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.
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.
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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
Copyright (c) 2025 International Journal Of Medical Case Reports https://creativecommons.org/licenses/by-nc/4.0
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.
A Single-Session Robotic-Assisted Approach for Renal and Bladder Calculi in a Pancake Kidney: A Rare Case Report
Background: Pancake kidney is an exceptionally rare congenital renal fusion anomaly characterized by complete medial fusion of both kidneys into a single discoid pelvic mass. It is often associated with abnormal rotation and atypical vascular supply. The coexistence of renal calculi and vesical calculus in a pancake kidney is exceedingly uncommon. Management of urolithiasis in this anomaly is surgically challenging due to distorted renal anatomy, short ureters, and limited percutaneous access. Case Report: A 27-year-old male presented with suprapubic pain, dysuria, and intermittent haematuria for one week. Imaging revealed a pelvic pancake kidney with two non-obstructing renal calculi and a large bladder stone. Due to severe mucosal edema preventing identification of the ureteric orifices during cystoscopy, a single-session robotic-assisted laparoscopic pyelolithotomy combined with cystolithotomy was performed. Pyelolithotomy and stone extraction were completed successfully followed by bladder incision and cystolithotomy. Retrograde double-J stenting and bladder reconstruction were performed. Follow-up low-dose CT at 6 weeks demonstrated complete stone clearance, and bilateral stents were subsequently removed. Conclusion: Robotic-assisted pyelolithotomy is a safe, effective, and versatile therapeutic modality for managing complex stone disease in patients with pancake kidney. Single-session combined management of renal and vesical calculi is feasible and minimizes morbidity.
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Pure Isolated Internuclear Ophthalmoplegia As A Presentation Of Midbrain Ischemic Stroke: A Case Report
Background: Internuclear ophthalmoplegia (INO) is a disorder of conjugate eye movements caused by lesions of the medial longitudinal fasciculus (MLF). Demyelination remains the most common etiology, while ischemic causes are less frequently observed. Isolated midbrain infarction presenting exclusively as INO is particularly rare. Case Presentation: A 48-year-old man presented with sudden onset dizziness and unsteady gait. Neurological examination revealed impaired adduction of the right eye with abducting nystagmus of the contralateral eye during left gaze, consistent with right-sided internuclear ophthalmoplegia. Other cranial nerve functions were intact, and systemic examination was unremarkable. Magnetic resonance imaging of the brain demonstrated a small focal acute infarct in the left lower anterior midbrain. Discussion: Most vascular INO lesions are localized to the pontine region; isolated involvement of the midbrain is infrequently reported. The paramedian location of the MLF at the midbrain level explains how small focal infarcts can produce isolated ocular findings without accompanying neurological deficits. Conclusion: Isolated internuclear ophthalmoplegia may be the sole manifestation of midbrain ischemic stroke. Careful ocular motor examination and early neuroimaging are critical for accurate diagnosis of subtle posterior circulation strokes.
Infant with Paediatric Astrocytoma and the “Rescuing Urgency” of Severe Acute Thrombocytopenia: Causally Related or Coincidental?
Although immune thrombocytopenic purpura (ITP) has been associated with solid tumors among adults, this coexistence is exceedingly rare in children. We present an infant with a brain tumor associated with severe acute thrombocytopenia (SAT), which has been very rarely reported in association with pediatric brain tumors. Case Presentation: A 7-month-old male twin presented with a 2-day history of fever and a 1-day history of right subconjunctival haemorrhage that had progressed to involve the left eye. Initial investigations showed severe thrombocytopenia and a provisional diagnosis of ITP was made. He was managed conservatively but he developed a forehead swelling and subcutaneous bruising with minimal improvement in thrombocytopenia. Three days later he had multiple episodes of vomiting, worsening subconjunctival haemorrhage and somnolence. Transfontanelle ultrasound revealed intracranial haemorrhage and computed tomography brain imaging demonstrated left-sided mass effect. He was admitted to the Intensive Care Unit (ICU) and dexamethasone, ceftriaxone, omeprazole and apheresed platelet concentrate were given. Later he was transferred to a specialized neurosurgical facility where he underwent a craniotomy with mass excision of intra-operative astrocytoma (biopsy confirmed). He had a second craniotomy on account of residual tumor tissue revealed on brain magnetic resonance imaging 48 hours after the first surgery. He was subsequently discharged 9 days post-2nd craniotomy after other supportive management and optimisation. Investigations showed dramatic normalization and elevation of platelet count at post-discharge review. This was sustained throughout the follow-up clinic during the 12-week follow-up care with no recurring thrombocytopenia. Patient continued to record significant improvement in the motor function throughout the follow-up clinic. Conclusions: This case highlights severe acute thrombocytopenia as a potential early clinical clue to an underlying intracranial pathology in infants. While a paraneoplastic immune mechanism is hypothesized, the association may also represent a coincidental coexistence. Further studies are required to clarify this relationship
17 Alpha-hydroxylase Deficiency: A Case Of Two Siblings With 46,XX And 46,XY Karyotypes
Background: 17α-hydroxylase deficiency (17α-OHD) is an uncommon autosomal recessive disorder and a rare variant of congenital adrenal hyperplasia (CAH). It results from CYP17A1 mutations leading to impaired cortisol and sex steroid synthesis with consequent compensatory elevations in ACTH and gonadotropins. Patients typically present with hypertension, hypokalemia, primary amenorrhea, sexual infantilism or disorders of sex development (DSD). We describe two siblings who exhibited distinct phenotypes despite sharing the same underlying condition. Case Report: Case 1 was a 36-year-old woman (46,XX) presenting with primary amenorrhea and long-standing hypertension. Clinical assessment revealed presence of partially developed breasts, infantile genitalia and presence of bilateral adrenal hyperplasia. Hormonal studies showed adrenal insufficiency, hypergonadotropic hypogonadism, markedly elevated DOC, and reduced 17-hydroxylated steroids. Treatment with hydrocortisone, estrogen–progesterone replacement, antihypertensives, and osteoporosis therapy resulted in complete pubertal maturation and regular menses. Case 2, her sibling (46,XY) was evaluated at age of 15 years for delayed puberty. The patient had female gender identity and phenotype despite 46,XY karyotype. She was found to have female external genitalia absent Müllerian structures, adrenal insufficiency and biochemical features that were consistent with 17α-OHD. An exploratory surgery was done which identified bilateral intra-abdominal testes. Hydrocortisone, estrogen therapy, and anti-osteoporotic measures were initiated, followed by vaginoplasty and gonadectomy. Conclusion: These cases highlight the importance of knowing phenotypic variability of 17α-OHD in both 46,XX and 46,XY individuals. The diagnosis of 17α-OHD should be considered not only in adolescents with delayed puberty but also in adults. Early recognition enables timely treatment thereby reducing complications such as hypertension and osteoporosis and is associated with improved quality of life.
Olfactory Neuroblastoma Masquerading As Benign Nasal Disease: A Case Report
Background: Olfactory neuroblastoma is a rare neuroendocrine malignancy of the sinonasal tract that frequently mimics benign nasal disease. Clinical features such as nasal obstruction, epistaxis or anosmia may overlap with inflammatory conditions. These overlapping clinical features require a high index of suspicion for early diagnosis and intervention. Advances in imaging, including 68Ga-DOTATATE PET-CT, have improved staging accuracy by targeting somatostatin receptor expression. Patients diagnosed at an early-stage disease can be managed by endoscopic resection often supplemented with adjuvant radiotherapy to optimize local control. Case Report: A 66-year-old African woman presented with a two-year history of progressive unilateral nasal obstruction and intermittent epistaxis. She was initially treated as a case of benign nasal polyp. Postoperative histopathology unexpectedly revealed Hyams Grade 2 olfactory neuroblastoma. Nasal endoscopy demonstrated a mass in the left middle meatus and CT imaging confirmed a well-defined lesion confined to the nasal cavity without bony erosion. 68Ga-DOTATATE PET-CT showed moderate tracer uptake without metastatic spread classifying the tumour as Kadish Stage A. The patient subsequently underwent endoscopic resection of the residual tumour, with histologically clear margins. Adjuvant intensity-modulated radiotherapy (60 Gy in 30 fractions) was administered to reduce recurrence risk while minimizing toxicity to adjacent optic structures. At 12-month follow-up, she remained disease-free with minimal treatment-related side effects. Conclusion: This case underscores the diagnostic challenges involved in management of olfactory neuroblastoma. It further highlights the importance of advanced imaging in cases presenting with persistent nasal masses. Endoscopic resection when combined with targeted radiotherapy offers excellent local control in cases diagnosed at an early-stage.
Severe Thrombocytopenia as a Life-Threatening Complication of Primary Epstein-Barr Virus Infection in a Young Adult: A Case Report.
Abstract: Background: Epstein–Barr virus (EBV) infection commonly manifests as infectious mononucleosis and is usually benign. However hematologic complications such as immune thrombocytopenia may occur and can be severe. Thrombocytopenia identified in the emergency department requires prompt evaluation to rule out life-threatening conditions including disseminated intravascular coagulation, thrombotic microangiopathy, and purpura fulminans. Case Report: A healthy 27-year-old man presented with fever, lumbar pain and dysuria. Initial laboratory testing revealed isolated thrombocytopenia (39 × 10⁹/L) which rapidly deteriorated to < 5 × 10⁹/L within 48 hours. He developed persistent bleeding at a venipuncture site, hemorrhagic oral bullae and purpura. Imaging showed presence of splenomegaly. Peripheral smear showed presence of activated hyperbasophilic lymphocytes. Serologic testing confirmed acute EBV infection. The findings supported a diagnosis of EBV-associated immune thrombocytopenia. The patient was admitted to the intensive care unit due to the high risk of hemorrhage and received intravenous immunoglobulin followed by corticosteroids. Clinical status and platelet counts improved rapidly and patient could be discharged after six days. Conclusion: Acute EBV infection should be recognized as a potential cause of severe isolated thrombocytopenia in adults. Early identification can prevent unnecessary invasive investigations and enable timely initiation of immunomodulatory therapy. Although infectious mononucleosis is usually self-limited its hematologic complications, such as severe thrombocytopenia, may be life-threatening.
Nursing Perspectives on Managing Pregnancy with Unicornuate Uterus: A Case Report.
Background: `Unicornuate uterus is a rare congenital uterine malformation resulting from incomplete development of one of the paired Müllerian ducts. It is associated with adverse reproductive outcomes such as infertility, recurrent pregnancy loss, increased miscarriages, preterm labor and adverse pregnancy outcomes. Diagnosis is often incidental during routine ultrasound or advanced imaging like 3D ultrasonography. Management of pregnancy in women with unicornuate uterus requires a multidisciplinary approach due to the increased risk of cervical insufficiency and other complications. Prophylactic cervical cerclage is considered an effective intervention to prevent preterm birth in such high-risk pregnancies. Nursing care plays a crucial role in antenatal monitoring, patient education, and supporting adherence to treatment plans. Case summary: We report the multidisciplinary management case of a 27-year-old pregnant woman with a unicornuate uterus who conceived naturally and underwent prophylactic cervical cerclage to prevent cervical insufficiency. Emphasizing nursing and midwifery perspectives. Discussion: Our present case study described the successful antenatal management of a 27-year-old woman with a unicornuate uterus. Despite a poor obstetric history observed natural conception and received prophylactic cervical cerclage to prevent cervical insufficiency. Although the patient remained asymptomatic inspite of associated anomalies throughout pregnancy. Early detection through routine ultrasound and 3D imaging enabled timely multidisciplinary intervention. Nurses and midwives played a pivotal role through regular antenatal monitoring, psychological support, and individualized health education. Counseling on signs of preterm labor, activity restriction, and hygiene maintenance empowered the patient to participate actively in her care. This case emphasizes that with early intervention and vigilant nursing care, favorable maternal and fetal outcomes are achievable even in complex pregnancies involving uterine anomalies.
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From Toxin to Triage: Nursing Strategies in Paraquat Poisoning Management.
Background: Paraquat (N,N′-dimethyl-4,4′-bipyridinium dichloride) is a widely used herbicide that is associated with high fatality rates following ingestion. Despite global bans, paraquat remains available in India which is an important factor contributing to intentional and accidental poisonings. Its toxicity results in severe multiorgan dysfunction, particularly pulmonary fibrosis, renal failure, and hepatic injury, with no specific antidote available. Supportive care and evidence-based nursing interventions are therefore central to improving outcomes. Case Report: We report the case of a 19-year-old male who presented to the medical intensive care unit following intentional ingestion of approximately 100 mL of a 24% paraquat solution. The patient developed systemic manifestations including vomiting, respiratory distress, acute kidney injury, hepatic dysfunction and leukocytosis. He required non-invasive ventilation, haemodialysis, and multimodal pharmacotherapy, including N-acetylcysteine, corticosteroids, antioxidants, antibiotics and hepatoprotective agents. Laboratory investigations showed derangements in renal and liver function, elevated bilirubin, and leukocytosis, with gradual biochemical improvement after supportive therapy. Nursing care emphasized airway and oxygenation monitoring, fluid balance, neurological status, infection prevention, and psychological support. Despite aggressive supportive measures, the prognosis in paraquat poisoning remains guarded, underscoring the importance of early recognition, comprehensive medical management, and structured nursing protocols. Conclusion: This case highlights the lethal nature of paraquat poisoning and the absence of a curative antidote. Multidisciplinary collaboration, vigilant nursing interventions, and early supportive care are pivotal in mitigating morbidity and mortality. Nursing strategies that combine physiological monitoring with psychosocial support play a crucial role in patient recovery.
One Anaesthesia, One Surgery: Synchronous Bilateral Robot-Assisted Laparoscopic Pyeloplasty in a 1.5-Month-Old Infant
Background: Robot-assisted laparoscopic pyeloplasty (RALP) is increasingly being utilized for pediatric ureteropelvic junction obstruction (UPJO). It is reported to offer outcomes comparable to open surgery. However, its application in infants is technically challenging due to limited intraperitoneal space and potential instrument collision. In cases of bilateral UPJO, synchronous bilateral repair provides advantages of reduced anesthesia exposure and shorter hospital stay, but its use in very young infants remains scarcely reported. Case Report: We report the case of a 1.5-month-old male with antenatally detected bilateral hydronephrosis. Postnatal imaging and renography confirmed obstructed bilateral UPJO with suboptimal renal function. Following recurrent episodes of urinary tract infection he underwent synchronous bilateral RALP using the da Vinci Si system. Conclusion: This case demonstrates the technical feasibility and safety of synchronous bilateral RALP in very young infants. Benefits of single-stage robotic approach reduces
Uterine Ischemia Secondary to Chronic Procidentia: A Rare Complication of Advanced Pelvic Organ Prolapse
Background: Uterine ischemia is an uncommon condition typically associated with uterine artery embolization or malignancy. Case Report: We report a rare case of uterine ischemia secondary to complete uterine prolapse in a generally healthy 53-year-old woman with fourth degree prolapse (procidentia). The patient had undergone significant weight loss prior to elective pelvic reconstructive surgery. At the time of the planned abdominal subtotal hysterectomy and sacrocervicopexy unexpected findings included uterine ischemia with necrotic areas and diffuse peritoneal inflammation. Due to concerns about tissue integrity the intended procedure was modified. Conclusion: This case highlights a previously unreported complication of advanced uterine prolapse and raises the possibility of vascular compromise exacerbated by mechanical factors and rapid weight loss. Awareness of this rare complication may aid surgical planning in similar cases.
Sinister Masquerade: A Rare Case of Primary Bone Follicular Lymphoma Mimicking Chronic Osteomyelitis and Tuberculosis
Background: Primary bone lymphoma (PBL) is a rare extra-nodal manifestation of non-Hodgkin lymphoma (NHL), constituting less than 1% of all NHLs and approximately 7% of malignant bone tumors. While diffuse large B-cell lymphoma is the predominant subtype, follicular lymphoma (FL) rarely presents as isolated primary bone disease. Accurate histopathological evaluation is therefore pivotal for diagnosis and management. Case Report: We describe a 26-year-old immunocompetent male presenting with progressive pain and swelling over the left humerus. Imaging revealed a destructive lytic lesion with soft tissue extension, initially suggestive of chronic osteomyelitis. Empiric antibiotic and anti-tubercular therapies were initiated without improvement. The patient subsequently developed pathological fracture, chest wall extension, lymphadenopathy, systemic “B” symptoms, and a cavitary lung lesion. Laboratory evaluation revealed anemia, elevated inflammatory markers, and markedly raised β2-microglobulin. Definitive diagnosis was achieved by excisional lymph node biopsy and bone marrow examination, which demonstrated Grade 3A follicular lymphoma with positive immunohistochemistry for CD20, CD10, BCL-2, BCL-6, and C-Myc, and a high Ki-67 index. The patient deteriorated rapidly and succumbed before initiation of definitive oncologic therapy. Conclusion: Primary bone follicular lymphoma represents a rare and diagnostically challenging entity that may masquerade as chronic osteomyelitis or skeletal tuberculosis. This case highlights the need for early consideration of lymphoproliferative disorders in atypical, treatment-refractory bone lesions.
From Blister to Breakthrough: A Case Report on Pemphigus Vulgaris with Early Rituximab Intervention.
Background: Pemphigus vulgaris (PV) is a rare, chronic autoimmune blistering disorder characterized by IgG autoantibodies targeting desmoglein-3. This results in loss of keratinocyte adhesion and intraepidermal blistering. While systemic corticosteroids have historically formed the cornerstone of therapy, long-term use is associated with significant morbidity. Rituximab, an anti-CD20 monoclonal antibody has recently emerged as a first-line agent due to its superior efficacy and safety profile. Early intervention with targeted immunotherapy is critical in improving disease outcomes and minimizing complications. Case Report: We report the case of a 50-year-old woman who presented with a one-month history of painful flaccid bullae and erosive, crusted lesions predominantly affecting the trunk, with extension to the chest, neck, scalp, ears, and oral cavity. Histopathological analysis revealed suprabasal clefting with acantholysis, and direct immunofluorescence demonstrated intercellular IgG deposition in a fishnet pattern, confirming the diagnosis of PV. The patient was started on rituximab as primary systemic therapy, combined with oral prednisolone, topical clobetasol, and dexamethasone elixir as adjunctive treatment. Supportive wound care and prophylactic supplementation with calcium and vitamin D were also provided. At two-week follow-up, the patient demonstrated reduced blister formation, improved healing of erosions, and no treatment-related complications. Conclusion: This case highlights the importance of early diagnosis and initiation of rituximab-based therapy in pemphigus vulgaris. Early intervention with B-cell–directed immunotherapy, combined with corticosteroids and supportive care, can reduce disease activity, limit steroid exposure, and improve long-term prognosis. A multidisciplinary, patient-centred approach remains essential to optimize outcomes in this potentially life-threatening disease.
Eosinophilic Granulomatosis with Polyangiitis Revealed by Cutaneous and Neurologic Manifestations in a Young Woman
Background: Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare immune-mediated vasculitis classified under anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides. It typically involves small- to medium-sized vessels and manifests as a triad of asthma, peripheral eosinophilia, and necrotizing vasculitis with extravascular eosinophilic granulomas. Due to its heterogeneous presentation, diagnosis is challenging and relies on clinical, laboratory, radiological, and histopathological correlation. Case report: We present the case of a 37-year-old woman with a history of asthma who developed painful cutaneous lesions, sensory-motor neuropathy, and respiratory complaints. Laboratory investigations revealed marked leukocytosis with eosinophilia, elevated inflammatory markers, and positive ANA with negative ANCA. Skin biopsy confirmed necrotizing vasculitis with eosinophilic infiltration. Imaging demonstrated bilateral ground-glass opacities and peribronchovascular nodules, while bronchoalveolar lavage showed eosinophilic predominance. Electroneurography indicated early polyneuropathy. Based on asthma, eosinophilia, pulmonary infiltrates, neuropathy, and histological findings, EGPA was diagnosed. The patient was treated with high-dose prednisone and cyclophosphamide pulses, leading to rapid hematological and clinical improvement, including resolution of cutaneous lesions and weight recovery, although neuropathic symptoms persisted. Conclusion: This case illustrates the multisystemic involvement of EGPA and highlights the diagnostic significance of cutaneous findings in the appropriate clinical context. EGPA should be suspected in patients with adult-onset asthma, unexplained eosinophilia, and systemic manifestations, even in the absence of ANCA positivity. Early recognition and initiation of immunosuppressive therapy are crucial to achieve remission and prevent irreversible organ damage.
Eosinophilic granulomatosis with polyangiitis
A Rare Case of Aortic Arch Penetrating Stab Wound Masked and Occluded by Mediastinal Hematoma: A Case Report and Literature Review.
Background: Penetrating injuries to the aortic arch are extremely rare and are associated with a very high prehospital mortality rate. Most patients succumb to massive hemorrhage even before reaching definitive care. In hemodynamically stable patients such injuries may be radiologically silent posing significant diagnostic and therapeutic challenges. Mediastinal hematoma can occasionally tamponade bleeding obscuring radiologic evidence of vascular injury, and delaying intervention. Case Report: An 18-year-old male presented to the emergency department after sustaining a penetrating stab wound over the suprasternal notch. He was hemodynamically stable with no external bleeding or signs of respiratory compromise. Initial investigations including transthoracic echocardiography and noncontrast computed tomography (CT) showed no evidence of major vascular injury however a retrosternal hematoma and mediastinal widening was evident. Surgical exploration via median sternotomy was done which revealed a full-thickness tear at the superior aspect of the aortic arch. This tear was seen to be involving the origins of the innominate and left common carotid arteries. The hematoma had effectively tamponaded the lesion thereby masking active bleeding. Cardiopulmonary bypass was instituted to provide optimal visualization. The tear was successfully repaired and the patient had an uneventful recovery. Conclusion: A high index of suspicion is essential in cases of penetrating chest injuries. Early surgical exploration should be strongly considered when clinical presentation and mechanism of injury raise concern for major vascular trauma regardless of reassuring imaging findings.
Complications of Robotic Gastrointestinal Surgery : A Case Report of An Adhesive Small Bowel Obstruction
Background: Robotic surgery is increasingly used in gastrointestinal surgical procedures for its precision, threedimensional visualization and smaller incisions. However, postoperative complications can still occur including adhesive small bowel obstruction (ASBO). ASBO results from fibrous bands that kink or entrap bowel loops and its diagnosis is primarily clinical and supported by CT imaging. Although overall safety profiles approximate laparoscopy studies have documented postoperative complications after robotic surgery. Case summary: A 74-year-old man underwent robotic umbilical hernia repair with mesh. Four months later, he presented with cessation of stool, abdominal distension and bilious vomiting, with a distended, tympanic abdomen on examination and air–fluid levels on plain radiography. Contrast-enhanced CT demonstrated small-bowel distension with a transition point in the right iliac fossa. Intraoperatively the small bowel was dilated without any signs of ischemia and the obstruction was caused by a fibrous band between the small intestine and mesentery (small bowel–mesenteric adhesion). Adhesiolysis with division of the adhesive band was performed. Bowel transit resumed within 24 hours and the patient was discharged on postoperative day two and had an uneventful 6-week follow-up with return to normal activity. Conclusion: This case highlights ASBO as a potential delayed complication after minimally invasive robotic abdominal surgery even following seemingly straightforward procedures such as umbilical hernia repair with mesh. Early recognition with CT to localize the transition point and timely operative adhesiolysis can yield rapid recovery and excellent short-term outcomes. Vigilance for ASBO should be maintained in post-robotic surgery patients presenting with obstructive symptoms and clinicians should counsel patients regarding this risk despite the overall favorable safety profile of robotic techniques.
Synchronous Breast and Prostate Cancer in a 76-Year-Old Male: A Case Report
Background: Synchronous primary malignancies defined as two or more distinct tumors diagnosed within six months are rare clinical entities. Male Breast Carcinoma (MBC) accounts for less than 1% of all breast cancers and about 1% of male malignancies, whereas prostate cancer is among the most common male cancers globally. Their coexistence is extremely uncommon often raising questions of shared hormonal and genetic aetiologies. Mutations in BRCA genes, particularly BRCA2, increase the risk of both cancers, though sporadic cases without genetic predisposition are also observed. Case Report: We present a 76-year-old male with type 2 diabetes mellitus, ischemic heart disease, and a family history of breast cancer who presented with left nipple retraction and a palpable retro-areolar mass. Ultrasound breast confirmed presence of spiculated mass with microcalcifications and nipple retraction. A biopsy was done which showed grade 3 invasive ductal carcinoma, ER/PR-positive, HER2-negative and Ki-67 50%. PET-CT unexpectedly identified a hypermetabolic prostate lesion. Further evaluation with MRI and targeted biopsy confirmed adenocarcinoma, Gleason score 4+3=7. Prostatic tumor was confined to the left lobe. The patient underwent left mastectomy with sentinel node biopsy (pT2N0) followed by tamoxifen. For the prostate cancer, androgen deprivation therapy was initiated, followed by brachytherapy and external beam radiotherapy. The patient tolerated treatment well and achieved excellent biochemical response with PSA suppressed to 0.012 ng/mL at 11 months without evidence of recurrence. Conclusion: Synchronous male breast and prostate cancer represents an exceptionally rare clinical scenario. This case highlights the importance of high index of suspicion, multimodal imaging and multidisciplinary planning in elderly patients presenting with atypical findings.
Small Bowel Intussusception Secondary to a Peutz-Jeghers Hamartomatous Polyp: A Rare Cause of Acute Abdominal Pain
Background: Intussusception in adults is an uncommon cause of intestinal obstruction, differing from pediatrics cases where idiopathic aetiologies predominate. In adults, it is usually associated with an underlying pathological lead point, frequently neoplastic. Peutz-Jeghers syndrome (PJS), an autosomal dominant disorder characterized by mucocutaneous pigmentation and hamartomatous gastrointestinal polyps, is a rare but important cause. Although PJS predisposes to both benign and malignant neoplasms, small bowel intussusception secondary to hamartomatous polyps is infrequently reported. Case Report: We present the case of a 27-year-old male with no significant past medical history who presented with progressive severe abdominal pain, nausea, and a single episode of vomiting. Physical examination revealed a vague abdominal mass, and laboratory investigations demonstrated leucocytosis and mild lactic acidosis. Contrast-enhanced abdominal CT showed a whirlpool sign and mural hematoma suggestive of volvulus or intussusception. Emergency laparoscopy converted to mini-laparotomy revealed a 20–30 cm ischemic small bowel segment with intussusception approximately 140 cm proximal to the ileocecal junction. A firm intraluminal polypoid lesion served as the lead point. Segmental small bowel resection with primary anastomosis was performed. Histopathological analysis confirmed a Peutz-Jeghers-type hamartomatous polyp without dysplasia or malignancy. The patient had an uneventful postoperative recovery and was discharged in stable condition. Conclusion: This case highlights the diagnostic and therapeutic challenges of small bowel intussusception in adults. Although rare, PJS-related intussusception should be considered in young adults presenting with nonspecific abdominal pain and bowel obstruction. Early recognition with cross-sectional imaging and prompt surgical intervention are essential to prevent ischemia and improve outcomes.Surveillance strategies remain critical in patients with PJS to prevent recurrence and other complications.
Successful Peripartum Management of Placenta Percreta with Bladder Invasion Using Prophylactic Internal Iliac Artery Balloon Occlusion and obstetric hysterectomy: A Rare Case Report.
Out of the placenta accreta spectrum (PAS), Placenta percreta is the most invasive form and it causes significant risk of haemorrhage. Prophylactic bilateral internal iliac artery balloon occlusion (PBO-IIA) has been proposed to reduce haemorrhage during surgical procedure, though its effectiveness remains questionable. We are reporting a case of 29-year-old multigravida (G3 P2 L2) pregnant women at 30 weeks of gestation with prior 2 caesarean sections who was referred to us from district hospital with antepartum haemorrhage first episode . Imaging investigations revealed placenta previa with MRI showing features of placenta accreta spectrum with placenta percreta with possibility of bladder and psoas muscle invasion. Patient was haemodynamically stable . patient was given corticosteroids for lung maturity , magnesium sulphate for neuroprotection, and tranexamic acid to control bleeding . The case was discussed with intervention radiologist and planned for elective cesarean section with prophylactic internal iliac artery ballon placement as and when required. On day 4 of admission , patient had sudden episode of bout of bleeding of around 400 cc blood transfusion started ,, and simultaneously intervention radiologist informed and patient was shifted for mri based PBO-IIA placement . Procedure done and then patient shifted for emergency cesarean, pt was haemodynamically stable . Prophylactic bilateral internal iliac artery balloon occlusion i.e., PBO-IIA was Performed through femoral access before surgical intervention. The balloon of the armada catheter was not inflated till the delivery of baby. The placenta was seen completely invading the myometrium and coming onto the surface and uterovesical plane and therefore the baby was delivered by classical scar and then the decision for hysterectomy taken , Balloons were intermittently inflated and deflated with 10 mins on and 1 min off by radiologist which made the procedure easy and the bladder could be dissected away from uterus with average blood loss and devascularisation helped in delineating the planes clearly. . The patient recovered without any complications. Intraoperatively pt was throughout haemodynamically stable with average blood loss of 1400 cc .and received only 2 units of packed red cells and no other blood products. This case supports the selective use of PBO-IIA in placenta percreta with bladder invasion to assist in surgical treatment of condition with minimal blood loss and less time of surgery .
AN OVERLOOKED TRACHEOBRONCHIAL FOREIGN BODY IN AN IMMUNOCOMPROMISED UNRESPONSIVE PATIENT
Tracheobronchial foreign body (TFB) aspiration is a rare but serious event in adults, often missed due to atypical or nonspecific presentations. We report the case of a 67-year-old male with multiple comorbidities including HIV, hepatitis B, type 2 diabetes mellitus (DM-2), and hypertension (HTN), who was brought to the emergency room in an unconscious state and found to have severe hypoglycaemia. Despite prompt correction, his Glasgow Coma Scale (GCS) did not improve, requiring endotracheal intubation and mechanical ventilation. During his ICU stay, he developed a right-sided pneumothorax on day 3, presumed to be barotrauma-related and managed with an intercostal drain (ICD). Subsequently, the patient developed left lung collapse, prompting flexible bronchoscopy, which revealed a large, previously overlooked intrabronchial foreign body. This foreign body, likely aspirated during his initial unconscious state, was the actual underlying cause of both the right pneumothorax—due to a ball-valve mechanism—and the later left lung collapse following its migration. This case underscores the importance of early suspicion of TFB aspiration in critically ill, neurologically compromised adults, especially in the absence of clear history.