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Introduction: Diabetic gastroparesis (DGP) is defined as delayed gastric emptying without any mechanical obstruction in diabetic patients., Methods: We conducted a cross-sectional study using an Arabic-validated translated version of the Gastroparesis Cardinal Symptom Index (GCSI). A total of 3,542 diabetic patients were interviewed, of whom 91.6% were finally included in the analysis., Results: DGP symptoms were present in 14.5% of the study population, of which 10.2% had a GCSI score of severe disease. Further analysis of individuals with GCSI scores≥1.9 (14.5%; 470) revealed that 50.8% of them visited a doctor at least once, and 18% had been hospitalized due to DGP symptoms. However, only nine patients (1.9%) were diagnosed with DGP. The most common symptoms were stomach fullness and early satiety. The binary regression model showed that DGP symptoms were more likely to occur in patients who had diabetes for >10 years and glycosylated hemoglobin >9. Furthermore, the model revealed that females were at a higher risk of developing DGP., Discussion: This was the first study in Palestine on DGP, which showed that the condition is underdiagnosed. This is not only because of the unavailability of standard diagnostic methods but also due to the under appreciation of gastrointestinal complaints in diabetic patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Asad, Zreqat, Idais, Hussein, Ayyad, Hunjul, AbuGharbieh, Neiroukh, Zuhour, AbuKhalaf, Al-Atrash, Alzughayyar, Njoum and Hallak.)

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a monogenic disorder characterized by multi-systemic autoimmunity secondary to loss-of-function mutations in the gene coding the forkhead box P3 (FOXP3) transcription factor which is important for the development, maturation, and maintenance of CD4 + regulatory T (T-reg) cells. Fewer than 300 affected individuals have been identified worldwide. The occurrence of IPEX is below 1:1,000,000. Herein we present a case of a 15-day-old male who was admitted to NICU 15 days after delivery due to respiratory distress. He was found to have metabolic acidosis due to DKA. During his stay in the NICU, he experienced seizures and was intubated for a month. He was diagnosed with neonatal diabetes. He also experienced recurrent respiratory infections and multiple episodes of diarrhea rash, and meningitis. At the age of 7 months, genetic testing confirmed IPEX with FOXP3 mutation, specifically the p.(Pro75Leu) variant of the FOXP3 gene. Subsequently, multiple family members were diagnosed. The unique variability observed in organ involvement and presentation timing among individuals within the same family, despite carrying an identical mutation, is a distinctive aspect, particularly considering the monoallelic expression of the FOXP3 gene in males. This phenomenon strongly suggests the presence of modifying genes that play a significant role in the pathogenesis of IPEX syndrome. The case presentation underscores the importance of clinical suspicion of IPEX in cases of neonatal DM. It also highlights the challenges associated with managing rare genetic disorders in pediatric patients. It also emphasizes that the IPEX genotype has a wide phenotype. This case is considered the first documented case of IPEX in Palestine., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Malhis, AbdalSalam, Njoum, Abdelhaq and Sharaf.)

Introduction: Mitral regurgitation (MR) is a common valvular abnormality that can be exacerbated by atrial fibrillation (AF). Mitral regurgitation is classified based on mitral leaflet motion and can be either primary (organic) or secondary (functional). This study investigates the relationship between AF and functional MR, specifically assessing whether cardioversion to sinus rhythm influences MR severity and echocardiographic indices., Methods: This retrospective cohort study included 417 patients with AF and significant MR (Grade III or IV) who were hospitalized for cardioversion. Patients underwent echocardiography during AF and again within six months after successful cardioversion. The primary outcome was the change in MR severity post cardioversion. Secondary outcomes included changes in left atrial size, left ventricular ejection fraction, and mitral valve anatomy. Statistical analysis involved chi-square tests for categorical variables, Student's t-tests for continuous variables, and multivariate logistic regression to assess the impact of sinus rhythm restoration on MR severity., Results: Of the 417 patients, 61% (n = 254) returned to sinus rhythm after cardioversion. Among these, 28.4% (n = 72) showed a two-grade or greater improvement in MR severity. Patients who returned to sinus rhythm also exhibited significant reductions in left ventricular and left atrial dimensions and improved transvalvular gradients. The multivariate analysis indicated that conversion to sinus rhythm was independently associated with MR improvement., Conclusions: Restoration of sinus rhythm is associated with significant improvement in functional MR, potentially reducing the need for surgical intervention. These findings suggest that rhythm control should be considered in managing patients with AF and significant MR, as it may lead to improved cardiac function and better clinical outcomes. Further large-scale prospective studies are needed to determine the most effective management strategy for functional MR in the context of AF., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mtour et al.)

Shone complex (SC) is a rare congenital heart disease characterized by four obstructive anomalies, including parachute mitral valve (PMV), left atrial supra-valvular ring, subaortic stenosis, and coarctation of the aorta. Typically, SC manifests early in life. However, we encountered a 52-year-old female with a history of hypertension diagnosed at 26 years and left-sided weakness poststroke. She presented with worsening dyspnea and palpitations, prompting a thorough investigation. Echocardiography revealed a heavily calcified bicuspid aortic valve with severe aortic stenosis and parachute mitral valve with severe mitral stenosis and preserved ejection fraction, raising suspicions regarding the presence of SC. Cardiac catheterization, aortic-angiography, and noncontrast chest computed tomography (CT) revealed abrupt occlusion of the postductal aorta, giving a picture of aortic coarctation with well-established collateral vessels including prominent right and left internal mammary arteries. So, she was diagnosed with an incomplete SC at the age of 52. Shone complex is a rare congenital heart disease that typically presents in early childhood, but late presentations due to misdiagnosis or incomplete work up are possible. This case emphasizes the rarity of late presentations of SC and highlights the importance of early diagnosis and intervention to improve outcomes. An incomplete SC should be considered in adult patients presenting with left-sided obstructive lesions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: A splenic artery aneurysm is considered an abnormal dilatation of the splenic artery layers greater than 1 cm in diameter. First described by Beaussier in 1770, it affects 1% of the population but carries a major risk for life-threatening complications of rupture in 3%-10% of cases regardless of its congenital or acquired etiology. The presentation is highly variable, from asymptomatic incidental discovery during routine imaging to aneurysmal rupture causing acute abdomen, massive gastrointestinal bleeding, and hemorrhagic shock., Case Presentation: Herein, we present a 19-year-old male patient who presented with epigastric pain and abdominal rigidity associated with a moderate amount of free peritoneal fluid that was found to be a ruptured SAA after immediate laparoscopy, which was successfully managed with splenectomy., Conclusion: SAAs are a rare etiology of acute abdomen and hemorrhagic shock but have a very high risk of mortality even upon immediate intervention, requiring a very high level of vigilance and a low threshold for surgical intervention in unstable patients presenting with abdominal pain., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Njoum, Barqawi and Maree.)

Introduction and Importance: Disseminated gonococcal infection (DGI) is an infrequent but serious complication of gonorrhea that can exhibit atypical symptoms. While rare, it can lead to infective endocarditis (IE), a condition that affects the heart valves and can result in severe and potentially life-threatening outcomes., Case Presentation: We present a case of Neisseria gonorrhoeae -caused IE confirmed by blood culture and direct isolation from the aortic valve vegetation. Our patient experienced complications, including glomerulonephritis, respiratory failure, and positive troponin. Urgent surgery successfully removed a large vegetation, replaced the aortic valve, and improved cardiac function. Follow-up showed symptom resolution., Clinical Discussion: DGI can present atypically with a triad of tenosynovitis, polyarthralgia, and rash, even without genitourinary symptoms. However, it can also present with nonspecific symptoms, leading to a later diagnosis of IE, as observed in our patient, who developed an aortic valve abscess and aortic regurgitation., Conclusion: This case provides important insights into the diagnosis and management of gonococcal endocarditis, emphasizing the significance of early recognition, timely intervention, and multidisciplinary collaboration in improving patient outcomes. It is imperative to have a high level of suspicion for this rare entity, given its high virulence and potential for severe complications., Competing Interests: The authors declare no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Takotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction. Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine., Results: A retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2-93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0-86.7%) and dyspnea (20.4%, 95% CI 16.3-24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2-75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8-89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20-49.9 to 59-76% within a mean time of 7-37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5-2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8-98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation., Conclusions: TC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study's results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population., (© 2023. Egyptian Society of Cardiology.)

Introduction and Importance: Sternal metastasis of follicular thyroid cancer (FTC) is rare as only 15 cases have been reported in the literature in which most cases of sternal metastasis occurs form breast and lung cancer. Surgical excision of the metastatic mass provides the best option due to its curative benefit, symptomatic palliation, and better response to radioactive iodine., Case Presentation: Herein, we present a 77-year-old female patient with a known history of follicular thyroid carcinoma with isolated sternal metastasis treated with total thyroidectomy and en-bloc resection of the metastasis, followed by chest wall reconstruction using pectoralis major muscle flap., Clinical Discussion: Surgical excision of metastatic FTC to sternum with chest wall reconstruction was seldom reported as the treatment of choice. In most cases in the literature, mesh was used. However, in our patient mesh was not used taking into consideration the drastic consequences of wound infection and the possible need for mesh retrieval in such a dangerous area in proximity to the mediastinum. We believe that myo-adipo-facial flap is a more reasonable and safe option., Conclusion: In patients with FTC, large tumors and bone metastases are factors that indicate poor prognostic factors, both of which were present in our patient. However, surgical excision provides hope for a better quality of life as it enhances subsequent Radioactive Iodine (RAI) therapy., Competing Interests: Declaration of competing interest There are no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction and Importance: Follicular thyroid carcinoma (FTC) exhibits the ability to metastasize hematogenously to distant organs. Spinal metastasis is an unusual site for metastasis that even when it does, spinal metastasis manifests late in the course of the disease and is frequently linked to advanced disease and a bad prognosis. Until 2019, the literature only showed 29 cases of FTC with spinal metastasis as the first presenting feature., Case Presentation: We present a case of a 67-year-old female who presented with an acute onset of severe neurological deficit that ended up bedridden. Magnetic resonance imaging of the spine revealed a spinal lesion causing severe spinal cord compression. Urgent surgical decompression was performed, and the histopathology confirmed metastatic FTC. Subsequent comprehensive evaluation, unveiled a primary thyroid tumor., Clinical Discussion: FTC accounts for 1 % of all malignancies, Therefore, regardless of how irrelevant symptoms may appear at first, it is important to understand all risk factors, screening recommendations, diagnostic techniques, treatment, and the vast range of potential presenting symptoms. Just like our patient, who had incontinence and abrupt loss of motor and sensory function in her lower limbs to be diagnosed with spinal cord compression by metastatic FTC., Conclusion: This instance emphasizes how crucial it is to consider FTC as a possible differential diagnosis in cases with spinal metastasis, even when there is no known primary thyroid cancer. Prompt diagnosis, comprehensive staging, and multidisciplinary management are crucial in optimizing outcomes., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Rosai-Dorfman disease (RDD) is a rare, benign non-Langerhans cell histiocytosis predominantly affects lymph nodes and skin. Despite its benign nature, RDD can cause serious hematological complications. A 14-year-old male, presented with 3-month history of hemolytic anemia, lymphadenopathy, hepatosplenomegaly and rash. After thorough investigation, RDD was diagnosed by mediastinal lymph node biopsy that revealed presence of S100 and CD68-positive cells with absence of CD1a confirming the diagnosis of RDD. Treatment involved combination of steroids and Rituximab, which proved to be highly effective. The patient had dramatic improvement and entered remission, with follow-up period of 2 years. It is important to note that although RDD is a rare disease, it causes severe complications, as evidenced by the patient's parameters. Thus, prompt diagnosis and treatment are paramount. Histological diagnosis is of great value, as it helps confirming and guiding treatment decisions. With the right treatment, patients can experience great recovery and quality of life., Competing Interests: There is no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press.)

Introduction and Importance: When the superior cornu or the top edge of the thyroid cartilage rubs against the hyoid, or when these structures come to rub against the cervical spine, Clicking Larynx Syndrome (CLS) occurs. Which is a very rare disorder in that only less than 20 cases are reported in the literature. Patients seldom ever mention past laryngeal injuries. The cause of the accompanying pain when present is yet unknown. Gold standard management appears to be thyroplastic surgery in which the structures responsible for the clicking sounds are removed or reduction of the size of the large horn of the hyoid bone., Case Presentation: Herein, we present a 42-year-old male patient with a history of papillary thyroid microcarcinoma treated with left thyroidectomy presented with a spontaneous continuous painless clicking noise and abnormal clicking movement of the larynx., Clinical Discussion: CLS is a very rare condition with a very limited number of cases reported worldwide, most reported cases revealed abnormal laryngeal structural anatomy. However, our patient had normal laryngeal structures where multiple diagnostic tools (i.e.: Computed tomography, laryngoscopy) failed to disclose causative abnormality to explain his symptoms, nor literature could reveal any previously reported similar causes or explain the causative relationship between our patient's history of thyroid malignancy or thyroidectomy with his condition., Conclusion: It is crucial to explain to patients with mild CLS that these clicking noises are safe and to provide them with information on the best possible case-dependent treatments to avoid the usually associated anxiety and psychological stress. Further observations and research are needed to analyze the association between thyroid malignancy, thyroidectomy and CLS., Competing Interests: Conflict of interest statement There are no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction and Importance: An arteriovenous malformation (AVM) in the inferior mesenteric artery is a rare vascular pathology that accounts for 6 % of the causes of gastrointestinal bleeding. AVMs are typically classified as congenital persisting embryonic vasculature that link both systems and do not develop into arteries or veins [3], but they may also develop later in life. The majority of documented cases are iatrogenic after colon surgery., Case Presentation: Herein we describe a 56-year-old man who presented complaining of fresh blood per rectum with passage of clots not related to defecation with no previous similar episodes, he was found to have extensive inferior mesenteric branches AVM invading the colonic splenic flexure via Computed Tomography (CT) angiography following three non-revealing upper and lower endoscopies which was later managed surgically with left hemicolectomy with primary end to end colo-colic anastomosis., Clinical Discussion: Although AVMs seldom manifest in multiple sites through the gastrointestinal tract, it is more prevalent in the stomach, small intestine, and ascending colon, and very unusual to affect the Inferior mesenteric artery and vein and to extend to the splenic flexure colonic wall., Conclusion: Even if rare, inferior mesenteric AVMs should be suspected in a patient presenting with GI Bleeding with unrevealing endoscopies, where CT Angiography is to be considered., Competing Interests: Declaration of competing interest There is no conflict of interest., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Gray platelet syndrome (GPS) is a rare hereditary hemorrhagic disorder characterized by macrothrombocytopenia and the absence of alpha-granules in platelets. Clinically, mild-to-moderate bleeding is the main manifestation, often accompanied by thrombocytopenia, splenomegaly, and myelofibrosis. Here, we present a case of a 15-year-old male patient with a history of hepatosplenomegaly, and thrombocytopenia for 8 years, who presented with sudden generalized abdominal pain. Despite initial suspicion of gastroenteritis, diagnostic imaging revealed an extensive hemoperitoneum. Subsequent genetic testing confirmed the diagnosis of GPS, which had not been previously identified. This case highlights the importance of considering inherited platelet disorders should be considered in adolescents with long-standing thrombocytopenia, and emphasizes the need for thorough evaluation in patients with suggestive symptoms.