Word count: 1102
Table and figures count:  2 figures
Funding Sources:  None
Conflict-of-interest:  None
Acknowledgement : none.
Data Availability:  the data used to support the findings of this study are included within the article. I Joe Khodeir have full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis
Patient consent statement: written informed consent was taken from each patient to publish their data and figures.
Author contribution statement: Joe khodeir: Data curation, Writing- Original draft preparation, conceptualization, Methodology. Houssein Chebbo: methodology, draft preparation Paul Ohanian: methodology, draft preparation. Sarah Saleh, Karam Karam , Emanuel-Youssef Dib: case presentation, data collection. Elias Fiani: Supervision.