A 36-year-old male patient came to the emergency department with high fever, cough, and sore throat consistent with an acute viral illness. His medical history was significant for medically controlled arterial hypertension. A chest radiograph showed no abnormalities (Figure 1). The patient was treated with antibiotics and antihistamines for presumed acute viral upper respiratory tract infection. He returned to the emergency department 12 hours later with pain in the left lower part of the chest that started after a recent bout of coughing. On examination, there was mild tenderness over the left lower area of the chest. No bruises were noted. Bilateral rhonchi were heard on auscultation. The patient was prescribed acetaminophen with codeine for musculoskeletal pain.He returned again 24 hours later in respiratory distress. A chest radiograph suggested that the stomach had herniated through the left hemidiaphragm. The study was repeated with oral contrast medium revealing herniation of 50% of the stomach into the left side of the chest. No pleural effusion was seen (Figure 2).A diagnosis of spontaneous rupture of the diaphragm (SRD) was made and the patient underwent emergency laparotomy. The operative findings included a 10-cm defect of the diaphragm extending from the posterior axillary line to the tendinous center right next to the pericardium. The stomach, spleen, and hepatic flexure of the colon were found in the thorax. The hernia was reduced and no alteration of the blood supply of the involved organs was noted. The edges of the diaphragmatic rupture looked macroscopically normal. Biopsy of the diaphragm was submitted for histopathologic review. The pleural cavity was drained and the defect repaired with figure-of-eight permanent sutures. The abdominal incision was closed primarily.

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A 69-year-old male patient underwent excision of hidradenitis suppurativa (HS) affecting both gluteal areas and the perineum. The perineal specimen contained a 1-cm superficially invasive, well-differentiated keratinizing squamous cell carcinoma. The patient was free of recurrence 1 year after surgery. A 66-year-old male patient was diagnosed with massive perineal HS more than 40 years previously. More than 30 abscesses and suppurative sinus tracts were surgically treated over the years. He eventually died of unresectable pelvic squamous carcinoma. Search of the literature and available bibliography revealed 47 retrospective studies of skin carcinoma arising in HS since 1959, including a total of 64 patients together with the two patients treated by our team. Squamous cell carcinoma is a rare but potentially fatal complication of HS. Surgery is the only known treatment method that provides a real chance for cure for both HS and a carcinoma that complicates it. HS must be treated early with complete excision to avoid chronic progression of the disease that can cause cancerous degeneration. A high index of suspicion, early tissue diagnosis, and immediate referral for radical surgery carry the only hope for cure in those whose HS harbors malignancy.