Ectopic pregnancy (EP) is a commonly seen, potentially life-threatening condition that can be challenging to diagnose in the emergency department (ED) setting. A retroperitoneal EP is an extremely rare condition, with a limited number of reported cases. Because of this, many emergency medicine physicians may not be familiar with presenting symptoms of a retroperitoneal EP. Rupture of an EP is a life-threatening complication that must be diagnosed quickly to reduce the risk of mortality. We present a 27-year-old female who presented with a two-day history of progressive right lower quadrant abdominal pain, nausea, and vomiting. ED evaluation revealed tachycardia of 140 beats per minute, and laboratory assessment was positive for leukocytosis of 27,030 k/uL and a positive qualitative human chorionic gonadotropin. The initial concern was for appendicitis versus ruptured ectopic pregnancy. Point-of-care ultrasound was negative for both intrauterine pregnancy and intraperitoneal fluid. However, there were heterogeneous contents within the pelvis of unclear etiology. Obstetrics was consulted, admitted the patient, and obtained a formal abdominal ultrasound to evaluate her appendix. The radiologist reported a 12 cm pelvic mass for which the differential diagnosis included a uterine fibroid, ectopic pregnancy, or appendicitis. The patient was taken to the operating room for a diagnostic laparoscopy and laparotomy and was diagnosed with a ruptured retroperitoneal EP. She underwent evacuation of the retroperitoneal hematoma and right salpingo-oophorectomy. She was discharged home on postoperative day four.

Isolated fallopian tube torsion (IFTT) is a rare cause of acute abdominal pain in adolescents. Its preoperative diagnosis is often challenging because imaging findings are usually nonspecific. Here we report the case of a 16-year-old girl with IFTT that closely mimicked a functional ovarian cyst. The patient, who had no history of abdominal surgery or pelvic infection, presented with persistent left lower quadrant pain. Initial computed tomography and ultrasonography showed a 30-mm simple cyst without signs of a twisted vascular pedicle, and a functional ovarian cyst was suspected. Her pain persisted, and on day 5 repeat ultrasonography again demonstrated the same simple cyst as at the initial visit, but the left ovary was clearly visualized separately, raising suspicion of a tubal origin. Diagnostic laparoscopy was performed, revealing a 1080° counterclockwise torsion of the left fallopian tube with necrosis, while the ovary appeared normal. As detorsion failed to restore color, a left salpingectomy was performed. Histopathology confirmed torsion secondary to hydrosalpinx. The postoperative course was uneventful, and the patient has remained symptom-free for one year. This case demonstrates that IFTT can occur even in adolescents without risk factors. Identifying a normal ovary on ultrasonography is crucial for suspecting IFTT, and early diagnostic laparoscopy is essential for confirming the diagnosis and preserving future fertility.

Torsion of the vermiform appendix is rare. When torsion involves an appendiceal mucocele, timely surgical management, and avoidance of rupture are essential to prevent intraperitoneal mucin spillage. A 68-year-old woman presented with 12 h history of severe lower abdominal pain. Examination revealed marked lower abdomen rebound tenderness and her laboratory tests showed leukocytosis and elevated C-reactive protein. Urgent computed tomography demonstrated a 9 × 3.4 cm predominantly cystic mass posterior to the uterus with mural calcifications, consistent with an appendiceal mucocele. Emergency laparotomy revealed a necrotic appendiceal mucocele with complete torsion. The lesion was resected intact. Histopathology confirmed an appendiceal mucocele. The patient had an uncomplicated recovery and remains in excellent condition 3 months postoperatively. Appendiceal mucocele torsion should be considered in acute abdomen with a cystic pelvic mass on computed tomography. Intact resection is a key operative principle.

Paraduodenal hernias are rare congenital internal hernias, with right-sided cases being particularly uncommon and often difficult to diagnose due to nonspecific symptoms. We report a 21-year-old male with a 1-year history of recurrent abdominal pain and vomiting, previously managed conservatively. Physical examination and laboratory findings were unremarkable. Computed tomography demonstrated clustered small bowel loops in the right hemiabdomen with displacement of the superior mesenteric vessels, suggestive of an internal hernia. Laparoscopy confirmed a right paraduodenal hernia caused by a congenital mesenteric defect, which was successfully repaired laparoscopically, with prophylactic appendectomy performed. The patient had an uneventful recovery. This case highlights the importance of considering internal hernias in young patients with recurrent, unexplained abdominal symptoms and the role of early imaging and surgical intervention in preventing complications.

Septic pelvic thrombophlebitis (SPT) is a rare postpartum complication that can be life-threatening if not promptly diagnosed and treated. We present the case of a 34-year-old woman who presented to the emergency department (ED) seven weeks postpartum with abdominal pain, nausea, vomiting, and diarrhea. Imaging revealed SPT with right ovarian vein thrombosis and concurrent acute pyelonephritis. The patient was found to be in septic shock requiring intensive care, broad-spectrum antibiotics, vasopressor support (norepinephrine) following 4.5 L of intravenous fluid resuscitation, and intravenous heparin. Initial workup was significant for urinalysis concerning infection and imaging showing a subtle filling defect with enlargement of the right ovarian vein with surrounding inflammatory changes. Despite negative blood cultures, she remained febrile following antibiotic change, prompting escalation to meropenem and daptomycin. Anticoagulation was initially started with therapeutic intravenous heparin, discontinued when the thrombus was considered potentially incidental, and later resumed as therapeutic enoxaparin at discharge for three months due to persistent thrombus burden and ongoing postpartum risk factors. This case highlights the diagnostic and therapeutic challenges of SPT, particularly when it presents alongside other infections such as pyelonephritis. In the absence of definitive guidelines, management decisions, including the use and duration of anticoagulation, must be individualized based on clinical status and thrombotic burden. Our case underscores the diagnostic overlap between pyelonephritis and SPT and the clinical challenges in determining when to initiate anticoagulation.

Adnexal torsion is a gynecological emergency resulting from the partial or complete rotation of the ovary, often involving the fallopian tube, around its vascular pedicle. Prompt diagnosis is crucial to prevent ischemic injury and preserve ovarian function. Mature cystic ovarian teratomas are common benign neoplasms and represent a frequent cause of torsion due to their size, mobility and mass effect. The present case report describes the case of a 36-year-old woman (gravida 2, para 2) who presented several hours following the sudden onset of right lower abdominal pain, initially accompanied by nausea, both of which had resolved by the time of evaluation. A transvaginal ultrasonography revealed a right ovarian mass measuring 6.13x5.20 cm, containing two mature cystic teratomas. Gray-scale and color Doppler imaging clearly demonstrated the characteristic whirlpool sign, indicating torsion of the adnexal vascular pedicle. An emergency laparoscopy revealed the quadruple torsion of the adnexa (fallopian tube and ovary), and a right salpingo-oophorectomy was performed, as the patient had completed her family. The post-operative course of the patient was uneventful. A post-operative pathological examination confirmed the torsion of mature ovarian teratomas with associated hemorrhagic necrosis. On the whole, the present study demonstrates that the ultrasonographic whirlpool sign is a highly specific pre-operative marker for adnexal torsion, particularly in cases with multiple mature cystic teratomas. Early recognition facilitates prompt surgical intervention, minimizes ischemic injury, and may preserve ovarian function. Incorporating the focused assessment of the whirlpool sign into routine ultrasonography for acute pelvic pain enhances diagnostic accuracy and guides timely operative management.

Musculoskeletal complaints of the shoulder/pelvic girdle are symptoms frequently described in patient care and are attributed to degenerative changes associated with increasing patient age. Polymyalgia rheumatica(PMR) is the second most common differential diagnosis of an inflammatory genesis after rheumatoid arthritis and should be ruled out. Patients diagnosed with PMR exhibit symptoms such as acute weakness, pain, morning stiffness in the neck, shoulders and pelvis. The manifestation of B-symptoms is possible. The clinical examination should encompass differential diagnoses and complications, such as giant cell arteritis. Laboratory testing shows elevated levels of inflammatory markers in almost all cases. Arthrosonography reveals tenosynovitis of the biceps tendon, bursitis or joint effusion of the hip. The initial treatment for PMR is the administration of steroids. In cases of disease activity, methotrexate, sarilumab or rituximab may be considered as potential treatment options.

Burkitt lymphoma is a highly aggressive B-cell malignancy characterized by rapid proliferation and a narrow therapeutic window in which early recognition of disease progression is critical to prevent morbidity. While diagnosis is typically established through histopathology and imaging, evolving physiologic and radiographic changes may provide early indicators of aggressive disease behavior, particularly in the post treatment setting. We present a 26-year-old male patient with previously treated Epstein-Barr virus-positive Burkitt lymphoma who presented with acute lower back pain, urinary symptoms, and rapid clinical deterioration consistent with disease progression. Laboratory evaluation demonstrated normocytic anemia, markedly elevated lactate dehydrogenase, progressive leukocytosis, and hypoalbuminemia, consistent with a high tumor burden. Cross-sectional imaging revealed interval enlargement of a necrotic pelvic mass with associated hydronephrosis, while MRI demonstrated diffuse marrow infiltration. Fluorodeoxyglucose-Positron emission tomography/Computed tomography (FDG PET/CT) showed extensive hypermetabolic disease involving nodal and extranodal sites, consistent with systemic progression. Peripheral blood flow cytometry failed to identify a clonal B-cell population, a finding consistent with known limitations of circulating markers in Burkitt lymphoma, particularly following recent chemotherapy. This case highlights a physiologic pattern of oncologic emergency, defined by integrated laboratory abnormalities, imaging progression, and clinical decline as indicators of disease progression. Recognition of these features may facilitate timely therapeutic escalation despite inconclusive peripheral findings.

BackgroundPercutaneous iliosacral screw fixation has become the gold standard for surgical stabilization of acute pelvic ring disruptions with unstable posterior pelvic injuries. Wound infection is uncommon owing to shorter operative time, reduced soft-tissue damage, less blood loss, and lower infection rates. Delayed sacroiliac joint infection after robot-assisted percutaneous iliosacral screw fixation is even rarer.Case presentation: We report a case of delayed sacroiliac joint infection after robot-assisted percutaneous iliosacral screw fixation for a tile type C2 pelvic fracture. A 43-years-old man developed recurrent low back pain and intermittent low-grade fever that occurred 10 months postoperatively and lasted 2 months. Symptoms temporarily improved with anti-inflammatory treatment but subsequently worsened, accompanied with chills and high fever (body temperature up to 39.0°C). Computed tomography revealed bone erosion and screw loosening, and inflammatory markers were elevated. The patient underwent open debridement and removal of the screws, followed by implantation of vancomycin- and gentamicin-loaded calcium sulfate beads. Cultures were negative; however, frozen section and pathology confirmed acute and chronic inflammatory infiltrations. The patient responded well to antibiotics and achieved full recovery.ConclusionsDelayed sacroiliac joint infection after robot-assisted percutaneous iliosacral screw fixation is a rare complication. Diagnosis can be challenging owing to the presence of atypical symptoms and negative cultures. Open debridement with removal of fixation and targeted antibiotic therapy can result in successful outcomes.