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Introduction Involvement of the large vessels is rarely reported and poorly understood in cases of Corona virus disease-19 (COVID-19). The aim of this study is to present a series of cases with large vessel thrombosis (LVT). Methods This is a multicenter prospective case series study. The participants were consecutive in order. All the patients were diagnosed as cases of COVID-19 with documented LVT were included in the study. Large vessels were defined as any vessel equal or larger than popliteal artery. The mean duration of follow up was 4 months. Results The study included 22 cases, 19 (86.4%) cases were male, 3 (13.6%) patients were females. The age ranged from 23 to 76 with a mean of 48.4 years. Four (18.2%) cases had pulmonary embolism confirmed by IV contrast enhanced chest CT scan. All of the cases showed pulmonary parenchymal ground glass opacities (GGO) and high D-Dimers (ranging from 1267 to 6038 ng/ml with a mean of 3601 ng/ml). Conclusion COVID-19 is a hidden risk factor of LVT that may endanger the patient's life and lead to major amputation. Despite therapeutic anticoagulants still all COVID-19 patients are at risk for LVT, a high index of suspicion should be created and with minimal symptoms surgical consultation should be obtained., Highlights • Involvement of the large vessels is rarely reported in COVID-19. • It may endanger both limb and life of the patients. • In the current report, vessel thrombosis discussed in 9 COVID-19 patients.

Chylothorax is the accumulation of chyle in the pleural cavity that typically contains a high concentration of triglycerides. Blunt chest trauma is a rare cause. The aim of this study is to review all of the reported cases of chylothorax caused by blunt chest trauma. Available databases were explored systematically for the condition and the eligible papers were included. The literature search revealed 30 studies with 39 cases, 72.3% of the cases were male, and 21.7% of the patients were female. The age range varied between 4 and 75 years with a mean age of 35.8 years. All of the patients were diagnosed after fluid sampling from the pleural fluid by thoracentesis and/or chest tube insertion. About 71.4% of the patients were treated successfully by conservative management: others (28.6%) were managed surgically. Although it is a rare condition, persistent milky drainage after blunt chest trauma should raise the suspicion of chylothorax. Pleural fluid sampling is the cornerstone of the diagnosis. In the majority of the cases, conservative treatment is quite enough. Surgery is indicated whenever non-operative measures failed.

Introdcution Cardiac echinococcosis is a zoonotic parasitic infection that necessitates a high index of suspicion in endemic areas. The purpose of this study is to introduce different clinical scenarios of four cases in two major cardiac centers. Methods A retrospective, case series study, conducted in three centers for the last two years. Addressing each case separately in regard to presentation and management. Results Four cases have been reported, three patients were female 75% and one patient was male 25%. Age ranged from 27 to 32 years. All the patients 100% had dyspnea as their main first presentation, one patient (25%) presented as pulmonary embolism with three attacks of hemoptysis. One patient (25%) had an attack of convulsion 25%. Different segments of the heart were involved, Left ventricle was involved in 50%, Right ventricle in 25%, combined pulmonary and pericardial involvement in another 25%. Median Sternotomy with the cardioplegic arrest was performed in three patients 75% and Posterolateral thoracotomy was the approach in one case 25%. Conclusion Cardiac Hydatid cyst is a sparse yet potentially perilous clinical entity. Early surgical intervention is the modality of choice might halt unfavorable consequences.

Highlights • Hydatid disease is an infestation by Echinococci species in the endemic areas. • Liver and lungs are the main two affected organs. • Hydatid disease of thyroid is an extreme rare variant of the condition • In this report, the details of thyroid hydatid disease occurring in a middle age female with brief literature review, Introduction Although hydatid cysts can affect any organ in the body, reports regarding affection of thyroid gland are scanty in the literature. This report aims to present a case of thyroid hydatid disease with literature review. Case report A 48-year-old female presented with painless anterior neck mass of about 2 year duration. There was an ill-defined, central anterior neck mass, with a smooth surface and mobile with deglutition. Ultrasound of the thyroid gland revealed an enlarged left lobe of thyroid gland due to well defined thick wall cystic nodule. The patient underwent left thyroid lobectomy under general anesthesia, the pathology report revealed hydatid cyst of thyroid gland. Discussion Liver and lungs are often the end destination for hydatid cysts, while other places like mediastinum, diaphragm, cardiac, smooth and skeletal muscles, abdominal and chest walls are rarely involved. In this case, the cyst affected even a rarer organ which was the left lobe of thyroid gland. Most of the time the disease is asymptomatic and is found accidentally, yet depending on the site and size of the cysts, symptoms can occur. Conclusion Hydatid disease of thyroid gland is an extremely rare condition. The main presenting symptom is swelling. Operation under general anesthesia is the only modality of treatment.

Introduction and importance For many years, thoracotomy has been considered as the standard approach for thoracic injuries. The aim of the current paper is to report a successful use of video assisted thoracoscopic surgery (VATS) as the first line approach for the removal of a bullet retained deep in the lung parenchymal tissue. Case presentation A 46-year-old male presented with a vague pain in the chest at the site of a penetrating bullet injury 26 years prior. Chest and native chest Computed Tomography scan (CT scan) showed a 22 mm foreign body inside the substance of the left lower lobe in the anterior segment. Decision was made to remove the foreign body using VATS. The surgery was performed through an uni-port. The left lower lobe was explored and the foreign body was found within the anterior segment. It was removed and the defect was sutured using Vicryl 2/0. Clinical discussion Although VATS has been established to be an accurate evaluating technique for direct evaluation of the chest wall, lung parenchyma, mediastinum and diaphragm, along with its effectiveness in successfully treating a variety of conditions, its use in thoracic trauma is still not well defined. Conclusion This report supports the use of VATS as an effective and minimally invasive approach in the removal of foreign bodies in lung parenchyma., Highlights • Video-assisted thoracoscopic surgery (VATS) has been suggested as a lessor invasive procedure. • It's use in thoracic trauma remains controversial. • Loss of tactile sensation is a major obstacle. • In this report, removal of a retained bullet in the lung parenchyma using VATS has been discussed.

Introduction Desmoid tumor is an uncommon tumor with variable spectrum ranged from being a locally lesion to an aggressive and destructive one. The current case aims to report a rare condition of desmoid type fibromatosis of the breast. Presentation of case A 59-year-old female presented with a right breast mass for 9-months. Mammography showed a small speculated iso-hyper dense mass, just anterior to the pectoralis muscle measuring about 15 mm (M5) in longest axis. Ultrasound examination revealed an irregular mass with internal vascularity and posterior shadowing in the right breast with a single borderline lymph node (25 ∗ 14 mm of 4 mm cortex). Wide local excision with sentinel axillary lymph nodes biopsy was performed. Histopathological examination of the specimen confirmed the diagnosis of desmoid type fibromatosis of the breast. Discussion The etiology of this tumor is unknown, however, physical, hormonal and genetic factors have a significant role in the development of desmoid tumor. Conclusion Desmid type fibromatosis of the breast is an uncommon, benign, locally aggressive fibroblastic tumor with lack of metastatic potential, it may present with features of malignancy., Highlights • Desmoid tumor is an uncommon tumor. • The occurrence of desmoid tumor in the breast is even rarer. • Differentiation from malignant disease is a challenging task. • The current report discusses a case of desmoid type fibromatosis of the breast.

Background Pin inhalation is an accidental entry of a pin into the respiratory passages. This study aims to shed the light on pin inhalation as a hazard and show the magnitude of such preventable thoracic problem and determine the safest method of management. Patients and methods This is a retrospective single center case series, conducted during 18 month period from January 2016 to April 2017, All patients with pin inhalation had been collected and analyzed according to the age, gender, time between aspiration to presentation and symptoms and signs, number of attempts, bronchoscopic or open removal of the pins with complications. Results The total number of patients in this study was 162. The mean age was 11years. Pin inhalation accident was more common in patients less than 10 years in males and less than 20 years in females. The most common gender was female (73%). The most common presenting symptom was cough (54%). The left tracheobronchial tree was the most common site for pin lodgment 107 (67.3%) followed by the right side 23 (14.4%). The majority of the pins were extracted in one piece (94%). Thoracotomy was done in one patient, no death reported. Conclusion Sharp pin inhalation is a serious hazard and can have lethal outcome. History is the major parameter to start the diagnosis of pin inhalation and radiography is the gold standard to confirm the diagnosis., Highlights • The number of patients presenting with foreign body aspiration is increasing. • The majority of deaths occur in children under the age of three years. • Scarf pin inhalation is a relatively frequent condition in the Muslim living countries. • In this paper, a series of cases with scarf pin foreign body inhalation was presented.

Introduction Hurthle cell carcinoma (HCC) is a rare type of thyroid cancer while Hodgkin's lymphoma (HL) is an uncommon cancer of the lymphocytes. The synchronous occurrence of HCC and HL in a single person has not been described in the literature. This report aims to present the first case of synchronous HCC and HL. Case report A 31-year-old male presented with a right side neck swelling for three months. Laboratory findings revealed elevated thyroglobulin (286.7 ng/ml). Ultrasound (US) examination showed several enlarged lymph nodes (, Highlights • Hurthle cell carcinoma is a rare, well-differentiated, and aggressive thyroid cancer. • Hodgkin's lymphoma is a cancer of the lymphocytes, associated with good prognosis. • This report presents the first case of synchronous Hurthle cell carcinoma and Hodgkin lymphoma.

Introduction Coronavirus disease 2019 (COVID-19) has emerged as severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Recently, various complications have been reported. The aim of the current study is to report a rare case of transverse myelitis after recovering from COVID-19. Case report A 34-year-old lady, presented with inability to walk for one day duration due to the lower limb weakness. After two weeks from the recovery of COVID-19; she developed progressive intermittent leg pain, paresthesia and weakness on both sides. Brain and cervical MRI showed evidence of a short segment inflammatory enhancing lesion at upper cervical region (at C1 level). The patient was treated conservatively. Discussion Transverse myelitis has many different causes, it occurs as an autoimmune phenomenon post-infection and vaccination, or it may result from direct infection or acquired demyelinating disease like multiple sclerosis. Conclusion Although it is a sporadic finding, SARS-CoV-2 can cause transverse myelitis. The condition responds to medical therapy., Highlights • Coronavirus disease 2019 has emerged as severe acute respiratory syndrome coronavirus 2. • Transverse myelitis (TM) is a very rare neurological complication of COVID-19 disease. • In this report a rare case of post-COVID19 transverse myelitis presented.

Introduction Subcutaneous emphysema is an extremely rare complication after lobectomy. The current study aims to report a case of lung cancer developing extensive subcutaneous emphysema after lobectomy. Case presentation A 73-year-old man presented with dyspnea and cough for one month duration associated with wheeze and sputum. He was a chronic heavy smoker (100 pack/year). Work up revealed squamous cell carcinoma. Although he had poor pulmonary function tests, he underwent left upper lobectomy. On the fifth postoperative day, he was discharged from the hospital as there was no air leak and the lung remained expanded 15 hours after clamping of the thoracostomy tube. Two days later, the patient developed generalized subcutaneous emphysema. The patient was re-admitted to the hospital and a thoracostomy tube was inserted. The lung expanded upon insertion while the subcutaneous emphysema remained the same and even slightly increased over night. A 3 cm incision was made at the left infra-clavicular area and a negative pressure applied to it. The subcutaneous emphysema completely subsided a few hours after this intervention. Discussion Because of the benign course, the majority of cases of subcutaneous emphysema (mild to moderate) only need nonoperative management alongside treatment of the predisposing factors. These patients may need nothing other than bed rest, good analgesia, supplemental oxygen, and reassurance. Conclusion Subcutaneous emphysema after lobectomy prolongs hospital stay. It mainly occurs in cases with poor pulmonary function tests, steroid use, and those with extensive adhesion., Highlights • Subcutaneous emphysema is one of the complications following thoracic surgery. • Subcutaneous emphysema might be a benign and self-limiting condition. • It might be a serious condition that ends with respiratory failure and death. • In this report, a case of lung cancer developing subcutaneous emphysema after lobectomy discussed.

Introduction and importance: Giant cell tumors of the tendon sheath in children have rarely been reported in the literature. This study aims to present a case of giant cell tumors of the tendon sheath on the big toe of a 5-year-old child. Case presentation A 5-year-old girl presented with a painless swelling over the dorsal aspect of right big toe for 2 weeks. Physical examination revealed non-tender rubbery like swelling over the dorsal aspect of the right big toe. Ultrasound scan of the swelling showed a 17 × 7 mm oval-shaped subcutaneous hypoechoic lesion. Magnetic resonance imaging showed evidence of 20× 8 mm well-defined fusiform soft tissue lesion scalloping the bone. Under general anesthesia, the mass was totally excised. Microscopic sectioning showed a mixture of fibroblasts and histiocyte like cells associated with multinucleated giant cells in the vascular connective tissue stroma with the definite diagnosis of the giant cell tumor of the tendon sheath. Discussion These tumors mostly compose of several types of cell like synovial, siderophages, foam, inflammatory and multinucleate giant cells. The major etiological factors that induce development of this tumor could be traumatic, inflammatory, metabolic or neoplastic disease. Conclusion although it is a sporadic finding, giant cell tumors of the tendon sheath might affect the lower limb in children. Complete excision is the main modality of treatment., Highlights • A giant cell tumor of tendon sheath is a painless benign soft tissue tumor. • There are only a few cases that have been reported in the feet of children. • In this study a case of giant cell tumor of tendon sheath in a 5-year-old child discussed.

Introduction and importance The thymus is a primary lymphatic organ within the mediastinum that plays an essential role in developing and maintaining cell-mediated immunity. The current study aims to report a case of intra-tumoral osseous metaplasia of the thymus gland, which is an infrequent phenomenon. Case presentation A 43-year-old male presented with weakness and easy fatigability for 2 months. The patient had an elevated anti-acetylcholinesterase antibody (19.5 nmole/L). Magnetic resonance imaging showed a round, capsulated, enhanced mass in the anterior mediastinum measuring 5.5 × 3.5 cm, suspecting thymoma. The patient underwent plasmapheresis three times in one week, under general anesthesia, in a supine position, sternotomy was performed, and the thymoma was totally resected. Discussion Thymomas are known to occur in all age groups with the peak of nearly between 35 and 70 years with the median age of 54 years. The sex distribution of thymoma is approximately equal with slight predilection of women in old age groups. However, among all reported cases of thymomas with osseous metaplasia, the majorities are female. The significance of this ossification is still to be clarified. Conclusion Although it is rare, secondary changes in thymoma may occur including calcification and ossification., Highlights • The thymus is dedicated to the growth of the immunocompetent T-cells. • Thymoma is an uncommon tumor of the thymic epithelium. • Thymoma with osseous metaplasia is a sporadic condition.

Highlights • A variety of methods for abdominal wall closure have been described. • Closure of a defect by myocuteous thigh flap is a viable option. • In this report, bilateral anterolateral myocutaneous thigh flaps has been discussed., Introduction Closure of the abdominal wall defect by myocuteous thigh flap is an option. The aim of this paper is to report a case of abdominal wall defect covered by bilateral anterolateral myocutaneous thigh flap. Case report A 45-year-old female presented with a large defect in the anterior abdominal wall. It was decided to cover the wound with bilateral anterolateral myocutaneous thigh flap as the defect was so large to be filled with a single flap. Under general anesthesia, a flap was elevated lateral to a line joining mid inguinal point to the lateral epicondyle, the flap was rotated under inguinal skin and sutured to the defect. The procedure was repeated for the contralateral side two weeks later. Discussion Lower abdominal wall defects can be reconstructed by the use of the combined technique of sublay technique, intraperitoneal mesh placement, pedicled great omentum flap and rotation skin graft, also tensor fascia lata has been proven to be a safe and versatile flap. Conclusion Bilateral anterolateral myocutaneous thigh flap is practical whenever indicated. It is best suited for covering of the lower abdominal defects.

Highlights • Extraskeletal chondroma is a benign, slow-growing cartilaginous tumor arising from tenosynovial sheaths. • It may present challenges for the treating physician. • This article reports and discusses a case of extraskeletal chondroma affecting upper thigh., Introduction Extraskeletal chondroma (ESC) is a benign, slow-growing cartilaginous tumor arising from tenosynovial sheaths. The aim of this article is to report and discuss a case of ESC affecting upper thigh. Case report A 41-year-old male presented with a swelling in the medial aspect of the left thigh. On clinical examination, there was a 10 × 15 cm non-tender, hard, ill-defined mass in the medial aspect of the left upper thigh. Ultrasound showed a large well defined thick wall mass, located inside gracillis or adductor muscles. Magnetic resonance imaging showed a large well defined mass involving the adductor compartment of the upper thigh. The patient underwent wide local excision under spinal anesthesia. The histopathological examination of the specimen revealed binucleated chondrocytes with dots of calcification confirming ESC. Discussion There are many theories trying to explain the origin of ESC, as some authors think that it originates from the pluripotent cells of the tenosynovium, while others state that it may be derived from metaplasia of the tendon sheath. In this case, the lesion was completely surrounded by muscle fibers away from the nearby tendons. Conclusion Extraskeletal chondroma is a rare benign lesion, although mostly affect the upper extremities, it can be found anywhere in the body, histopathological examination of the specimen is the diagnostic method of choice.

Highlights • There is a considerable debate regarding implant or autologous reconstruction of breast. • Single session reduction mammoplasty with contralateral autologous reconstruction is feasible. • A novel procedure has been presented. • Dividing the contralateral breast and creating a myocutaneous flap for reconstruction., Introduction The aim of this paper is to introduce a novel procedure for concomitant contralateral reduction and ipsilateral reconstruction mammoplasty by dividing the contralateral breast and creating a pectoralis myocutaneous flap for reconstruction. Presentation of case A 34-year-old female, with a history of left side mastectomy presented for reconstruction. Under general anesthesia, the scar of the previous operation was resected in an elliptical shaped incision, the right breast was divided in middle, leaving the flap (pectoralis myocutaneous flap) with pectoralis branch of thoracoacromial artery. The superiomedial part of right breast (the flap) was rotated under the bridge of intermammary skin into the left incision. Ten days after the operation, the flap was viable and healthy. Discussion The aim of breast reconstruction is to provide psychosocial support and improve quality of life in the long term by restoring the shape of the breast surgically. New techniques have emerged constantly, and each comes with its list of advantages and risks. The benefits of reconstruction are clear, yet often it is not found as a part of breast cancer treatment routinely. Conclusion In single session reduction mammoplasty in one breast and using the resected piece as a flap to reconstruct the contralateral breast is possible whenever indication.

Highlights • DVT presentation may be an atypical manifestation of an occult malignancy. • Thorough search and work up for idiopathic DVT is mandatory. • The aim of this article is to report a case of lymphoma presented as DVT with brief literature review., Introduction Idiopathic deep venous thrombosis is a relatively common clinical finding. The aim of this article is to report and discuss a case of lymphoma presented as DVT in line with SCARE guidelines with brief literature review. Case report A 19-year-old male presented with right lower limb swelling for two week duration. Examination showed pitting leg edema with warm tense calf. Hematological investigations showed lymphopaenia. Duplex ultrasound showed DVT of right common femoral vein with inguinal lymphadenopathy. Computed tomography showed inguinal lymphadenopahthy. Histopathological examination of lymph node specimen confirmed the diagnosis of Non-Hodgkin’s Lymphoma (Burkett's type). Discussion Several series have documented a significantly higher risk of malignancy in patients with presumed idiopathic DVT. Among such patients, 7.6% have been noted to have a malignancy during follow-up; the incidence of occult malignancy diagnosed within 6–12 months of an idiopathic DVT is 2.2–5.3 times higher than that expected from general population estimates. Conclusion Idiopathic DVT regardless of age should be approached seriously with a special consideration to malignancy, lymphoma could present only with DVT.

Highlights • Phytobezoar is described as an impacted indigested or incompletely digested vegetable and fruit fibers. • Bezoar is a rare cause of gastric outlet obstruction. Being multiple and giant is even rarer. • The aim of this study is to report a case of unusual gastric outlet obstruction by two giant bezoars., Introduction Phytobezoar which is described as an undigested or incompletely digested food. It is an odd cause of gastric outlet obstruction (GOO). The aim of this study is to present and discuss a case of GOO caused by multiple giant bezoars. Case report A 24-year-old female, presented with abdominal pain and vomiting (non-bilious) with negative past history. Examination and investigations revealed multiple giant bezoars requiring emergent surgical intervention. An exploratory laparotomy was conducted. Two giant bezoars were palpated in the stomach and removed through an anterior gastrotomy. Discussion Bezoars are regarded as rare benign causes of GOO. Bezoars can present with vomiting, nausea, and/or symptoms of GOO. Predisposing risk factors include delayed gastric emptying (as in case of diabetic mellitus) vagotomy, partial gastrectomy pyloroplasty, peptic ulcer disease, chronic gastritis, Crohn’s disease, and carcinoma of the gastrointestinal tract. The current case had phytobezoar without any known risk factor. Conclusion GOO caused by phytobezoar can occur in patients without history of previous gastric surgery or diabetes mellitus. Urgent laparotomy may be indicated.

Highlights • Zenker’s diverticulum is an acquired mucosal pulsion of the upper esophagus. • Post operative leak and infection could lead to a dilemma to both surgeon and patient. • We reported a case of Zenker’s diverticulum with a complicated postoperative course., Introduction Zenker’s diverticulum is an acquired mucosal pulsion of the upper esophagus. The aim of this paper is to report a case of Zenker’s diverticulum with a complicated postoperative course including infection by Acinetobacter baumannii causing diagnostic as well as management dilemma. Case report A 43-year-old male complained from dysphagia for three months. Barium swallow revealed Zenker’s diverticulum. Under general anesthesia, the small Zenker’s diverticulum was ligated and myotomy was done. He developed erythematous swelling at the site of the operation. The patient was taken to the operation theater. The esophagus was tested, no trace of leak was found. The patient developed cardiac arrest. He was admitted to the intensive care unit and remained there for twenty eight days. Bronchial wash culture showed Acinetobacter baumannii. The patient was on antibiotic, supportive treatment and enteral feeding through nasogastric tube. After recovery he was extubated and barium swallow was done which was normal and showed no signs of leak. Three months after the operation, the patient was completely normal. Discussion This case had a positive culture for Acinetobacter baumannii. It is commonly accounted for nosocomial infections. It has been documented as a serious threat worldwide because of the emerging prevalence of multidrug resistant. However, an inadequate understanding of A. baumannii pathophysiology and ecosystem confines the progress of alternative therapeutic policies. In the current case, it was not clear either leak or Acinetobacter baumannii was the cause of deterioration. Conclusion Both esophageal leak and infection with Acinetobacter baumannii are fulminant debilitating conditions that could be managed with conservative strategies.

Highlights • Sacrococcygeal PNS is the commonest variant of the condition. • However, it can occur in other areas like umbilicus, hand, scalp intermammary, suprapubic, nose, etc. • Infra mammary PNS is an extremely rare condition, with no previous report. • This study aims to present and discuss a case of PNS occurring in both infra mammary regions., Introduction Pilonidal sinus (PNS) is a chronic inflammatory perianal disorder that rarely occurs outside sacrococcygeal region. The aim of this study is to report an extremely rare case of bilateral inframammary PNS with brief literature review. Case report A 25-year-old female presented with a discharging sinuses in both inframammary region for two years. Examination showed multiple discharging sinuses with several centimeters of induration and tenderness. Under general anesthesia, complete excision of the sinuses with primary closure done. Histopathological examinations showed chronic foreign body granuloma surrounding hair shaft pictures consistent with PNS. Discussion Inframammary PNS has never been reported in the literature. As with intermammary PNS, in this case also it is associated with obesity and large breasts with tight brassieres. Diagnosis is usually clinical. In contrast to sacrococcygeal PNS, operation under general anesthesia is main treatment modality. Conclusion Pilonidal sinus of inframammary region is an extremely rare condition. High index of suspicion is required for diagnosis. Excision with primary closure is the definitive therapy.

Highlights • Sacrococcygeal area is the commonest site of PNS. • However, it could be found in other regions like hand, intermammary, suprapubic, umbilicus, nose etc. • Breast pilonidal sinus is an extremely rare variant of PNS. • The aim of this report is to present a case of pilonidal sinus occurring in breast., Introduction Breast pilonidal sinus is an extremely rare variant of the condition, the report aims to present a case of pilonidal sinus occurring in the breast. Case presentation A 35-year-old female presented with a left breast discharging lesion for a 5-month duration. There was a local redness with multiple discharging sinuses on her left breast at 3–5 o’clock, 3–4 cm away from the nipple. The discharge was serosanguinous in appearance. The lesion was excised totally with primary closure under general anesthesia. Histopathological examination was consistent with pilonidal sinus. Discussion For atypical pilonidal sinus disease, surgery is the modality of choice but regarding sacrococcygeal pilonidal sinus, non-operative treatment begins to grow. The cardinal risk factors for recurrence and complications are male gender, family history, tobacco smoking, obesity, size of sinus, poor personal hygiene and surgical methods. Conclusion Breast pilonidal sinus is an extremely rare variant of the condition. It should be suspected on clinical examination. Surgical excision is the definitive treatment strategy.

Highlights • Total thyroidectomy represents one of the commonest procedures performed for thyroid diseases. • Ischemic tracheal necrosis an extremely rare complication of thyroidectomy. • In this paper is to report a rare case of trachea-cutaneous fistula after total thyroidectomy., Introduction Total thyroidectomy represents one of the commonest procedures performed for thyroid diseases. The aim of this paper is to report a rare case of tracheocutaneous fistula after total thyroidectomy. Case report A 44-year-age female presented with left side neck swelling for 2 month duration. Neck ultrasound showed a well-defined left thyroid nodule (25 × 15 × 14 mm) with features highly suggestive of malignancy, under general anesthesia total thyroidectomy was performed. On the third postoperative day, the patient came back with neck swelling especially during speaking, there was subcutaneous emphysema, wound opened with residual air leak. Under local anesthesia, the wound opened, there was 10 × 10 mm opening in the anterior aspect of trachea, a tracheostomy was inserted, the patient was sent home after decannulation with an opening in the anterior neck. Twenty days later the tracheal opening closed spontaneously. Discussion The possibility of a tracheal wall ischemic necrosis is plausible due to cautery use. Some autopsy studies have demonstrated that small branches of inferior thyroid artery form the main blood supply of the upper segment of trachea. These fragile branches have a lateral entry point that can be damaged readily leading to ischemia and necrosis. Conclusion Ischemic tracheal necrosis, although very rare, is possible after total thyroidectomy, minimal use of electro-cautery is advised whenever possible.

Highlights • Enterobius vermicularis is one of the commonest parasitic infestations worldwide. • Its association with acute appendicitis remains controversial. • It is very rarely encountered during appendectomy. • In this report, a case of acute appendicitis caused by Enterobius vermicularis has been presented., Introduction Enterobius vermicularis is one of the commonest parasitic infestations worldwide but its association with acute appendicitis remains controversial. It is very rarely encountered during appendectomy. The aim of this paper is to report a case of acute appendicitis caused by Enterobius vermicularis. A 23-year-old housewife presented with a right lower abdominal pain for the past 8 h. Clinical examination revealed right iliac fossa tenderness upon palpation and rebound tenderness upon release. The patient was diagnosed as a case of suspected acute appendicitis. The patient was anesthetized and intubated. Delivery of the vermiform appendix done through right grid iron incision. Intra operatively an inflamed appendix obstructed by Enterobius vermicularis was noted. Conclusion Enterobius vermicularis can habit the appendix and induce the signs and symptoms of A.A with or without actual histopathological acute appendicitis. The treatment of choice is surgical resection of the appendix.

Introduction Scalpel blades and suture needles are the two most perilous nonhollow-bore gadgets causing percutaneous injuries in hospitals. The prevalence of these injuries and type of injuries in the Kurdistan federal region is not known. Patients and methods a retrospective, multicenter study, enrolling four medical personnel suffering from significant blade injuries necessitating surgical intervention. Results This study reports a series of four cases who had critical injuries caused by surgical blades. These injuries occurred in the femoral artery, radial artery, index figure and thumb. Surgical intervention was performed under general anesthesia in three cases and under local anesthesia in one case. The injuries left long term sequelae in two cases. Conclusion Accidental scalpel injury is a continuous and neglected threat to health care staffs especially surgeons and could be tragic and both time consuming and financially exhausting. Elucidating the circumstances and risk factors resulting in such injuries is important in order to develop preventive guidelines and to increase awareness about this relatively hidden yet tragic event.

Introduction Co-presentation with both coronary and valve diseases is increasing as the age of the individuals referred for coronary artery intervention rises. The study aims to report a single center experience in combined coronary artery bypass grafting and aortic valve replacement (CABG-AVR). Methods This is a retrospective study from January 2014 till January 2019 in a single center. Inclusion criteria included those patients that underwent combined coronary and aortic valve procedure in a single operation. The data were collected from the hospital registry. All patients underwent preoperative coronary angiography, transthoracic echocardiography (TTE), Doppler study was performed for those patients with previous stroke and peripheral vascular diseases. The cases were followed up for a mean duration of 2 years. Result The study included 62 patients, 38 of them were males, the mean age was 57 years. Prosthetic mechanical valves were inserted in all of the cases, left internal mammary artery (LIMA) was harvested in all the cases, 24 patients (38.7%) had single graft, 26 cases (41.9%) two grafts, and 12 (19.3) had three grafts. The mean cross clamp time was 148.9 min and mean cardiopulmonary bypass (CPB) time was 187 min. The overall mortality rate was 6.4% (4 patients). Conclusion With maximum myocardial protection and minimum cross clamp and CPB time and meticulous technique, the outcome of combined CABG-AVR is comparable with isolated CABG or isolated AVR.

Highlights • Primary diaphragmatic lipoma is a very rare condition. • It may present with logically unrelated signs and symptoms. • The aim of this paper is to report a case of diaphragmatic lipoma presenting as a case of diaphratmatic hernia., Introduction Primary diaphragmatic lipoma (PDL) is a very rare condition. The aim of this paper is to report a case of diaphragmatic lipoma presenting as a case of diaphratmatic hernia with a brief literature review. A 73-year-old female presented with chronic dry cough for three month duration. The patient was stable, there was no significant finding on general, chest and abdominal examination. Chest-x-ray showed vague shadow above the left dome of the diaphragm. Computed tomography scan (CT scan) of the chest revealed a round mass with features consistent with either diaphragmatic hernia or malignancy. The patient underwent resection under general anesthesia and histopathological examination confirmed the diagnosis of PDL. Conclusion Although PDL is a benign condition, in most of the time, it needs aggressive management because of the possibility of malignancy or other critical diseases.

Highlights • Lipoma is the most frequent soft tissue tumor in adults. • Its occurrence in the retroperitoneal region is extremely rare. • It presents with various clinical scenarios. • We present a case of retroperitoneal lipoma with a brief literature review., Introduction lipoma is the most frequent soft tissue tumor in adults. Its occurrence in the retroperitoneal region is extremely rare. The aim of this study is to report a case of retroperitoneal lipoma with a literature review. Presentation of case A 34-year-old female presented with abdominal distension and severe back pain for one year duration. She also reported weight loss and constipation. The examination revealed asymmetrical abdominal distension and everted umbilicus. There was a big irregular mass occupying the whole abdomen reaching into the xiphisternum, firm in consistency, smooth surface, and well defined borders. Abdominal ultrasound demonstrated a large retroperitoneal heterogeneous mass. Computed tomography (CT) scan showed a large well defined hyperechoic mass with fibrous septa extending from the left ovary up to the diaphragm. Exploratory laparotomy revealed a giant clearly demarcated fatty tumor adherent to the retroperitoneal fatty tissues. The histopathological examination of the specimen confirmed the diagnosis of the retroperitoneal lipoma. Discussion Retroperitoneal lipomas have been reported in various age groups; namely children, middle and old age patients. Based on the characteristic radiological features of the tumor, enormous diagnostic work-up is not justified. Conclusion Retroperitoneal lipoma is a very rare variant of lipoma, presents with various signs and symptoms that may be misleading. Radiologic imaging especially CT scan is the diagnostic tool of choice. Surgical resection is the main modality of management.

Introduction Intrathyroidal parathyroid is a parathyroid completely embedded within the thyroid parenchyma. The aim of this study is to present a case with co-occurring bilateral normal intrathyroidal parathyroid glands and papillary thyroid carcinoma (PTC). Case presentation A 35-year-old female presented with anterior neck swelling for a duration of a week. The patient was generally asymptomatic. Ultrasound showed mild enlargement of the thyroid gland, and a well-defined solid nodule measuring 9 ∗ 8 ∗ 7 mm in the left lobe with malignant characteristics. Laboratory findings were within normal limits. Fine needle aspiration of the nodule resulted in the diagnosis of PTC. The patient underwent total thyroidectomy. Histological examination confirmed the diagnosis of well differentiated multifocal bilateral PTC alongside two bilaterally located intrathyroidal parathyroid glands. Discussion The occurrence of normal ITP is exceedingly rare, and even rarer when simultaneous with other thyroidal lesions. It is theorized that inferior parathyroid glands arise from the third pharyngeal pouch, and during embryogenesis they might migrate to other anatomic locations. In this case, two bilateral normal ITP were present with PTC. Conclusion Normal ITP presents a diagnostic challenge due to their high insensitivity to current preoperative diagnostic techniques; hence, surgeons are required to carefully examine thyroid tissue during thyroidectomy when missing parathyroid glands are observed., Highlights • Intrathyroidal parathyroid is completely embedded parathyroid gland within the thyroid parenchyma. • The ectopic localization of parathyroid inside the thyroid is uncommon. • It is even rarer when synchronous with another thyroidal tumor. • In this study, a case of co-occurring bilateral normal ITP and papillary thyroid carcinoma is discussed.

Introduction and importance Lymph node metastasis is the most prominent prognostic factor in breast cancer. The aim of this paper is to report a case of contralateral axillary lymph node metastasis (CAM) which look like metachronous initially, but histopathologicaly confirmed as synchronous CAM. Case presentation A-44-year old female was a known case of left breast cancer five years prior to this presentation (T2,N2,M0, grade III, Triple negative, multifocal invasive ductal carcinoma). On follow up, multiple contralateral axillary suspicious lymph nodes were discovered. Fine Needle Aspiration Cytology from the lesion revealed grade III, Triple negative, invasive ductal carcinoma consistent with metastasis from the left invasive ductal carcinoma. Bilateral mastectomy and right axillary dissection were performed. The histopathological examination and immunohistochemistry showed left breast recurrent 0.5 cm grade III, Triple negative invasive ductal carcinoma. Discussion If a cancer is found in the contralateral axilla, three main potential sources should be considered: contralateral spread from the original breast tumor, metastasis from an occult primary in the ipsilateral breast, and metastasis from an extramammary site. Conclusion Although CAM in patients with breast cancer is an uncommon condition, it is still possible to occur. There is a controversy regarding the appropriate management., Highlights • Lymph node metastasis is the most prominent prognostic factor in breast cancer. • Ipsilateral axillary lymphnode metastasis is the most common site of involvement. • Contralateral axillary lymphnode metastasis is an unusual finding. • In this paper, a case of synchronous contralateral axillary lymph node metastasis has been discussed.

Introduction and importance Several complications after corona viral infection-19 (COVID-19) have been reported. The study aims is to present a case with post-covid-19 pulmonary fungal infection with antifungal resistance characteristics. Case presentation A 50-year-old male presented with hemoptysis, dyspnea, cough, fever, and rigor for 4-month duration. Three weeks before this complaint, he had cured of COVID-19. Investigations showed multiple ill-defined cavitary lesions involving the left upper lobe. The patient underwent a left upper lobectomy. The post-operative period was uneventful. Clinical discussion All studies of COVID-19 fungal infections reported occurrence during the COVID-19 infection, mostly 14 days after the appearance of COVID-19 symptoms. The case in the current study was a 50-year-old patient, who was previously diagnosed with COVID-19 for a period of 4 months. After a few days from his recovery, the patient developed dyspnea, cough, fever, and rigor again. Conclusion Pulmonary aspergillosis is a serious complication of COVID-19 patients that may not respond well to medical therapy. Pulmonary resection is the last and effective strategy to control the disease.

Introduction Mullerianosis is a sporadic condition of the urinary bladder. The study aims to present a case of mullerianosis with a brief literature review. Case presentation A 52-year-old lady presented with hematuria for one-year duration. A general urine examination showed microscopic hematuria. Abdominal and transvaginal ultrasonography revealed a soft tissue mass (13 * 10 mm) within the base of the urinary bladder. Cystoscopy showed 1.0 * 1.3 cm benign-looking mass bulging into the posterior bladder wall covered by a normal bladder mucosa. Transurethral resection was done. The histopathological examination was consistent with mullerianosis. Discussion Two hypotheses have been proposed; the first one (implantation theory) believing that at the time of pelvic surgery and caesarian delivery Mullerian tissues become implanted inside the bladder. The second theory (metaplastic theory) holds the probability of differentiation of Mullerian epithelium to endometrial, endocervical, and tubal components and proliferation in the bladder. Conclusion mullerianosis is a very infrequent entity that mainly affects the urinary bladder and is mainly reported in females during the reproductive period, medical and surgical treatment are both regarded as the management options., Highlights • Mullerianosis is an extremely rare condition of the urinary bladder. • Mullerian-derived components are endosalpinx, endometrium, and endocervix. • Clinical symptoms vary from dysuria, abdominal pain, hematuria and recurring renal colic. • In this study a case of mullerianosis is discussed.

Background Pilonidal sinus disease (PNS) is a disorder of the young population. The aim of this study is to analyze the risk factors associated with development of PNS in the secondary school students. Methods This case control study enrolled 189 participants, (Control group: 95 cases, case group: 94 cases). The inclusion criterion for the trial group was those secondary school students with PNS and age ranged between 16 and 20 years without the known risk factors of PNS. Result About 80 (42.3%) patients were male and 109 (57.7%) were female. Each group included 95 patients. There was no significant difference in both groups regarding basic features. Among the control group 36 (37.9%) participants were used to study while sitting on a hard place whereas among the case group 62 (66%) cases were used to study while sitting on a hard place, the difference was statistically significant (, Highlights • Pilonidal sinus disease is a disorder of the young population. • Several risk factors have been recognized like job, being hairy …. etc. • Studying for prolonged time has never being studied to cause PNS. • In this study, factors have been assessed to cause PNS in preparatory students.

Introduction Lymphedema affects the extremities of breast cancer patients post-surgical or radiation therapy. This study aims to report a case of primary lymphedema of breast. Case presentation A 41-year-old female presented with right breast swelling. It associated with hotness and intermittent mastalgia for the past 8 years. Ultrasound (US) examination showed diffuse trabeculate, skin thickening and edematous with normal glandular tissue. Magnetic resonance imaging (MRI) showed diffuse homogeneous parenchymal enhancements with diffuse tranecular and skin edema (high signal on Short-TI Inversion Recovery (STIR)). The result of the biopsy showed normal breast tissue and lymph node. Discussion The major risk factors of lymphedema are breast cancer surgery, radiation therapy, axillary lymph node dissection, length and location of breast incision, taking biopsy, trauma, wound infection. Forearm is the most common site of swelling. Primary lymphedema of the breast is a very rare condition without a known risk factor. Conclusion Although it is rare, primary lymphedema can affect the breast. US and MRI are necessary to exclude other pathologies. It is managed conservatively., Highlights • Lymphedema mainly develops in breast cancer patients post-operatively. • Usually affects the extremities and rarely occur in the breast • It is characterized by the accumulation of extracellular fluid. • In this paper, a case of breast lymphedema has been discussed.

Introduction Hydatid cyst commonly affects liver and lung. Cardiac Hydatid cyst is an extremely rare disease. The aim of this study is to report the presentation and management of cardiac Hydatid diseases admitted to two major cardiac centers. Method A retrospective, case series study, conducted in two centers during two years. Each case presented separately regarding presentation, diagnosis and management. Results Four cases have been reported, age ranged from 14 to 42 years with mean age of 24.75 years. Three patients (75%) were male, one patient (25%) was female. Three cases (75%) had history of chest pain, 2 cases (50%) had palpitation, and one case (25%) had nausea, vomiting and fever. Echocardiography was the initial diagnostic test in 2 cases (50%), final diagnostic test in two cases (50%). In 3 cases (75%) the cyst was found in the left ventricle and one case (25%) in right ventricle. Median sternotomy was performed for all cases. Conclusion Cardiac Hydatid cyst is a very rare disease. Chest pain is the most common symptom. Surgery is the main modality of treatment., Highlights • Hydatid disease is a common disease in the endemic area, commonly affecting the liver and lung. • Muscular Hydatid disease is a very rare disease, cardiac Hydatid disease is even rarer. • The aim of this study is to report 4 cases of cardiac Hydatid disease involving the heart muscles.

Highlights • Deep vein thrombosis (DVT) is a relatively common medical problem. • Extrinsic compression with resulting obstruction of the iliac veins is recognized as a crucial cause of DVT. • Different pelvic pathologies may cause compression of iliofemoral vein and cause venous thrombosis. • Impacted ureteric stone has caused the left iliofemoral thrombosis in the current case., Introduction Extrinsic compression with resulting obstruction of the iliac veins is recognized as a crucial cause of deep vein thrombosis (DVT). We report a case of impacted ureteric stone causing DVT. Case report A 65-year-old man presented with left lower limb swelling that diagnosed and treated as extensive DVT. Further evaluation revealed incidental left severe hydroureteronephrosis and impacted ureteric stone compressing iliac vessels. Immediate percutaneous nephrostomy done followed by left ureterolithotripsy 6 weeks later. Discussion several iliofemoral venous thromboses have been reported due to extrinsic compression by various pathologies, but to best of our knowledge, this is the 1st report of the impacted ureteric stone causing life-threatening proximal DVT. Conclusion Isolated unilateral iliofemoral DVT may raise the suspicion of pelvic pathology including ureteric stone.

During the past decades, several methods to measure and rank journal impact were explored. To best of our knowledge, no ranking or evaluating approach for papers has been addressed in the literature. To encourage authors and create a national field for competition and challenge, we suggested and performed a method for paper evaluation denoted as source normalized annual paper ranking (SNAPR). It measures a paper's contextual impact, taking into account several of its characteristics like type of the study, the state of the publishing journal, the contextual citation and affiliation. The details with example of SNAPR have been discussed. SNAPR is a measure of contextual impact of papers, designed to be used in developing countries to evaluate articles and induce competition among the researchers.

Highlights • Solid pseudopapillary tumor of the pancreas is a rare tumor of low malignant potential. • It may be diagnosed incidentally, or present with nausea and vomiting. • The aim of this paper is to present a case of solid pseudopapillary tumor of the pancreas., Introduction Solid pseudopapillary tumor of the pancreas is a rare tumor of low malignant potential. The aim of this paper is to present and discuss a case of solid pseudopapillary tumor of the pancreas occurring in a 17-year-old female. A 17-year-old girl presented with dull aching poorly localized left hypochondrial pain for two years, she had no clinical findings on physical examination. Ultrasound of the abdomen showed well-defined 9 cm * 7 cm heterogeneous lesion with cystic contents in the region of the tail of the pancreas. Computed tomography scan (CT scan) of the abdomen showed a mass of 8 cm * 7 cm in the region of the tail of the pancreas; that could be pancreatic mass, left suprarenal mass, or lymphoma. Resection of the mass and histopathological examination confirmed the diagnosis of pseudopapillary tumor of the pancreas. Conclusion Pseudopapillary neoplasm of the pancreas is a rare condition, which needs surgical intervention. Close follow up is necessary to early detection of the recurrence and metastasis.

The trend through which academia finances scientific publication has been changed into open access publishing, the latter is exploited by predatory journals and publishers. The aim of this paper is to review the current situation of predatory publishing and introduce Kscien's list of predatory journals and publishers. Kscien has recruited a special committee consisting of 23 young researchers. They are working unceasingly to keep the list refurbished, expose current tricks invented by the predators and guide authors. The list is designed to be updated daily. Currently, the criteria used to recognize predatory journals and publishers basically depend on the journal's misconduct, fabrication and inadequate peer review. Researches are ongoing to recapitulate more solid criteria with objective evidence to overcome the critics faced by Beall. Kscien's list has been proposed to replace the vanished Beall's list from the interior of the drawn region in fake journals and publishers.

Introduction Cerebral venous sinus thrombosis (CVST) in the setting of coronavirus disease 2019 (COVID-19) is an uncommon phenomenon with increasing incidence. This study aims to present a rare case of post COVID-19 CVST. Case report A 58-year-old female presented with headache, nausea, left sided weakness, and slurred speech. She recently recovered from COVID-19 who had severe presentations. On examination, mild left central facial palsy, high grade left sided hemiparesis (Grade 2/5), positive Babinski on left side, left side hypoesthesia, and inability to walk were observed. Laboratory and ultrasound findings were not significant, however magnetic resonance imaging (MRI) revealed CVST. The patient was prescribed Clexane 6000 IU twice daily, and after 14 days, it was changed to warfarin with an INR between 2 and 3. After 3 weeks of treatment, the patient was able to walk, and after 3 months her warfarin medication was discontinued. Discussion COVID-19 has been reported to be linked with CVST, however there is limited information about it. The exact figures regarding the affected groups and incidence rates are highly controversial. The diagnosis of CVST poses a challenge to physicians as their symptoms are highly unspecific, hence MRI is required for definitive diagnosis. Anticoagulant is commonly used in their treatment; however, the ideal anticoagulant of choice and the management duration are yet to be known. Conclusion Active or recently resolved COVID-19 can be considered as an independent risk factor for developing CVST and it rises the mortality rate of the disease.

Introduction Although the rate and severity of complications after coronavirus 2019 disease (COVID-19) resolution is currently unknown, evidence regarding their presence is increasing in the literature. This study presents a series of cases with post COVID-19 short-term pulmonary complications. Methods This is a single center retrospective case series study. The demographic and clinical data were collected from the center's electronic records. All the included cases were confirmed COVID-19 patients who had pulmonary complications even after their recovery. Results Nineteen COVID-19 patients were involved in this study. Fourteen of them were male (73.7%) and only 5 (26.3%) cases were female, with a mean age of 52.05 years (26–77). All of the patients developed severe COVID-19 and were admitted to intensive care unit (ICU). The average infection duration was 13.5 days (10–21). The most common complaints after recovery from COVID-19 were shortness of breath, fever, and hemoptysis. Computed tomography scan showed different pulmonary abnormalities between the cases. Different surgical procedures were performed for the patients according to their conditions, such as decortications, lobectomy, and bullectomy. More than half of the patients (n = 10) recovered and were discharged from hospital without complications, five patients were admitted to the ICU, 3 cases developed mucormycosis, and one case passed away. Conclusion Following the resolution of COVID-19, patients may experience severe pulmonary complications that may last for months and can affect quality of life, ICU admission, or even death.

Introduction Paget's disease of the breast is a rare cutaneous eczema-like condition that occurs in the nipple-areolar complex of the breast. The current study aims to report a rare case of Paget's disease of the breast associated with invasive ductal carcinoma in a male breast. Case report A 54-year-old male presented with ulceration of the left nipple-areolar complex that has been progressing over the last 6 months. On examination; there was a palpable axillary lymph node. On ultrasound, a small hypoechoic heterogenous mass was seen beneath the areola (8*4 mm) with surrounding vascularity, and a few axillary lymph nodes with normal morphology and cortical thickness. The mammography revealed some points of calcification arranged in clusters. The patient underwent left side mastectomy and sentinel lymph node biopsy. The result of histopathological examination showed left side unifocal invasive ductal carcinoma. Discussion There are two main theories that explain the histogenesis of Paget's disease of the breast with and without underlying malignancy: epidermotropic theory, which suggests an epidermal infiltration of the nipple with Paget cells, and transformative theory, which proposes a malignant transformation of normal glandular cells of the epidermis. Conclusion The clinical presentation of Paget's disease of the breast is characteristic and should always warn the surgeon of the possibility of underlying malignancy., Highlights • Paget's disease of the breast (or nipple) is a very rare cutaneous entity. • Paget's disease of the male breast is an extremely rare clinicopathologic condition. • Breast cancer in male is likewise very rare.

Introduction Fibrolipoma is a less frequent variant of lipoma, it is rarely reported in the oral cavity, especially in the tongue. This study aims to report a very rare case of tongue fibrolipoma. Case report A 53-year-old female presented with a painless mass at the anterior part of the tongue. It was soft with a smooth regular border. The patient underwent wide local excision to remove the lesion, and the sample was sent for histopathological examination which confirmed the diagnosis of a single fibrolipoma. Discussion Fibrolipoma is rare in the oral cavity, however, they have been seen in the buccal mucosa, lips, buccal vestibule, floor of the mouth, and retromolar area. It has been proposed that disturbance in glucose and lipid metabolism, hormone therapy, and trauma can lead to the formation and proliferation of the tumor. Conclusion Fibrolipoma of the tongue is a rare occurrence. Surgical excision is the ideal management strategy. Histopathological examination is the gold standard for definitive diagnosis., Highlights • Fibrolipoma is a benign adipose tissue tumor. • Fibrolipoma rarely occurs in the oral cavity. • Histopathological examination is the gold standard for the diagnosis. • This report presents a rare case of tongue fibrolipoma.

Introduction Several types of vaccine have been shown to significantly reduce the risk of severe coronavirus disease 2019 (COVID-19). This study aims to report the first case of meningoencephalitis after receiving the second dose of Pfizer COVID-19 vaccine. Case report A 62-year-old lady presented with headache, fever and rigor for 4 days. She had acute confessional state and inability to talk. She was conscious, disoriented, not obeying commands. Acyclovir vial IV 750 mg three times a day for 14 days were prescribed. She responded very well. Discussion Concern has been raised about the safety of vaccinations. The most common side effects of COVID-19 vaccinations are local responses at the injection site, followed by non-specific systemic symptoms such as headache, tiredness, myalgia, and fever. These may appear shortly after immunization and disappear in a short period of time. Conclusion Although extremely rare, aseptic meningoencephalitis could occur after COVID-19 vaccination. The patient could be managed conservatively with a good clinical outcome.

Introduction Cushing syndrome (CS) is an endocrinological abnormality that results from a high level of glucocorticoids in the blood. Iatrogenic CS due to the overuse of topical corticosteroids is rarely reported. The current study aims to present a rare case of topical corticosteroid induced iatrogenic CS in an infant. Case presentation A 4-month-old female infant presented with an insidious onset of face puffiness that progressed over a 2-month period. The mother reported to have used a cream containing Betamethasone corticosteroid 5–8 times a day for a duration of 3 months to treat diaper dermatitis. Laboratory findings revealed low levels of adrenocorticotrophic hormone (ACTH) and serum. Abdominal ultrasound showed normal adrenal glands. The topical corticosteroid was halted and physiologic topical hydrocortisone doses were administered. Clinical discussion Infants are more likely to acquire topical corticosteroid induced iatrogenic CS due to their thin and absorptive skin, higher body surface area, and the high prevalence of conditions that necessitates the use of these medications. Most iatrogenic CS cases following topical steroid application have been reported in infants with diaper dermatitis that are most commonly treated with Clobetasol and Bethamethasone. Conclusion Infants are susceptible to develop CS due to topical corticosteroid overuse. Hence, physicians need to consider this in infantile CS cases, and take appropriate measures to avoid their occurrence., Highlights • Cushing syndrome is an abnormality resulting from high level of blood glucocorticoids. • Iatrogenic Cushing syndrome due to the overuse of topical corticosteroids is rarely reported. • This report presents a case of topical corticosteroid induced iatrogenic Cushing syndrome in an infant.

Introduction A small portion of Corona Virus disease-2019 (COVID-19) cases associated with co-infections, however occasionally they turn out to be false positive due to possible cross-reactivities. The current report aims to present a rare case of false-positive human immunodeficiency virus (HIV) in a COVID-19 patient. Case report A 32-year-old female complaining from thyroid problems referred for thyroid operation. She had mild symptoms of COVID-19. Her preoperative laboratory findings were normal, except for HIV screening test which was repetitively positive. RNA PCR was performed to confirm the diagnosis of HIV, it revealed a negative result. The patient underwent thyroidectomy as planned and was given the required supportive treatment to recover from COVID-19. Two-month follow up revealed that she was negative for COVID-19 on PCR testing, and HIV immunoassay test was no longer positive. Discussion Due to structural similarities between the spike protein chains of SARS-CoV-2 and some other viruses such as dengue, Zika, and other closely related coronaviruses (SARS-CoV, MERS-CoV), the protein can potentially interfere with the immunoassay tests. Although HIV immunoassay tests have high sensitivity and specificity, false-positive results have been reported, such as in the case of Epstein Barr virus, Influenza vaccination, and the Australian COVID-19 vaccination. Conclusion Similarity between HIV and SARS-CoV-2 spike proteins can lead to antibody cross-reactivities, yielding false-positive results on immunoassay screening tests.