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Introduction: Isolated oculomotor nerve palsy after mild traumatic brain injury is unusual and prognostically significant due to unclear mechanisms and recovery challenges. We present a case of isolated oculomotor nerve palsy following minor head trauma, shedding light on this unusual occurrence.Case Report: A 24-year-old male experienced severe vision loss and right-sided oculomotor nerve palsy after a motor vehicle collision. Initial imaging showed a hemorrhagic focus in the left posterior fossa and a contusion in the corpus callosum, yet no direct cause for the nerve palsy was found. Partial recovery was observed after 12 months.Conclusion: This case underscores the importance of maintaining a heightened suspicion for occult intracranial findings, especially when the initial non-contrast computed tomography was inconclusive. Timely clinical assessment and appropriate radiological investigations by emergency physicians are crucial for improving the prognosis.

Yu Zhang,1 Hong-Hai Li,1 Min-Feng Ye,1 Wei-Wei Li,2 Chu Zhang,3 Hai-Feng Wang1 1Department of Gastrointestinal Surgery, Shaoxing People’s Hospital, Shaoxing, Zhejiang Province, 312000, People’s Republic of China; 2Department of Gastroenterology, Shaoxing People’s Hospital, Shaoxing, Zhejiang Province, 312000, People’s Republic of China; 3Department of Thoracic Surgery, Shaoxing People’s Hospital, Shaoxing, Zhejiang Province, 312000, People’s Republic of ChinaCorrespondence: Hai-Feng Wang, Department of Gastrointestinal Surgery, Shaoxing People’s Hospital, No. 568 Zhongxing North Road, Shaoxing, Zhejiang Province, 312000, People’s Republic of China, Email drwanghaifeng01@163.comBackground: Foreign body-induced cancer is a traditional way of understanding cancer development. The induction of cancers by exogenous foreign bodies has been identified in many organs. However, small bowel adenocarcinoma induced by foreign bodies has not been reported in the literature, although the incidence of small bowel adenocarcinoma is increasing globally.Case Presentation: A 70-year-old man was hospitalized for persistent right-sided abdominal pain for 3 months. Abdominal computed tomography revealed localized thickening and clustering of the small bowel wall in the right abdominal cavity. A comminuted fracture of the right 11th rib protruding into the abdominal cavity was observed, with a bone fragment located within the intestinal mass. Exploratory laparotomy was performed, and extensive adhesions were noted among the greater omentum, small bowel, mesentery, and right abdominal wall. Radical resection and lymph node dissection of the affected small bowel and appendix were performed. We also excised the rib end and repaired the abdominal wall to prevent further irritation. The patient was discharged 12 days post-surgery and follow-up assessments revealed no reported discomfort.Conclusion: We first report a case of small bowel adenocarcinoma induced by self-bone tissue, along with successful radical tumor excision and thorough foreign body removal. This case highlights the significant role of chronic inflammation in carcinogenesis.Keywords: foreign body, small bowel adenocarcinoma, chronic inflammation, rib fracture, case report

Bo Liu,* Yao Zhang,* Zheng Yuan, Qiang Zhang Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, National Center for Infectious Diseases, Beijing, 100015, People’s Republic of China*These authors contributed equally to this workCorrespondence: Qiang Zhang, Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, National Centre for Medical Infectious Diseases, No. 8 Jingshun Eest Road, Beijing, 100015, People’s Republic of China, Email sydtzhangqiang@163.comBackground: Brucellosis is a zoonotic disease that can affect various organs, including the spine. Cervical spondylitis caused by Brucella is rare but can lead to significant morbidity if not diagnosed and treated promptly.Case Presentation: We report a case of a 46-year-old female who presented with intermittent high fever and intractable neck, shoulder, and back pain for two months. She was diagnosed with Brucella cervical spondylitis based on clinical manifestations, Rose-Bengal Plate Agglutination Test (RBPT, positive), and cervical MRI findings. She was treated with a combination of antibiotics for at least two weeks, followed by surgical intervention including abscess clearance, partial vertebral resection, and titanium mesh bone fusion. Real-time Polymerase Chain Reaction (RT-PCR) confirmed the presence of sheep Brucella DNA. The patient recovered well postoperatively with significant pain reduction and restoration of full mobility in the right upper limb.Conclusion: This case highlights the diagnostic value of RT-PCR and tissue biopsy in cervical brucellosis spondylitis. Our study found that anterior cervical subtotal corpectomy can restore cervical stability, clear abscess, and relieve spinal cord compression on the basis of drug treatment, with good clinical results.Keywords: Brucellosis, cervical spondylitis, anterior cervical subtotal corpectomy, RT-PCR, gam staining, case report

Ahlam M Al-Kharabsheh,1 Bushra Khalaf AlTarawneh,2 Seham M Abufraijeh,1 Omar Abu Azzam1 1Department of Obstetrics and Gynecology, Faculty of Medicine, Mutah University, Alkarak, Jordan; 2Department of Pathology, Faculty of Medicine, Mutah University, Alkarak, JordanCorrespondence: Ahlam M Al-Kharabsheh, Obstetrics and Gynecology department, Faculty of Medicine, Mutah University, Alkarak, Jordan, Tel +962-798009216, Email alkharabsheh@mutah.edu.joAbstract: Aggressive angiomyxoma is a locally invasive, rarely diagnosed mesenchymal tumor that predominantly affects the perineal region of women in their reproductive years. It is typically found in areas such as the vagina, vulva, and other pelvic soft tissues, but its presentation can be highly variable. We describe a particularly unique case of aggressive angiomyxoma, presenting in an atypical manner within the vaginal region of a 31-year-old virgin woman. This case is noteworthy for the unusual growth pattern of the angiomyxoma—located strictly within the vaginal epithelium, showing no signs of invasion into surrounding tissues, which is not typical of the aggressive nature of this type of tumor. The patient presented with a mass that protruded through the hymen, an uncommon presentation that led to initial speculation about the nature of the mass. The definitive diagnosis of aggressive angiomyxoma was made by meticulous histopathological examination after surgical excision of the mass. This case emphasizes the critical importance of considering aggressive angiomyxoma in the differential diagnosis of vaginal masses, particularly those that do not exhibit invasive characteristics. The case also highlights the need for increased awareness among clinicians about the potential for atypical presentations of this rare tumor, to facilitate timely and accurate diagnosis, and to guide appropriate management strategies. This report contributes to the growing body of literature on aggressive angiomyxoma, highlighting the variability in its presentation and the need to heighten suspicion in atypical cases.Keywords: aggressive angiomyxoma, vaginal cyst, vaginal tumor, mesenchymal tumor, case report

Nabeel Yahya Almadwahi,1 Mohamed Ali Alshuja’a,1 Hamza Zaid Al-Hodiafy,2 Haitham Mohammed Jowah1 1Department of Surgery, Faculty of Medicine, Sana’a University, Sana’a City, Yemen; 2Department of Vascular Surgery, 48 Model Hospital, Sana’a University, Sana’a City, YemenCorrespondence: Haitham Mohammed Jowah, Department of Surgery, Faculty of Medicine, Sana’a University, Sana’a City, Yemen, Tel +96774831058, Email h.jowah@su.edu.yePurpose: In this case we report a rare presentation of a ruptured gastroduodenal artery aneurysm (GDA) accompanied by a duodenal perforation. It contributes to the scientific literature by discussing the management approach and results in a patient with dual complications and emphasizes the importance of early diagnosis and appropriate treatment.Case presentation: A 50-year-old male presented with severe abdominal pain, anemia, and signs of hemodynamic instability. Diagnostic imaging including CTA revealed a large, thrombosed gastroduodenal artery aneurysm with evidence of rupture. The patient underwent open surgical exploration and repair to address both the aneurysm and the duodenal perforation. The patient’s recovery was satisfactory and was discharged home in stable condition.Conclusion: Early diagnosis and appropriate management in gastroduodenal artery aneurysms is crucial. There is a need for individualized surgical interventions based on the patient’s hemodynamic status and associated complications. Dual complications required open surgical exploration and repair, resulting in favorable outcomes.Keywords: gastroduodenal artery aneurysm, duodenal perforation, open surgical exploration, outcomes, case report

Chunhua Wang,1 Haifeng Jin,1 Hua Xue,1 Yanwei Zhang2 1Department of Gastroenterology, Bethune International Peace Hospital, Shijiazhuang, Hebei, People’s Republic of China; 2Department of Diagnostic Radiology, Bethune International Peace Hospital, Shijiazhuang, Hebei, People’s Republic of ChinaCorrespondence: Chunhua Wang; Haifeng Jin, Department of Gastroenterology, Bethune International Peace Hospital, No. 398 Zhongshan West Street, Qiaoxi Disctrict, Shijiazhuang, Hebei, People’s Republic of China, Email crown99@126.com; jinhfhfjin@163.comPurpose: Hepatic portal venous gas is not a specific disease and is often only an imaging manifestation in patients with acute abdomen. However, its appearance often indicates serious disease and poor prognosis. It is not difficult to distinguish typical portal venous gas from biliary tract gas on computed tomography because of their relatively different distribution within the liver. But the difference is not absolute.Case Description: An 82-year-old female was admitted to the emergency department due to epigastric pain, nausea and vomiting for 1 day. Intrahepatic gas was found on computed tomography (CT), which was initially diagnosed as portal venous gas, and contrast-enhanced abdominal CT was performed 3 hours after the first plain CT scan and revealed a significant reduction of intrahepatic gas, then diagnosed as biliary tract gas. Two days later, enhanced abdominal CT showed that biliary tract gas had disappeared. Continuous gastrointestinal decompression, anti-infection, rehydration and other treatments were given. After treatment, abdominal pain, nausea, vomiting and other symptoms of the patient were gradually relieved. The patient refused gastroenteroscopy and was discharged after 13 days of hospitalization.Conclusion: Portal venous gas and biliary tract gas may have similar CT findings and be misdiagnosed, and enhanced CT examination is necessary to confirm the diagnosis.Keywords: hepatic portal venous gas, biliary tract gas, acute gastroenteritis, computed tomography, case report

Sudden deafness is a common cause of emergency consultation in otology. Usually, despite investigations, no etiology is known. Intracochlear hemorrhage is a rare cause of sudden sensorineural hearing loss (SSNHL) and may be associated with various labyrinthine disorders. In such cases, magnetic resonance imaging (MRI) is the clef of the diagnosis. We report the case of a 70-year-old patient who was referred to our department for sudden hearing loss, tinnitus, and vertigo. Otoscopic and neurological examinations were normal, and pure-tone audiometry revealed left profound sensorineural hearing loss. Videonystagmography (VNG) revealed left vestibular deficit. MRI demonstrated a high signal intensity inside the cochlea on unenhanced T1-weighted images, and no other abnormalities were found; in particular, no enhancement after intravenous administration of gadolinium. No etiology was identified. Vertigo disappeared rapidly with corticosteroid treatment and hyperbaric oxygen therapy, but hearing did not improve. Intra-labyrinthine hemorrhage causing SSNHL is rare, and the hearing prognosis is poor.

Introduction: Wellens’ syndrome represents an important, at times overlooked, spectrum of left anterior descending (LAD) coronary artery occlusion, spontaneous reperfusion, and impending reocclusion. Once considered pathognomonic for a thromboembolic coronary event, an increasing number of clinical scenarios have been demonstrated to result in pseudo-Wellens’ syndrome, each requiring unique forms of assessment and management. Case Report: We describe two clinical presentations in which myocardial bridging (MB) of the LAD led to clinical and electrophysiologic presentations of a pseudo-Wellens’ syndrome. Conclusion: These reports represent a rare cause of pseudo-Wellens’ syndrome attributed to MB of the LAD. Transient ischemia secondary to myocardial compression of the traversing LAD leads to intermittent angina and electrocardiogram changes that are typical in patients presenting with Wellens’ syndrome secondary to an occlusive coronary event. As with other previously reported pathophysiologic mechanisms that have been shown to mimic Wellens’ syndrome, myocardial bridging should be considered in patients presenting with a pseudo-Wellens’ syndrome.

Introduction: Psychosis associated with coronavirus disease 2019 (COVID-19) has been previously, but infrequently, reported in the literature. We present a rare case of COVID-19-associated severe psychosis and suicide attempt in an 80-year-old male with no personal or known family history of psychiatric disease. Our patient’s symptoms appeared to be longer lasting than most other reported cases in the available literature. Case Report: After a COVID-19 diagnosis, our patient experienced fluctuating, long-lasting psychiatric symptoms over a six-month period. During this time, he was unable to function independently. Suggested mechanisms involve a multifactorial combination of neuroinflammation and increased societal stress due to the direct and indirect effects of the virus, respectively.Conclusion: More research is needed to help identify risk factors, prognostic indicators, and a standard of care for psychosis associated with COVID-19.

Optic neuropathy is very rare and exceptionally inaugural in systemic erythematous lupus erythematosus (SLE), and posterior reversible encephalopathy syndrome (PRES) is a novel clinical disorder. What makes this observation unique is the combination of these two pathologies. We Hereby present the case of a severe presentation of PRES in a 15-year-old girl who was transferred to the intensive care unit for worsening hypertension and abdominal pain. The patient was first admitted to the adult medical department for sudden onset of binocular blindness. Therefore, antihypertensive drugs were prescribed and mechanical ventilation was required. A head computed tomography and MRI supported the diagnosis of PRES. The course was marked by a progressive improvement in blood pressure and recovery of normal vision after 2 days. The patient was transferred to the nephrology department for renal biopsy. The diagnosis of SLE was based on four ACR criteria: positive ANA, positive anti-DNA, proteinuria greater than 0.5 g/l and lymphopenia. In the presence of PRES, there should be no hesitation in requesting an immunological workup to look for a systemic disease. Despite a worrying clinical and radiological presentation, the prognosis of PRES remains favorable.

* Hypoglossal nerve injuries are classified according to their anatomical localization in: Infranuclear, nuclear, and supranuclear. Supranuclear injuries can occur in cerebral cortex, corticobulbar tracts, internal capsule, cerebral peduncles, or in the pons, and most often caused by a stroke. These lesions usually do not generate a significant alteration of tongue motility due to the bilateral innervation of both nuclei from the cortex. We present a case of a 43-year-old male with dysarthria, left central facial paralysis, and an important tongue palsy and deviation to the same side. Brain CT revealed a right frontotemporal stroke with little hemorrhagic transformation, and an EKG that showed auricular fibrillation. He received treatment with amiodarone and rivaroxaban was initiated when a second brain CT scan showed no evidence of hemorrhage. This case is remarkable due the unusual presentation in a supranuclear lesion of the hypoglossal nerve. It is important to enrich the semiology and consider the possibility of cortical cerebrovascular events in patients with acute deviation of the tongue, even in the absence of involvement of other cranial nerves; or marked ipsilateral motor implication.

Sudden deafness is a common cause of emergency consultation in otology. Usually, despite investigations, no etiology is known. Intracochlear hemorrhage is a rare cause of sudden sensorineural hearing loss (SSNHL) and may be associated with various labyrinthine disorders. In such cases, magnetic resonance imaging (MRI) is the clef of the diagnosis. We report the case of a 70-year-old patient who was referred to our department for sudden hearing loss, tinnitus, and vertigo. Otoscopic and neurological examinations were normal, and pure-tone audiometry revealed left profound sensorineural hearing loss. Videonystagmography (VNG) revealed left vestibular deficit. MRI demonstrated a high signal intensity inside the cochlea on unenhanced T1-weighted images, and no other abnormalities were found; in particular, no enhancement after intravenous administration of gadolinium. No etiology was identified. Vertigo disappeared rapidly with corticosteroid treatment and hyperbaric oxygen therapy, but hearing did not improve. Intra-labyrinthine hemorrhage causing SSNHL is rare, and the hearing prognosis is poor.

Chaoe Zhou,1,* Jun Li,2,* Fude Zhou,3 Lei Huang,4 Xinmin Liu,1 Haichao Li5 1Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China; 2Department of Respiratory and Critical Care Medicine, Beijing Tsinghua Changgung Hospital, Beijing, People’s Republic of China; 3Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People’s Republic of China; 4Department of Clinical Laboratory, Peking University First Hospital, Beijing, People’s Republic of China; 5Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Xinmin Liu, Department of Geriatrics, Peking University First Hospital, Tel +86-10-8357-2128, Beijing, 100034, People’s Republic of China, Email lxm2128@163.com Haichao Li, Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Tel +86-10-8357-2128, Beijing, 100034, People’s Republic of China, Email lhch91767@sina.comAbstract: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an acute, rare and potentially fatal drug reaction. To date, limited studies have reported secondary Pneumocystis jirovecii pneumonia (PJP) infection during the treatment of DRESS syndrome. A 53-year-old man was admitted to the hospital due to a persistent fever lasting for 5 days. He had a medical history of hypertension, psoriasis, urticaria, and had recently been treated with carbamazepine for nerve spasm two weeks ago. After admission, the patient presented with a high fever accompanied by chills, abdominal pain, bilateral upper limb muscle pain, and generalized lymph nodes enlargement. Laboratory tests revealed elevated eosinophils and atypical lymphocytes. Subsequently, the patient developed multiple internal organ complications, including oliguria, elevated serum creatinine, liver enzymes, and cardiac troponin I. Based on diagnostic criteria, the patient was diagnosed with DRESS syndrome. To manage the DRESS syndrome, the patient was successively or simultaneously prescribed methylprednisolone, cyclosporin and intravenous immunoglobulin, resulting in an improvement of the condition. However, during the treatment, the patient was infected with Pneumocystis jirovecii. Despite targeted therapy with trimethoprim/sulfamethoxazole, primaquine and clindamycin successively, no remission was observed. Chest CT scans exhibited multiple exudations in both lungs, indicative of interstitial pneumonia. Unfortunately, the patient’s oxygenation progressively declined, leading to his untimely demise. This rare case further highlights the need for clinicians to be aware of the risk of Pneumocystis jirovecii infection in DRESS syndrome patients treated with long-term and high-dose glucocorticoid therapy.Keywords: DRESS syndrome, Pneumocystis jirovecii pneumonia, carbamazepine, glucocorticoid therapy, case report

* Hypoglossal nerve injuries are classified according to their anatomical localization in: Infranuclear, nuclear, and supranuclear. Supranuclear injuries can occur in cerebral cortex, corticobulbar tracts, internal capsule, cerebral peduncles, or in the pons, and most often caused by a stroke. These lesions usually do not generate a significant alteration of tongue motility due to the bilateral innervation of both nuclei from the cortex. We present a case of a 43-year-old male with dysarthria, left central facial paralysis, and an important tongue palsy and deviation to the same side. Brain CT revealed a right frontotemporal stroke with little hemorrhagic transformation, and an EKG that showed auricular fibrillation. He received treatment with amiodarone and rivaroxaban was initiated when a second brain CT scan showed no evidence of hemorrhage. This case is remarkable due the unusual presentation in a supranuclear lesion of the hypoglossal nerve. It is important to enrich the semiology and consider the possibility of cortical cerebrovascular events in patients with acute deviation of the tongue, even in the absence of involvement of other cranial nerves; or marked ipsilateral motor implication.

Dan Yin,1 Yan-Jiao Jiang2 1The Second Clinical College of Zhejiang Chinese Medical University, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People’s Republic of China; 2Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhejiang Chinese Medical University (Xinhua Hospital of Zhejiang Province), Hangzhou, Zhejiang, People’s Republic of ChinaCorrespondence: Yan-Jiao Jiang, Email 1403699722@qq.comIntroduction: Endometriosis-associated ovarian cancer (EAOC) is rare, occurring approximately in 1% of women with ovarian endometriosis. The main histological types are endometrioid adenocarcinoma and clear cell carcinoma (CCC), with the latter being the least common.Case Presentation: In our hospital, we recently summarized two patients with ovarian clear cell carcinoma with similar characteristics. They all had endometriosis for a long time and had undergone ovarian cyst removal due to a chocolate cyst. Unfortunately, the cyst recurred after surgery, and the histological diagnosis was clear cell carcinoma. In case 1, the expression of P53 was found in the tumor by regular examination, and the stage was IIB. In Case 2, we found it in intraoperative freezing; the stage was IA. Case 1 has been treated with the TP regimen six times, and the survival period has reached one year. Case 2 had a survival period of 6 years after completing six TP regimen treatments. Clinicians should pay attention to patients with a long history of endometriosis and postoperative recurrence of ovarian cysts accompanied by serum CA-125 of more than 200U/mL. Imaging examination has a good prospect in diagnosing malignant transformation of endometriosis, especially PET-CT.Conclusion: This case report highlights the risk factors related to the formation of ovarian clear cell carcinoma and suggests that the follow-up of patients with ovarian endometriosis is essential because of its recurrence characteristics. Radical surgery and postoperative platinum-containing chemotherapy are the primary treatment methods at present.Graphical Abstract: Keywords: gynecological tumor, endometriosis, malignant transformation, ovarian clear cell carcinoma, case report

Introduction: Iron deficiency anemia is commonly seen in the emergency department (ED), and the cause can be complex and variable.Case Report: We present a case of a female without known medical history who presented to the ED for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation.Conclusion: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia. In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early packed red blood cell transfusion and subsequent investigation of causes of severe anemia.

Introduction: Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease.Case Report: We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point-of-care ultrasound associated with traumatic hand amputation. The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition 10 days later.Conclusion: Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Introduction: Necrotizing mediastinitis is a rare complication following a dental procedure. It is frequently lethal and requires prompt diagnosis with advanced imaging, administration of broad-spectrum antimicrobials, and early surgical consultation.Case Report: A 19-year-old, otherwise healthy male presented to the emergency department with chest pain, muffled voice, and facial and neck swelling six days following dental extraction. He was found to have a retropharyngeal abscess causing necrotizing mediastinitis and septic shock. The patient was started on broad-spectrum antimicrobials, required 10 surgical procedures, and experienced a prolonged hospitalization.Conclusion: Consider necrotizing mediastinitis in patients presenting with chest pain and signs of retropharyngeal infection after dental procedures. Prompt imaging, antimicrobial therapy, and surgical consultation is critical in treating this frequently fatal disease.

Introduction: The perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician.Case Report: A 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day.Conclusion: This case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated.

Background This study aims to compare the effect of Bone Morphogenetic Proteins (rhBMP), carried on a gelatin sponge scaffold in comparison with the Xenograft BioOss ® in the management of mandibular bone defects. Case presentation The case is a 48-year-old woman who had 2 cysts in the mandibular bone, BMP2 was placed within the first hole with a gelatin sponge, and a BioOss ® graft was placed within the second defect. The radiographic evaluation was conducted before and after surgery and 1, 3, and 6 months after the surgical work. Histological assessment was conducted after 6 months of the surgical work. Results The results of the radiographic evaluation found that there was no big difference between the healing in the holes filled with rhBMP2 with gelatin sponge and the healing in the holes filled with BioOss ®. Conclusion The use of a gelatin sponge impregnated with Bone Morphogenetic Proteins improves and accelerates the healing of bone defects and is comparable to the effectiveness of using a BioOss ® graft.

Background: Ataxia-telangiectasia (A-T) is a rare autosomal recessive DNA repair disorder, characterized by progressive cerebellar degeneration, telangiectasia, immunodeficiency, recurrent sinopulmonary infections, radiation sensitivity, premature aging and predisposition to cancer. Although the association with autoimmune and chronic inflammatory conditions such as vitiligo, thrombocytopenia and arthritis has occasionally been reported, an onset with articular involvement at presentation is rare. Case presentation: We herein report the case of a 7-year-old Caucasian girl who was admitted to the Rheumatology Department with a history of febrile chough and polyarthritis which led initially to the suspicion of an autoinflammatory disease. She had overt polyarthritis with knees deformities and presented with severe pneumonia. A chest Computed Tomography (CT) scan showed bilateral bronchiectasis, parenchymal consolidation and interstitial lung disease; rheumatoid factor and type I interferon signature resulted negative, therefore excluding COatomer Protein subunit Alpha (COPA) syndrome. A diagnosis of sarcoidosis had been suspected based on histological evidence of granulomatous liver inflammation, but ruled out after detecting normal angiotensin converting enzyme and chitotriosidase blood levels. Based on her past medical history characterized by at least six episodes of pneumonia in the previous 4 years, immunological phenotyping was performed. This showed complete IgA and IgE deficiency with defective antigen-specific antibodies to Pneumococcal, Tetanus toxin and Hemophilus Influenzae B vaccines. Additionally, low numbers of B cells and recent thymic emigrants (RTE) were found (CD4Ra 1.4%), along with a low CD4+/CD8 + T cells ratio (< 1). Finally, based on gait disturbances (wobbly wide-based walking), serum alfa-fetoprotein was dosed, which resulted increased at 276 ng/ml (normal value < 7 ng/ml). A diagnosis of Ataxia-Telangiectasia was made, strengthened by the presence of bulbar telangiectasia, and then confirmed by Whole Exome Sequencing (WES). Conclusions: Although rare, A-T should always be ruled out in case of pulmonary bronchiectasis and gait disturbances even in the absence of bulbar or skin telangiectasia. Autoimmune and granulomatous disorders must to be considered as differential diagnosis. [ABSTRACT FROM AUTHOR]

Yijia He,1 Sen Feng,1 Lulu Yao,1 Guoqiang Zhang1,2 1Department of Dermatology, the First Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China; 2Candidate Branch of National Clinical Research Center for Skin Diseases, Shijiazhuang, People’s Republic of ChinaCorrespondence: Guoqiang Zhang, Department of Dermatology, the First Hospital of Hebei Medical University, No. 89, Donggang Road, Shijiazhuang, Hebei Province, People’s Republic of China, Email zlx090702@163.comAbstract: We report the case of a patient with Lymphocytic thrombophilic arteritis (LTA) with a history of 67 years. This is a relatively rare disease with no recognised guidelines for diagnosis and treatment. The long medical history from birth of this patient and the lack of positive progression may provide some new ideas for the treatment of this disease.Keywords: lymphocytic thrombophilic arteritis, macular lymphocytic arteritis, vasculitis, treatment, case report

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Pemphigus Vulgaris is an uncommon autoimmune skin disorder that is characterized by persistent and blistering lesions. In approximately 50% of patients, mucous membrane erosions are the initial symptom. The primary presenting symptom is often oral mucosal erosions. Affected individuals frequently experience flaccid blisters and erosions on healthy skin and mucous membranes, and other areas of the body may also be affected. This condition is the result of autoantibodies that target desmosomal antigens. We are presenting a case of a 28-year-old male who presented to the hospital with fluid-filled lesions on his forehead and in his oral cavity. A skin biopsy was performed, and he was diagnosed with pemphigus vulgaris. Initially, he was started on a combination of steroids and azathioprine, but he did not respond to this treatment regimen. However, he was successfully treated with injection rituximab. Rituximab has been found to be an effective treatment approach towards pemphigus vulgaris. It can help prevent further complications and reduce the severity of the disease. By targeting the autoantibodies that cause the disorder, rituximab can help control the patient’s symptoms and improve their quality of life. It is important to note that early diagnosis and treatment can play a critical role in the management of pemphigus vulgaris.

Introduction: Pheochromocytoma, a neuroendocrine tumor that secretes catecholamines, can present with episodic sweating, diaphoresis, headaches, and hypertension, as well as cardiac and pulmonary involvement. In a pregnant patient, it must be differentiated from preeclampsia, a leading cause of maternal mortality in the developed world, which can similarly present with hypertension and multiorgan involvement. Both conditions require early diagnosis and treatment to reduce maternal and fetal morbidity and mortality.Case Report: We discuss the case of a pregnant patient at approximately 24 weeks’ gestation presenting with chest pain and shortness of breath who was found to have a left adrenal mass and hypertensive urgency. The patient acutely decompensated during the course of evaluation. She ultimately suffered pregnancy loss and multiorgan failure requiring percutaneous heart pump placement and extracorporeal membrane oxygenation therapy for support before fully recovering. The adrenal mass was confirmed to be a pheochromocytoma after excision and contributed to the development of hypertensive emergency with multiorgan failure.Conclusion: Pheochromocytoma during pregnancy is a rare condition but must remain on the differential until ruled out to improve patient outcomes as much as possible. Obtaining blood pressure control is imperative to reducing maternal and fetal mortality. Preeclampsia is similarly serious, and early diagnosis is essential for adequate management of the condition until delivery can occur.

Introduction: Abdominal pain and flank pain cause a significant proportion of emergencydepartment (ED) visits. The diagnosis often remains unclear and is frequently associated withrepeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank painis compression of the left renal vein between the aorta and the superior mesenteric artery known asnutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameterproximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describesuch a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the finaldiagnosis and intervention occurred.Case Report: A 16-year-old female, long-distance runner presented four times complaining ofintractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visiturinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomographyrevealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred tovascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements andeliminated symptoms.Conclusion: Emergency physicians must maintain a large list of possible diagnoses during theevaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndromemay mimic other causes of abdominal and flank pain such as renal colic and requires appropriatereferral.

Introduction: Point-of-care ultrasound (POCUS) is accepted as an important tool for evaluatingpatients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2Identifying the etiology and type of shock is time-critical since treatments vary based on thisinformation. Clinicians typically rely on the history, exam, and diagnostics tests to identify theetiology of shock. In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock.Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causesof shock in resource-limited settings.Case Report: We discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, withacute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a rupturedpulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expeditedefinitive surgical intervention.Conclusion: In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock.

Introduction: Pott’s puffy tumor (PPT) is a rare clinical disease characterized by forehead swelling from a subperiosteal abscess coupled with frontal bone osteomyelitis. It is often associated with severe complications and poor outcomes if left undiagnosed; thus, rapid recognition is crucial. Point-of-care ultrasound (POCUS) may provide an alternative pathway to diagnosis. It can be performed rapidly at the bedside and assist in early screening of patients, identifying those with high suspicion for PPT and prioritizing imaging and consultation.Case Report: A 59-yghb ar-old-male presented to the emergency department for evaluation of a “lump” on his forehead. He recently had a bifrontal craniotomy to de-bulk a polyp burden in an effort to manage his recurrent sinusitis. To further characterize the mass, a POCUS examination was performed by the treating emergency physician. The examination found a subcutaneous, hypoechoic fluid collection extending superficially along the frontal bone. A discontinuity in the surface of the frontal bone was visualized through which the collection appeared to extend. Given the heightened concern for PPT based on the POCUS examination findings, otolaryngology service was consulted and the patient was admitted for further imaging and treatment.Conclusion: Pott’s puffy tumor is a rare diagnosis that has the potential for life-threatening complications. Timely diagnosis is imperative. Point-of-care ultrasound can easily be used to help identify patients with suspicion for PPT in the acute care setting and influence patient management with regard to obtaining further imaging and plans for early consultation.

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Jiangpeng Zhu, Guangyao Li, Zhengjun Zhang, Yandong Wang The Second People’s Hospital of Wuhu, Department of Gastrointestinal Surgery, East China Normal University, Wuhu, 241000, People’s Republic of ChinaCorrespondence: Guangyao Li, Department of Gastrointestinal Surgery, The Second People’s Hospital of Wuhu, East China Normal University, Wuhu, 241000, People’s Republic of China, Email 18409444@masu.edu.cnIntroduction: Colorectal cancer (CRC) is the 3rd most common malignant tumors after breast cancer and lung cancer, accounting for 9.4% of patients. Some patients had distant metastasis at the time of diagnosis without surgery opportunity. It is particularly important to prolong patient survival and improve quality of life.Patient Concerns: A 73-year-old female was admitted with discomfort over 2 months. Enlarged lymph nodes in the left supraclavicular fossa were observed in chest computed tomography (CT). Enhanced abdominal CT showed thickening of the right colon wall with multiple metastatic lymph nodes in the abdomen. Colonoscopy showed ileocecal mass and pathology showed moderately and poorly differentiated adenocarcinoma. Physical examination showed a 2&ast;2 cm lymph node could be touched in the left supraclavicular fossa. The patient was diagnosed advanced colon cancer by the histopathological examination and imaging findings. Actually, it is hardly to resect radically.Intervention: Sintilimab combined with XELOX was initiated. Two period of treatment after initial therapy, laparoscopic radical resection of right colon cancer was performed successfully.Outcomes: After conversion treatment, the enlarged lymph nodes and primary tumor were significantly reduced. The patient was discharged successfully three weeks after surgery. Both specimen and 14 lymph nodes dissected showed no malignancy in pathology. Tumor regression grading (TRG) is 0, which indicate complete regression with no residual tumor cells including lymph nodes. The patient obtained a pathological complete response (pCR).Lessons: The patient achieved a great therapeutic benefit with the above-mentioned chemotherapy in this case. The case provides a potential reference for pMMR CRC patients treating with immune checkpoint inhibitors (ICIs).Keywords: immunotherapy, sintilimab, advanced colon cancer, pathological complete response, microsatellite stability, case report

Schatzker fracture belongs to the tibial plateau fracture. This fracture is frequently characterized by excessive trauma, such as a fall from a terrific height or an automobile collision. They are identified by a vertical break in the tibial plateau, which disturbs the joint surface and surrounding tissues. A schatzker type six fracture is a complex fracture that is difficult to manage conservatively and typically requires surgery to reestablish articular realignment and integrity. The purpose of this study is to examine the rehabilitation method and actual outcomes of a 41-year-old male patient who had a tibial plateau fracture as well as a fibular head fracture. This case study shows the need for a comprehensive rehabilitation program in assisting individuals with this specific fracture pattern to achieve their maximum functional potential. The patient undertook a rehabilitation program that comprised several therapy interventions such as range-of-motion training, enhancing power, balance and proprioceptive training, gait re-training, and pain control measures. To assess the patient's progress, objective measurements such as goniometry, muscular strength by manual muscle testing, functional outcome ratings, and patient-reported outcomes were employed. As demonstrated by the case study, a comprehensive treatment approach is required to properly treat tibial plateau fractures in conjunction with fibular head fractures. The patient achieved a considerable and favorable affiliation with the therapy techniques and the outcome measures rating.

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Abstract Post-Acute COVID-19 syndrome (PACS) is considered to be one of the least understood post-infectious syndromes. We report a case of a 21-year-old female who had a history of SARS-CoV-2 infection and presented with a right atrioventricular thrombus associated with pulmonary embolism and thrombocytopenia. At the time of admission, she was not vaccinated against SARS-CoV-2, and her serological tests for IgG and IgM antibodies against SARS-CoV-2 were positive. The size of the thrombus measured approximately 6 × 8 × 4 cm, which also led to tricuspid valve insufficiency due to mechanical dilatation of the valve’s ring. The right atrioventricular thrombus also extended up to the inferior vena cava, leading to mild congestive hepatomegaly. Moreover, during thrombectomy, the mass of the thrombus was attached to the interseptal right atrial wall. The histopathological assessment of the core mass revealed that it was a right atrial myxoma hidden inside that large thrombus. We suspect that the formation and propagation of the thrombus to that size occurs as a part of Post-Acute COVID-19 syndrome (PACS). This study reviews and discusses coronavirus disease 2019-relate to thrombus formation inside cardiac chambers in case of a cardiac tumor, like myxoma in the setting of post-acute phase COVID-19 syndrome.

Ahmed Issak Hussein,1 Abdikarim Ali Omar,1 Hodan Abdi Hassan,1 Mohamed Mukhtar Kassim,2 Abdisalam Abdullahi Yusuf,2 Ahmed Adam Osman3 1Obstetrics and Gynecology Department, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia; 2Pediatric Department, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia; 3Radiology Department, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, SomaliaCorrespondence: Ahmed Issak Hussein, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia, Tel +252615597479, Email daacat100@gmail.comBackground and Importance: Spontaneous uterine rupture, especially in an unscarred uterus, is a rare pregnancy complication that can cause severe morbidity and mortality in both the mother and the fetus. The vast majority of uterine ruptures occur in the presence of a previous uterine scar, most commonly from a previous cesarean delivery. To our knowledge, here we reported the first case of spontaneous rupture of unscarred uterus in a term primigravida secondary to lethal skeletal dysplasia fetus (Type 1 Thanatophoric dysplasia) faced by a practicing clinician in an underdeveloped country (Somalia) with a successful outcome.Case Presentation: The patient was 24 yrs. Old Primagravida, at 40 weeks gestation by LMP, presented with abdominal pain and active vaginal bleeding; she did not receive antenatal care during pregnancy; after initial abdominal ultrasonography and vaginal examination, laparotomy was performed due to high suspicion of uterine rupture. After dead fresh fetal extraction, the uterine defect was repaired successfully, and the patient was discharged home in good condition after several days.Conclusion: Through this case, we would like to highlight the urgent need to focus on and recognize the importance of receiving antenatal care in the community so that the burden of thousands of lives lost each year can be reduced.Keywords: uterine rupture, Thanatophoric dysplasia, Primagravida, antenatal care, case report

Hao Wu, Yanna Shen, Li Zhang, Mouzhe Yang, Yougang Ren, Feng Mao, Zhongxiao Wu Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of ChinaCorrespondence: Zhongxiao Wu, Department of Dermatology, Ningbo No.6 Hospital, No. 1059, Zhongshan East Road, Ningbo, People’s Republic of China, Email 2016123801@jou.edu.cnAbstract: Psoriasis is relatively common in clinical practice, whereas niacin deficiency is relatively rare. We describe the clinical case of a patient with plaque psoriasis for over 20 years who also had a concomitant latent tuberculosis infection. After secukinumab and anti-tuberculosis treatment for 1 year, the psoriatic rash mostly resolved, but atypical symptoms of niacin deficiency suddenly appeared. The patient’s symptoms rapidly subsided after experimental treatment with niacin. After 2 weeks, the patient suddenly developed an erythroderma-like rash, manifesting as large areas of erythema and plaque psoriasis throughout the body. The patient was admitted to the hospital and treated with an anti-inflammatory, biologic adalimumab, tripterygium glycoside, and sodium thiosulfate. The patient was discharged after a week. This case suggests the need for caution and to look out for the emergence of new symptoms when treating patients with moderate-to-severe plaque psoriasis, especially with biologics.Keywords: psoriasis, niacin deficiency, case report

Despite a dissecting aortic aneurysm being a surgical emergency, it is frequently misdiagnosed in the Emergency Department. It is no surprise that the thoracic aorta's walls can rupture catastrophically with over 200 million litres of blood travelling through it in an average lifetime. Chest pain +1 (symptom) should prompt a differential diagnosis of a thoracic aortic dissection. Unfortunately, up to 33% of aortic dissection patients are misdiagnosed in the ED. Although the diagnostic imaging of choice is the CT aortogram, the question is whether transthoracic Echocardiography (TTE) is a robust enough imaging modality to rule in or rule out the presence of a type A thoracic dissection on first presentation in the ED and if it is helpful in the ED without immediate access to a cardiothoracic surgeon? This case highlights the importance of Point-of-care ultrasonography (POCUS) in helping with risk stratification and patient streaming in the emergency department. The likelihood of missing an ascending thoracic aorta pathology is reduced if the image acquisition is of good quality.

Suaad Hamsho,1 Isam Alannouf,1 Anas A Ashour2 1Faculty of Medicine, Damascus University, Damascus, Syria; 2Department of Internal Medicine, Hamad Medical Corporation, Doha, QatarCorrespondence: Anas A Ashour, Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar, Tel +974 55336238, Email aashour3@hamad.qaAbstract: Felty syndrome (FS) is a disorder that develops after a long history of erosive rheumatoid arthritis and presents with splenomegaly and neutropenia. In addition to joint deformities, FS causes a variety of extra-articular manifestations such as vasculitis, skin lesions, and lymphadenopathy. FS is also reported to cause non-cirrhotic portal hypertension which may result in variceal bleeding. FS is usually treated by disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate. Herein, we report a case of rapidly deteriorating FS and a severe relapsing neutropenia only a few weeks after discontinuation of methotrexate and other available DMARDs. The patient presented with a fever and a multi-drug resistant gangrenous ulcer consistent with ecthyma gangrenosum. The patient was also found to have hepatosplenomegaly and portal hypertension. The case was managed with antibiotics and symptomatic treatments only as DMARDs were either unavailable or not affordable by the patient. However, the patient’s condition did not improve. This case highlights that DMARDs are considered an essential part of preventing infections due to FS neutropenia. Patients with FS should continue DMARDs for life to avoid the relapse of their condition.Keywords: felty syndrome, rheumatoid arthritis, DMARDs, portal hypertension, case report

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Neng Wang,&ast; Conglin Zhao,&ast; Congchen Tang, Lichun Wang Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Lichun Wang, Center of Infectious Diseases, West China Hospital of Sichuan University, 37 Guoxue Lane, Chengdu, 610041, People’s Republic of China, Tel +86 288 542 2859, Fax +86 288 542 3052, Email mindywang0218@163.comBackground: Histoplasmosis is a deep fungal infection caused by Histoplasma capsulatum and can be classified as pulmonary, disseminated or central. Disseminated histoplasmosis is the most dangerous of all clinical types and is characterized by rapid onset, rapid progression, high mortality, and difficulty in diagnosis and treatment.Case Presentation: This report describes a 31-year-old female who presented with fever, with a maximum temperature of 39.8 °C. There were no concomitant symptoms, such as cough, sputum, abdominal pain and diarrhoea, before the onset of fever, and the illness lasted for more than 20 days. On examination, the liver and spleen were enlarged, and laboratory tests showed a significant decrease in CD4 cell count, suggesting immune deficiency. Broad-spectrum antibiotic treatment was ineffective, and specific infectious diseases and haematological neoplasms were considered likely. She was finally diagnosed with disseminated histoplasmosis after undergoing bone marrow aspiration and metagenomic next-generation sequencing (mNGS) and was treated with amphotericin B, fluorouracil and itraconazole, with good results.Conclusion: This case demonstrates that disseminated histoplasmosis infection can present with unexplained fever and that mNGS can be an important complement to bone marrow aspiration for the diagnosis of this disease.Keywords: disseminated histoplasmosis, immune deficiency, metagenomic next-generation sequencing, amphotericin B, case report

Yukang Dong,1,&ast; Yingying He,1,&ast; Xia Zhou,1 Xia Lv,1 Jia Huang,1 Yaqi Li,1 Xin Qian,2 Fangfang Hu,3 Jiaying Zhu1 1Department of Emergency, Guizhou Provincial People’s Hospital, Guiyang, People’s Republic of China; 2Department of Pharmacy, Guizhou Provincial People’s Hospital, Guiyang, People’s Republic of China; 3Department of Clinical Laboratory, Guizhou Provincial People’s Hospital, Guiyang, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Jiaying Zhu, Email miraclezhujy@163.comBackground: Mycoplasma hominis meningitis is a rare postoperative complication of neurosurgery. Accurate and early diagnosis of M. hominis remains challenging because of the limitations of traditional detection methods. Metagenomic next-generation sequencing (mNGS) is an advanced technique with high sensitivity and specificity for identifying infectious pathogens; however, its application in diagnosing M. hominis meningitis has not been widely studied.Case Presentation: We report the case of a 61-year-old man who presented with fever and headache after neurosurgical treatment for a cerebral hemorrhage. Empiric antibiotic therapy was ineffective. Traditional culture of pathogens and serological testing yielded negative results, but M. hominis was detected in the cerebrospinal fluid by mNGS. After further verification by polymerase chain reaction (PCR), the patient’s clinical treatment was adjusted accordingly. With targeted antibiotic intervention, the patient’s symptoms were effectively alleviated, and clinical indicators returned to normal levels. Furthermore, the abundance of M. hominis decreased significantly compared to the initial mNGS reading after targeted treatment, indicating that the infection caused by M. hominis was effectively controlled.Conclusion: Using mNGS, we found that M. hominis may be a candidate causative agent of meningitis. The technique also has the advantage of timeliness and accuracy that traditional cultures cannot achieve. A combination of mNGS with PCR is recommended to identify pathogens in the early stages of infectious diseases to administer targeted clinical medication.Keywords: Mycoplasma hominis, meningitis, metagenomic next-generation sequencing, cerebrospinal fluid, case report

Sebastian Giraldo-Ocampo,1 Rafael Adrian Pacheco-Orozco,2 Harry Pachajoa2,3 1Universidad del Valle, Cali, Colombia; 2Genetics Division, Fundación Valle del Lili, Cali, Colombia; 3Centro de Investigaciones en Anomalías Congénitas y Enfermedades Raras (CIACER), Cali, ColombiaCorrespondence: Harry Pachajoa, Genetics Division, Fundación Valle del Lili, Carrera 98 # 18-49, Cali, Colombia, Tel +57 5552334 ext 7653, Email hmpachajoa@icesi.edu.coAbstract: White–Sutton syndrome is a rare type of autosomal dominant neurodevelopmental disorder caused by mutations, mostly de novo, in the POGZ gene. No more than 120 patients have been described so far in the literature. Common clinical manifestations include intellectual disability, developmental delay, autism spectrum disorder, other behavioral abnormalities, sleeping problems, hyperactivity and visual problems. We describe a 20-year-old male patient from Colombia who presented with delayed psychomotor development, intellectual disability, obesity, sleep difficulties, hypotonia, hypogonadism, gynecomastia, visual abnormalities and several facial dysmorphisms. Genetic testing showed a novel heterozygous frameshift variant (c.3308del; p.Leu1103Profs&ast;19) in the POGZ gene (NM_015100.3). This is the first report of a diagnosed patient with WHSUS in Colombia.Keywords: WHSUS, neurodevelopmental disorder, Colombia, case report

Introduction: Our case is unique because the differential diagnosis was a challenge. At first, the patient presented with septic shock and multi-organ failure in the context of a suspected lymphoproliferative syndrome. Once the lymphoproliferative process had been ruled out, hemophagocytic syndrome due to COVID-19 infection was suspected, so he is probably one of the few patients with such an exhaustive study that could contribute to our understanding of COVID-19. We followed therapeutic guidelines that differ from the usual, using adrenalin and levosimendan. Corticosteroids helped to modulate the cytokine storm. Case report: A 16-year-old adolescent was admitted to the intensive care unit with fever, diarrhea, multiorgan failure and septic shock. He was IgG positive for COVID-19 and IgM negative. Thoraco-abdominal computed tomography demonstrated multiple para-aortic and peri-pancreatic lymphadenopathy and acute respiratory distress syndrome. The first suspected diagnosis was a lymphoproliferative syndrome and bacterial infection. The second possibility was a hemophagocytic syndrome in a patient recovering from COVID-19. He was treated with broad spectrum antibiotics because the differential diagnosis was difficult, and we removed them when the microbiological screening was negative. During the course of the disease he presented with severe biventricular dysfunction, probably due to the cytokine storm, so we used inotropic drugs (adrenaline, levosimendan). Infection with Salmonella species group B was diagnosed later, when the patient was in the Internal Medicine ward, although he was asymptomatic. Conclusion: The severity of COVID-19 infection ranges from mild to severe, causing serious disease in some people. Although the pathophysiology is not well known, it seems that in some cases an immune storm is triggered, and it is related to more serious and prolonged disease. In our case, heart failure was important, because it could have worsened the prognosis. Fortunately, the response to levosimendan and corticosteroids was adequate and he recovered favorably until discharge.

Background: Goodpasture syndrome (GPS) rarely affects parturients which may quickly result in severe pulmonary and renal damage with significant fetomaternal morbidity. Case Presentation: A 35-year-old white multiparous lady, presented with acute progressive respiratory failure at 32th gestational age. She had fever, cough, severe dyspnea and lately hemoptysis and severe hypoxia with bilateral alveolar opacity in chest imaging, with no response to broad spectrum antibiotic. GPS diagnosis was confirmed by high anti- glomerular basement membrane (anti GBM) titer, without the similar history in the past parities. High dose intravenous methylprednisolone ended to dramatic clinical response. She was maintained on glucocorticoids for five weeks before the successful delivery of a live healthy fetus at 39 Weeks. Conclusion: This study demonstrated a successful pregnancy outcome which was achieved in the present GPS parturient with a careful antepartum care involving maternal-fetal status by serial pulmonary, renal monitoring and special treatment of disease.

Introduction: Our case is unique because the differential diagnosis was a challenge. At first, the patient presented with septic shock and multi-organ failure in the context of a suspected lymphoproliferative syndrome. Once the lymphoproliferative process had been ruled out, hemophagocytic syndrome due to COVID-19 infection was suspected, so he is probably one of the few patients with such an exhaustive study that could contribute to our understanding of COVID-19. We followed therapeutic guidelines that differ from the usual, using adrenalin and levosimendan. Corticosteroids helped to modulate the cytokine storm. Case report: A 16-year-old adolescent was admitted to the intensive care unit with fever, diarrhea, multiorgan failure and septic shock. He was IgG positive for COVID-19 and IgM negative. Thoraco-abdominal computed tomography demonstrated multiple para-aortic and peri-pancreatic lymphadenopathy and acute respiratory distress syndrome. The first suspected diagnosis was a lymphoproliferative syndrome and bacterial infection. The second possibility was a hemophagocytic syndrome in a patient recovering from COVID-19. He was treated with broad spectrum antibiotics because the differential diagnosis was difficult, and we removed them when the microbiological screening was negative. During the course of the disease he presented with severe biventricular dysfunction, probably due to the cytokine storm, so we used inotropic drugs (adrenaline, levosimendan). Infection with Salmonella species group B was diagnosed later, when the patient was in the Internal Medicine ward, although he was asymptomatic. Conclusion: The severity of COVID-19 infection ranges from mild to severe, causing serious disease in some people. Although the pathophysiology is not well known, it seems that in some cases an immune storm is triggered, and it is related to more serious and prolonged disease. In our case, heart failure was important, because it could have worsened the prognosis. Fortunately, the response to levosimendan and corticosteroids was adequate and he recovered favorably until discharge.

Fanconi anemia (FA) is a rare form of an inherited disorder that mainly results in aplastic anemia. In our case, a three-year-old female child presented with recurrent episodes of fever and persistent pancytopenia refractory to any treatment. The chromosomal breakage analysis (CBA) with mitomycin C and solid staining was done, which showed no chromosomal breakage. Considering negative results due to mosaicism, her younger brother’s CBA was performed, which showed a positive result. Therefore, based on clinical features, persistent cytopenia, and the younger siblings’ CBA, both children were diagnosed with FA.

Action Induced Myoclonus in a 11-Year-Old Boy with Silver-Russell Syndrome Myoclonus-dystonia syndrome associated with Russell silver syndrome. 8 Martins J, Gabriel D, Borges T, Soares G, Temudo T. Child neurology: myoclonus-dystonia in Russell-silver syndrome: two syndromes caused by one genetic defect. [Extracted from the article]

Post-Acute COVID-19 syndrome (PACS) is considered to be one of the least understood post-infectious syndromes. We report a case of a 21-year-old female who had a history of SARS-CoV-2 infection and presented with a right atrioventricular thrombus associated with pulmonary embolism and thrombocytopenia. At the time of admission, she was not vaccinated against SARS-CoV-2, and her serological tests for IgG and IgM antibodies against SARS-CoV-2 were positive. The size of the thrombus measured approximately 6 × 8 × 4 cm, which also led to tricuspid valve insufficiency due to mechanical dilatation of the valve's ring. The right atrioventricular thrombus also extended up to the inferior vena cava, leading to mild congestive hepatomegaly. Moreover, during thrombectomy, the mass of the thrombus was attached to the interseptal right atrial wall. The histopathological assessment of the core mass revealed that it was a right atrial myxoma hidden inside that large thrombus. We suspect that the formation and propagation of the thrombus to that size occurs as a part of Post-Acute COVID-19 syndrome (PACS). This study reviews and discusses coronavirus disease 2019-relate to thrombus formation inside cardiac chambers in case of a cardiac tumor, like myxoma in the setting of post-acute phase COVID-19 syndrome. [ABSTRACT FROM AUTHOR]