Necrotic Fat Research Articles

Chitin Extracted from the Shell of Blue Swimming Crabs (Portunus pelagicus Linn.) Inhibits NF-kappaB p65 in Ethanol-Induced Gastric Ulcerative Wistar Rats.

Peptic ulcer disease is generated by the activation of NF-kappaB activity. A recent clinical study reported a significant increase in NF-kappaB2 gene expression in 79 samples of peptic ulcer patients compared to the control group. Moreover, the deacetylated chitin could alter the translocation of NF-kappaB p65 to the nucleus. Considering this, our work aims to explore the effect of chitin extracted from the shell of blue swimming crabs (Portunus pelagicus Linn.) towards NF-kappaB p65 levels in ethanol-induced gastric ulcerative Wistar rats. The shells are found abundantly as the waste of seafood processing in the northern part of West Java, Indonesia. In this study, chitin extraction was carried out using the microwave-assisted extraction method by employing choline chloride (C5H14ClNO) and DL-malic acid (C₄H₆O₅) as the solvents. The inhibitory activity assay of chitin on the expression of NF-kappaB p65 was performed by using Western blot. The extraction yielded a good quality of chitin with a deacetylation degree of 30.8026%, molecular weight of 3.35 × 105 Da, and a negligible heavy metals level. Moreover, chitin extract at doses of 150, 300, and 600 mg/kg BW significantly reduced the percentage of gastric ulcer index compared to the negative control group. Meanwhile, chitin extract at doses of 300 and 600 mg/kg BW significantly inhibited NF-kappaB expression compared to the negative control group. Histopathological examination demonstrated a decrease in the number of necrotic cells and fat degeneration in the gastric mucosa and an increase in normal cells. Taken together, chitin extract obtained from the shells of blue swimming crabs may be able to prevent gastric ulcers induced by ethanol via the inhibition of NF-kappaB p65; however, further studies are needed to verify its anti-ulcerative properties.

A Postmortem Case Study-An Analysis of microRNA Patterns in a Korean Native Male Calf (Bos taurus coreanae) That Died of Fat Necrosis.

Korean native cattle are highly valued for their rich marbling and flavor. Nonetheless, endeavors to enhance marbling levels can result in obesity, a prevalent contributor to fat necrosis. Fat necrosis is characterized by the formation of necrotic fat masses in the abdominal cavity, which physically puts pressure on affected organs, causing physical torsion or obstruction, resulting in death and consequent economic loss. Pancreatic injuries or diabetes mellitus were reported as factors of fat necrosis in humans; however, the pathogenesis in animals has not been established. In this study, we identified fat necrosis in a 6-month-old Korean native cow and investigated its potential underlying causes. Serum samples were utilized for a microarray analysis of bovine miRNA. Comparative examination of miRNA expression levels between cattle afflicted with fat necrosis and healthy cattle unveiled notable variances in 24 miRNAs, such as bta-miR-26a, bta-miR-29a, bta-miR-30a-5p and bta-miR-181a. Upon conducting miRNA-mediated KEGG pathway analysis, several pathways including the prolactin signal pathway, insulin resistance, autophagy, the insulin-signaling pathway and the FoxO-signaling pathway were found to be significantly enriched in the calf affected by fat necrosis. As a result, this study potentially indicates a potential connection between fat necrosis and diabetes in Korean native cattle.

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

A RARE CASE OF MOREL LAVELLEE LESION

Introduction: Morel-Lavallée lesions are post-traumatic, closed degloving injuries occurring deep to subcutaneous plane due to disruption of capillaries resulting in an effusion containing hemo-lymph and necrotic fat. It is an uncommon condition that results from a shearing force, causing a gloving injury which may get infected and lead to a life-threatening situation. Case Presentation: A 28 year old female patient presented to the emergency department with a history to Road trafc accident and sustained minor lacerations to the left lower limb and a contusion over the lateral aspect of the left thigh. The patient was found to have MLL upon ultrasound over the contused area, which was then incised and drained. The wound healed well over 3 weeks and split skin grafting was done which was successfully taken up. MLL's are rare forms of closed degloving Discussion: injuries which may be missed upon initial examination and mis-diagnosed as a contusion. If not treated promptly, it may lead to infection of the collected blood and overwhelming sepsis. It is important for clinicians to be Conclusion: aware of Morel Lavellee lesions as the diagnosis is more reliable on clinical examination and prompt diagnosis may prevent life-threatening complications in trauma patients

Significance of Magnetic Resonance Imaging Combining with Detection of Serum HE4, TSGF, and CD105 Levels in Diagnosis and Treatment of Moderate to Advanced Cervical Cancer.

To explore the significance of magnetic resonance imaging (MRI) combining with detection of serum HE4, TSGF, and CD105 levels in diagnosis and treatment of moderate to advanced cervical cancer. By means of retrospective study, 50 patients diagnosed with moderate to advanced cervical cancer by cervix biopsy pathology examination in our hospital from October 2018 to October 2019 were selected as the study group, and another 50 healthy individuals who did not have cervical cancer after routine gynecological examination and conventional ultrasound examination in the same period were selected as the control group. At the time of enrollment and 3 months after treatment, all study subjects received MRI examination and serological examination, and their HE4 and TSGF levels were measured by the enzyme-linked immunosorbent assay (ELISA) and chromatography method, respectively, and additionally, the immunohistochemistry SP method was adopted for patients in the study group to measure the microvessel density (MVD) marked by CD105. The relationship between MRI staging and FIGO staging was assessed, the efficacy of combining MRI with detection of serum HE4, TSGF, and CD105 levels in diagnosing moderate to advanced cervical cancer was calculated by plotting the ROC curve, and the imaging changes and serological changes of tumor tissue before and after treatment were analyzed. There were 3 of 4 patients in stage IIa and 14 of 15 patients in stage IIIb presenting MRI findings compatible with clinical examinations; 26 patients in stage IIb and 5 patients in stage IVb presenting MRI findings totally compatible with clinical examination. Before treatment, MRI finding of cervical lesion was irregular soft tissue mass, T1WI appeared isointensity or hyperintensity, and obvious lesion enhancement could be seen by enhanced scan. T2WI appeared mixed signal intensity or hyperintensity, with necrotic tissue and fat suppression being hyperintensity. After treatment, lesions shrunk, originally abnormal signals in 5 patients disappeared, and T1WI and T2WI signals in 45 patients presented no difference compared to before treatment. After T1WI enhancement, mild enhancement could be seen in 41 cases and no enhancement in 4 cases. The CD105-MVD of the study group was (68.98 ± 5.23); before and after treatment, the differences in HE4 and TSGF levels between the study group and the control group were significant (P < 0.001). The sensitivity, specificity, and accuracy rate of diagnosis of MRI diagnosis were respectively 82.0% (41/50), 90.0% (45/50), and 86.0% (86/100), and for the diagnosis combining with serum HE4, TSGF, and CD105 levels, they were 96.0% (48/50), 96.0% (48/50), and 96.0% (96/100), respectively, and AUC (95% CI) = 0.960 (0.908-1.000). MRI staging is objective and accurate and has higher sensitivity when combined with serum HE4, TSGF, and CD105 levels in diagnosing moderate to advanced cervical cancer. All MRI, HE4, and TSGF can reflect the treatment effect of patients and are of great importance to efficacy assessment.

326. Radiologic Findings of COVID-19 Associated Mucormycosis (CAM) from India

BackgroundThe unique feature of the second wave of the COVID -19 pandemic in India has been the alarming surge of acute invasive fungal infection among COVID -19 patients. The increased incidence of rhino-orbito-cerebral mucormycosis is a matter of concern, as this fulminant infection has high morbidity and mortality. Hence, it is imperative to understand it’s imaging features, for early diagnosis, staging and treatment.MethodsWe systematically reviewed 32 COVID-19 cases with imaging diagnosis of acute invasive fungal rhino-sinusitis or rhino-orbital-cerebral disease between March to May 2021. These patients underwent contrast MRI of the paranasal sinus, orbit and brain. Contrast enhanced CT chest and paranasal sinuses were done as needed.ResultsThe age group ranged between 30 to 71 yrs with male preponderance. The most common predisposing factors were intravenous steroid therapy and supplemental oxygen. All cases were confirmed by fungal culture and most common was Mucor. The rhino-orbito-cerebral mucormycosis was staged as belowStageNo. of cases1 (Limited to nasal cavity)22 (Involving Paranasal sinuses) 143 (Involvement of orbit)84 (Involvement of CNS)8In our study we found that the most common site in the nasal cavity was the middle turbinate /meatus and the earliest sign was non-enhancing / “black” turbinate. Premaxillary and retroantral fat necrosis was the earliest sign of soft tissue invasion. Spread via the sphenopalatine foramen and pterygopalatine fossa was more common than bony erosions. Orbital cellulitis and optic neuritis were the most common among stage 3 cases. Of patients with CNS involvement, the most common were cavernous sinus thrombosis and trigeminal neuritis. Two patients with pulmonary mucormycosis showed large necrotic cavitary lesions, giving the characteristic “bird’s nest” appearance.Figure 1. Black turbinate Contrast enhanced coronal T1 FS images of paranasal sinuses shows necrotic non-enhancing right superior and middle turbinates (*)Figure 2: Axial contrast enhanced T1 FS image showing necrotic non enhancing premaxillary (arrowhead) and retroantral fat (straight arrow) walled off by thin enhancing rim. Figure 3: Contrast enhanced axial T1 FS images of paranasal sinuses shows necrotic non-enhancing left middle meatus spreading along sphenopalatine foramen in to pterygopalatine fossa (arrow head) ConclusionThe mortality rate was 20% in our study. In our short term follow up, 30 % of recovered patients had relapse on imaging due to incomplete clearance and partial antifungal treatment. High clinical suspicion and low imaging threshold are vital for early Mucormycosis detection in COVID-19 patients. Familiarity with early imaging signs is critical to prevent associated morbidity /mortality.Figure 4: Contrast enhanced coronal T1 FS and diffusion weighted images shows necrotic non-enhancing left middle meatus with left orbital cellulitis (*) and optic neuritis (white arrow) Figure 5. Bird’s nest Axial CT chest image in lung window shows necrotic right upper lobe cavity with internal septations and debris on a background of surrounding COVID-19 changes.Disclosures All Authors: No reported disclosures

P161 EMERGENCY LAPAROSCOPIC REPAIR OF A PARASTOMAL HERNIA

Abstract Aim The aim of this video is to present the laparoscopic approach to an incarcerated parastomal hernia, using the modified Sugarbaker technique. Material and Methods A 50-year-old man with a definitive terminal colostomy after undergoing an abdominoperineal resection due to a rectal cancer, consulted in the emergency room with abdominal pain and an incarcerated mass below the colostomy, without evidence of intestinal obstruction. A CT scan was performed, with the finding of infarcted epiploic appendages inside the parastomal hernia. After evaluation of the case, emergency surgery was decided, opting for a laparoscopic approach to the parastomal hernia, employing the modified Sugarbaker technique. Results Following the dissection of the hernial sac and resection of the necrotic fat content, a partial closure of the hernial orifice was done. A hernioplasty was performed using a composite synthetic mesh, that was fixated with helical sutures. After surgery, the patient evolved favorably and was discharged 72 hours after the procedure. In the one year of follow-up, the patient was asymptomatic and there were no data of recurrence either on the clinical examination or the control CT scan. Conclusions The laparoscopic approach to an incarcerated parastomal hernia is possible and safe when performed in well-selected cases by the hands of experienced surgeons, offering good short and long-term results.

S1881 Colonic Intussusception From a Necrotic Giant Lipoma

Introduction: Lipomas are the most common benign subepithelial lesions (SEL) of the colon. They usually originate in the submucosa, however, could rarely be found within muscularis propria or subserosa. Although usually asymptomatic, lipomas can become symptomatic depending on their size and/or location. Herein we present a case of colonic intussusception secondary to a necrotic giant lipoma. Case description/methods: Patient is a 58 year old woman with past medical history of uncontrolled hypertension resulting in two cerebrovascular accidents without residual deficits (currently on clopidogrel) and uncontrolled insulin dependent diabetes type 2 with nephropathy resulting in stage 5 chronic kidney disease leading to iron deficiency anemia (IDA) who presented to ambulatory surgery unit for colonoscopy for further evaluation of IDA. Colonoscopy revealed a 5 cm nearly obstructing ulcerated and necrotic SEL in distal transverse colon. Procedure was complicated by transient desaturation and patient underwent post-procedural computerized tomography (CT) scan to rule aspiration pneumonia as patient was found to have a pieces of ginseng root within the oral cavity. CT scan revealed a 4.8 cm predominantly fatty mass-like lesion at splenic flexure with edematous fat and mild circumferential thickening of wall of proximal descending colon possibly suggesting colocolic intussusception without evidence of bowel obstruction. The patient was admitted to surgical service and taken to the operating room for laparoscopic left hemicolectomy. Pathology revealed a partially necrotic submucosal lipoma with acute inflammation, fat necrosis, ulceration and granulation tissue. Discussion: Colonic lipoma leading to intussusception is a rare complication of otherwise benign SEL. They are typically asymptomatic but can present with obstruction, bleeding, intussusception, and/or abdominal pain. CT scan is the preferred imaging modality for diagnosing aforementioned complications. The differential diagnosis for incidental lesions identified on imaging includes malignancy, large pedunculated polyps or liposarcomas. Management for symptomatic colonic lipomas can be either endoscopic or surgical. Size, location and presenting symptoms are the determining factors for deciding on type of management. Endoscopic ligation (“Loop-And-Let-Go”) technique was contemplated, however, due to finding of intussusception and the fact that patient had to resume clopidogrel, a decision was made to proceed with surgical resection.Figure 1.: A. Image from CT scan revealing a mass in the colon B. Imaging from colonoscopy depicting large lesion nearly obstructing with intussusception C. Microscopic Appearance: Necrotic mucosa and fat globules with foamy macrophages consistent with necrotic lipoma.

Huge scalp Morel-Lavall\xe9e lesion with eye involvement in a 3-year-old girl: a case report

BackgroundMorel-Lavallée lesions are posttraumatic, closed degloving injuries in which the skin and subcutaneous tissue are separated abruptly from superficial underlying fascia. This condition leads to an effusion containing hemolymph and necrotic fat. Magnetic resonance imaging, when available, is the modality of choice in the evaluation of Morel-Lavallée lesion. Early diagnosis and management is essential as any delay in diagnosis or missed lesion will lead to the effusion becoming infected or leading to extensive skin necrosis. We present a condition of a Morel-Lavallée lesion involving the scalp and complicated by conjunctival chemosis.Case presentationWe report on a 3-year-old black African girl who presented a fluctuant swelling of entire scalp, extending to upper part of the face on the seventh day after a forehead trauma due to falling on a rock while playing. Skull x-ray revealed soft-tissue swelling, giving an impression of large fluid collection in the deep subcutaneous tissues with no bone fracture. A diagnosis of Morel-Lavallée lesion of the scalp complicated by conjunctival chemosis was made. The patient was managed with percutaneous drainage and compression bandage. The patient improved well and was subsequently discharged without any vision impairment. There was no recurrence of the lesion on follow-up.ConclusionsThe Morel-Lavallée lesion of the scalp complicated with conjunctival chemosis is a rare presentation of this condition. Prompt diagnosis and management are crucial for preventing complications. Image-guided diagnosis and treatment still remain a challenge in the setting of low-resource health facilities.

The potential of standard technologies for radiological diagnosis of posttraumatic breast abnormalities

Rationale: A standard algorithm for the assessment of patients with breast trauma does not exist, as such trauma usually does not incur any significant health problems. However, according to existing clinical and work-up data and various radiological signs, posttraumatic abnormalities of the breast can mimic cancer lesions and complicate the differential diagnosis for a radiologist.Aim: To evaluate the potential of digital mammography and breast ultrasound examination in the identification of breast posttraumatic abnormalities and to describe their semiotics.Materials and methods: The study included 150 female patients aged 40 to 86 years (mean±SD, 60±11.9 years) with a history of breast trauma. Digital mammography with tomosynthesis (combined mode) and multiparametric ultrasound were able to identify breast abnormalities in 62 patients. The results of all assessments (n=62) were interpreted according to BI-RADS. Should any confirmation of the abnormalities be necessary, fine needle aspiration biopsy or core-biopsy with stereotaxic or ultrasound control were performed.Results: At mammography, the typical posttraumatic abnormality in the breast was fat necrosis (n=54). It was represented as nodular masses with round (20/34; 58.8%) or oval shape (13/34; 38.2%) and circumscribed margins. In most cases, the masses contained eggshell calcification (27/34; 79.4%). In 35.1% (19/54) of the cases fat necrosis was represented by various calcifications. At ultrasound, fat necrosis could be identified as avascular (40/40; 100%), mostly round (26/40; 65.0%), less frequently oval (12/40; 30.0%), and hypoechoic (19/40; 47.5%) masses with circumscribed margins. Atypical signs of fat necrosis (BIRADS 4) were found in 16.1% (10/62) of the cases, in which 7 (11.2%) core-biopsies with ultrasound control and 3 (4.8%) stereotaxic biopsies were performed. In all the cases, breast fat necrosis was confirmed, with various ratios of fibrous and necrotic fat tissue and lymphoid infiltration.Conclusion: In most cases, standard radiological methods used in the diagnostic algorithm for posttraumatic breast lesions are sufficient for the diagnosis. In uncertain diagnostic cases, morphological verification seems necessary.

The Addition of Partial or Circumferential Liposuction to Abdominoplasty Is Not Associated With a Higher Risk of Skin Necrosis

Combining abdominoplasty with liposuction is a common practice for optimal patient aesthetic outcomes. In the past, several practitioners have argued against liposuction due to the potential for vascular insufficiency, especially with central liposuction. Despite these concerns for flap damage with resultant necrosis, the incidence of this complication has not been comprehensively investigated. The authors therefore examined the incidence of necrotic complications, including skin and fat necrosis as well as partial/total flap loss, in patients who underwent abdominoplasty alone (AA) or abdominoplasty with partial or circumferential liposuction (APCL). Literature searches were performed in PubMed/Medline and Embase with no query limits. For the systematic review, data from the studies were extracted into a form including primary author, publication year, study design, number of AA and APCL patients, abdominal zone(s) treated with liposuction, average lipoaspirate volume, follow-up time, necrotic complications, and revision procedures. A meta-analysis was separately performed for 13 studies that included patients who underwent both AA and APCL. The overall rate of necrotic complications was lower in the APCL group (0.39%) compared with the AA group (1.01%). The incidence of necrotic complications was low for all patients, with a pooled partial flap loss rate of 0.24% and a pooled skin necrosis rate of 0.23%. The forest plots revealed that patients who underwent APCL do not face a higher risk of skin necrosis or revision compared with those who underwent AA. Performing APCL is a safe combined procedural approach and can confer added benefits of improved patient satisfaction and aesthetic outcomes.

MON-697 Necrotising Fasciitis- Importance of Glycemic Control

Introduction:Necrotising fasciitis is an infection of the deep soft tissues characterised by fulminant tissue destruction, systemic toxicity and high mortality. We report a case where accurate diagnosis, timely surgical intervention and antibiotic therapy along with strict glycemic control resulted in a favourable outcome.Case:A 74 year old woman with a history of type 2 diabetes mellitus, hypertension and end stage renal disease(ESRD) on peritoneal dialysis(PD) presented to the emergency department with the complaint of pain in the right lower quadrant of abdomen, right pelvis and right groin since 4 days which acutely worsened overnight. Of note the patient has Peritoneal catheter for dialysis and was last dialysed last night without any difficulty. Other associated symptoms were chills, nausea. The patient denied fever, skin changes in the affected area.On physical examination, the patient was awake, alert and oriented, in moderate distress. Abdomen was soft, non distended, PD catheter was in place with no surrounding skin erythema or tenderness. Genitourinary examination showed swelling of Mons Pubis with overlying erythema on the right side with extension to the right labia majora, exquisitely tender to palpation, no crepitus, no pustules, no palpable abscesses or visible wounds.Initial labs showed elevated WBC count(36.4K/UL; n<10.5K/UL) and Blood glucose of 361mg/dl(n 70-100mg/dl). CT scan of the abdomen and pelvis showed right anterior pelvic wall subcutaneous infiltration extending inferiorly into the mons pubis and right labial regions suspicious for cellulitis with no abscess. Broad spectrum intravenous antibiotics Meropenem, Vancomycin and Fluconazole were started and patient was taken to the operative room for debridement and approximately 25 cm long and 15 cm wide and 8 cm large abscess originating in the right labia extending up into her right groin was found along with necrotic skin, subcutaneous tissue and fat which was sharply excised. Peritoneal dialysis catheter site looked non infected and was left in place and fluid cultures were sent. Patient was switched to Hemodialysis while awaiting PD catheter fluid cultures. Hospital course was complicated by multiple debridements, severe septic shock requiring upto 4 pressors and intubation. She was started on insulin drip for glycemic control as the blood sugars were constantly ranging 300mg/dl(n 70-100mg/dl). HbA1C was 10.9% (n 5.7-6.4%). After 10days she was extubated and off pressors and was stable to be transferred to subacute rehab facility for diligent wound care for the next few weeks before she could go home.Conclusion:In patients with uncontrolled diabetes mellitus who present with critical illness like necrotising fasciitis, strict glycemic control with insulin drip yield favourable outcomes.

736 Autologous Skin Cell Suspension in Combination with Meshed Autograft: A Case Report Demonstrating the Efficacy in NSTI

Abstract Introduction Necrotizing soft tissue infections (NSTIs) are some of the more difficult disease processes encountered by physicians. Most patients require multiple surgical debridements, and survivors often have complex wounds requiring soft tissue coverage and prolonged hospitalizations. The goal of this report is to describe the use of autologous skin cell suspension over widely meshed skin graft in a patient with large wound secondary to a NSTI. Methods A retrospective chart review was performed of a patient with NSTI of the abdomen.The patient received autologous skin cell suspension as an epidermal graft in combination with widely meshed skin grafting. Results A 41 year-old female had an abdominal wound infection resulting in a NSTI. The patients had poorly controlled diabetes, congestive heart failure, and coronary heart disease with a drug eluting stent on dual antiplatelet therapy. She presented septic to an outside facility where she underwent multiple abdominal wound debridements. She was transferred to our institution with concerns for ongoing infection. Upon arrival, the wounds appeared stable with granulation tissue present over the wound bed with small areas of necrotic fat. She underwent debridement and autologous skin cell suspension in combination with a widely (3:1) meshed skin graft. The donor site also received treatment with the cell suspension. The wounds were covered with a non-adherent dressing along with bismuth-impregnated, petroleum-based gauze. Additional padding was secured with sutures to prevent post-operative shearing. On post-operative day (POD) 2 the outer dressings were changed with excellent adherence of the graft. On POD 4 her dressings were taken down completely, staples were removed, and she was transitioned to daily topical antimicrobial ointment and a non-adherent dress to her torso. She had &amp;gt;95% closure on POD 7 on both her graft and donor site. Conclusions Similar to severe burn injuries, the magnitude and scope of NSTI necessitates radical debridement often creating challenges in wound care, preservation of function, and cosmesis. Autologous skin cell suspension in combination with widely meshed skin grafts appear to be well-suited for treatment of large wounds resulting from NSTI. Treatment of this patient demonstrated decreased healing times, decreased donor sites, and an acceptable cosmetic outcome. Applicability of Research to Practice Autologous skin cell suspension has been approved for the use in partial and full thickness burn either as an epidermal graft alone or in combination with widely meshed grafts. This case report represents an example of its use in large complex wounds secondary to NSTI with acceptable outcomes.

A case review of a Morel Lavellee Lesion with Delayed Presentation

A Morel Lavellee lesion is a relatively rare post traumatic condition which is missed at the time of early presentation. It involves a closed internal degloving injury where the subcutaneous tissue is torn away from the underlying fascia and thus creating a cavity containing hematoma and necrotic fat. It occurs most commonly over the greater trochanter. The lesion can be treated conservatively and surgically. Here we report an unusually delayed presentation of a Morel Lavellee lesion that was treated by incisions, drainage and primary closure.

Twisted "appendix epiploica" as extraordinary cause of discomfort at the right lower abdomen and rare differential diagnosis of acute appendicitis - a representative case

Introduction Appendicitis can be considered the most frequent cause of discomfort at the right lower abdomen. Simultaneously, it is the most frequent indication for a surgical intervention. In addition, there is a broad spectrum of differential diagnoses, which can lead to a very challenging finding-specific management in good time as found out in the presented case. Case description A 44-year old female patient was transfered to the surgical department because of discomfort of the right lower abdomen with changing intensity which had persisted since the day before. Patient showed a reduced but stable clinical status (normosomic nutritional status; no relevant accompanying diseases). Previous oral nutrition was normal. Clinical examination revealed pain by palpation at the right lower abdomen. Laboratory parameters: White blood cell count, 8.2Gpt/L; CrP, 10.4mg/L; urine with no pathological finding; no increased serum β-HCG level. Transabdominal ultrasound as orienting initial imaging detected free fluid around the cecum and along the right iliac vessels (appendiceal diameter, approximately 6.5mm) – in summary, no sign of appendicitis with certainty. Because of a persisting symptomatology, indication for a surgical intervention was derived (intraoperatively, laparoscopic appendectomy and partial resection of the greater omentum). Postoperative course was uneventful (no general/specific complications, wound healing was properly, initiation of oral nutrition and mobilization were well tolerated). Pathohistological investigation revealed lipofibromatosis of the appendage of the cecum with attached necrotic fat tissue and hemostasis, which can be associated with the diagnosis of a twisted appendix epiploica (no hint for malignant tumor growth). Results and Conclusions The finding as presented occurs very rarely (approximately, 0.2%), which was initially misinterpreted as appendicitis with regard to symptomatology, ultrasound and laboratory findings. A definite diagnosis became only possible during the postoperative course by pathohistological investigation (suspicion already raised by intraoperative inspection aspects). Taking the final diagnosis into account, the question of a necessary indication for surgical intervention can be brought up, which can not be circumvented in case of unclear findings and medical history according to the surgical policy (“case of doubt“). However, as a consequence a more intense and extended diagnostic including a well developed clinical experience level as well as the clinical suspicion can be derived and concluded. This was an exciting and instructive case from a didactic point of view (relevant also for medical students) with rare occurrence in daily clinical practice, which includes the whole spectrum of differential diagnoses of i) unclear discomfort at the right lower abdomen in general and ii) acute appendicitis specifically.

Morel-Lavallée Lesion: A not so rare, but often missed diagnosis

The Morel-Lavallee lesion is a closed, post-traumatic, soft tissue degloving injury. There is separation of the skin and subcutaneous tissue from the underlying fascia resulting in an effusion and creation of a perifascial space often containing lymph and necrotic fat.

Morel-Lavallee Lesion: Case Report with Review of Literature

Morel-Lavallee lesions are closed degloving soft tissue injuries which occur because of trauma and in which the skin and subcutaneous tissue are separated from superficial fascia. This shear trauma results in creation of a potential space filled with serosanguinous fluid, blood and necrotic fat. We discuss a case of 52-year-old female with history of trauma one week back, who presented with a boggy swelling over the postero-lateral aspect of proximal forearm and distal arm. Local examination showed fluctuating fluid collection. MRI showed variable intensity fluid collection in a potential space between the subcutaneous tissue and deep fascia in arm and forearm. Percutaneous decompression and evacuation of the collection with systemic antibiotic therapy resulted in rapid improvement.

Intraosseous lipoma of the calcaneum

Calcaneal Intraosseous lipoma is a very rare lesion usually benign tumor, which constitutes not more than 2% of bone tumors. On plain radiographs, an intraosseous lipoma is usually seen as benign-appearing osteolytic bone lesion with well-defined margins and calcified/ossified dense matrix. Plain radiographs alone cannot establish the diagnosis of intraosseous lipoma as it imitates several other benign and malignant bone lesions. Intraosseous lipoma contains calcified necrotic fat with mature adipose tissue and characteristically induces expansion/remodeling of the affected bone.

Histopathological changes in the pancreas of cattle with abdominal fat necrosis.

The association between pancreatic disorder and abdominal fat necrosis in cattle remains unclear. The pancreases of 29 slaughtered cattle with or without fat necrosis were collected to investigate pathological changes. Japanese Black (JB) cattle were classified into the FN group (with abdominal fat necrosis; n=9) and N group (without fat necrosis; n=5). The pancreases were also collected from 15 Holstein Friesian (HF) cows. All JB cattle showed high body condition scores. Regarding the pathological findings, fatty pancreas which involves adipocyte infiltration into the pancreas and fat necrosis (saponification) were observed in 25 and 27 cases, respectively. Immunohistochemical staining with anti-Iba-1 antibody showed large numbers of macrophages surrounding the saponified fat in the pancreas. CD3-positive T cells were significantly more common in the pancreas of both the FN and N groups compared with the HF group (P<0.05). Furthermore, fibrosis in the pancreas exhibited a correlative tendency with the formation of necrotic fat mass in the peritoneal cavity (P<0.1). These results indicate that obesity leads to increased severity of pancreatic disorder, including fatty pancreas and pancreatitis. The pathological lesions in the pancreas may play a key role in abdominal fat necrosis through the inflammatory process.

Saksenaeae Subcutaneous Abscess in an Immunocompetent Child

Molds, in the order Mucorales, are found worldwide in soil and decaying vegetation. They lead typically to disseminated infection in immunocompromised patients. In contrast, members of the family Saksenaeaceae can cause skin and soft-tissue infections in healthy individuals.1 We report a rare case of a subcutaneous abscess because of Saksenaea vasiformis in a previously healthy 4-year-old boy without a history of recent injury. He presented initially with calf cellulitis, which despite intravenous flucloxacillin, evolved into a subcutaneous abscess requiring multiple incision and drainage procedures (see Fig., Supplemental Digital Content 1, http://links.lww.com/INF/C291). He remained systemically well with a normal full blood count, C-reactive protein was 11 mg/L and erythrocyte sedimentation rate of 11 mm/h. Operative findings revealed caseous material and histology showed necrotic fat, suppurative inflammation and numerous pauciseptate hyphae with right-angled branching and angioinvasion (see Figs., Supplemental Digital Content 2 and 3, http://links.lww.com/INF/C292 and http://links.lww.com/INF/C293).