and negative profiles in KTs from standard or elderly donors. However, only KTs with AGPN and a donor <60 years showed reduced death-censored graft survival (p = 0.015); most of this subgroup received anti-thymocyte globulin (ATG) induction (40.4% vs. 17.7%), and their MRI presented either a multifocal AGPN pattern (73.9% vs. 56.7%) or abscedation (28.3% vs. 11.7%). No difference was noted in death-censored graft survival between early (<3 months post-KT) or late (3-12 months) AGPN, solitary/recurrent forms, or types of multidrug-resistant pathogens. Linear regression confirmed the independent role of multifocal pattern, abscedation, ATG induction, and donor age on the eGFR at the first year. AGPN, influenced by multifocal presentation, ATG induction, donor age, and abscedation, affects kidney function and significantly impacts allograft survival in KTs with donors <60 years.

Clinicopathologic and molecular correlates to neoadjuvant chemotherapy-induced pathologic response in breast angiosarcoma.

Both primary and secondary breast angiosarcoma (AS) are characterized by multifocal presentation and aggressive behavior. Despite multimodality therapy, local and distant relapse rates remain high. Therefore, neoadjuvant chemotherapy (NACT) is employed to improve the R0 resection rates and survival, but its benefits remain controversial. Herein, we investigate pathologic and molecular correlates to NACT-induced histologic response in a group of 29 breast AS, 4 primary and 25 radiation-associated (RA). The two NACT regimens applied were anthracycline- and non-anthracycline-based. The pathologic response grade was defined as: I: ≤ 50%, II: 51%-90%, III: 91%-99%, and IV: 100%. An additional 45 primary AS and 102 RA-AS treated by surgery alone were included for survival comparison. The genomic landscape was analyzed in a subset of cases and compared to a cohort of AS without NACT on a paired tumor-normal targeted DNA NGS platform. All patients were females, with a median age of 31 years in primary AS and 68 years in RA-AS. All surgical margins were negative in NACT group. The NACT response was evenly divided between poor (Grades I-II; n = 15) and good responders (Grades III-IV; n = 14). Mitotic count >10/mm2 was the only factor inversely associated with pathologic response. By targeted NGS, all 10 post-NACT RA-AS demonstrated MYC amplification, while both primary AS harbored KDR mutations. TMB or other genomic alterations did not correlate with pathologic response. All four patients with Grade IV response remained free of disease. The good responders had a significantly better disease-specific survival (p = 0.04). There was no survival difference with NACT status or the NACT regimens applied. However, NACT patients with MYC-amplified tumors showed better disease-free survival (p = 0.04) compared to MYC-amplified patients without NACT. The overall survival of NACT group correlated with size >10 cm (p = 0.02), pathologic response (p = 0.04), and multifocality (p = 0.01) by univariate, while only size >10 cm (p = 0.03) remained significant by multivariate analysis.

Multiple solitary plasmocytoma with multifocal medullary asymptomatic presentation for diabetic patient (Case Report)

Multiple solitary plasmocytoma with multiple bone involvement, it’s very rare cases, in the literature, special skull vault associated with other medullary involvement, In our case is the first case report for multiple skull vault, with multiple focal medullary, asymptomatic for diabetic patient, also highlighted the accurate diagnostic of plasmocytoma and management.

Interest of rare autoantibodies in autoimmune encephalitis and paraneoplastic neurological syndromes: the utility (or futility) of rare antibody discovery.

The increasing recognition and diagnosis of autoimmune encephalitis (AE) and paraneoplastic neurological syndromes (PNS) is partly due to neural autoantibody testing and discovery. The past two decades witnessed an exponential growth in the number of identified neural antibodies. This review aims to summarize recent rare antibody discoveries in the context of central nervous system (CNS) autoimmunity and evaluate the ongoing debate about their utility. In the last 5 years alone 15 novel neural autoantibody specificities were identified. These include rare neural antibody biomarkers of autoimmune encephalitis, cerebellar ataxia or other movement disorders, including multifocal presentations. Although the clinical applications of these rare antibody discoveries may be limited by the low number of positive cases, they still provide important diagnostic, prognostic, and therapeutic insights.

Multifocal presentation of cutaneous tuberculosis in a HIV positive patient.

Multifocal presentation of cutaneous tuberculosis in a HIV positive patient.

Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review

BackgroundMultiple sclerosis (MS) is a rare but serious condition associated with significant morbidity. ObjectiveThis review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence. DiscussionMS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity. ConclusionsAn understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.

The Clinical Complexity of Langherans Cell Histiocytosis in Adult Patients: Experience of the Institute of Hematology of Bologna

Langerhans cell histiocytosis (LCH) in adult patients is a rare disease with protean manifestations, including single system unifocal (SSU) or multifocal (SSM) presentation or multisystemic (MS) involvement. Clinical care of adult patients is based on case series and reports. Regimens applied in pediatric patients show unacceptable toxicity in the adult setting. Our single-center experience with LCH is presented. Data on 30 patients diagnosed between 1997 and 2022 have been reviewed. Patients with isolated pulmonary histiocytosis were excluded. Responses to any treatment were classified according to the acknowledged criteria. Progression-free survival (PFS) after frontline treatment was calculated on all treated patients. Overall survival (OS) was determined on the whole cohort irrespective of any treatment received. Eighteen male and 12 female patients received a diagnosis of LCH at a median age of 46 years (range 20-75). Sixteen patients had single system (SS) disease, with SSU involvement in 12 cases and SSM involvement in 4 cases. The skeleton was the mostly involved system (Figure), while SSU extra-skeletal disease was detected in 25% of cases. Fourteen patients had MS disease: axial skeleton, lungs, hypophysis, skull, skin and appendicular skeleton were the predominantly involved sites, in this order. Ten patients with SS disease received chemotherapy because of symptoms (mostly bone pain) or due to multifocal dissemination. Two patients underwent radiotherapy (RT), 2 had their disease completely excised and 1 received systemic steroids. One patient was observed. A complete response (CR) was obtained in 60% of treated cases, while a partial response (PR) in 27%. Four patients relapsed after frontline therapy and were rescued with RT or autologous transplant. Among patients with MS disease, chemotherapy (MACOP/VNCOP-B, cladribine, vinblastine) was applied in 6 cases; 2 patients received RT and 1 systemic steroids. One patient underwent surgery and 4 were observed because of asymptomatic disease. A CR was obtained in 70% of treated patients and a PR in 10%. Five patients relapsed, with symptomatic disease requiring treatment (chemotherapy and RT) in 3 cases. Median PFS among all treated patients was 177 months. OS was 91% at 20 years. Appropriate treatment based on disease extension, site involvement and clinical manifestations yields high remission rates and long term PFS and OS. The optimal approach to relapsed patients remains undefined.

Successful Treatment of Unilateral Hailey-Hailey Disease

Hailey-Hailey Disease is a notoriously difficult to treat genodermatosis. While several treatment modalities are available, successful treatment of recalcitrant disease is not well documented. Superficial radiotherapy, a treatment typically reserved for skin cancer, has recently been utilized to treat Hailey-Hailey disease. In this case report we present the successful treatment of Hailey-Hailey disease in a patient with an unusual unilateral multifocal presentation. Based on the results of this case report, we believe SRT has strong potential to become the standard of care for recalcitrant HHD. Though there are risks to this treatment, the overall risks are minor compared to the decades of antibiotics, recurring infections, long term scarring and loss of self-esteem that arise from chronic recalcitrant HHD.

Granulomatosis with polyangiitis: The wily masquerader of cavitary pulmonary lesions

Background: Granulomatosis with Polyangiitis (GPA) is a small and medium vessel vasculitis with predominant respiratory and renal involvement that causes florid presentation of the disease entity with varying spectrum of illness at different time intervals. Case: We report the case of a 42-years-old female patient with symptoms of low-grade fever, productive cough and significant loss of weight with multiple cavitary lesions on Chest radiograph. The patient was initially suspected to have tuberculosis which was eventually ruled out. A diagnosis of vasculitis was suspected as patient gave history of repeated hospitalisations with symptoms of upper respiratory tract involvement, left facial nerve palsy and sensorineural hearing loss, A diagnosis of limited GPA was made when the cytoplasmic Antineutrophil Cytoplasmic Antibodies, (c-ANCA) and antiproteinase-3 antibodies (anti-PR3) was elevated. The patient was treated with combination immunosuppressive therapy of prednisolone and methotrexate which induced clinical remission within one month and complete radiological remission within 4 months. Conclusion: GPA is an important non infective cause of cavitary pulmonary lesions that presents with extrapulmonary clinical spectrum (recurrent sinusitis, ear infections, renal dysfunction and neurological disease). Multifocal presentation of the disease at different time intervals results in considerable delay in diagnosis and adds to the morbidity of the disease entity.

Fusion transcriptome profiling defines the monoclonal origin of multifocal epithelioid haemangioma of bone.

Epithelioid haemangioma (EH) of bone remains a highly controversial entity. Indeed, the WHO classifies EHs of soft tissues as benign tumours, whereas bone EHs are considered intermediate-locally aggressive tumours due to common multifocal presentation and local destructive growth. To gain insights into theclinical behaviour and biology of EH of bone we retrospectively analysed 42 patients treated in a single institution from 1978 to 2021. Multifocal presentation was detected in 17 of 42 patients (40%) primarily as synchronous lesions. Patients were treated with curettage (57%), resection (29%) or biopsy, followed by radiotherapy or embolisation (14%). Follow-up (minimum 24 months) was available for 38 patients, with only five local recurrences (13%) and no death of disease. To clarify whether the synchronous bone lesions in multifocal EH represent multicentric disease or clonal dissemination, four cases were profiled by RNA-sequencing. Separate lesions from the same patient, which showed a similar transcriptional profile, expressed the same fusion transcript (involving FOS or FOSB) with identical gene breakpoints. These results indicate that, in EH of bone, multifocal lesions are clonally related and therefore represent the spread of a same neoplastic clone rather than simultaneous independent tumours. This finding is in apparent contradiction with the benign clinical course of the disease, and suggests that tumour dissemination in bone EH probably reflects a phenomenon of passive spreading, with tumour cells colonising distal sites while maintaining their benign biological nature.

Presentation, treatment, and outcomes of unifocal and multifocal osseous vertebral Langerhans cell histiocytosis lesions in patients under 18 years old.

This study aims to (1) clinically and radiographically characterize a series of unifocal (single-system single-site) and multifocal (single-system multiple-site) langerhans cell histiocytosis (LCH) lesions in the vertebra and (2) determine the success and recurrence rates with different treatment modalities in a pediatric population at a tertiary children's hospital. Patients younger than 18 years old with a diagnosis of LCH before 1 June 2021 at our institution were reviewed. The inclusion criteria were a unifocal or multifocal vertebral lesion without systemic disease. Clinical presentations, lesion sites, radiographic findings, treatments, complications, recurrence rates, and length of follow-up were reviewed and recorded. Thirty-nine patients had unifocal (36%) or multifocal (64%) vertebral lesions. 44% of patients had vertebral lesions only. The most common clinical presentation was neck or back pain (51%) and difficulty or inability to ambulate (15%). 70 vertebrae were involved in total; 59% cervical, 62% thoracic, 49% lumbar, and 10% sacral. 88% of multifocal patients underwent chemotherapy compared to 60% of unifocal patients. The recurrence rate in the entire cohort was 10%. The median length of follow-up was 5.2 years (0.6-16.8). Chemotherapy is often utilized as a treatment for vertebral LCH lesions regardless of unifocal or multifocal osseous presentation, with good outcomes and low recurrence rates. However other treatments such as observation only and steroid injections may be a better option with smaller and less widespread lesions due to side effects and length of treatment with chemotherapy. Determination of more invasive treatments including surgical excision or fixation will need to be considered on a case-by-case basis. Level of evidence: IV.

Villar’s Nodule with Multifocal Endometriosis: Case Report

Umbilical endometriosis which was first described by Villar in 1886 is a rare clinical entity with a frequency of only 0.5-1%. The overall prevalence rate of endometriosis among women in their reproductive age is put at 5-10%. This is a descriptive presentation of a Villar’s nodule with concurrent multifocal presentations paradoxically affecting the pelvic structures and the peritoneal wall in a patient with no prior history of a diagnosis or treatment for endometriosis. It is worth considering of the diagnosis in any given patient with nodules, cysts, bleeding and pelvic and/or abdominal pain in order to overcome the delayed and/or under diagnosis of the entity. To the best of our knowledge, this is the first ever reported enigmatic case from Ethiopia. It is intended to highlight aspects of issues pertaining to endometriosis and amplify its importance for academicians and practicing physicians in Ethiopia as an increasingly interesting phenomenon; and finally, to contribute to the world literature from our geographic location.

A Suspicious Skin Lesion: Sufferings of A Remittance Warrior

Tuberculosis verrucosa cutis (TVC) is a rare form of cutaneous tuberculosis. it is usually found as a solitary lesion but Extensive multifocal presentation is very rare. Here, we report this case of extensive, multifocal tuberculosis verrucosa cutis in a 36-year-old immunocompetent male patient in the absence of any primary tubercular focus. J MEDICINE 2023; 24: 67-68