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Neonatal hyperbilirubinaemia is a very common entity witnessed in most of the newborns. Rarely are there events where the bilirubin levels reach extreme values mandating invasive therapy. Unconjugated hyperbilirubinaemia when solely present is easy to manage and diagnose the common aetiological factors associated with it. The issue arises when we come across a mixed picture of conjugated with unconjugated hyperbilirubinaemia and puts us in a dilemma as to what are we treating. Our case highlights a similar picture where we witnessed the highest documented levels of total bilirubin but to our surprise the major component of which was direct bilirubin. This report takes us through the differentials which were ruled out and our management strategies for solving this rare mystery.

Detailed knowledge of the anatomy and different variations of the superficial branch of the radial nerve could be of great importance not only to anatomists but also to clinicians. A predominant radial nerve supply to the dorsum of the hand is rare. Herein, we present an unusual case of unilateral sensory innervation of the dorsal hand found during routine anatomical dissection of a 72-year-old at death male Caucasian cadaver. We also present a brief discussion of the reported variation and emphasize its potential clinical implications.

Venous fenestrations are rare and when present often are not pierced by regional nerves. Herein, we report an unusual case of a fenestrated superficial temporal vein (STV). Anterior to the external ear, where the STV and superficial temporal artery normally travel with the auriculotemporal nerve (ATN), the nerve was found to pierce the STV. The fenestration within the STV was approximately 0.35mm in diameter, and there was no sign of compression of the ATN as it traversed this vessel. Following the site of penetration of the STV by the ATN, the nerve had a normal course into the skin and surrounding fascia. To our knowledge, this is the first report of a fenestrated STV being pierced by the ATN. Such an anatomical variation might be considered by clinicians who treat patients with pathology of this region.

Leiomyomas are the most common benign smooth muscle tumors of the uterus. The incidence during pregnancy ranges between 1.6 to 10%. The management of fibroids encountered during caesarean section poses a therapeutic dilemma. We present a case of giant anterior wall leiomyoma complicating term pregnancy which posed a great surgical challenge. We didn’t go for myomectomy in the same setting because the patient was primigravida and leiomyoma occupied complete anterior wall of the uterus, an attempt of myomectomy could result in profuse uncontrollable bleeding.

Takotsubo cardiomyopathy (TCM) secondary to an infusion reaction is extremely rare in the literature. Here, we present an unusual case of TCM in a patient with cervical squamous cell carcinoma who presented with acute hypoxic respiratory failure following the initiation of the first-cycle paclitaxel infusion therapy.

A 19-year-old female patient presented to the outpatient department of ear, nose and throat with complaints of hard swelling behind her left ear for the past 5 years. It was a large bony swelling arising from the left temporal bone causing a cosmetic deformity that was surgically excised. The patient made a good recovery post procedure. Histopathology confirmed the lesion to be osteoma.

Spontaneous coronary artery dissection (SCAD) is a non-traumatic non-iatrogenic coronary dissection. It's a frequent cause of acute coronary syndrome (ACS) in women without or with few traditional cardiovascular risk factors. We report an unusual case of multivessel SCAD in a middle-aged woman with successful medical management.

Wilms tumors are the most common renal malignancy of childhood, often presenting as asymptomatic abdominal masses. These tumors can occur either in a unilateral or bilateral fashion, with bilateral tumors more commonly associated with various genetic syndromes and familial inheritance with some known loci. Bilateral tumors present challenges with regards to balancing oncologic control with renal function. Here, we present an unusual case of a young female patient diagnosed with bilateral Wilms tumors on the background of a strong family history and unknown genetic loci.

Medial dislocation of patella has been commonly reported as a complication of the surgical release of the lateral patella-femoral ligament. A traumatic medial eversion-dislocation of the patella has not been earlier reported. We report an unusual case of traumatic medial patellar eversion-dislocation in a young adult patient whose MRI showed a discontinuity in medial and lateral patellar retinacula. However, intraoperatively the retinacula were found intact and relocation of the patella was achieved by flipping the patella through a small hole in the patellar tendon. No reconstruction of the ligaments was needed. At 1-year follow-up, the patient achieved full range of movements of the knee and there were no subjective complaints of instability. In our case, although the patella was medially everted and dislocated, both the retinacula were still intact. Clinicians should be aware that acute traumatic patella medial dislocation and eversion can occur without disruption of the medial or lateral retinaculum. Furthermore, knee MRI may suggest patellar retinacula disruption due to the retinaculum's obscure and tortuous course in patients with these injuries.

Actinomycotic mycetoma is a disease of the tropical region and usually presents as a chronic, suppurative and deforming granulomatous infection. We present an unusual case of actinomycotic mycetoma of the abdominal wall that was found to infiltrate into the bowel. A 51 year-old man presented with pain and swelling in the left flank of 2-year duration. Even after comprehensive preoperative evaluation with advanced radiological imaging, biochemistry and pathology, the diagnosis could not be arrived at. Histopathological examination of the excised specimen after the surgery guided to the diagnosis of actinomycotic mycetoma, which entirely changed the management in the postoperative period. We propose that mycetoma should be kept as a possible differential diagnosis for anterior abdominal wall swelling in the indicated clinical setting and the investigations be done keeping the same in mind. Otherwise, a lot of valuable time may be lost allowing the disease to progress further.

Solitary fibrous tumor is neoplasm of mesenchymal origin commonly involving visceral pleura however we are presenting an unusual case with involvement of urinary bladder. It is generally indolent in nature therefore proper diagnosis is required for complete characterization to avoid unnecessary extensive surgical resection. Our patient was a 64-year-old female who presented with lower abdominal fullness with change in her bowel movement pattern. On imaging partially necrotic mass with heterogenous enhancement was found which was later biopsied and resected with clean surgical margin. Solitary fibrous tumor is overall a benign tumor with satisfactory outcome. Physicians should keep it in a differential of pelvic masses and with the risk recurrence, 6 monthly follow up imaging are usually required after resection.

Pyomyoma is a rare but life-threatening condition that results from the infarction and infection of uterine leiomyoma.[1][1] The most likely cause of pyomyoma is vascular compromise, followed by bacterial seeding from direct, haematogenous or lymphatic spread. Cases in postmenopausal women result

The rare occurrence of polymyalgia rheumatica (PMR) in married couples has been reported in the literature. Susceptibility to PMR is contributed by genetic and environmental factors and cases of PMR developing after influenza vaccine have also been described, in a debated phenomenon known as ‘ASIA’ syndrome. We report the case of two cohabitating married patients developing PMR few weeks after the first dose of ChAdOx1-S SARS-CoV-2 vaccine. Both patients presented with typical symptoms suggestive of PMR. Laboratory findings and ultrasound examination confirmed the diagnosis. Glucocorticoid therapy led to rapid improvment of symptoms. Anti-receptor-binding domain IgG titre was tested and, eight weeks after vaccination, both patients showed no antibody response. It has been suggested that vaccines might trigger autoimmune or inflammatory states in predisposed individuals and various hypotheses have been made regarding the pathogenesis of PMR. Although the causative effect of vaccines cannot be determined, the close temporal correlation observed in our case supports the potential role of environmental factors in triggering the onset of PMR. However, the literature indicates that post-COVID19 vaccination immune-mediated or inflammatory adverse events are extremely rare and vaccination should be encouraged since the benefit largely outweighs possible risks.

Takotsubo cardiomyopathy is a transient cardiac condition commonly triggered by a stressor, presenting with clinical features mimicking acute coronary syndromes. We report an unusual case of Takotsubo cardiomyopathy in a man with severe three-vessel coronary artery disease awaiting coronary bypass surgery who developed rapid spontaneous recovery of cardiac function before revascularization.

A bee sting can be a serious problem that affects people all over the world. Several clinical manifestations of bee sting have been described elsewhere. Furthermore, local allergic reactions are more common, causing pain, redness, and swelling of soft tissue within a few hours. In some cases, severe neurological deficits that can lead to death have been reported. According to the literature, the onset of neurological symptoms can range from 30 seconds to 96 hours. Herein, we present the case of a 48-year-old man who developed allergic encephalitis and toxic hepatitis as a result of multiple bee stings.

Meconium peritonitis is defined as aseptic chemical inflammation caused by an intrauterine bowel perforation. Its incidence is 1 in 35,000 live births. We present a case of meconium peritonitis presented at second day of postnatal life with isolated gross fetal ascites. Exploratory laprotomy was performed, suggestive of gross ascites with fecal contamination and perforation at terminal ileum for which ileal resection with double barrel ileostomy had been done. Postoperatively patient condition had improved and discharged. We would like to highlight this rare presentation of meconium peritonitis following intrauterine bowel perforation in fetus.

Ring avulsion injuries are an uncommon, often catastrophic, pattern of digit injuries that result from sudden traction onto a ring-bearing digit. The reconstructive treatment of these injuries can be complex because of the characteristic involvement of nerves, muscles, vasculature, and bone. There is paucity of literature describing isolated arterial injuries in the absence of overlying soft tissue and underlying bone involvement. We present an unusual case of a closed ring avulsion injury, wherein a patient initially presented to his local urgent care center with a cool and pale digit without wounds or fractures, and abnormal pulse oximetry readings prompted his transfer to a tertiary care center for further evaluation. Surgical exploration demonstrated isolated disruption of both digital arteries and the preservation of both digital nerves. The digit was successfully revascularized with venous autografting and stripping of arterial thrombi.

Central osteomas of the jaws have been infrequently reported, mostly presenting as a well-defined opacity on conventional radiography projections and as a hyperdensity on computed tomography scans. To increase the knowledge of the phenotypic expression of gnathic central osteomas, an unusual case has been described, including the clinical, radiographic, cone beam computed tomography (CBCT) and histopathologic findings. The lesion was initially discovered 4 years prior as an asymptomatic ovoid radiolucency in the posterior mandible. A 25-year-old female presented with a hyperdense expansile mass with a hypodense rim on a CBCT scan. The enucleated mass was diagnosed as a compact central osteoma. A literature search has identified 4 other cases with similar hypodense borders on CT scans. We propose that a subset of central osteomas should be considered in the differential diagnosis of osteopathologies of the jaws with hyperdense internal architecture and hypodense borders, as seen on CT images.

Spontaneous splenic rupture (SSR) is a rare life-threatening emergency. In hematological settings, it is uncommon in acute myeloid leukemia (AML). We report an atypical case of SSR in a 73-year-old male with AML where a prompt imaging ultrasound assessment played a key role. Performed noninvasively at bedside, it allowed rapid imaging diagnosis, confirming its essential role even in the presence of hematological disease.

We report the unusual case of a 68-year-old man with coral reef aorta complicated with severe calcified valvular heart disease who has been undergoing dialysis for 21 years. This report highlights the etiology and the unusual manifestations of coral reef aorta in a long-term dialysis patient. (Level of Difficulty: Intermediate.), Central Illustration

The present case report highlights the need to identify variations in root canal anatomy as a prerequisite for effective nonsurgical root canal therapy planning. As clinicians, we need to develop our observational and clinical abilities as well as amend our understanding of the complexities of the canal anatomy. Reports describing the structure of teeth and pulp canals rarely report the presence of two pulp canals in two permanent upper 1st molars. In this case, it describes the nonsurgical root canal therapy of the upper right 1st permanent molar with two pulp canals, which was confirmed by a cone beam.

Chromoblastomycosis (CBM) is a granulomatous mycosis rarely described outside tropical countries. Degeneration into squamous cell carcinoma (SCC) is its most serious complication. We report the first case of nasal CBM degenerating into SCC. In 2006, a sixty-year-old male presented himself with an infiltrated plaque on the right thigh. The diagnosis of CBM was confirmed by the presence of fungal elements. In 2019, the patient had developed a mass coming from the right nasal cavity. It had rapidly involved the nasal dorsum. An ulcer-budding nasal tumor and an elevated erythematous and verrucous plaque on the thigh were noted. A biopsy revealed a granulomatous dermis with fungal elements. Other nasal biopsy fragments showed differentiated SCC. A fungal culture inoculated with tissue from both lesions showed dark colonies. The diagnosis of nasal CBM with SCC degeneration was reached. The patient presented asymptomatic endonasal CBM that had slowly evolved and recently degenerated.

Renal lymphangiectasia (RLM) is a rare condition characterized by dilatation of perirenal, parapelvic or intrarenal lymphatics. We report an unusual case of bilateral RLM in a 20-year-old Malay male who presented with 1 month duration of bilateral flank pain. Bedside ultrasound showed bilateral perinephric collections, which were further confirmed on computer tomography intravenous pyelogram (CT IVP). Other causes of perinephric collections were ruled out based on laboratory and radiological findings, and he was managed conservatively as for RLM with surveillance ultrasound kidneys at 3 to 6 monthly intervals.

A tracheostomal epithesis is a plastic prosthesis that serves for sealing a tracheostoma and ensuring the position of the tracheostomy tube. The production of a tracheostomal epithesis requires an impression of the tracheostoma. To this end, silicone impression material is applied by an anaplastologist in and around the tracheostomal region, including the trachea. The blocked cuff of the tracheostomy tube serves to prevent aspiration of the material. We report on a 13-year-old boy who died during this procedure because the lower airways were obstructed with cured silicone. Forensic autopsy confirmed asphyctic suffocation as cause of death. Forensic physical investigation of the tracheostomy tube and its cuff revealed no structural or functional defects. Yet, the investigation results prove that the viscous silicone must have passed the cuff. To conclude, this case report demonstrates that the production of an impression of a tracheostoma is a procedure with a potentially lethal outcome. Hence, professional guidelines, including clear safety precautions, are urgently needed.

With the widespread use of antibiotics, Gradenigo syndrome is a rare complication of acute otitis media (AOM) and acute mastoiditis. It is an uncommon form of petrous apicitis and can be life-threatening. We report the case of a 14-year-old female with unresolved AOM, who developed otorrhea, ipsilateral headaches, diplopia and raised inflammatory markers. Magnetic Resonance Imaging (MRI) demonstrated features of petrous apicitis and confirmed the suspicion of Gradenigo syndrome. The objective of this clinical case report is to highlight this unusual syndrome together with its radiological appearance to improve its diagnosis and management.

Chronic tophaceous gout is a common disease but rarely found in the head and neck region. Here we report a case of a middle aged male who presented with a mass over the right side of the nasal bridge. CT of the paranasal sinuses revealed a tophi lesion in the right nasal bridge with erosion of the underlying nasal bone. The mass was excised and histologically confirmed to be a gouty tophus. This case report illustrates how a common disease presented in an uncommon location could pose a diagnostic challenge.

We reported the metastatic chordoma in the right gluteus maximus of a 73-year-old man. The patient was initially diagnosed with sacrococcygeal chordoma and treated with surgical resection. Unfortunately, he had a gluteal metastasis and recurrence and suffered the third-operation therapy. Chordoma is a rare malignant tumor and may metastasize, but the metastasis and recurrence of chordoma at the right gluteus maximus following sacrococcygeal region are extraordinarily rare. This unusual case report may be helpful to clinical workers in diagnosing chordoma.

Resection and reconstruction of the chest wall for the radical surgical treatment of malignant soft tissue tumors are currently considered a substantial challenge for thoracic surgeons. We present an unusual case of infantile fibrosarcoma with tropomyosin 3-neurotrophic receptor tyrosine kinase 1 fusion in a 13-year-old patient. The surgical treatment consisted of radical resection of the right posterior chest wall and reconstruction with the use of the STRATOS (Strasbourg Thoracic Osteosynthesis System) titanium rib bridge system. The patient had a favorable postoperative course and received respiratory-ventilatory rehabilitation, adjuvant therapy with chemotherapeutic agents, immunotherapy, and radiotherapy.

Squamous odontogenic tumor is a benign epithelial odontogenic tumor that is very unusual in the maxilla & mandible. Mostly, these are present as single lesions, but rarely they can be multifocal lesions. The nature of maxillary lesions is more aggressive. Because of their benign nature, these lesions are frequently treated with conservative surgical techniques that include curettage and surgical enucleation. We will discuss the instance of a 29-year-old lady who was misdiagnosed and treated conservatively by us. This case was examined in the light of current knowledge of the prevalence, genesis, diagnosis, and treatment of squamous odontogenic tumors, as well as a literature review.

Pseudomyogenic hemangioendothelioma (PHE) is a rare vascular neoplasm with intermediate malignant potential first described by Mirra et al. in 1992. Young males are most commonly effected, with the distal extremities the most likely site of disease. Metastases are extremely uncommon, and widely metastatic disease present at initial diagnosis even less so. These tumors are associated with FOSB gene fusions. We present an unusual case of PHE with widely metastatic disease at presentation, along with novel EGFL7-FOSB gene fusion.

Perivascular epithelioid cell neoplasms (PEComa) constitute a rare, but increasingly recognized family of seemingly distinct mesenchymal tumors which can occur in any part of the body. Due to their rarity, radiological descriptions of PEComas in the current literature are few and non-specific, making diagnosis difficult, though some common imaging features have been reported. We present an unusual case of multifocal retroperitoneal and pelvic PEComas, mimicking liposarcoma, subsequently treated with open surgery.

Malignant PEComa is a rare entity that usually origins at visceral, retroperitoneal and abdominopelvic sites. In the present paper, we describe an extremely unusual manifestation of malignant PEComa involving the mandible in a 48 years-old female patient focusing on the anatomopathological findings and differential diagnosis. The therapeutic management based on the head and neck tumor board indications is also discussed. Key words:Malignant PEComa, PEComa of the mandible, PEComa pathology, Oral cavity unusual neoplasm.

Background:Suicides are usually known to be either simple or complex, the latter which is defined as a combination of more than one method. Additionally, complex suicide can be practiced in an unplanned manner where several methods are used, consecutively, when the first method has not achieved the desired outcome. The procedure usually gets changed after the first method chosen failed, was working slowly, or proven to be overly painful. The rotation between failed suicidal acts causes difficulties in determining the manner and the mode of death. Method: In the present study, we will discuss some of the relevant previous studies regarding complex suicide and a systematic approach to managing such cases from a medicolegal perspective. Besides, an unusual case of complex suicide, which was handled in 2018 in the Kuwaiti Forensic Medicine Department, will be presented. She is a middle-aged female, domestic worker, who was found dead in the bathroom, with secured inlets and outlets from inside. She was incompletely hanged with multiple neck, chest, and abdominal cut wounds, apart from bilateral wrist cut. Furthermore, bloody knife, razor and razor-blade were found inside the basin. Result and conclusion: After a complete autopsy, forensic pathology and toxicology examination were done, the forensic and crime scene reports together with the criminal investigations were declared. Consequently, the case was reported as a complex suicide case and the cause of death was haemorrhagic shock after lung stabbing. The case represents a novel complex suicide with self-stabbing, wrist cutting and hanging

Ectopic pancreas within the anterior mediastinum is a rare congenital anomaly. We present a case of a solid anterior mediastinal mass that presented with hemoptysis and ground glass parenchymal changes in the right upper lobe. Robotic surgical resection was completed, and final pathology was consistent with benign pancreatic tissue. The patient fully recovered with no recurrence of hemoptysis. Ectopic pancreas, although uncommon, should be included in the differential for solid and cystic anterior mediastinal masses, and surgical resection is often curative and effectively manages symptoms.

A 63-year-old man with hypertension and 3-vessel coronary artery disease previously treated with coronary artery bypass graft was admitted to our emergency room complaining of chest pain. He had undergone pacemaker implant 5 months before due to paroxysmal advanced atrioventricular block. Electrocardiography and troponin testing were unremarkable. Echocardiography and chest X-ray ruled out lead displacement and perforation. Interrogation showed normal parameters [right atrium: impedance 550 Ohm bipolar, sensing 2.4 mV bipolar; threshold 0.50 V/0.4 ms bipolar; right ventricle (RV): impedance 580 Ohm bipolar, sensing > 25 mV bipolar; threshold 1.5 V/0.4 ms bipolar and 0.4 V/0.4 ms unipolar]. Pain was evoked only during RV pacing. An electrophysiology study demonstrated painful RV pacing from multiple sites. We hypothesized that pain was associated with pacing-induced dyssynchrony. His-bundle pacing (HBP) was considered as a solution. We achieved HBP with a bipolar fixed-screw catheter connected to a cardiac resynchronization therapy pacemaker generator. During HBP above threshold (4.00 V/1.00 ms) the patient did not complain of any pain. He was discharged 3 days later pain-free with His-bundle lead amplitude set at 5.00 V/1.00 ms. After 6 months the patient was asymptomatic, with the device showing normal functioning. This is the first clinical experience of painful RV pacing treated with HBP.