International Journal Of Medical Case Reports
International Journal of Medical Case Reports (ISSN- 2455-0574) is 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 journals main aim is to publish original research papers 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, and interesting image-based short articles and brief communication provided that they are beneficial for other medical professionals. Our emphasis is on publications of case reports by residents working as Junior residents as they come across different cases during their residency. To start with International Journal of Medical Case Reports (IJOMCR)will be published quarterly but sooner 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 requirements as prescribed by International Committee for Medical Journal Editors.
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.
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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.
Copyright (c) 2026 International Journal Of Medical Case Reports
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.
Primary Cutaneous Adenoid Cystic Carcinoma of the Scalp Mimicking Cylindroma on Cytology and Squamous Cell Carcinoma Clinically: A Diagnostic Pitfall with Literature Review
Background: Primary cutaneous adenoid cystic carcinoma (PCACC) is an exceptionally rare neoplasm that poses significant diagnostic challenges. It may clinically mimic SCC due to ulceration, firm consistency, and occurrence in sun-exposed areas, cytological features on fine-needle aspiration cytology (FNAC) closely overlap with those of Cylindroma. Accurate diagnosis is imperative since PCACC and squamous cell carcinoma exhibit aggressive behavior despite an indolent initial course, demanding surgical excision and often adjuvant therapy. Case Report: We report the case of a 67‐year‐old female with a firm, raised scalp swelling with a clinical suspicion of squamous cell carcinoma (SCC). FNAC smears showed clusters of basaloid cells arranged around hyaline globules; the cytomorphology was reminiscent of Cylindroma. However, subsequent histopathological evaluation and immunohistochemistry confirmed the diagnosis of PCACC. Notably, thorough clinical workup excluded lesions in the salivary glands or breast. Conclusion: This report underscores the considerable overlap of clinical features between PCACC and SCC as well as FNAC features between Cylindroma and PCACC and highlights the necessity of integrating clinical, cytological, histopathological, and immunohistochemical data for accurate diagnosis. An extensive review of the literature demonstrates that misdiagnosis based on clinical findings and cytology alone may lead to improper management, given PCACC’s potential for aggressive local invasion and distant metastasis.
Thymoma-Associated Multiorgan Autoimmunity with Concomitant Good’s Syndrome: A Rare Clinical Presentation
Background: Multisystem involvement with fever, arthritis and gastrointestinal symptoms commonly suggests infection or connective tissue disease. Paraneoplastic multiorgan autoimmunity is uncommon and may pose a significant diagnostic challenge. Thymoma is classically associated with myasthenia gravis and presentations with inflammatory arthritis, chronic diarrhoea, mucocutaneous lesions and unexplained fever are rare manifestations. The coexistence of thymoma-associated multiorgan autoimmunity (TAMA) and Good’s syndrome further adds to the diagnostic complexity and carries an adverse prognosis. Case Report: A 42-year-old man presented with three months of intermittent high-grade fever, inflammatory large-joint polyarthritis, chronic non-bloody diarrhoea, mucocutaneous lesions, hyperpigmentation and significant weight loss. Examination revealed fever, hypotension, inflammatory arthritis of knees and ankles, oral ulcers, exfoliative skin lesions and generalized hyperpigmentation. Laboratory evaluation showed elevated inflammatory markers, hypogammaglobulinemia, low serum cortisol and raised fecal calprotectin. Computed tomography performed during evaluation of chronic diarrhoea identified an anterior mediastinal mass. Surgical excision was undertaken, and histopathology confirmed stage IIA thymoma. The clinical picture was consistent with thymoma-associated multiorgan autoimmunity with concomitant Good’s syndrome. Post-thymectomy, the patient showed marked improvement in fever, arthritis, skin lesions, and diarrhoea. Hypogammaglobulinemia and recurrent infections persisted on follow-up. Conclusion: This case highlights an unusual presentation of thymoma with concurrent TAMA and Good’s syndrome. Persistent immunodeficiency despite thymectomy showed the irreversible nature of immune dysfunction seen in Good’s syndrome. Early diagnosis of thymoma as an etiological cause of unexplained multisystem autoimmunity is crucial for early diagnosis and appropriate management.
Primary Extraosseous Plasmacytoma of Pancreas: A Case Report.
Background: Extramedullary (extraosseous) plasmacytoma is an uncommon plasma-cell neoplasm that typically arises in the upper aerodigestive tract; primary pancreatic involvement is exceptionally rare and can mimic other pancreatic head masses. Case Report: A 55-year-old man presented with 3 months of right-sided abdominal pain, dyspnea, and pallor, with examination revealing anemia and a palpable right abdominal lump. Hemoglobin was 7.8 g/dL. Abdominal ultrasonography showed a large heterogeneous mass. ^18F-FDG PET/CT demonstrated a 6.5 × 8.3 × 10.1 cm heterogeneously enhancing lesion with internal calcifications in the pancreatic head extending to the periportal region, encasing the hepatic artery and compressing the portal vein with collateral formation, with intense FDG uptake (SUVmax 10). Endoscopic ultrasound-guided core biopsy (22G) revealed sheets of mature and atypical plasmacytoid cells, raising suspicion for a plasma-cell neoplasm. Immunohistochemistry showed tumor positivity for EMA, CD138, CD38, kappa light chain, and MUM1, and negativity for cytokeratin, lambda, CD20, CD3, synaptophysin, IgG4, EBER, and chromogranin—supporting a clonal plasma-cell process. Comprehensive evaluation for multiple myeloma (bone marrow aspiration, skeletal survey, serum/urine electrophoresis, and serum immunofixation) was negative; serum β2-microglobulin was elevated with an abnormal serum free light-chain ratio but insufficient for diagnosing systemic myeloma. A diagnosis of primary extraosseous pancreatic plasmacytoma was made. The patient received packed red blood cell transfusions and was referred for definitive external-beam radiotherapy. Conclusion: Primary pancreatic plasmacytoma should be considered in hypermetabolic pancreatic head masses with plasmacytoid histology; EUS-guided biopsy with immunophenotypic confirmation and systematic exclusion of multiple myeloma are essential, and local radiotherapy remains the mainstay of treatment.
Endoscopic Ultrasound-Guided Fine Needle Aspiration
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Roseomonas bacteremia: A clue to underlying severe combined immunodeficiency.
Background: Severe combined immunodeficiency (SCID) is a rare but fatal inborn error of immunity characterized by profound defects in cellular and humoral immunity. It predisposes infants to severe, recurrent opportunistic infections. Unusual or low-virulence pathogens may serve as early clinical clues to an underlying immunodeficiency. Roseomonas species are slow-growing, gram-negative bacilli with low pathogenic potential and are rarely implicated in paediatric infections and predominantly affect immunocompromised hosts. Case Report: A 40-day-old male infant with an unremarkable perinatal history presented with high-grade fever and elevated inflammatory markers. Evaluation showed leukocytosis, raised C-reactive protein and multiple hepatic microabscesses on ultrasonography. Cerebrospinal fluid analysis was unremarkable. During hospitalisation, he developed multiple pustular skin lesions and blood culture grew a slow-growing Roseomonas species identified by the VITEK system. Antibiotics were adjusted according to susceptibility which led to clinical improvement and resolution of hepatic abscesses. Owing to the unusual organism and hepatic abscesses, an inborn error of immunity was suspected. At nine months of age, the child was hospitalised again with recurrent lower respiratory tract infections, pneumonia, mucocutaneous candidiasis and failure to thrive. Immunological workup revealed markedly reduced CD3 and CD56 cells with hypogammaglobulinemia, absence of the thymic shadow on chest radiography. Genetic studies confirmed X-linked SCID due to a hemizygous stop-gain mutation in IL2RG gene. He was referred for hematopoietic stem cell transplantation. Conclusion: Paediatricians should maintain a high index of suspicion for inborn errors of immunity in infants presenting with unusual or opportunistic infections including Roseomonas infection. This will enable early diagnosis and appropriate interventions at an early and appropriate time.
Spinal anesthesia for scheduled cesarean delivery in a patient with phacomatosis pigmentovascularis type V.
Background: Phacomatosis pigmentovascularis (PPV) is a rare and usually sporadic congenital disorder marked by the coexistence of vascular malformations and pigmentary mosaicism. Although many patients have predominantly cutaneous disease, extracutaneous involvement (neurologic, ophthalmologic, musculoskeletal, and vascular) has been reported. In pregnancy physiological changes and peripartum hypercoagulability may exacerbate vascular complications. In these cases safety of neuraxial anesthesia depends on careful assessment for neuraxial or intracranial vascular malformations and appropriate anticoagulation management. Case report: A 30-year-old primigravida at 39 weeks’ gestation with PPV type V (phacomatosis cesiomarmorata; cutis marmorata telangiectatica congenita with dermal melanocytosis) was scheduled for elective cesarean delivery. Comorbidities included bilateral ocular melanosis with raised intraocular pressure and a prior right lower-limb deep venous thrombosis 4 years earlier. Pregnancy was otherwise uncomplicated apart from diet-controlled gestational diabetes. She received enoxaparin 40 mg twice daily during pregnancy, brinzolamide eye drops and cetirizine. Enoxaparin was withheld for 24 hours preoperatively. Examination revealed characteristic pigmentary lesions; cardiopulmonary and neurologic findings were normal. Hematologic and coagulation tests and echocardiography were unremarkable. Electrocardiography showed a short PR interval. Following multidisciplinary review, spinal anesthesia was performed at L4–L5 with hyperbaric bupivacaine 10 mg, fentanyl 20 μg, and morphine 100 μg. Cesarean delivery and recovery were uneventful with stable hemodynamics and effective postoperative analgesia. Conclusion: Cesarean delivery under spinal anesthesia can be safely accomplished in pregnant women with PPV when individualized multidisciplinary evaluation excludes clinically significant systemic involvement. Neuraxial risk is minimized through strict anticoagulation timing and vigilant perioperative monitoring.
Hypoglossal Nerve Schwannoma Masquerading As A Plunging Ranula: A Diagnostic Pitfall In Submandibular Masses.
Background: Schwannomas are benign, encapsulated peripheral nerve sheath tumors that most commonly arise from the vagus nerve or sympathetic chain in the neck. Extracranial schwannomas of the hypoglossal nerve are distinctly rare and may be clinically silent. When cystic degeneration predominates, these tumors can radiologically mimic common cystic lesions of the submandibular region, particularly plunging ranula, and fine-needle aspiration cytology (FNAC) may be non-diagnostic due to hypocellular aspirates. Awareness of this masquerade is important for appropriate preoperative planning and nerve-preserving surgery. Case report: A 57-year-old man presented with a progressively enlarging, painless right submandibular swelling for 6 months. Examination revealed a well-defined, firm, mobile, non-tender mass (~3 × 3 cm) without overlying skin changes, floor-of-mouth swelling, cervical lymphadenopathy, or apparent cranial nerve deficits. FNAC was non-contributory. Contrast-enhanced computed tomography demonstrated a well-circumscribed hypodense lesion in the right submandibular space (approximately 2.7 × 6.3 × 3.4 cm) extending superiorly toward the sublingual region and compressing the submandibular gland without invasion, leading to a provisional diagnosis of plunging ranula. Surgical excision was performed with removal of the presumed ranula, sublingual gland, and right submandibular gland. Histopathology of the neck mass showed a circumscribed spindle cell neoplasm with Antoni A and Antoni B areas and Verocay bodies, with focal hyalinized thick-walled vessels. Tumor cells were diffusely positive for S100 and SOX10 and negative for CD38 and CD163, confirming schwannoma. The submandibular gland showed chronic sialadenitis. Conclusion: Hypoglossal nerve schwannoma should be considered in the differential diagnosis of “ranula-like” cystic submandibular swellings, particularly when FNAC is inconclusive. Definitive diagnosis relies on histopathology and immunohistochemistry, and preoperative suspicion may facilitate nerve-conscious surgical management.
Uterine Rupture in a Multiparous Woman with Previous Spontaneous Vaginal Deliveries: A Rare Case Report
Background: Uterine rupture is an uncommon but life-threatening obstetric emergency. Classical risk factors include previous cesarean delivery, uterine surgery, labor induction or obstructed labor. It is particularly uncommon in women with an unscarred uterus. However, spontaneous rupture may still occur in multiparous women without identifiable predisposing factors. Advanced maternal age and cumulative myometrial thinning from repeated pregnancies have been suggested as potential contributors. Because clinical manifestations may be subtle, diagnosis can be challenging leading to delayed intervention and significant maternal and fetal morbidity. Case Report: We report the case of a 40-year-old gravida 3, para 2 woman at 33 + 1 weeks’ gestation who initially presented with mild abdominal pain and reassuring maternal and fetal evaluations. She had two prior uncomplicated spontaneous vaginal deliveries but no history of cesarean section, uterine instrumentation, or use of uterotonics. Twelve hours after discharge, she returned with severe abdominal pain, hemodynamic instability, and fetal demise. Emergency laparotomy revealed a 7-cm longitudinal fundal rupture of an unscarred uterus with complete extrusion of the fetus and placenta into the peritoneal cavity, accompanied by massive hemoperitoneum. The uterus was repaired, and the patient required extensive transfusion support. Postoperatively, she developed acute respiratory distress syndrome, aspiration pneumonia, and acute kidney injury, necessitating intensive care management. She eventually recovered and was later extubated on postoperative day 7 and was discharged on day 14. Conclusion: Spontaneous uterine rupture can occur in multiparous women without any previous uterine surgery and may present with nonspecific symptoms leading to delayed diagnosis. Treating obstetricians should maintain a high index of suspicion for possibility of uterine rupture in any pregnant patient presenting with acute abdominal pain. Timely diagnosis and early intervention is essential to prevent maternal as well as fetal morbidity and mortality.