International Journal Of Medical Case Reports
IJOMCR Accepted for Elsevier EMBASE Coverage We are delighted to announce that International Journal of Medical Case Reports (IJOMCR) (ISSN 2455-0574) has been officially accepted by Elsevier for EMBASE coverage, effective July 1, 2026. This has been confirmed in writing by Elsevier. Elsevier updates the EMBASE Source List twice yearly (January and July). Elsevier has indicated that recently accepted journals undergoing content activation may appear in a subsequent public source list following completion of the activation process. Accordingly, IJOMCR is currently undergoing content activation and is awaiting inclusion in a forthcoming public EMBASE Source List. This announcement reflects Elsevier's written acceptance of the journal for EMBASE coverage and will be updated as further public indexing information becomes available. — Editorial Office, IJOMCR ----------------------------------------------------------------------------------------------------------------------------- International Journal of Medical Case Reports (ISSN 2455-0574) is an open access, peer-reviewed journal. It strives for the publication of high-quality case reports as well as case reviews in the field of medicine. All published papers will be available immediately from the date of publication on the journal's website. The journal and its editorial board are committed to providing immediate, full, and unconditional access to all its published papers for everyone to read. The journal's main aim is to publish original research papers, case reports, case reviews, and case series in clinical as well as non-clinical subjects including anatomy, physiology, biochemistry, forensic medicine, microbiology, pathology, pharmacology, medicine including pediatrics, surgery including orthopedics, obstetrics and gynecology, psychiatry, radiology, dermatology, anesthesiology, ophthalmology, ENT, and preventive and social medicine. International Journal of Medical Case Reports (IJOMCR) not only aims to publish rare case reports but also rare presentations of not-so-rare cases. It also particularly emphasizes publication of case reviews, conference abstracts, interesting image-based short articles, and brief communications, provided that they are beneficial for other medical professionals. Our emphasis is on publications by residents and junior residents as they come across different cases during their residency. Right now, International Journal of Medical Case Reports (IJOMCR) is published quarterly, but sooner rather than later we strive to publish it every month. Our emphasis is on the quality of papers rather than the number of papers published. This journal strives to comply with the requirements prescribed by the International Committee of Medical Journal Editors (ICMJE).
Rosuvastatin-Induced Rhabdomyolysis: A Silent Culprit of Acute Kidney Injury.
Background Statins are widely used for the prevention of atherosclerotic cardiovascular disease and are generally well tolerated. However, statin-associated muscle symptoms (SAMS), including rhabdomyolysis, remain rare but potentially life-threatening adverse effects. Rosuvastatin, a high-potency statin, has been associated with an increased risk of rhabdomyolysis, particularly in elderly individuals, patients with renal impairment, and Asian populations with altered pharmacogenetic profiles. We report a biopsy-proven case of rosuvastatin-induced rhabdomyolysis leading to pigment nephropathy and severe acute kidney injury (AKI). Case Report A L We report a case of a 64 years old male with a history of multiple vascular comorbidities, who was switched from 40 mg atorvastatin to 40 mg of rosuvastatin daily. Two months later, the patient presented with renal failure and severe myopathy. On evaluation, creatinine and liver enzymes were elevated. Rhabdomyolysis was suspected and supported by markedly elevated creatine phosphokinase (CPK) levels (25,745 IU/L). Renal biopsy showed features of pigment nephropathy. Despite initial supportive care therapy, haemodialysis was required. Rosuvastatin induced rhabdomyolysis was suspected and the drug was discontinued. Patient became dialysis-independent after 2 weeks with gradual partial recovery of renal function. Conclusion This biopsy-proven case demonstrates high dose rosuvastatin induced rhabdomyolysis with acute kidney injury (AKI) in an elderly patient without documented pre-existing chronic kidney disease. It highlights the need for individualized dosing and careful monitoring, particularly in elderly and Indian populations who maybe more susceptible to statin toxicity. Early recognition and prompt discontinuation of the offending agent are crucial to prevent irreversible renal damage and optimize patient outcomes.
Copyright (c) 2026 International Journal Of Medical Case Reports https://creativecommons.org/licenses/by-nc/4.0
Negative Pressure Pulmonary Oedema Mimicking Infectious Pneumonia: Diagnostic Value of Ground-Glass Opacity Distribution in Acute Respiratory Failure.
Background Diffuse ground-glass opacities (GGOs) on thoracic imaging are a common but non-specific finding in patients presenting with acute respiratory failure and may result from infectious, inflammatory, or oedematous lung diseases. In young adults with substance abuse, differentiating among aspiration syndromes, opportunistic infections, drug-induced lung injury, and pulmonary oedema can be particularly challenging. Recognition of radiological distribution patterns may provide important diagnostic clues and facilitate early diagnosis. Case Report A L A 26-year-old male heavy-vehicle driver with a history of recreational drug use was admitted with acute respiratory distress, altered consciousness, profound hypoxaemia (oxygen saturation 48%), hypotension, and frothing from the mouth. Examination revealed complete upper airway obstruction caused by tongue collapse and secretions. Chest radiography showed bilateral diffuse pulmonary opacities. High-resolution computed tomography (HRCT) showed bilateral dependent GGOs with patchy consolidations which was predominantly seen involving the posterior basal lung segments. Initial differential diagnoses included aspiration pneumonia with Pneumocystis jirovecii pneumonia. Urine toxicology positive for benzodiazepines. The patient received oxygen therapy, flumazenil, and non-invasive ventilation, resulting in rapid clinical improvement within hours. Repeat chest radiography and follow-up computed tomography showed near-complete resolution of pulmonary infiltrates. The combination of acute upper airway obstruction, characteristic gravity-dependent imaging distribution, rapid radiological improvement and prompt response to positive-pressure ventilation supported a diagnosis of negative pressure pulmonary edema (NPPE) secondary to benzodiazepine-associated airway obstruction. The patient was subsequently referred for rehabilitation. Conclusion NPPE is an important, potentially reversible cause of acute respiratory failure that may mimic infectious and aspiration-related lung diseases. Careful assessment of the distribution of GGOs, particularly gravity-dependent involvement, together with clinical context and rapid response to treatment, can facilitate accurate diagnosis, prevent unnecessary antimicrobial therapy, and enable timely management.
Mitral Valve Prolapse: Notching Up The Diagnosis.
Background Mitral valve prolapse affects 2-3% of the general population and 30% of cases are genetic. These syndromes are associated with mutations in transcription factors like NKX2–5, GATA-4, TBX5 and NOTCH signaling pathway that affect the development of the mitral valve. Case Report This is a case report of a 28-year-old male who presented with hematemesis of one-week duration. He had acromelia of the hands with dysplastic nails and amelia of the feet. On further evaluation he was found to have mitral valve prolapse and portal hypertension. Thus, a syndromic diagnosis was considered. Whole exome sequencing identified a heterozygous pathogenic NOTCH 1 gene mutation, leading to a diagnosis of Adams-Oliver Syndrome (AOS). A L C Adams Oliver Syndrome is a rare genetic disorder characterized by terminal transverse limb defects, cutis aplasia, cardiac defects along with vascular anomalies. Mitral valve prolapse in Adams Oliver Syndrome is however rare. Mutations in NOTCH 1 also have a higher incidence of cardiac anomalies as this pathway has a pivotal role in cardiac and vascular development. Conclusion This highlights the importance of considering genetic syndromes in patients with unexplained congenital anomalies and valvular disease as early recognition and a multidisciplinary approach are essential for optimal management.
Chronic Rhinosinusitis with Nasal Polyps in an Adolescent with a History of Allergies and Asthma.
Background Chronic rhinosinusitis with nasal polyps (CRS-NP) is an inflammatory condition of the nasal mucosa and paranasal sinuses that persists for more than 12 weeks. It is relatively uncommon in children and adolescents but is frequently associated with allergic diseases and asthma. Diagnosis is based on persistent symptoms and objective findings on nasal endoscopy and imaging. This case report describes CRS-NP in an adolescent patient with allergic and asthmatic risk factors who required functional endoscopic sinus surgery (FESS) and polypectomy. Case Report A L A 14-year-old girl presented with left-sided nasal congestion for 3 months, worsening over the preceding 2 weeks. Symptoms were associated with hyposmia, rhinorrhoea, pain, intermittent headache, snoring and itchy watery eyes. She had a history of asthma as well as allergy to dust and cold air. Anterior rhinoscopy revealed a narrow left nasal cavity and a solitary greyish-white mass in the left middle meatus. Nasoendoscopy confirmed a polypoid mass in the left middle meatus. Computed tomography demonstrated left maxillary sinusitis with hypertrophy of the left nasal conchae and obliteration of the left Osteomeatal complex. Based on the clinical, endoscopic, and radiological findings, a diagnosis of CRS-NP was established. The patient received antihistamines, systemic corticosteroids and intranasal corticosteroids followed by FESS and polypectomy. Postoperative evaluations showed marked improvement in nasal patency, complete relief of obstruction and no evidence of early recurrence. Conclusion CRS-NP needs to be considered in adolescents presenting with persistent nasal obstruction, hyposmia and a history of allergic disease or asthma. Endoscopy and CT imaging facilitate accurate and timely diagnosis. Management consists of combined medical therapy and FESS with polypectomy. Regular follow-up remains essential to detect recurrence.
Acute Pancreatitis Complicated by Subacute Intestinal Obstruction and Acute Chest Syndrome in a Patient with Sickle Cell Disease: A Case Report.
Background Sickle cell disease (SCD) is a hereditary hemoglobinopathy associated with chronic haemolysis, vasoocclusion, endothelial dysfunction, and multiorgan complications. Acute abdominal pain in SCD is diagnostically challenging because vaso-occlusive crisis may mimic pancreatitis, bowel obstruction, mesenteric ischemia, or hepatobiliary disease. Acute pancreatitis and intestinal obstruction are uncommon complications, while acute chest syndrome (ACS) remains a major cause of morbidity and mortality. Their simultaneous occurrence during a single admission is rare and requires prompt multidisciplinary recognition and management. Case Report A 26-year-old male with known SCD and beta-thalassemia trait presented with acute abdominal pain associated with vomiting, loose stools and fever. The abdominal pain was preceded by alcohol intake. Examination revealed abdominal tenderness and sluggish bowel sounds. Laboratory investigations showed anemia, leukocytosis, thrombocytopenia, deranged liver function tests and markedly elevated serum amylase and lipase. Erect abdominal radiography showed multiple air-fluid levels suggestive of subacute intestinal obstruction or ileus Contrast-enhanced computed tomography revealed autosplenectomy, mildly dilated bowel loops without definite mechanical obstruction. He was managed conservatively with bowel rest surgical monitoring and supportive care. He subsequently developed signs consistent with ACS. Intensive care management included oxygen supplementation, blood transfusion, broad-spectrum antibiotics and supportive management. With appropriate intensive case his haemodynamic parameters improved and he was discharged in stable condition. Conclusion Persistent abdominal pain in SCD should not be solely attributed to vaso-occlusive crisis. Early abdominal imaging, pancreatic enzyme estimation, respiratory assessment and multidisciplinary conservative management is essential for detecting overlapping pancreatitis, functional intestinal obstruction and ACS in cases of SCD.
Dapsone-Induced Hemolytic Anemia, Severe Acute Liver Injury and Clinically Suspected Methemoglobinemia in a Patient with Hansen's Disease: A Rare Case Report.
Background Dapsone is a key component of multidrug therapy (MDT) for Hansen's disease but is associated with serious adverse effects, including methemoglobinemia, hemolytic anemia, and hepatotoxicity. The simultaneous occurrence of these complications is rare and potentially life-threatening. Early recognition is critical, especially in resource-limited settings where advanced diagnostic tools may not be readily available. Case Report The patient presented with jaundice, fever, and breathlessness approximately one month after initiation of dapsone therapy. Examination revealed pallor, icterus, and edema. Laboratory findings showed severe hyperbilirubinemia (>25 mg/dL), elevated transaminases, anemia (hemoglobin ~8 g/dL), markedly elevated lactate dehydrogenase (1705 U/L), and negative Coombs test, consistent with non-immune hemolysis. Inflammatory markers were elevated, and arterial blood gas analysis indicated metabolic acidosis. Methemoglobinemia was clinically diagnosed by the treating team. Imaging revealed pleural effusion and ascites, suggesting systemic involvement. Dermatology consultation suggested dapsone hypersensitivity syndrome, and dapsone was discontinued. The overall findings were consistent with dapsone-induced multisystem toxicity involving hepatic, hematological, and respiratory systems. Conclusion This case highlights a rare but severe presentation of dapsone-induced methemoglobinemia, hemolytic anemia, and acute liver failure. Clinicians should maintain a high index of suspicion for dapsone toxicity in patients presenting with jaundice, anemia, and respiratory symptoms shortly after initiation of therapy. Early drug withdrawal and prompt supportive management are essential to prevent life-threatening complications.
Chronic Suppurative Otitis Media in Adolescents: Risk Factors, Clinical Manifestations, and Management.
Background Chronic Suppurative Otitis Media (CSOM) is a persistent infection of the middle ear. It is characterized by recurrent or continuous otorrhea through a perforated tympanic membrane. It remains a significant cause of preventable hearing impairment, particularly in developing countries. This report highlights the risk factors, clinical presentation, diagnosis, management and outcome of CSOM in an adolescent patient with identifiable modifiable risk factors. Case Report A 15-year-old male presented to the Ear, Nose and Throat outpatient clinic of Pelabuhan Hospital, North Jakarta with two-month history of right-sided ear pain, ear discharge, aural fullness, tinnitus and progressive hearing loss. The patient reported frequent swimming and habitual ear cleaning with cotton swabs. Otoscopic examination revealed purulent otorrhea, hyperemia of the external auditory canal and a central perforation of the pars tensa with mucopurulent discharge. Pure-tone audiometry demonstrated mild-to-moderate conductive hearing loss in the affected ear, while the contralateral ear was normal. A diagnosis of right-sided tubotympanic (safe type) CSOM was made. Patient was managed by aural toilet, 3% hydrogen peroxide ear drops, topical ofloxacin, oral erythromycin. Additionally counseling regarding prevention of water entry particularly in affected ear and avoidance of ear canal manipulation was also done. At two-week follow-up, the patient showed marked symptomatic improvement, with significant reduction in otorrhea, otalgia, and tinnitus. Additionally subjective improvement in hearing was reported. Conclusion This case emphasizes the contribution of modifiable behavioral risk factors, particularly frequent water exposure and cotton-swab use, in the development of CSOM among adolescents. Early diagnosis, audiometric assessment, appropriate antimicrobial therapy and preventive education can result in favorable clinical outcomes and help prevent long-term auditory sequelae.
Unmasking The Unusual Respiratory Pathogen: Kerstersia gyiorum
Background Kerstersia gyiorum is a rare gram-negative, oxidase-negative, non-fermenting coccobacillus belonging to the family Alcaligenaceae. Human infection with this organism is uncommon, and respiratory isolation has been only rarely described. We report a case of acute infective exacerbation in a patient with chronic bronchiectasis in whom K.gyiorum was identified from respiratory specimens, representing one of the rare cases from India. Case report A 44-year-old woman with long-standing cough, wheeze, exertional dyspnea, and recurrent rhinosinusitis presented with worsening respiratory symptoms. Evaluation revealed grade III clubbing, bilateral crepitations and rhonchi, peripheral edema, elevated jugular venous pressure, loud P2, and tricuspid regurgitation murmur. High-resolution computed tomography of the thorax demonstrated bilateral cystic and cicatricial bronchiectasis with centrilobular nodules and tree-in-bud opacities. She was initially managed as bilateral bronchiectasis with obstructive airway disease, cor pulmonale, and severe pulmonary hypertension, but required readmission after clinical deterioration. Laboratory findings showed neutrophilic leukocytosis, elevated C-reactive protein, and raised NTproBNP. Chest radiography demonstrated bilateral hyperinflation with patchy non-homogenous opacities. Sputum and bronchoalveolar lavage cultures yielded moderate growth of gram-negative bacilli identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry as K.gyiorum . The isolate was susceptible to amikacin, gentamicin, ceftriaxone, ceftazidime and ciprofloxacin. Mycobacterial and fungal cultures were negative. During the course of hospital stay she developed type 2 respiratory failure requiring non-invasive ventilation. Bronchoscopy was done which showed mucopurulent secretions in both bronchial trees. Treatment with intravenous ceftriaxone, azithromycin, bronchodilators, mucolytics and diuretics was started. Supportive care was continued. These measures led to gradual improvement and she was eventually discharged from hospital in stable condition. Conclusion This case highlights the need to keep K.gyiorum in the list of potential and emerging opportunistic respiratory pathogen in patients with chronic structural lung diseases. Identification of these organisms by advanced microbiological techniques is essential for early diagnosis and targeted antimicrobial therapy.
Multisystem Involvement in Tuberous Sclerosis Complex: Incidentally Detected Subependymal Giant Cell Astrocytoma with Extensive Abdomino-visceral Manifestations
Background Tuberous sclerosis complex is a multisystem genetic disorder characterized by hamartomatous lesions involving the brain, kidneys, skin, lungs, heart, and hepatobiliary system. Although typically recognized in childhood, attenuated phenotypes may remain undiagnosed until adulthood, particularly when seizures, cognitive impairment, or cutaneous stigmata are absent. Case Report A 47-year-old woman presented with insidious dull aching right flank pain without haematuria, fever, weight loss, seizures, headache, visual symptoms, focal neurological deficit, or altered sensorium. She had no family history or clinical cutaneous features suggestive of tuberous sclerosis complex. Contrast-enhanced computed tomography of the abdomen revealed bilateral enlarged kidneys with multiple well-defined fat-containing lesions consistent with multifocal renal angiomyolipomas, including a dominant 8 cm exophytic right renal angiomyolipoma with increased hemorrhagic risk. Additional findings included multiple hepatic fat-density lesions, a mildly enhancing fat-rich hepatic angiomyolipoma, and multiple tiny pancreatic lipomas. In view of multisystem fat-containing lesions, an underlying phakomatosis was suspected. Non-contrast computed tomography of the brain demonstrated a well-defined partially calcified hyperdense lesion near the right foramen of Monro, consistent with subependymal giant cell astrocytoma, along with multiple calcified subependymal nodules showing a characteristic “candle-guttering” appearance and a right parietal cortical tuber. There was no hydrocephalus. The combined intracranial and abdomino-visceral imaging findings established the diagnosis of tuberous sclerosis complex. The patient was advised multidisciplinary follow-up and imaging surveillance, particularly for the large renal angiomyolipoma and intracranial lesion. Conclusion Tuberous sclerosis complex may present for the first time in adulthood with extensive multisystem involvement despite absence of classical clinical manifestations. Comprehensive cross-sectional imaging is crucial for diagnosis, assessment of disease burden, risk stratification, and long-term surveillance.
Hypercoagulability As A Paraneoplastic Manifestation Of Suspected Primary Lung Malignancy: A Case Report
Background Trousseau syndrome is a paraneoplastic hypercoagulable state most often associated with mucin producing adenocarcinomas. Lung adenocarcinoma commonly presents with venous thromboembolism, but multifocal arterial thrombosis as the initial manifestation is rare and diagnostically challenging. Recognition of occult malignancy is essential when unexplained, recurrent, or multi-territorial thrombosis occurs in older adults. Case Report A 62-year-old non-smoking woman presented with acute breathlessness, altered sensorium, and severe subacute pain involving the left upper and lower limbs. General examination showed presence of cyanosis of the left-sided nail beds, cold peripheries. In addition, there were absent peripheral pulses and absent Doppler signals on left side. These findings suggested acute limb ischemia. Examination of respiratory system showed reduced right basal air entry with dullness to percussion. Additionally, there was progressive leukocytosis, neutrophilia, hypoalbuminemia, and progressive coagulopathy on serial testing. Hypokalaemia was also present. Pleural fluid was lymphocyte-predominant, exudative, and cytology-negative for malignant cells. CT aortogram demonstrated complete thrombosis of the left axillary and left iliac arteries, splenic thrombosis, bilateral peripheral vascular compromise, and involvement of the abdominal aorta and mesenteric vessels. CT brain showed left temporal ischemic changes suggestive of embolic phenomena. High-resolution CT thorax revealed a heterogeneously enhancing right lower lobe mass with satellite nodules and right-sided pleural effusion, radiologically favouring primary lung adenocarcinoma. A diagnosis of suspected right lung adenocarcinoma with paraneoplastic hypercoagulability causing multifocal arterial thrombosis was made. Histopathological confirmation could not be obtained during the hospital stay. The patient was managed in intensive care with unfractionated heparin followed by subcutaneous heparin, dual antiplatelet therapy, statin therapy, supportive care, and monitoring. Surgical vascular intervention was considered unfeasible because of extensive thrombotic disease. Conclusion Multifocal arterial thrombosis may be the first manifestation of occult lung adenocarcinoma. Clinicians should evaluate for malignancy in unexplained arterial thromboembolism, particularly when vascular involvement is extensive and conventional risk factors are insufficient.
Metronidazole-Induced Encephalopathy Mimicking Hepatic Encephalopathy in a Patient With Residual Liver Abscess: A Case Report
Background Metronidazole is commonly used for anaerobic and protozoal infections, including liver abscess. Though it's a relatively safe drug, it can rarely cause neurotoxicity leading to metronidazole-induced encephalopathy (MIE). This entity is clinically important because it may present with acute or subacute altered sensorium and may closely mimic hepatic encephalopathy, This is particularly more likely to occur in patients with underlying liver disease or in cases with intra-abdominal infection. Case Report We report a 45 years old man with a recent liver abscess which was managed with percutaneous drainage and prolonged metronidazole therapy. Patient developed progressive anorexia followed by confusion and irritability without focal neurological deficits. Given the clinical context, hepatic encephalopathy, central nervous system infection, metabolic causes and drug-induced toxicity were considered as differential diagnosis and a work-up was initiated. Magnetic Resonance Imaging (MRI) demonstrated a characteristic bilateral symmetric pattern involving cerebral white matter and the corpus callosum with additional symmetric signal changes in the cerebellar dentate nuclei and brainstem-related structures. These imaging findings were consistent with toxic encephalopathy highly suggestive of MIE. Metronidazole was promptly discontinued and supportive care was provided. concurrent measures for possible hepatic encephalopathy were continued during the acute phase. The patient improved steadily after withdrawal of metronidazole and was discharged with complete clinical recovery. Conclusion This case underscores the need for heightened awareness of MIE in patients receiving prolonged metronidazole particularly when co-existing hepatic comorbidity creates diagnostic ambiguity. Recognition of the typical symmetric MRI pattern and early cessation of the offending agent are key to preventing unnecessary investigations and achieving favorable neurological outcomes.
Severe Traumatic Brain Injury with Multiorgan Dysfunction: Case Report of A Critical Case.
Background: Severe traumatic brain injury (TBI) predisposes patients to secondary systemic complications such as sepsis, acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI). These complications significantly worsen neurological outcomes and increase ICU mortality. Early recognition, evidence-based critical care, and continuous nursing vigilance are crucial for survival. This case report highlights the multidisciplinary management of a young female with severe TBI who developed sepsis, severe ARDS, and sepsis-associated AKI requiring renal replacement therapy. Case Report: We report the multidisciplinary management of a complex critical care case of a 30 yrs old female admitted with closed head injury and cerebral edema following trauma. She demonstrated rapid neurological deterioration requiring intubation and mechanical ventilation. Her ICU course was complicated by multiple issues making her condition more fragile. Conclusion: This case demonstrates the complex interplay between severe TBI and secondary multisystem complications. Coordinated multidisciplinary critical care interventions, combined with vigilant nursing surveillance, played a central role in preventing further deterioration and achieving a favorable outcome despite severe ARDS and AKI.
Primary Bilateral Lipoma Arborescens of the Wrist: A Rare Case Report
Background: Lipoma arborescens (LA) is an uncommon benign synovial disorder characterized by villous lipomatous proliferation of the synovium. It most frequently affects the knee; involvement of the wrist is distinctly rare and may be misdiagnosed as ganglion cyst, tenosynovitis, or other synovial proliferative conditions. Primary LA is typically described in younger patients without underlying degenerative or inflammatory arthropathy. We report an exceptionally rare presentation of primary bilateral wrist LA. Case Report: A 30-year-old man presented with a gradually progressive, painless-to-intermittently painful swelling over the dorsal aspect of the right wrist for 2 years. There was no antecedent trauma or systemic symptoms. He had undergone excision of a similar lesion from the left wrist 3 years earlier, suggesting bilateral disease. Examination showed a soft, lobulated, non-tender dorsal wrist mass with painful limitation of extension. Wrist radiograph showed no arthropathy or bony abnormality. The lesion was excised under regional anesthesia and found to be a well-encapsulated yellow, lobulated villous fatty synovial mass which was completely removed while preserving extensor tendons and retinaculum. Histopathology demonstrated villous synovial hypertrophy with subsynovial mature adipose tissue and lymphoid follicles; immunohistochemistry (CD3/CD20 negative, reactive Ki-67 pattern) excluded lymphoproliferative pathology confirming LA. Postoperatively, recovery was uneventful with restoration of painless wrist extension. The patient remains under follow-up for recurrence. Conclusion: Primary LA of the wrist is rare and may present with bilateral involvement. Characteristic intraoperative appearance and histopathology along with immunohistochemistry enables the diagnosis. Complete excision yields excellent functional outcomes. Regular follow-up and surveillance is recommended given limited evidence on recurrence in small-joint LA.
Anemia in Pregnancy : Risk Factors to Comprehensive Management.
Background: Anemia in pregnancy remains a major contributor to maternal and perinatal morbidity, particularly in low- and middle-income settings. In late gestation, even mild anemia may become clinically important because maternal hematologic reserve is reduced at a time when delivery-related blood loss and operative intervention may be imminent. This report highlights the importance of diagnosing third trimester anemia in a patient with additional obstetric risk factors. Case Report: A 36-year-old multigravida woman (G3P2) at 36–37 weeks of gestation was admitted with third trimester anemia, persistent oblique lie, a short interpregnancy interval, and a history of two previous cesarean deliveries. On admission, she was hemodynamically stable, and cardiotocography showed a reassuring category I fetal heart rate pattern. Laboratory evaluation demonstrated mild anemia, with hemoglobin 10.4 g/dL and hematocrit 33%. Because of persistent malpresentation in the context of two prior cesarean sections and near-term pregnancy a repeat cesarean delivery was planned The postoperative course was favorable. Hemoglobin remained at 10.1 g/dL after surgery and 10.0 g/dL on postoperative day 1. There was no evidence of hemorrhagic complications or need for blood transfusion. Uterine involution was found to be adequate and maternal recovery was satisfactory. Patient was discharged in stable condition. Conclusion: This case underscores that even mild third-trimester anemia warrants careful evaluation when combined with advanced maternal age, multiparity, short interpregnancy interval and anticipated operative delivery. Timely admission, close maternal as well as fetal monitoring and close postoperative surveillance can support favorable outcomes while minimizing the risks associated with antepartum anemia
Complex Foot Injury With Grade III B Compound Fracture Involving Lisfranc And Chopart Fracture Dislocation With Bone Loss Of Middle And Lateral Cuneiform Bones Treated With A Novel Technique Of Tricortical Iliac Bone Graft: A Case Report.
Background: Open fractures of the foot with combined Chopart and Lisfranc fracture-dislocations are rare, limb-threatening injuries that are difficult to manage because of severe contamination, osseous instability, and associated soft-tissue loss. Segmental loss of two cuneiform bones in this setting is exceptionally uncommon, and successful reconstruction with tricortical iliac crest bone grafting has rarely been described. We report the management and short-term outcome of a young man with Grade IIIB open complex foot trauma involving combined Chopart and Lisfranc fracture-dislocations, loss of the middle and lateral cuneiforms, and extensive soft-tissue damage. Case Report: A 22-year-old man sustained a road traffic injury to the right foot and presented with a Grade IIIB open injury characterized by combined Chopart and Lisfranc fracture-dislocations, severe contamination with grass particles, extensive soft-tissue injury, loss of the middle and lateral cuneiform bones, and loss of the extensor digitorum tendon. Emergency management included thorough debridement, broad-spectrum intravenous antibiotics, and temporary stabilization with multiple Kirschner wires. The soft-tissue defect was addressed with staged wound care and coverage using a reverse sural artery fasciocutaneous flap, supplemented with skin grafting. In a subsequent stage, osseous reconstruction of the cuneiform defects was performed using a tricortical iliac crest bone graft. Conclusion: At 6 months, all fractures had united, the iliac crest graft had fully incorporated, and the fasciocutaneous flap had survived completely. Functional outcome was satisfactory, with an American Orthopaedic Foot and Ankle Society score of 80/100. This case highlights that urgent debridement, early stable fixation, staged biological reconstruction with a tricortical iliac crest graft, and timely flap coverage can preserve the limb, restore midfoot stability, reduce the risk of amputation, and provide good functional recovery in severe open complex foot trauma with cuneiform bone loss.
A Rare Presentation of Primary Abdominal Wall Hydatid Cyst with Intraperitoneal Extension: A Diagnostic Challenge.
Background: Hydatid disease (cystic echinococcosis) commonly involves the liver and lungs, while primary involvement of the abdominal wall is exceedingly rare. Because muscular and parietal tissues are unfavorable for parasite implantation, abdominal wall hydatid cysts are seldom encountered and often present as a diagnostic challenge. Their nonspecific clinical appearance may mimic abscess, hematoma, hernia, lipoma, or soft-tissue tumor, increasing the risk of misdiagnosis and hazardous invasive procedures. Intraperitoneal extension from a primary abdominal wall hydatid cyst is even more unusual and has important implications for surgical planning and prevention of spillage. Case Report: A 65-year-old man presented with a gradually progressive swelling over the left lower anterior abdominal wall associated with mild local discomfort. Examination revealed a solitary, non-tender,non-reducible cystic-to-firm parietal mass measuring approximately 8 × 6 cm in the left lumbar/iliac region. Contrast-enhanced computed tomography demonstrated a hydatid cyst involving the left rectus abdominis/anterior abdominal wall musculature with multiple internal daughter cysts, along with subcutaneous and intraperitoneal extension. The intraperitoneal component was seen abutting bowel loops, psoas muscle, and urinary bladder without definite invasion. Two hepatic hydatid cysts were also identified, including one in the left lobe showing detached membranes suggestive of endocyst rupture. Percutaneous aspiration or biopsy was avoided because of the risk of rupture and dissemination. The patient underwent surgery with hydatid precautions. Intraoperatively, controlled evacuation yielded hydatid fluid and multiple daughter cysts, confirming the diagnosis and demonstrating continuity with the intraperitoneal component. Histopathology showed a laminated acellular ectocyst with parasitic elements consistent with hydatid disease. Recovery was uneventful, and postoperative albendazole therapy was advised. Conclusion: Primary abdominal wall hydatid cyst with intraperitoneal extension is an exceptionally rare presentation of echinococcosis. In endemic settings, hydatid disease should be considered in chronic abdominal wall masses to avoid unsafe aspiration or biopsy. Cross-sectional imaging is important for diagnosis as well as operative planning. Meticulous surgery combined with antihelminthic therapy usually offers favorable outcomes.
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Pemphigus Vulgaris with Extensive Mucocutaneous Involvement: Importance of Early Recognition of Oral Lesions – A Case Report.
Background: Pemphigus vulgaris (PV) is a chronic autoimmune blistering disorder usually presenting in 5th decade of life. The hallmark feature of PV is intraepidermal acantholysis which is mediated by autoantibodies against desmoglein 1 and 3. PV predominantly affects mucous membranes and skin. Many cases often present initially only with oral lesions after which cutaneous involvement is gradually noticed. Early diagnosis is critical from the point of view of managing these patients as delayed recognition can lead to significant morbidity and mortality due to complications. In patients of PV oral manifestations are frequently misdiagnosed initially, thereby resulting in delayed treatment. This report highlights the importance of early identification of oral lesions in cases of PV and underscores the need of multidisciplinary approach in these cases. Case Report: A 35-year-old female presented with 1 month history of painful oral ulcers. These ulcers initially appeared as fluid-filled blisters that later ruptured to form erosions. There was a history of similar lesions gradually developing over the chest and abdomen. Clinical examination revealed multiple oral erosions involving the buccal mucosa and palate along with flaccid bullae and erosions on the trunk. Nikolsky's sign was positive. Tzanck smear demonstrated acantholytic cells. Histopathological examination showed suprabasal clefting with a “row of tombstone” appearance of basal keratinocytes. Clinical features and histopathology confirmed the diagnosis of PV. The patient was treated with systemic prednisolone and azathioprine therapy along with topical therapy as well as supportive care. Significant clinical improvement occurred within two weeks of starting therapy with reduced lesion formation and improved oral intake. Conclusion: This case underscores the importance of identifying oral manifestations of PV and doing further evaluation in selected cases. Early recognition and timely initiation of immunosuppressive therapy are important in preventing disease progression and improving outcomes. A high index of suspicion for possibility of PV in cases with oral ulcers is essential to reduce diagnostic delays.
Microscopic Polyangiitis Presenting With Diffuse Alveolar Hemorrhage In A Patient With Chronic Kidney Disease.
Background: Diffuse alveolar hemorrhage (DAH) is a rare, life-threatening manifestation of pulmonary–renal syndrome and may occur in microscopic polyangiitis (MPA), a myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)-associated small-vessel vasculitis. Early diagnosis is particularly challenging in patients with pre-existing chronic kidney disease (CKD), in whom worsening renal function and pulmonary infiltrates may be misattributed to progression of CKD, infection, or fluid overload. Case Report: A 60-year-old man with type 2 diabetes mellitus, hypertension, and stage 4 CKD presented with fever, haemoptysis, weakness, oliguria, and hypoxemia. Investigations revealed severe anemia (hemoglobin 5.5 g/dL), leukocytosis, and acute-on-chronic kidney injury with serum creatinine rising from a baseline of 3.8 mg/dL to 6.4 mg/dL. Chest radiograph showed bilateral patchy consolidations. High resolution computed tomography (HRCT) chest demonstrated diffuse ground-glass opacities with septal thickening, suggestive of DAH. Despite empiric broad-spectrum antibiotics, oxygen therapy, blood transfusions, and renal replacement therapy, hypoxemia and haemoptysis persisted. Flexible bronchoscopy on day 3 showed progressively bloodier bronchoalveolar lavage aliquots, confirming DAH. Serology revealed MPO-ANCA positivity, and a diagnosis of MPA presenting as pulmonary–renal syndrome was established. The patient received high-dose intravenous methylprednisolone, six sessions of plasma exchange, and two doses of rituximab. He showed progressive clinical improvement with resolution of haemoptysis, stabilization of hemoglobin, improved oxygenation, and recovery of renal parameters, and was discharged in stable condition on day 24. Conclusion: MPA should be considered in patients with CKD who develop haemoptysis, anemia, bilateral pulmonary infiltrates, and acute worsening of renal function. Early recognition of DAH using imaging, bronchoscopy, and serology, followed by prompt immunosuppressive therapy, can be lifesaving.
Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis
Multiple Intracardiac Tumors Causing Obstructive Shock Mimicking Sepsis in a Late Preterm Neonate
Background: Intracardiac tumors in neonates are rare, with cardiac rhabdomyoma being the most common primary cardiac tumor in this age group. Although many cases are asymptomatic and may regress spontaneously, large or strategically located lesions can result in significant hemodynamic compromise. Case Presentation: We report a late preterm male neonate who presented on day three of life with severe respiratory distress, shock, hypoglycaemia, and seizures. Initial evaluation showed presence of thrombocytopenia, metabolic acidosis and acute kidney injury with features suggesting septic shock. The infant was managed by mechanical ventilation, inotropic support, glucose infusion and administration of broad-spectrum antibiotics. Despite intensive care the clinical course was marked by recurrent episodes of desaturation as well as cyanosis. In view of cyanosis not responding to oxygen therapy echocardiography was done which revealed multiple well-circumscribed intracardiac masses involving the left atrium and left ventricle. There was also partial left ventricular inflow obstruction. Features on 2D Echo suggested cardiac rhabdomyoma. The infant subsequently developed refractory sepsis complicated by persistent thrombocytopenia, recurrent bleeding episodes and progressive clinical deterioration. Surgical intervention was deferred due to hemodynamic instability and ongoing sepsis. Despite aggressive supportive management, including blood product transfusions and immunomodulatory therapy, the neonate suffered recurrent cardiac arrest and succumbed on day 21 of life. Conclusion: This case highlights a rare as well as fatal presentation of multiple intracardiac tumors causing functional inflow obstruction in a late preterm neonate. It underscores the importance of early echocardiographic evaluation in newborns with unexplained cyanosis accompanied by refractory shock
Left Ventricular Aneurysm: A Late and Underrecognized Complication of Acute Myocardial Infarction — A Case Report
Background: Left ventricular aneurysm is an uncommon but clinically relevant late complication of acute myocardial infarction in the contemporary reperfusion era. It is associated with adverse ventricular remodeling, systolic dysfunction, functional mitral regurgitation, and increased risk of heart failure, arrhythmias, and thromboembolic events. Early recognition and appropriate risk stratification are essential to guide management and avoid unnecessary invasive procedures. Case presentation: We report the case of a 71-year-old man with a history of ST-segment elevation myocardial infarction two years prior, managed conservatively without documented reperfusion. He presented with progressive exertional dyspnea and reduced exercise tolerance. Transthoracic and dobutamine stress echocardiography revealed a true chronic left ventricular aneurysm involving the mid anterolateral, mid inferolateral, and basal inferior segments, associated with reduced left ventricular ejection fraction and moderate functional mitral regurgitation, without evidence of contractile reserve or inducible ischemia. Given the absence of myocardial viability and high procedural risk, a conservative, optimized medical approach was adopted. Conclusion: This case highlights left ventricular aneurysm as a late and underrecognized complication of myocardial infarction. Advanced echocardiographic evaluation was crucial in confirming irreversible myocardial injury, guiding individualized management and preventing unnecessary invasive interventions
Chronic Eosinophilic Pneumonia As A Diagnostic Mimic of Tuberculosis : A Case Report.
Background : Pulmonary tuberculosis (PTB) is endemic in Sri Lanka, and many patients with chronic cough, constitutional symptoms and upper-zone opacities are treated empirically when microbiological confirmation is unavailable. This practice risks diagnostic anchoring and delayed recognition of important mimics. Chronic eosinophilic pneumonia (CEP) is an uncommon, steroid-responsive eosinophilic lung disease that can closely resemble PTB clinically and radiographically particularly when infiltrates involve upper lobes. A key clue is the presence of “flitting” (migratory) consolidations, supported by peripheral or bronchoalveolar lavage (BAL) eosinophilia. Case report: A 25-year-old woman presented with a 6-month dry cough and a 3-week history of low-grade evening fever with night sweats, anorexia, myalgia/arthralgia and 4-kg weight loss. Examination was unremarkable aside from low body mass index (16.2 kg/m²). Initial investigations showed elevated inflammatory markers (ESR 118 mm/h; CRP 36 mg/dL), mild eosinophilia (697 cells/μL), Mantoux induration 10 mm, negative sputum AFB smear and a right upper-zone opacity on chest radiograph. She was started on standard anti-tuberculosis treatment for clinically diagnosed PTB. Within one week, symptoms persisted with vomiting and a markedly raised CRP (174 mg/dL), rising eosinophils (3289 cells/μL) and repeat radiography showing resolution of the right-sided lesion with new left upper-zone consolidation. HRCT demonstrated bilateral apical peripheral consolidations with ground-glass opacities. Parasitic studies, filarial antibodies, HIV testing and ANCA were negative and IgE was elevated (620 IU/mL). Bronchoscopy was normal; BAL showed 90% eosinophils with negative AFB smear, GeneXpert, bacterial cultures, and pyogenic cultures. Anti-tuberculosis therapy was stopped and oral prednisolone 30 mg/day initiated leading to complete clinical and radiological resolution within two weeks. Conclusion: In tuberculosis-endemic settings, CEP should be considered when presumed PTB is bacteriologically unconfirmed, fails to improve on therapy and demonstrates migratory infiltrates with eosinophilia. Early BAL differential counts and prompt corticosteroid treatment can rapidly reverse disease and prevent unnecessary anti-tuberculosis exposure.
Primary Thyroid Diffuse Large B-Cell Lymphoma Presenting As A Rapidly Progressive Compressive Goitre: A Case Report.
Background: Primary thyroid lymphoma (PTL) is a rare extranodal lymphoma that typically arises in a background of chronic autoimmune thyroiditis and often presents as a rapidly enlarging goitre with compressive symptoms, closely mimicking anaplastic or other aggressive thyroid malignancies. Diffuse large Bcell lymphoma (DLBCL) is the most common high-grade PTL subtype and may progress abruptly, making prompt tissue diagnosis and immunophenotyping essential to guide lymphoma-directed therapy. Case report: A 52-year-old woman presented with a rapidly enlarging anterior neck mass associated with fever, dysphagia, and respiratory distress. Examination revealed a solid thyroid mass measuring approximately 10 × 6 × 5 cm with irregular surface and diffuse cervical lymphadenopathy. Due to progressive pressure symptoms, she underwent isthmulobectomy at a rural hospital. Initial histopathology showed lymphocytic thyroiditis with atypical lymphoid proliferation suspicious for intermediate-to-large cell non-Hodgkin lymphoma. Postoperative ultrasonography demonstrated multiple bilateral cervical lymphadenopathies (levels III–IV) and right thyroid fossa lymphadenopathy, with spongiform lesions in the contralateral lobe. After referral, immunohistochemistry confirmed DLBCL with CD20 positivity, CD3 negativity, and a high proliferative index (Ki-67: 95%). Staging with thoracic computed tomography revealed subcarinal lymphadenopathy without pulmonary metastases; disease was classified as stage IIE (extranodal organ with regional nodes). The patient was treated with immunochemotherapy (R-CHOP) and remained clinically well during the third cycle. Conclusion: PTL should be strongly considered in patients—particularly women with thyroiditis—who develop a rapidly progressive goitre with compressive symptoms and cervical lymphadenopathy. Adequate tissue sampling with immunohistochemistry is critical for distinguishing DLBCL from thyroid carcinoma and for enabling timely initiation of rituximab-based chemotherapy, which can achieve favorable early outcomes and help avoid unnecessary extensive surgery.
More Than Meets the Eye: A Rare Encounter of Fuchs' Uveitis Syndrome in Multiple Sclerosis.
Background: Fuchs' Uveitis Syndrome (FUS) is a chronic form of anterior uveitis characterized by low-grade intraocular inflammation, stellate keratic precipitates, and iris heterochromia. The disease often follows an indolent course and may remain asymptomatic until detected during routine ophthalmic examination. Although most cases are idiopathic, associations with systemic immune-mediated disorders have been increasingly recognized. Case Presentation: We report the case of a 47-year-old male with secondary progressive multiple sclerosis (SPMS), type 2 diabetes mellitus, Graves' disease, vitiligo, and dyslipidemia who was referred for routine ophthalmologic evaluation. The patient reported no ocular complaints. Slit-lamp examination showed presence of diffuse stellate keratic precipitates and iris heterochromia in the right eye with a deep anterior chamber. Intraocular pressure was found to be 10 mmHg bilaterally. Fundoscopic examination demonstrated normal retinal and optic disc morphology. Optical coherence tomography of the macula was normal in both eyes. Based on characteristic slit-lamp findings, a diagnosis of unilateral Fuchs' Uveitis Syndrome was made. Since the patient was asymptomatic conservative management with periodic follow-up was recommended. Conclusion: This case underscores the subtle presentation of Fuchs' Uveitis Syndrome and emphasizes the importance of routine ophthalmologic evaluation in patients with systemic autoimmune or neuroinflammatory conditions including multiple sclerosis. Early recognition of this association may facilitate timely diagnosis and monitoring that will help in preventing long-term ocular complications.
Coexistence of Hereditary Angioedema and Homozygous Factor V Leiden Mutation in a 31-Year-Old Patient: A Rare Clinical Overlap.
Background: Hereditary angioedema (HAE) is a rare autosomal dominant disorder which is caused by deficiency or dysfunction of C1-esterase inhibitor (C1-INH). This leads to dysregulation of the kallikrein–bradykinin pathway which is responsible for recurrent episodes of non-pruritic angioedema seen in these cases. The condition typically manifests as episodic swelling of the skin, gastrointestinal tract or involvement of airway. It is frequently misdiagnosed as allergic angioedema due to overlapping clinical features. Factor V Leiden mutation the most common inherited thrombophilia is caused by a point mutation in the F5 gene that produces resistance to activated protein C and increases the risk of venous thromboembolism. Although both disorders involve dysregulationof plasma protease cascades reports describing their coexistence are exceedingly rare. This case highlights the diagnostic and therapeutic challenges associated with the simultaneous presence of HAE and homozygous Factor V Leiden mutation. Case Report: A 31-year-old woman presented with recurrent episodes of facial and right upper limb edema. This was accompanied by burning sensation, body aches and abdominal cramps. Episodes occurred one to two times per week and resolved spontaneously within two to six hours. The patient, diagnosed case of homozygous Factor V Leiden mutation, had a prior history of recurrent venous thromboembolism including deep venous thrombosis and pulmonary embolism. Physical examination during attacks revealed non-pitting and non-pruritic edema. There was minimal response to antihistamines and bronchodilators. Serum tryptase was normal and autoimmune markers were negative. In addition C1- INH levels were reduced with normal C1q.Complement C4 levels were decreased. These changesconfirmed the diagnosis of hereditary angioedema secondary to C1-INH deficiency. Initial treatment with fresh frozen plasma was started which was subsequently discontinued due to worsening pulmonary arterial hypertension. Therapeutic plasmapheresis was performed which caused marked symptomatic improvement. Conclusion: This is a rare case in whom there was coexistence of hereditary angioedema due to C1-INH deficiency and homozygous Factor V Leiden mutation. This represents a rare clinical overlap involving dysregulation of complement, kallikrein–kinin and coagulation pathways. Recognition of bradykininmediated angioedema in patients with recurrent swelling unresponsive to antihistamines is essential for appropriate management as these patients are less likely to respond to antihistamines, corticosteroids, or epinephrine
Treatment of Ceftazidime-Avibactam–Aztreonam-Resistant New Delhi Metallo-β-Lactamase-Producing Escherichia coli Bacteremia With Imipenem-Cilastatin-Relebactam Plus Aztreonam: A Two-Case Report.
Background: Bloodstream infection due to New Delhi metallo-β-lactamase (NDM)-producing Escherichia coli poses a major therapeutic challenge because these isolates are frequently resistant to carbapenems and often co-produce serine β-lactamases that compromise Aztreonam activity. Although Ceftazidime- Avibactam plus Aztreonam is commonly used for metallo-β-lactamase-producing Enterobacterales, resistance to this combination is increasingly recognized. Clinical evidence for Imipenem-Cilastatin- Relebactam plus Aztreonam as salvage therapy remains limited. We report 2 cases of Ceftazidime- Avibactam–Aztreonam-resistant NDM-producing E. coli bacteremia in which microbiological clearance was achieved with this combination. Case Report: The first patient was a 59-year-old man with newly diagnosed FLT3-ITD- and NPM1-mutated acute myeloid leukemia who presented with suspected hematologic sepsis and was found to have carbapenem-resistant NDM-producing E. coli bacteremia. The isolate was resistant to Ceftazidime- Avibactam and Ceftazidime-Avibactam plus Aztreonam, with susceptibility retained only to Colistin and aminoglycosides. Persistent fever and inflammatory progression occurred despite Ceftazidime-Avibactam plus Aztreonam, Meropenem, and Colistin. After switching to Imipenem-Cilastatin- Relebactam plus Aztreonam with Colistin and Gentamicin, blood cultures cleared and inflammatory markers improved, although the patient later died from leukemia-related complications rather than persistent bacteremia. The second patient was a 91-year-old woman with chronic obstructive pulmonary disease, Alzheimer disease, diabetes mellitus, and chronic kidney disease who developed respiratory failure requiring intensive care. Blood and respiratory cultures grew NDM- and CTX-Mproducing E. coli resistant to Ceftazidime-Avibactam and Ceftazidime-Avibactam plus Aztreonam. Renally adjusted, prolonged simultaneous infusions of Imipenem-Cilastatin-Relebactam and Aztreonam were associated with rapid clinical improvement, negative follow-up blood cultures, procalcitonin decline, and eventual discharge to long-term care. Conclusion: Imipenem-Cilastatin-Relebactam plus Aztreonam may be a valuable salvage option for severe bacteremia caused by extensively drug-resistant, Ceftazidime-Avibactam–Aztreonam-resistant NDM-producing Escherichia coli. In both patients, this regimen was associated with microbiological clearance despite major host-related risk factors and extensive antimicrobial resistance. These cases support further evaluation of this regimen in difficult-to-treat metallo-β-lactamase-producing Enterobacterales infections.
Scar Endometriosis of the Abdominal Wall After Cesarean Delivery: A Rare Cause of Catamenial Abdominal Pain
Introduction: Abdominal wall endometriosis (AWE) is an uncommon, estrogen-dependent inflammatory condition caused by ectopic endometrial glands and stroma within the abdominal wall. It is most often seen following obstetric or gynecologic surgery particularly cesarean delivery. Diagnosis is frequently delayed because presentations can mimic hernia, granuloma, abscess or soft-tissue tumors. Cyclical (catamenial) pain in proximity to a prior surgical scar remains a key clinical clue while imaging may assist operative planning, definitive diagnosis requires histopathology. Case report: A 33-year-old multiparous woman (G4P3+1; living 4) presented with progressively worsening cyclical periumbilical pain that consistently exacerbated during menses. She had a history of three prior cesarean sections and other abdominal surgeries including umbilical hernia repair and inguinal hernia repair. Examination revealed a well-defined, tender abdominal wall nodule located approximately 5 cm lateral to the midline and 5 cm above the cesarean scar. Pelvic MRI demonstrated an enhancing lesion within the left lower abdominal wall with T1 hyperintensity, iso–T2 signal and diffusion restriction suggestive of AWE. The lesion was completely excised surgically intraoperatively it was a firm, well-circumscribed 5 × 3 × 2 cm mass immediately beneath the rectus sheath containing “chocolate-colored” material. Histopathology was done which showed endometrial glands and stroma within fibrofatty tissue admixed with skeletal muscle fibers. These histopathology features confirmed endometriosis. Recovery was uneventful and she remained symptom-free without recurrence at 6-month follow-up. Conclusion: AWE should be suspected in reproductive-aged women with cyclical pain and an abdominal wall mass after cesarean delivery even when the lesion is not directly within the scar line. MRI supports characterization and surgical planning but wide local excision with histologic confirmation is the cornerstone of definitive management and recurrence prevention.
Intraoperative Identification and Preservation of a True Double Left Recurrent Laryngeal Nerve During Total Thyroidectomy for Benign Multinodular Goitre: A Case Report.
Background: Recurrent laryngeal nerve (RLN) injury remains one of the most feared complications of thyroid and parathyroid surgery because during these surgeries dissection is performed in a confined anatomical field adjacent to vital structures. Although temporary vocal fold palsy and permanent RLN injury are well recognized after thyroidectomy, the risk is amplified by anatomical variations of the RLN. While extra-laryngeal branching is relatively common true RLN duplication is exceptionally rare and may be overlooked unless the nerve is routinely visualized and traced to its laryngeal entry near the ligament of Berry. Case report: A69-year-old man presented with a 10-year history of progressively enlarging anterior neck swelling, with rapid enlargement and bilateral extension during the month prior to admission. Imaging demonstrated tracheal deviation and narrowing at the C7–T2 level. Neck MRI revealed a large right thyroid mass with central degenerative areas and suspected mediastinal extension; fine-needle aspiration cytology showed benign findings (Bethesda II). The patient was diagnosed with bilateral suspected non-toxic thyroid nodules with compressive effect and underwent total thyroidectomy. Intraoperatively, two distinct RLN structures (double RLN) were identified on the left side ascending in close proximity toward the laryngeal entry point. Both components were meticulously dissected in the capsular plane, traced through the critical region near Berry's ligament, and preserved without traction or thermal injury. Postoperatively, there was no hoarseness, respiratory compromise, or clinical hypocalcemia. Conclusion: This case highlights an extremely rare anatomical variant—true duplication of the left RLN—encountered during thyroidectomy for benign multinodular goitre. Systematic RLN visualization and careful tracing to the laryngeal inlet, especially around Berry's ligament, are essential to prevent nerve injury and postoperative vocal cord dysfunction.
Severe Pancreatic Involvement In Severe Dengue: Simultaneous Presentation Of Acute Pancreatitis And Diabetic Ketoacidosis: A Case Report.
Background: Dengue fever is a major global health problem in tropical and subtropical regions. Moreover, severe dengue is associated with significant morbidity and mortality. Pancreatic involvement is an uncommon but clinically important manifestation which is reported in less than 2% of hospitalized dengue cases. Diabetes mellitus is increasingly recognized as a risk factor for severe dengue and dengue-associated diabetic ketoacidosis (DKA) has been infrequently described. The simultaneous occurrence of severe dengue, acute pancreatitis and DKA is rare and poses significant diagnostic and therapeutic challenges because of overlapping clinical features and competing management priorities. Case Report: We report a case of 50-year-old woman with long-standing poorly controlled diabetes mellitus who presented with a 5-day history of febrile illness, severe abdominal pain, vomiting and progressive dyspnea. On admission, she was hypotensive, hypoxemic, hyperglycemic and had Kussmaul breathing. Laboratory evaluation revealed high–anion gap metabolic acidosis with ketonuria consistent with DKA. Additionally, haemoconcentration, leukopenia, severe thrombocytopenia, acute kidney injury and markedly elevated serum amylase and lipase levels were also present. Dengue NS1 antigen was positive. Contrast-enhanced computed tomography demonstrated acute interstitial edematous pancreatitis (Balthazar grade E) with minimal ascites and bilateral pleural effusions. A diagnosis of severe dengue complicated by acute pancreatitis, DKA and hypovolemic shock was thus made. The patient was managed in the intensive care unit. Carefully titrated intravenous fluids, insulin infusion, vasopressor support was given along with close monitoring of vitals. She showed progressive clinical improvement and was subsequently discharged in stable condition. Follow-up imaging showed asymptomatic pancreatic pseudocyst which was managed conservatively. Conclusion: This case of a patient with poorly controlled diabetes mellitus highlights a rare but life-threatening triad of severe dengue, acute pancreatitis and DKA. A high index of suspicion, early diagnostic workup and individualized multidisciplinary management were important determinants for favorable outcomes.
Anastomosing Hemangioma of the Retroperitoneum with Contiguous Renal and Hepatic Involvement: A Rare Benign Vascular Tumor Mimicking Malignancy.
Background : Anastomosing haemangioma (AH) is an uncommon benign vascular neoplasm characterized by anastomosing capillary-sized vessels lined by bland hobnail endothelial cells. Despite its benign nature AH frequently mimics aggressive vascular tumors or carcinomas on imaging and intraoperative assessment. The genitourinary tract especially the kidney, is the most frequently involved site. Retroperitoneal AH with contiguous involvement of multiple organs is exceedingly rare and poses significant diagnostic and therapeutic challenges often resulting in radical surgical resections. Case Report: A 56-year-old man presented with a short history of vague right upper abdominal pain without systemic symptoms. Imaging revealed a large heterogeneously enhancing retroperitoneal mass inseparable from the upper pole of the right kidney with apparent extension into hepatic segments VI and VII. The imaging findings were strongly suggestive of renal cell carcinoma with hepatic involvement. Surgical exploration demonstrated a highly vascular mass densely adherent to the right kidney, liver and adrenal gland prompting en bloc resection with right radical nephrectomy and nonanatomical hepatic resection. Grossly, the tumor was well circumscribed and adherent to adjacent organs without definite parenchymal invasion. Histopathological examination showed a wellencapsulated lesion composed of anastomosing capillary-sized vascular channels lined by bland hobnail endothelial cells, without cytologic atypia or significant mitotic activity. Immunohistochemistry revealed diffuse CD34 positivity and a Ki-67 index of less than 1%, confirming the diagnosis of retroperitoneal anastomosing haemangioma. The postoperative course was uneventful and no recurrence was noted at three-month follow-up. Conclusion: Retroperitoneal anastomosing haemangioma can closely mimic malignant neoplasms radiologically and surgically particularly when it is large and adherent to contiguous organs. Awareness of this entity and its characteristic histomorphological and immunohistochemical features is essential to prevent overtreatment and unnecessary radical surgery.
A Rare Case Of Prehepatic Pseudocyst Of Pancreas In A Tertiary Care Center Of A Rural District Of Central India.
Introduction: Pancreatic pseudocyst is localized collection of pancreatic enzymes that are enclosed by a nonepithelial wall. These cysts typically develop after pancreatitis or pancreatic ductal disruption. While peripancreatic pseudocysts are relatively common the prehepatic location is exceptionally rare. Such cysts occur when pancreatic secretions track through the hepato-gastric or hepato-duodenal ligaments and accumulate anterior to the liver. The importance of knowing this entity is that it may occasionally mimic hepatic or subphrenic pathology. Accurate radiological diagnosis is essential for management planning and differentiation from other cystic lesions. Case Report: A 35-year-old male presented with a one-month history of upper abdominal swelling and dull aching pain without fever or jaundice. On examination, a firm, non-tender lump was palpable in the epigastrium extending to the left hypochondrium. Contrast-enhanced CT revealed a large thick-walled peripancreatic collection extending into the perihepatic, perisplenic and gastrosplenic regions. This collection was compressing the posterior gastric wall and communicating with a dilated pancreatic duct. CT findings suggested a prehepatic pseudocyst with features of chronic calcific pancreatitis and splenic vein thrombosis. The patient underwent cystogastrostomy with evacuation of approximately 2.5 Litres of thick cystic fluid. Dense adhesions were noted between the cyst, peritoneum and left hepatic lobe. Postoperative recovery was uneventful and the patient was discharged with an advice to follow-up after 2 weeks. Conclusion: Prehepatic pseudocyst of the pancreas is an extremely uncommon entity. It poses a significant diagnostic challenge because of its unusual site and resemblance to hepatic lesions. Imaging plays an important role in diagnosis and surgical planning. This case underscores the importance of considering atypical pseudocyst locations particularly in patients with chronic pancreatitis.