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Nephrobronchial fistula is an extremely rare complications of renal infections. We present a case of nephrobronchial fistula in a middle age immunocompetent woman who complained cough and weight loss, with underlying asymptomatic nephrolithiasis. She underwent a chest X-ray that showed left lower lobe infiltrate and abdominal ultrasound. Abdominal ultrasound showed a complicated pyonephrosis ; CT of chest-abdomen-pelvis with intravenous contrast was performed in order to stage and define the extension of the pathology. At CT, a suspected diagnosis of stage III xanthogranulomatous pyelonephritis complicated with pyonephrosis and a nephrobronchial fistula was formulated. A nephrostomy tube was placed, and the patient was treated with antibiotics. Follow up CT, performed after 15 days, showed the healing of the fistulous connection between the perinephric abscess and bronchi; the patient underwent nephrectomy with no airway complication during intubation. Histopathological diagnosis confirmed the presence on complicated xanthogranulomatous pyelonephritis.

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

A Spigelian hernia is a rare hernia, making up approximately 0.1% of all abdominal wall hernias. This hernia goes through a defect in the Spigelian fascia which is the part of the transversus abdominis aponeurosis lateral to the rectus muscle, often at the level of the arcuate line, where the fascia is widest and weakest. Clinical diagnosis is difficult in patients without obvious abdominal mass but imaging can be a valuable adjunct in diagnosis. We report the case of a 64-year-old male who presented to our hospital with small bowel obstruction secondary to an incarcerated Spigelian hernia who was pre-operatively diagnosed with ultrasound and computed tomography. At ultrasound and computed tomography a closed loop obstruction in a Spigelian Hernia was detected, resembling on both imaging modalities a "bulb-like" appearance.

Primary aortic occlusion (PAO) is defined as acute occlusion in the absence of aortic atherosclerosis or aneurysm. PAO is a rare disease with acute onset and can determine massive parenchymal ischemia and distal arterial embolization. The aim of our study was to focus on the assessment of clinical characteristic, CT signs, medical and surgical treatment, complication rates and the overall survival of PAO. Materials and Methods: We retrospectively analyzed the data of all patients with acute lower limb ischemia and a final surgical or discharge diagnosis of PAO who underwent aortic CT angiography in ER settings in our hospital from January 2019 to November 2022. Results: A total of 11 patients (8 males/3 females; male/female ratio, 2.66:1, age range 49 to 79 years-old, mean age 65.27 y/o) with acute onset of lower limb impotence or ischemia were diagnosed with PAO. The etiology was thrombosis in all patients. The aortic occlusion was always located in the abdominal aorta and extended bilaterally through the common iliac arteries. The upper limit of the thrombosis was detected in the aortic subrenal tract in 81.8% of the cases, and in the infrarenal tract in 18.2%. A total of 81.8% of the patients were referred to the ER for symptoms related to lower limb: bilateral acute pain, hypothermia and sudden onset of functional impotence. Two patients (18.2%) died before undergoing surgery for multi-organ failure determined by the severe acute ischemia. The other patients (81.8%) underwent surgical treatment that included aortoiliac embolectomy (54.5%), aortoiliac embolectomy + aorto-femoral bypass (18.2%) and aortoiliac embolectomy and right lower limb amputation (9.1%). The overall mortality was 36.4% while the estimated survival at 1 year was 63.6%. Conclusions: PAO is a rare entity with high morbidity and mortality rates if not recognized and treated promptly. Acute onset of lower limb impotence is the most common clinical presentation of PAO. Aortic CT angiography is the first-choice imaging technique for the early diagnosis of this disease and for the surgical treatment, planning and assessment of any complications. Combined with surgical treatment, anticoagulation is considered the first-line medical therapy at the time of diagnosis, during surgical treatment and after at discharge.

Background: Malignant pleural mesothelioma is an aggressive form of cancer originating in the pleural mesothelioma. It generally appears as a local disease in the affected hemithorax, and metastasis are rare. It is unusual for malignant pleural mesothelioma to manifest with gastrointestinal complications due to metastatic implants, but clinicians should be careful to take into consideration this hypothesis in patients with a history of malignant pleural mesothelioma referring to the Emergency Department with acute abdominal pain. Case Presentation: A 65-year-old man, with a medical history of pleural mesothelioma, presented to our emergency department for acute abdominal pain. The patient underwent abdominal ultrasound and abdominal Computed Tomography with intravenous contrast. At US examination a small bowel obstruction diagnosis was made, CT confirmed a mechanical small bowel obstruction due to an intussuscepted multiloculated mass in the terminal ileum, with CT’s signs of parietal damage; another peritoneal mass was reported adjacent to the posterior wall of the cecum and in contiguity with the iliopsoas muscle. Considering the acute medical presentation, the patient underwent surgery, with segmental bowel resection and a stapled side-by-side bowel anastomosis. Histopathology revealed metastasis of sarcomatoid pleural mesothelioma. The post-operative course was complicated by anastomotic leak treated with a conservative approach. The patient was discharged on the 24th post-operative day. Conclusion: Our case highlights the potential of pleural mesothelioma to metastasize within abdominal viscera, causing bowel obstruction. In presence of the patient’s critical clinical condition and advanced state of local disease, a surgical approach based on damage control procedure consisting in exploration, biopsies and ileostomy upstream the obstruction or, exploration and resection without anastomosis, carry on several advantages, solving the acute clinical condition, staging the disease and offering the possibility to proceed rapidly with supportive care (chemotherapy and/or surgery).

A 75-years-old man presented at our ED with acute onset of paraplegia and severe bilateral lower limb hyposthenia. The patient ‘s neurological assessment was negative except for lower limbs positive Mingazzini test. CT angiography detected a complete lack of opacification of the abdominal aorta immediately below the emergency of the inferior mesenteric artery, caused by a coarse thrombus in the left ventricle. We present a case of acute aortic and lumbar arteries thrombosis with paraplegia and no clear symptoms of acute limb ischemia, in which the motor deficit in the lower extremities was explained by anterior spinal cord syndrome secondary to acute occlusion of lumbar arteries.

Globally, at the time of writing (20 March 2021), 121.759.109 confirmed COVID-19 cases have been reported to the WHO, including 2.690.731 deaths. Globally, on 18 March 2021, a total of 364.184.603 vaccine doses have been administered. In Italy, 3.306.711 confirmed COVID-19 cases with 103.855 deaths have been reported to WHO. In Italy, on 9 March 2021, a total of 6.634.450 vaccine doses have been administered. On 15 March 2021, Italian Medicines Agency (AIFA) decided to temporarily suspend the use of the AstraZeneca COVID-19 vaccine throughout the country as a precaution, pending the rulings of the European Medicines Agency (EMA). This decision was taken in line with similar measures adopted by other European countries due to the death of vaccinated people. On 18 March 2021, EMA’s safety committee concluded its preliminary review about thromboembolic events in people vaccinated with COVID-19 Vaccine AstraZeneca at its extraordinary meeting, confirming the benefits of the vaccine continue to outweigh the risk of side effects, however, the vaccine may be associated with very rare cases of blood clots associated with thrombocytopenia, i.e., low levels of blood platelets with or without bleeding, including rare cases of cerebral venous thrombosis (CVT). We report the case of a 54-year-old woman who developed disseminated intravascular coagulation (DIC) with multi-district thrombosis 12 days after the AstraZeneca COVID-19 vaccine administration. A brain computed tomography (CT) scan showed multiple subacute intra-axial hemorrhages in atypical locations, including the right frontal and the temporal lobes. A plain old balloon angioplasty (POBA) of the right coronary artery was performed, without stent implantation, with restoration of distal flow, but with persistence of extensive thrombosis of the vessel. A successive thorax angio-CT added the findings of multiple contrast filling defects with multi-vessel involvement: at the level of the left upper lobe segmental branches, of left interlobar artery, of the right middle lobe segmental branches and of the right interlobar artery. A brain magnetic resonance imaging (MRI) in the same day showed the presence of an acute basilar thrombosis associated with the superior sagittal sinus thrombosis. An abdomen angio-CT showed filling defects at the level of left portal branch and at the level of right suprahepatic vein. Bilaterally, it was adrenal hemorrhage and blood in the pelvis. An evaluation of coagulation factors did not show genetic alterations so as the nasopharyngeal swab ruled out a COVID-19 infection. The patient died after 5 days of hospitalization in intensive care.

Small bowel obstruction (SBO) is a common condition requiring urgent attention that may involve surgical treatment. Imaging is essential for the diagnosis and characterization of SBO because the clinical presentation and results of laboratory tests may be nonspecific. Ultrasound is an excellent initial imaging modality for assisting physicians in the rapid and accurate diagnosis of a variety of pathologies to expedite management. In the case of SBO diagnosis, ultrasound has an overall sensitivity of 92% (95% CI: 89–95%) and specificity of 93% (95% CI: 85–97%); the aim of this review is to examine the criteria for the diagnosis of SBO by ultrasound, which can be divided into diagnostic and staging criteria. The diagnostic criteria include the presence of dilated loops and abnormal peristalsis, while the staging criteria are represented by parietal and valvulae conniventes alterations and by the presence of free extraluminal fluid. Ultrasound has reasonably high accuracy compared to computed tomography (CT) scanning and may substantially decrease the time to diagnosis; moreover, ultrasound is also widely used in the monitoring and follow-up of patients undergoing conservative treatment, allowing the assessment of loop distension and the resumption of peristalsis.

Urinary tract infections (UTIs) are the most frequent community-acquired and healthcare-associated bacterial infections. UTIs are heterogeneous and range from rather benign, uncomplicated infections to complicated UTIs (cUTIs), pyelonephritis and severe urosepsis, depending mostly on the host response. Ultrasound and computed tomography represent the imaging processes of choice in the diagnosis and staging of the pathology in emergency settings. The aim of this study is to describe the common ultrasound (US) and computed tomography (CT) features of pyonephrosis. US can make the diagnosis, demonstrating echogenic debris, fluid/fluid levels, and air in the collecting system. Although the diagnosis appears to be easily made with US, CT is necessary in non-diagnostic US examinations to confirm the diagnosis, to demonstrate the cause and moreover to stage the pathology, defining extrarenal complications. In emergency settings, US and CT are differently used in the diagnosis and staging of pyonephrosis.

PURPOSE: Typhlitis, also known as neutropenic colitis, is a rare inflammatory condition and a potentially life-threatening disease process that typically involves the cecum. Delay in diagnosis may lead to a fatal prognosis with a death rate of 21–48%. Ultrasound evaluation of right lower quadrant may lead to an accurate and rapid diagnosis. METHODS: We describe the case of a 59-year-old female with advanced Churg–Strauss syndrome treated with cyclophosphamide, with acute right lower quadrant pain. RESULTS: Ultrasound was the first diagnostic step in the diagnosis of typhlitis. Sonographic findings were comparable to CT imaging. CONCLUSIONS: Bowel bedside ultrasound evaluation in emergency settings may lead to a prompt and definitive diagnosis. Although CT is considered the gold standard in the diagnosis and staging of neutropenic colitis, ultrasound was able to identify the pathology accurately. Ultrasound findings of typhlitis are highly characteristic, showing circumferential wall thickening with predominant submucosa.

The aim of this study was to compare the diagnostic efficacy of dynamic MR defecography (MR-D) with entero-colpo-cysto-defecography (ECCD) in the assessment of midline pelvic floor hernias (MPH) in female pelvic floor disorders.From August 2004 to August 2010, 3,006 female patients who required ECCD for the evaluation of pelvic floor disorders were enrolled in this study. All the 1,160 patients with ECCD findings of MPH were asked to undergo MR-D; 1,142 accepted to undergo MR-D and constituted the object of analysis. This study was approved by the Institutional Ethical Committee. All the patients gave their written informed consent to take part in the study.Overall, the prevalence of MPH at ECCD was higher if compared with that at MR-D. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on ECCD than on MR-D, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at ECCD was significantly higher than that at MR-D. In spite of a 100% specificity, the sensibility of MR-D in the detection of an omentocele, sigmoidocele, and enterocele was, respectively, 95%, 82%, and 65%, showing an inferior diagnostic capacity if compared with that of ECCD.MR-D shows lower sensitivity than ECCD in the detection of MPH development. The less-invasive MR-D may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

This is the first reported case of long remission of abdominal metastases spread through a ventriculo-peritoneal shunt in an infant diagnosed, four years ago, at age 1 year and 10 months, to have cerebral medulloblastoma. Two years later, while in second complete remission of his cerebral tumor, he showed abdominal metastases, successfully treated by platinum based chemotherapy and surgery. One year later, a second abdominal relapse and hepatic metastases were treated by doxorubicin administration and surgery. Since then the child remained in continuous complete remission. This unusual favorable outcome can be explained by an extreme responsiveness of the tumor, unprotected by the blood brain barrier, to systemic chemotherapy, particularly to doxorubicin administration. The need for careful surveillance of patients with ventriculo-peritoneal shunts is emphasized. Searching for new tools, such as entrapment of doxorubicin in liposomes, able to overcome the blood-brain barrier and to expose brain tumors to effective drugs, probably represents the best choice for future treatment strategies of CNS tumors.

CT is the most accurate method for guiding fine needle biopsies in deep and/or small sized lung and mediastinic lesions. The authors have performed 2109 CT-guided lung biopsies (FNAB). The results are given in terms of sensitivity, specificity and rate of complications. In every examination, Westcott or Chiba needles (22 or 21 gauge) were used. From 2109 lung examinations performed, 1413 (66.99%) were positive, 538 (25.5%) negative, 15 (0.7%) suspicious and 143 (6.78%) inadequate for diagnosis. 267 patients underwent surgical or clinical follow-up and, in all cases, the cytological diagnosis was confirmed. Other considerations were made on lesion topography, histological type, dimensions, complication rate, sensitivity, specificity and diagnostic accuracy. CT, of course, is the best method for guiding fine needle biopsy of the lung for its high spatial resolution and excellent anatomical definition, so that samples with smaller than 2 cm lesions, even in continuity with large vessels or other critical organs, are performed. Nevertheless, the result quality depends on the ability of the operator.