International Journal of Case Reports 2021-07-16T21:27:57+00:00 International Journal of Case Reports Open Journal Systems <p>ISSN:2572-8776<br>DOI:10.28933/IJCR</p> Acute cholecystitis with intraluminal gallbladder bleeding: Case report and literature review 2021-07-16T21:27:57+00:00 Jerica Novak, Aleksander Göntér, Jurij Janež <p>Background: Hemorrhagic cholecystitis is an infrequent complication of acute cholecystitis associated with high mortality rate. Recognition of this acute abdominal condition is often challenging. Authors present a case of acute intraluminal gallbladder bleeding with a consequential gallbladder wall perforation and hematoperitoneum requiring emergency surgery in a patient on anticoagulant therapy.</p> <p>Case Presentation: An 80-year old woman with atrial fibrillation on warfarin was presented to abdominal surgeon due to acute abdominal pain with hemodynamic instability and active intraluminal gallbladder bleeding on CT-scan. An emergency laparotomy with cholecystectomy was performed. Despite intensive treatment patient died on the third postoperative day.</p> <p>Conclusions: Hemorrhagic cholecystitis is a potentially life-threatening condition. Patients on anticoagulant therapy with clinical signs of acute cholecystitis are more prone to develop bleeding into the gallbladder. Contrast-enhanced CT of the abdomen is the diagnostic modality of choice and cholecystectomy definitive therapy in patients with hemorrhagic cholecystitis.</p> 2021-07-16T00:00:00+00:00 Copyright (c) 2021 PICC Insertion could be an optimal choice of central venous access in prone position mechanically ventilated COVID-19 ARDS patient 2021-07-05T16:10:56+00:00 Ali Al Bshabshe1, Ali Abdullah Kablan2, Nasser Mohammed Alwadai3, Omprakash Palanivel3, Ghaida Nawi A. Alharthi4, Khloud Faleh S. Alahmari4, Hala Khamis S. Alghamdi4, Raghad Abdullah M. Brkout 4, Lamees Abdullah M. Brkout 4, Lama Abdullah M. Brkout 4 <p>During the management of critically ill covid-19 patients obtaining an appropriate centrally inserted central catheter (CICC) can be a prime necessity. Traditionally, a CICC is inserted in a supine position. However, a CICC may not be possible in some COVID-19 patients with severe hypoxia or sudden clinical deterioration who need urgent intubation and immediate proning. Therefore, CICC in pronated COVID-19 ARDS patients is challenging. Recent studies limited to case reports have shown that peripherally inserted central catheters (PICC) are safer in pronated ARDS patients. PICC lines minimize mechanical complications and lower catheter-related bloodstream infections when compared to standard CICC. However, there is a scarcity of evidence showing the efficacy of PICC in pronated COVID-19 ARDS patients, possibly due to the complex precautionary safety measures, insertion techniques, and expertise team deficit. Herein, we present a 57-year-old male as a case of COVID-19 ARDS, mechanically ventilated in a prone position with existing subcutaneous emphysema. Our case illustrates PICC insertion challenges in the prone position, ultrasound guidance in PICC insertion to comprehend the vein’s diameter for accurate vein needling in proportion to the external catheter diameter, and intracavitary electrocardiographic (ECG) navigation method to confirm catheter tip location. So that chest X-ray and radiology risk of contamination is avoided. Long-term research urged to validate the efficacy of PICC in this group of patients.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Gastric schwannoma: a case report and review of literature 2021-07-05T02:36:06+00:00 Ahmad Abuamr1, Moamena Ahmed El-Matbouly1,2, Hussien Aly Touny1, Ahmed Zuhair AlBahrani 1, Ahmed Mohammed Suliman1,2 <p>Background: Schwannoma is a rare mesenchymal tumor, that arise from the Schwan cells of the nerve sheath. Schwannoma in the gastrointestinal tract is a very uncommon finding, with the stomach being the most common location. Preoperative diagnosis is difficult due to the wide variety of other mesenchymal tumors, definitive diagnosis is after histopathological examination and immunohistochemical staining of the specimen.</p> <p>Case presentation: We are presenting a rare case of stomach schwannoma, in a 50-year-old male who presented with urological complaints. He had a CT scan that incidentally showed a polypoidal gastric mass.</p> <p>Discussion: Schwannomas generally present asymptomatically; however, in some cases they can cause abdominal discomfort, pain or digestive symptoms. The definitive diagnosis of gastric schwannomas is determined by pathological examination of the surgically removed specimen.</p> <p>Conclusion: Schwannoma usually runs a benign course with excellent prognosis, yet there are very few reported cases of Malignant GI schwannoma. Benign or malignant, until now the treatment of choice is surgical excision with free margin.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Torsion of the gallbladder leading to gangrene: A case report and literature review 2021-07-05T02:34:29+00:00 Sabrina Bhattacharya MbChB1, Priyal Taribagil MbChB2, Sanjay Taribagil FRCS3 (Gen Surg) Vish Bhattacharya FRCS4 (Gen Surg) <p>Gallbladder torsion is a rare but potentially catastrophic presentation to an acute surgical unit. It was first described by Wendel in 1898 where this presentation was labelled as a ‘floating gallbladder’, with a high propensity for perforation1. Since then approximately 500 cases have been reported in the literature2.</p> <p>Anatomically, gallbladder torsion occurs where the gallbladder rotates along its mesentery causing vascular compromise and obstruction to biliary drainage. This leads to subsequent necrosis and perforation3. Shaikh A. et al have reiterated that the entire aetiological sequence of gallbladder torsion continues to remains a debated topic although, generally, a redundant mesentery is required for torsion to occur4. In most reported cases, the gallbladder has been shown to undergo a clockwise rotation 5. As described later, this presentation has predominantly been reported in elderly females suggesting that age plays a role in anatomically predisposing to torsion. Factors hypothesised for this include decrease in visceral fat and liver atrophy making free movement of the gallbladder and ultimately volvulus more likely to occur6.</p> <p>The symptoms of gallbladder torsion are in keeping with those of cholecystitis, typically presenting with right upper quadrant pain, nausea and vomiting 2. Clinical examinations of previously reported cases have documented abdominal distention, right upper quadrant pain and localised peritonitis2. These non-specific signs can make this specific phenomenon a challenge to diagnose in clinical practice. It has been documented that a partial volvulus can present with intermittent symptoms, similar to those seen in biliary colic, although the majority of cases will present acutely with signs described above 3.</p> <p>Due to the relatively low numbers reported in the literature it is difficult to determine the most appropriate investigations in patients where this is expected. Classically, patients presenting with right upper quadrant pain will likely receive an abdominal ultrasound on admission. From the cases reported we have found that a range of investigations have been implemented in practice including ultrasound and computed tomography (CT), although this diagnosis is often pragmatically difficult to diagnose based on imaging alone 3. Non-specific findings of gallbladder inflammation have been reported in cases of gallbladder torsion including gallbladder wall thickening and fluid collections surrounding the gallbladder neck 7. Other imaging modalities useful in pre-operative diagnosis include Magnetic Resonance Cholangiopancreatography (MRCP) which may show tapering and twisting of the cystic duct 3, 8. Interestingly, gallbladder calculi have not been considered a causative factor and where present in less than a third of patients carrying this diagnosis in a review performed by Reilly et al 5, 9.</p> <p>Other baseline investigations including white cell count, CRP and liver function tests have been shown to be relevant in diagnosing the acute abdomen. However, these are generally non-specific as a predictor for gallbladder volvulus.</p> <p>Reilly et al performed a systematic review of 324 cases shown in the literature between 1898 and 2011 9. From this the predominant risk factors associated with gallbladder volvulus include female sex, age over 60 years and patients with several comorbidities 9 Previous authors have suggested that female to male ratios in presentation are approximately 4:1, although the condition is more prevalent in males in children 10.</p> <p>Management of this condition is primarily surgical and the reports published show that these patients are mainly treated by cholecystectomy. In general, this is done laparoscopically in experienced hands where this presentation is identified 3, 4, 9. It has been suggested that the gallbladder should first be decompressed if distended to allow for a more straightforward removal 3. There has also been a case reported managed with ERCP although this is not the preferred method of managing this condition 11.</p> <p>Prognosis of this condition is dependent on several factors. The literature has demonstrated that those patients with a pre-operative diagnosis have more favourable outcomes 9. Reilley et al suggested from their review that overall mortality was approximately 6% 9.</p> <p>In this report we discuss the case of gallbladder torsion managed at a large district hospital in North East England.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Colo-renal fistula following percutaneous radiofrequency ablation of a renal tumor. A case report and review of treatment options 2021-07-05T02:33:02+00:00 Allan Stolarski, MD1,2, Joanna Wang, MD1,2, Katherine He, MD1,3, Lori Lerner, MD1,2, Gentian Kristo, MD1,3 <p>Background: Colo-renal fistula formation is a very rare complication following percutaneous radiofrequency ablation (RFA) in the management of renal cell carcinoma. In this paper we describe the management of a patient with a left colo-renal fistula occurring after renal tumor RFA. Additionally, we present a thorough literature review of reported cases of colo-renal fistulae after percutaneous RFA to further highlight their treatment challenges.</p> <p>Summary: Two weeks after undergoing percutaneous RFA of an incidental 3cm left renal mass, a 67-year-old male was re-admitted to the hospital with a symptomatic colo-renal fistula. Patient ultimately failed conservative management with broad spectrum antibiotics and ureteral stent placements, and subsequently underwent segmental colonic resection and renorrhaphy, with complete renal preservation.</p> <p>Conclusion: Although complications after RFA of renal tumors are rare, iatrogenic colo-renal fistula formation is a significant complication requiring a multi-disciplinary approach with a trial of non-operative management prior to surgical intervention.</p> <p>&nbsp;</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Sclerosing angiomatoid nodular transformation of the spleen: an unusual cause of abdominal pain 2021-07-05T02:31:07+00:00 Hussien Aly Touny, Einas Al Kuwari, Ahmed Al Moudaris, Salahddin Gehani <p>Vascular neoplasms are the most common primary nonhematopoietic tumors of the spleen. They include hemangiomas, littoral cell angiomas, splenic hamartomas, lymphangiomas, hemangioendotheliomas, angiosarcomas, and Sclerosing Angiomatoid Nodular Transformation (SANT)1. SANT is a rare and benign lesion arising from the red pulp of the spleen 2.Martel et al first described the disease entity in 2004 in middle aged- adults with slight female preponderance , the etiology and pathogenesis are still not clear3, SANT poses diagnostic clinical and radiological challenges4, we present this case report with review of the literature.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Invasive Haemophilus influenzae disease in Northwestern Ontario First Nations communities: Case Series 2021-07-05T02:29:31+00:00 Chelsea J. Kubinec MSci1, Len Kelly MD MClinSci2, Sarah Byce MD, MSci1, Raymond S.W. Tsang MMedSc PhD3, Marina Ulanova MD PhD4 <p>We present clinical and microbiological data of 5 pediatric cases of invasive Haemophilus influenzae disease, which occurred over a period of 10 months in the service area of a regional hospital of Northwestern Ontario. Four cases of invasive H. influenzae type a (Hia) disease presented either as meningitis, non-complicated and complicated pneumonia, or soft tissue infection in children between 7 months and 6 years of age. Although the cases were from different communities with no known common exposure, the Hia isolates demonstrated similar phenotypic and genotypic characteristics. One case of invasive disease due to nontypeable H. influenzae (NTHi) presented as chorioamnionitis in an adolescent. The data emphasize the significance of Hia and NTHi as a cause of serious disease in Indigenous communities.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Oral Lesion like Mucous Membrane Pemphigoid under Carboplatin-induced Hemolytic Anemia and Pancytopenia as Hypersensitive Reactions in a case with Maxillary Sinus Cancer: A Case Report 2021-07-05T02:27:38+00:00 Yuki Hokita, DH1, Kazuyo Mori, DH1, Taihei Yamaguchi, DDS2*, Takahiko Oho, DDS2 <p>Here we report the first case of fatal carboplatin induced immune hemolytic anemia in a patient with head and neck malignant neoplasms followed by onset of multi-organ failure. While carboplatin is an effective agent used to treat many kinds of malignant tumorigenic lesion, a number of reports about allergic side effects are present. A 64-year-old male patient diagnosed as maxillary sinus cancer was treated by radiation therapy associated with weekly intravenous infusions of carboplatin. After five times of carboplatin infusion, white blood cell and platelet counts and hemoglobin value gradually decreased, and reached to almost bottom level. Both direct and indirect coombs tests were negative. Reticulocyte count and the value of platelet-associated IgG were high level, and oral lesion-like mucous membrane pemphigoid appeared on tongue and hard plate. Recognition of the particular oral abnormality in the early stage could allow for correct diagnosis and a potentially effective therapy. Funding: This study was supported in part by JSPS KAKENHI Grant Number 18K09885.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Large Posterior Vaginal Wall Inclusion Cyst after Posterior Vaginal Wall Repair 2021-07-05T02:25:27+00:00 Jawaher Alsahabi.MD1 and Elham Bamanie.MD2 <p>Introduction: Large posterior vaginal wall inclusion cysts are rarely reported. According to our review, this case is the largest such cyst reported after posterior vaginal repair.</p> <p>Aim: We present the successful excision of a very large posterior vaginal wall inclusion cyst that developed after posterior vaginal wall repair.</p> <p>Methods: A 44 year old patient presented with a 7 cm symptomatic posterior vaginal wall cyst 5 years after posterior vaginal wall repair. She underwent aspiration of the cyst twice with recurrence before successful surgical excision.</p> <p>Results: The patient recovered without complications. Histopathology revealed a benign inclusion cyst.</p> <p>Conclusions: Although most epidermal inclusion cysts are asymptomatic and can be managed expectantly, cysts that enlarge or become symptomatic should be excised surgically.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Bronchial Artery Embolization for Life-Threatening Massive Hemoptysis in a young female patient: A case report 2021-07-05T02:24:03+00:00 Mohammed H Habib1*, Mohammed Hillis2 and Khaled H Alkhodari3 <p>Introduction: Massive hemoptysis is a potentially life-threatening respiratory emergency mandating immediate management. It is defined as expectoration of 300 to 600 mL of blood in a period of 24 hours. The most common etiologies include bronchiectasis, cystic fibrosis, neoplasm, sarcoidosis, tuberculosis, and other infections. While only five percent of hemoptysis is massive, some studies report a mortality rate of up to 80 percent in this subgroup, mainly due to asphyxiation. One of the novel ways to manage the later condition is transarterial embolization of the bronchial artery, which is minimally invasive, well tolerated relatively safe procedure. Here we present a case presents with massive hemoptysis due to iatrogenic arteriovenous fistula happened as a complication of previous right middle lobectomy treated successfully by coils.<br>Case presentation: A 25-year-old female patient, a known case of right middle lobectomy 3 years ago due to lobar bronchiectasis presented complaining of less than one day of dyspnea and hemoptysis which was moderate in amount of fresh red blood, there was no fever, cough, recent history of upper respiratory tract infection, chest pain, symptoms of deep vein thrombosis, or anticoagulant use. On examination, the patient was generally ill, conscious, oriented, with average body built, without pallor, not in respiratory distress. She was vitally stable as the blood pressure was 100/65 mmHg, the pulse was 90 beats per minute, respiratory rate was 21 per minute, and temperature was 38.2 C.. Chest examination revealed decreased breath sounds on the right lung, no added sounds and otherwise it was normal. The cardiovascular system examination, neurological examination, abdominal examination, lower limbs examination was normal. Complete blood count was done, and it revealed: hemoglobin level of 14.6 mg/dl, platelet 186.000 per microliter and white blood cells count of 4100 per microliter. Coagulation studies were slightly abnormal as the PT was 15 seconds, and the INR was 1.28.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Mucin-producing papillary thyroidal carcinoma with unusual histology: A rare case report 2021-07-05T02:22:13+00:00 Kimihide Kusafuka, D.D.S., Ph.D.1, Masaru Yamashita, M.D., Ph.D.2 <p>Background: Although mucinous carcinoma or mucoepidermoid carcinoma of the thyroid gland are an extremely rare but an established entity, papillary thyroidal carcinoma (PTC) with mucin production is also exceedingly rare.</p> <p>Case report: We reported one rare case of mucin producing PTC with unusual histology. The patient was 71 years-old Japanese man. The hemi-thyroidectomy was performed. Histologically, the tumor cells harbored the similar features with conventional PTC, but this case indicated extracellular and intracellular mucin. On the other hand, the tumor showed cystic-papillary or cribriform growth of the columnar tumor cells.</p> <p>Conclusions: We diagnosed it as mucin-producing PTC with columnar cell variant (CCV). We examined it immunohistochemically, and this case expressed TTF-1, thyroglobulin, and cytokeratin (CK)7, but was negative for HBME-1. We discuss on the differential diagnosis.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Solitary extramedullary plasmacytoma of prostate on the background of treated prostate adenocarcinoma 2021-07-05T02:20:33+00:00 Rehman Faryal, Amjad Hayat <p>Solitary Plasmacytoma is a rare entity which accounts for &lt; 5% of all plasma cell dyscrasias. Most commonly involved sites for solitary extramedullary plasmacytoma are head and neck (90 %) especially upper respiratory tract, followed by Gastrointestinal tract. Rarely it can involve testes, bladder and orbit. PET/CT provides an invaluable imaging support for initial evaluation of additional plasmacytomas and response to treatment. There are no randomized trials regarding the best treatment approach. Generally, radiotherapy remains treatment of choice of solitary plasmacytoma. Our case, with its rare site of occurrence along with patient’s history of radiotherapy treated prostate malignancy and significant history of radiation cystitis provides a unique diagnostic and therapeutic challenge. Treatment can be personalised in cases such as this, where patients can be treated with chemotherapy in contrary to radiotherapy as further exposure to the radiations could exacerbate the bleeding risks.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Homocystinuria a rare cause of low BMD in young patients: A case report with literature review 2021-07-05T02:18:53+00:00 Abdul-Wahab Al-Allaf, Theresa Paul, Basem Awadh <p>Background: Homocystinuira is a rare autosomal recessive disorder in the metabolism of sulfur-containing amino acid caused by mutations in the cystathionine beta-synthase gene which encodes the pyridoxine (Vitamin B6) dependent enzyme cystathionine beta-synthase. It is characterized by significant elevations in plasma and urine homocysteine concentrations, which could be associated with increased risk of fracture.</p> <p>Methods: We describe a case of Homocystinuria who suffered from a low impact patellar fracture with a literature review to highlight the critical relationship between homocysteine level and bone health.</p> <p>Results: We reported a 36-year-old female with a diagnosis of Homocystinuria due to pyridoxine (B6) unresponsive severe Cystathionine Beta-Synthase deficiency. After a minor knee injury she developed a right patellar fracture and her X-ray revealed osteopenia. On examination, she has severe scoliosis in the spine with bilateral aphakia (absence of the lens of the eye). Her labs showed, persistent high Homocysteine above 100 umol/L, Methionine: 383 umol/L (10-42), Vitamin D 12 ng/ml. Her spine X-ray revealed very severe scoliosis with osteopenia but no vertebra fracture. Her DXA scan showed her Z-Score was within the expected range for her age in hip, spine and 1/3 radius areas, however her ultra-distal radius Z-Score was -4.0. Her Homocystine level was mostly higher than 100 due to non-compliance with dietary advice and treatment. High homocysteine levels in Homocystinuric patients impair the function of bone cells that regulate bone remodeling as well as bone material properties such as collagen cross-linking. This imbalance between bone formation and resorption may lead to a low BMD and fracture in patients with homocystinuria. Interestingly, even in general population hyperhomocystinemia with a plasma level of more than &gt; 13 nmol/ml has been found to be associated with low BMD and an increased risk of fractures that is independent of BMD. Deficiencies in vitamin B6, B12, or folate can lead to increased serum levels of Homocysteine as these vitamins act as co-factors for various enzymes involved in homocysteine metabolism. This can be easily rectified with dietary intervention.</p> <p>Conclusion: In young patients with a fracture or low bone mineral density, hyperhomocystinemia could play an important role in the pathogenesis. This should be included in the work up for secondary causes for osteoporosis for this age-group. Simple dietary measures and vitamin B6, folate and B12 supplement should be considered as adjuvant therapeutic option for any patient with osteoporosis and fractures, if deficient. Possibly the BMD of the ultra-distal radius is the most sensitive to detect bone changes in these patients.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Prepyloric Diverticulum in a Nigerian: Case Report of a Rare Finding 2021-07-05T02:17:21+00:00 Aderemi Oluyemi1+, Dayo Ajayi2 <p>Diverticulae are uncommonly encountered in the stomach. They can be congenital or acquired- the latter variety being the less frequent of the two. This article details one such rare case from Lagos, Nigeria and discusses certain aspects of its clinical and endoscopic presentation. We present a 59-year old with a background history of non-steroidal anti-inflammatory drugs abuse presented with hematemesis and melena and was in hemorrhagic shock. After stabilization, the gastroscopy findings were of a gastric diverticulum (GD) in the anterior prepyloric wall. There was a Forrest IIb ulcer in the GD’s wall with surrounding erythema and edema. The patient was successfully managed medically and conservatively and with good long term results.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Recurrence of Graves’ disease in thyroid remnant after total thyroidectomy 2021-07-05T02:15:47+00:00 Óscar Moreno Domínguez1, Beatriz Barquiel Alcalá1, Alejandro Castro Calvo2, Lucrecia Herranz de la Morena1 <p>Recurrences of Graves’ disease (GD) after total thyroidectomy (TT) are uncommon, with few cases reported in literature. This article describes the case of a 58-year-old man who was treated with TT due to GD over 15 years ago. A progressive reduction of levothyroxine treatment was observed due to persistent subclinical hyperthyroidism. Thyroid-stimulating hormone receptor antibodies were detected in blood analysis and in the imaging test, a lesion was identified in the upper left anterolateral cervical region. A histopathological study of the lesion revealed colloid goiter. The patient was diagnosed with GD recurrence in a thyroid remnant and was remitted to an otorhinolaryngologist to remove the lesion. The histopathological study showed diffuse thyroid hyperplasia. The objective of this clinical case report is to highlight this unusual recurrence to better treat and improve long-term outcomes in patients treated with TT.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 The diagnostic conundrum posed by Hypereosinophilia with a foot drop: A Case Report 2021-07-05T02:12:56+00:00 Jonathan Moriarty1, Natassja Moriarty 1, Anthony Macheta2, Fiona Wood3 <p>We present a case of an 81-year-old asthmatic female with a left foot drop and an incidental finding of hypereosinophilia with an initial differential diagnosis of Eosinophilic Granulomatosis with Polyangiitis (EGPA). However, after extensive investigations, all causes of hypereosinophilia were excluded and the left foot drop was secondary to a radiculopathy. This led to a diagnosis of Idiopathic Hypereosinophilic Syndrome (IHES), a diagnosis of exclusion. This is the first case report where hypereosinophilia and a left foot drop where unrelated conditions occurring simultaneously thus posing a diagnostic dilemma. Therefore, this case report aims to highlight the importance of a systematic approach in the investigation of hypereosinophilia, to ascertain the cause and to rule out organ damage as this will affect the management and the outcome.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 ANOMALOUS FORMATION OF THE PORTAL VEIN – A CASE REPORT 2021-07-05T02:10:41+00:00 WMS Johnson1, Gunapriya Raghunath2, Sreelekha D3, Archana Rajasundaram3 <p>The knowledge about the formation and relation of the portal vein is important for surgeons. The variation in the level of formation and the pattern of formation of portal vein is a cause of concern during surgical procedures. An abnormal formation of portal vein that was encountered during routine dissection is reported. The portal vein was formed by the union of splenic vein, superior mesenteric vein and inferior mesenteric veins. Identification of these variations is useful in managing traumatic rupture of the mesentery.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Outcome of intrahepatic cholestasis of pregnancy: Case report 2021-07-05T02:08:22+00:00 Avleen Kaur1, Gurinder Mohan2, Umang3 <p>We present a patient diagnosed with intrahepatic cholestasis of pregnancy at 30 weeks 6 days of gestation. She presented with complaint of pruritus associated with hepatic cytolysis and elevated transaminases revealed by laboratory tests. The emphasis must be laid on importance of early diagnosis of intrahepatic cholestasis of pregnancy to improve the fetal prognosis and to eliminate other severe conditions associated with hepatic cytoloysis syndrome and pruritus.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A rare case of Warthin-like papillary thyroid carcinoma associated to Graves’ disease 2021-07-05T02:06:33+00:00 Olfa Adounia, Imen Zawatia , Sabrine Boukhrisb, Ilhem Bettaieba, Fatma Tekaria, Aida Gouchaa, riadh charguib, Amor Gamoudia, Khaled Rahalb <p>Warthin-like variant of papillary thyroid carcinoma (WLV-PTC) is a recently described rare variant of papillary thyroid carcinoma with favorable prognosis. We present a rare case of WLV-PTC in a 29-year-old female patient with graves’ disease along with emphasis on the difficulty of positive diagnosis both clinically and histologically since the association of thyroid nodules with Graves’ disease is not common and this variant of thyroid cancer is frequently misdiagnosed with other subtypes.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Supraglottitis secondary to Haemophilus influenzae serotype f infection: Case report and review of literature 2021-07-05T02:04:55+00:00 Chelsea Jocelyn Kubinec, Marina Ulanova <p>Introduction: Haemophilus influenzae is an important human pathogen capable of causing serious invasive disease. The H. influenzae serotype b (Hib) conjugate vaccine successfully reduced the incidence of invasive Hib disease globally, revealing the significance of other H. influenzae serotypes. The emergence of H. influenzae type f (Hif) invasive disease has been reported worldwide.</p> <p>Case report: We identified a case of supraglottitis secondary to Hif in a 57-year-old female from northwestern Ontario without significant predisposing conditions. We describe the clinical presentation, disease progression, and outcome. The case is discussed in the context of current epidemiology of invasive Hif disease.</p> <p>Conclusion: This report emphasizes the severity of Hif invasive disease and the need for continued surveillance at the international level. We call for the development of health promotion strategies and the consideration of a vaccine against this organism.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Follicular Dendritic Cell Sarcoma of Colon Presenting as Colo-colic Intussusception: a Rare Entity in Gastrointestinal Site With Extremely Rare Presentation 2021-07-05T02:03:01+00:00 Sumanta Das1, Charanjeet Ahluwalia2, Dhruv Jain3, Rashmi Arora4 <p>Follicular dendritic cell sarcoma is a rare mesenchymal tumor of follicular dendritic cells arising from nodal and extranodal site. FDCS generally involves the lymph nodes while many extranodal sites are also affected. We report a case of follicular dendritic cell sarcoma primarily arising in colon and presenting as colo-colic intussusception.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Idiopathic Acquired Factor VIII deficiency presenting with compartment syndrome: A case report and Literature Review 2021-07-05T02:01:18+00:00 Khalid E. Ahmed1, Amna Gameil2, Marcus D. Lance3, Arshad H. Chanda3, Lubna Riaz2, Anas Hamad4, Ahmed A. Shible4, Shehab F. Mohamed2 <p>Haemophilia is a disorder that affects the ability of the blood to form clots. The congenital form of the disease is the most prevalent, is inherited as X-linked recessive and it causes deficiency of clotting Factor VIII or IX. clinically it presents with joint bleeding. Its counterpart, acquired haemophilia is a rare condition that usually presents with cutaneous, soft tissue or internal bleeding.<br>The pathophysiology of the disease is centred on the formation of auto antibodies which inactivate factor VIII. Haematologically this is reflected as a prolonged aPTT with normal PT and failure of mixing studies to correct aPTT to more than 50%. To confirm the diagnosis Bethesda assay has to be performed to detect the presence of factor inhibitors. In half of the cases it is associated with an underlying condition such as autoimmune diseases, malignancy, pregnancy or infections.<br>The mainstay treatment is to control the bleeding with bypassing agents such as recombinant factor VIIa or Factor VIII inhibitor bypassing agent as well as eradicating the inhibitor with immunosuppressive and/or cytotoxic agents. Here we report a patient with idiopathic acquired haemophilia who presented with a thigh compartment syndrome. He was successfully treated with fasciotomy, bypassing agents and immunosuppressive therapy.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Retained Penile Ring: Case Reports 2021-07-05T01:59:06+00:00 Odusanya Benjamin Olasunkanmi1, Omisanjo Olufunmilade Akinfolarin2, Salami Olayinka Abdurraheem3, Saliu Abdulwaid Niran4 <p>Background: Penile constriction rings have been used to prolong erection with vacuum devices in the treatment of erectile dysfunction. Some have also employed it for recreational purposes with the attendant risks of penile edema, strangulation and necrosis. We present two cases of entrapped phallus by penile rings.</p> <p>Case reports: 16 years old with pain and swelling of the phallus of 12 hours duration. This started after placement of a phallic ring to purportedly prolong erection which he was later unable to remove the ring despite several attempts and developed progressive swelling and pain in the phallus. He was also unable to pass urine. Examination revealed a circumcised phallus that was detumescent but grossly edematous, tender with shiny skin. Initial simple manoeuvres in the casualty proved abortive and ring had to be cut with an orthopaedic instrument. He was subsequently able to void without difficulty or any haematuria. 47 year old Asian male with a 12 hour history of penile pain and swelling following entrapment of a penile ring he had inserted for sexual gratification about 24 hours before presentation. There was a history of haematuria. The removal of the penile ring was achieved with a combination of cold compress squeeze, corporal aspiration and lubrication under general anaesthesia.</p> <p>Conclusion: Successful management of retained penile ring depends on early presentation by the patient to avoid adverse outcomes. It may require instruments not normally found in the urologist armamentarium.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 An increasing trend of iatrogenic scar endometriosis after lower segment cesarean section 2021-07-05T01:57:34+00:00 Nishat Fatema1*, Dil Anziz Begum1, Shirin Fatema1, A.K.M Arif Uddin Ahmed2 <p>Cesarean scar endometriosis is an uncommon disorder developed due to iatrogenic implantation of endometrial tissues in the cesarean incision site. The frequency of the scar endometriosis is assumed to increase because of the increasing trend of lower segment cesarean section in modern obstetric practice. Cesarean section might be a great risk factor for the development of scar endometriosis due to higher exposure of endometrial cells to the subcutaneous tissue during the procedure. Prevention of decidual cell contamination to the superficial abdominal layers may reduce the occurrence of iatrogenic scar endometriosis. We reported a 21-year old para 2 woman with a history of cesarean section 2.5 years back who presented with a small mass at the middle of the cesarean scar which was associated with pain and blood-stained discharge during menstruation. Based on clinical and USG findings the provisional diagnosis was made scar endometriosis and subsequently we managed her by wide local excision of the lesion followed by adjuvant hormone therapy. No recurrence of scar endometriosis was observed during her follow up period.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Combined factor V and factor VIII deficiency: A rare case report and literature review 2021-07-05T01:49:31+00:00 Khalid E. Ahmed1, Amna Gameil2, Dina S. Soliman3, Aliaa Amer3, Mohamed A. Yassin2, Shehab Mohamed2 <p>Background: Combined factor V and factor VIII deficiency (F5F8D) is a rare autosomal recessive inherited coagulopathy. It has a higher prevalence in the Mediterranean region (1:100,000) compare to its prevalence in the general population which is estimated to be (1:1000,000).</p> <p>Case report: We report a 59 years old Lebanese lady who was referred from the general surgery clinic with an asymptomatic prolongation of prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (aPTT) detected during preoperative work up for an elective umbilical hernia repair. The patient had history of bleeding following dental procedures since childhood as well as easy bruising with minimal trauma. Physical examination was unremarkable. haematological investigations were normal apart from the prolonged PT, INR and aPTT which were corrected following mixing studies. Factor assay revealed factor V level of 5.5% and factor VIII level of 11.9% with other factors within normal ranges confirming the diagnosis of combined F5F8D.</p> <p>Conclusion: Combined factor V and factor VIII deficiency should be suspected in patients with prolonged PT, INR and aPTT especially if they are of Mediterranean, Middle east or Arabic origin with a history of consanguineous marriages. Treatment is generally not indicated unless the patient has recurrent serious bleeding manifestations.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Factor XII deficiency: A rare case report and literature review 2021-07-05T01:40:41+00:00 Khalid E. Ahmed1, Mohamed G. Ali1, Deena Mudawi2, Mohamed Yassin2, Shehab Mohamed2 <p>Background: Factor XII is part of the intrinsic pathway. the activity of this pathway is assessed by measuring the activated partial thromboplastin time (aPTT). Deficiency of Factor XII is rare, often inherited as autosomal recessive, nevertheless autosomal dominant pattern has also been reported. congenital deficiency is associated with mutations in the F12 gene on chromosome 5. Here we report a patient with factor XII deficiency which is considered as a rare inherited coagulation disorder.</p> <p>Case report: we report the case of a 37 years old gentleman known to have Diabetes mellitus, hypertriglyceridemia, past history of pancreatitis and an episode of gingival bleeding a year prior to this presentation which was attributed to periodontitis. He presented to the emergency room complaining of epigastric pain radiating to the back as well as non-projectile vomiting. He used to drink alcohol but stopped 6 years ago. physical examination showed epigastric tenderness, poor dental hygiene and periodontitis. investigations showed neutrophilic leucocytosis, high lipase and raised triglycerides level of 11.3 mmol/L. He was treated successfully for triglycerides induced pancreatitis with IV insulin, Dextrose 5% infusion and fenofibrates. Isolated prolonged aPTT was detected incidentally which was corrected with mixing study indicating a factor deficiency. Factor assays revealed factor XII deficiency (5.8%) with other factors being within normal ranges. Past records did not show any thrombotic event. No specific treatment was given for Factor XII deficiency.</p> <p>Conclusion: Factor XII deficiency is associated with an isolated prolonged aPTT without increasing risk of bleeding. patients with this condition should be offered regular follow up because of the increased rate of thromboembolic complications.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Functional Neurological Deficit: one of the most controversial diagnosis- case report of a patient with paraplegia 2021-07-05T01:38:36+00:00 Mohmad Jamal Hafeza, Hassan Bourjia, Hasan Sroura <p>Background: Conversion disorder, also called functional neurological symptom disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors.any case of FND is challenging and hard to manage due to overlapping of symptoms with other organic illnesses and also hard to be treated due to multidisciplinary approach needed.</p> <p>Case Report: A 34 year old patient known to have schizophrenia with previous admissions to psychiatric hospital suddenly complaining of paraplegia with no sensory deficit . these symptoms persist for 6 months.</p> <p>Conclusion: Long lasting symptoms is something unusually seen in conversion disorder cases where the course of illness stay for a couple of days.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Necrotising fasciitis of the abdominal wall 2021-07-05T01:34:31+00:00 KJ Williams <p>A 53 year old gentlemen, with a history of intravenous drug use, presented to the Emergency Department in septic shock with an acute abdomen. He had been recently treated with dalteparin for a deep venous thrombosis of his left leg. He was resuscitated with fluids and antibiotics, and cross-sectional imaging suggested a diagnosis of necrotising fasciitis of the abdominal wall. He was admitted to ITU, and a laparotomy, abdominal washout, muscle debridement and laparostomy was performed overnight. No bowel perforation or contamination was identified. Over the next few weeks he underwent multiple debridements, and a negative pressure abdominal dressing was utilised. After a prolonged rehabilitation phase he was discharged home to live independently. He is currently in discussion with the plastics team regarding reconstruction of his abdominal wall. We would like to stress the importance of consideration of necrotising fasciitis as a diagnosis in the context of a critically unwell and septic patient with a history of subcutaneous/intravenous medication usage.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Immunotargeted Monotherapy by Anti-PD-1 in Patients with Primary Non-small Cell Lung Cancer 2021-07-05T01:32:42+00:00 SUN Liqiu1*, ZHANG ge1, YU Tingting1, TANG Songyan1, WANG Hongli1 <p>The 5-year survival rate of advanced non-small cell lung cancer is less than 5%. In recent years, immunotherapy represented by PD-1 antibody has become the standard treatment recommended by many lung cancer guidelines. With the treatment, the total survival time and quality of life have been significantly prolonged in patients with advanced Primary non-small cell lung cancer (NSCLC). In this study, the domestic anti-PD-1 monoclonal antibody, Camrelizumab, combined with chemotherapy was used to treat advanced non-small cell lung cancer. The efficacy of Camrelizumab and occurrence of cutaneous capillary hyperplasia (CCEP) were analyzed.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer 2021-07-05T01:30:27+00:00 Allan Stolarski, MD1,2, Katherine He MD1,3, Ducksoo Kim MD4,5, Gentian Kristo, MD1,3 <p>Background: Gastro-cutaneous fistula following re-leak of omental patch repair of perforated peptic ulcer is a very rare but challenging surgical complication. We describe the use of a novel biological plug as a viable repair for gastro-cutaneous fistula that failed medical, endoscopic, and operative management. Additionally, we present a thorough literature review of reported cases of gastro-cutaneous fistulae following omental patching of peptic perforations to further highlight their treatment challenges.</p> <p>Summary: A 69-year-old man underwent repair of a perforated pyloric ulcer with a pedicled omental patch. After one week, patient developed a re-leak from the omental patch, and underwent a second laparotomy with repeat omental patching of the gastric perforation. Ten weeks after the second operation, the patient developed a gastro-cutaneous fistula that failed conservative management with nil per os and enteral nutrition delivered distal to the fistula site; multiple image-guided percutaneous attempts at fistula closure by interventional radiology via fibrin sealant injection and collagen-based vascular closure device; and endoscopic clipping by gastroenterology. Ultimately, this refractory gastro-cutaneous fistula was closed with a novel biological plug (Biodesign® Enterocutaneous Fistula Plug, Cook Biotech).</p> <p>Conclusion: Gastro-cutaneous fistulae following omental patching of perforated peptic ulcer represent a significant complication requiring a multidisciplinary management approach. The Biodesign® Enterocutaneous Fistula Plug offers a promising new tool for the non-operative treatment of refractory gastro-cutaneous fistulae.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Autologous Tenocyte Implantation for the Treatment of Chronic Degenerative Rotator Cuff Tendinopathy 2021-07-05T01:26:19+00:00 Bonnie McRae, Jane Fitzpatrick, Hussain Khan <p>The use of injectable cell therapies to treat tendon pathology has become significantly more popular in recent years. They are appealing treatment modalities as they are minimally invasive, autologous, non-surgical management options which theoretically allow tendon regeneration and return to function. This case report will focus on the use of autologous tenocyte implantation (ATI) injection therapy to treat chronic degenerative rotator cuff tendinopathy.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 An accessory aberrant testicular artery branching from the inferior suprarenal artery: embryologic and genetic consideration 2021-07-04T23:16:43+00:00 Maryna Kornieieva, Sayeh Nabati, Brooke Mower <p>During routine educational dissection of a cadaver (61-year-old, male, white descent), multiple aberrant right testicular artery and veins were discovered.<br>Detailed analysis of the abdominal vascular pattern showed that the accessory aberrant testicular artery branched off the right inferior suprarenal artery. It crossed the anterior pararenal space, gave several branches to the soft tissues of the posterior pararenal space, and descended towards the deep inguinal ring. The accessory aberrant testicular vein accompanied the aberrant artery and was drained by the right inferior suprarenal vein into the renal one. Two other testicular veins followed a typical course and opened into the inferior vena cava.<br>The anatomical variability reported in this paper requires attention of the related specialists, as it may significantly complicate surgical and minimally invasive procedures on the organs of the retroperitoneal space and inguinal region. Thorough preoperative investigation regarding the variability of the vascular pattern should be conducted in patients considered for intervention on the adrenal gland, kidney, or testis.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 THE COEXISTENCE OF A PRE-AURICULAR SINUS WITH POST-AURICULAR DERMOID CYST 2021-07-04T23:14:58+00:00 Christopher Ndoleriire, Sedrack Matsiko, Brian Muhereza <p>A pre-auricular sinus will rarely present in coexistence with a post-auricular dermoid cyst. The coexistence of a discharging pre-auricular sinus with a post-auricular dermoid cyst presents a diagnostic challenge. Without meticulous history taking and physical exam, one would subject the patient to aggressive and unwarranted investigation and management modalities as though the infected post-auricular dermoid cyst were a mastoid abscess. We present a 15-year-old male who presented to the ENT clinic of Mulago National Referral Hospital and was diagnosed with an infected pre-auricular sinus with an infected post-auricular dermoid cyst.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Surgical Correction of Intra-Areolar Polythelia 2021-07-04T23:13:22+00:00 Eunice Beh, TS Chong <p>Intra-areolar polythelia (IAP) is an extremely rare congenital malformation with the presence of two or more nipples within a normal sized areola. This is a case report of a 25-year-old gentleman who presented with two nipples on the areola of his left breast since birth. Surgical excision was done under local anesthesia for aesthetic purpose.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Individualized approach for Coarctation of the Aorta in a Patient with PHACE syndrome and Extensive Hemangiomas 2021-07-04T23:11:55+00:00 Wejdan Ba-Atiyah, Riad Abou Zahr, Amjad Kouatli <p>PHACE syndrome is a neurocutaneous disorder with large facial segmental hemangiomas associated with anomalies of the brain, eye and heart.<br>We report a case of a 3 years old girl who presented at the age of 6 weeks with severe coarctation of the aorta and aortic arch aneurysm. In addition, she had extensive strawberry hemangiomas over the scalp, neck and chest which, after extensive investigation, led to the diagnosis of PHACE syndrome.<br>After complete evaluation we successfully initiated treatment with propranolol that was pursued without complications over three years with striking success and remarkable regression of her hemangiomas. Meanwhile the coarctation was managed conservatively.<br>This case highlights that propranolol treatment, while effective against hemangiomas, may contribute to slow the progression of aortic arch aneurysm and delay the need for high risk surgical intervention.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Merkel cell polyomavirus on primary Merkel cell carcinoma of the skin with partial regression after biopsy 2021-07-04T23:10:17+00:00 Irene Moysset,MD (*), Juan Carlos Arias, MD (**); Beatriz Bellosillo, MD; PhD (***) <p>Introduction: Merkel cell carcinoma (MCC) is an uncommon primary cutaneous tumour. The majority of these tumour (about 80%) have integration of the polyomavirus DNA into the genome of Merkel cell carcinoma. Reports about at least nine cases of partial regression in primary and or metastatic lesions have been published. It is likely that regression is an immunological response mediated by T cells.</p> <p>Case Report: We report an 81year old woman who presented with a rapidly growing tumor in the left thigh. An incisional biopsy of the lesion was performed. Histopathologic and immunohistochemically diagnosis were consistent with Merkel cell carcinoma. Scant peritumoral lymphocytic infiltrate was CD3+, CD4+, and scant CD8+ was observed. The reporter test polymerase chain reaction (PCR) for Merkel virus yielded a positive result. Twenty days after the initial biopsy the lesion began to regress.</p> <p>Conclusion: Merkel cell carcinoma is a rare and aggressive tumour. At least nine cases of partial regression on primary and or metastatic lesions have been published. It is likely that regression is a T cell-mediated immunological response. A reporter test (PCR) for Merkel virus and both types of lymphocytic infiltrate and distribution (intratumoral and peritumoral) in our case very important as there are several known mechanisms that can contribute to cellular immune escape in MCP y V positive Merkel cell carcinoma. Study of integration and regulation of the immunological system implies future development of individually of different immunological therapies.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 The multifactorial etiology and approach to iron deficiency anemia in adolescent girls 2021-07-04T23:06:38+00:00 Lopes, Lisa1; Verlooy, Joris2; Norga, Koen2; van Heerden, Jaques2 <p>Iron deficiency anemia (IDA) is a common but underdiagnosed cause of morbidity in adolescent females. Associated thrombocytopenia is rare, but resolves when the anemia is treated with iron supplementation. Menorrhagia is an important cause in the multifactorial etiology and may be familial. This article presents a case of severe anemia and thrombocytopenia in the presence of iron deficiency due to menorrhagia. A holistic approach to IDA is discussed with an approach to the management thereof in adolescent females.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Miller Fisher syndrome associated with respiratory failure 2021-07-04T21:39:03+00:00 Frentescu Alexandra1*, Feys Odile2, Mangion Jean-Paul3, Osseman Michel2, Horlait Geoffrey1 <p>Miller Fischer syndrome (MFS) is a rare clinical variant of Guillain-Barre syndrome. The diagnosis suspected primarily on clinical trial of areflexia, ophtalmoplegia and ataxia, is confirmed by the mandatory presence of antiganglioside antibodies (anti GQ1b). An acute onset is typical of MFS, beginning with neurological symptoms following a respiratory or digestive infectious illness. The therapeutic options are either the plasmapheresis or the administration of intravenous immunoglobulin (IVIG). Although rare, in certain cases the patients present with respiratory symptoms needing intensive care. We report the case report of a patient which presented with the classical triad of MFS but also with rapid progressive respiratory failure due to bilateral vocal cords palsy and general muscle weakness. He needed respiratory mechanical support. The patient received a treatment by IVIG without any improvement in symptomatology. Eventually he completely recovered and he was discharged from the hospital 3 month later.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 TUBERCULOSIS MIMICKING A TESTICULAR TUMOR 2021-07-04T21:37:28+00:00 Menaka Thilakarathna1*, Sasanka Wijayawardhane1, Aflah Sadikeen1, Amitha Fernando1 <p>Genitourinary tuberculosis is a challenging clinical entity which can affect the entire male genital tract.<br>Seventy-five- year old male presented with a testicular lump masquerading a testicular malignancy. Histological and microbiological examination of testicular biopsy specimens established the diagnosis of tuberculosis.<br>Isolated testicular tuberculosis is rarely reported. High degree of clinical suspicion and histological sampling are paramount important in the process of diagnostic evaluation.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Conditional Dysosmia: a Very Unpleasant Symptom Causing Severe Anorexia and Breathing Problems in Covid-19: a Case Report 2021-07-04T21:35:51+00:00 Abdulmohsin Younus Saleem1, Abdul-Wahab Al-Allaf2* <p>The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new coronavirus that is highly contagious and responsible for the ongoing pandemic disease; coronavirus disease (COVID-19). The disease was first identified in December 2019, and the World Health Organization declared the pandemic on the 11th of March 2020. Although individuals infected with SARS-CoV-2 may be asymptomatic, the disease can present as an upper respiratory tract illness. In the majority of the cases, it is of a mild type, however, some patients experience severe viral pneumonia that leads to respiratory failure, and, in some cases to death.</p> <p>A COVID-19 diagnosis is confirmed by viral RNA detection in nasopharyngeal swab specimens; nonetheless, in some countries, COVID-19 tests are not available for screening and are only used to diagnose severe cases. Since 31 December 2019 and as of 17 October 2020 and in accordance with the applied case definitions and testing strategies in the affected countries 39 400 032 cases of COVID-19 have been reported, including 1 105 353 deaths [1].</p> <p>The main way to control the spread of COVID-19 is to prevent human-to-human transmission, which can be achieved through a combination of public health measures, including the rapid identification and isolation of infected people [1].</p> <p>Diagnostic suspicion is based on nonspecific symptoms, such as fever, odynophagia, head- ache, and dry cough which are present in almost all acute respiratory virus cases [2].</p> <p>Anosmia, which may be associated with the loss of taste, has been initially observed in European cases and seems to be a more specific symptom of COVID-19. Thus, during the pandemic, individuals with these symptoms should be tested for COVID-19; when tests are not available, isolation of the patient is indicated [3].</p> <p>It should also be noted that olfactory dysfunction significantly influences the physical well-being, quality of life, safety, and nutritional status of those affected. And it becomes a greater problem when it becomes permanent. Yet, very little is known about olfactory dysfunction in COVID-19. Through our case report and review of the subject of the olfactory dysfunction, we would like to contribute to the existing knowledge and clinical evolution and to reinforce the importance of this manifestation from the patient prospected, and in the diagnosis and control of the disease from Otolaryngological point of view.</p> <p>We, self-reported an Anosmia turned to Dysosmia (in Otolaryngeal senior consultant) and in one of his patient with anosmia which was followed by Dysosmia as well. This occurred in August 2020 and September 2020 in Duhok, Iraq.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Fatal diffuse pleural calcification due to Tuberculosis- An unexplained entity 2021-07-04T21:34:16+00:00 Sugeesha Wickramasinghe, Bandu Gunasena, Sumudu Palihawadene <p>Diffuse pleural thickening has many causes and often need to be diagnosed early as delay in treatment can be lethal. Diffuse pleural thickening can be due to calcifications and may occur as a result of chronic infections including Tuberculous effusion. Primary pleural calcification due to Tuberculosis is extremely rare. A 28 year old patient was presented with exertional dyspnea, chronic cough and pleuritic type chest pain for a period of 4 months. CXR showed left sided diffuse pleural calcifications and ultrasonography showed calcified pleura with thick echogenic material suggestive of an empyema. Further evaluation with a CECT showed left sided diffusely calcified, septated pleura with empyema and contralateral early pleural and peritoneal calcification. Pleural aspiration showed a hemorrhagic exudative lymphocytic effusion with high ADA titer. Cytology did not reveal malignant cells. His serum calcium level was normal. He was diagnosed to have extra-pulmonary tuberculosis and was treated with standard anti TB treatment with an intercostal tube drainage. Despite TB treatment he passed away due to respiratory distress caused by pleural thickening. This case highlights the importance of timely initiation of anti TB treatment and the capacity of Tuberculosis to cause diffuse pleural calcification which can be fatal in an untreated setting.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Successful non-operative management of extensive pneumomediastinum and pneumoperitoneum 2021-07-04T21:32:42+00:00 Dylan Johnson, MD1*; Stephan Jones, MD1; Subhasis Misra, MD, FACS1 <p>Background: A 70 year old male presented with acute left flank pain and was found to have extensive free air in both the mediastinal and peritoneal cavities. He was managed successfully without surgery.</p> <p>Case: A 70 year old male presented with left flank pain that began an hour prior to arrival. He had a history of obstructive sleep apnea that had been treated with continuous positive airway pressure therapy (CPAP) at home for many years. His vital signs, physical exam, and laboratory testing were all unremarkable. However, imaging findings were impressive for massive pneumoperitoneum and pneumomediastinum. Given his clinical stability, operative exploration was deferred, and he was admitted for observation and bowel rest. He was discharged less than 48 hours after admission without incident. His history of home CPAP therapy was the only attributable cause for the ominous findings seen on his imaging. Recognizing that this was a case of benign free air saved this patient from the morbidity and potential for death that comes with an unnecessary operative exploration.</p> <p>Conclusion: Continuous positive airway pressure therapy can result in benign free air within the mediastinal and peritoneal cavities. Evaluating the complete clinical scenario will allow for recognition of similar cases in which these grim findings are not indicative of surgical disease, thus avoiding the iatrogenesis of unnecessary surgery.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Shewanella, not just found in the marine environment. A rare case of Shewanella algae bacteremia 2021-07-04T21:31:18+00:00 Asha Ramsakal, DO1, Jacqueline Wesolow, DO, MBA1* <p>A 63 year old Caucasian female with ampullary pancreatic cancer s/p pancreaticoduodenectomy in 2016 was admitted to our cancer center with complaints of fever (temperature 103° F) and abdominal pain. She was found to have multiple liver abscesses. Her blood culture grew out Shewanella algae. We herein report on this rare human bacterial infection.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A suspected insulinoma with the unexpected histopathological finding of a nesidioblastosis – A case report and literature review 2021-07-04T21:29:34+00:00 Carlos Hernández Brito1*, Mauricio Luis Barrón Soto2, David Ramírez Sosa3, Dante Díaz Martínez4, María Alicia Díaz Orea5, Arsenio Torres Delgado2, Eibar Guzmán Vera2, Héctor David Pérez Domínguez2, Pedro Arredondo Ruiz1 <p>Introduction: Nesidioblastosis is a hyperplasia of the beta cells that causes persistent hyperinsulinemic hypoglycemia, unfortunately, it is difficult to diagnose through imaging studies.</p> <p>Case presentation: A 68-year-old woman with palpitations, diaphoresis, dizziness and alterations in the level of consciousness that improve with food intake. Laboratories: glucose 35.0 mg/dl, insulin 12.5 mUI/ml, proinsulin 14.1 pmol/L and peptide C 2.55 ng/ml. Octreoscan reveals an abnormal epigastric uptake area and the tomography shows a focal hypervascular lesion in pancreatic body of 12×11 mm. A distal pancreatectomy was performed without palpating the tumor in transoperative period, and a diffuse nesiodioblastosis was reported in the histopathological study. The patient persists with hypoglycemia and an additional pancreatic resection was performed, resecting 90% of the organ. Although an insulinoma was not located in the piece, an area surrounded by connective tissue was observed where islet hyperplasia was more accentuated.</p> <p>Discussion: The pathophysiology of nesidioblastosis is unknown, its main differential diagnosis is insulinoma and this should be suspected when the tumor can not be identified. Most agree that a pancreatectomy that involves 60-80% of the total organ can control glucose levels with low risk of diabetes and pancreatic insufficiency.</p> <p>Conclusion: The nesidioblastosis should be suspected when a hyperinsulinemic hypoglycemia is difficult to control and when a tumor can not be identified. The extension of the pancreatectomy should be individualized and if an insulinoma is not localized and a nesidioblastosis is suspected, an intraoperative histopathological examination with frozen section evaluation for the margins could determine the extent of pancreatectomy.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Rare case of ectopic pleomorphic adenoma on the plane of the cheek 2021-07-04T21:28:06+00:00 Adnan Mohammed Brayyich Al-Obaidi1, Karen Shabano Stalin2, Humam Adnan Mohammed Al-Obaidi3, Mohammed Jasim Mohammed4 <p>Pleomorphic adenoma is a benign tumor of the salivary gland with the highest incidence rate among all salivary gland tumors in the general population. Even though it’s common, ectopic presentation of the same is rare. When it happens, it presents in the head and neck region. We discuss in this paper a rare case of ectopic pleomorphic adenoma on the plane of the cheek.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Phosphate Enema Causing Life-Threatening Rectal Perforation 2021-07-04T21:26:34+00:00 N. Bobb, V. Naraynsingh, S. Islam, Y. Singh, D. Harnanan, S. Cawich <p>We report a near fatal rectal perforation due to a phosphate enema in an elderly male. The presentation in septic shock within 4 hours of the enema is quite rare. Early recognition and prompt management are essential for a good outcome. A defunctioning colostomy is standard for these cases but we recommend a distal rectal washout since intraluminal faeces in a loaded rectum could be a cause of ongoing sepsis. Although enemas are commonly used for constipation in the elderly, suppositories and oral preparations should be used preferentially where appropriate.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Methemoglobinemia – A review and recommendation for management – Acute methemoglobinemia with hemolytic anemia following suicidal use of aniline based substance 2021-07-04T21:24:46+00:00 Jakub Nożewski MD1*, Maria Klopocka Prof1, Klara Nicpon-Nozewska PhD2, Jakub Konieczny MD2 <p>Methemoglobinemia is a rare disease classification related with congenital or acquired (usually iatrogenic) hemoglobin oxygenation disorder. Despite the fact that number of potentially methemoglobin forming agents is very long, methemoglobinemia is still a case-report of patients admitting to the Emergency Departments. The patient was brought after consuming resin hardener for suicidal purposes from the Center of lower reference to the hospital Emergency Department with suspected burns of the gastrointestinal tract. The patient presented cyanosis, dyspnoea and brown-colored urine on admission.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 COVID-19 infection In Beta Thalassemia Major: Case series 2021-07-04T21:23:09+00:00 Lina Okar1*, Maya Aldeeb1, Rita Ahmad1, Mohamed A. Yassin2 <p>COVID-19 infection was first described in Wuhan, China after an increasing spread of atypical pneumonia of unknown pathogen. Unfortunately, this novel virus continues spreading causing a pandemic. Thalassemia considered one of the most common hemoglobinopathies. Beta thalassemia is the commonest type with a variety in clinical picture due to the deference in homozygous. A lot of vulnerable categories were at high risk of getting infected with the coronavirus and more even its complication. Despite the conflicting data and ongoing research on this topic, thalassemia patients were categorized among the high-risk population.<br>Here we present a case series describing the clinical progression of two splenectomised patients who has transfusion dependent beta thalassemia major.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Recurrent Post-Cardioversion Takotsubo Syndrome 2021-07-04T21:21:33+00:00 Jean Paul Mangion1, Geoffrey Horlait1 <p>Takotsubo syndrome (TTS) is characterised by transient regional wall motion abnormalities of the left or right ventricles often associated with new ECG changes (including ST-segment elevations, ST-segment depressions, T-wave inversions and QTc prolongation) in the absence of a culprit atherosclerotic artery which could explain the ventricular dysfunction. In this article we present an unusual case of recurrent TTS following electrical cardioversion in a 61 year old female patient who was admitted to our unit.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Metastatic bladder tumor from pancreatic adenocarcinoma 2021-07-04T21:20:01+00:00 Konstantinos M. Skrepetis1, Ioannis Efthimiou1, Zacharias Chousianitis1, Stavros Peroukidis1 <p>Metastatic pancreatic adenocarcinoma to the urinary bladder is extremely rare and has only been reported 4 cases worldwide. We describe such a case presented with hematuria and dysuria after ten months of the initial diagnosis. Immunohistochemistry helped to confirm the diagnosis of metachronous metastasis. Six months after being diagnosed with the bladder metastasis, progression with severe right hydronephrosis and mild dilatation of the left pyelocaliceal system palliated with an UventaTM metallic ureteral stent and a double J ureteric catheter.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Priapism as A Warning Sign for Chronic Myeloid Leukemia 2021-07-04T21:18:23+00:00 Boudreaux, J, BS, BA1, Haller, CN, MD2, Maslov, D, MD, MS1,2, Bateman, L, MD2 <p>CML is a chronic myeloproliferative disorder associated with activating mutations in tyrosine kinases forming a BCR-ABL fusion gene, causing hyperproliferation of neoplastic myeloid progenitors [1,2]. The incidence of CML peaks in the fourth and fifth decades of life [3]. In the United States, nearly 4,500 cases are diagnosed annually [3]. The onset of the disease is insidious due to the nonspecific initial “B symptoms,” such as increased fatigability, weight loss and weakness. The natural history of CML is slow with a median survival of three years if untreated [3,4]. The current treatment is targeted therapies to the BCR-ABL tyrosine kinase using imatinib or nilotinib and hydroxyurea. Although B symptoms are common, priapism can be an initial presentation of CML in 1-5% of cases [5]. Priapism is a urological emergency defined by a sustained erection of four or more hours. Hyperviscous blood in leukemias, such as CML, prevents appropriate venous drainage of the corpora cavernosa, resulting in failure of detumescence [4]. This case reports highlights priapism as a presenting sign of CML and reviews the pathophysiology between the association.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Ptosis resolved after cataract surgery – A case report 2021-07-04T21:16:19+00:00 Ming Chen, MD, MSc, FACS <p>It is well known in the literature that adult ptosis can be induced or worsen by cataract surgery even with modern sutureless clear cornea phacoemulsification. [1, 2, 3, 4,5,6,7,8] We are presenting this unusual case was the opposite. The ptosis resolved after cataract surgery. A possible effect from the successful management of dry eye disease before cataract surgery is explained.</p> <p>Drooping of the unilateral upper eyelid is unilateral ptosis. Ptosis may be myogenic, neurogenic, and aponeurotic from healthy aging, injury, eye diseases. [9, 10] Ptosis also can be associated with hard contact lens wear, immunological, degenerative, or hereditary disorders, tumors, or infections. [7]</p> <p>Patients with ptosis often present with a lower position of the upper eyelid, complain of a tired appearance, and defect in their superior visual field even blurred vision. The levator muscle controls the position of the eyelid and is innervated by the oculomotor nerve. The Mueller muscle also controls partially by providing sympathetic innervation. The deficiency of these two muscles may cause ptosis. [11]</p> <p>Hering’s law of motor correspondence of a ptosis lid can affect the contralateral lid position [5, 7] as the levator muscles work in synchrony with each other. Therefore, unilateral ptosis can induce a retraction of the contralateral lid or a pseudo retraction. When ptosis is causing visual field defects, the innervation input to both eyelids will increase to reduce the ptosis. There will be a compensatory elevation of eyebrow to reduce the amount of ptosis. [11] These phenomena need to be considered in the evaluation of unilateral ptosis for surgery. Another essential examination, such as Margin Reflex Distance 1 (MRD1), is the crucial measurement for ptosis besides levator function and palpebral fissure. MRD1 is the distance from the margin of the upper lid to the central corneal reflex (normal is between 4.0-4.5 mm). [11]</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Meningoencephalitis in a Child with Mycoplasma Pneumonia 2021-07-04T21:13:25+00:00 J. Kelly Smith, MD, FACP <p>The patient is a 15-year-old girl who presented with a 4-day history of fever, a persistent cough, and x-ray evidence of a right middle lobe pneumonia. On day 10 of her illness, at a time when she was afebrile and her pneumonia had cleared, she developed a severe headache and within hours lapsed into coma. Cerebral spinal fluid analysis and serological tests were diagnostic of a post-infectious meningoencephalitis due to Mycoplasma pneumoniae.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A severe case of toxic epidermal necrolysis which started with AGEP-like features: Does a new clinical type of drug eruption? 2021-07-04T04:40:17+00:00 Sevil Alan <p>Acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN) are adverse cutaneous reactions. Despite the fact that these 2 cutaneous reactions differ in presentation, prognosis, pathologic features, and treatment, overlap can exist between them, creating a diagnostic challenge. It has rarely been reported that AGEP overlaps or mimics TEN, while TEN which starting by mult?ple pustules like AGEP has not<br>been reported. The present study reports a rare case of a 14-year-old male patient with the clinical manifestations of multiple purulent bullae caused by amoxycillin ingestion. On 3. day dermatological examination revealed flaccid bullae and epidermal splitting with positive Nikolsky’s sign on right pectoral area, erosions on oral and anogenital mucosa. Histopathologic examination showed a massive inflammatory infiltration and epidermal necrosis indicated Steven Johnson syndrome. Later on added systemic symptoms with haemodynamic, respiratory imbalance and the patient was exitus. The case is discussed to reveal whether a new clinical pattern of drug eruption has been identified. We describe a patient with TEN who presented initially with clinical features of acute generalized exanthematous pustulosis (AGEP). To the best of our knowledge, one report drug eruption with purulent bulla and epidermal necrolysis has previously been documented, and therefore the present study is the second case report of its kind. Because the initial presentation of such adverse drug reactions may vary, diagnosis is difficult and dermatologists must careful the possibility of mimics among adverse cutaneous reactions.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 15q11.2 Deletion Syndrome: Expanding the Phenotype 2021-07-04T04:38:19+00:00 Luis F. Escobar1*, Rebecca Carr1, 2, Lauren Bogue1 <p>Background: Although multiple reports exist in the literature of patients with 15q11.2 deletion syndrome, the variability of the phenotype has made clinical delineation difficult. Neuro-developmental scores have not been previously reported. We present clinical findings in a group of 16 patients referred to our center for evaluation and management of neurodevelopmental difficulties.</p> <p>Methods: All patients were seen in our center between 2005 and 2016. They were seen by a clinical geneticist and their diagnosis of 15q11.2 deletion syndrome was confirmed by a microarray analysis. Bayley Scales of Infant Development was done and provided a mental developmental index and a motor developmental index. The data collected was then compared to previous reports in the literature of patients with 15q11.2 deletion syndrome.</p> <p>Results: The reviewed group consisted of 10 males and 6 female patients between the ages of 3 and 15 years. The most common clinical findings included developmental delay (94%), hypotonia (88%), ADHD (75%), anxiety (50%), feeding difficulties (44%), autism (31%), dolichocephaly (25%), 2-3 toe syndactyly (19%), seizure activity (19%), and congenital heart disease (13%). Additional findings included prominence of the metopic suture, epicanthal folds, micrognathia, ankle torsion, incontinence, and sleeping difficulties. Our developmental evaluation by the Bayley Scales of Infant Development indicated an average Mental Developmental Index of 75 (NL = &gt;85) and Motor Developmental Index of 75 (NL = &gt;85) in the patients less than 3 years old. Close to 43% of patients had an occipitofrontal circumference (OFC) greater than or equal to the 97th.</p> <p>Conclusion: The data provided here intends to expand the phenotype of the 15q11.2 deletion syndrome. Neurodevelopmental scores have not been previously reported in 15q11.2 del syndrome which were found to be in the mild developmental delay range.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A rare case of Hepatic Sinusoidal obstruction syndrome due to a drug use 2021-07-04T04:36:40+00:00 Melike Ruşen Metin1, Hasan Aydın2 <p>Here, we report a case of hepatic sinusoidal obstruction syndrome(HSOS) of a 30 years old female patient with Ulcerative colitis(UC) who was being treated by mesalazine.<br>The patient was admitted to the emergency unit by harsh and cramping abdominal pain, she had increased AST-ALT-Bilirubine and GGT levels in the blood laboratory analysis. In the Portal venous Doppler US; Splenomegaly and coarse granular appearance in liver parenchymal echogenecity were observed. In the abdominal CT, Splenomegaly was confirmed.<br>In the Dynamic Abdominal MRI, pathognomonic liver finding which was the patchy contrast-enhancing reticular appearance, was visualized and the exact diagnosis was handled by true-cut biopsy.<br>The aid of Dynamic Abdominal MRI to the early diagnosis of HSOS was also demonstrated in this case.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Surgical difficulties with a giant carcinoid in the anterior mediastinum 2021-07-04T04:35:05+00:00 Miklos Boros MD1*, Ulf Hermansson MD1, Ingemar Vanhanen PhD1 <p>Atypical carcinoid in the anterior mediastinum is a rare neoplasm. In our case the huge mediastinal carcinoid was treated with surgery using a median sternotomy and clamshell incision because of the extension of the tumor. We describe our difficulties under the surgery and take a look at the literature.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Classic Neuroimaging Features in a Case of Congenital Muscular Dystrophy [Fukuyama Variant] – a Rare Cause of Infantile Hypotonia in an Indian Male 2021-07-04T04:30:56+00:00 Dr.Sayema1, Dr. Shaan Hassan2, Dr. Ibne Ahmad3, Dr.Shagufta Wahab4 <p>The aetiological diagnosis in an infant with hypotonia is a challenging task for a clinician due to variable and long list of differentials [1]. It could be due to an insult within the central nervous system (CNS) or less commonly result from a peripheral defect at neuro-muscular level and other miscellaneous causes (rickets, hypothyroidism) [2]. Most commonly it is a central hypotonia where the muscular weakness is absent or not profound. In Indian scenario, it is mostly idiopathic central hypotonia, followed by HIE (cerebral palsy) [2]. In cases of cerebral palsy, neuro-imaging reveals the severity of affliction. The peripheral aetiologies like congenital myopathies, congenital myasthenia, infantile botulism etc. are rather rare occurrences.</p> <p>Infants with congenital muscular dystrophy have muscular dystrophy, central neural affliction and involvement of multiple systems (skeletal, cardiovascular, respiratory, ocular etc.). It is a rare disease with studies in Italian population showing point prevalence of 0.563 per 100,000 total population [3]. Unlike HIE, the affliction in CMD is multi-system and it is an inherited disease with variable penetration, the distinction between the two is important to a clinician for the management. CMDs generally have early fatal outcome. So, early diagnosis is important for prognostication, supportive treatment and genetic counselling. The neuro-imaging findings of CMD clearly stand out from the rest aetiologies and can guide a clinician to go in early , for an invasive test like muscle biopsy which is the gold standard diagnostic test .</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 UNEXPLAINED HARMONY; TUBERCULOSIS AND SARCOIDOSIS 2021-07-04T04:28:54+00:00 Menaka Thilakarathna1*, Sasanka Wijayawardhane1, Aflah Sadikeen1, Amitha Fernando1 <p>Sarcoidosis and tuberculosis are chronic granulomatous diseases with predominant pulmonary involvement. Simultaneous occurrence of sarcoidosis and tuberculosis is a rarely encountered clinical entity. We present two Sri Lankan males with coexisting bacteriologically confirmed tuberculosis and histologically diagnosed sarcoidosis. Careful and timely commencement of anti-tuberculous treatment followed by steroids treatment for sarcoidosis lead to improvement of both conditions. These cases are reported to describe the dilemmas in diagnosis and management of this underrecognized clinical entity.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Microangiopathic hemolytic anemia/Acquired Thrombotic Thrombocytopenic Purpura as a first presentation of pancreatic cancer 2021-07-04T04:26:06+00:00 Meshaal Alanzi1, Khalid E. Ahmed1, Bassel Dakkak1, Mhd Baraa Habib1, Ahmed O. Saleh2, Mohamed A. Yassin3, Shehab F. Mohamed3 <p>Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening hematologic disorder. It is mainly characterized by thrombocytopenia, microangiopathic hemolytic anemia (MAHA), fever, renal impairment and neurological abnormality. Plasmapheresis and steroids are the standard of care.</p> <p>MAHA/TTP can be the initial presentation of solid organ malignancies especially gastrointestinal tumors. We report a 56-year-old female patient who presented with progressive back pain, tiredness, easy bruising, fever and weight loss. Laboratory results showed anemia, thrombocytopenia, and schistocytes in the peripheral smear. An initial diagnosis of thrombotic thrombocytopenic purpura (TTP) was made on the basis of clinical presentation and lab findings. She was treated with corticosteroids and plasma exchange but with no major response.</p> <p>CT abdomen and PET CT were suggestive of pancreatic carcinoma with extensive lymph nodal, organs and bone metastases. Supraclavicular lymph node biopsy was compatible with metastatic adenocarcinoma. As a result, the diagnosis of pancreatic cancer was established and the decision was for palliative treatment.</p> <p>This case highlights the need to consider malignancy in patients with MAHA/TTP especially if it does not respond to plasmapheresis. Hence, the treatment of MAHA/TTP could be directed to the underlying malignancy if available.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Visceral Angioedema caused by Angiotensin Receptor Blocker 2021-07-04T04:24:35+00:00 Arun Minupuri, Roshni Patel, Jesus Salas Noain <p>In literature we see clear evidence of Angiotensin Converting Enzyme inhibitors (ACEI’s) causing visceral angioedema, but further evidence is required to establish the causality for Angiotensin Receptor Blockers (ARB’s). With the widespread usage of these anti-hypertensives and the potential serious adverse effect in the form of angioedema; clinicians should consider medication induced as part of their differentials.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Atypical Presentation of Renal Cell Carcinoma in a 47-year Old Hypertensive Female Patient – Case Report 2021-07-04T04:22:46+00:00 Mihai Gherman1, Anca Madalina Sere2, Ioana Duca3 <p>Characterized by a wide range of nonspecific symptoms, renal cell carcinoma tends to be found only at advanced stages or when kidney failure occurs.<br>In this case report we describe the incidental finding of a 6 cm renal cell carcinoma in a 47-years old hypertensive female patient with peculiar symptomatology. Contrast-enhanced-US showed supplementary intratumoral necrotic areas rising the suspicion of renal carcinoma, which was confirmed by CT and histology. Incidental detection rate of renal masses has increased, ultrasound, and especially contrast-enhanced-US having an important role in its diagnosis.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Obturator Internus Muscle Abscess (OIMA) Successfully Treated With CT-Guided Trans-gluteal Drainage and Antibiotics. A Case Report and Literature Review 2021-07-04T04:21:06+00:00 Mazhar Fuad Vayalil, MD; Ahmed Khalil Attia, MD; Adel AlSabahi, MD; Ardeshir Motazedian, MD; Mohammed Munir Bakdash, MD <p>Background: Obturator Internus Muscle Abscess (OIMA) is a rare cause of infection around the adult hip with a handful of cases reported in the literature. The management usually consists of antibiotics and open surgical drainage.<br>Case: We present a case of a 38-year old diabetic gentleman with an OIMA causing mass effect and shifting of intrapelvic organs. To our knowledge, this is the first case that was successfully treated with CT- guided trans-gluteal drainage and culture-specific antibiotics.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Rhabdomyolysis requiring emergency dialysis as a consequence of simultaneous administration of simvastatin and clarithromycin 2021-07-04T04:19:24+00:00 Michael Toolis1, Iouri Banakh2, John Botha3 <p>Iatrogenic complications from polypharmacy have significantly increased over the past decade and clinicians and pharmacists must remain aware of potentially dangerous drug interactions 1–3. Our case is a reminder of the potential for significant patient harm from drug interactions when additional medication that is seemingly innocuous is prescribed in addition to a patient’s regular long-term medications. Our case also highlights the diagnosis and management of rhabdomyolysis and acute kidney injury.</p> <p>A 75-year-old Caucasian male presented to the emergency department with nausea, bilateral calf tenderness and a reduced urine output. Creatinine Kinase (CK) levels demonstrated severe rhabdomyolysis and the patient’s creatinine was significantly elevated with a concurrent metabolic acidosis requiring urgent renal replacement therapy in the intensive care unit (ICU). He was recently prescribed clarithromycin 500mg twice daily as part of Helicobacter pylori eradication therapy in addition to his regular combination therapy of simvastatin 80 mg and ezetimibe 10 mg daily dose.</p> <p>Statins may cause dose dependent Statin Associated Myopathies (SAMs) such as myositis and rhabdomyolysis and are metabolised by the hepatic cytochrome P450 (CYP450) 3A4 enzyme4,5. Clarithromycin is a potent CYP450 3A4 hepatic enzyme inhibitor that leads to significantly elevated plasma levels of statin medications, increasing the risk of SAMs4,6–8. Our patient responded to the cessation of the offending medications and initiation of continuous renal replacement therapy. This case demonstrates the dangerous side effects and interactions of commonly prescribed medications.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Primary Mucosal Melanoma Mimicking High Grade Urothelial Carcinoma: A Potential Diagnostic Pitfall 2021-07-04T04:17:50+00:00 Dr Christopher Julien, Dr. Xiaowei Xu, Dr. David Elder, Dr. Lauren Schwartz, Dr Norge Vergara, Dr Karen Gustafson, Dr Priyanka Karam, Dr. Priti Lal <p>Primary malignant melanomas of the genitourinary tract are rare, representing &lt; 1% of all cases of melanoma1,2. We report a case of a 68-year-old female patient with primary malignant melanoma of the urethra with morphology mimicking that of high grade papillary urothelial carcinoma. The patient presented following a workup with an outside urologist that revealed a urethral mass. The patient complained of urinary incontinence and pelvic pain at initial presentation. A CT scan of the abdomen &amp; pelvis revealed a soft tissue density within the vaginal vault, consistent with urethral cancer. A cystoscopy and urethral excisional biopsy was performed. Histologic examination of the specimen revealed an invasive tumor composed of epithelioid cells with prominent eosinophilic cytoplasm forming papillary structures. However, the tumor cells were negative for CK7, CK20, GATA 3 and Pancytokeratin and positive for S-100, SOX 10 and Melan A. The case was ultimately diagnosed as malignant melanoma.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 COVID19 infection revealed chronic myeloid leukemia in chronic phase: A case report 2021-07-04T04:16:07+00:00 Khaldun obeidat1, Mohamed aboukamar2, Mohamed A Yassin3 <p>COVID-19 outbreak has been a serious threat and it has been reported with different presentations and complications, here we report a 39 year old healthy male who presented with respiratory symptoms and investigation revealed that he is positive for SARS-CoV-2 and work up for Leukocytosis confirmed the diagnosis of CML.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A rare case of Pleuroparenchymal fibroelastosis in Sri Lanka 2021-07-04T04:14:14+00:00 Prasanjanie A. Jayasinghe, Ruwanthi Jayasekara, Amitha Fernando <p>Pleuroparenchymal fibroelastosis (PPFE) is a very rare interstitial lung disease which carries many challenges in the process of diagnosis. A 73 years old female was evaluated for exertional dyspnea with CXR PA evidence of bilateral upper lobe fibrosis and pleural thickening. HRCT revealed typical features suggestive of PPFE. Lung biopsy was not performed considering the risk. Though it is rare PPFE should be considered when evaluating bilateral apical fibrosis. Proper radiological evaluation is paramount important in the process of diagnostic evaluation. Performance of lung biopsy as an essential criterion should be reconsider with associated risks.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Logical Beauty Harmony and Natural Shape zones (NSz) 2021-07-04T04:11:00+00:00 Noviello S, Gritzalas K, Maroni A, Tocchio M, Cogliandro G, Di Benedetto N <p>The concept of beauty in the world is certainly influenced by ethnicity and cultural factors, but generally harmony, balance and simmetry are common characteristics positively considered by every population.<br>Logical Beauty Harmony is an innovative System for using filler and botulinum toxin in aesthetic medicine based on Natural Shape zones (NS zones). These compartment consist of strategic sequential injection areas that allow creating, improving or restoring adequate volumes, guaranteeing natural results and expressiveness.<br>Starting from the recent acquisitions of Functional Anatomy, Physiology of Aging, Product Rheology and considering the objective analysis of the characteristics of harmony of each individual we have developed an approach that uses injectables in a targeted way using Support and Lifting vectors at the level of Upper, Middle and Lower Third of the face, injecting first deep and then passing to the surface.<br>The face is divided into vertical and horizontal proportions. These simply but fundamental principle of facial proportion, modified by recent anthropometric studies, have found their way into the teaching and practice of cosmetic facial medicine and surgery.<br>The series of data that can be detected by applying the previous parameters offers the chance of identify the variants that the face can present, so as to make eventually those changes that lead closer to the ideal model. In planning the treatment, the study of the different parameters, proportions, lines, ideal movements and angles linked to the comparison of the measurements of the different parts of the face will be more useful in determining type and extent of the corrections to be made.<br>9 treatment protocols for the face have been precisely established.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Paratesticular Ewing’s sarcoma: A case report 2021-07-04T04:09:06+00:00 Dr Samia Khalfi1, Dr Zakaria.Youbi1, Dr Meryeme Belhouari1, Dr Hasna El Khiraoui2, Pr Hassan Jouhadi1, Pr Farida Marnissi2 <p>Introduction: Ewing extra bone sarcoma is a rare entity accounting for 4% of soft tissue tumors1 and 1.5 to 4% of sarcomas2,3. It usually occurs in the extremities or soft tissues deep, cutaneous and subcutaneous. Paratesticular localization is exceptional4. We are reporting a case of paratesticular Ewing’s sarcoma in a 19-year-old patient by neoadjuvant chemotherapy followed by surgery.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 SURGICAL PRACTICE IN A MEDICAL COLLEGE HOSPITAL IN COVID TIMES 2021-07-04T04:07:04+00:00 Rekha A1, Dinesh KB2, Sivarahini3, Arihanth Ravichandran4 <p>Introduction: We studied the incidence of surgical admissions in our hospital and the presentation of COVID patients</p> <p>Results: Of the 190 patients who were admitted during the lockdown period, 5 patients were COVID positive. Soft tissue infections especially diabetic foot and appendicitis were the common presentations</p> <p>Conclusion: The theory of obliterative emboli could account for the overall surgical presentations seen due to COVID 19.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A Patient with ACHOO – The Autosomal Dominant Compelling Helio-Ophthalmic Outburst syndrome 2021-07-04T04:05:28+00:00 J. Kelly Smith, MD, FACP <p>Case report:</p> <p>The patient is a 36-year-old woman who was referred to our allergy-immunology clinic by her primary care physician to be assessed for a possible allergic disorder.</p> <p>The patient states that since early teenage she has had frequent bouts of sneezing generally preceded by nasal itching and often occurring when she first goes outdoors. She denies having a chronic cough or wheezing and has no symptoms suggestive of allergic conjunctivitis or sinusitis. She has not had urticaria or anaphylactoid reactions. Her mother and 29-year-old sister have similar complaints but have never been assessed for possible allergies. The patient’s medical history is otherwise unremarkable.</p> <p>On physical examination her vital signs were within normal limits. Her conjunctivae were not inflamed or edematous and she had no edema or pallor of her nasal mucosa and no tenderness of her paranasal sinuses. Her lungs were clear to auscultation and free of wheezes on deep breathing. The remainder of her exam was unremarkable.</p> <p>Laboratory assessment revealed a normal complete blood count and metabolic panel. Skin testing to 66 regional allergens was negative, and her serum IgG, IgA, IgM, IgD, and IgE levels were within normal limits.</p> <p>Because she was suspected as having ACHOO, she was dark adapted and then exposed to a bright light which instantaneously precipitated her nasal itching and sneezing, confirming the diagnosis.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Intra Cholecystic Papillary Tubular Neoplasm – A Case Report Of A Rare Differential Diagnosis Of Carcinoma Gall Bladder 2021-07-04T04:03:02+00:00 Dr. Sana Aboosalih1*, Dr. K. R. Manoj Prabu2, Dr. P. Jayaganesh3, Dr. Pichaimuthu Anbalagan4, Dr. Devy Gounder Kannan5, Dr. Arcot Rekha6 <p>We present a case report of a 57 year old lady who presented with complaints of right sided upper abdominal pain. The patient was initially diagnosed with carcinoma gall bladder(CAGB) by CECT Abdomen and PET CT imaging studies. Intra cholecystic papillary tubular neoplasm of the gall bladder(ICPN) was diagnosed after histopathological examination of the radical cholecystectomy specimen. ICPN can be managed with a cholecystectomy if the diagnosis is known pre operatively as the prognosis for ICPN is much better as compared with that for gallbladder adenocarcinoma.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Evaluation of laboratory risk indicator for necrotizing fasciitis (Lrinec) scoring system for diagnosis of necrotizing fasciitis in patients presenting with soft tissue infection 2021-07-04T03:55:28+00:00 Naresh Duthaluri, Adith C, Prabhu P, Rekha A <p>Necrotizing soft tissue infection represents a diverse process; the term itself encompasses a continuum ranging from pyoderma to life threatening infections (clostridial gas gangrene with myonecrosis, anaerobic cellulitis, and severe, necrotizing vibrio infections). These can occur in any anatomical area but the commonest site is the extremities. Necrotizing fasciitis is often underestimated because of the lack of specific clinical findings in the initial stages of the disease. The paucity of specific cutaneous signs to distinguish necrotizing fasciitis from other soft tissue infections such as cellulitis makes the diagnosis extremely difficult. The first and most important consideration for an accurate, prompt diagnosis is to have a high index of suspicion. It has been shown by numerous studies in the past that early recognition and surgical intervention at the earliest is the sole factor in preventing the morbidity and mortality in patients with necrotizing fasciitis [1-3]. So a scoring system which is easy to follow and cost effective with high positive and negative predictive value is required. One such scoring system is the LRINEC scoring system devised by Wong et al [4] in 2005 which claims to have a positive predictive value of 92.0% and negative predictive value of 96.0%. The mortality in necrotizing fasciitis is as high as 34%. [5] We evaluated LRINEC scoring system in patients presenting with symptoms and signs suggestive of soft tissue infection that progresses to necrotizing fasciitis in Sri Ramachandra Medical College and Hospital, Porur, Chennai over a period of two years.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Secondary hyperparathyroidism and symptomatic hypercalcemia: overlooked complications of chronic liver disease 2021-07-04T03:48:35+00:00 Hoilat JN1, Hoilat GJ2, Kadan S3, Emanuele MA1 <p>A 71-year-old female with biopsy-proven liver cirrhosis was brought to the ER due to confusion for 5 days. She was diagnosed with acute decompensated liver disease and hepatic encephalopathy. Investigations also revealed PTH-dependent hypercalcemia. Both of these entities could be causing her symptoms. Neck ultrasound did not reveal any parathyroid lesions. Alteration in mental status persisted even after the management and resolution of hepatic encephalopathy. Symptomatic resolution occurred after normalization of her calcium levels which required normal saline, cinacalcet as well as calcitonin over the course of 7 days. Hypercalcemia secondary to chronic liver disease should be considered in the differential diagnosis of patients with liver cirrhosis presenting with an altered mental status. Hypercalcemia of chronic liver disease is not always transient and managed with normal saline as previously reported; It could necessitate more aggressive therapy with calcitonin and cinacalcet as reported in this case.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Pseudo-endocarditis secondary to ruptured posteromedial papillary muscle with anatomical variation: A Case Report 2021-07-04T03:46:40+00:00 Natassja Moriarty, MBBS1*; Jonathan Moriarty, MBBS2; Nadeem Attar,MBBS3; Adrian Brodison, MB chB4 <p>Myocardial infarction is the leading cause of papillary muscle rupture. This complication occurs in up to 5% of cases post MI and although rare, it constitutes a cardiac emergency if left untreated.</p> <p>On this basis, a 59-year-old male presented with low-grade fever and atypical chest pain with raised inflammatory markers and troponin levels. He was treated for infective endocarditis after echocardiography revealed a mass on the mitral valve, which was presumed to be a mitral valve vegetation and so he completed a 6-weeks course of antibiotics followed by elective mitral valve replacement surgery.</p> <p>During surgery, it was discovered that there was no endocarditis. Instead an unusually small muscle head of one of the posteromedial papillary muscle groups had ruptured secondary to an inferior myocardial infarction. This ruptured muscle head was highly mobile and mimicked a mitral valve vegetation. The mitral valve was successfully repaired, and the right coronary artery grafted.</p> <p>He made a full recovery but developed new-onset atrial fibrillation for which he is awaiting elective cardioversion.</p> <p>One should have a high index of suspicion for diagnosing papillary muscle rupture as it may mimic valvular vegetation on echocardiography, especially if the papillary muscle involved is an anatomical variant.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Hormone Receptor Expression in Non Cancer Breast Lesions 2021-07-04T03:44:58+00:00 Arcot Rekha, Vimal Chander, Arihanth Ravichandran, Chitra S <p>Background Estrogen receptors (ER), Progesterone receptors (PR) expression is seen in non cancer breast lesions like juvenile fibroadenomas and phyllodes tumour. Materials and Methods This is a prospective study on a study population that comprised fibroadenomas and phyllodes tumor. Results While a few studies indicate that ER/PR expression correlates with a more benign outcome ,we did not see the same in our population. Ki 67 proliferation was greater in the stromal component of phyllodes tumours,compared to fibroadenomas.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Epithelial-myoepithelial carcinoma of floor of mouth: A case report of double clear cell variant with immunohistochemical correlation 2021-07-04T03:40:56+00:00 Mohamed.H.Ibrahim1, Hossam Abdel Halim2, Ihab S. Abd Elhamid3, Marwa M. Elshafei4 Shaimaa E. Ghazy5, Nermeen S. Afifi6, Ismail M. Shebl7 <p>Epithelial-myoepithelial carcinoma (EMC) is a rare biphasic low-grade malignancy accounting for only 0.5% of all salivary gland tumors. Commonly, EMC affects parotid gland (70%) and rarely affecting other salivary glands. Clearing of both, epithelial and myoepithelial cell types, is rare and gives an impression of a monocellular neoplasm. Case report: A 42-year-old male reported to Oral and Maxillofacial Surgery Department in Faculty of Oral and Dental Medicine, Misr International University with a painless growth in the floor of mouth since 5 years. The soft tissue window of computerized tomography (CT) revealed a well-circumscribed swelling in the sublingual space. The provisional diagnosis was pleomorphic adenoma. Results: The histopathological examination showed solid sheets of rounded to polyhedral clear cells forming lobes and lobules separated by connective tissue mucoid septa. A thin fibrous capsule, invaded with some tumor cells was also present. The presented pattern of clear cells together with the encapsulation of the tumor provides an impression of clear cell variant of monocellular neoplasm. Conclusion: The presented case relates to an epithelial-myoepithelial carcinoma originating from the sublingual salivary gland, which is a rare site for this lesion. Based on immunohistochemical staining, differentiation between the double clear cell types was confirmed using S-100 protein and SMA for the myoepithelial nature of the outer cells while the epithelial nature of the inner cells was confirmed by CK-19 and EMA. Thus, the diagnosis of double clear cell variant of EMC was given.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Successful experiments with Salvia officinalis and Salvia microphylla and COVID19 2021-07-04T03:38:44+00:00 Florent Pirot <p>This paper presents results of the author on Salvia officinalis and Salvia microphylla and COVID19. The results were achieved with dried Salvia officinalis leaves and with fresh Salvia microphylla leaves. The properties of fresh leaves appear with the taste as being much richer in antiviral agents, drying reduces the antiviral activity. The experiments presented in this paper are on the author himself, do not involve biosampling to confirm in laboratory but existing data in the published literature confirms the excellent efficiency of Salvia officinalis against COVID19 and a large array of other diseases. The self-experiments were very successful against COVID19, opening a path for natural treatment.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A rare case of Rubinstein-Taybi Syndrome and gynecological malignancy 2021-07-04T03:36:53+00:00 Mahfooz, Faisal, Bartholomew, Chase, Franquemont, Stephanie, Mathew, Jr., Jacob; <p>Rubinstein-Taybi syndrome (RSTS) is a congenital syndrome most associated with mutations on chromosome 16p13.3 that can result in both benign and malignant neurologic and hematologic neoplasms of various primary origins. We present the case of a 39-year old female with RSTS who presented with severe abdominal and pelvic pain. Abdominal and pelvic imaging revealed multiple masses involving the uterus, liver and spleen concerning for malignancy. Biopsies from the endometrium and cervix confirmed this as a poorly differentiated, widely invasive squamous cell carcinoma. This represents the first case of primary squamous cell carcinoma of gynecologic origin in a patient with Rubinstein-Taybi syndrome. This case aims to raise awareness of the gynecological malignancy in patients with RSTS as well as serves as a reminder to clinicians to have a broad differential diagnosis in all patients which may help lead to early recognition of pathology.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Male Sexual Assault – A Case Report of Foreign Body in the Rectum from Sexual Assault by Female Partner 2021-07-04T03:34:38+00:00 A. Monday Yilkudi.1, Nathaniel Adewole.2, Kenneth Onyejekwe.1, Pius Ogelekwu1, Stephen Edino1 <p>Most rectal foreign bodies (FB) are a result of insertion for sexual gratification. FB in the rectum as. result of sexual assault in males by the female partner is rare. A 32-year-ol man presented with a 6-day history of deep anal pain and lower abdominal pain, following an assault by a female partner while he was drunk. Physical examination and plain radiography confirmed a FB in the rectum. The FB was removed at exploratory laparotomy following failed attempt at trans rectal removal under spinal anaesthesia. The FB was confirmed to be a perfume canister. The patient has remained well at two months of follow up.<br>Male sexual assault by female is not uncommon and can lead to disastrous effects. The female sexual assault on male is underreported and reported usually when there are complications. There is need to do more in-depth study to investigate the incidence of this.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 A world in the head: Brain abscess caused by Paradoxical embolism due to pulmonary arteriovenous fistula as a debut of hereditary hemorrhagic telangiectasia 2021-07-04T03:32:22+00:00 Calle-Gómez, MI., Escobar- Sevilla, J., Domingo-Roa, S., Yagui Beltrán, S., Constan De la Revilla, E., Mediavilla García, JD. <p>66-year-old patient with a history of alcoholism and smoking, chronic iron deficiency anemia treated with oral iron who was admitted for streptococcal brain abscess, during the etiological study we found arteriovenous shunt on echocardiography and pulmonary arteriovenous fistula, undergoing endovascular closure of the same during stay. In the physical examination, perioral teleangiectasis was observed, when meeting the Curaçao criteria, a genetic study of hereditary hemorrhagic teleangiectasia was requested, which was positive.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Feeling of Imminent Death after Long Bone Surgery 2021-07-04T03:30:09+00:00 Guzmán Rodríguez, Raúl; Borregón Rivilla, Miguel; Palomares Morales, Aitana <p>71-year-old male patient with hypertension, obesity and personal history of prostate adenocarcinoma with blast bone metastases.</p> <p>Admitted after fall and pathological right pertrochanteric fracture. Programmed surgery is performed by means of endomedullary nailing on the fractured right hip and prophylactic left hip. Pre-surgical nasopharyngeal exudate for coronavirus is positive, with no apparent clinical translation.</p> <p>Three hours after surgery, the patient begins with dyspnea, central thoracic pain of a pleuritic nature and a feeling of imminent death. Physical examination reveals poor general condition, hypotension, diaphoresis, tachypnea and desaturation, without neurological affectation. Treatment is initiated with intensive serotherapy, oxygen therapy and analgesia.</p> <p>Analysis reveals troponin and normal NT-proBNP with elevated LDH and D-dimer, as well as mild metabolic acidosis. The electrocardiogram and transthoracic echocardiogram do not show any alterations. Urgent pulmonary CT-angiography targets signs compatible with fat embolism (see figure 1).</p> <p>The hemodynamic and respiratory instability improve progressively, not requiring admission to ICU, appearing at twelve hours bilateral axillary petechiae.</p> <p>Pulmonary fat embolism syndrome is rare, and can appear after fractures and long-bone surgery [1]. The classic clinical triad is hypoxemia, neurological alteration and petechiae[²], due to the presence of fatty emboli in the circulation and pulmonary parenchyma.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Long Progression-free-survival Pancreatic Carcinosarcoma Under Gemcitabine-nabpaclitaxel First Line Chemotherapy 2021-07-04T03:27:45+00:00 Miguel Borregón Rivilla, Katherin Martínez-Barroso, Alba Ramos Garrido, Irene Ramos Reguera, Beatriz Berzal Hernández, Manuel Alejandro Mazariegos Rubi, Cristina Gómez Palmero, Margarita Díez de los Ríos, Irene Otero Blas, Ana Belén Rupérez Blanco, Javier <p>Carcinosarcoma of the pancreas is a rare entity with short case series reported in the literature. Diagnosis is established by immunohistochemical examination including both carcinomatous and sarcomatous components. Prognosis is usually limited to 6-9 months life expectancy. Standard chemotherapy regimen is not well defined.<br>We present a case of pancreatic carcinosarcoma with long-time progression-free-survival under first line chemotherapy treatment with gemcitabine-nabpaclitaxel combination. Tumor histopathological and clinical characteristics are reviewed.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Bilateral Distal Humeral Fracture in a patient with Osteogenesis imperfecta During the Covid Pandemic– A Rare Case Report 2021-07-04T03:24:42+00:00 Dr. Vaisakh Reghuram1*, Mr. Milind Mehta2, Mr. Gautam Talawadekar3 <p>Introduction: Osteogenesis imperfecta (OI) is a genetic disorder which is characterised by bone deformity, low bone mass, connective tissue manifestations and brittle bones with history of multiple fractures. Although recurrent fractures are known in patient with OI, the occurrence of bilateral simultaneous fracture of humerus is quite rare.</p> <p>Presenting complaint and investigations: The patient had a fall in the outdoors during a storm during the height of covid pandemic and sustained injury to both arms. Radiographs revealed comminuted fracture of left distal humerus and transverse extraarticular supracondylar fracture of right humerus.</p> <p>Diagnoses, therapeutics interventions, and outcomes: Although, conservative measures were advised as per the guidelines for orthopaedic surgery during the covid pandemic for most of the fractures, the decision to operate was made considering the morbid obesity and hampered mobility due to bilateral above elbow plaster.The patient underwent staged open reduction and internal fixation of both distal humerus with anatomical locking plates in a span of 2 weeks. She recovered uneventfully with a good functional range of movements and resumed her routine activities.</p> <p>Conclusion: The treatment for complex and unusual fractures should be individualised and should take into consideration of patient’s general condition and safety.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Diffuse-type tenosynovial giant cell tumour of the temporo-mandibular joint: an indication for alloplastic joint replacement 2021-07-04T03:21:27+00:00 An-Sofie Vandeput1, MD; Michel Bila1, MD; Titiaan Dormaar1, MD; Anne-Marie Delsupehe2, MD; Constantinus Politis1, MD, PhD <p>A 25-year old female patient was referred to our department with a mass at the level of the right temporomandibular joint (TMJ). The patient experienced symptoms of paroxysmal pain of the TMJ and weight loss. Magnetic resonance imaging (MRI) revealed a tumour in the right masticatory space extending into the right TMJ, with invasion of the temporal bone. Surgical resection of the mass and total TMJ replacement surgery with a custom-made pros-thesis were performed. Final histological diagnosis of the resected specimen showed a dif-fuse-type tenosynovial giant cell tumour (D-TGCT). The multidisciplinary team’s decision was to give adjuvant radiotherapy; however, the patient declined further treatment. At 6 months follow-up, the patient had an excellent recovery with no signs of tumour recurrence on MRI. This is the first described case of D-TGCT treated with total TMJ replacement sur-gery using a custom-made alloplastic device.</p> 2020-12-18T00:00:00+00:00 Copyright (c) 2021 Case Report on Port Site Sinus 2021-07-04T03:14:07+00:00 SD Sandhya*, Joshua Jacinth* <p>Port site infection (PSI) is an infection which is seen at port site after any laparoscopic surgery or at the site where any other medical devices are inserted into the body. It is one of the rare but preventable complications of successful laparoscopic surgeries due to improper sterilization of instruments. PSI is already known to be a rare complication but if it is occurring because of mycobacterium then it is considered to be the rarest. One of the commonest causative organisms is Staphylococcus and mycobacterial species also. Antibiotics are prescribed based on culture sensitivity reports. If mycobacterium is seen to be the cause, then second line anti-tubercular drugs (ATT drugs) like Macrolide (Clarithromycin), Quinolones (Ciprofloxacin), Tetracyclines (doxycycline) and aminoglycosides (amikacin and tobramycin) are prescribed. A case of male patient is reported who underwent laparoscopic surgery (TAPP) and developed pus discharge from supraumbilical port site. Sinus tract excision for port site infection was tried two times but every time recurrence was seen. Anti-tubercular drugs was started by patient after collecting excision biopsy reports showing Langerhans cells which are associated with TB and progress was seen in patient.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A Case of Klinefelter Syndrome Presenting with Infertility and Gynaecomastia 2021-07-04T03:12:29+00:00 Odoh G1, Edah JO1, Uwakwe UJ1, Ofoha C G2, Ojobi JE3, Enamino M I4, Puepet FH1 <p>The term Klinefelters syndrome refers to a group of chromosomal disorders in which the normal male karyotype 46XY has at least one extra X chromosome. The 47XXY aneuploidy is the most common human male sex chromosomal disorder associated with infertility and hypogonadism .It has prevalence of 1 in 500 to 1 in 800 live births independent of race. The aim of this case report is to document the rare case in the literature with the view of raising awareness about its existence in our environment and beyond.<br>The Case: We present a case of a 31 year old black male patient with a 7 years history of progressive bilateral painless breast swelling that has rapidly increased in size over the past 3 years. He has no associated breast discharge. He also complained of associated infertility since he married his wife about 7 years ago despite regular unprotected intercourse within the same period. Hormonal assays done showed elevated gonadotropins( Leuteinising hormone and follicle stimulating hormone) , low levels of testosterone and elevated estradiol. Karyotype done revealed 47XXY karyotype.he was counseled on the need for assisted reproductive therapy, which he accepted. Subsequently, his wife was delivered of a baby boy following a successful assisted reproductive therapy by an obstetrician.<br>Conclusion: Klinefelter syndrome is a rare clinical syndrome but a common chromosomal cause of male infertility. The introduction of assisted reproductive therapy has greatly improved infertility outcomes in terms of achieving pregnancy and live births.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Evaluation of Macular Circulation in Patient with Sudden Visual Loss Secondary to Behcet’s Perifoveal Vasculitis by Using (Retinal Flow) Swept-Source Optical Coherence Tomography Angiography Map 2021-07-04T03:10:43+00:00 Almamoori Fawwaz*, Hara Mutaz. <p>Objective: To evaluate macular vascular circulation in patient with perifoveal vasculitis secondary to Behcet’s disease by using (Retinal Flow) swept source optical coherence tomography angiography map. Methods: We retrospectively review a 39-y old female patient, with history of Behcet’s disease, presented with history of sudden unexplained central loss of vision which was more significant on the right eye with best corrected vision (BCVA=0.1) and less on the left eye with best corrected visual acuity (BCVA=0.7). The clinical ophthalmic examination of both anterior and posterior segments for the both eyes were normal with no any signs of uveitis. Imaging with DRI Triton Swept Source (SS- OCTA) (Topcon, Japan) was performed for evaluation of both superficial and deep capillary plexus of macular area. Fluorescein angiography (FA) was used also for assessing foveal avascular zone features. Results: The SS-OCTA Retinal Flow map was more sensitive than FA in marking out hypoperfusion in both superficial capillary plexus (SCP), and deep capillary plexus (DCP), especially in the right eye which had the positive correlation with visual acuity. SS-OCTA Retinal Flow map was also sensitive in showing improvement of macular hypoperfusion after treatment of Behcet’s Perifoveal Vasculitis. Conclusion: OCTA is a noninvasive imaging modality that can be used to evaluate macular vascular changes in Bechet’s perifoveal vasculitis and can explain acute visual loss in Behcet.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Traumatic Tooth Aspiration: Case Report and Review of the Literature 2021-07-04T03:09:03+00:00 Georges El Hasbani1, Richard Assaker2, Jose Vargas Gamarra2, Christopher G Bertely2, Sami Rabah2, Jose Amaya Suarez2, Menachem Gold2 <p>In the setting of polytrauma, several foreign bodies could be aspirated, including avulsed teeth. Because a minimally responsive polytrauma patient could be at risk of airway compromise, emergency intubation is performed which can by itself lead to aspirated tooth. A complete dental examination is required to check for any fracture. A CT scan is the most sensitive modality for diagnosis. A rigid or flexible bronchoscopy is indicated for removal of the foreign bodies.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Late Presentation of Posterior Urethral Valve in a 24-Year-old Man 2021-07-04T03:07:20+00:00 OO Moemenam1, NR Njeze2 and OD Ray-Offor3 <p>Posterior urethral valve (PUV) is the most common cause of lower urinary tract obstruction in male neonates, with an incidence of one case per 8,000 to 25,000 live births1. The diagnosis is usually made prenatally or at birth, when male newborns are evaluated for prenatal hydronephrosis, or during early childhood, but rarely during adolescence or adulthood. Late presentation of PUV is rare and it has been estimated to account for 10% of cases2. Presentation in adulthood may occur due to the presence of a mild form of the disease devoid of the life threatening complications seen in children with the severe form3.<br>A rare case of PUV which manifested in adulthood with lower urinary symptoms is presented to create awareness of the likelihood of the disease outside the paediatric age group.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Levothyroxine malabsorption induced by gastroparesis in type one diabetic patient: effect of intravenous levothyroxine therapy case report 2021-07-04T03:05:33+00:00 Homaid Alsahafi, Bandar Damanhori, Faisal AL Malky, Ashjan Alrogi, Khulood Alkhuzaie <p>19 year old female known case of primary hypothyroidism on levothyroxine replacement, type one diabetes on insulin pump with good glycemic control and stable thyroid function, developed diabetic gastroparesis with worsening response to oral levothyroxine therapy. Her symptoms of hypothyroidism and her thyroid function improved dramatically by intravenous levothyroxine three times weekly for 4 weeks then she restarted on her usual dose of oral levothyroxine.<br>Intravenous levothyroxine three times weekly for 4 weeks followed by oral levothyroxine therapy maintained her euthyroid, improved hypothyroidism and gastroparesis symptoms till the date of editing of this report (more than 15 months.).</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Psychosis Due to Hypothyroidism: Are Antipsychotics Indicated? 2021-07-04T03:04:05+00:00 Deborah L. Sanchez, M.D. 1,2, Adam J. Fusick, M.D2, William B. Hudson, M.D.2, Theresa A. Schwitalla,M.D.2, Maria C. Catalano,D.O.2,3, Susan K. Schultz, M.D.1,2,4, Glenn Catalano, M.D. 1,2 <p>Objective: To present a case of thyroid-related psychosis and review the literature to assess evidence regarding the use of antipsychotic medications in patients who develop this condition.</p> <p>Data Sources: The OVID database was utilized to search for the terms “myxedema madness” and the combination of the terms “psychosis” and “thyroid.” The database was searched from 1946 until July 2018 and was limited to English language articles.</p> <p>Study Selection: A total of 25 articles were included in this study. These included 27 distinct case reports.</p> <p>Data Extraction: The abstracts of identified articles were reviewed. If an abstract was unavailable or inconclusive, the full article was reviewed. If there was no case report, or if the case was not clearly related to hypothyroidism, it was excluded. Authors assessed and identified cases included. Studies were excluded if recovery time was unreported; if cases included patients with pre-existing, chronic mental illness or intellectual disability, or if thyroid replacement medication was not initially administered.</p> <p>Results: Data suggested that there may be no benefit to treating thyroid-related psychosis with scheduled dosing of antipsychotics in addition to thyroid replacement. The review also suggested that male patients with thyroid-related psychosis seemed to respond more rapidly to thyroid replacement than female patients.</p> <p>Conclusions: Scheduled dose antipsychotic therapy was not observed to hasten recovery. Males with thyroid-related psychosis were observed to respond more quickly to thyroid replacement than females among the identified cases identified. Consideration should be given to initial trials of thyroid replacement alone in cases of thyroid-related psychosis.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Temozolamide-Associated Pancytopenia in a Patient with Glioblastoma Multiforme 2021-07-04T03:02:20+00:00 Kubra Bozkurt¹ , Esra Terzı Demırsoy2, Esma Turkmen Bekmez3, Dıncer Aydın4 <p>Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor. GBM treatment is a combined modality approach involving maximum surgical resection, adjuvant postoperative radiation and adjuvant chemotherapy treatment.There is a greater risk of hematological toxicity in concurrent temozolomide and radiation therapy. We reported that pancytopenia has been developed on a 54-year old female patient with GBM after concurrently used temozolomide and radiotherapy treatment. It should be kept in mind that this side effect may develop because the risk of morbidity and mortality may be elevated. Therefore, supportive therapies should be started immediately in patients where this toxicity developed.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Regional Anaesthesia for Lumbar Laminectomy- Case Series 2021-07-04T03:00:31+00:00 Idehen H O, Agbonkhese G, ⃰ Obeta E C, Imarengiaye C O <p>The use of central neuraxial anaesthesia for lumbar laminectomy is evolving in our centre with its attendant advantages like decrease in intraoperative blood loss, peri-operative cardiac ischemic incidents, postoperative hypoxic episodes, arterial and venous thrombosis, and it provides longer/ adequate postoperative pain control. Nonetheless, blindness a possible complication under general anaesthesia is preventable with regional anaesthesia, this is because patient is awake and there is no restriction in neck movement. This case series helps to provide feasibility of lumbar laminectomy under central neuraxial anaesthesia (spinal, epidural and combined spinal epidural anaesthesia).</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A Case Report of Warfarin Induced Coagulopathy and Upper Gastro Intestinal Bleeding 2021-07-04T02:58:46+00:00 Dr.K.Swapnaa <p>Warfarin is an oral vitamin k antagonist prescribed to those patients for the treatment and prevention of venous thromboembolism. The major challenges to be faced during the therapy were a greater risk for both major well as minor bleeding, which makes the regular monitoring of INR (international normalized ratio) mandatory. Here we report a case study of 76 year old male who presented to institution with the complaints of bleeding from oral cavity due to consumption of conventional anticoagulant therapy. Patient was on anticoagulation therapy for paroxysmal atrial fibrillation since 2011. The blood investigation revealed anemia (Hemoglobin: 6.1g/dl). He was immediately transfused with packed RBC and fresh frozen plasma to replenish the body reserves. Prothrombin time (PT)/INR was reported undetectable and warfarin was withheld from the past medications and was restarted at INR therapeutic range. Furthermore this case highlights the need for a better communication by providing counselling regarding all aspects of medications as well as lifestyle modifications and also by giving patient information leaflets.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Inadvertent epidural administration of remifentanil (Ultiva®) during labour analgesia 2021-07-04T02:56:46+00:00 Dany Khodra <p>The use of remifentanil patient-controlled analgesia for labour analgesia remains controversial. The high potency of the drug, the fear of serious adverse drug reactions and drug administration errors are all legitimate concerns. We report the case of a woman in labour who inadvertently received a remifentanil solution via epidural route. In addition to the risk of respiratory depression, the epidural administration of remifentanil contains glycine in its solution and is therefore contraindicated due to potential neurological injury. The patient received a total of 2 mg of remifentanil and 15 mg of glycine in her epidural over a long period before the error was identified. Interestingly the patient was mostly comfortable during labour and fortunately no maternal or neonatal adverse events occurred.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Pulmonary metastasis of a Dermatofibrosarcoma of Darier and Ferrand treated by IMATINIB: a case report 2021-07-04T02:53:49+00:00 Kamal EL BAKRAOUI 1, Mohamed TARCHOULI2, Ibrahim ELGHISSASSI 1, Rhizlane BELBARAKA3, Hassan ERRIHANI1. <p>Dermatofibrosarcoma (DFS) described by Darier and Ferrand represents less than 5% of soft tissue sarcomas and metastases only very rarely.<br>We report the case of a 51-year-old patient followed for six years for a DFS of the right thigh root recurrent several times after non-optimal surgical resections. The occurrence of thoracic pain associated with a cough with dyspnea, motivated the realization of a thoracic computed tomography (CT) showing a right basal pulmonary mass with pulmonary nodules. CT biopsy of one of the pulmonary nodules confirmed the metastatic nature of these lesions. The search for translocation t (17,22) could not be performed. A treatment based on imatinib has been started. The evolution was marked by the disappearance of the respiratory symptomatology and a good radiological response.<br>The advent of targeted therapy with imatinib transformed the prognosis for this disease, which was considered incurable at the metastatic stage.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Pseudo-Ortner Syndrome 2021-07-04T02:51:23+00:00 Nikhil Bhatia, MD1, Asha Ramsakal, DO, MBS, FACP2, Bjorn Holmstrom, MD, FACP, FHM3 <p>Ortner syndrome is vocal cord paralysis secondary to left recurrent laryngeal nerve palsy from atrial dilation. We present the case of a 28 year old woman with metastatic appendicular cancer to the peritoneum and pleura who experienced chest pain, progressive dyspnea and change in vocal quality secondary to esophageal impingement on the recurrent laryngeal nerve. This novel case of “Pseudo-Ortner Syndrome” further demonstrates the susceptibility of the laryngeal nerve to palsy secondary to mechanical impingement stemming from an unlikely distal non cardiac source.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Foreign Body Aspiration in Adult, What Would You Expect? Case Report 2021-07-03T21:41:14+00:00 Zeyad Faoor Alrais1, Mohamed Ibrahim Shoaib1, Hesham Mohamed ElKholy1, Asad Alsabbah2 <p>Foreign body (FB) aspiration is an uncommon but potentially life-threatening event, while the majority of accidental aspiration events occur in children, adults represent up to 25% of cases.<br>When the diagnosis is not established immediately, retained FBs may lead to recurrent pneumonias, bronchiectasis, recurrent hemoptysis, pneumothorax, lung abscesses, pneumo-mediastinum, or other complications. Extraction of aspirated FBs should be undertaken as soon as possible to alleviate acute symptoms and prevent long term complications.<br>FB aspiration is slightly more common in males. The vast majority of adult patients with FB aspiration have obvious risk factors for aspiration including neurological deficits with swallowing difficulties or altered mental status, neuromuscular disease, intoxication, or have an iatrogenic cause. Still, 10% of adult patients with FB aspiration have no known risk factors.<br>Our case is 35 y old male patient who was brought to Accident and Emergency department after being found unresponsive in the street, on arrival to hospital his GCS was 9/15 with pin points pupils , spontaneous breathing and hemodynamic stable . CT brain was unremarkable Patient failed to respond to repeated doses of naloxone and his GCS dropped with episode of apnea so was intubated and mechanically ventilated.<br>Follow up chest x-ray show opacification of the right lung, and ABG reveled hypoxia with respiratory acidosis in spite high ventilator settings, So CT chest was the best option which reveled bronchial obstruction mostly due to foreign body.<br>Urgent bronchoscopy was done and unexpectedly obstruction was due to chewing gum pieces, aspiration of four large pieces of chewing gum, following that patient remained in the ICU for 2 days where chest x-ray show significant improvement and he was weaned and extubated successfully.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Percutaneous Nephrolithotomy in the supine flank free modified position for the removal of a 3 year Double-J ureteral stent in a horseshoe kidney 2021-07-03T21:36:19+00:00 Michael Nomikos, Sarantis Papanikolaou, Anastasios Tsalavoutas, George Koritsiadis, George Athanassopoulos <p>Horseshoe kidney is one of the most common congenital renal abnormalities with increased incidence of stone formation. We present a case of an HIV seropositive patient with a both-ends encrustated 3 year forgotten DJ stent and a staghorn stone in the left moiety of a horseshoe kidney. He was treated with percutaneous nephrolithotomy in the supine flank free modified position and simultaneous cystolitholapaxy. Supine percutaneous nephrolithotomy is safe and feasible in horseshoe kidney and facilitates simultaneous thansurethral access for cystolitholapaxy.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A patient with dysphagia and muscle weakness 2021-07-03T21:34:09+00:00 Kelly Smith MD, FACP1*, Blair Reece, MD2, Clint Smith, BS1 <p>BACKGROUND:</p> <p>There are five major types of inflammatory myopathies (IM), including dermatomyositis, polymyositis, immune-mediated necrotizing myopathy, antisynthetase syndromes, and inclusion body myositis. Grouped together, the incidence of IM is &gt;4 cases/100,000 with a prevalence of 14-32/100,000. Type-specific IM diagnoses are based on the pattern of muscle weakness and the results of electromyographs, MRIs, muscle biopsies, and measurements of myositis-specific autoantibodies1.</p> <p>We report the case of an elderly man with an inflammatory myopathy whose presenting complaint was dysphagia.</p> <p>OBJECTIVE:</p> <p>To review the clinical and laboratory manifestations of inflammatory myopathy-associated dysphagia.</p> <p>CASE REPORT:</p> <p>The patient is an 81-year-old retired Navy aviator who presented with a chief complaint of difficulty in swallowing both solids and liquids of several months duration. The dysphagia was associated with bouts of coughing, the expectoration of white foamy sputum, increased production of saliva, a weight loss of 5 kg, generalized myalgias, and worsening fatigue and weakness.</p> <p>The patient had a past medical history of essential hypertension, hyperlipidemia, autoimmune thyroiditis, V617F JAK2 + essential thrombocytosis, white matter microangiopathy, and a small lacunar infarction of the right caudate nucleus. There was no family history of autoimmune disease.</p> <p>On neurological examination, testing of cranial nerves II-XII and sensation to light touch, pin, temperature, and vibration was normal. The shoulder and upper arm strength was diminished bilaterally without evident muscle tenderness, atrophy or fasciculations. The patient could not rise from the supine position without assistance nor keep his arms elevated above his head without fatiguing. The strength in his lower extremities was normal. Deep tendon reflexes were normal and plantar responses were flexor. He had a single Gottron’s nodule and a faint erythematous rash involving his scalp, back and forearms. His Myositis Disease Activity Assessment (MDAAT) is shown in Table 1.</p> <p>Table 1. Myositis Disease Activity Assessment Tool (MDAAT)</p> <p><br>Findings on laboratory assessment included a normochromic normocytic anemia, thrombocyth-emia, a positive FANA IgG titer of 1:1280, and elevated levels of creatinine phosphokinase (1,373 U/L), aldolase (25.8 U/L), and antibodies to Mi-2 alpha, Mi-2 beta, MDA-5 and NXP-2 antigens. Anti-doubled stranded DNA, anti-RNP, anti-SM, anti-Jo-1, anti-SRP, anti-TIF-1? and anti-synthetase antibody titers were negative. A modified barium swallow revealed severe oropharyngeal dysfunction with aspiration. An electromyograph, a muscle biopsy, and a MRI of cervical spinal muscles were indicative of an inflammatory myopathy.</p> <p>DISCUSSION:</p> <p>Dysphagia as a result of weakness of the oropharyngeal, laryngeal and esophageal musculature has been reported to develop in 10% to 73% of patients with inflammatory myopathy (IM) at some time during the course of their disease, and is most frequently seen in those with inclusion body myositis or malignancy- associated dermatomyositis.</p> <p>In a Mayo Clinic review of 62 patients with IM-associated dysphagia, 42% had inclusion body myositis, 29% dermatomyositis, 15% polymyosi-tis, and 15% an overlap syndrome. Dysphagia as the presenting complaint was most common in patients with inclusion body myositis (42%) followed by polymyositis and the overlap syndrome (11% each). IM-associated dysphagia had a mortality rate of 31% – 64% with the highest incidence of death occurring in patients with percutaneous endoscopic gastrostomies, an indirect measure of the severity of dysphagia. Death was most commonly the result of recurrent aspiration2.</p> <p>In a study of 92 patients with adult-onset dermatomyositis, Mugii and associates found that dysphagia was most prevalent in elderly patients, in males, and in patients with internal malignancies and/or elevated anti-TIF-1? antibody levels3. In keeping with this report, the presented case is an elderly man with clinical and immunological evidence supporting a diagnosis of dermatomyositis, including an erythematous rash, a Gottron’s sign, and anti-Mi-2, anti-MDA-5, and anti-NXP-2 antibodies – autoantibodies associated with myositis, a classic dermatomyositis rash, and possible malignancy (see Table 2).</p> <p>Table 2. Patient’s myositis-specific autoantibodies*</p> <p><br>Agents most commonly used and reported to be beneficial in treating IM-associated dysphagia include prednisone, azathioprine, methotrexate, intravenous immunoglobulin, hydroxychloroqui-ne, and mycophenolate mofetil. Interventional procedures include enteral feeding and cricopharyngeal myotomies and dilations2. Inclusion body myositis is often recalcitrant to immunosuppressive treatment and is more likely to require interventional measures4. Our patient’s dysphagia is improving on methotrex-ate and prednisone.</p> <p>It is important to note that myositis patients presenting with complaints of dysphagia and weakness may be misdiagnosed as having amyotrophic lateral sclerosis, a disease in which serum CPK levels may be elevated and bulbar onset is common.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Neonate with 10q Interstitial Deletion within the Long Arm of Chromosome 10- A Case Report and Literature Review 2021-07-03T20:27:12+00:00 Raja Nandyal1, Sara Hagan2 and Tavleen Sandhu3 <p>Introduction: Partial deletion of distal chromosome 10q was first reported in 1978 by Lewandowski1. Interstitial deletions within bands 10q25e10q26.3 are rare. Seven such cases were reported so far2. Patient Information: A term AGA male newborn was delivered at our perinatal center with antenatal diagnosis of unbalanced translocation of chromosomes 10 and 12, and fetal cleft lip and cleft palate. Blood was sent for chromosome analysis using GTG banding method. Baby had facial dysmorphism, left cleft lip, bilateral cleft of soft and hard palate, intact nasal septum, normal ears and micrognathus. Abdominal ultrasound showed absence of right testis in inguinal canal and abdomen (anorchia). Hospital course was unremarkable except for feeding problems requiring feeding team, plastic surgery planned at 2- 3 months of age, and taping of the cleft lip. He went home on day 7. Conclusion: Here, we reported an extremely rare case of a male newborn with an interstitial deletion within the long arm of chromosome 10 between bands 10q25.1 and 10q26.1, with dysmorphic features, along with a few unreported associations (atypical Pierre-Robin sequence and bilateral dorsal horn ventriculomegaly). We added a comprehensive review of literature on chromosome 10q deletions to the case report. We also listed clinical implications of 71 RefSeq and OMIM genes noted in that ~13.3Mb 10q deletion in the Appendix. Earlier detection of both common and rare chromosomal- genetic abnormalities might prepare the family and health care team to plan optimal care to the mother, and baby.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A Rare Case of Glandular Odontogenic Cyst With a Breif Review Of Literature 2021-07-03T20:24:12+00:00 1Dr. Priyadarshini, 2Dr. Prashant Patil, 3Dr. Vajendra Joshi, 4Dr. Kiran Kumar K R, 5Dr. Shilpa R T, 6Dr. Satyanarayana P <p>Glandular odontogenic cyst (GOC) is an extremely rare cyst of jaw bone with only 182 cases documented so far in the English literature. GOC is considered to be a locally aggressive lesion with high rate of recurrence. Anterior mandible is the most common site of involvement for GOC, involvement of the maxillary bone which is a rare occurrence. The clinical and radiographic finding of GOC are varied &amp; often pathognomic. As clinical &amp; radiographic findings are overlapping with those of other odontogenic cyst, a careful histopathological examination is needed to arrive at a definite diagnosis of GOC. In the present paper we reported a rare case of GOC in a 23yrs old male involving maxillary bone along with a review of literature focussing on clinical &amp; radiological presentation and treatment outcome.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Tracheal rupture after endotracheal intubation – a case report 2021-07-03T20:21:45+00:00 Jana Šimonová1, Róbert Šimon2, Janka Vašková3* <p>Tracheal rupture is a rare condition associated with high morbidity and mortality. Iatrogenic tracheal injury is also very rare and can occur as a serious complication after endotracheal intubation. We report a case study of tracheal rupture of patient with a history of rheumatoid arthritis and corticosteroid treatment during surgical procedure with orotracheal intubation in a supine position. Lesions were healed after conservative treatment without stenosis, signs of mediastinitis or local infection. Patient was able to undergo three other surgical procedures during the next 8 month without any other complications connected to endotracheal intubation.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Osseous metaplasia in thyroid nodule: A case report and review of literature 2021-07-03T20:20:10+00:00 Soha Yahya Hejazi1, Nisar Haider Zaidi1, Ahmad Ghanem2, Adel. A. Aljawhari1 <p>Objective: To present a case of osseous metaplasia in thyroid nodule. Introduction: Long standing thyroid nodules undergo changes. Sometimes they degenerate, may lead to hemorrhage or fibrosis and sometimes ectopic bone formation. Case report: 41 years old Yemeni married lady, presented to our surgical clinic with left thyroid nodule for 3 years duration. She had right thyroid lobectomy 6 years ago. She presented with left neck swelling and was taken to OR for thyroidectomy. histopathology came as extensive fibrosis and osseous metaplasia with small remnant of thyroid tissue. Discussion; Most thyroid stay longer with no complications but some undergo calcification or hemorrhage, fibrosis and sometimes osseous metaplasia. It may occur in benign or malignant thyroid swellings.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 The intriguing post –caesarean sinus : A case report 2021-07-03T20:18:27+00:00 Ranjit Kumar Sahu, Deepti Katrolia <p>The post caesarean fistula and sinus can take place due to tuberculosis , Crohn’s disease , deep pelvic infections or non absorbable sutures and even gauzes.<br>A thirty year old woman ( P1 ,L1 ) who presented with multiple discharging sinuses at left lower abdomen since five months . She underwent lower segment caesarean section 10 months ago.<br>On local examination , there were three linear scars two cm below the previous horizontal scar . The Ultrasound of local site revealed irregular loculated collections of size 3 × 2 cm in subcutaneous plane. We excised the sinus tracts ,but after two month came with reccurence . We did re- exploration and the sinus tract of size 9 cm was excised.<br>Sinuses reccur even without retained foreign body or chronic disease. The management does not differ with the size of sinus.</p> <p>&nbsp;</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 ISOLATED ORBITAL CYSTICERCOSIS… CAUSE OF PTOSIS IN CABBAGE EATERS 2021-07-03T20:16:49+00:00 Perwez Khan, Alok Ranjan, Jayati Pandey <p>PURPOSE: To report case of isolated orbital cysticercosis<br>METHODS: Patients with drooping of eyelid were referred to our hospital. Patients were evaluated and investigated to find the cause of ptosis.<br>RESULTS: Two patients with acute unilateral ptosis were referred to our hospital. Patients were investigated, blood test, stool tests and MRI were done to rule out the causes. In both the patients ptosis was due to involvement of LPS muscle by cysticercus larva. All the patients gave history of excessive consumption of cabbage and pork. The mainstay of treatment included oral albendazole (15 mg/kg/day) and oral prednisolone (1mg/kg/day) for 4 weeks. After 4 weeks, oral albendazole was stopped and oral prednisolone was slowly tapered over the next one month. The effect of above treatment was seen after few days with regression of swelling and improvement of signs and symptoms.<br>CONCLUSION: Orbital cysticercus stands as one of the major causes of ptosis in the lower socioeconomic status people who are consuming mainly unhygienic leafy vegetables such as cabbage, burgers and undercooked pork. Therefore, these patients should be vigorously evaluated on scans (MRI and CT) so that early diagnosis can be made and treatment can be given to prevent the permanent visual loss or dissemination to brain.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Transfer Factor Revisited: Treatment of Candida Prosthetic Valve Endocarditis 2021-07-03T20:15:09+00:00 J. Kelly Smith, MD, FACP1,2* <p>Candida prosthetic valve endocarditis (CPVE) is most commonly seen in persons who inject drugs intravenously or have indwelling catheters, pacemakers, or prosthetic joints that can serve as a nidus for candida suprainfection and seed the valve. Current treatment guidelines for CPVE include valve replacement and long-term antifungal therapy with intravenously administered Amphotericin B and parenteral or oral therapy with 5-fluorocytosine. Despite treatment, CPVE is characterized by a high recurrence rate (up to 36%) and a 5-year survival of less than 50%.<br>I review my past experience in treating recalcitrant CPVE with transfer factor (TF) immunotherapy and conclude that TF can be a valuable adjuvant in the treatment of CPVE that does not respond to conventional interventions.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Aberrant inferior suprarenal vessels crossing posterior pararenal space: a case report 2021-07-03T20:03:57+00:00 Maryna Kornieieva, Andrew Vierra, Abdul Razzaq <p>During routine educational dissection of a cadaver (63-year-old, male, USA), an atypical course of the left inferior suprarenal vessels via the posterior pararenal space was discovered.<br>Detailed analysis of the abdominal vascular pattern showed that the atypical inferior suprarenal artery represented a terminal branch of the left inferior phrenic artery. The last one branched off from the very beginning of the left renal artery, ascended between the fibers of the left crus of the diaphragm, then ran laterally giving off muscular branches and, finally, descended along the costal part of the diaphragm to the left posterior pararenal space. The terminal branch of the inferior phrenic artery pierced the retrorenal fascia and entered the perirenal space as an atypical left inferior suprarenal artery. It ran upward and medially crossing the anterior surface of the kidney to reach and supply the lower pole of the left suprarenal gland. The left inferior phrenic vein accompanied the artery taking a similar course. It received numerous tributaries passing via the posterior pararenal space, drained the inferior suprarenal vein, and opened into the left renal vein.<br>Such anomalous pararenal vascular pattern is a challenge for surgeons performing open procedures on retroperitoneal organs, not to mention specialists employing minimally invasive laparoscopic techniques. The anatomical variation reported in this paper requires urgent attention of the related specialists.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Penile Fracture – Case Series 2021-07-03T20:02:03+00:00 1Ann Rhoda Abraham, 2Narayanasami Bharath, 3Arcot Rekha <p>Fracture of the penis is a misnomer, the cause being rupture of one or both of the tunica albuginea that covers the corpora cavernosa. It usually occurs following sexual intercourse or masturbation. Here we report 2 cases of penile fracture in our institution. Ultrasonography was done which confirmed the diagnosis. In both the cases, the urethra was intact. Exploration with evacuation of the hematoma and repair of the tunica albuginea was done.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A rare branching pattern of the celiac trunk associated with an accessory aberrant cystic duct 2021-07-03T19:59:34+00:00 Maryna Kornieieva1 and Chase Doiron2 <p>During routine educational dissection of the upper part of the abdominal cavity in a female cadaver (67 years old, Netherlands) a unique association of two rare biliary and vascular patterns was discovered.<br>The gastroduodenal artery originated from the celiac trunk along with the right hepatic, gastric and splenic arteries, and gave origin to the accessory right and left hepatic vessels. The right hepatic artery took the course typical for the common hepatic artery; however, as a component of the portal triad, the artery was located behind the bile duct and portal vein. Next to the hilum of the liver, it branched off the cystic artery to the gallbladder and bifurcated into two segmental hepatic branches. The described hepatic vascular pattern was associated with the presence of an accessory aberrant cystic duct connecting the body of the gallbladder with the right anterior inferior segmental bile duct.<br>The case is reported to emphasize the importance of a detailed preoperative investigation of the patients considered for open and laparoscopic procedures on the liver and gallbladder documenting the variability of both the biliary and vascular patterns.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Ototoxicity and neurotoxicity from exposure to a mixture of organic solvents and noise, a case report 2021-07-03T19:57:54+00:00 Rebeca Velasco-Reyna1, Ana Luisa Nayeli Torres-Flores2, Rubén Rojo-Ramírez2, Guadalupe Aguilar-Madrid3, Arturo Torres-Valenzuela4, Cuauhtémoc Arturo Juárez-Pérez4 <p>Background: Neuropsychological alterations and decreased hearing, are related to organic solvents (OS) exposure; and if noise is present it potentiates the hearing damage. Aim: to evaluate neuropsychological performance and hearing of a 50 years old worker, occupationally exposed to OS mixtures for 26 years (toluene, ethyl acetate and isopropyl alcohol) and noise &gt; 85 dB (A). Design of study: Report of a case assessed by Neuropsychological tests, CT and SPECT studies of hearing and clinic-occupational history. Results: He presented, loss between 35 to &gt; 55 dB HL of his hearing in both ears, both in low frequencies (125 Hz-2 kHz) as well as the treble ones (3-8 kHz), in relation to his age. There was an otoacoustic emissions absence at the same frequencies. He showed cerebellar atrophy, cognitive, motor and emotional disorders. Conclusions: We Integrated diagnosis of: moderate to severe hearing loss, mental and behaviour disorders due to the simultaneous exposure to noise and an OS mixture, mainly toluene. It should fully evaluate workers exposed to noise and OS.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Crowned dens syndrome: a case report followed by an update on differential diagnosis and treatment 2021-07-03T19:55:55+00:00 Yahya El Soufi**, Georgio El Koubayati**, Ahmad El Kayed**, Mariana Mezher** Karen Nicolas*** and Tony El Murr* <p>Introduction</p> <p>Crowned dens syndrome (CDS) is a rare clinical presentation of chondrocalcinosis or calcium pyrophosphate crystal deposition (CPPD) disease, characterized by fever, neck pain and stiffness, associated with increased biological markers of inflammation. Diagnosis is made mainly via imaging, and the best modality remains the magnetic resonance imaging (MRI) of the neck showing calcification and calcium pyrophosphate crystals deposition around the odontoid process (1).<br>The aim of this report is to increase awareness of this rare and ill-known clinical tableau and to review its complications and the latest modalities of its diagnosis and treatment.</p> <p>Clinical case:</p> <p>An 83-year-old female patient presented to the emergency department (ED) of the Middle East Institute of Health (MEIH) with severe acute onset neck stiffness and pain of 10/10 intensity, radiating to the submandibular area and reaching the occipital part of the head, associated with nausea and 2 episodes of chills one day prior to presentation. Patient denied any recent history of trauma or surgery of the head and neck. Physical exam at that time was only remarkable for marked limitation of neck motion, and positive Kernig and Brudzinski signs. No skin changes, facial sinuses tenderness, cervical lymphadenopathies or neck swellings were noted. Vital signs at ED were within normal range except for a low grade fever. Laboratory work-up upon presentation showed hyperleukocytosis (WBC = 14000/mm3) with left shift and a C-reactive protein (CRP) of 189 mg/L (0-5 mg/L). Chest X-Ray only showed degenerative osteoarthritis of the thoracic spinal vertebrae. CT-scan of the brain without IV contrast done urgently showed no acute changes. As Clinical and biological features were suggestive of acute meningitis, cultures were taken including blood, urine and CSF fluid from lumbar puncture. The patient was admitted to the hospital for IV antibiotic treatment with a large spectrum carbapenem and close observation. On next 2 days, the patient continued to develop low grade fever with a fluctuating pattern, and levofloxacin and amikacin shots were added for maximal bacterial coverage. Urine and blood culture yielded positive for Escherichia Coli only resistant to penicillin. CSF fluid analysis and culture was unremarkable. So, the patient continued to receive IV antibiotics for urinary tract infection and bacteremia. And although the cultures were sensitive to the antibiotics given, the patient continued to suffer from fever, headache, neck stiffness with minimal improvement and response to IV acetaminophen. Laboratory markers continued to increase and CRP reached 325. The patient then underwent a series of imaging and laboratory tests to determine the cause of fever, including CT-scan of the chest, abdomen and pelvis with IV contrast, widal, wright, Rose Bengal, stool analysis, stool culture, clostridium difficile toxins, transthoracic and transesophageal cardiac ultrasound that were all negative. Finally, neck MRI was done to rule out spondylodiscitis or a cervical abscess and showed evidence of osteoarthritis on multiple cervical spinal levels, calcification of the odontoid process of C2, and thickening of the synovium and posterior ligaments (Fig C – D). Those results were compatible with a CT-scan of the neck then done and was in favor of a corona of calcification around the odontoid process suggesting a crowned dens syndrome (Fig A – B). The patient was put on colchicine therapy, and started to improve slowly, then corticosteroids were added and yielded a faster improvement. The C-reactive protein finally started to drop until reaching 23 mg/L upon the discharge. The patient was finally discharged on NSAIDs and colchicine. And after 1 month, the patient was seen in an outpatient setting where she reported dramatic improvement of her symptoms.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Idiopathic Spontaneous Pneumoperitoneum: When Not to Operate 2021-07-03T19:54:10+00:00 Giang Quach D.O.1, Sahithi Gogineni M.D.2, Chadi Faraj D.O. 3, Abby Navratil M.D.4 <p>Pneumoperitoneum is often a surgical emergency related to gastrointestinal tract perforation. On rare occasions, free intraperitoneal air can be present without any discernible cause and is considered Idiopathic Spontaneous Pneumoperitoneum (ISP). Deciding which patients with ISP can be managed conservatively would help prevent some patients from undergoing unnecessary surgery. We describe here two cases of successful management of ISP and the review of literature of ISP management for the past 29 years. In the first case, a patient with ISP with no significant abdominal symptoms was successfully managed nonoperatively. In the second case, a patient with ISP and symptoms of small bowel obstruction was successfully treated surgically with exploratory laparotomy and small bowel resection. We recommend conservative management for the subset of ISP patients with no sign of peritonitis or sepsis.</p> 2019-12-02T00:00:00+00:00 Copyright (c) 2021 Acute soft head syndrome and a mini review of bone and neurologic complications in patients with sickle cell disease 2021-07-03T19:52:20+00:00 Ehab Hanafy1, Saad Al Amri2, AbdulKareem Alenazi2, Amal Al Balawi2, Nadia Abdullah3, Nazim Faisal1, Gihan Mahmoud1 <p>Introduction: Acute soft head syndrome is a rare complication in patients with sickle cell disease (SCD) that is characterized by progressive skull pain and swelling, it is usually related to skull bone infarction and full recovery is achieved with conservative management. This case represents a very rare association of sickle cell disease and acute soft head syndrome that necessitates to be differentiated from other bone and neurologic presentations occurring in this entity of patients.<br>Case: We report a rare case of an 11 years old Saudi male patient with sickle cell disease who developed acute soft head syndrome that presented with severe headache. An underlying osteomyelitis of skull and lower limb bones couldn’t be excluded and the patient had full recovery after conservative treatment.<br>Conclusion: Acute soft bone syndrome seldomly occurs in SCD, however, its presentations mimics those of bone and neurologic complications so differentiation is essential in order to set up a clear plan of management.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Twins With Endogenous Tinea Versicolor 2021-07-03T19:50:37+00:00 Alen J Salerian MD <p>Identical Twins with Endogenous Tinea Versicolor</p> <p>This case report was inspired by recent medical data consistent with the obser-vation that Tinea Versicolor caused by Malassezia Furfur species may be en-dogenous produced by human body.<br>This case report involves a pair of identical twins –ages 71- who have had recur-rent Tinea Versicolor infections for over six decades.<br>The author of this article twin A, a physician and his brother twin B have in summer months had skin lesions – on chest and upper extremities of round ap-proximately 1 inch wide – diagnosed as tinea versicolor by many doctors in di-verse medical settings in different countries since their adolescence. The infec-tions have been successfully treated by antifungal medications.<br>Both twins were born in Istanbul Turkey. Twin A who lives in Houston Texas had lived in Los Angeles California and Dahran Saudi Arabia. Twin B who lives in Athens and spent the majority of his adult life in Washington DC. Neither twin reported any association between location and tinea versicolor infections yet they both observed that almost always infections emerged in warmer climates.<br>Both twin A and twin B have been diagnosed with hypertension and hypercho-lesterolemia well controlled by amlodipine 10 mg and atorvastatin 20 mg respec-tively.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 The torsed intraabdominal testis presenting with a mechanical large intestinal obstruction – A maiden case report 2021-07-03T19:48:27+00:00 Mukesh Kumar Sangwan1, Vijayata Sangwan2, Mohinder Kumar Garg3, Deepak Singla4, Pushpender Malik5, Atul Khandelwal6 <p>Torsion of an intraabdominal testis is a well-known complication and is usually associated with a testicular malignancy. Torsed intraabdominal testis compressing the large bowel leading to a mechanical gut obstruction is still an unreported entity. A 27 years old young patient presenting with nonspecific abdominal pain after 48 hours of delay. Due to features of gut obstruction, an emergency laparotomy was done. A large torsed intraabdominal testis was found with an empty right scrotum which was compressing the sigmoid colon leading to a complete gut obstruction. Interestingly, two of his siblings also were also suffering from undescended testicles.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 From Colonoscope to Microscope: the Diagnosis of Trichuris Trichiura 2021-07-03T15:08:47+00:00 Sushma Krishna*1, Shine Sadasivan2, Kavitha Dinesh3, Aswathy S4, Shamsul Karim5 <p>Soil Transmitted Helmenthiasis (STH) is a major public health problem in the developing countries. Trichuriasis is one of the common prevalent parasitic infestations in the tropical and sub-tropical countries across the globe incuding India. However, there has been a steady decline of STH in the last five years where there has been success of albendazole with Mass Drug Administration (MDA) in National Filariasis Control Program and Kerala state has been one of them. We report a case of whipworm infection that was incidentally diagnosed by colonoscopy where repeated stool microscopy was uncontributory. The worm can be overlooked, particularly if colon preparation is not good.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Safety of percutaneous dilational tracheostomy in patients ventilated with high positive end-expiratory pressure (PEEP) and high FiO2 2021-07-03T15:06:45+00:00 Sachin Pralhad Sasane 1, Zeyad Faoor Alrais2, Giovanni C. Ronquillo3, Yasser Ibrahim4 <p>Case report of bronchoscopically guided percutaneous dilational tracheostomy in-patient with acute respiratory distress syndrome ventilated with high positive end-expiratory pressure (PEEP) and high FiO2.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Oral pyridostigmine for treatment of postoperative ileus associated with elevated catecholamine levels: A case report 2021-07-03T14:48:03+00:00 Sherif Aly, MD 1,2; Gentian Kristo, MD, MPH, FACS1,3. <p>The etiology of post-operative ileus is usually multifactorial, but increased catecholamines have been implicated as an important cause. We present a case of catecholamine-induced prolonged post-operative ileus treated successfully with Pyridostigmine. A 70-year-old male underwent a low-anterior resection and diverting loop ileostomy for rectal cancer. Immediately post-operatively he developed refractory hypertensive urgency and a small bowel ileus. Biochemical testing revealed markedly elevated 24-hour urinary metanephrines and normetanephrines. However, radiologic studies failed to identify a pheochromocytoma. The ileus persisted despite employing a multimodal regimen consisting of avoidance of narcotic pain medications, gastric decompression via a nasogastric tube, maintenance of normal levels of electrolytes, parenteral nutritional support, and early mobilization. Two weeks after the surgery the patient was treated with oral Pyridostigmine with appropriate return of bowel function. Excessive circulating catecholamines play an important role in the etiology of refractory post-operative ileus, and cholinesterase inhibitors such as Pyridostigmine could be used as an effective treatment in such cases.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Serious Staphylococcus Aureus Infection in a Patient with Diabetes Mellitus 2021-07-03T14:45:30+00:00 Cátia Pereira, Joana Cascais Costa, Joana Coelho <p>The immune system and metabolism are closely related and it is recognized that diabetes mellitus (DM) and its complications have a compromising impact on the degree of immunosuppression.<br>The authors present the case of a 65-year-old man with a history of type 2 DM and ulcers of the lower limbs who went to the emergency departament with odynophagia, dysphagia, fever and cervicalgia. He had a painful cervical and supraclavicular region and highly infectious parameters in blood samples. The cervical radiography suggested vertebral fusion and cervical computed tomography with soft tissue thickening, hypopharyngeal deviation and gaseous foci suggestive of abscess.<br>He started empiric antibiotic therapy and was performed an abscess drainage where Staphylococcus aureus oxacillin susceptible was isolated.<br>S. aureus bacteremias have a higher prevalence in diabetics, being essential the rapid orientation in situations of bacteremia to clarify the infectious focus and immediate onset of antibiotic therapy which decreases mortality.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Emergency surgery for a Morgagni hernia causing respiratory failure 2021-07-03T14:43:24+00:00 Yoshitsugu Tsukamoto, Takeharu Enomoto, Takehito Otsubo, Kenta Katsumata, Natsuko Kamei, Jin Shimada, Shinya Mikami <p>Reports of emergency surgical repair of a retrosternal hernia causing respiratory failure in an adult are rare. We treated an 82-year-old man who had been suffering breathlessness upon exertion, some speech difficulty, and, most recently, visual hallucinations. He had consulted a physician who ordered an arterial blood gas test, which revealed hypoxemia, and thoracoabdominal computed tomography (CT), which revealed a hernia that was compressing the pulmonary parenchyma. Over the next 30 days, the hernia worsened, acute respiratory failure developed, and the patient was transferred to our hospital by ambulance. The patient presented to us not only with respiratory failure but also a decreased level of consciousness. CT performed upon admission revealed prolapse of the transverse colon from the posterior surface of the sternum to the right thoracic cavity, left deviation of the mediastinum, and compression of the pulmonary parenchyma, which we believed to be the cause of the hypoxemia. With the hernial orifice appearing to be on the right, a Morgagni hernia was diagnosed. Emergency surgery was deemed necessary. An epigastric midline laparotomy incision was placed, and we observed a retrosternal hernia, with an enlarged foramen of Morgagni measuring 70mm × 50 mm as the hernial orifice. The hernia contained portions of the greater omentum and transverse colon. We returned the contents to the peritoneal cavity manually closed the hernia orifice by simple suturing and reinforced the repair with a mesh patch. With signs of cardiac failure developing, temporary noninvasive positive-pressure ventilation was instituted from postoperative day 5 to postoperative day 11, but the patient’s general condition improved thereafter, and he was discharged on postoperative day 29.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Endodontic Management Of C-shaped Root Canal Followed By a Post Less Core and Crown-a Case Report 2021-07-03T14:30:03+00:00 Dr. Madhuri A. PatilA, Dr. Amol S. PatilB <p>C-shaped canal is one of the most difficult situations with which the dentist is confronted during endodontic treatment of teeth. Recognition of unusual variation in the canal configuration is critical because it has been established that the root with a single tapering canal and apical foramen is the exception rather than rule. The early recognition of these configurations facilitates cleaning, shaping and obturation of the root canal system. “C” configuration, which is an important anatomic variation, presents a thin fin connecting the root canals. In this case report we have discussed the successful management of C-shaped canal (Melton’s category II) in mandibular second molar diagnosed by using cone-beam computed tomography and operating microscope and also used self-adjusting file (SAF), sonic irrigation and thermoplasticized gutta percha obturating technique. Endocrown-type restorations are single prostheses fabricated from reinforced ceramics that can be acid etched, indicated for endodontically treated molar teeth that have significant loss of coronal structure. Endocrowns are formed from a monoblock containing the coronal portion integrated into the apical projection that fills the pulp chamber space, and possibly the root canal entrances. A endocrown-type restoration was fabricated from lithium disilicate ceramic (IPS e.Max) in a mandibular second molar with extensive lingual destruction.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Rare Anomaly Of Aberrant Right Subclavian Artery Associated With Right Common Carotid Artery In The Pre Tracheal Position –A Case Report 2021-07-03T14:26:18+00:00 Palaniappan Ravisankar1, Manogarane Shanmugapathy2, Chatterjee Dwaipayan3, Selvakumar Kothandapani2, Ilakkiya Selvaraj2, Saranya Ravichandran3, Bhaskara Rao Bezawada2 <p>Congenital variations of the aortic arch and great vessels are often encountered in clinical practice. This is a case report of a 60 year old lady diagnosed with carcinoma thyroid and during the procedure, incidentally diagnosed to have right common carotid artery crossing the trachea anteriorly. Post operative computed tomographic angiographic study confirmed the common carotid artery in the pretracheal position and aberrant right subclavian artery (ARSA) was discovered. This is a rare anamoly of the common carotid artery and to be kept in mind during the procedures done in the pretracheal position and other associated anomalies are to be evaluated.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Probable Transient Anterior Bulging Fontanelle after Measles Vaccination: A Case in Arba Minch General Hospital, Southwestern Ethiopia 2021-07-03T14:24:30+00:00 Silabat Aschalew1, Sisay Legesse2, Abate Waldetensai3 <p>Transient anterior bulging fontanelle is a rare but serious medical condition, which can be classified as definite and probable transient bulging fontanelle. Conducting case surveillance, diagnosis and on time reporting during vaccination is of paramount importance in managing the adverse events following immunization. We diagnosed probable transient bulging fontanelle in a 9 month infant weighing 7.8Kg with ultrasound in Arba Minch General Hospital after 12 hours of measles vaccination. A physical examination was conducted to confirm probable transient bulging fontanel. Treated with her mother’s breast milk at her home and visiting was done after three and five days. We used a measles vaccine adverse effect case report, to find potential transient bulging fontanelle (TBF) and to describe the characteristics of probable cases of TBF on admitted infant to Arba Minch General Hospital. The Infant was alert; a febrile to touch whose temperature measured at the left auxiliarysitewas37.8oc with non-tender, bulging and tense swelling that includes non-pulsatile anterior fontanelle size of 3cm.The infant was found with no fever, vomiting, bleeding and no problem of feeding and respiratory difficulties except a history of fallen down accident from bed on her head 15 days back of the swelling. The swelling was decreased gradually and the fontanel started pulsation and the swelling returned back to the normal after the three and five day of visits without any medication. Despite this rare side effect, vaccination against the preventable disease, measles need to be sustained since transient bulging fontanelle is a self-limited case and immunization balances the impact of adverse events following immunization. Adequate case surveillance, diagnosis and reporting are very essential up to the management.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 The Rare Case of Thromboangiitis Obliterans in a Patient Previously Diagnosed with a Stroke 2021-07-03T14:22:31+00:00 Niki Parikh, Franklyn Babb <p>Thromboangiitis obliterans (Buerger’s disease) is a disease of small and medium-sized vasculature, mainly involving the distal upper and lower extremities in male patients under the age of 45. Smoking tobacco is considered to be a predisposing and triggering agent. This presentation discusses the case of JS, a 35-year old male patient who initially presented with a stroke, followed by pain and swelling in the upper extremity, and finally with pain, absent peripheral pulses, and necrosis of the left lower extremity requiring below knee amputation. This case is of interest due to the rarity of this disease in the developed world, the presentation of a stroke in a young patient later diagnosed with thromboangiitis obliterans, and the use of a prostaglandin analog in treatment. This case highlights the difficulty of making the diagnosis of vasculitis and the time consuming, multispecialty approach that is required. The availability of subspecialists, medical record integration, communication between community hospitals, and the drug Iloprost could have positively affected the patient’s outcomes and prognosis.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Acute Coronary syndrome in a patient newly diagnosed with Charcot-Marie-Tooth Neuropathy: a review of cardiovascular disease in this inherited neuropathy 2021-07-03T14:19:32+00:00 Garrick Edouard Laudin1, Thomas De Beenhouwer2 <p>Whilst we suspect that there is no clear association between the two major diagnoses we made in this patient during this hospitalisation (i.e. coronary artery disease and CMT neuropathy), the literature from a series of published case reports does perhaps show an association between CMT and abnormalities of cardiac conduction.</p> <p>Brief Summary:<br>This case reports follows the occurrence of an antero-lateral ST segment elevation myocardial infarction in a 34-year-old male newly diagnosed with an inherited neuropathy in the form of Charcot-Marie-Tooth type 1A.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 An unusual presentation of a known condition: Q fever manifesting as an acute abdomen 2021-07-03T03:57:03+00:00 Elisabeth Ng1,Tunde Ibrahim2 <p>Q fever is an endemic zoonotic infection in Australia cause by Coxiella burnetii. It has been recognised in other parts of the world, especially among livestock rearing occupations, stock yard and abattoir workers. Majority (65%) of patients infected with C.burnetti are asymptomatic while symptoms similar to those of respiratory and hepatitis are the most common making diagnosis difficult in the early stages.<br>We report a case of a young man who was exposed to and infected with Q fever as an occupational hazard. He presented in an unusual way with the predominant initial symptoms of abdominal pain, fever, hepatitis and sterile peritonitis necessitating an emergency surgical procedure to explore a suspected surgical abdomen. Respiratory involvement ensued only several days later. The diagnosis of Q fever was confirmed with positive convalescent serology phase II IgM and IgG antibodies to Coxiella burnetii. A marked clinical response to doxycycline pending serological confirmation was supportive of this highly suspected diagnosis in an at-risk patient.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Orbital, subcutaneous, and subconjunctival emphysema following blow-out medial wall fracture 2021-07-03T03:55:30+00:00 Ahmed A.1, Waris A.2, Rizvi S.A.1 , Haque O.I.1 <p>A 40-year-old male presented to the emergency department with the complaint of a sudden, painful left eye and swelling after episodes of sneezing. A day earlier, he had sustained a blunt trauma to the left orbit as the result of a fall from motorcycle. The initial examination showed subcutaneous and subconjunctival emphysema. Visual acuity in the left eye was 20/40 (0.50), the pupils were reactive with no relative afferent pupillary defect, and there were limitations in levoduction, dextroduction, infraduction and supraduction. A slit-lamp examination revealed normal anterior and posterior segments with an intraocular pressure of 24mmHg. An orbital computed tomography scan showed orbital, subconjunctival, and subcutaneous emphysema associated with a small fracture of medial wall of the left eye. Following conservative management with broad-spectrum oral antibiotics, a topical antiglaucoma drug, low dose systemic steroid drug, and lubricating eye drops, the patient improved dramatically within one week.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent 2021-07-03T03:53:38+00:00 Teh CY1, Ahmad Kashfi AR2 <p>BACKGROUND<br>Salmonella infection is common in tropical countries including Malaysia. It is invasive in immunocompromised and those of extreme ages. It typically presents with gastrointestinal symptoms such as diarrhea, abdominal pain or vomiting. Extra-intestinal manifestations are seen in 30% of salmonellosis cases. These atypical manifestation leads to difficulty and delay diagnosis thus poorer outcome. Pericardium involvement is estimated to be less than 2% of all cases and has mortality rate as high as 50%1. As high as 70% of pericarditis cases were identified to be immunosuppressed2; these include chronic immunosuppressant usage, autoimmune disease, end stage renal failure, malignancy and etc. Herein, we report a fatal case of pyogenic pericardial effusion by Salmonella enteritidis in an immunocompetent adolescent.<br>CASE PRESENTATION <br>A 16-years-old Malay boy was referred from GP to our centre in April 2015 with CXR finding suggestive of pericardial effusion. He had prolonged cough for 8 months, associated with breathlessness and failure symptoms. He had on and off fever but denied gastrointestinal symptom. He had multiple visits to private practitioners and was investigated for Tuberculosis, which yielded negative result. His condition continued to deteriorate.<br>Of note, he had no significant medical and surgical illness. There was no history of contact with tuberculosis patients, recent travelling history or high risk behaviour.<br>Upon admission, he was tachypnea and in shock. His blood pressure was 90/56mmHg with a pulse rate of 102bpm. His JVP was raised and heart sound was muffled. Lung examination revealed reduced breath sound bilaterally with generalized rhonchi. Initial blood investigations revealed leukocytosis with predominant neutrophils (16 x 109/L). ABG showed type 1 respiratory failure. ESR was raised, 100mm/hour. Chest X-ray showed a congested lung field consistent with pulmonary oedema. Bedside echocardiogram revealed a large pericardial effusion with diastolic right atrium and ventricle collapsed, indicating temponade effect. Emergency pericardialcentesis drained 1.3L of frank pus. IV Augmentin (Amoxicillin and calvulanate potassium) was empirically started.<br>Pericardial fluid culture grew Salmonella Enteritidis which was sensitive to ceftriaxone and ciprofloxacin, thus antibiotic was switch to Ceftriaxone. Despite given targeted therapy, his general condition did not improve; pericardial pus re- accumulates, causing temponade thus requiring second drainage. Antibiotic was switch to ciprofloxacin and later meropenem in worried of poor pericardium penetration. Average daily drainage was 25 to 35ml. Repeated Echocardiogram showed loculated collection of pus in pericardium. HIV screening and autoimmune screenings were negative. Full blood picture was normal. No screening of malignancy done.<br>His condition continued to deteriorate, requiring ventilator and inotropic support. He succumbed to death on third week of admission.</p> <p>&nbsp;</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Subcutaneous Emphysema in Peri-Operative Period – An unusual case 2021-07-03T03:51:23+00:00 Mosab A. Alarfaj, Yasser M. Aljehani, and Yasser F. Elghonimy <p>Pharyngeal perforation is a rare serious finding with fatal outcomes if not diagnosed and managed promptly(1). The main cause is an iatrogenic injury during pharyngeal instrumentation and commonly present with neck pain, swelling, and subcutaneous emphysema. Many predisposing factors played a major role like difficult instrumentation, pharyngeal infection and old age(2). In our case, we present a patient with prostate cancer who underwent radical prostatectomy and was found to have mediastinal and surgical emphysema.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Transfer Factor Revisited: Treatment of Congenital Cytomegalovirus Infection 2021-07-03T03:49:43+00:00 J. Kelly Smith1,2* <p>A 7-month-old girl with congenital cytomegalovirus (CMV) infection underwent an immune assessment in anticipation of Transfer Factor therapy. She had been symptomatic since birth, with jaundice, rhinorrhea, diarrhea, pneumonia, hepatosplenomegaly, chorioretinitis, hydrocephalus (for which she was shunted), motor retardation, and failure to thrive. Her sputum and urine cultures were positive for CMV and her IgM anti-CMV antibody titer was positive at 1:16-1:32 dilutions. Her baseline immune assessment was normal except for a failure of her peripheral blood mononuclear cells to produce migratory inhibitory factor in response to CMV antigen. Treatment with transfer factor prepared from CMV seropositive donors resulted in clinical improvement, clearance of the virus, normal migratory inhibition factor responses to CMV antigen, and subsequent development of normal growth and development parameters.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 The Effectiveness of Extracorporeal Shock Wave In Pediatric Renal Stones 2021-07-03T03:46:09+00:00 Ali Dawas Alshahrani1, Saleh mohammad alghamdi2, Ali Saad Alshahrani3, Ahmed Youssef Abouelyazid4 <p>Introduction: Renal stones are endemic in low income countries among children below 15 years old. This should not be underestimated due to high association with other morbidity and highly recurrence rate when compared with adults.<br>Objective : To explore the Effectiveness of Extracorporeal Shock Wave In Pediatric Renal Stones. Methodology: Study the case of a child girl reported with renal stone, clinical and laboratory data were obtained , Radiological investigations as US and CT were done, The patient underwent dj stent, then patient received one session of Extracorporeal Shock Wave 4000 us guided storz eswl Lithotripsy for urinary Stones then uralyt-u pediatric dose and allpourinol 100 mg once daily then start to passing stones gravels Results: Follow up by CT for the patient after 3 months revealed no stone, renal scan split function from 12 to 18%.<br>Conclusion: Renal stones could be presented even among pediatric group even with negative family history. Ultrasound is the first choice imaging modality for diagnosis of suspected renal stones , CT could be used for follow up. Dihydroxyadenine stones could be missed during routine diagnosis of renal stones so imaging is mandatory and stones analysis should be done.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Subclinical chronic sinusitis causing presumed ventriculoperitoneal shunt sepsis in a child 2021-07-03T03:43:13+00:00 A.Chaouki, A.Ballage, M.Beghdad , A.Mkhatri, R.Abada, S.Rouadi,M.Roubal ,M.Mahtar. <p>Glomangiopericytoma is defined as a sinonasal tumor with perivascular myoid phenotype, which was first described in 1942 by Stout and Murray as a soft tissue tumor with characteristic proliferation including branching vessels and small vessel perivascular hyalinization. A 47-year-women presented with two years history of permanent left nasal obstruction and frequent epistaxis , without anosmia or any other sinonasal symptoms Rhinoscopy was done which revealed a friable grayish pink polypoidal mass, fully occupying the left anterior naris. the right nasal cavity was free . Computed tomography showed a lesion involving the left nasal cavity, with a soft tissue density (70 UH) consisting of about 50*16 mm , widely infiltrative (left nasal turbinates , uncinate process , left half of nasopharynx and palatine bone ) , with a posterior left ethmoidal sinus mucosal thickening and without any bony destruction .Microscopic examination of the biopsy showed subepithelial tissue showed the lobular arrangement of spindle-shaped cells admixed with vascular channels of variable size, The differential diagnosis of hemangiopericytoma and solitary fibrous tumor (SFT) , The staining of STAT 6 immunohistochemistry (IHC) was heterogeneous confirmed the solitary fibrous tumor . Endoscopic surgery was performed to remove the mass , considering the size, limited expansion and the accessible location of the tumor.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Emergency presentation of a giant paraoesophageal hernia- A case report 2021-07-03T03:41:32+00:00 Amin Tanveer1,a, Sumeet Singh2,b, Asiri Arachchi3,c, Abhinav Vasudevan3,d <p>An emergency presentation of a paraoesophageal hernia with acute respiratory distress and an acute abdomen is a rare presentation.<br>Hereby, we are presenting a 73year old female who presented with an acute dyspnoea and acute bowel obstruction, the imaging revealed large paraoesophageal hernia almost collapsing the right lung, she had an emergency surgery, an anterior gastropexy was performed since she was unstable. Despite subsequent surgeries e.g Collis gastroplasty and mesh cruroplasty, patient developed recurrent hiatal hernia. Unfortunately, the patient ultimately passed away from a vancomycin resistant enterococci (VRE) bacteraemia and due to overwhelming medical comorbidities.<br>As presentation of paraoesophageal hernia with acute dyspnea and acute abdomen is a rare incidence, we discuss this and its management options through a case report.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Non-union after correction of femoral deformity combined with total knee arthroplasty 2021-07-03T03:39:40+00:00 Takatomo Mine, M.D., Ryutaro Kozuma, M.D., Koichiro Ihara, M.D., Hiroyuki Kawamura, M.D., Ryutaro Kuriyama, M.D., Yasunari Tominaga, M.D. <p>AnIn knee arthritis with extra-articular deformity of the femur, total knee arthroplasty becomes more challenging. Simultaneous femoral deformity correction and TKA can be a complex procedure. We present a case in which TKA and femoral osteotomy for varus femoral deformity were performed simultaneously. Non-union in the osteotomy portion occurred after the operation. Teriparatide therapy and low intensity pulsed ultrasound therapy was administered after a diagnosis of non-union. Bony union was partially obtained at 29 months after surgery.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Ansa Pancreatica: An Uncommon Cause Accounting for Recurrent Pancreatitis in Children 2021-07-03T03:36:39+00:00 Syeda Namayah Fatima Hussain1, Munir Iqbal Malik2, Sabeen Abid Khan3 <p>Acute recurrent pancreatitis is a rare entity in children. It can be caused by a number of reasons, anatomical variations being one of them. Panctreatica divisum is the most common form of ductal anomaly while ansa pancreatica is the least studied and explored. In recurrent pancreatitis, Ansa Pancreatica was recently found to be a key risk factor. It is usually found among adult alcoholics. We submit a report of a rare but important cause of acute recurrent pancreatitis; an 11-year-old child with 2 previous episodes of pancreatitis diagnosed with ansa pancreatica on magnetic resonance cholangiopancreatography (MRCP). He was advised to get stenting of Pancreatic duct. To the best of our belief, only another case has been reported in the pediatric population.</p> 2019-12-26T00:00:00+00:00 Copyright (c) 2021 ART (Anti Retroviral Therapy) Induced Anemia: Case Series 2021-07-03T03:33:47+00:00 Gundramy Reddy.Sravani1, M.Rameela1, Seetharam babu1, T.S.Durga Prasad2 <p>Anemia is a common finding in patients on Nucleoside Reverse Transcriptase Inhibitors (NRTI’s) among which LAMIVUDINE induced anemia is uncommon whereas ZIDOVUDINE induced anemia is common. This is the first case series related to TLE (TENOFOVIR + LAMIVUDINE + EFAVIRENZ) regimen induced anemia. In case one, two and three Hb levels dropped within one year, 7 months, 6 months respectively. Anemia can be managed by intake of Iron, vitamin B12, Folate and nutritional supplements or with draw of medication based on severity.</p> 2019-12-18T00:00:00+00:00 Copyright (c) 2021 Intraventricular Tuberculoma : Single Case Report from Tertiary Care Centre in Eastern India 2021-07-02T16:13:42+00:00 Pan Koushik 1, Sen Barun Kumar2 <p>Intraventricular tuberculomas as a manifestation of CNS tuberculosis is a rare finding.Suspicion for tuberculosis in these lesions is by the constitutional symptoms like low grade fever, weight loss, presence of tuberculosis elsewhere, contact with a TB patient, low socioeconomic status, occurrence in an endemic region, raised ESR, abnormal Chest X Ray findings, positive mantoux test. It is difficult to make a differential diagnosis from lesions if no systemic tuberculosis is present. Medical treatment is the preferred management method of this disease, and surgical intervention should be considered in certain situations. We report a case of an intraventricular tuberculoma in a 15- year-old girl and we discuss the pathogenesis and the radiological findings according this location.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A Case Report Highlighting Some of the Difficulties Faced Diagnosing Appendicitis in Children 2021-07-02T16:11:42+00:00 S. Lewis, A. Rasheed <p>Introduction: In England 12,000 children are diagnosed with appendicitis each year. The diagnosis of appendicitis is difficult especially in children. There are many other diagnoses which mimic appendicitis including Meckel’s diverticulum, intussusception, gastroenteritis and mesenteric adenitis. Unfortunately there is no gold standard in the diagnosis of appendicitis and often clinicians are hesitant to submit a child to radiological investigations.<br>Presentation of the case: An eleven year old boy, of Bangladeshi origin, presented to the Royal Gwent Hospital, South Wales, with an acute onset of centralised abdominal pain and vomiting. Following a period of observation and re-examination his pain had localised to the right iliac fossa and it was decided on clinical grounds to perform a laparoscopy for suspected appendicitis. Intra-operative findings showed an intussusception of the small bowel secondary to a mucosal lesion. Histology showed high grade non-Hodgkin’s lymphoma with a pattern suggestive of Burkitt’s lymphoma.<br>Conclusion: The case highlights the importance of accurate diagnosis of appendicitis and the difficulties of managing abdominal pain in children. More needs to be done to develop a better criterion and judicial use of imaging to guide surgical intervention.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Anomalous Right Coronary Artery with LV Non-compaction having Malignant Course, A Rare but Lethal Combination 2021-07-02T16:10:07+00:00 Ahmad Hasan1, Fahar Adnan2, Shahzad Shoukat1, Umer Aftab1, Muhammad Waqas1, Muhammad Iqbal1 <p>Anomalous Right coronary Artery origin from contralateral sinus is a rare but lethal variant that may mimic like acute coronary syndrome and is a potential cause of sudden cardiac death. This needs early diagnosis with prompt treatment which may be conservative or interventional depending upon the clinical presentation, exact anatomy and route of the vessel. Here we present a unique case of combination of anomalous right coronary artery origin from opposite sinus causing ischemia, with LV non-compaction ending in non-hemorrhagic stroke.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Ovarian Mucinous Cystadenoma Complicating Pregnancy- A Case Report 2021-07-02T16:08:10+00:00 Padmini Kumari and Mala Sinha <p>Diagnosis of ovarian tumor during pregnancy presents a management dilemma. We herein report a case of huge ovarian cyst adenoma complicating pregnancy in a 25 years old gravida 3, previous two caesarian, presenting at 13 wks. pregnancy. She was referred from periphery for uterine size more than the period of gestation and ultrasound (USG) showing 25×12 cm ovarian cyst. USG was inconclusive of benign or borderline ovarian tumor. Neoadjuvent chemotherapy followed by cytoreductive surgery was planned. USG guided fine needle aspiration cytology (FNAC) was done before starting chemotherapy which suggested benign etiology. Management plan was changed to continuation of pregnancy and conservative surgery at 20 wks of pregnancy. Planned exploratory laparotomy with left sided salpingoophorectomy was done under general anesthesia at 22 wks. of gestation. Post-operative period was uneventful. Patient was delivered by LSCS at 38 wks. of gestation.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Dasatinib-Induced Colitis in a Patient with Chronic Myeloid Leukemia (Chronic Phase) 2021-07-02T16:06:32+00:00 Lubna M. Riaz1, Khaled M. Galal2, Radwa M. Hussein2, Abdulqadir J. Nashwan1, Mohamed A. Yassin1 <p>Chronic myeloid leukemia (CML) is a Philadelphia (Ph) chromosome-positive myeloproliferative neoplasm. The molecular consequence of reciprocal translocation t(9;22)(q34;q11) is the generation of the BCR–ABL fusion gene, which encodes a constitutively active tyrosine kinase signaling protein. The tyrosine kinase is responsible for the leukemia phenotype through the constitutive activation of multiple signaling pathways involved in the cell cycle and in adhesion and apoptosis. Dasatinib is an oral BCR-ABL tyrosine kinase inhibitor (TKI) which is mainly used for treating CML patients with resistance or intolerance to Imatinib. Dasatinib has several significant adverse reactions and gastrointestinal side effects including colitis. We report a case of a 33-year-old male, diagnosed with CML (Chronic Phase) who received Dasatinib as second-line therapy and developed chronic diarrhea and colitis attributed to Dasatinib and improved after stopping it.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Paraparesis following commencement of Anti Tuberculosis drugs for latent Tuberculosis. Case report and review of literature 2021-07-02T16:04:30+00:00 Danish Waqar1 and Mohamed A Yassin2 <p>A 43 year old female Patient, with recently diagnosed latent Tuberculosis (TB), started On anti - TB drugs (Isoniazid, Rifampicin), came with symptoms of Motor and sensory polyneuropathy only 4 weeks after starting the drugs. Extensive investigations were pursued. Nerve conduction study showed Features of Guillain - Barre syndrome (GBS). After stopping the Anti TB medications, patient symptoms Improved. This gives us an idea that Anti TB medications can itself trigger GBS. The Association of TB and GBS will be reviewed in Literature as well as the differentials and management.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Novel Technique In Strangulated Para-Umbilical Hernia Repair Under Local Anaesthesia Block For High-Risk Patient : Case Report 2021-07-02T16:00:08+00:00 Talal Alsofyani1, Emad M AL-Osail2 , Sayed Sadek3, Eman Zakarnah4 , M Yassin Taha5 <p>Background: Strangulated hernia is one of the most emergency cases that require surgery under general anaesthesia. Here, we present a rare case of strangulated PUH repair done under rectus sheath block (RSB).<br>Case Presentation: We report here a case of a 74-year-old male with diabetes mellitus, hypertension, ischemic heart disease with ejection fraction 20% who presented to our ER with peri-umbilical hernia (PUH) swelling and constipation. On examination, incarcerated PUH was found with massive ascites. Under local anaesthesia, rectus sheet block was performed. During midline laparotomy, there was a supra-umbilical hernia defect of about 3 cm narrow neck containing bowel loop about 5-7cm in length, initially appeared ischemic then regain Its normal colour, primary repair done for the defect. No complication was observed in the post-operative period.<br>Discussion: Strangulated hernia is an emergency case that requires surgical intervention, hernia reduction and resection of necrotic tissue if needed. PUH repair as a day case by using local anaesthesia is a good option as it has advantages of low recurrence and infection rate. For patients with 3 to 4 ASA class, general or spinal anaesthesia is risky, and RSB is the best alternative option in such high-risk patients.<br>Conclusion: Rectus sheath block is a good option for strangulated PUH patients.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Chronic Lymphocytic Leukemia, a Case Report 2021-07-02T15:58:17+00:00 Aurelian Udristioiu <p>Purpose of the presentation. The case presentation has as aim to describe the onset and evolution of a case of Chronic Lymphocytic Leukemia, (CLL), less common, which does not fit into the standard treatment criteria for malignant hemopathies.<br>Case description. The patient TA, female, 39 years of age, married, with 2 children, was admitted to the Emergency County Hospital of Targu Jiu in 2014, in the Internal Medicine Department for the Obstructive Chronic Bronchopathy with frequent coughing, night sweats, retrosternal pain. Clinical and ultrasound examination revealed splenomegaly, with spleen enlargement of 3 cm above normal diameters. The patient was also in the Endocrinology department with the diagnosis of Type II Diabetes and Grade III Obesity.<br>Laboratory results. Hemogram in 3 Diff revealed Hb = 14g / dL, Ht = 45%, Nr. Platelets of 275,000 / mm cub, but an increased number of Leucocytes, 117,000 / mm cub, and in the leucocyte formula from peripheral blood, the lymphocyte count was 80%, the absolute value being 9360. All biochemistry assays were in normal values, inclusive LDH = 375 md / dL, (N = 200-400 mg / d L. In the cytological examination of the peripheral blood smear stained with My Grunwald-Giemsa staining in the LPF 100 microscopy, was described the lymphocytosis with very small lymphocytes in high percent.<br>Conclusions; CLL onset occurs in a young female patient, contrary to the frequency of LLC in people over 65 years of age, especially in men. The normal baseline Hb, Ht%, Platelet counts in establishing the CLL diagnosis directly in stage I / II could be falsely positive due to the patient’s comorbidities with COPD and DZ type II and Obesity. Also low platelet counts in the final stage III / IV may be appropriate for the LLC disease stage or may be low due to applied chemotherapy.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Broncho-Oesophageal Fistula Complicating Carcinoma of the Oesophagus 2021-07-02T15:56:44+00:00 Moemenam O.O1, Madukaife V. O2, Ray-Offor OD2 <p>Broncho-oesophageal fistula refers to an abnormal communication between a bronchus and the oesophagus. Broncho-oesophageal fistula is rare and can be either congenital or acquired. Congenital fistulas are usually diagnosed in the neonatal period as they present with respiratory distress and cyanosis during feeding. Whereas developmental anomaly is the commonest cause in infancy and childhood, the aetiology in adults is most frequently secondary to an oesophageal malignancy1. Non-malignant causes of fistulae are rare. Diagnosis of a broncho-oesophageal fistula may sometimes be difficult because of an insidious and non-specific clinical course2.<br>A rare case of broncho-oesophageal fistula due to carcinoma of the oesophagus, which was discovered incidentally during a barium swallow study is presented.<br>SUMMARY<br>A 68-year-old man with dysphagia who was diagnosed to have carcinoma of the oesophagus, which was complicated by broncho-oesophageal fistula is presented. The role of radiology in the management of this condition is discussed.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A Rare Case of Adrenaline- Induced Kounis Syndrome presenting to the Emergency department 2021-07-02T15:54:57+00:00 Radhika Bulusu, Madhukiran Dontula, Indranil Das, VGR Shastry, Tamorish Kole <p>Introduction: Kounis syndrome is the concurrent occurrence of acute coronary syndromes with hypersensitivity reactions [4] [3]. It has been established as a hypersensitivity coronary disorder induced by various conditions, drugs, environmental exposures, foods and coronary stents. Allergic, hypersensitivity, anaphylactic and anaphylactoid reactions are associated with this syndrome. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells. There are three principal variants of the syndrome: type 1 is allergy – related angina due to coronary spasm, whereas, type 2 is allergy related myocardial infarction due to plaque rupture or erosion and type 3 is allergy – related stent thrombosis with re – infraction.</p> <p>Case summary: A young healthy male with no significant risk factors for coronary artery disease developed ventricular tachycardia and myocardial infarction following therapeutic dose of intramuscular administration of adrenaline for an anaphylactic reaction to the ED.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A Rare Case of Pantoprazole Induced Anaphylactic Shock 2021-07-02T15:53:07+00:00 Indranil Das, Dolly Yadav, Annu Yadav <p>INTRODUCTION: Pantoprazole,a drug from the proton pump inhibitors group (PPI), is widely used for gastroesophageal disease and peptic ulcer . PPI’s act on H+/K+-ATPase pump,the process needed for gastric acid secretion 1. Drug induced hypersensitivity is an immune mediated reaction. Drug hypersensitivity reactions are commonly encountered in clinical practice1.</p> <p>OBJECTIVE: The objective of reporting this case is to show that anaphylaxis reaction may occur with tablet pantoprazole.</p> <p>CASE SUMMARY: A 40 year old female reported to emergency department in hemodynamically unstable condition, with a history of loose stool, vomiting, spasmodic abdomen pain, redness all over the body after approximate 1 and half hour back after ingestion of tablet pantoprazole 40mg .</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Role of Aspirin on Keloid : a Case Report 2021-07-02T15:51:27+00:00 DR. MOHAMMAD ASIF KHAN*, DR. RABIA NIZAM**,DR.SHAKEEL ANSARI***,DR.MAHJABEEN FATIMAH**** <p>A keloid is a cutaneous mass that characteristically develops following dermal injury. Keloids extend beyond the borders of the original wound invading normal skin. Usually appear as firm nodules, often pruritic and painful, and generally do not regress spontaneously. Most often occur on the chest, shoulders, upper back, back of the neck, and earlobe. We report a case of excessive keloid formation in a 40 years old female following itching in which no other aetiology could be found after detailed history, examination and investigation. Because of the rapid and extensive nature of the disease it is a matter of further research.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Natural orifice endoscopic drainage of a perforated duodenal ulcer 2021-07-02T15:46:17+00:00 Mark Scaife MD, Thomas J Melvin MD, Harry W Sell MD, Kurt R Stahlfeld MD <p>Posterior perforation of gastric and duodenal ulcers is uncommon and frequently misdiagnosed due to nonspecific clinical exam findings. The need for surgical treatment has recently been questioned in patients with contained perforations due to the success of nonoperative management and the morbidity and mortality associated with surgical intervention.<br>We present a clinically stable 65-year-old morbidly obese female transferred to our institution with radiographic evidence of posterior perforation of a duodenal ulcer with a large associated abscess cavity. A fenestrated 9.5 French nasal feeding tube was directed over a guide-wire into the abscess cavity under endoscopic/fluoroscopic guidance and used for decompression. The patient was managed conservatively and repeat computed tomography (CT) demonstrated resolution of the cavity. She was discharged to home after an uncomplicated 10-day hospital course.<br>Contained posterior peptic/duodenal ulcer perforations associated with an abscess cavity can be successfully managed conservatively in patients that are hemodynamically stable and without overt signs of peritonitis. Natural orifice drainage of the cavity, gastric decompression, antibiotics, PPI administration, and nutritional support can avoid the morbidity and mortality associated with traditional surgical management.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Posterior Reversible Encephalopathy Syndrome in Class IV Lupus Nephritis – Case report and brief review of literature 2021-07-02T15:44:24+00:00 Kalpita Hatti1, Amit Habbu2, Joe R. Gamboa3, Arezoo Haghshenas4, Karina D. Torralba5 <p>Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiographic syndrome characterized clinically by new onset neurological manifestations as well as neuroimaging findings of reversible cerebral edema. We report a case of PRES in the setting of systemic lupus erythematosus (SLE) with new-onset Class IV Nephritis treated with pulse corticosteroids, plasma exchange, intravenous immunoglobulin (IVIG) and cyclophosphamide. We also present a brief review of the associations between PRES and SLE.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Goblet Cell Carcinoid (GCC) of the Appendix presenting as a Small Bowel Obstruction: Case Report and Literature Review 2021-07-02T15:11:50+00:00 Amin Tanveer1 MD, Shaani Sighal2 MBBS, Asiri Arachchi3 MBBS, Zoltan Hrabovszky3 MBBS, FRACS, Mikhail Fisher3 MBBS, FRACS. <p>Goblet Cell Carcinoid (GCC) is a rare, low grade malignancy, and GCC presenting as a small bowel obstruction (SBO) is incredibly rare.<br>Hereby, we presenting a 68-year-old male presented to our Emergency Department with a one-day history of right sided abdominal pain, distention and vomiting, he had no previous abdominal surgery and had no significant other medical problem. Abdominal Computed Tomography (CT) demonstrated a high grade, closed loop small bowel obstruction involving the terminal segment of the ileum, and a low-density appendiceal nodule. He had laparoscopy converted to open caecectomy, the histology, confirmed the diagnosis of Goblet Cell Carcinoid of the appendix, eventually he had right hemicolectomy, progressed well, and made a good post-operative recovery, discharged home.<br>As presentation of GCC of the appendix with sbo is a very rare incidence, we discussed this through a case report with its immunohistochemical, behavioral features, presentation and treatment options.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Sweet syndrome associated with differentiation syndrome in a patient with acute promyelocytic leukemia – a case report and review of literature 2021-07-02T15:10:21+00:00 Mohammad A. Abdulla1, Mohamed A Yassin1, Anil Ellahi1, Shehab F. Mohamed1, Halima Elomri1, Nancy Kassem2, Deena Mudawi1, Sonia Allouch3 <p>Sweet Syndrome (SS) (acute febrile neutrophilic dermatosis) is an inflammatory disorder characterized by the appearance of painful, edematous, and erythematous papules, plaques, or nodules on the skin. It might also cause fever and internal organs’ involvement. There are three clinical settings in which SS has been described: classical or idiopathic, malignancy-associ¬ated and drug-induced. (1) SS is described in patients with acute promyelocytic leukemia (APL), and is a rare side effect of all-trans retinoic acid (ATRA), which causes differentiation of promyelocytes and used in therapy of APL. ATRA may also cause Differentiation Syndrome (DS), previously called retinoic acid syndrome, and there is overlap with SS. (2)<br>There is a limited number of case reports describing SS in association with DS. We present here a case of SS associated with DS in a patient with APL treated with ATRA.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Panniculitis in Cutaneous Leishmaniasis: a Study in Sri Lanka 2021-07-02T15:08:24+00:00 Thilakarathne BMIK, Ratnayake RMP, Vithanage A, Sugathadasa WDP <p>Introduction: Panniculitis is the inflammation of subcutaneous adipose tissue which is caused by many infectious and inflammatory conditions. It is high time to document panniculitis in the skin lesions with cutaneous leishmaniasis (CL) in Sri Lanka.</p> <p>Objectives: This study was performed to assess demographic data and to describe panniculitis in patients with CL.</p> <p>Methods: A descriptive cross-sectional study was done from 2013 to March 2018 at Teaching Hospital Kandy, Sri Lanka. The skin biopsies clinically suspected as CL evaluated histologically for diagnostic or indicative evidence of CL, and patients responded completely to the specific anti-leishmaniasis treatment were taken as the study population. Skin biopsies of 123 patients were assessed in view of dermal granulomata, Leishman-Donovan bodies and panniculitis.</p> <p>Results: The majority of patients were in the age group of 36 to 50 years (N= 36:29.3%: mean=41.64 years: SD18.15 years) and there was a slight female predominance in the study (N=65:52.8%). A majority of skin biopsies revealed Granulomata (N=95: 77.2%). Leishmania Donovan bodies were identified among 43.1% of the lesions (N=53). Though there were 123 patients, only 66 (53.6%) skin biopsies were deeper enough to reveal subcutaneous tissue. A significant amount of skin lesions showed subcutaneous tissue inflammation (N=59:89.39%), predominantly non-granulomatous in morphology (N=44:74.6%).</p> <p>Conclusion: Subcutaneous tissue inflammatory infiltrates in the non-granulomatous morphology is an important feature of the skin biopsies of CL especially in the granulomatous variant of the CL, which can be achieved by a deeper elliptical biopsy.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Morel-Lavallee Lesions: A Non-Operative Case Series 2021-07-02T15:06:02+00:00 Guy W. Nicolette1, Charlie Michaudet2, Bryan Pierce3 <p>In the late 1800’s, Morel-Lavallèe described a pattern of injury to the proximal thigh involving a fluid collection associated with a de-gloving type of injury. These injuries typically result from blunt trauma and falls. There is existing literature that suggests surgical management as primary treatment, although no rigorous controlled trials are found in English language medical literature. Non-surgical aspiration with sclerodesis is an option, however individual case reports suggest that using multiple aspirations without sclerodesis could be effective. This series illustrates that nonsurgical management (i.e. aspiration without sclerodesis) is a viable option for these injuries.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Multiple peripherally “ring” enhancing lesions of the brain in a young man: A diagnostic dilemma 2021-07-02T15:04:29+00:00 Aiman Ahmad1, Asmaa Atteya1, Afraa Moustafa2, Afaf Al-Battah2, Mohamed Talaat3, Abdulrazzaq Haider4, Mohamed A Yassin2 <p>Primary central nervous system (CNS) lymphomas are tumours localised only in the brain, spinal cord, and rarely, the eyes (i.e. involving only the CNS). These can be detected by imaging modalities, namely computed tomography (CT) and magnetic resonance imaging (MRI), in which they appear as lesions, most often with surrounding enhancement (i.e. peripherally-enhancing or ring-enhancing lesions). However, similar lesions can be seen in a variety of other conditions and differentiating these diagnoses by imaging alone is difficult. We report a case of primary CNS lymphoma in a 21-year old gentleman who was misdiagnosed as and treated for neurocysticercosis and brain tuberculomas due to misleading investigation results, in addition to the relative unlikelihood of CNS lymphoma in this patient compared to other similar individuals. Fortunately, appropriate management was initiated as soon as CNS lymphoma was confirmed by biopsy of the brain lesion, with good treatment response.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Primary lymphoma of bone, myeloma mimicker: a case report and review of literature 2021-07-02T15:02:35+00:00 Deena Mudawi1, Samah Kohla2,3, Feryal Ibrahim2, Hesham Elsabah1, Mohamed Abdelrazek4, Lajos Szabados5, Mohammad A Abdulla1, Omar M Ismail1, Abdulqadir J Nashwan1 And Mohamed A Yassin1 <p>Primary lymphoma of the bone (PLB) primarily arising from the medullary cavity is an extremely rare entity, with only limited number of studies and sporadic cases reported in the literature. The current study presents one case of PLB presented with unique presentation and treated with chemotherapy only. A 66 year old male presented with severe pain in the left hip that persisted for two months. Initial laboratory work up showed anemia, hypercalcemia and increase in free light chains kappa to lambda ratio, a diagnosis of multiple myeloma was suspected, magnetic reso¬nance imaging of the vertebral spine extensive involvement of bone marrow of the vertebrae.<br>An 18F fluorodeoxyglucose positron emission tomography computed tomography (FDG PET CT) scan showed widely scattered moderate to intense uptake in multiple lytic of skeleton, Impression was : Image compatible with extensive multiple myeloma, No extra osseous involvement was found.<br>Bone marrow examination was performed confirmed a diagnosis of extensive bone marrow involvement by High grade B-cell neoplasm with areas of bone marrow necrosis.<br>The patient received six cycles of R-CHOP regimen (Rituximab, cyclo-phosphamide, Anthracycline, vincristine and prednisone) and achieved a complete response, as confirmed by FDG PET CT. At present, the patient is in a good condi¬ this patient presentation mimicking multiple myeloma, which represent diagnostic dilemma.<br>Primary lymphoma of the bone is rare disease entity, there is no strong evidence supporting some diagnostic and therapeutic decisions, and therefore, case presentation of the rare disease may facilitate treatment of similar diseases. A review of the literature to elucidate the clinical, radiological, pathological phenotype and optimal treatment of PLB done.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Missing Intrauterine Device (Copper T) Forming Stone in the Urinary Bladder 2021-07-02T15:01:05+00:00 Ofoha C.G*., Galam Z.Z., Dakum N.K. <p>Intrauterine device (IUD) is the commonest method of contraception used by women. Complete migration into the urinary bladder though rare, results in lower urinary tract symptoms and stone formation around the migrated IUD. We present a 53 year old woman with a missing IUD (Copper T) who presented with lower urinary tract symptoms and haematuria. Cystoscopy showed a bladder stone anchored to the anterior bladder wall by an intrauterine device. She had cystolithotomy and retrieval of oblong shaped stone measuring about 3cm and intact IUD (Copper T) after failed endoscopic procedure. Adequate counselling prior to insertion is important. This will reduce the incidence of missing IUD.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Colchicine Overdose: Journey to recover. Case Report 2021-07-02T14:59:13+00:00 Mohamed Ibrahim Shoaib1, Zeyad Faoor Alrais1, Hesham Mohamed ElKholy1, Khalid Omar Hassan1, Marisol Reyes2 <p>Colchicine is an anti-inflammatory alkaloid used for the treatment and prevention of gout, and more recently for the treatment of familial Mediterranean fever (FMF). It has a narrow therapeutic index, with no clear- cut distinction between nontoxic , toxic and lethal doses. Colchicine is rapidly absorbed from the gastrointestinal tract after ingestion, In patients with pre exciting renal and hepatic impairment the possibility of toxicity greatly increases.The clinical course of acute colchicine overdose is divided into three sequential and usually overlapping phases. The first phase is gastrointestinal and the second phase is multi organ failure and death will occur in this phase, the third phase is the recovery stage typically occurs after weeks. We present 38 years old patient who presented to our hospital Accident and Emergency after 8 hours of ingestion of 40 tablets of colchicine. Patient was complaining of nausea and vomiting with repeated watery diarrhea. After 24 hours, Patient was diaphoretic , orthopenic and tachycardic , fluid resuscitation was ongoing , but as patient hemodynamic was unstable requiring vasopressor support patient was shifted to ICU.As the patient had worsening lactic acidosis and acute kidney injury, elective intubation was done and patient was mechanically ventilated. During this stage patient was in multi organ failure (cardiogenic shock, coagulopathy, acute kidney injury, pancytopenia and electrolyte disturbance). After 10 days Patient was tracheostomized due to prolonged intubation , then gradually weaned from mechanically ventilation , pancytopenia resolved with rebound leukocytosis but with delayed in recovery of kidneys so CRRT was continued till renal recovery that was achieved after 3 weeks , Successfully the patient had his tracheostomy tube de-cannulated and discharged after full recovery.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Intracranial Angiomatous Meningioma: Case Report and Literature Review 2021-07-02T14:57:14+00:00 Fatima Zahra FARHANE, Touria BOUHAFA, Khalid HASSOUNI <p>Angiomatous meningioma (AM) is a rare subtype of meningioma characterized by highly vascular tumor tissue comprising predominantly variable sized hyalinized blood vessels. This manuscript describes a case of intracranial Angiomatous meningioma and reports briefly its clinical, radiological, histopathological and therapeutic characteristics through a literature review.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Intracardiac Hydatid Cyst 2021-07-02T14:54:47+00:00 Abdullah Orhan Demirtas1, Yeşim Alpay2, Gencehan Kumtepe3, Erdogan Bulbul4, Ayberk Görcan5 <p>Human echinococcosis is a zoonotic infection caused by larval forms (metacestodes) of tapeworms of the genus echinococcus found in the small intestine of carnivores. The eggs of these tapeworms excreted by carnivores may infect various species of natural intermediate host animals and humans. Hydatid cysts may be found in almost any part of the body, leading to many clinical presentations. The most common locations are the liver and lungs (2). In the heart, the left ventricle is the most common location (46%), followed by the right ventricle (21%), interventricular septum (19.3%), right atrium (9.7%), left atrium (1.6%), and sinus of valsalva (1.6%) .The treatment of intracardiac hidatid cyst is surgery (3).</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Immunotherapy induced pyrexia and the role of PET/CT 2021-07-02T02:39:33+00:00 Luke McLean, Jennifer A Soon, Andrew Haydon <p>Background: Immunotherapy has revolutionised the management of metastatic melanoma, however, immune-related adverse events remain an important complication of therapy. We hypothesise pyrexia is a rare presentation that may herald the development immune-related toxicities and identify a potential role for fluorodeoxyglucose-positron emission tomography (FDG -PET) in the earlier diagnosis of these toxicities.<br>Case Presentation: We report a case of a 54-year-old man with metastatic melanoma, on combination immunotherapy with ipilumimab and nivolumab, where several days of fever heralded the development of clinical enterocolitis. He ultimately required treatment with infliximab with quick resolution of his symptoms. FDG- PET imaging performed as a work up for his pyrexia demonstrated extensive entero-proctocolitis and a follow up FDG-PET 3 months post infliximab demonstrated complete resolution of the entero-proctocolitis and ongoing complete extracranial response of the melanoma.<br>Conclusion: Early FDG-PET in patients with unexplained pyrexia on immunotherapy may help in an earlier diagnosis of immune-related toxicities allowing prompt initiation of therapy and a reduction in morbidity and mortality associated with these treatments.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Primary cerebral lymphoma in immuno-competent patient: report of 2 cases and literature review 2021-07-02T02:37:28+00:00 Fatima zahra Farhane, Touria Bouhafa, Abderrahmane Elmazghi, Khalid Hassouni <p>Primary cerebral lymphoma is a form of non-Hodgkin lymphoma with a solitary localization in the brain, excepting other localizations involving the central nervous system. This is a rare cancer but with increasing incidence, it was predominantly observed in immunodepressed HIV-positive patients but since the advent of effective antiretroviral treatments, it has essentially been observed in immunocompetent patients.<br>We report two cases of primary cerebral lymphoma observed in immunocompetent patients.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Bilateral Septic Arthritis Resulting in Mortality in the Elderly: A Case Report 2021-07-02T02:35:54+00:00 1Kadir, Dotun Musiliu, 2Ahmed, Bola Abdulkadir, 3Ibraheem, Gbadebo Hakeem <p>Bilateral septic arthritis is a rare presentation and when present is seen in the elderly resulting in morbidity and mortality. We present a 79 year old lady who died as a result of complications arising from bilateral septic arthritis.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A case of lumbar intraspinal schwannoma presenting as positional headache 2021-07-02T02:34:13+00:00 1,2 Shu-Shong Hsu, MD; 3 Ying-Tso Chen, MD <p>The association between spinal tumors with hydrocephalus and intracranial hypertension is rare, and the exact mechanism has remained uncertain. We present a case of L4/5 intraspinal schwannoma presenting as positional headache, with the aim to discuss the underlying pathophysiology and alert clinicians of the possibility of lower spinal tumor as a differential diagnosis of headache.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Manual physical therapy clears adhesive bowel obstruction and strictures in a patient with Crohn’s disease 2021-07-02T02:32:34+00:00 1 Leonard B Weinstock, 2Janey S A Pratt, 3Lawrence Wurn, 4 Sharon Hepburn, <p>A woman with Crohn’s disease with prior resection presented with a one-year history of persistent abdominal pain. The small bowel follow-through radiograph demonstrated the presence of two strictures in the small intestine due to adhesive scarring. Opting for conservative management, the patient underwent a specialized manual physical therapy regimen. Following treatment, the patient experienced significant decrease of abdominal pain and improved biomechanical function. Radiologic imaging revealed complete resolution of both strictures. Manual physical therapy may be a viable non-operative option to manage small bowel strictures or obstruction.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Flu B or not Flu B: An atypical case of minimal change disease triggered by Influenza B presenting with multi-organ dysfunction 2021-07-02T02:30:37+00:00 Jordana Cheta1, Alamgir Mirza1, Michael Binder1, Sandeep Magoon1 and Thomas McCune1 <p>Minimal change disease (MCD) accounts for 10-15% of idiopathic nephrotic syndrome in adults. Patients typically present with nephrotic range proteinuria, hypertension, microscopic hematuria and can even progress to acute renal failure. MCD can be primary (idiopathic) or secondary from etiologies such as cancer, medications, autoimmune conditions and infections. The link between infectious etiologies for MCD is important to recognize, since MCD tends to show a good response to treatment of the underlying cause. Influenza A has been reported as a secondary cause of MCD and rarely, influenza A, not B, can also present with liver failure. We present an atypical case of a 60-year-old female with no past medical history who presented with liver failure along with acute kidney injury and nephrotic range proteinuria. She was diagnosed with liver failure and secondary MCD from influenza B, the first reported case, and made a full recovery with treatment of Influenza B.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Totally Cystic Schwannoma in the posterior mediastinum on right side- A rare presentation 2021-07-02T02:28:36+00:00 Amarjit singh, K S Sidhu, Shivaji Rai, Karandeep singh. <p>A 54 year old female presented with a short history of dyspnoea on exertion and pain right hypochondrium, radiating to back. X-Ray chest showed a well-defined opaque mass in the posterior mediastinum. A computed Tomography (C T) scan chest done revealed a thick walled cystic lesion in the posterior mediastinum compressing the right lower lobe bronchus along with minimal pleural effusion on same side. Ultrasound guided aspiration was done and clear watery fluid aspirated. Standard postero-lateral thoracotomy was under taken and the whole cystic mass was excised. Postoperative period was uneventful. Histopathological examination of the cyst wall revealed it to be a cystic schwannoma.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Major bleeding precipitated by interactions between antibiotics and warfarin: a case series 2021-07-02T02:26:53+00:00 Luana Marchesan1, Raíssa Londero Chemello1, Vanessa Thomé1, Diego Chemello1,2 <p>Warfarin is a widely used anticoagulant agent with a large spectrum of indications for prevention and treatment of thromboembolic complications. Despite its low cost, warfarin and all other vitamin K antagonist (VKA) use has several limitations, including narrow therapeutic index requiring frequent laboratory monitoring to prevent complications related to under- and over-anticoagulation. The concomitant use of medications may alter the metabolism of warfarin by inducing or inhibiting the cytochrome P450-2C9, resulting in a decrease or increase in anticoagulant effect. In this setting, interactions between warfarin and antibiotics have been described. These interactions represent one of the problems with VKA use in the clinical setting. We aimed to report four cases where the prescription of antibiotics without proper control of anticoagulation levels led to major hemorrhagic complications.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Idiopathic Sigmoid Intussusception Prolapse per Anus 2021-07-02T02:25:11+00:00 Loay M. AlJaberi,MD1, Alaa K. Salameh,MD2, Rafiq M. Salhab,MD3,Hazem A. Ashhab,MD4 <p>Sigmoidal intussusception protrusion through the anus is extremely rare and has only been reported a few times. The majority of cases of prolapsed sigmoid intussusception in adults have an underlying bowel pathology such as carcinoma, polyps, or benign neoplasms, which are usually discovered intra-operatively. Our case is a 25-year old male patient, previously healthy, with no history of constipation or straining, who presented with a painless prolapsed mass out of the anus. It is very unusual for a young healthy male to present suddenly with such a complaint. After failed attempts to reduce the prolapsed segment under general anesthesia, laparotomy was performed and the prolapsed mass was determined to be an intussuscepted sigmoid. Hartmann procedure was performed. 9 cm of the sigmoid was resected. Findings were consistent with a healthy but edematous prolapsed sigmoid colon.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Comparative Evaluation of Healing following Gingival Depigmentation Procedures using Four Techniques: a report of 5 cases 2021-07-02T02:23:27+00:00 1Dr Shreya Shetty, Bds, Mds (Periodontics), Ficoi*, 2 Dr Aruna Vanka, Bds, Mds( Periodontics). <p>Background:The outcomes of techniques employed for depigmentation are varied and no one method can be deemed as ideal. The present case series is an evaluation of 4 popular depigmentation procedures `carried out today.<br>Material and methods: 5 patients with non-syndrome associated gingival hyperpigmentation in all 4 quadrants based on Dummetts scoring criteria were included. Healing and pain were assessed following depigmentation carried out by scalpel, bur, electro surgery and laser in the 4 quadrants respectively and followed up for a period of 2 years.<br>Results: Healing following Scalpel method and laser were better than bur and electro surgery. Post-operative pain was less with the use of scalpel and laser when compared to the other 2 techniques at the end of 1month. Pain was still evident at the site of electro surgery at the end of 2 months. However at the end of 3, 6 months and 1 and 2 years there was no difference in all 4 techniques.<br>Conclusion: Better treatment outcomes were observed with the scalpel and laser techniques than bur and electrosurgery.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Kakuchi-Fujimoto Disease Associated with Autoimmune Hepatitis and Systemic Lupus Erythematosus 2021-07-02T02:21:43+00:00 Mithu Maheswaranathan, M.D.1 and Melissa Cunningham, M.D., Ph.D.2 <p>Systemic lupus erythematosus (SLE) is often associated with various systemic manifestations, from peripheral cytopenias to renal involvement or neuropsychiatric symptoms. Here, we present a patient in whom the cause of fever and altered mental status was unknown despite repeated lumbar punctures, but later became elucidated following the development of rash and lymphadenopathy with subsequent biopsies. This case demonstrates a unique presentation of Kakuchi-Fujimoto Disease, a necrotizing lymphadenitis manifesting in association with SLE and autoimmune hepatitis. Further, this case illustrates the proclivity of autoimmune disorders to occur concurrently.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A case report on the effect of plasmapheresis in the treatment of severe calcium channel blocker toxicity 2021-07-02T02:19:52+00:00 Mohamed Foda Hendi1, Zeyad Faoor Alrais1, Ahmed Hossam Awad1, Mouayad Abdulghani1, Demme Shammass2 <p>Overdose by calcium channel blocker (CCB) antihypertensive agents has been shown to be a cause of significant morbidity and can often be fatal. (1) Although overdoses of calcium-channel blockers and beta blockers are uncommon, they have a high mortality rate, and management may be complicated. (2) Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. (3) We report a case of severe Amlodipine/Atenolol overdose that was refractory to multiple therapeutic approaches but rapidly responded to plasmapheresis. We describe the case of a previously healthy 25-year-old lady presented after ingesting 30 tablets of Amlodipine 5 mg/Atenolol 50 mg in a suicide attempt. The patient was initially managed with fluid resuscitation, calcium boluses, glucagon bolus, methylene blue boluses and multiple vasoactive agents. Hyperinsulinemic euglycemic therapy was initiated when hypotension persisted despite conventional treatments but was stopped later due to life threatening hypoglycemia and hypokalemia. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels as knowing that amlodipine is highly protein bound. Plasmapheresis is a procedure used to remove pathologic substances from a patient’s blood that has proven useful in some cases of drug overdose. (1) A dramatic improvement of cardiovascular stability was already observed during plasmapheresis. The primary outcomes were to reduce mortality and improve hemodynamic parameters. The secondary outcomes included reduce length of stay in intensive care unit, duration of vasopressor use and functional outcomes. (4) Conclusion: This case demonstrates that a Plasmapheresis can be effective in restoring hemodynamic stability in severe calcium channel blocker toxicity and recommend its use in patients with calcium channel blocker toxicity that is not responsive to traditional therapies.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Long-term efficacy of dobesilate in chronic patellar tendinopathy 2021-07-02T02:18:10+00:00 Pedro Cuevas1, José Antonio Rodas2, Tomás Fernández Jaen3, Pedro Guillen3, Javier Angulo4, Guillermo Giménez-Gallego5 <p>There is a wide variety of treatment options available for patellar tendinopathy, the majority of which are non-surgical, and no consensus exists on the optimal method of treatment. We report that peritendinous injection of dobesilate in patients with chronic patellar tendinopathy, resulted in significant long-term improvement in knee function and reduced pain.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Efficacy of topical application of etamsylate in herpes simplex labialis 2021-07-02T02:16:30+00:00 Pedro Cuevas1, Javier Angulo2 Guillermo Giménez-Gallego3 <p>Herpes simplex virus type-1 (HSV-1) causes a wide variety of clinical disorders of major public health concern. HSV-1 infections are common in oral and perioral area. We report the short-term efficacy of topical application of etamsylate in herpes simplex labialis lesion. Mucosal lesion resolved after 4 days of treatment leaving behind no apparent signs of cosmetic disturbance.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Cardiovascular Disease Associated with the Chronic Use of Ergotamine: A Case Report 2021-07-02T02:12:24+00:00 Vesga C 1* Sotomayor JA2 , Giraldo-González GC3 <p>Ergotamine and its derivatives were used for multiple diseases; in the nineties, its use in association with caffeine was considered a standard treatment for migraines, although it has been in decline, due to the evidenced toxic effects related to its chronic use including vascular, cardiovascular and central nervous system manifestations. In this article is reported a case of a 59-year-old female with chronic use of caffeine plus ergotamine for more than 20 years; afterwards she develops peripheral artery disease, severe mitral and tricuspid valve regurgitation with requirement of valve replacement. In the absence of past cardiovascular history and rheumatic fever, its clinical evolution and pathology results are associated with ergotism.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 A Rare Reason of Ileus: Atypical Hemolytic Uremic Syndrome 2021-07-02T02:10:44+00:00 Eray Eroglu1, Aysenur Cirak2, Ismail Kocyiğit1, Kemal Deniz3, Murat Hayri Sipahioglu1, Bulent Tokgoz1, Oktay Oymak1 <p>Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy that is characterized by intravascular hemolytic anemia, thrombocytopenia and acute renal failure. Typical form occurred with the shiga-like toxin produced by Escherichia coli bacterium or Shigella dysenteriae bacterium while atypical HUS is sporadic or familial form of the disease which develops due to uncontrolled activation in alternative complement pathway. It may present with recurrent attacks and it has a potential of poor prognosis. In this case report we presented a 36-year-old woman in her 22nd week pregnancy without any history of chronic disease or medication whom admitted to hospital with abdominal pain, bloody diarrhea, oliguria and diagnosed with atypical HUS. She was diagnosed with ileus at the first month of Eculizumab treatment and a polyploid lesion obstructing the lumen of the colon was detected. Pathologic examination of the mass revealed a chronic active inflammatory lesion.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Use of Benzodiazepines and Hypnotic Medications in Psychiatry Older Adult Outpatients 2021-07-02T02:06:35+00:00 Nahid M. Elhassan*, Zerak Al-Salihy, Bushra, Elhusein, Muayad Jouda, Sanabel, Al-Akras, Yahia Albobaly, Yaseen Eltorki and Majid Alabdulla <p>Benzodiazepines have anxiolytic, hypnotic, anticonvulsant, and muscle-relaxing properties, therefore, a widely prescribed treatment for anxiety and insomnia. They bind to gamma-aminobutyric acid type A (GABAA) receptors, which are responsible for most of the inhibitory neurotransmission in the central nervous system and these receptors are a major target of alcohol, barbiturates, muscle relaxants, and other medications with sedative effects, resulting in tolerance and dependence [1]. Benzodiazepines are categorized into short (15 to 30 minutes), intermediate (30 to 60 minutes), and long-acting agents (one hour or longer).<br>Benzodiazepines are frequently prescribed for elderly patients living in the community and for those in hospitals and institutions. Prolonged use of benzodiazepines is particularly likely in old age for the treatment not only of insomnia and anxiety, but also of a wide range of nonspecific symptoms. Long term users are likely to have multiple concomitant physical and psychological health problems [2].<br>Benzodiazepines produce dependence, reduce attention, memory, and motor ability. They can cause disinhibition or aggressive behavior, facilitate the appearance of delirium, and increase accident and mortality rates in people older than 60 [3].<br>According to Maudsley guidelines, benzodiazepines use in elderly are poorly supported for their link to cognitive decline, increase risk of falls and hip fractures [4]. And, if indicated, short acting agents should be avoided. Long acting agents should be started in low doses and patients need to be followed and reassessed regularly. Zolpidem or melatonin are indicated for insomnia, clonazepam and diazepam for agitation and pregabalin for generalized anxiety disorder [5].</p> 2018-12-31T00:00:00+00:00 Copyright (c) 2021 T Prolymphocytic Leukemia, a rare disease, case presentation with typical pathological findings and review of management 2021-07-02T00:25:46+00:00 Mohammad AJ. Abdulla1, Firyal Ibrahim2, Mahmoud Aldapt1, Halima Elomri1, Ahmad Al-Sabbagh2, Dina Sameh Soliman2,3, Sonia Allouch4, Liam Fernyhough4, Mohamed A. Yassin1 <p>Background:<br>Prolymphocytic leukemia (PLL) is a rare disease, accounting for &lt; 2% of lymphoid leukemias [1].There are 2 quite different entities with distinct pathologic features and different therapeutic strategies, T-cell and B-cell [2]. T-PLL is more common [3]. Although termed ‘prolymphocytic,’ T-PLL is characterized by the proliferation of post-thymic T-lymphocytes. It is estimated that physicians will see a case of T-PLL every five to ten years [4]. Over the last 15 years, 3 cases of T-PLL were diagnosed in our center. We present here the latest case, with typical pathological findings.</p> <p>Case Report:<br>A 63-year-old British gentleman, previously healthy with good performance, presented with fatigue for 6 – 8 weeks with puffiness of face and eyelids and weight loss of 5 kilograms. Physical exam showed periorbital edema and conjunctival injection (Figure 1), cervical lymphadenopathy, and hepatosplenomegaly. Initial complete blood count (CBC): white blood cells (WBCs) 331.9 x109/L (4.0 – 10.0), with 94% lymphocytes, hemoglobin (Hb) 119 gm/L (130 – 170), platelets (Plts) 128 x109/L (150 – 400). Lactate dehydrogenase 10.4 µkat/L (2.1 – 3.7), uric acid 537 µmol/L (210 – 420). Abdomen ultrasound showed markedly enlarged spleen (20.3 cm).<br>The peripheral blood smear showed profound leukocytosis with 94% abnormal lymphoid cells. The cells were small to medium in size with high nucleo-cytoplasmic ratio, moderately condensed chromatin and almost all with prominent nucleolus. Substantial number of the cells show irregular nuclear contour with short indentation. The cytoplasm was basophilic agranular and many cells show irregular cytoplasmic protrusions (Figure 2).<br>Flow cytometry on peripheral blood revealed one homogenous abnormal population positive for cluster of differentiation 45 (CD45) and express the pan T-cell markers (CD3, CD2, CD5 and CD7). All were positive for CD4, T-cell receptor (TCR) alpha/beta, CD43 and BCl2 with partial expression of CD38. These cells were negative for CD56, CD57, CD16, CD25, CD103, CD10, CD117, Terminal deoxynucleotidyl transferase (TdT), CD1a and CD34. (Figure3A) TCRVb region analysis by flow cytometry using IO Test Beta Mark TCR Repertoire kit (Beckman Coulter, Brea, CA, USA) using the panel of 24 monoclonal antibodies to TCR Vb families showed restricted expansion of region 13.1 in 99%. (Figure 3B)<br>Bone marrow aspirate was remarkably hypercellular and extensively infiltrated with abnormal lymphoid cells comprising approximately 75% of total nucleated cells, morphologically similar to those seen in peripheral blood. The biopsy showed extensive diffuse infiltration with small to moderately sized lymphoid cells with prominent nuclear irregularity (Figure 4A&amp;B). The immunophenotype was confirmed by immunohistochemistry and the cells were positive for CD3, CD5, CD7, CD2, CD4, BCL2 as well as for Zap70. BCL6 was uniformly negative.<br>Based on the morphology and the immunophenotypic profile, a diagnosis of CD4+/CD8? T-prolymphocytic leukemia was made.<br>FISH analysis revealed ATM deletion at 11q22 and TRA/D rearrangement in 93% of the cells analyzed and karyotype was complex with multiple numeric and structural abnormalities including inv(14)(q11.2q32); Karyotype: 43,XY,del(11)(q14),add(11)(p15),-13,inv(14)(q11.2q32),der(19)t(13;19)(q11;q13.4),-20,-22[7]/42,idem,-9,add(14)(p11.1),add(17)(p13)[23]<br>After confirming the diagnosis of T-PLL the patient travelled back to his home country. He was started on treatment with alemtuzumab, then pentostatin was added in week 4, after 10 weeks of treatment he achieved complete remission. After that he received reduced intensity conditioned allogeneic stem cell transplant from a matched brother, complicated by mild acute graft versus host disease. Until the time of writing this report he was doing fine.</p> 2018-12-18T00:00:00+00:00 Copyright (c) 2021 Subclinical chronic sinusitis causing presumed ventriculoperitoneal shunt sepsis in a child 2021-07-02T00:23:01+00:00 A. DANIEL, A.O. ADELEYE <p>Rhinosinusitis is often under diagnosed and overlooked in children. Fever as the only symptom of rhinosinusitis is rare and largely unreported. A three-year-old boy with a right frontal ventriculo-peritoneal (VP) shunt for congenital hydrocephalus presented with a three-month history of recurrent high grade intermittent fever. He had no other symptoms. A cranial Computed Tomogram for VP shunt evaluation revealed isodense lesions filling the right and left ethmoidal and maxillary sinuses. Bilateral inferior meatal puncture revealed frank pus in both maxillary sinuses. Microbacterial culture yielded Streptococcus pyogenes sensitive to Erythromycin. Following treatment, fever subsided and remained so in subsequent outpatients’ visits.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Venous Blood Gases for Femoral Line Placement Confirmation Are We Secured 2021-07-02T00:05:28+00:00 Mohamed Ibrahim Shoaib, Zeyad Faoor Alrais, Khalid Omar Hassan, Ahmed Hossam Awad <p>A large number of central venous catheters (CVC) are placed each year in the emergency room, operation theatre and critical care units. Although rarely associated with life threatening complications, femoral CVC is known to have the highest incidence of mechanical complications. The femoral veins are frequently preferred when other access sites are exhausted or there is increased risk for complications such as with emergency access, coagulopathy, and in the uncooperative patient .Femoral line placement confirmation is not routine practice. We present our case 59 years old male, Known case of Diabetes ,liver cirrhosis and portal hypertension presented to Accident and Emergency with repeated hematemesis and melena 3 times. On arrival to hospital patient was drowsy and hallucinating. Two large bore venous cannula were inserted and due to his hemodynamic instability requiring vasopressor support, Femoral venous catheter was inserted because of his deranged coagulation profile, with good blood flow and backflow , venous blood gases ( VBG) for placement confirmation was done. Patient was admitted for urgent upper GI endoscopy which revealed esophageal varix where bands were applied and with suspicious of Gut perforation. Urgent Computed Tomography ( CT ) of the abdomen was done . accidental radiological finding that the femoral line appeared to be curled posteriorly on itself. Patient was admitted to ICU where the malpositioned femoral line was removed and new central line was inserted confirmed position by the ultrasound and x-ray. Our conclusion from this case that even with functioning femoral lines confirmation by VBG alone is not enough and we recommend use of ultrasound not even during insertion but after placement for confirmation.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 A case report of primary ovarian fibrosarcoma 2021-07-02T00:02:16+00:00 Paige Grenier, Anita Agrawal, and Rajni Chibbar <p>Background: Ovarian fibrosarcoma is a rare malignant tumor that should be distinguished from benign fibrous ovarian tumors and other malignancies, as it has a predilection for early and aggressive metastasis.<br>Case: A 52-year-old woman presented with a large adnexal mass comprised of atypical spindle cells with increased mitotic activity, high Ki-67 index, and positive vimentin staining, consistent with primary ovarian fibrosarcoma. The patient required multiple laparotomies for large volumes of recurrent, rapidly growing disease. She died 15 months after initial surgery.<br>Conclusion: Ovarian fibrosarcoma is an important diagnostic consideration when evaluating adnexal masses. Further study is required to clarify the impact of potential prognostic factors and establish optimal management and treatment.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Use of Internet for medical information by patients & its impact on Consultation time- A Patient Survey 2021-07-01T23:59:23+00:00 Hemanth.K.Subrahmanyam <p>Our patient survey revealed that there is equal number of Internet user and Internet non-user patients visiting our outpatient consultation. This raises an interesting fact about the importance of the need for the present day clinician to keep updated about not only the recent advances in the field but also with the IT skills. Literature has suggested prior Internet awareness amongst patients have resulted in explicitly patient controlled outcomes during consultation (10). Our patient survey did not focus on this aspect. Statistically significant was the increased consultation time of 0.8 minutes among the Internet user group in comparison to the Internet non-user group is still debatable. But does this point to the possible change in the consultation models in the Internet age is still questionable. Poor IT skills among the clinicians may result in defensively asserting an authoritative “expert opinion” when encountered with the Internet user group of patients as studies do suggest (10).<br>Though the internet has revolutionized the world with access and availability of information, health texts needs more regulation as it does seem to start having an impact on the consultation times as seen in our patient survey. Is this the beginning of a change for the physician-patient relationship model in the Internet age?</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Bilateral Anterior Cruciate Ligament (ACL) Tears treated by double bundle grafting 2021-07-01T23:57:38+00:00 Sushanta Kr. Das., B. Valya, Sandeep Ankam, P. Vishnu. <p>Anterior Cruciate Ligament (ACL) tears are orthopaedic injury, particularly in athlete and youth populations. ACL is composed of longitudinally oriented bundles of collagen tissue arranged in fascicular subunits within larger functional bands. Ligament is surrounded by synovium, thus making it extra-synovial. Unilateral ACL tear is common &amp; seen by sports medicine orthopaedic surgeons. But bilateral ACL injury is extremely rare and reported only three times in the previous literature. In this case of bilateral ACL tear, which was surgically treated and managed by performing arthroscopic double bundle ACL reconstruction in left knee using quadruplet hamstring graft. This particular surgery is a rare practice adopted by orthopaedic surgeons. We would like to highlight that, performing double bundle grafting not only helped the patient back into his sports field in shorter duration, but also shows that orthopaedic surgeons are espousing newer techniques and accomplishment of such procedure opening new dimension in ACL tear management.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Duodenal duplication cyst: a rare cause of gastro-intestinal obstruction 2021-07-01T23:55:25+00:00 S.Jarboui ; A. Saidani, I. farhat, Z. Bokal, D. Cherif. <p>Duodenal duplication cysts are rare congenital anomalies usually found in children, but rare cases have been described in adults.<br>We report the case of a duodenal duplication cyst in a 54-year-old man who presented with a gastrointestinal obstruction inherent to endoluminal hemorrhage. Diagnosis was evocated by endoscopy. It was confirmed by computed tomography, oesogasto duodenal swallowing and magnetic resonance imaging.<br>Partial cystectomy with mucosal stripping was performed via a midline laparotomy. The patient’s recovery was uneventful. The diagnosis was confirmed by histological examination of the operative specimen.<br>In elderly patients with atypical presentation associated to cystic structures neighboring the duodenum, a high index of suspicion is required to diagnose this rare congenital pathology. Complete excision is the optimal treatment, but in some cases, partial cystectomy or endoscopic procedures can be performed.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 A case report on Lassa fever and hearing loss: A rare occurrence and review of the literature 2021-07-01T23:53:40+00:00 Daniel Adekunle, Raji Yemi Raheem, Ijitola Julius Olowo, Bello Temitope Oluwatobi, Jinadu Olanrewaju Yusuf, Ajayi Samuel Oluwole, Olaleye Olufemi David*, Salako Babatunde Lawal, Lasisi Olawale Akeem <p>Lassa fever is highly endemic in Nigeria and other West African countries, it is a disease associated with high case fatality and chronic sequelae in those that survived. Lack of effective vaccine has made the disease difficult to control and it prevention depends on eradications of the multimammate rats and universal precautions by all when a case is identified. We report a case of a 51 years old health worker who had a severe form of Lassa fever complicated by sensorineural deafness at the University College Hospital, Ibadan, South West Nigeria.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Sudden Death in African Adult Males: Case Reports and Review of Literatures 2021-07-01T23:51:52+00:00 Ayodele J Omotoso, Lawson Ekpe, Akintunde Akintomide, Patience Odusolu, Martin A Nnoli <p>Sudden death is common in Africans especially in males in their middle ages. With increasing evidence in reduction of life expectancy among the populace due to several confounding factors there is need to review some of the causes of sudden unexpected death. The study came from the observation of the authors on autopsy requests and reports in Calabar. Two middle aged security officers attached to different private homes were found dead on their duty posts on different days. Autopsy reports on them were similar revealing enlarged heart with evidence of myocardial infarction. Other findings include fatty change, pulmonary oedema and contracted kidneys. Hypertensive heart disease is a common disease condition with resultant high morbidity and mortality if not diagnosed early and well managed.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Death On Campus: A Case Report Of A Student Stabbed During Election On Campus 2021-07-01T23:49:27+00:00 Omotoso J Ayodele, Irabor I Godstime, Ekpe E Lawson, Odusolu O Patience, Nnoli A Martin, Egbe E Eja <p>Homicide from stabbing is the commonest cause of death all over the world and unwholesome activities such as cultism usually result into this in university environment. We present a case of 23 year old undergraduate who was murdered during election within the school premises. He sustained a deep laceration into the chest cavity with injuring to the main vessels resulting in massive internal bleeding, hypovolemic shock and irreversible organ failure and death. All hands must be on deck to prevent unnecessary death on our campuses.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Stammering –Ayurvedic Management with Sookshma Aushadhi Chikitsa –A Case Report 2021-07-01T23:43:38+00:00 Vd.Shivani Sanjeev Gavande <p>A patient suffering from stammering since childhood was treated with Tota Vati for six months ,got resque from his suffering and now is acting confidently in play. He can speak fluently now. In Ayurved ,sookshma aushadhi chikitsa is the most popular system of management where we can get better result with processed microfined particals of the same medicine even at very low dose .Ayurved says ,when the medicine is reprocessed with the decoction of same ingredients repeatedly, we get better efficacy with very small quantity of medicine. Tota vati is such type of processed medicine which was prepared by Vaidya .Narhar Bhole Prabhu.These tablets are much more useful in stammering.</p> 2017-12-01T00:00:00+00:00 Copyright (c) 2021 Efficacy and safety of Bosutinib in Patient with Chronic myeloid leukemia who was intolerant to DASTANIB,NILOTUNIB -Case report 2021-07-01T23:39:48+00:00 Abdullah M Arshad1, Mohamed A Yassin2 <p>Treatment for Chronic myeloid leukemia has been revolutionized because of availability of different tyrosine kinase inhibitors. Each TKI come with its on toxicity profile as this needs to be taken in account before starting therapy with particular agent in a patient. Most of the adverse effects related to TKI are mild and can be managed by either symptomatic treatment or either by dose reduction. But some patients can become intolerant and to switch to other TKI remains the only option. Bosutinib is currently approved for treatment of chronic phase CML in patients who are either resistant or intolerant to previous TKI. We present a case of 59 year old male patient with CML who was intolerant to Dastanib and Nilotinib but showed excellent hematological and major molecular response to bosutinib</p> 2021-07-01T00:00:00+00:00 Copyright (c) 2021 A case study of ruptured cornual ectopic with successful outcome in subsequent pregnancy 2021-07-01T23:37:48+00:00 Snigdha Kumari1 MS,DNB, Bharti Joshi MD1*, DNB, Rashmi Bagga MD2, Jasvinder Kalra2 MD, Pradip Kumar Saha3, MD <p>Cornual pregnancy is a fearful condition with dreadful complications. Due to rarity and late presentation, it poses diagnostic and therapeutic challenges. There is no consensus on treatment strategies till date and risk of rupture after repair in subsequent pregnancy always remains a major concern. We hereby discuss a case of 27 year female who presented with ruptured cornual ectopic pregnancy, underwent cornual wedge resection with repair and had subsequent pregnancy with a successful outcome.</p> 2021-07-01T00:00:00+00:00 Copyright (c) 2021 Unilateral Vestibular schwannoma with Pituitary macroadenoma- Rare concurrent dual intracranial lesion 2021-06-30T19:23:13+00:00 Ram Moorthy1, Segana Hasan Abdul Cader2 <p>The presenting clinic features of the cerebellopontine angle tumours and their management are well known, however there is limited knowledge regarding coexistence of other primary brain tumours which can be incidentally detected. A 70-year-old otherwise normal gentleman was referred from routine hearing screening programme centre with more of right sided hearing loss and occasional right sided tinnitus. Pure tone audiogram revealed an asymmetric high frequency sensorineural hearing loss .Gadolinium contrast enhanced MRI showed a right distal mass filling the entire internal acoustic meatus with an intracanalicular dural extension indenting the middle cerebellar peduncle with no significant enhancement. Additionally, an incidental enhancing asymmetric macroadenoma was detected in the pituitary sella indenting the left cavernous sinus without an extension and displacing the pituitary stalk to the right and displacing the carotids superiorly exerting insignificant pressure on the optic nerves. He had Hyperprolactinemia but normal visual fields. Here we present this rare concurrent presentation of dual intracranial primary tumours which by itself clinically is very uncommon.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Intra-Abdominal Desmoplastic Small Round Cell Tumor: A Diagnostic Dilemma In Resource-Constrained Settings – A Case Report & Literature Review 2021-06-30T19:20:02+00:00 ABIORO Imodoye Ayokunbi <p>Introduction. Desmoplastic small round-cell tumours (DSRCT) are primarily intra-abdominal soft tissue sarcomas that are extremely rare and aggressive with a rapidly deteriorating clinical course and poor outcome despite therapy. It belongs to the family of small round blue-cell tumours, symptoms of the disease are non-specific and metastasis is often present at diagnosis. Objective. This report presents a typical case of an intra-abdominal DSRCT while highlighting how challenging the diagnosis can be in resource-poor settings and best-practice in the management of its attendant complications. Case presentation. This is a case 10-year-old boy who presented with a two-month history of weight loss and a two-week history of colicky abdominal pain, abdominal distension and vomiting and loss of appetite. He was pale, had left mandibular lymphadenopathy with a distended abdomen and ascites. A palpable mass was occluding ~80% of his rectal lumen. CT scan showed intra-abdominal masses in the rectovesical pouch and hepatic flexure with abdominopelvic lymphadenopathy Patient was worked up for exploratory laparotomy, colostomy placement and tumor biopsy, with the subsequent histology and immunohistochemistry a diagnosis of DSRCT was made. The patient developed moderate anaemia, acute kidney injury, hypertension and anarsarca while on admission; these were successfully managed with blood transfusions, intravenous fluids and drugs subsequently. He had a re-exploration for fecal disimpaction and adhesiolysis due to persistent intestinal obstruction. Patient was discharged 15 days after admissionin a stable clinical state. Conclusion. Desmoplastic round-cell tumour (DSRCT) primarily occurr within the abdomen, it is capable of mimicking the symptomatology of other intra-abdominal malignancies and a high index of suspicion is requisite to make a diagnosis especially in resource-poor settings with swift implementation of treatment modalities necessary to halt disease progress.Desmoplastic small round-cell tumour, aggressive course, complications.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Idiopathic retroperitoneal fibrosis and ankylosing spondylitis – A new case report with review of the literature 2021-06-30T19:17:28+00:00 Soumaya Boussaid <p>Retroperitoneal fibrosis (RPF) is an uncommon disease (annual incidence estimated at 1/20,000–500,000) characterized by the development of dense fibrous tissue in the retroperitoneal compartment [1].<br>RPF can be idiopathic or secondary to drugs, infections, radiotherapy, malignant diseases, major abdominal surgery, trauma and retroperitoneal injuries [2,3]. RPF has also been reported in patients with systemic autoimmune diseases including rheumatic diseases [4-7]. Several cases of RPF in patients with ankylosing spondylitis have been described.<br>Herein, we report a new case of retroperitoneal fibrosis in a patient with ankylosing spondylitis.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Post Appendectomy Blindness, Extremely rare complication after abdominal surgery 2021-06-30T19:15:35+00:00 Maram Salah1, Mohannad Al-Tarakji2, Fakhar Shahid11, Syed Muhammad Ali2*, Khalid Ahmed2, Ahmad Zarour2 <p>Perioperative visual loss (POVL) is a drastic complication that can result after ocular and more commonly non-ocular surgery, mostly reported after spine and cardiac bypass procedures. Despite the rarity of such complication, it has been reported following the abdominal surgeries. Overall, the most common cause of POVL is ischemic optic neuropathy but any pathology to the optical system from the cornea to the occipital lobe can lead to this rare phenomenon. Here, we are reporting the second case in the literature of post-operative visual loss after laparoscopic appendectomy. A young female, with no underlying disease, underwent laparoscopic appendectomy after septic shock secondary to acute appendicitis. Postoperatively, patient complained of complete blindness after extubation. Neurologic examination revealed bilateral near complete blindness, and hemodynamic ischemic stroke in the occipital cortex.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Intestinal anastomosis blowout following post-operative cardiopulmonary resuscitation: A case report 2021-06-30T19:13:55+00:00 Olivia A. Sacks, MD1,2, Priyanka Chugh, MD1,2, Katherine He, MD1,3, Allan Stolarski, MD1,2, Gentian Kristo, MD1,3* <p>Background: Pneumoperitoneum following cardiopulmonary resuscitation (CPR) is a very rare complication with a challenging management. In this paper we describe the management of a patient who suffered a blowout of his colorectal anastomosis after undergoing CPR for a cardiac arrest in the early post-operative period. Additionally, we present a thorough literature review of the management of CPR-related pneumoperitoneum.</p> <p>Summary: Five days after a sigmoid resection for colon cancer, a 71-year-old male went into pulseless electrical activity and CPR was initiated, with complete clinical recovery. After CPR the patient was found to have new hydropneumothorax and pneumoperitoneum. Because he had a normal abdominal examination, lack of leukocytosis, and no evidence of a bowel perforation on water-soluble CT imaging, the patient was initially managed non-operatively with close clinical follow-up. However, he failed the non-operative management and ultimately required a laparotomy demonstrating a blowout of his colonic anastomosis.</p> <p>Conclusion: Physicians should remain aware of the risk of damage to fresh bowel anastomoses following CPR. There should be a low threshold for surgical exploration in patients that develop CPR-related pneumoperitoneum soon after intestinal surgery, even when patient’s clinical status is stable.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Identification of Interictal Paroxysmal Diffuse Sharp Activity with Eye Closure in Patients with Generalized Epilepsy 2021-06-30T19:12:14+00:00 Mary Payne, MD*, Mary Miller RPSSGT, RST, R.NCS.T, CNCT, R.EEG.T <p>Interictal EEG recordings of patients with generalized epilepsy have known interictal abnormalities such as generalized spike and wave activity during photic stimulation and hyperventilation, interictal spike and wave or diffuse sharp activity [1]. We report three patients with confirmed generalized epilepsy who’s interictal recordings showed paroxysmal diffuse sharp 10 Hz activity in all leads with eye closure following eye blinking. This pattern was not associated with interictal generalized spike and wave activity, clinical change in the patient or did not follow seizure activity. Abnormal eye movement with generalized spike and wave activity has been described in Jeavon’s syndrome, eyelid myotonia and Sunflower syndrome. However, our patients did not meet criteria for any of these diagnoses. Therefore, we feel that our finding of paroxysmal diffuse sharp alpha activity is a novel finding in these patients with primary generalized epilepsy and may be a newly reported marker for patients with primary generalized epilepsy. Recognition of PDSA activity and further study of this pattern is encouraged.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Extra-synovial Pigmented Villonodular Synovitis of the knee joint, Case Repor 2021-06-30T19:10:39+00:00 Rebar Mohammed Noori, Musaab Mohammed Hazim* <p>Background: PVNS is a rare, benign &amp; aggressive disorder arising from either synovial joints or tendon sheaths; it may erode articular structures and bones. We present a case with unique features of PVNS being extra-synovial and by this report we open a gate for more researches in this field.</p> <p>Case Presentation: This case report concerns a 35-year-old female with a history of right knee pain for 6-month duration proceeded by gradual swelling over posterior aspect of the knee, she denies any history of trauma, clinical examination was unremarkable but apart from tenderness over the infrapatellar region with full flexion.</p> <p>MRI shows a heterogenous signal extra-articular and extra-synovial lesion in posterior aspect of the knee suggesting Pigmented Villonodular Synovitis, FNA revealed a hemosiderin-laden macrophages and multinucleated giant cells, Tru-cut biopsy result was suggesting PVNS as synovial cells were seen admixed with hemosiderin-laden macrophages with fibroblastic elements.</p> <p>Through posterior approach; the lesion was surgically excised and histopathological examination confirmed the diagnosis, the lesion was recurrent after 1-year and MRI revealed the same features, the lesion was excised by arthroscopic intervention.</p> <p>Conclusion: We concluded that PVNS cannot be excluded when extra-synovial lesion is assessed, and further researches on this topic will expand our understanding of the etiological and pathological aspects of this tumor.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Virus transmission through fragmented flight in cooked meat fumes at more than 10 meters of distance, a case report with SARS-CoV2 / COVID19 2021-06-30T19:08:54+00:00 Florent Pirot <p>Meat is a known virus carrier and its ability to spread viruses is shown here in a different way. Meat fumes from a cooking process carrying a virus led to indirect contamination.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Autologous Tenocyte Implantation (ATI) and the Use of Collagen Scaffolds: a Case Report of a Novel Surgical Treatment for Gluteal Tendon Repair 2021-06-30T19:07:09+00:00 John M O’Donnell1,2, Rowan Flanagan3, Jane Fitzpatrick4,5 <p>Background: Ortho-biological therapies such as platelet-rich plasma and autologous tenocyte implantation injections are hypothesized to introduce cellular mediators such as growth factors into tendons, promoting natural healing.</p> <p>Methods: This case introduces a 63-year-old female with an extensive history of lateral hip pain and treatment refractory tendinopathy with tearing. She underwent open surgery to repair the gluteus medius tendon, using supplementary autologous tenocyte implantation (ATI) in conjunction with a Celgro (Orthocell, Perth, Australia) collagen scaffold.</p> <p>Level of evidence: 4</p> <p>Results: She had normal function in the hip at 12 months. MRI scans post-operatively at 12 months showed a marked reduction in inflammation, an intact tendon and a reduction in atrophic changes in the muscle belly.</p> <p>Conclusion: Surgical repair of a large degenerate tear of the gluteus medius tendon, augmented with autologous tenocyte implantation in a collagen scaffold led to an excellent patient outcome and MRI findings demonstrated tendon healing with improved tendon structure and reduced inflammation.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Isolated Aortitis with multiple Aortic aneurysms and widespread venous, arterial and intracardiac thrombosis: A challenging Vascular Behcet’s Disease case management 2021-06-30T19:05:34+00:00 Ahmed AR Mohamad Al Ani, Abdul-Wahab Al-Allaf, Ahmed Mansour Al Ani, Haajra Fatima, Haneen Ahmed Al Ani <p>In 1937, Hulusi Behcet’s brought to our attention the existence of a disease characterized by recurrent oral aphthae and any of several systemic manifestations including genital aphthae, ocular disease, skin lesions, gastrointestinal involvement, neurologic disease, vascular disease, or arthritis [1-3]. He became the first physician to describe this and the disease was henceforth named after his name. The aetiology of this disease remains unclear however it has been noticed that Behcet’s syndrome is remarkable for its systemic vasculitides which include its ability to involve blood vessels of all sizes (small, medium, and large) on both the arterial and venous sides of the circulation with occlusive nature [4]. This makes Vasculitis the major cause of the clinical manifestations of the disease with the involvement of almost any organ.</p> <p>We herein report an unusual case of a thirty-year-old Syrian man with no past medical illnesses. On presentation, he suffered from a sudden onset of shortness of breath and a history of hoarseness of voice for less than a week, and drastic weight loss of about thirty kgs within a month. Imaging confirmed the presence of pulmonary embolism, bilateral deep venous thrombosis, intracardiac thrombosis, popliteal artery thrombosis with thoracic, and abdominal aortic aneurysms. This case highlights the importance of having a high suspicion of the possibility of Behcet’s disease when multiple thrombi and aneurysms manifest in a patient on the silk root country. Thereby, stressing the importance of familiarizing ourselves with such unusual presentations of Behcet’s disease and the course of this unusual presentation with some learning points with a good literature review included below.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Clinical and biochemical manifestations of undiagnosed Hashimoto’s thyroiditis 2021-06-30T19:03:44+00:00 Dr Sarah Lewis*, Dr Daniel Fineberg <p>We report the case of a 69 year old female who presented with mild cognitive impairment and difficulty mobilising in the setting of profound hypothyroidism secondary to Hashimoto’s thyroiditis with associated elevated creatine kinase (CK), hyponatraemia, anaemia, renal impairment, hypercholesterolaemia and hypertryglyceridaemia.<br>On initial investigations the patient had a thyroid stimulating hormone (TSH) of 49 mU/L, free T4 &lt;5.4 pmol/L, thyroid peroxidase (TPO) antibody positive, CK 1628 units/L, sodium 120 mmol/L, haemoglobin 87 g/L, creatinine 109 mcmol/L, total cholesterol 8.1 mmol/L and tryglycerides 4.7 mmol/L. On examination the patient had no features of myxoedema coma but was found to have delayed relaxation of tendon reflexes, puffy facies with loss of outer one third of eyebrows, coarse hair, brittle nails and slowing of speech and movement with obvious cold intolerance. There was no muscle weakness on examination to suggest myositis although the patient complained of generalised aches and lethargy. The patient was initially treated with 100mcg oral thyroxine daily however this was increased and oral liothyronine introduced following an inadequate improvement.<br>Eleven days post admission the TSH was 6.26 mU/L and the free T4 was 12.4pmol/L following a total of 1500mcg oral thyroxine replacement and 60mcg oral liothyronine replacement. The hyponatraemia improved with a strict fluid restriction of 500 millilitres daily to sodium 133 mmol/L and the renal function improved to a creatinine of 70 mcmol/L on discharge. Atorvastatin was withheld due to the elevated CK which improved to 370 units/L and the anaemia remained stable throughout the admission. Although the patient refused formal cognitive assessments her functional abilities improved with treatment. This case highlights the clinical and biochemical features of severe hypothyroidism in the setting of undiagnosed Hashimoto’s thyroiditis.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A CASE OF UPPER LIMB DEEP VEIN THROMBOSIS IN A KNOWN HIV PATIENT WITH NON HODGKINS LYMPHOMA 2021-06-30T19:02:10+00:00 Dr. Abolarin Ademola Toyosi,MBBS, FMCPATH1*, Dr. Olufemi-Aworinde Kehinde Joyce, MBBS, FWACP, FMCPATH1, Dr. Olutogun Toluwalase, MBBS, FWACP, FMCPATH1 <p>This is a case of upper limb deep vein thrombosis in a HIV positive patient who had also been diagnosed of Non-Hodgkins Lymphoma. This case highlights the importance of thromboprophylaxis and thrombotic risk assessment in all HIV positive as well as cancer patients particularly in low resource setting which are at risk of increased morbidity and mortality.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Paget´s disease of bone in a patient on peritoneal dialysis 2021-06-30T19:00:35+00:00 Flores-Padilla Guillermo1,2, Solis Jose Gabriel1,3*, Zavala-Jonguitud Luis Fernando1,4, Juarez-Villa Daniel1,5, Olascoaga-Lugo Arturo1,6 <p>Paget´s disease of bone is a disorder characterized by disorganized bone remodeling. It´s occurrence in patients with end-stage kidney disease on renal replacement therapy is rare. Here we report a case of Paget´s disease of bone in an 80-year-old male on peritoneal dialysis that presented a high level of alkaline-phosphatase with a mildly elevated parathyroid hormone level and typical imaging findings localized to the pelvis. This is the fourth reported case of Paget´s disease in a patient on peritoneal dialysis and the first treated with denosumab.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Intramucosal esophageal dissection after esophagogastroduodenoscopy: two case reports 2021-06-30T18:58:39+00:00 Simone Isolani1,* Marta Ribolla2, Gabriele Regina1 ,Filippo Banchini and Patrizio Capelli1 <p>Introduction: Intramucosal esophageal dissection (IED) is an uncommon disorder, described as the separation of the mucosa and/or submucosa from deeper muscular layers due to abrupt increase in intraesophageal pressure.</p> <p>Case presentation: The first case il that of a 52 – years old female patient who underwent an esophagogastroduodenoscopy for control. After the procedure an extensive subcutaneous emphysema of the neck and a massive pneumomediastinum occurred. The patient was successfully treated with a conservative approach.</p> <p>The second case is that of a 43-years old male patient affected by Down’s Syndrome, who underwent an esopagogastroduodenoscopy because of persisting dysphagia. The endoscopic showed the presence of a serrated stricture at 20 centimeters from dental arcade. After the procedure he fell dysphagia. A neck-chest TC-SCAN showed superior and posterior pneumomediastinum and subcutaneous emphysema, without signs of mediastinitis. The patient was successfully treated with conservative approach. After a few days, a new chest CT-SCAN showed the presence of an anomalous right subclavian artery arising from the descending part of the aortic arch, causing dysphagia lusoria.</p> <p>Discussion: The causes of IED include iatrogenic instrumentation, hemostatic applications, mucosal injuries from ingestion of sharp foreign body, or spontaneous. A fluoroscopic upper gastrointestinal series or upper gastrointestinal endoscopy has been widely used to diagnose IED. CT and magnetic resonance are useful for differential diagnosis. In the absence of signs of mediastinitis management is conservative.</p> <p>Conclusion: CT SCAN should be the first exam to perform in the suspicion of IED. The first line treatment should be conservative. In case of the onset of complications and in patients who are refractory to conservative management, endoscopic or surgical treatment are indicated.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A rare case of adult ileo-colic intussusception: Hamartomatous polyp as a lead point with concurrent appendiceal neurofibroma in Neurofibromatosis Type 1 2021-06-30T18:56:27+00:00 Sena Park, MD1*, Janaka Balasooriya, MBBS MD (Surgery) MRCS1 <p>Intussusception is a rare cause of adult intestinal obstruction and unlike in children, adult intussusception is commonly caused by a lead point, requiring surgical intervention in most cases. Hamartomatous polyp is a non-neoplastic growth of tissue containing mature cells, distributed in an abnormal manner. It is often associated with intestinal polyposis syndromes such as Peutz-Jeghers syndrome and Juvenile polyposis. In the current case, we report an extremely rare case of ileo-colic intussusception secondary to a lead point of an isolated ileal hamartomatous polyp in an elderly gentleman with Neurofibromatosis type-1. Patient was successfully treated with ileo-colic resection involving the intussuscepted segment of bowel. There was an incidental finding of a nodule in the appendix and the histology confirmed this as a neurofibroma. Post-operative recovery of the patient was unremarkable.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 BEYOND PSEUDO-ACCOMODATIVE CORNEA LASIK (PAC LASIK). A PERSONAL INSIGHT 2021-06-30T18:54:31+00:00 Tjahjono D. Gondhowiardjo, MD, PhD1,2 <p>Laser in-situ keratomieleusis (LASIK) is a common intervention for young, active, ametropic individuals to improve their visual acuity. pseudo-accommodative cornea (PAC), a variant of LASIK, to correct ametropia among presbyopic patients is proven in maintaining good distant vision; yet, the satisfactory spectacle free reading vision is limited to the ageing progression.<br>However, successful treatments do not guarantee patient’s satisfaction. Assesment of the objective topographic indicators, visual acuity, higher order abrasion, and contrast sensitivity; revealed the clarification of a mild headache as a personal subjective experience after the treatment.<br>The role of the persistent, dominant eye, the brain perception, seems to be critical factor to a patient’s satisfaction. To a certain degree, the interplay amongst the optical part and it’s supporting tissue, within and between the eyeballs, as well as its relationship to the neurosensory parts of the visual systems after Lasik surgery have not yet been assessed and reported elsewhere.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Detection of SARS-CoV-2 by real time Reverse Transcriptase-Polymerase Chain Reaction assay in pleural effusion 2021-06-30T18:52:48+00:00 Gatti E. MD1, Ulisciani S. MD2, Guglielmo M. MD1*, Tinivella M. MD2, Farina C. MD2, Ascenzi C. MD2, Righi L. MD3, De Renzi G. MD4, Ciacco C. MD1 <p>SARS-CoV-2 (severe acute respiratory syndrome-coronavirus-2) is a novel coronavirus identified for the first time in Wuhan (China) in 2019, responsible of the current pandemic infection known as Coronavirus-19 disease (COVID-19). Wide range of clinical presentation of COVD -19 has been observed, from asymptomatic carriers to ARDS.</p> <p>The common signs and symptoms of SARS-CoV-2 infection include fever, fatigue, dry cough, and dyspnoea; the severity of the disease is due to the impairment of the respiratory function.</p> <p>The radiological findings include a large variety of lesions; bilateral interstitial pneumonia is the most concerning presentation of COVID-19. Pleural involvement has been described in a minority of cases: pleural thickening had been observed in 32% of cases whereas pleural effusion is uncommon being described in only 5%. Furthermore, pleural involvement has been significantly associated with a worse prognosis.</p> <p>Coronavirus 2 (SARS-CoV-2), beyond the nasopharyngeal swab, has been detected in other samples; up to now, data about RT-PCR specific results in the pleural fluid of patients suffering from coronavirus disease 2019 5 (COVID-19) are very limited.</p> <p>The current gold standard for diagnosis is nucleic acid detection by real time Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) in nasopharyngeal swab.</p> <p>In this report, a case of a positive RT-PCR for Sars-Cov-2 in the pleura fluid and in the naso- pharyngeal swab of a patient affected by bilateral interstitial pneumonia and severe respiratory failure is described.</p> <p>As the presence of SARS-Cov-2 in the pleural fluid seems to be associated to a poor prognosis, physicians should carry out the specific RT-PCR assay both in the nasopharyngeal swab and in the pleural sample also when the fluid amount is very scarce and not recognizable in the chest X ray. Furthermore, the analysis of multiple samples allows to increase the test reliability.</p> <p>&nbsp;</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Seckel Syndrome & Skull Morphology: Quantifying Characteristics 2021-06-30T18:51:04+00:00 Steven A. Lewis*, Stuart Inglis, PhD, Scott Doyle, PhD <p>Seckel Syndrome is a rare genetic disorder which causes morphological changes throughout the body. Some of the most commonly reported changes are those present within the cranium and mandible such as microcephaly, a beak-like nose with convex nasal ridge, and mandibular deformities such as micrognathia. However, these clinical terms provide insufficient information to allow for proper diagnosis or to understand the distortions in physiology that take place with the disease. Therefore, quantification of the features of the skull are necessary to further explain this pathology, and comparisons to normal variation will help to understand the degree to which the anatomy is affected. Seckel Syndrome is classified as a member of the microcephaly family of pathologies; however, our results demonstrate that the overall volume of the skull is not as significantly decreased as the cranial vault itself, which may provide the catalyst for Chiari Type I malformations. The mandible, likewise, is severely altered by Seckel Syndrome decreases in approximately 44% of its volume and demonstrating altered physical proportions. Finally, the osteological measurements of the facial features demonstrated inconsistent findings between different anatomical structures providing evidence that Seckel Syndrome may have a variable effect on the different bones and tissues of the skull.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A NEW TYPE-2-LIKE CALR MUTATION IN ESSENTIAL THROMBOCYTHEMIA 2021-06-30T18:49:14+00:00 Mattia Brescini, dr, Maria Giovanna Loglisci, biotechnologist, Gioia Colafigli, dr, Luisa Bizzoni, dr, Sonia Buffolino, biologist, Daniela Diverio, biologist, Massimo Breccia, dr, Maurizio Martelli, full professor, Stefania Trasarti, dr* <p>CALR mutations, together with JAK-2 and MPL ones, are recognized as “driver” mutations in Philadelphia-negative chronic myeloproliferative neoplasms (MPNs). Most frequent CALR mutations are Type-1 deletions (45-55% of cases) and type-2 insertion (32-42% of cases). These mutations are usually associated with younger age, higher platelet counts, lower leukocyte counts, lower hemoglobin levels and a higher incidence of transformation from ET to MF. Recognizing and describing cases with different mutations can be useful to create a database that might help clinicians to include these patients in risk categories and to guide the appropriate therapeutic choices. We report a case of a 77-years old woman who presented a new type-2 like CALR mutation.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Mesothelial Cyst in a Young Female: Case report and literature review 2021-06-30T18:47:08+00:00 Thabet Alghazal*1, Anwar Alzahrani2, Shomukh Alshamrani3, Jumanah Felemban4, Abdulwahed Meshikhes5 <p>Mesenteric cysts are rare intra-abdominal benign tumors (1 in 100,000 cases in adults) with various clinical presentations. [1,2] They commonly originate from the small bowel mesentery, although a proportion has been found to originate from the mesocolon, and retroperitoneum. [1,3]</p> <p>The formation of mesenteric cysts depends on the histologic origin, where they could be classified into cysts of lymphatic origin, cysts of mesothelial origin, cysts of enteric origin, cysts of urogenital origin, dermoid cysts and pseudocysts. [4,5]</p> <p>Diagnosis is extremely difficult since. The Mesenteric cyst is usually asymptomatic, but if symptomatic, abdominal pain (82%), nausea and vomiting (45%), constipation (27%) are the most common presenting symptoms. [2,3] The clinical finding of abdominal mass is encountered in more than 61% of the patients. [2,3]. As this condition is very rare and its symptomatology can resemble any other abdominal diseases, diagnosis is extremely difficult and incorrect preoperative diagnosis is often made. Hence, performing physical examination and conducting radiological investigations such as ultrasonography (USG) and computed tomography (CT) are important in making a correct diagnosis. [2,3]</p> <p>As well as cases of mesothelial cysts, they are typically asymptomatic but occasionally, their symptoms are vague and non-specific. [6,7] As mentioned above, imaging modalities such as USG, CT and magnetic resonance imaging (MRI) are great in identifying the character, size, location, surrounding tissues and the wall and content of the cysts. [7]</p> <p>Surgery is the treatment of choice, as a complete resection with negative borders is curative and often prevents recurrence. [3]</p> <p>We report a case of a young female patient who presented with a vague abdominal symptoms and a large cystic mass in lower abdomen. After proper evaluation, surgical exploration revealed a large simple mesothelial cyst.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Fibromyalgia as A Sole First Presentation of Recurring Idiopathic Intracranial Hypertension in a child. A Case Report and Literature Review 2021-06-30T18:45:28+00:00 Sondos Altaraqji1, Rayan S. Terkawi2,3, Abdallah Alneirab2,3, Diyaa Rachdan4,5 and Khalid Mohamed1 <p>Idiopathic intracranial hypertension (IIH) is a condition characterized by raised intracranial pressure (ICP) with no evidence of brain pathology, also known as pseudo tumor cerebri. Headache and visual obscuration are the most common presenting symptoms for IIH with a frequency of (68-84%) respectively. Other symptoms of IIH include neck pain, back pain, and radicular pain in the arms and legs resulting from increased spinal pressure and forced filling of the spinal nerves with CSF.</p> <p>Case summary: We present an 11-year-old boy known to have chronic kidney disease stage II, due to obstructive uropathy. He had a history of Idiopathic intracranial hypertension that was treated completely and condition resolved, then presented with generalized pains and aches without headaches or visual symptoms and found to have IIH for the second time, the symptoms resolved with appropriate treatment.</p> <p>Conclusion: Widespread pain and several other characteristics of IIH share similarities with characteristics of fibromyalgia (FM) and chronic fatigue syndrome (CFS), two overlapping chronic pain conditions.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Acute Demyelinating Encephalomyelitis (ADEM) following rabies vaccination 2021-06-30T18:43:35+00:00 Lucia Cavanagh1*, Adriana M. Strutt2, Paul E. Schulz3 <p>Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system (CNS). Its diagnosis can be challenging due to having varied clinical presentations, including a range of motor, speech, cognitive, and behavioral changes that can vary in frequency and intensity, and there being no strictly defined diagnostic criteria for it in adults. Here we present a 58-year-old White male who developed ADEM following an uncommon cause (i.e., rabies vaccination), which was difficult to diagnose due to atypical manifestations.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A challenging diagnosis in a patient with Odynophagia 2021-06-30T18:41:46+00:00 Claudia Colomba1, Raffaella Rubino1, Rosario Maugeri2, Antonio Anastasia1, Paola Di Carlo1, Federica Paolini2, Riccardo Speciale2, Domenico Gerardo Iacopino2, Antonio Cascio1 <p>Tuberculous retropharyngeal abscesses are rare but potentially life-threatening manifestations of tuberculosis. We present herein a case of an 18-year-old male patient, a migrant from Somalia, accusing fever, odynophagia and neck pain. CT scan and MRI study of the neck showed a retropharyngeal and prevertebral abscess from C1 to D1 with the involvement of epidural space and spondylitis. Resolution of the abscess with few signs of residual spondylitis was achieved after surgical evacuation and antitubercular treatment.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Delayed traumatic cardiac tamponade: An extremely rare sequela of blunt trauma 2021-06-30T03:48:44+00:00 Sena Park*, MD and Janaka Balasooriya, MBBS MD (Surgery) MRCS <p>To our knowledge, there have been minimal information on the delayed traumatic cardiac tamponade, which is an extremely rare but a life-threatening condition if not treated promptly. We present a 25-year-old female who had cardiac tamponade of delayed onset after a motor vehicle crash. It was found on a computed tomography scan of the chest, and confirmed on subsequent echocardiography. Urgent operation of creation of pericardial window was performed. She made a good recovery after the operative intervention. The current report emphasises the importance of having high index of suspicion in patients with non-penetrating multi-trauma with careful observation and appropriate investigations.</p> 2021-05-22T00:00:00+00:00 Copyright (c) 2021 Deletion of 15q26.1 region with absence epilepsy respond to valproic acid: A Literature Overview and A Case Report from Qatar 2021-06-30T03:46:30+00:00 Rana AL-Shami , Sondos Altaraqji <p>Chromosomal abnormalities involving deletions and duplications are known to cause severe developmental disorders, including mental retardation, dysmorphism, and seizures, in children. As the technique of array-based comparative genomic hybridization is being applied more frequently in the diagnostic evaluation of children with developmental disorders; novel pathologic chromosomal abnormalities are being identified in relation to various type of epilepsies in childhood.<br>We report the case of a 4-year-old girl with a history of speech delay and communication disorder, mild dysmorphic features, and absence epilepsy with a de novo microdeletion 15q26.1. A much larger (5 Mb) but overlapping microdeletion has been previously reported in similar several cases with similar phenotype including intractable myoclonic and absence epilepsy, growth delay, and dysmorphic features. This leads us to propose that a potential candidate gene or genes within the deleted region involved in the pathogenesis of some forms of generalized intractable epilepsy, previously considered idiopathic should consider genetic study for childhood epilepsies especially if it was associated with underlying developmental delay in any particular aspect as speech delay in our case.</p> 2021-06-01T00:00:00+00:00 Copyright (c) 2021 Acute cauda equina syndrome due to lumbar spinal stenosis caused by prolonged supine position during cardiac catheterization: a case report 2021-06-30T03:44:22+00:00 Kazuki Kobayashi, Kazuyuki Watanabe, Kinshi Kato, Michiyuki Hakozaki, Jun-ichi Handa, Hiroshi Kobayashi, Takuya Nikaido, Koji Otani, Shoji Yabuki, and Shin-ichi Konno <p>Background: Cauda equina syndrome (CES) is a severe neurologic condition marked by progressive loss of function of the neurologic elements in the spinal canal below the termination of the spinal cord. This article reports an instructive case of CES with acute aggravation of neuropathy after catheter ablation for atrial fibrillation.</p> <p>Patient concerns: A 63-year-old Japanese man underwent catheter ablation for atrial fibrillation. Because he complained of severe low back pain and numbness in the posterior of both lower limbs while in the supine position, he was given analgesia with pentazocine and sedated with propofol, and the procedure continued. He was then forced to maintain lumbar extension while in the supine position for 13 hours. After the treatment, he noticed urination disor-der, numbness, and paralysis of both lower limbs.</p> <p>Diagnosis: Neurological findings included sensory impairment and motor deficit of L5 and below, including bowel/bladder dysfunction. Lumbar magnetic resonance imaging showed severe lumbar spinal stenosis at L4-L5. He was diagnosed with CES due to lumbar spinal stenosis.</p> <p>Interventions: The patient received emergency surgery for L4-L5 decompression. Decompression of the spinal canal was achieved 33 hours after the start of catheterization.</p> <p>Outcomes: The patient’s leg symptoms improved immediately after surgery, and he was able to walk with a walker. On postoperative day 6, the urinary catheter was removed. However, he experienced urinary retention and needed intermittent self-directed urination. Five months after surgery, he was able to urinate on his own, and completed the intermittent self-directed urination. Nine months after surgery, his muscle strength had recovered almost completely, and he was able to walk with a cane. However, bladder dysfunction such as frequent urination and residual urination remained 4 years after surgery.</p> <p>Lessons: If the supine position elicits low back pain and leg numbness, the presence of lumbar spinal stenosis should be considered. Forcing patients with such symptoms into a sustained posture can lead to CES.</p> <p>&nbsp;</p> 2021-06-15T00:00:00+00:00 Copyright (c) 2021 SYNGAP1 Mutation in absence Epilepsy with eyelid myoclonia: A Literature Overview and A Case Report from Qatar 2021-06-30T03:39:42+00:00 Rana AL-Shami , Sondos Altaraqji, Khalid Mohamed <p>Background: SYNGAP1, which encodes a RAS-GTPase-activating protein, is located on the short arm of chromosome 6.Mutations of the SYNGAP1 gene were first identified in 2009 in patients with nonsyndromic intellectual disability (ID) acquired microcephaly, and autism spectrum disorder (ASD), followed in 2013 by recognition of their important role in the developmental and epileptic encephalopathies (DEEs). Developmental delay was identified soon after birth in the majority of patients and pre-ceded seizure onset in all. Development regressed or plateaued with seizure onset were observed. Language was severely impaired together with intellectual disabilities and some other features (1, 4).Most affected individuals have de novo mutations, with truncating mutations predominating, although missense mutations, chromosomal translocations, or microdeletions disrupting SYNGAP1 are also described. (1,5).</p> <p>&nbsp;</p> 2021-05-22T00:00:00+00:00 Copyright (c) 2021 Intramyocardial haemorrhage: a rare sequela of acute myopericarditis 2021-06-30T03:35:55+00:00 Sahar Mohmed1, Kate Batouskaya1, Jakub Lagan2, Pei Gee Chew1,2, Dania Mohty3,4, Aleem Khand1,2,5* <p>INTRODUCTION</p> <p>Acute myopericarditis is an inflammatory disease of myocardium and pericardium. The disease has variable presentation ranging from mildly symptomatic cases to severe disease manifested by cardiomyopathy with associated risk of sudden cardiac death. However, the association with intramyocardial hemorrhage (IMH) has not been previously described.</p> <p>CASE REPORT</p> <p>We describe an IMH detected by cardiac magnetic resonance imaging, in a patient with classical ‘de novo’ myopericarditis. To the best of the authors’ knowledge, this has not been previously described in patients without associated haematological or connective tissue disorders.</p> <p>CONCLUSION</p> <p>The adverse prognostic signal of IMH in acute myocardial infarction may also be reflected by IMH in acute myopericarditis and lead to adverse ventricular remodeling. The pathophysiology of IMH in myopericarditis is unknown and warrants further exploration.</p> 2021-05-22T00:00:00+00:00 Copyright (c) 2021 A Case of Recurrent Facial Palsy Associated with Anti-GM2: is it anyway Guillain-barré syndrome? 2021-06-30T03:33:33+00:00 Giovanni Bonaccorso <p>Objective: A rare case of possible hereditary predisposition to autoimmune neuropathy</p> <p>Background: This case report is of a patient who presented two episodes of Facial paresis in her live without ascertained apparent causes. Bell’s palsy is commonly known as peripheral idiopathic facial nerve palsy, because in the most cases the triggers remain unknown (1).</p> <p>Case Report: I want to present a case of a 34 year old woman who we will call A.B. and who came to us to evaluate the severity of the sequelae of a Bell´s palsy and any eventual need for cosmetic measure. But she had another Bell´s Palsy 9 years ago, so I started to investigate the most common and treatable causes of Facial paresis. I found a significate increase of anti-bodies against ganglioside GM2. When I explained to her that these anti-bodies is commonly related with several neurological diseases, she started to investigate her family history and she found that his father’s brother died of GuillainBarré syndrome about 40 years ago.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Giant gastric carcinosarcoma infiltrating the left hepatic lobe: a case report 2021-06-30T03:31:33+00:00 Leonardo Vincenti MD1, Cinzia Bizzoca MD1, Salvatore Fedele MD2, Anna Maria Valentini BScD3, Valeria Andriola1, Graziana Arborea MD3 <p>Gastric carcinosarcoma is a rare biphasic tumor that consists of both carcinomatous and sarcomatous components. Clinical presentation and neoplastic markers are not specific for the disease. Moreover, CT scan cannot distinguish among gastric carcinoma, sarcoma or carcinosarcoma, so it is essential to perform histopathological and immunohistochemical analysis on biopsy specimens or resected tissue to ensure a correct diagnosis.<br>A 72-year-old woman was transferred to our Department from another hospital with a diagnosis of a bleeding tumor localized on the lesser gastric curve, infiltrating the left hepatic lobe.<br>The mass was treated as a gastric malignant mesenchymal neoplasia (gastro-intestinal stromal tumor versus sarcoma) infiltrating the liver. Owing to the bleeding, no further invasive examinations, such as fine needle aspiration biopsy, were planned. Furthermore, no neoadjuvant chemotherapy could be administered before surgery due to persistent anaemia.<br>The scheduled surgical procedure was an atypical gastric resection with “en bloc” hepatic resection. This operation included upper polar and lesser curve resection, with tubulization of the stomach along the greater curve, as well as left lateral hepatic sectionectomy.<br>Histopathological examination and immunohistochemical staining confirmed the diagnosis of gastric carcinosarcoma.<br>This is first report of gastric carcinosarcoma with local liver infiltration, treated with surgical resection.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Prostate stromal tumour: case reports and review of literature 2021-06-30T03:29:47+00:00 Odusanya Benjamin O.1*, Saliu Abdulwaid N.2, Oyewole Olugbenga O.3, Mabadeje-Isowo Bilikisu A.4, Nwamannah Faith O.5 <p>Background</p> <p>Prostate cancer is a common malignancy in men; however, sarcoma of the prostate is an uncommon variant. Sarcoma of the prostate occurs in all age groups with rhabdomyosarcoma being more common in children while leiomyosarcoma occurs more in the older adults. Stromal tumour of uncertain malignant potential (STUMP) occurs in adults. Modalities of treatment include surgery, radiotherapy and chemotherapy used singly or in combination, but all report poor long term survival despite treatment selected. We present 2 cases of prostate stromal tumours.</p> <p>Case report</p> <p>We present two patients in their fourth decade who presented with acute urinary retention. Computed tomography scan was performed in both cases and showed a large tumour arising from the prostate. Prostate specific antigen was less than 4ng/ml in the two cases and core needle biopsy performed and samples taken for histology. The histology reports showed embryonal carcinoma and STUMP in the first and second cases respectively.</p> <p>Conclusion</p> <p>Prostate sarcomas are uncommon but may pursue aggressive clinical course while STUMP has a variable course. Early diagnosis and use of combined modalities of treatment may be required to improve survival.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Giant hydronephrosis in an 82-year-old woman with multiple comorbidities: a case report 2021-06-30T03:27:47+00:00 Bouveret P.1, Robinet P.1, Brocquet E.1, Averlant L.1, Maladry F.1, Delecluse C.1, Visade F.1* <p>Giant hydronephrosis is a rare urinary tract disorder characterized by a collection arising from the kidney. Because of its complications, surgery remains the main treatment. Here we report the case of an 82-year-old woman with multiple comorbidities and diagnosis of giant hydronephrosis. After multidisciplinary concertation between urologists and geriatricians, no specific treatment was initiated. This case report highlights a non-specifically presentation of this rare disorder, including no symptom. The presence of multiple comorbidities has changed the management commonly reported in the literature.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Double PTEG (percutaneous trans-esophageal gastro-tubing) was useful in nutrition and decompression for a gastric cancer patient with pyloric stenosis: a case report 2021-06-30T03:23:54+00:00 Junji Takahashi1*, Hironori Ohdaira1, Teppei Kamada1, Keigo Nakashima1, Norihiko Suzuki1, Masashi Yoshida1, Yutaka Suzuki1 <p>Background</p> <p>For gastric cancer patients with strong pyloric stenosis, decompression by nasogastric tube insertion for gastric distension and central venous nutrition management have been performed. However long-term indwelling of the nasogastric tube is accompanied by pain, and Central venous catheter placement is inferior to enteral nutrition from infection risk and nutritional viewpoint. Furthermore, these generally require management in hospitalization.</p> <p>Case presentation</p> <p>An 81-year-old male was referred to our hospital for gastric cancer accompanied by pyloric stenosis. Blood test resulted in low nutrition and anemia. CT showed thickening of the wall from the anterior gastric part to the pylorus and enlargement of 50mm in the regional lymph node, and gastric distention. We planned resection after preoperative chemotherapy. We performed double PTEG (Percutaneous Tran Esophageal Gastro-tubing) from cervical co-wound for decompression and nutrition management of the stomach. Total laparoscopic gastrectomy was performed on day 114 after insertion of the double PTEG. During which time he had been good nutrition and no gastric distention with stayed at home for 42 days. On the 10th postoperative day, he was clinically released from hospital without any complications.</p> <p>Conclusions</p> <p>We conducted a new management to reduce and nourish patients with gastric cancer who had a pyloric stenosis by double PTEG (percutaneous trans-esophageal gastro-tubing), and can perform curative surgery after preoperative chemotherapy including home management period.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Advances in Diagnosis of Mitochondrial Diseases: Case Report of an Infant with Pearson Syndrome 2021-06-30T03:21:20+00:00 Lilian Cohen MD, MPH1, Ana Maria Rodriguez Barreto MD1, Miguel Dario Cantu MD2, Catherine McGuinn MD1, Madhu Ouseph MD, PhD2, Sanjay Patel MD, MPH2, Shipra Kaicker MD1 <p>Pearson syndrome (PS) is a mitochondrial disorder that presents in early infancy as a multisystemic disease affecting the bone marrow and pancreas. It may present with anemia, diarrhea, exocrine pancreatic dysfunction, and failure to thrive.[1] Delay in diagnosis can lead to severe morbidity and mortality in infancy. We report the case of a 9-month-old presenting with failure to thrive, severe macrocytic anemia and pancytopenia initially thought to have gastroesophageal reflux and feeding intolerance. Severe macrocytic anemia and pancytopenia prompted an early bone marrow evaluation. Abnormal bone marrow findings including vacuolated marrow precursors and ringed sideroblasts along with persistent mild lactic acidosis led to a rapid and extensive genetics workup. Whole exome sequencing including mitochondrial genome sequencing detected a 2.3 kb heteroplasmic deletion in m.12113_14421 encompassing the MT-ND5 gene consistent with the diagnosis of Pearson Syndrome. This case report highlights the advances in molecular genetic testing to diagnose patients with complex medical histories along the spectrum of mitochondrial diseases and the importance of early diagnosis to start treatment.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A shift in surgical management of perforated jejunal-ileal diverticulitis? Two case reports 2021-06-30T03:18:49+00:00 Wei Liu, MD1, Ali Darehzereshki, MD1, Michael Matsuura, MD2, Christopher You, MD2 <p>Small bowel diverticular disease is usually asymptomatic, but complicated small bowel diverticular disease can present as an acute abdomen, manifesting as diverticulitis, perforation, abscess, obstruction or bleeding. Due to the rarity of the disease, very few studies have been conducted on complicated small bowel diverticular disease. Therefore, there are no clear guidelines on management. General peritonitis remains the best indication for surgical management due to its correlation with high mortality and prolonged hospital stay. Traditionally, perforated small bowel diverticular disease is managed with exploratory laparotomy, primary bowel resection and anastomosis regardless of acute presentation. However, more recent studies demonstrated a trend towards conservative or less invasive surgical management. Here, we report two perforated small bowel diverticulitis cases at our institution that underwent different management and had different outcomes.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Case of severe head trauma caused by a car accident 2021-06-30T03:14:27+00:00 Liliana Dragomir1*; Virginia MARINA2; Mihaela Anghele3 <p>According to the literature, the term “poly-trauma” was first used by Tscherne, in 1966 for patients who demonstrated a combination of at least two “severe head, chest or abdominal injuries” or “one of them in association with an extremity injury. Trauma, despite all efforts to control its impact, is now a recurrent cause of high incidence of mortality and morbidity worldwide. Studies show that road traffic injuries are currently the leading cause of death among people aged between 1 and 45-years old. Only 21 countries in the WHO (World Health Organization), European Region have implemented legislative changes regulating drink-driving, with blood alcohol test limits varying between ?0.02 g/dl and ?0.05 g/dl.</p> <p>INTRODUCTION: It is well known that poly-trauma is a challenge for the clinician, regardless of specialization. In this regard, we wanted to present this case to raise an alarm on the approach to poly-trauma, which involves, in addition to the pre-hospital, hospital and follow-up stages, the follow-up of victims after discharge, in an attempt to identify possible causes of death and their prevention.</p> <p>CASE PRESENTATION: In this clinical case, we present the outcome of a 44-year-old patient who presented to the emergency room with multiple trauma injuries resulting from a road traffic accident. During her admission to the neurosurgery department of the Emergency “Sfântul Apostol Andrei”, Clinical Hospital of Galati, the patient underwent numerous clinical and imaging investigations, which provided findings statistically associated with increased mortality and morbidity rates.</p> <p>CONCLUSION: The management of patients presenting with poly-trauma is continuous, dynamic and extremely challenging in terms of the staff involved, the multidisciplinary team that will monitor the patient’s progress. All this is a goal that can only be achieved through good interdisciplinary and inter-hospital communication, providing standards of care and quality-oriented cooperation, increasing efficiency through the use of existing resources, regulating the financial aspects of inter-hospital transfers, cooperating in a common system of continuous training.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Congenital Bilateral Microtia-Anotia: A Clinical Challenge 2021-06-30T03:09:41+00:00 Dr Sumita Mehta1*, Senior Specialist & In-Charge, Dr Anshul Grover1, Specialist, Dr Avdesh Mehta 2, ENT Consultant, Dr Deepak Chugh3, CMO & Head of Department, Paediatrics <p>Microtia- Anotia (M-A) is a rare congenital malformation of the external ear structure commonly associated with atresia or stenosis of the ear canal. Its prevalence is more common in Asians and Hispanics, is generally unilateral and is seen more commonly in males. It can either be an isolated defect or be a part of specific pattern of anomalies involving other organs. It has been documented as a component of either a teratogenic embryopathy (isotretinoin, thalidomide or alcohol) or single gene disorders like Treacher Collins and as a part of a pattern of multiple defects like Goldenhar, Nager and CHARGE syndrome. We report a case of a newborn with bilateral microtia-anotia and facial palsy, who on further evaluation was found to have congenital heart disease also. The triad of anotia, facial paralysis and cardiac anomaly is rare and has been first described by Pearl in 1984.Thus, the obviously visible ear malformation at birth should be evaluated in depth to rule out other underlying malformations.</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 A Rare Occurrence of Primary Breast Mucormycosis, A Case Report 2021-06-30T02:53:55+00:00 Dr. Sanjeev Shah, Dr. Kamlesh Patel, Dr. Chetna Bhullar, Dr. Nidhi Barot <p>Zygomycosis occurs primarily in immunosuppressed patients and those with diabetes mellitus. Incidence of zygomycosis has increased among transplant recipients, patients with hematologic malignancy and Covid-19 associated pulmonary complications. Soft tissue zygomycosis may be localized, extend to deep underlying tissues, or may be disseminated. The most common clinical presentation is induration of the skin with surrounding erythema, rapidly progressing to necrosis.Histological examination and culture of soft tissue are important for the diagnosis of cutaneous zygomycosis. Treatment consists of surgical excision or debridement, reversal of predisposing factors and administration of antifungal agents (amphotericin B formulations, Posaconazole/or Isavuconazole).</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021 Case of recurrent pulmonary thromboembolism due to therapeutic non-compliance 2021-06-30T02:47:03+00:00 Mihaela Anghele1*, Liliana Dragomir2, Virginia MARINA3 <p>Pulmonary embolism occurs when thrombi enter the pulmonary arterial circulation. Most pulmonary embolisms are the result of deep venous thrombosis of the pelvic limbs, chest or pelvis, and, less commonly, the jugular veins or inferior vena cava.</p> <p>Venous thromboembolism includes deep vein thrombosis and pulmonary embolism. It is the third most common cardiovascular disease, with a total annual incidence of 100-200 per 100 000 population.</p> <p>INTRODUCTION: Acute pulmonary embolism is the most serious clinical presentation of venous thromboembolism. Overall, pulmonary embolism is a major cause of mortality, morbidity and hospitalization. Mortality in pulmonary embolism depends on haemodynamic impairment, age and co morbidities.</p> <p>The prognosis of patients with pulmonary embolism depends on two factors : underlying disease state plus diagnosis, and appropriate treatment. Approximately 10% of patients who develop pulmonary embolism die within the first hour, and 30% subsequently die of recurrent embolism.</p> <p>CASE PRESENTATION: In this presentation we present the case of a 49-year-old male patient without co morbidities, presented repeatedly to the Emergency Room for symptoms suggestive of pulmonary thromboembolism, who benefited from life-saving therapies due to timely diagnosis and appropriate treatment, with subsequent favorable outcome.</p> <p>CONCLUSIONS: The particularity of the case is that, on the one hand, the thromboembolic event recurred in a short time, on the other hand, the evolution was favorable in both cases, with complete recovery of right ventricular function and disappearance of pulmonary hypertension, despite the fact that the patient was non-compliant with initial anticoagulation therapy. This was due to both early diagnosis and timely administration of appropriate treatment.</p> <p>&nbsp;</p> 2021-06-18T00:00:00+00:00 Copyright (c) 2021