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Herein, we present a case of a 67-year-old woman diagnosed with breast cancer, where lymphoscintigraphy unveiled a distinct focal uptake within the falciform ligament of the liver, an exceedingly rare phenomenon in breast cancer lymphatic mapping. | Oncology |
A 67-year-old woman presented with a palpable mass in the left breast, subsequently diagnosed as invasive ductal carcinoma through core needle biopsy. Clinical examination and ultrasound evaluation revealed no evidence of axillary lymph node involvement. The patient was referred to our center for pre-operative lymphoscintigraphy to facilitate sentinel lymph node biopsy. Lymphoscintigraphy was conducted using a single injection of 37 MBq of [ 99m Tc]Tc-Phytate in 0.1cc volume in the supero-lateral border of the left breast peri-areolar area. Post-injection planar imaging conducted one hour later unveiled two distinct foci of activity in the axillary region. | Nuclear Medicine |
Following acquisition of the initial planar images, the patient underwent single-photon emission computed tomography (SPECT)/ computed tomography (CT) for precise localization of the focal uptake in the hepatic region, revealing alignment with the falciform ligament. Nevertheless, no distinct underlying lymph node was discerned along the ligament . Histopathologic evaluation of the sentinel nodes at the level I of the left axilla on the subsequent day's surgery revealed an absence of metastatic involvement. | Nuclear medicine |
The patient has a history of pain behind the heel, especially during ambulation. Physical examination revealed swelling and tenderness over the posterior calcaneus at the Achilles tendon insertion. Functional assessment was conducted wherein the American Orthopedic Foot & Ankle Society's (AOFAS) hindfoot score was used to assess the function of each foot. A score of 90 to 100 indicates excellent function, 80 to 89 indicates good function, 70 to 79 indicates fair function, and less than 69 indicates poor function. | Orthopedics |
A 38-year-old woman presented with a two-year history of chronic left heel pain. Despite undergoing physiotherapy and using heel raises and analgesics, her symptoms persisted. Pre-operative radiographic evaluation revealed a Fowler's angle of 54 degrees, a calcaneal pitch angle of 40 degrees, and a total calcaneal angle of 94 degrees. The pre-op AOFAS score was 68. Post-operative AOFAS score at six months improved to 73 . | Orthopedic surgery |
A 45-year-old female patient presented with chief complaints of right posterior heel pain for the last year, and six months. Pain is aggravated by walking long distances and on uneven surfaces. No history of recent trauma or injury. The patient was diagnosed with anemia and managed accordingly. Pre-operative radiographic evaluation revealed a Fowler's angle of 50 degrees, a calcaneal pitch angle of 30 degrees, and a total calcaneal angle of 80 degrees . The pre-op AOFAS score was 52. Post-op AOFAS score at six months improved to 83. | Orthopedic surgery |
We report the case of a 47-year-old white Middle Eastern female, who was apparently in good health with no significant medical history until 1 week prior to admission, when she started to complain of new-onset shortness of breath that increased with exertion and was relieved by rest. This was associated with frequent episodes of central chest pain that increased with activity, generalized weakness, fatigue, and decreased appetite and oral intake. Notably, she described progressive tiredness and observed a yellowish discoloration of her face. Over the course of the week, her symptoms gradually intensified to the point where she experienced dizziness upon standing. | Cardiology |
So, she presented to the emergency department and remained hospitalized for 15 days. Initial screening revealed evidence of macrocytic anemia and thrombocytopenia, with a hemoglobin level of 4.5 g/dL, a mean corpuscular volume (MCV) of 120, and a platelet count of 77 × 10 9 /L (Table 1 ), without signs of active bleeding. Clinical examination revealed an afebrile patient with a pallid appearance, pale conjunctiva, and icteric sclera. Vital signs indicated tachycardia, with a heart rate of 105 beats per minute, and tachypnea, with a respiratory rate of 27 breaths per minute. Other systemic examination yielded normal findings. Table 1 Complete Hematological and Metabolic profile Result name Normal range Results HCT 37.0–51.0 11.2 Hb 12.0–14.0 4.5 RBC 4.20–6.30 0.93 MCHC 31.0–36.0 40.2 MCH 26.0–32.0 48.4 MCV 80.0–97.0 120.4 MPV 8–11 10.8 PLT 140–440 77 NEUT 1.8–7.70 17.94 LYMPH 1–4.8 4.78 WBC 4–11 23.94 BASO 0.0–0.2 0.02 EO 0.00–0.50 0 PDW 0.1–99.9 11.6 RDW % 11.0–16.0 37.6 CRP 0–5 62.77 Albumin 3.5–5.2 3.88 Creatinine, serum 0.5–0.9 0.52 SGPT (ALT) 10–33 26.6 Blood urea nitrogen 6–20 12.6 SGOT (AST) 0–32 72.4 Chloride 98–107 99.1 Potassium 3.5–5.3 3.09 Sodium 135–145 136 Calcium (Ca), serum 8.4–10 8.51 Mg 1.6–2.6 2 Troponin high sensitivity quantitative 0.008–0.02 0.027 HCT Hematocrit; Hb Hemoglobin; RBC Red blood cell; MCHC Mean corpuscular hemoglobin concentration; MCH Mean corpuscular hemoglobin; MPV Mean platelet volume; PLT Platelets; NEUT Neutrophils; LYMPH Lymhocytes; WBC White blood cell; BASO Basophils; EO Eosinophils; PDW Platelet distribution width; RDW Red cell distribution width; CRP C-reactive protein; ALT Alanine aminotransferase; AST Aspartate aminotransferase; Mg Magnesium | Hematology |
Owing to the patient’s hemodynamic instability, admission to the intensive care unit was warranted. An electrocardiogram (ECG) conducted during this period revealed supraventricular tachycardia (SVT), recurring three times within a 3-day span. The SVT episodes were successfully treated with 6 mg of adenosine. Additionally, two units of least-incompatible packed red blood cell concentrates were transfused. A whole-body computed tomography (CT) scan was performed, which revealed an enlarged spleen that measured 14.5 cm in bipolar length. A peripheral blood smear revealed thrombocytopenia and spherocytes without an increase in the number of schistocytes. Markers for hemolysis (Table 2 )were requested, and the results demonstrated a positive direct Coombs test, indicating the presence of autoimmune hemolytic anemia (AIHA). Table 2 Labratory results for Hemolytic workup Test name Normal range Results Bilirubin (direct) 0–0.2 0.748 Bilirubin (total) 0–1.2 2.180 Lactate dehydrogenase total (LDH) 135–214 836 Haptoglobin 0.3–2 0.01 Reticulocytes % 25.84 Direct Coombs test (DCT) Positive + 4 (IgG) / + 2 (C3d) Indirect Coombs test (ICT) Positive + 3 | Hematology |
In light of the hemolytic anemia, thrombocytopenia, and positive direct antiglobulin test (DAT) and after ruling out other possible diagnoses, including thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, paroxysmal nocturnal hemoglobinuria, hemolytic-uremic syndrome, antiphospholipid syndrome, and drug-induced AIHA, a clinical diagnosis of Evans syndrome was established. | Hematology |
Upon confirming the diagnosis of Evans syndrome, the patient was initiated on an intensive therapeutic regimen after showing resistance to the initial treatment with corticosteroids. This began with a pulse therapy of methylprednisolone at 1 g × 1 for 3 days. Simultaneously, a course of 40 g of IVIG 2 g/kg for 4 days was initiated. In addition, four doses of rituximab at a dosage of 375 mg/m 2 weekly for 4 weeks were administered. The first two doses were administered while she was in hospital, while the other two doses were administered weekly as an outpatient. After this comprehensive intervention, clinically, the patient became asymptomatic, and her CBC and hemolytic lab tests, including reticulocytes count and LDH, returned to normal. | Hematology |
Throughout the patient’s hospitalization, the emergence of a malar rash on the face, and the occurrence of oral ulceration, prompted the requisition of rheumatological markers. The results revealed positive anti-nuclear antibodies (ANA), positive anti-DsDNA, a decreased C4 level at 4 mg/dL (with a normal range of 10–40 mg/dL), and an elevated ESR level of 150 (compared with the normal range of less than 20 mm/hour). Notably, the extractable nuclear antigen (ENA) profile yielded negative findings except for SS-A native (SS A/RO60). This constellation of clinical and laboratory evidence aligns with the diagnostic criteria for systemic lupus erythematosus (SLE), as stipulated by the American College of Rheumatology (ACR) . Consequently, a diagnosis of Evans syndrome concomitant with SLE was conclusively established. | Rheumatology |
A few months later, during the patient’s ongoing evaluation, the patient reported fatigue and significant weakness. Additional laboratory tests and an autoimmune panel were conducted to explore the possibility of other autoimmune diseases. The results revealed an elevated TSH level at 5.85 mU/L (normal range 0.35–4.94 mU/L), a reduced free T4 level at 0.5 mU/L (normal range 0.7–1.48 mU/L), and positive findings for anti-thyroglobulin antibody and anti-thyroid peroxidase antibody, which confirmed the diagnosis of Hashimoto’s thyroiditis. Furthermore, the tests indicated deficient vitamin B12 levels, and the confirmation of anti-parietal cell and anti-intrinsic factor antibodies confirmed the diagnosis of pernicious anemia. In response to these findings, the patient initiated a therapeutic regimen consisting of thyroxine at 25 mcg and intramuscular vitamin B12 injections. A year later, her general symptoms, including those associated with SLE, as well as her laboratory values, including CBC and liver function, had returned to normal. | Endocrinology |
We present a case of systemic lupus erythematosus (SLE) manifesting as Evans syndrome. Our patient presented with shortness of breath, chest pain, fatigue, jaundice, and orthostatic hypotension. Evans syndrome was confirmed as the initial diagnosis, characterized by a combination of AIHA and ITP. Subsequently, SLE was identified on the basis of positive Ds-DNA and positive ANA. Patients diagnosed with SLE should be considered for other autoimmune disorders. Considering the association of SLE with other autoimmune conditions, a comprehensive autoimmune panel was conducted. The results unveiled the coexistence of Hashimoto’s thyroiditis and pernicious anemia, highlighting the significance of thorough evaluation in patients diagnosed with SLE. | Rheumatology |
We present the clinical case of a 3-year-old boy who was admitted to the hospital emergency department due to a second seizure episode in the context of a viral illness caused by influenza A. The initial blood tests in the emergency room revealed hypocalcemia with a calcium level of 5.48 mg/dL (NV 9.4-10.8 mg/dl). Further examinations were conducted, showing a low ionized calcium level of 4.15 mg/dL (4.8-5.3 mg/dl), phosphorus of 6.1 mg/dL (3.5-6 mg/dL), PTH of 859 pg/mL (10-65 pg/ml), alkaline phosphatase of 181 UI/L (150-600 UI/L), and vitamin D (25 OH cholecalciferol) of 17 ng/mL (25-85 ng/ml). The conclusion from these results was a possible diagnosis of pseudohypoparathyroidism. | Endocrinology |
There was no consanguinity or relevant family history reported. Dichorionic diamniotic opposite-sex twin pregnancy was ended by Cesarean section due to the malposition of his twin. The full-term neonates were born at 37 + 5 weeks of gestation. The patient was born small for his gestational age with a birth weight of 2.250 g (-2.0 SD), birth length of 45 cm (-2.4 SD), and a head circumference of 31.5 cm (-1.46 SD). The birth weight of the female twin was normal at 2.700 g (-0.6 SD) with a length of 46 cm (SD –1.1 SD) and her head circumference was 32 cm (-0.9 SD). Both twins had a normal perinatal evolution. | Neonatology |
The patient had a first episode of seizure at 2 years and 10 months. In that context, he was febrile, concluding a diagnosis of atypical febrile seizure due to the seizure’s long duration, his slow recovery, and residual Todd´s paralysis on the left side of his body, which evolved successfully. Brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed with normal results. However, electroencephalography showed epileptiform paroxysms in the occipital regions with right-sided predominance, and treatment with levetiracetam was started. The patient also had a history of mild congenital heart disease due to a bicuspid aortic valve and mild aortic stenosis, which is currently followed by the pediatric cardiology department with no current treatment. | Neurology |
Follow-up of the patient was satisfactory, with normalization of the phosphate-calcium metabolism parameters after 2 months of the treatment (calcium 9.3 mg/dl, ionized calcium 5.07 mg/dl, phosphate 5.38 mg/dl, PTH 96 pg/ml, alkaline phosphatase 151 U/L, and 25OH vitamin D 42 ng/mL). Neurologically, while on the treatment with levetiracetam, the patient has not presented with new seizures, but a current electroencephalogram (EEG) (at the age of 4 years) continues to show the presence of epileptiform discharges. | Neurology |
In this report, we describe a patient with multiple synchronous malignancies, including metastatic HCC, NSCLC, and urothelial carcinoma, whose treatment with an ICI doublet regimen proved effective. | Oncology |
An 80-year-old male with a medical history of diabetes, hypertension, dyslipidaemia, multiple neuroendocrine duodenal tumors, and micronodular exogenous cirrhosis (classified as Child-Pugh class A) was diagnosed in December 2022 with non-invasive bladder carcinoma, classified as pT1N0M0. The patient did not receive further treatment for the bladder carcinoma. During an abdominal ultrasound performed for cirrhosis monitoring, a bilocular hepatic tumor with an encapsulated appearance was discovered in segment VI of the right liver, along with an endoportal tumor thrombosis. Subsequent 18 F-FDG PET-Scan on January 2023 confirmed hypermetabolic tissue lesions suggestive of primary HCC and a suspicious spiculated pseudo-nodular lesion in the right lung. Alpha-fetoprotein (AFP) levels were elevated to 12.217 U/ml, surpassing the normal range (<10 U/ml) ( Table 1 ). Following hepatic radioembolization in February 2023, a liver MRI revealed a mixed response with a partial response in the right liver, indicating a tumor response in the endovenous system and progression of the disease due to regional invasion of the biliary ducts . | Oncology |
In May 2023, a CT-guided biopsy of the suspicious pulmonary lesion identified a squamous cell lung carcinoma in the right lower lobe, classified as cT1bN0M0 , with a 100% PD-L1 expression level. The multidisciplinary team meeting recommended stereotactic radiotherapy. A thoracic CT scan in June 2023, performed prior to radiotherapy, revealed the appearance of pulmonary nodules. A lung biopsy confirmed pulmonary metastatic involvement of the HCC. The patient did not undergo stereotactic radiotherapy for his NSCLC after confirmation of metastasis. Owing to the rapid progression of pulmonary tumors secondary to hepatic carcinoma, first-line treatment with dual ICI, consisting of durvalumab and tremelimumab, was started in August 2023 . This treatment led to a partial pulmonary , hepatic response , and decreased AFP level to 9 U/ml ( Table 1 ). | Oncology |
After the patient had received four cycles of ICI with durvalumab and tremelimumab, he developed CTCAE grade I acute pancreatitis. This complication was detected based on lipase levels, which were significantly higher than the normal range. Upon diagnosis, the patient was promptly treated with corticosteroids at a dose of 1 mg/kg/day, which led to a marked improvement in his clinical condition. The patient had a complete recovery from the pancreatitis, with normalization of lipase levels within two weeks of initiating steroid therapy. Regarding immune-related adverse events (irAEs), the patient did not experience any other immune-related toxicities. | Oncology |
After six months of ICI therapy, the patient developed cerebellar syndrome, and further imaging revealed secondary brain lesions: a 17 mm lesion in the right temporal lobe and a 49 mm lesion in the left cerebellum . Following surgical resection of the cerebellar tumor, histological analysis revealed carcinoma proliferation with GATA3 positivity, consistent with the patient’s primary urothelial carcinoma. Immunostaining revealed a combined positive score (CPS) of 40. Post-surgery, the patient received cerebral radiotherapy to the operative bed in the left cerebellum and the right temporal lesion under stereotactic conditions. It was decided to continue with ICI, which have permitted disease control for 12 months. The patient is still receiving ICI therapy . | Oncology |
This rare case reported an extended response to dual ICI therapy in a patient with synchronous pulmonary metastatic hepatocarcinoma, squamous lung cancer and brain metastatic urothelial carcinoma. Focal treatment for brain progression allowed the continuation of ICI therapy. | Oncology |
Neurofibromas can present in a localized or diffuse form. The localized form, as seen in this case, is more common and involves a defined area, whereas the diffuse form involves extensive skin and subcutaneous tissue. Isolated nasal neurofibromas are exceedingly rare, especially in children, and pose challenges in diagnosis and management due to the cosmetic and functional significance of the nasal tip . This case report discusses an 11-year-old girl with an isolated neurofibroma of the nasal tip, presenting without other signs of NF1 . | Neurology |
An 11-year-old female with no personal or family history of neurofibromatosis presented to the ENT clinic with a gradually enlarging mass on her nasal tip, which had been noticeable for several months. The patient and her family were primarily concerned with the cosmetic appearance of the mass, as it had become more prominent over time. There were no associated symptoms such as pain, bleeding, or nasal obstruction. The family was worried about the nature of the lesion, fearing it might be malignant. Upon clinical examination, a firm, non-tender, well-circumscribed, mobile lesion approximately 1 cm in diameter was identified at the nasal tip, with normal overlying skin. No signs of ulceration, discoloration, or discharge were noted. The patient exhibited no other symptoms, such as nasal congestion or respiratory issues, and further examination revealed no additional cutaneous lesions suggestive of neurofibromatosis, such as café-au-lait spots. A comprehensive head and neck examination showed no abnormalities, and the patient did not display any neurological or ocular deficits. | Otolaryngology |
The lesion in this patient was localized to the subcutaneous region and did not involve the lower lateral cartilage, allowing for a straightforward excision without compromising the lower lateral cartilage. Preoperative imaging confirmed that the lesion's boundaries did not reach the lower structures such as lower lateral cartilage. In cases where larger lesions involve the lower lateral cartilage, partial excision of the affected cartilage may be necessary. Reconstruction using conchal cartilage from the auricle or costal cartilage from the ribs can be used to restore the nasal form and function while preserving the aesthetic outcome. Given the prominence of the nasal tip in facial aesthetics, particular care was taken to preserve symmetry and avoid deformity, which is especially important in pediatric patients with ongoing nasal development. Postoperative follow-up showed that the lesion was successfully excised with no recurrence noted at follow-up. | Otolaryngology |
Lipomas are noncancerous tumours composed of mature fat cells, with an incidence of 2.1 per 1000 individuals . They are classified into subcutaneous, subfascial, intermuscular, and intramuscular lipomas [ 2–4 ]. Giant lipomas, defined as tumours measuring at least 10 cm in diameter or weighing 1000 g, can cause lymphedema, discomfort, or nerve compression due to their size and location . These are rare, representing 1% of all lipomas, and are often found on the neck, shoulders, back, abdomen, arms, or thighs . Surgical excision is the standard treatment, although it can be complicated by the tumour’s size and location. Postoperative histological assessment is essential to confirm the diagnosis . This case report presents a 52-year-old male with a giant lipoma in the periscapular muscles, emphasizing early diagnosis and management. | Oncology |
Physical examination identified a well-circumscribed mass measuring 15 cm × 20 cm in the right scapular region. A computed tomography (CT) scan showed a low-attenuation intramuscular mass without calcification . A magnetic resonant imaging (MRI) scan was recommended as the primary investigation, but the patient refused. Surgical excision was performed with the patient in the prone position . A 15 cm incision was made between the spinal process and the scapula’s medial border . Subcutaneous flaps were raised, revealing the palpable mass beneath the trapezius and rhomboid muscles. The mass, appearing benign, was removed and sent for histopathological analysis . The muscle fascia was repaired, and the incision was closed in layers over a surgical drain. The procedure was uneventful, and the patient was transferred back to the ward. | Surgery |
Postoperatively, the patient developed a seroma, which required evacuation and drain placement until resolution . The pathology report described the mass as a thinly encapsulated, oval-shaped fatty lump weighing 200 g and measuring 12 × 9.3 × 3 cm. The cut surface showed soft yellow fatty tissue without cyst formation, haemorrhage, or necrosis . Microscopic analysis confirmed a benign lipoma consisting of mature fibroadipose tissue. | Pathology |
This case underscores the importance of considering giant lipomas in the differential diagnosis of soft tissue masses in the scapular region. Accurate diagnosis requires thorough clinical examination and imaging, including US, CT, and MRI, to guide biopsy decisions and avoid unnecessary invasive procedures. Surgical excision with a recommended 1 cm margin and drain placement remains the preferred treatment to prevent local recurrence and complications such as hematomas or seromas. Postoperative pathological analysis is essential to confirm the diagnosis. While prognosis is generally favourable, recurrence remains possible. | Orthopedic Oncology |
Intracranial Hypertension (ICHT) is the elevation in Cerebrospinal Fluid (CSF) pressure in the absence of any discernible neurological pathology such as lesions or ventricular dilatation . ICHT predominantly impacts young and overweight women, and may be accompanied by other symptoms such as headaches, pulsatile tinnitus, and visual disturbances or diplopia in the majority of cases . Papilledema represents the most severe clinical presentation of ICHT and may be accompanied by varying degrees of ophthalgia . The pathophysiology of papilledema is thought to occur as a result of impaired axoplasmic flow, secondary to increased Intracranial Pressure (ICP), which in the long term can lead to optic nerve damage . However, Optic Neuritis (ON), which presents as acute or subacute vision loss accompanied by periorbital pain, dyschromatopsia, and visual field defects , is not a complication of ICHT and the coexistence of these two conditions should raise suspicion for another underlying disease. This case report discusses the clinical course, diagnostic measures, and treatment of two unrelated adolescent girls with concurrent occurrence of ICHT and ON, and explores the potential causes of this co‐occurrence. | Neurology |
A 15‐year‐old girl, born to non‐consanguineous parents, without any history of past neurological disorders or neurodevelopmental delay (BMI of 18.3). Her parents report tension‐type headaches along with low‐grade fever, nausea, and vomiting a week before admission. On the day of admission, she experienced sudden bilateral visual loss (left dominant) as well as faint tinnitus. Her headaches also worsened and developed a pulsatile quality that worsened with Valsalva maneuvers. She was not on any significant medications, nor did she have a history of chronic supratherapeutic Vitamin‐D supplementation. On examination, she had optic nerve swelling, bilateral papilledema, and optic disc pallor. All other neurological assessments, including muscle force, hearing, cranial nerves, DTRs, and sensorium were normal. Laboratory results and lumbar puncture (LP) are detailed in Table 1 , and CSF opening pressure was documented as an elevated 52 cmH2O. Brain MRI showed bilateral bulging of the optic discs, with no pathological findings in contrast enhancement, while Orbital MRI showed signs of bilateral Optic Nerve sheath dilation with tortuosity, along with concavity in optic discs . Cervical and Thoracic MRIs were normal, brain MRV showed hypoplastic left Transverse Sinus without signs of thrombosis. An initial diagnosis of ON along with ICHT was made and the patient was started on Methylprednisolone and IVIg and discharged after 22 days with Prednisolone, Topiramate, and Acetazolamide. | Neurology |
A 13‐year old girl, with any significant past medical history (BMI of 17.5), born to non‐consanguineous parents, reported rhinitis and low‐grade fever a week prior to admission. The patient had a history of worsening Occipital headaches, starting from a month prior, each lasting for about 4 h and repeating several times throughout the day. Similar to Case 1, she experienced sudden onset bilateral vision loss (left dominant), tinnitus, and headaches, which worsened with Valsalva maneuvers, on admission. On examination, on top of bilateral papilledema, she had slightly reduced upper distal muscle force (grade 4 out of 5) and paresthesia. Similar to Case 1, she had no significant drug history, and denied past history of similar symptoms. Laboratory results and LP are detailed in Table 1 , and CSF opening pressure was documented as an elevated 47.5 cmH2O. Brain, Orbital, and Cervicothoracic MRIs were all normal, and devoid of any pathological findings or contrast enhancements. Subsequently, she was diagnosed with bilateral ON and ICHT, and started on Methylprednisolone and IVIg, and discharged with Acetazolamide and Prednisolone after 10 days. | Neurology |
Regarding Case 1, 40 days after discharge, the patient stopped taking all her prescribed medications, and returned after 2 weeks with the same symptoms in addition to ophthalmalgia. This time the CSF opening pressure was 30 cmH2O, and all neuro‐imaging studies were normal. Similar treatment was once again initiated and the patient was discharged after 4 days. The patient was followed‐up after 2 months, wherein her sight had returned to normal, although she still complained of recurring left eye pain and mild headaches. Case 2 was followed‐up after 3 months, she was myopic in both eyes and had a visual acuity of 2/6 along with mild horizontal diplopia. | Neurology |
This report describes two young girls who presented with initial symptoms of headache and sudden onset bilateral vision loss, and were ultimately diagnosed with ICHT and ON. Sudden bilateral vision loss in these two patients prompted consideration of several potential differential diagnoses in addition to ON, including: Nonarteritic Anterior Ischemic Optic Neuropathy (NAION), Papilledema with rapidly progressive vision loss due to space‐occupying CNS lesion, Cerebral Sinus Venous Thrombosis (CVST), Fulminant IIH, Trauma, Intoxication, and Basilar Migraine . Based on the parents' history and the results of U/A toxicology, trauma and intoxication were ruled out. Moreover, MRV, Orbital and Brain MRI performed on the patients revealed bilateral bulging of the Optic Discs and bilateral Optic Nerve sheath dilation, which is diagnostic for IIH . Furthermore, no evidence of thrombosis or distinct CNS lesions was seen in MRI and MRV, ruling out space‐occupying pathologies and CVST. Following these evaluations, a diagnosis of ICHT was made, and to rule‐out fulminant IIH as the potential cause, VEP testing was conducted, which reported latency in both patients' pre‐chiasmatic pathways, ultimately leading to the diagnosis of ICHT accompanied by bilateral ON. | Neurology |
A 62-year-old male presented with intermittent precordial chest pain at rest for 6 days, accompanied by chest tightness and sweating. Benazepril was administered to the patients with a history of hypertension. At presentation, the patient was hemodynamically stable. His vital signs included a blood pressure of 112/76 mm Hg, pulse rate of 78 beats per minute, respiratory rate of 14 breaths per minute, temperature of 36.2°C and oxygen saturation of 100% in room air. He had clear lungs, and his heart sounds were consistent without murmurs or gallops. The results of other systemic examinations were normal. ECG examination immediately after admission revealed normal sinus rhythm, normal heart rate, and poor progression of R-waves in the precordial leads . The patient underwent ECG assessment in the outpatient department prior to admission. Sinus rhythm with biphasic T waves in leads V2 to V6 was observed on the first ECG. The results of complete blood count and blood chemistry tests were within acceptable ranges. His myoglobin level was 40 ng/mL (reference range, <70 ng/mL), his creatine kinase isoenzyme level was 12 U/L (reference range, 0–25 U/L), his cardiac troponin T level was 0.01 ng/mL (reference range, <0.1ng/mL), and his B-type natriuretic peptide level was 20.21 pg/mL (reference range, <125pg/mL). In addition to intermittent precordial chest pain, ECG changes, and normal cardiac serum markers, Wellens’ syndrome was considered. Dual antiplatelet, nitrate, and statin drugs were administered and the patient underwent urgent coronary angiography. The results revealed that the proximal LAD artery was nearly completely occluded . Intravascular ultrasonography confirmed plaque rupture with thrombosis in the proximal LAD artery , and the minimum lumen area was 2.4 mm 2 . A drug-eluting stent was successfully implanted after balloon dilatation . Echocardiography revealed no abnormal left ventricular wall motion after the procedure, normal left ventricular ejection fraction (65.1%), and normal reexamination levels of troponin T and B-type natriuretic peptides. The patient was discharged 6 days later. | Cardiology |
An 85-year-old male with a medical history of benign prostatic hyperplasia presented to the emergency department with altered mental status and a generalized tonic-clonic seizure. His condition rapidly deteriorated, resulting in a decreased level of consciousness, which required endotracheal intubation for protection of the airway. Initial CT and computerized tomography angiography (CTA) of the head revealed no acute intracranial abnormalities but identified chronic occlusion of the left internal carotid artery and an ulcerative plaque in the right internal carotid artery. Subsequent MRI of the brain without contrast showed an increased T 2 signal in fluid-attenuated inversion recovery images within the left basal ganglia and medial aspect of the right thalamus . A 72-hour continuous electroencephalogram (EEG) demonstrated frequent generalized periodic discharges with frontally maximal triphasic morphology at a frequency of 1.5 to 2.0 Hz. Lumbar puncture revealed CSF analysis with elevated protein levels (101 mg/dL), 29 white blood cells (WBCs)/mm³ with 79% monocytes/macrophages. An infectious meningitis/encephalitis panel detected positive EEE IgM antibody via enzyme immunoassay (EIA), confirming the diagnosis. The patient was treated with high-dose intravenous methylprednisolone . Anticonvulsant therapy with levetiracetam , and valproate (750 mg twice daily) was started. The patient had a significant risk factor for exposure as an avid gardener, spending several hours outdoors daily. A repeat MRI on hospital day 7 showed an improvement in the interval with no contrast enhancement. The patient was successfully extubated on hospital day 6 and subsequently discharged to an acute rehabilitation facility on hospital day 11 for further recovery and rehabilitation. | Neurology |
A 77-year-old man with a history of aortic valve replacement on chronic warfarin therapy presented to the emergency department with several transient episodes of altered mental status. The patient experienced 5 to 6 episodes of confusion, each lasting several hours to days, mainly affecting his ability to recall history and causing disorientation to time and place. There was no impairment in activities of daily living. The initial CT and CTA of the head were unremarkable. However, MRI of the brain with and without contrast revealed increased T 2 signal on the fluid-attenuated inversion recovery sequence involving the right mesial temporal lobe, raising concerns for a possible seizure episode . Susceptibility-weighted imaging showed scattered punctate foci of microbleeds at the gray-white matter junction, which were considered chronic. | Neurology |
A continuous EEG recorded intermittent sharp waves in the right frontal area during sleep, further supporting seizure-related etiology. CSF analysis revealed 21 WBCs/mm³ with 52% neutrophil predominance, normal glucose levels, and elevated protein (55 mg/dL). The presence of 8700 red blood cells (RBCs)/mm³ in tube 1 and 17,250 RBCs/mm³ in tube 4 was noted. An infectious panel, including meningitis, autoimmune, and viral encephalitis tests, identified an elevated EEE IgM in the CSF via EIA, confirming the diagnosis of EEE. The patient was started on anticonvulsant therapy with levetiracetam (750 mg twice daily) and closely monitored. Despite the severe nature of the disease, the patient remained stable and was discharged to a rehabilitation facility on hospital day 12 for further recovery and continued treatment of his neurological symptoms. A repeat MRI of the brain without contrast was completed in 6 months that showed resolution of previous mesial temporal sclerosis and the patient continued to remain seizure free. | Neurology |
A 29-year-old male came to the emergency department following a generalized tonic clonic seizure. His symptoms began with flu-like manifestations, including abdominal pain, diarrhea, muscle cramps, nausea, and a fever of 101 °F. The sudden onset of seizure activity prompted further investigation. CSF analysis revealed an elevated protein level of 146 mg/dL, normal glucose of 60 mg/dL, 28 RBCs/mm³, and 310 white blood cells WBCs/mm³, with a differential showing 77% neutrophils and 17% lymphocytes. Given the initial findings, the patient was empirically treated for bacterial meningitis and herpes simplex virus encephalitis with acyclovir, ceftriaxone, and vancomycin. MRI of the brain demonstrated a linear focus of T 2 hyperintense signal abnormality within the subcortical white matter of a single gyrus in the right frontal lobe, suggestive of cerebritis . A comprehensive meningitis/encephalitis panel was performed in the CSF, which confirmed the presence of EEE IgM via EIA. A routine EEG was conducted, which returned normal results. The patient started anticonvulsant therapy with levetiracetam (750 mg twice daily). His condition stabilized and he was discharged from the hospital on day 7. A follow-up MRI of the brain, completed 3 years later, showed complete resolution of the previously identified lesion, indicating full recovery from the initial encephalitic process. | Neurology |
A 70-year-old man with a medical history of hypertension, type 2 diabetes mellitus, coronary artery disease status after percutaneous coronary intervention, and hyperlipidemia presented to the emergency department with acute left-sided hemiparesis of acute onset and twitching of the left upper extremity. He was activated as a code stroke with a National Institutes of Health Stroke Scale score of 13, primarily due to dense left-sided hemiplegia and sensory deficits. Initial head CT and CTA did not show acute abnormalities or large vessel occlusion. The patient was loaded with 2000 mg of levetiracetam. Subsequently, he developed a high fever of 39.7 °C. Given the clinical picture, empiric antibiotics, and antivirals were started for suspected meningitis/encephalitis, including ceftriaxone, vancomycin, and acyclovir. MRI of the brain revealed an acute infarct in the right posterior cerebral artery territory, specifically involving the right thalamic pulvinar. Additionally, there was a larger amorphous area of faint T 2 hyperintensity with diffusion restriction involving the right temporal-parietal gyri, insula, sub-adjacent white matter, and basal ganglia . CSF analysis showed elevated glucose (82 mg/dL), protein (140 mg/dL), 11 RBCs/mm³, and 8 WBCs/mm³, with a differential of 44% lymphocytes, 27% neutrophils, and 29% monocytes/macrophages. A meningitis/encephalitis panel returned positive for EEE IgM in the CSF via EIA. The patient’s hospital course was complicated by generalized tonic-clonic seizures, which required intubation and mechanical ventilation. He was loaded with fosphenytoin and started on a maintenance dose. Continuous EEG monitoring revealed evidence of nonconvulsive status epilepticus originating in the right hemisphere. On hospital day 5, a repeat MRI of the brain showed evolution of the previously identified acute infarction and increased T 2 signal in the basal ganglia and thalamic regions bilaterally, with the left side more affected than the right . Given the worsening clinical picture, the patient started on high-dose intravenous methylprednisolone and intravenous immunoglobulin (IVIG) on hospital day 7. Unfortunately, on day 8 of hospitalization, the patient developed ventilator-associated pneumonia. Due to the poor prognosis and the patient’s declining condition, the family opted to withdraw care. A full summary of the clinical and radiographic findings of call reported cases are provided in Table 1 . | Neurology |
A 70-year-old patient was admitted, evaluated for her complaints, and diagnosed with a case of follicular carcinoma of the thyroid (PT3AN0MX). She underwent a total thyroidectomy on March 23. The intraoperative period was uneventful, and the patient was managed with broad-spectrum antibiotics and electrolytes. Immediately after surgery, a 4/6 (house-Brackman grading) degree of facial palsy was evident. On postoperative Day 1 (POD-1) the patient developed seizures that may be secondary to dyselectrolytemia. A neurology opinion was sought for the same and electrolytes were corrected with 3% NaCl along with KCl according to neurology advice. On the second postoperative day, the patient reported moderate headache and asthenia and his body temperature was 37°C. She developed hypercalcemia and stridor. Infusion with calcium gluconate was started along with oral calcium supplementation. She was intubated and moved to the ICU for additional treatment because of her low GCS. She underwent a tracheostomy given her prolonged need for ventilatory support. Blood count showed neutrophilic leucocytosis and antibiotic therapy was continued without change. On the seventh postoperative day, the patient complained of a significant worsening of his headache, and multiple small fluid-filled lesions were noticed on her face around the mouth and eyes. The lesions were initially fluid-filled blisters, which later oozed fluid, formed a crust, and spread to the left upper arm . The patient continued to have low consciousness levels and was provisionally diagnosed with a case of herpes encephalitis. For the diagnosis, virological and radiological testing (CT and MRI brain scans) were done. T2-weighted magnetic resonance imaging of the brain showed a high-intensity area in the bilateral temporal lobes and insular cortex and the patient was radiologically diagnosed with herpetic encephalitis. Real-Time Polymerase Chain Reaction (RT-PCR) from serum, nasal swabs, lesions, and CSF was positive for HSV1 ( Table 1 ). Tzanck smears showed multinucleated giant cells that are suggestive of HSV . Intravenous administration of acyclovir (750 mg TDS) for 3 weeks led to gradual improvement of consciousness and the patient was able to respond to verbal clues. Tzanck smears showed multinucleated giant cells that are suggestive of HSV . Intravenous administration of acyclovir (750 mg TDS) for 3 weeks led to gradual improvement of consciousness and the patient was able to respond to verbal clues. | Neurology |
Small bowel obstruction (SBO) in pediatric patients is a common surgical emergency, often resulting from adhesions, hernias, or congenital abnormalities ( 1 ). However, SBO caused by the ingestion of a whole grape is exceptionally rare, particularly in infants. Previous literature has primarily focused on foreign body ingestion involving objects like coins, magnets, and bezoars, with fruits being an uncommon cause ( 2 – 7 ). This case report presents a unique instance of SBO in a 7-month-old infant due to the ingestion of a whole Shine-Muscat grape, a situation not well-documented in current medical literature. | Pediatric Surgery |
This case adds to the understanding of pediatric gastrointestinal emergencies by highlighting the need for increased awareness among pediatricians and caregivers regarding the potential hazards of feeding whole fruits to young children. It emphasizes the importance of thorough history-taking, careful radiological evaluation, and consideration of minimally invasive surgical techniques for effective management. By documenting this rare occurrence, we aim to provide valuable insights for clinical practice and preventive strategies to reduce the risk of such potentially life-threatening events in pediatric patients. | Pediatrics |
On physical examination, the infant appeared dehydrated with abdominal distension but was afebrile and showed no signs of abdominal tenderness or palpable masses. No surgical scars were present on the abdomen, and no bilateral inguinal hernias were detected. The rectal examination revealed no fecal matter, and a corkscrew enema failed to induce bowel movement. Additionally, abdominal x-ray was performed, which revealed characteristic air-fluid levels, further supporting the diagnosis. Given these findings, a diagnosis of mechanical small bowel obstruction was suspected. | Gastroenterology |
Day 4: A follow-up abdominal CT scan showed dilated small bowel loops with a spherical low-density lesion, consistent with an obstructive foreign body . While the imaging clearly indicated the presence of a foreign body in the right lower quadrant within the ileum, it could not precisely determine the exact position of the object. Despite the parents denying any history of foreign body ingestion, the clinical and imaging findings indicated mechanical small bowel obstruction, necessitating surgical intervention. The patient underwent diagnostic laparoscopy, which confirmed the presence of a whole grape located in the terminal ileum, approximately 80 cm from the ileocecal valve. The obstruction was successfully managed laparoscopically by crushing the grape and advancing it into the colon to avoid an intestinal incision . | Pediatric Surgery |
Postoperative Days 1–2: The infant was managed with fasting, gastrointestinal decompression, and intravenous fluids. A nasogastric tube was placed in the emergency department prior to surgery and remained in place postoperatively to ensure effective decompression until gastrointestinal function was restored. During the surgery, additional decompression was achieved by using atraumatic grasping forceps to crush the foreign body and advance it towards the cecum, which contributed to the early recovery of lower gastrointestinal function. By the second postoperative day, the infant naturally passed grape fragments, and her gastrointestinal function gradually returned to normal. | Pediatric Surgery |
Initial diagnostic workup included laboratory tests and imaging studies. The laboratory results showed an elevated C-reactive protein (CRP) level of 19.6 mg/L (normal <5 mg/L) and a procalcitonin level of 0.97 ng/ml (normal <0.5 ng/ml), indicating a potential inflammatory or infectious process. Imaging included an upright abdominal x-ray, which revealed step-like air-fluid levels, suggestive of small bowel obstruction . An abdominal CT scan further confirmed the presence of dilated small bowel loops with multiple air-fluid levels in the left mid-upper abdomen , along with a spherical low-density lesion measuring approximately 2.8 cm by 2.4 cm in the right lower abdomen, which was suspected to be a foreign body . Despite the parents' denial of foreign body ingestion, the imaging findings raised a strong suspicion of this etiology. Differential diagnoses, including intussusception, volvulus, and infectious or inflammatory bowel disease, were considered but deemed less likely due to the clinical presentation and imaging findings. Ultimately, the diagnosis of mechanical small bowel obstruction caused by a foreign body was confirmed intraoperatively . | Gastroenterology |
The patient underwent an emergency diagnostic laparoscopy. A transition point in the ileum, approximately 80 cm from the ileocecal valve, was identified with proximal dilation and distal decompression. Under laparoscopic guidance, a 5 mm trocar was inserted into the abdominal cavity to introduce atraumatic grasping forceps, which were used to locate and externally crush a soft spherical foreign object through the bowel wall. The object was later identified as a Shine-Muscat grape. During the surgery, after identifying the foreign body, the parents were questioned again, and they confirmed recent grape ingestion. Based on this information, we decided to crush the grape and push it into the colon rather than making an intestinal incision, which minimized surgical trauma and facilitated a quicker recovery. Postoperatively, the patient received gastrointestinal decompression, infection prevention with antibiotics, and rehydration therapy. | Pediatric Surgery |
This case report documents a rare presentation of small bowel obstruction (SBO) in a 7-month-old infant caused by the ingestion of a whole Shine-Muscat grape, a common but overlooked dietary risk. The primary strength of this case lies in its contribution to the limited literature on fruit ingestion as a cause of SBO in pediatric patients. Unlike the more frequently encountered foreign bodies, such as coins, magnets, or sharp objects, which are widely recognized and addressed in pediatric guidelines, fruits like grapes are often considered benign and are not typically associated with severe complications. This case emphasizes the need for pediatricians and caregivers to be aware that even seemingly harmless foods can pose a significant risk of gastrointestinal obstruction in young children. Given the rarity of this presentation, we reviewed the relevant literature to better understand the broader context of pediatric SBO. | Pediatrics |
Moreover, our case demonstrates the clinical significance of integrating imaging findings, laboratory results, and patient history to make an accurate diagnosis. The lack of a clear ingestion history from the parents initially complicated the diagnostic process, highlighting the need for pediatricians to maintain a high index of suspicion for foreign body ingestion, even when common symptoms like vomiting and abdominal distension are the primary clinical signs. By relying on imaging, which demonstrated characteristic air-fluid levels and an intraluminal foreign body, the diagnosis of SBO became evident, guiding the subsequent minimally invasive intervention. Such cases underline the need for increased awareness among caregivers and healthcare providers about the risks posed by seemingly harmless foods like grapes, which can lead to severe complications if not properly managed. | Pediatrics |
The clinical decision-making in this case was guided by both the laboratory and imaging findings. The elevated C-reactive protein (CRP) and procalcitonin levels indicated an inflammatory response, possibly secondary to bowel obstruction. Though non-specific, the elevated CRP level further supports the presence of an inflammatory process. Meanwhile, the abdominal CT scan provided definitive evidence of a foreign body causing luminal obstruction. Despite the initial denial of foreign body ingestion by the parents, the diagnostic imaging suggested otherwise, underscoring the importance of correlating clinical, laboratory, and imaging data for accurate diagnosis. The successful use of a minimally invasive laparoscopic approach to crush and mobilize the grape into the colon, rather than performing an enterotomy, minimized surgical trauma and promoted a faster recovery, consistent with current surgical best practices. | Surgery |
The limitations of this case report include its singular nature, which limits the generalizability of the findings to broader pediatric populations. However, it serves as a valuable reminder that common dietary items can pose unforeseen risks. Moreover, the report's strength is its detailed documentation of a novel management approach for a rare cause of pediatric SBO, potentially guiding future cases with similar presentations. | Pediatrics |
In conclusion, based on the above discussion, this case reinforces several important takeaways for clinical practice. First, it is crucial to consider less common etiologies, such as fruit ingestion, when evaluating pediatric patients with gastrointestinal symptoms, particularly when typical causes are excluded. Second, this report underscores the importance of preventive education for caregivers on safe feeding practices, such as cutting grapes into smaller pieces or avoiding whole grapes altogether for young children. Finally, adopting minimally invasive surgical techniques where feasible can reduce patient morbidity and lead to better outcomes, as evidenced by the rapid recovery in this case. | Pediatrics |
A 39-year-old woman was treated with galcanezumab since June 2021 for migraine without aura. She was a non-smoker and had no vascular risk factors such as hypertension, hyperlipidemia, or diabetes. Her family history did not include any cardiovascular or cerebrovascular diseases. After the 16th dose of galcanezumab, the patient developed neck pain on the left side followed by severe headaches that differed from her usual migraine headaches. This unusual headache was unilateral, non-pulsatile, and worsened with physical movement. Headache severity was 9–10/10 on a numerical rating scale. The patient had no traumatic or triggering events prior to the onset of headache. The patient did not report nausea, photophobia, or phonophobia. The patient visited her physician two weeks after experiencing persistent neck pain and headaches. Brain magnetic resonance imaging (MRI) revealed left vertebral artery stenosis, and the patient was referred to our department for further evaluation and treatment. Head and neck magnetic resonance angiography (MRA) showed a 15 mm-long vertebral artery dissection distal to the left V2 segment . She had no physical findings, including sensory disturbance or ataxia, and did not report vomiting and vertigo. She had no family history suggestive of connective tissue disorders such as Marfan syndrome. Blood tests showed no specific abnormal findings in blood count and the coagulation systems, nor were there any indications of vasculitis. We did not administer anti-platelet therapy and followed up with pain control. Considering the effects on the blood vessels, we did not resume galcanezumab and initiated amitriptyline to control the attack of migraine. For the same reason, we switched from triptan to lasmiditan for the acute treatment of migraine. Her neck pain and headache were relieved, and MRA conducted two months later suggested a complete resolution of the dissection. | Neurology |
In summary, we describe a case of vertebral artery dissection in a patient with migraine who received CGRP mAb treatment for more than one year. It is unclear whether vertebral artery dissection and the use of CGRP mAb are causally related. To the best of our knowledge, however, our case report is the first focusing on CeAD and CGRP mAb. Considering the characteristics of CGRP and the result of FAERS database analysis, the potential for CGRP mAb to be related to CeAD cannot be ruled out. Further case series and studies are required to validate the association between CGRP mAb and CeAD. | Neurology |
A 62-year-old female patient with Eastern Cooperative Oncology Group performance status (ECOG-PS) of zero, and a remote history of stage IIA bulky mediastinal nodular sclerosis Hodgkin’s disease successfully treated with 35 Gy in 20 fractions, presented for surveillance scans. Computed tomography (CT) of the chest revealed a 1.0 cm left upper lobe nodule, and CT-guided biopsy revealed a bronchopulmonary carcinoid. The patient underwent video-assisted thoracoscopic surgery (VATS) left upper lobectomy with mini thoracotomy. The presence of tumor nests with central necrosis and salt-and-pepper chromatin on surgical pathology confirmed the diagnosis of atypical carcinoid tumor . Lymphovascular invasion and visceral pleural involvement were also identified. | Oncology |
The patient was subsequently classified with stage IIB (pT3N0M0) disease and was given four cycles of adjuvant cisplatin and etoposide. Two years after completing systemic therapy, the patient underwent a CT scan of the abdomen and pelvis, which demonstrated 1.3 cm, 2.4 cm, and 1.6 cm lesions within the right hepatic lobe and a 1.1 cm lesion in the left hepatic lobe. She was asymptomatic and reported no new concerns when these surveillance scans were performed. CT-guided biopsy confirmed the presence of liver-metastatic atypical carcinoid and systemic therapy with capecitabine and temozolomide was initiated. Due to the presence of these liver metastases, gallium-68 dotatate positron emission tomography-computed tomography ( 68 Ga-PET/CT) and contrasted magnetic resonance imaging (MRI) of the brain were performed shortly after biopsy to survey the extent of metastatic disease. MRI brain revealed multiple punctate contrast-enhancing lesions in the supratentorial and infratentorial brain. | Oncology |
Given her high functional status and the asymptomatic nature of the lesions, treatment with maintenance capecitabine and temozolomide was continued. The patient continued to receive systemic therapy and undergo repeat brain imaging for another two years, until she began to develop headaches and dizziness requiring dexamethasone (4 mg daily). Repeat MRI brain showed an increase in the number of punctate lesions throughout the brain and brainstem, with no clear leptomeningeal involvement . Of note, no lesions were found to be within five millimeters of the hippocampi bilaterally, making her a viable candidate for HS-WBRT as per Radiation Therapy Oncology Group (RTOG) 0933 . | Oncology |
The patient tolerated the treatment well and experienced only grade one fatigue by the end of her radiation course. At her one-month follow-up, she denied any acute toxicities, had discontinued dexamethasone, and exhibited ECOG-PS of zero. Genetic testing revealed that her tumor had mutations in epidermal growth factor receptor (EGFR) and the platelet-derived growth factor receptor β (PDGF-β). As per the multi-disciplinary tumor board recommendations, she was placed on everolimus, but she discontinued the medication four months post-radiation due to poor tolerance and declined further systemic therapy. Due to the metastases in her upper cervical and thoracic spine, the patient developed progressive bilateral lower extremity weakness requiring a wheelchair for mobility. These symptoms prompted her to move into a nursing home six months after receiving HS-WBRT, which limited her follow-up. When examined 10 months after the HS-WBRT, the patient exhibited ECOG PS of two, with bilateral lower extremity strength rated two out of five throughout. However, she remained oriented to person, place, and time, was able to answer questions appropriately, and denied lapses in her memory or cognition. Repeat MRI brain at 11 months post-radiation revealed decreased as well as stable size and number of brain metastases, with no new ones identified, demonstrating effective local control . The patient’s systemic disease unfortunately continued to progress elsewhere and she passed away 13 months after delivery of HS-WBRT. | Oncology |
Brain-metastatic atypical carcinoid is a rare occurrence that confers a poor prognosis. This case details successive palliation of intracranial metastases using HS-WBRT, showing its utility in conferring excellent local control while preserving cognition. However, this case also testifies to the aggressive nature of atypical carcinoids, warranting active surveillance and treatment. More frequent surveillance for intracranial metastases in patients with atypical histologies, advanced stage on initial presentation, or signs of clinical or radiographic disease progression may prompt earlier diagnosis, leading to necessary changes in systemic therapy and earlier inclusion of brain-directed radiotherapy. Multidisciplinary approach and treatment is needed from diagnosis onwards. Well-designed prospective randomized trials and meta-analyses focused on atypical pulmonary carcinoids are warranted. | Oncology |
Here, we report a case of CWP in a 75‐year‐old female with a history of cured breast cancer posing a diagnostic challenge due to its presentation as a left upper lobe lung mass resembling lung cancer. | Oncology |
In December 2020, a 75‐year‐old female with a history of cured breast cancer, hypertension, and more than 30 years of cooking with biomass fuels in poorly ventilated kitchens was referred to the radiology department for further evaluation of an incidental mass found on the chest X‐rays. She reported left shoulder pain persisting for a year and previously was diagnosed and treated as a frozen shoulder. About 11 months after the start of treatment, she did not notice a significant improvement in her symptoms; hence, her family physician ordered a chest x‐ray based on the suspension of possible underlying cancer. She had undergone treatment for left breast cancer 25 years ago, including total mastectomy, adjuvant chemotherapy, and radiotherapy. The chest X‐rays revealed a consolidation favoring lung mass in the left upper hemithorax , and subsequently, she was referred to our hospital. She had no respiratory or constitutional symptoms such as fever, fatigue, weight loss, cough, dyspnea, hemoptysis, etc. | Oncology |
Physical examination revealed controlled blood pressure and other vital signs within normal range. Left shoulder movements were painful and restricted. There was a mastectomy scar on the left side of the chest. Auscultation revealed normal lung and heart sounds. No lymphadenopathy was detected. There were no other significant findings. Primary lab tests were as follows: white blood cell 6300/μL, hemoglobulin 12.7 g/dL, platelet count 327,000/μL, urea 40 mg/dL, creatinine 0.9 mg/dL, international normalized ratio (INR) 1 and partial thromboplastin time (PTT) 30 s (reference range: 30–45 s). A chest tomography (CT) scan was ordered. It showed a solid mass with dimensions of 31 x 16 x 22 mm with a spiculated edge containing calcifications in the left upper lobe of the lung. | Oncology |
A CT‐guided percutaneous core needle biopsy was planned, and the patient was transferred to the operating room. After prepping and draping, multiple nerve blockages in the third and fourth left intercostal spaces with lidocaine 2% were done, and a biopsy specimen was taken, which subsequently caused hemopneumothorax. Immediately, a chest tube was placed, and intensive fluid therapy started. 1.5 L of blood drained into the bottle in minutes. A complete blood count was requested. The patient's hemoglobin decreased from 12.7 to 10.8 g per deciliter, and his platelet count dropped from 327,000 to 242,000/μL. Two units of packed red blood cells were infused, and after stabilization, the patient was transferred to the intensive care unit (ICU). | Radiology/Interventional Radiology |
In conclusion, this case highlights the diagnostic challenges in distinguishing CWP from lung cancer, particularly when presenting as a suspicious upper lobe lung mass. In our patient, the presence of a spiculated mass with calcifications necessitated thorough investigation to rule out malignancy, ultimately leading to a CWP diagnosis confirmed by histopathology and immunohistochemistry. This underscores the importance of a comprehensive diagnostic approach, particularly in patients with overlapping risk factors, such as a history of biomass fuel exposure and prior cancer. Multidisciplinary collaboration among clinicians, radiologists, and pathologists proved essential in reaching an accurate diagnosis, underscoring that such integration is crucial for optimal patient outcomes. Enhanced awareness of CWP's atypical presentations and potential imaging mimics, including malignancy, can support early and accurate diagnosis, thereby avoiding unnecessary interventions and reducing healthcare burdens. | Pulmonology |
While numerous studies have explored the genetic underpinnings of CPP, data from the Chinese population remains limited. This report presents a case of CPP in a Chinese child attributed to a novel MKRN3 gene mutation, aiming to enhance clinical understanding of this condition and its genetic determinants. | Genetics |
The patient’s height was 116 cm, which is slightly above the average for her age (109 ± 4.1 cm), with a weight of 20 kg and a BMI of 14.9, all in the normal range (17.8 ± 2.4 kg and 15.3 ± 1.6). No dysmorphic facial features were observed. A 3 cm × 4 cm irregular café-au-lait macule was present on the right waist. There was no evidence of acne or dorsocervical fat pad. The thyroid gland was non-palpable. Breast development was consistent with Tanner stage II, with bilateral breast buds measuring approximately 1.5 cm × 1.5 cm, and no areolar hyperpigmentation. The external genitalia were age-appropriate, with the labia majora fully covering the labia minora. Pubic hair development was consistent with Tanner stage I, and no axillary hair was present. The spine and limbs showed no deformities, and the neurological examination was unremarkable. | Pediatrics |
Breast ultrasound revealed bilateral breast buds with the left breast measuring 2.9 cm × 0.7 cm × 3.4 cm and the right breast measuring 2.9 cm × 0.6 cm × 2.9 cm. The margins were ill-defined, with no significant internal abnormal echogenicity or increased vascularity detected. | Radiology |
A 46-year-old female, with no significant medical or surgical past medical history, presented to the emergency department (ED) with 2-week history of severe progressive back pain radiating lower limbs along with bilateral lower limbs weakness and numbness. Physical examination revealed thoracolumbar tenderness, bilateral paraplegia, and bilateral positive Babinski signs. Her blood pressure was elevated 200/110 mmHg with normal body temperature and results of initial blood tests revealed slightly raised inflammatory markers, white blood test (WBC) 10.6 × 10^3/uL [normal range: 4.0-10 x 10^3/uL] and C-reactive protein (CRP) 27.6 mg/L [normal range: 0-5 mg/L]. A computed tomography (CT) head scan ruled out acute hemorrhagic stroke and a CT angiography of the aorta excluded aortic dissection but spotted a T6 vertebral body compression fracture . Fig. 1 Selected thoracic region sagittal (A) and axial (B) images of computed tomography scan -bone window- revealed T6 vertebral body partial collapse with suspicion of an underlying bone lesion (red arrow). Fig 1: | Neurology/Radiology |
Due to the patient neurological deficits and radiologic finding, the patient underwent T4-T8 pedicle screw fixation, T6 decompressive laminectomy, and biopsy of the epidural lesion. Histopathological analysis revealed findings consistent with LCH, with positive immunohistochemical staining for CD1a, langerin, S100, and CD68 . BRAF mutation was negative. Screening whole body positron emission tomography (PET) CT scan for metabolic assessment showed increased uptake at the area of T6 vertebra, suggestive of residual/active disease, and high right parotid gland uptake . MRI of the head showed a thickened pituitary stalk . Accordingly, endocrine assessment was made, which was unremarkable. Fig. 3 Histopathology examination. (A) CD1a, (B) CD68, (C) Langerin, (D) S100. Fig 3: Fig. 4 Whole body positron emission tomography. (A) Coronal plane showing asymmetric right-sided parotid gland high uptake (red arrow). (B) Sagittal plane showing mild increased uptake at the area of T6 vertebra consitent with post operative changes. Note the T4-T8 interpedicular screw fixation artefact at mid-thoracic spine. Fig 4: Fig. 5 Selected T1 sagittal (A) and coronal (B) images of multiplanar multisequence MRI of pituitary gland without intravenous contrast (avoided due to acute kidney injury), showing mild thickening of the pituitary stalk (red arrows). The width of pituitary stalk measured 4 mm. Fig 5: | Neurosurgery/Oncology |
In short, this is a very rare case of an adult lady who was presented with back pain along with sensory and motor deficits in the lower limbs. MRI spine showed T6 vertebral body pathological collapse with epidural soft tissue component compressing the spinal cord. She underwent T4-T8 pedicle screws fixation with T6 decompressive laminectomy and biopsy of the epidural lesion, which revealed histopathological features of LCH. Other imaging modalities showed findings suggestive of multi-system involvement. | Neurosurgery |
We present a case where EP is evident in a patient, serving as a manifestation of recent psychological stress on a background of multiple treatment failures. The extent of the disease in this report was measured using the Dermatology Life Quality Index (DLQI). DLQI is a questionnaire comprising 10 questions aimed at assessing the influence of skin conditions on an individual's quality of life. Each question receives a score between 0 and 3, resulting in a total score range from 0 (indicating no effect of the skin condition on quality of life) to 30 (suggesting the highest impact on quality of life) . | Dermatology |
During the clinical assessment, psoriasis was observed to involve the entire body surface area, accompanied by a low-grade fever. The skin was warm to touch, dry, and thickened with prominent silvery-white scaling . Notably, there was substantial edema in the lower extremities with localized cellulitis, resulting in restricted mobility . In the hospital setting, the patient was initially treated with intravenous clindamycin at a dose of 600 mg four times daily for two days, after which therapy was switched to oral clindamycin, and the patient subsequently remained afebrile. Methotrexate was withheld while treating the acute infection, and the patient was started on adalimumab following a short course of intravenous hydrocortisone. The results of the blood tests during admission indicated an improvement in C-reactive protein and normalization of serum creatinine following fluid management (Table 1 ). Mild thrombophilia had also improved after discharge from the hospital, and neutrophilia was observed to be related to steroid initiation. | Dermatology |
In this report, the patient’s symptoms were classic EP, including widespread erythema, desquamation, and systemic involvement. Notably, the patient also developed cellulitis of the lower limbs . Given the severity of the infection, the cellulitis was treated with antibiotics to prevent further complications, such as sepsis, which can occur if left untreated. The co-occurrence of an infection with EP underscores the delicate nature of the skin’s integrity in this condition. | Dermatology |
This case report represents a rare presentation of EP associated with psychological stress. When patients present critically ill with an erythrodermic rash, it is important to consider EP in the differential diagnosis, especially with recent psychological stress. The mechanisms through which psychological stress interferes with psoriasis onset or exacerbations are not completely understood. However, psychoneuroimmunology studies have shown that acute and chronic stress can affect immune function, leading to a worsening of psoriasis by inducing keratinocyte proliferation and incomplete maturation. | Dermatology |
Out-of-hospital-cardiac arrest (OHCA) is a significant health concern with approximately 275,000 annual cases in Europe and 420,000 in the United States. 1 Immediate recognition of cardiac arrest, initiation of cardiopulmonary resuscitation (CPR) and early defibrillation are key factors to improve survival. 2 However, bystander CPR are only reported on average in 58 % (range 13 % to 83 %) of episodes. 2 In addition, there is considerable variation in the quality of bystander CPR, with only a minority demonstrating high quality CPR. 3 Simulation studies have shown that video assisted CPR (V-CPR) may improve cardiac arrest recognition, improve the quality of basic CPR and that it can be performed in a real-life setting. 4 , 5 In OHCA, clinical studies show promising results of V-CPR on CPR quality, return-of-spontaneous-circulation (ROSC) rates and survival to hospital discharge. 6 , 7 , 8 , 9 However, there are considerable knowledge gaps regarding possible benefits of applying this technology in patients with cardiac arrest. 10 We present a case with witnessed OHCA, where dispatcher V-CPR was initiated early and considered essential to provide a tailored approach to a complex OHCA. | Cardiology |
A 58-year-old male with known paroxysmal atrial fibrillation (AF) sustained an OHCA at 9:47 a.m. while changing tires on his jacked-up car together with his son. An emergency call was received at 9:48 a.m. The patient was reported unconscious with agonal respiration and no CPR was performed. Guided by the Norwegian Index for Medical Emergency Assistance, a stepwise tool for decision-making and to guide callers in emergency medical situations by the Emergency Medical Coordination Centre (EMCC), the patient was identified as unresponsive and not breathing normally. 11 The medical dispatcher immediately instructed the two laypersons on-scene to perform CPR, which they did without hesitation. None had previous CPR experience. Emergency medical services (EMS) and the on-call general practitioner were also immediately dispatched. No other emergency resources (e.g. volunteer first responders) were available during the incident. Since there were two persons on-scene, the medical dispatcher decided to initiate a video call (VC) to better guide the ongoing layperson CPR. The video transmission was initiated two minutes after the emergency call and showed high-quality chest compressions, and a patient with apparent spontaneous respiration and limb movements. After three minutes, they paused compressions according to Norwegian CPR guidelines. 12 The medical dispatcher then observed that the patient‘s breathing pattern changed into agonal respiration. When compressions were continued, the respiration was again considered normal. Because the breathing pattern was deemed normal due to well performed chest compressions, the medical dispatcher decided not to instruct in mouth-to-mouth ventilations according to standard CPR guidelines. The patient therefore received compression-only CPR until arrival of EMS at 10.21 am, 33 min after start of bystander CPR, at which point V-CPR was discontinued. The two laypersons alternated in performing CPR during the whole incident prior to EMS arrival. | Cardiology |
On EMS arrival, the patient was still in cardiac arrest and presented with ventricular fibrillation (VF). A direct current (DC) defibrillation with 200 Joule was delivered by EMS personnel before they continued CPR. The patient obtained ROSC at 10:23 am. However, the ROSC only lasted for 30–40 s, and the patient resumed to VF. Another two DC 200 J defibrillations were delivered, but the patient remained with VF. A physician-staffed air ambulance helicopter arrived on-scene at 10:30 am. With ongoing CPR with the patient in VF, the patient showed signs of life with head and limb movements, verbal sounds and a normal respiration pattern with a respiration rate of 12 breaths per minute during chest-compressions. A fourth DC 200 Joule defibrillation was delivered which resulted in sustained ROSC with AF rhythm at 10:33, 46 min after the time of cardiac arrest. Before transportation a rapid sequence induction with intravenous (iv) analgesia (fentanyl 0.2 mg iv), sedation (ketamine 75 mg iv), muscle relaxation (rocuronium 50 mg iv) and endotracheal intubation was performed without any complications. An arterial line was inserted and an intravenous ketamine infusion (1.5 mg/kg/hour) was started for maintenance of sedation during transport to hospital. The patient was hemodynamically stable in-flight with a blood pressure of 150/80 and a pulse rate of 70–90/min, except a brief period of ventricular tachycardia during take-off from the scene. A dose of intravenous amiodarone 100 mg was administered, and the patient converted to AF. The measured oxygen saturation level was 98 % and the patient was normothermic. Transport to the nearest university hospital was uneventful and he was admitted to hospital at 11:59 a.m. | Cardiology |
The first arterial blood gas showed a metabolic acidosis with pH 7.20, pCO2 5.7 kPa, pO2 12.2 kPa, base excess −11.2 mmol/L, lactate 5.5 mmol/L, bicarbonate 17 mmol/L and glucose 13.6 mmol/L. Other values were normal. A percutaneous coronary intervention was performed with a successful revascularisation and stent implementation of partly occluded left anterior descending and circumflex arteries. A one-chamber cardioverter-defibrillator was implanted and he was discharged to a local hospital for follow-up on day 11, with full neurological recovery. | Cardiology |
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