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Bilateral medullary syndrome (BMS) is an extremely rare and devastating neurological disorder resulting from ischemia or infarction of the medulla oblongata. This case report presents two unique instances of BMS, both leading to fatal outcomes. Case 1 describes a 70-year-old male with a history of systemic hypertension who presented with limb weakness, slurred speech, and dysphagia. An MRI revealed a heart-shaped infarct in the medulla, confirming the diagnosis of BMS. Despite medical intervention, the patient developed quadriplegia and respiratory failure due to aspiration pneumonia and ultimately succumbed to his condition. Case 2 involves a 40-year-old male with poorly controlled diabetes and hypertension, presenting in an unresponsive state after a suspected seizure. MRI findings confirmed bilateral medial medullary stroke. The patient's condition deteriorated in the intensive care unit (ICU), complicated by a urinary tract infection and systemic inflammatory response syndrome (SIRS), leading to his demise. These cases underscore the complexity and severity of BMS, highlighting the need for prompt diagnosis and multidisciplinary management. The heart-shaped infarct seen in Case 1 serves as a radiological hallmark, while Case 2 emphasizes the importance of identifying underlying risk factors such as protein C deficiency. Despite advanced imaging techniques and supportive care, the prognosis for BMS remains poor, with high mortality rates. Further research into novel therapeutic approaches is warranted to improve outcomes in this rare and challenging condition., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lankapothu et al.)

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a rare autoimmune vasculitis that primarily affects small to medium-sized blood vessels, typically involving the respiratory tract and kidneys. However, central nervous system involvement, particularly in the form of pachymeningitis, is an exceptionally rare presentation. This case report details a 55-year-old female who presented with pachymeningitis as the initial manifestation of GPA. The patient exhibited non-specific symptoms, including ear pain, voice changes such as hoarseness of voice, and dysphagia, suggestive of neurological deficits affecting lower cranial nerves IX, X, and XII. Diagnostic imaging, particularly MRI, revealed characteristic smooth dural thickening and enhancement, suggesting an inflammatory etiology. Laboratory investigations, including positive cytoplasmic-antineutrophil cytoplasmic autoantibody and anti-proteinase 3 antibodies, confirmed the diagnosis of GPA. The patient was treated with high-dose corticosteroids and mycophenolate mofetil, followed by cyclophosphamide due to a relapse, resulting in significant improvement in her condition. This case underscores the importance of considering GPA in the differential diagnosis of pachymeningitis and highlights the diagnostic challenges posed by its nonspecific symptoms. Early recognition and a multidisciplinary approach are crucial for effective management and prevention of severe neurological complications. The report also emphasizes the need for adherence to treatment regimens to avoid relapses and manage the disease effectively., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lankapothu et al.)

Immunoglobulin (Ig)A nephropathy, also known as Berger's disease, is characterized by IgA deposits in the kidney's mesangium and can lead to serious outcomes, including rapidly progressive glomerulonephritis. While Hepatitis C virus (HCV) infection is commonly associated with liver involvement, it is also linked to various renal pathologies, including membranous nephropathy and membranoproliferative glomerulonephritis. However, IgA nephropathy secondary to HCV is rare. This case study involves a 24-year-old male with a known history of untreated Hepatitis C, who presented with hematuria and foamy urine. Laboratory findings revealed increased levels of serum creatinine and urea, significant proteinuria, and a high HCV RNA viral load. A renal biopsy confirmed the diagnosis of IgA nephropathy with strong IgA and C3 deposits observed on immunofluorescence. Treatment with angiotensin receptor blockers and antiviral therapy led to substantial symptomatic improvement and stabilization of renal function. This case underscores the critical importance of considering IgA nephropathy in the differential diagnosis of renal complications in HCV-infected patients. Early detection and treatment of Hepatitis C are vital, as timely intervention can markedly enhance patient outcomes and mitigate the risk of serious complications. A heightened awareness of the potential renal implications of HCV emphasizes the urgency of proactive monitoring and swift management to safeguard kidney function and overall health., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kakumani et al.)

Xanthogranulomatous pyelonephritis (XGP) and Plummer-Vinson Syndrome (PVS) are two rare disorders that pose considerable diagnostic difficulties mainly because their signs overlap and are multifaceted. XGP is a severe form of pyelonephritis imitating cancer, whereas PVS is defined by dysphagia, iron deficiency anemia, and esophageal webs. This article presents the case of a 53-year-old female with a previous history of renal calculi and multiple transfusions who presented with dysphagia, flank pain, and hematuria. Findings from investigations showed severe anemia, a renal lesion suggesting malignancy, and GI findings pointing to the presence of PVS. The coexistence of XGP and PVS in this patient highlights the need for careful differential diagnosis and the importance of a multidisciplinary approach in managing patients with rare overlapping syndromes. Furthermore, this example shows how chronic infection, malnutrition, and their potential for leading to neoplasms connect. In summary, one should recognize that the possibility these two conditions can coincide is paramount for accurate diagnosis and effective management. Lastly, this case demonstrates that comprehensive assessment can only be achieved through coordinated care addressing both direct effects as well as secondary complications due to such uncommon diseases., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kakumani et al.)

Background: Acute chest pain is a common and challenging clinical presentation, necessitating rapid and accurate differentiation between potentially life-threatening etiologies like acute coronary syndrome (ACS) and acute myocarditis. The Salzburg Myocarditis Score (SMS), designed to aid in the early detection of myocarditis, offers a structured approach to this diagnostic challenge. However, the lack of a reliable clinical score for differentiating between these two conditions has been highlighted in recent literature, particularly in the context of limitations in using troponin levels alone for myocarditis diagnosis., Objective: This study aimed to assess the diagnostic accuracy of the SMS for differentiating ACS and myocarditis in adult patients presenting with acute chest pain at Saveetha Medical College, Chennai, India., Methods: A retrospective observational cohort study was conducted involving 100 consecutive patients presenting with acute chest pain. The SMS was calculated for each patient, and the final diagnoses of ACS or myocarditis were confirmed through comprehensive cardiac imaging (echocardiography or cardiac MRI) and additional biomarker analysis, following recommendations from established guidelines. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and a chi-square test were employed for statistical analysis., Results: Among the 100 patients, 60 were diagnosed with ACS, and one was diagnosed with myocarditis. The SMS demonstrated high sensitivity (84.09%) and specificity (88.76%) for ACS, aligning with previous research findings. However, for myocarditis, the sensitivity was notably lower (25.81%), while specificity remained high (95.12%), consistent with concerns raised about the limitations of the score in identifying myocarditis. The PPV and NPV for ACS were 60% and 100%, respectively, while for myocarditis, the PPV and NPV were 2.5% and 100%, respectively. A chi-square test revealed a significant association between SMS predictions and the final diagnosis (p<0.001)., Conclusion: The SMS is a valuable tool for identifying ACS in patients with acute chest pain. However, due to its low sensitivity for myocarditis, additional diagnostic tests, such as cardiac MRI, are crucial when myocarditis is suspected, despite a low SMS., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of Saveetha Medical College issued approval 829/03/2024/PG/SRB/SMCH. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lankapothu et al.)

Bullous pemphigoid is an autoimmune blistering disorder predominantly affecting the elderly, with rare systemic complications, including cardiac involvement. This case study presents a 46-year-old female with a history of arterial hypertension who developed complete heart block (CHB) associated with bullous pemphigoid. The patient initially presented with bilateral lower limb swelling and discoloration, later diagnosed as bullous pemphigoid following the appearance of characteristic skin lesions. Concurrently, she was found to have asymptomatic bradycardia, with an electrocardiogram confirming CHB. After ruling out other causes of heart block, a dual-chamber pacemaker was implanted, and the patient was treated with immunosuppressive therapy to control the autoimmune blistering disorder. This case highlights the rare but significant association between bullous pemphigoid and CHB, emphasizing the importance of multidisciplinary care and timely intervention in managing such complex cases., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kakumani et al.)