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A woman in her mid-30s presented to our 30-bed healthcare centre with extensive burns, hours after falling into a shallow pit of burning dried tea leaves. On arrival, there was no evidence of airway compromise. She was fully conscious but had signs of shock and hypovolemia. Forty-five per cent of the total body surface area was burned, including the face, neck, thorax, abdomen, upper limbs and thighs. The family refused referral to a burns centre and insisted on continuing treatment at our facility. Our hospital, not equipped to manage burns, was adapted to deliver effective, immediate care. After initial stabilisation, the patient was unwilling to remain hospitalised because of her husband's employment commitment. Subsequently, we were notified that the patient died within 1 month of discharge. This article highlights the importance of burns care facilities in rural India and the impact of a failure to access quality health on outcomes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A man in his mid-40s presented to the colorectal surgery clinic with complaints of chronic perianal pain for over 20 years. He had episodes of urinary incontinence associated with pain. There were no other symptoms to suspect bowel pathology. On examination, he was found to have a tender mass in the retro-rectal plane without any evidence of rectal mucosal irregularity. He underwent an MRI of the pelvis, which showed a well-defined T2 hyperintense partly cystic lesion in the presacral region abutting the mesorectal fascia and a normal prostate gland. With a suspicion of a tailgut cyst or a duplication cyst, he underwent an excision of the presacral mass. Intraoperatively, there was a 2 × 2 cm well-defined firm, cystic lesion anterior to the fifth sacral vertebra and coccyx. The lesion was adherent to the mesorectum and was excised. On histopathology, there were features of muscular stroma and bilayered glandular epithelium with clear cytoplasm conclusive of a benign ectopic prostate., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We describe a 68-year-old postmenopausal woman who presented with a history of rapidly enlarging lumps in both breasts. Though the breast lumps appeared suspicious on ultrasonography, the core biopsy was reported to be benign. In view of the clinical and radiological suspicion of malignancy, she underwent a diagnostic excision of both the lumps, the histopathology was consistent with mammary hibernoma. To the best of the authors' knowledge, this is the first report of a bilateral mammary hibernoma in an elderly postmenopausal woman. Given the clinical presentation, it is important to differentiate mammary hibernoma from carcinoma breast, which is a more common condition in this age group. However, preoperative diagnosis is challenging in view of the lack of definitive radiological and histological features. Although benign, hibernoma may have a propensity for local recurrence and, therefore, complete surgical excision remains the mainstay of treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Adenocarcinoma of the bowel is a dreadful sequelae of inflammatory bowel disease that can be difficult to diagnose and has been shown to have poor prognosis. The diagnosis is often made on histopathological examination of the resected specimen for what is suspected to be an exacerbation of the underlying intestinal Crohn's. A 39-year-old woman who was being treated for small bowel Crohn's disease for 4 years presented with features of intermittent intestinal obstruction that was refractory to medical therapy. A contrast CT of the abdomen was suggestive of ileocaecal Crohn's disease, and colonoscopy revealed a stricture at proximal transverse colon with multiple superficial ulcers. She underwent a mesentery sparing right hemicolectomy and had an uneventful recovery. The biopsy, however, was reported to be moderately differentiated adenocarcinoma stage T3N0 with a harvest of four pericolic nodes. Adjuvant chemotherapy was advised, which she deferred. Ten months later, she presented to the emergency room with features of intestinal obstruction. Contrast CT of the abdomen showed thickening at the anastomotic site with intestinal obstruction. On exploratory laparotomy, tumour recurrence was noted at the site of the anastomosis and diffuse peritoneal metastasis. A palliative diversion ileostomy was done due to inoperable obstructing disease. She was then given palliative therapy and subsequently succumbed to the illness. The inclusion of mesentery with the resected specimen in Crohn's disease has been a debate over many years. Since the preoperative diagnosis of carcinoma of the bowel in Crohn's disease is challenging, all ileocolic resections should be radical as done in oncological resections. This would yield better oncological safety and may improve survival rates., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 67-year-old man with diabetes and hypertension presented with complaints of abdominal pain and lower back ache for 7 months, with intermittent episodes of fever. On examination, there was an expansile mass in the upper abdomen with bruit on auscultation. He also had tenderness in the L1-L2 vertebral space with paraspinal fullness, causing painful restriction of lower limb motor functions but without affecting sensation. On evaluation, he was found to have an abdominal aortic aneurysm with infective lumbar spondylodiscitis. The aspirate from the paravertebral infected tissue and cultures from blood grew Pseudomonas aeruginosa , a rare causative agent of mycotic aortic aneurysm. Whether the infective spondylitis spread to the abdominal aorta causing the mycotic aneurysm or vice versa is a dilemma in such a case. However, the mainstay of treatment remains adequate source control and repair of the aneurysm with appropriate antibiotic therapy. Our patient received intravenous antibiotics for P . aeruginosa based on sensitivity, following which he underwent debridement of the infective spondylodiscitis with aneurysmorrhaphy. He had an uneventful recovery and was well at 3-month follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 26-year-old man who was previously well presented to the emergency in septic shock. He had a preceding history of fever, right upper abdominal pain and jaundice. On examination, there was tenderness over the right hypochondrium and epigastrium, without features of generalised peritonitis. His blood tests were suggestive of sepsis with deranged liver function tests. CT scan of the abdomen showed multiples abscesses in various segments of the liver and a thrombus in the inferior venacava, without any other intraabdominal focus of infection. The abscess was aspirated under sonographic guidance, and the cultures grew Streptococcus constellatus species of S. milleri group (SMG). He received crystalline penicillin, based on culture sensitivity and underwent drainage of the abscess. There was a clinical improvement and he was subsequently discharged in a stable condition. On 3 months follow-up, there was a complete resolution of the liver abscess and normalisation of the liver function tests., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)