Reports, Volume 8, Issue 2 (June 2025) – 63 articles

Background and Clinical Significance: Perforation of the left ventricle related to microaxial ventricular assist devices (Impella) is a rare but fatal complication related to placement or adjustment. It results in left ventricular hemorrhage and tamponade, leading to rapid deterioration and death. Case Presentation: We present a case report of a 73-year-old man who developed this complication postoperatively and was successfully managed to a full recovery. Conclusions: To our knowledge, he is the only reported patient to have this complication outside the setting of immediate placement who subsequently survived to discharge. Full article

Background and Clinical Significance: The incidence of persistent ductus arteriosus (PDA) in preterm infants is the highest and depends on their birth weight (BW) and respiratory condition after birth. Previously, after the unsuccessful drug treatment, surgical ligation was the primary treatment option. However, according to clinical studies, the Amplatzer Piccolo Occluder was approved for PDA closure for patients ≥700 g. In our country, percutaneous PDA embolization has not been performed yet. Case Presentation: We present three premature infants with hemodynamically significant patent ductus arteriosus (hsPDA) in whom percutaneous occlusion was performed using the Amplatzer Piccolo Occluder (APO). The average gestational week (GW) was 27 ± 1, while body weight was 1030 ± 60 g. All patients had respiratory deterioration, with dilatation of the left heart chambers, and renal failure. The second developed a severe form of broncho-pulmonary dysplasia. Transthoracic echocardiography (TTE) examinations revealed a hemodynamically significant PDA (LA/Ao 1.8–2.2) and medical closure was unsuccessfully carried out. Due to the hemodynamically significant PDA maintenance in all neonates, transvenous PDA closure was performed using the APO (APO 9-PDAP-04-02-L, 9-PDAP-04-04-L, 9-PDAP-05-054L, respectively). The entire devices, with both retention discs, are implanted within the duct. TTE pointed out adequate device position without descending aorta, left pulmonary artery obstruction, residual shunt, and reverse remodelling of the left ventricle and left atrium. The first newborn was weaned from mechanical ventilation three days after the procedure and discharged three weeks after. The second patient was extubated 2 weeks after the procedure, and even the severe BPD, X-ray showed improvement. The third patient’s renal failure completely resolved, weaned from inotropic drug support and mechanical ventilation. Conclusions: Due to a significantly lower complication rate than surgical ligation, we will strive to make percutaneous PDA occlusion a new standard for treatment in newborns, especially preterm newborns, in our country. Full article

Background and Clinical Significance: The mesenchymal–epithelial transition (MET) exon 14 skipping mutation (METex14) is a rare genetic alteration occurring in non-small cell lung cancer (NSCLC). Tyrosine kinase inhibitors (TKIs) are the approved treatment for first-line therapy in a metastatic setting. However, the unusual presentation of gastrointestinal metastasis and leptomeningeal carcinomatosis (LMD) poses significant treatment challenges. Case Presentation: Here we report a case of a 72-year-old male with metastatic METex14-positive NSCLC, presenting with brain and duodenal metastases. Conclusions: The patient responded exceptionally well to first-line chemoimmunotherapy, achieving clinically complete remission for 2 years. He subsequently developed cerebellar metastasis and leptomeningeal disease (LMD) but demonstrated a remarkable response to tepotinib and continued to enjoy radiographic complete remission over 2.5 years at the time of this report. Full article

Background and Clinical Significance: Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening condition, often triggered by infections or undiagnosed diabetes. Spontaneous pneumomediastinum (SPM) and pneumothorax are rare but recognized complications of DKA, possibly due to alveolar rupture from increased respiratory effort or vomiting. Sometimes, acute pancreatitis (AP) may further complicate DKA, but the co-occurrence of these three conditions remains exceptionally rare. Case Presentation: We describe the case of a 60-year-old woman without a known history of diabetes who arrived at the emergency department with abdominal pain, fatigue, vomiting, and altered mental status. Initial laboratory findings showed metabolic acidosis, hyperglycemia, and elevated anion gap, consistent with DKA. Imaging revealed spontaneous pneumomediastinum and subsequently a left-sided pneumothorax, without evidence of trauma or esophageal rupture. Epigastric pain, along with elevated serum lipase and CT findings, also confirmed acute pancreatitis. Despite the complexity of her condition, the patient responded well to supportive treatment, including oxygen therapy, fluid resuscitation, insulin infusion, and antibiotics. She was discharged in good condition after 28 days, with a confirmed diagnosis of type 2 diabetes, without further complications. Conclusions: This case highlights an unusual combination of DKA complicated by spontaneous pneumomediastinum, pneumothorax and acute pancreatitis in a previously undiagnosed diabetic patient. Because prompt intervention can lead to favorable outcomes even in complex, multisystem cases, early recognition of atypical DKA complications is critical in order to avoid misdiagnosis. Full article

Background and Clinical Significance: Mitral valve prolapse (MVP) is commonly benign, but may result in life-threatening arrhythmias and sudden cardiac death (SCD). Mitral annular disjunction (MAD) often coexists with mitral valve prolapse (MVP) and has been implicated in the development of ventricular arrhythmias through myocardial stretch and fibrosis. Case Presentation: Here, we present a case that highlights the diagnostic value of multimodal imaging in evaluating ventricular ectopy in the context of MVP and MAD. A 72-year-old male presented to the cardiology clinic with palpitations and fatigue, compounded by an arrhythmia identified by his Apple Watch. Holter monitoring revealed premature ventricular contractions (PVCs), with cardiac magnetic resonance imaging (CMR) demonstrating MAD and basal inferolateral scarring. Despite minimal symptoms and normal echocardiographic imaging, CMR findings highlight the utility of advanced cardiovascular imaging in patients with newly detected ventricular arrhythmias. Conclusion: This case highlights the importance of integrating consumer wearables and advanced imaging in evaluating ventricular ectopy and its evolving role in risk stratification for patients with MVP, even in the absence of overt symptoms. Full article

Background and clinical significance: Functional/dissociative seizures (FDSs) in adolescents are paroxysmal events which superficially resemble epileptic seizures or syncope. This study evaluated the effectiveness of brief cognitive analytic therapy (CAT). Case presentation: The patient was a 17-year-old white cisgender male with a diagnosis of non-epileptic attack disorder. The functional/dissociative seizures were treated with 8-session CAT, with follow-up at 5 weeks. Two target problems (TPs) and associated target problem procedures (TPPs) were rated for recognition and revision at each session and at follow-up. An A-B-C-FU single-case experimental evaluation of the TP/TPPs was conducted. Nomothetic outcome measures (DES-2 and RCADS) were administered at session 1, session 8, and at follow-up, and the YP-CORE and the Session Rating Scale were completed at each session. The patient was independently interviewed using the Change Interview 13 weeks after completing therapy. The results show that CAT effectively increased the recognition and revision of TPs/TPPs, four specific changes occurred (including cessation of functional seizures). There were pre–post reliable and clinically significant improvements to psychological wellbeing, but these were not maintained at follow-up. Conclusions: This study indicates that CAT was a partially effective intervention. The use of CAT as a treatment for FND in adolescents holds promise, but more research is needed. Full article

Background and Clinical Significance: To describe the effectiveness of alveolar ridge preservation under the radiological and histological analysis of a customized resorbable scaffold three-dimensionally printed with polycaprolactone (PCL) reinforced with a coating of a copolymer of polycaprolactone-block-polyethylene glycol (PCL–PEG) by electrospray. Case Presentation: A 62-year-old male with vertical root fractures of teeth #14 and #15. From the cone beam CT (CBCT) image, the scaffold root replicas were designed with the shape of the roots and printed with PCL coated with PCL–PEG by electrospray. The scaffold was inserted into the alveolar bone and maintained with a tension-free flap closure. After six months, a CBCT of the surgical site and histological analysis of a bone sample at the dental implant installation site were performed. After 6 months, the wound in tooth #14 was closed, clinically proving no adverse reaction or complications. The histological analysis of the bone sample showed new bone formation with lamellar structure, Haversian canal structure, and osteocyte spaces. However, the scaffold in tooth #15 was exposed and not osseointegrated, and it was covered with membranous tissue. Histologically, the sample showed tissue compatible with lax connective tissue with mixed inflammatory infiltrate. In tooth #14, the dental implant presented an insertion torque >35 Ncm and was rehabilitated three months after its installation. Conclusions: Three-dimensional printed PCL scaffolds showed the ability to regenerate vital and functional bone with osseointegration capability for maxillary bone regeneration and oral rehabilitation based on dental implants. A case of inadequate scaffold osseointegration accompanied by lax connective tissue formation is shown. Full article

Background and Clinical Significance: Implantation of an embryo in the cervical canal is the rarest location of ectopic pregnancy, as it occurs between 1 in 1000 and 1 in 18,000 pregnancies. Dilation and curettage in previous pregnancies have been identified as risk factors in most cases. Other predisposing factors include pelvic inflammatory disease (PID), prior tubal surgeries, assisted reproductive technologies, as well as the presence of fibroids and intrauterine. Importantly, ectopic pregnancies are the main cause of maternal morbidity and mortality in the first trimester. Given the rarity of cervical ectopic pregnancies (CEPs) and the lack of specific recommendations, clinical data supporting current evidence is of utmost significance. Case Presentation: A 29-year-old nulliparous woman presented with spotting from the genital tract and lower abdominal pain persisting for four days. Pregnancy could not be ruled out based on the patient’s medical history. The level of β-Human chorionic gonadotropin (β-HCG) on admission was 1487.99 mIU/mL. The first ultrasonography examination revealed a non-specific imaging appearance suggestive of the presence of cervical mucus. Targeted examination with visualization of the cervical canal revealed a gestational sac measuring 4–5 mm in diameter, containing an embryonic echo. The patient was treated with 84 mg of methotrexate (MTX) i.v. in a 1, 3, 5, 7 scheme along with 0.1 mg/kg calcium folinate i.m. in a 2, 4, 6, 8 scheme prior to curettage. Conclusions: A diagnosis of cervical pregnancy cannot be excluded even in the absence of prior risk factors. Methotrexate should be considered a safe and efficient option in the management of CEP. As shown in our case, early detection of CEP is of utmost significance. Full article

Background and Clinical Significance: Papillary Fibroelastoma is a benign primary cardiac tumor, commonly located in a valvular position, predominantly on the aortic valve. Case Presentation: We present a 73-year-old male patient with a medical history of chronic lymphatic leukemia, kidney failure, diabetes, and obstructive sleep apnea. In a routinely performed echocardiogram an abnormal structure in the left ventricle was found. The patient presented completely asymptomatically at the time of examination. A cardiac magnetic resonance-scan provided further information about the size and localization of the tumor in the left ventricle, which seemed to be attached to a papillary muscle and was about 1.6 cm in diameter. Due to visible scarring of the myocardia, which was identified in the scan, a cardiac catheter examination was performed. A coronary artery disease was detected with a severe stenosis in three vessels. During an elective bypass-operation, the removal of the structure was performed with an approach through the left atrium, passing the mitral valve using a valve sizer for better exposure. The tumor of 1 cm presented macroscopically with an anemone-like shape. The histopathological examination confirmed the intraoperative assumption of a papillary fibroelastoma, found in an aberrant location. Conclusions: Unexpectedly challenging surgical removals of structures in the left ventricle require innovative techniques with available instruments for better exposure. Full article

Background and Clinical Significance: Non-prosthetic peri-implant fractures (NPPIFs) are rare injuries occurring around internal fixation devices, and are distinct from periprosthetic fractures. While most studies focus on the femur, humeral NPPIFs remain poorly documented. This case illustrates a complex humeral NPPIF and highlights key surgical considerations. Case Presentation: A 62-year-old woman presented with a spiral humeral shaft fracture (AO 12B2) after a fall. Following closed reduction and antegrade intramedullary nailing, an intraoperative peri-implant fracture occurred at the distal interlocking screw. CT imaging revealed a complex fracture extending from the lateral condyle to the proximal humerus. Treatment included implant removal and open reduction with dual plate fixation—lateral distal and helically contoured proximal plates—plus cerclage bands and antibiotic-loaded beads. Recovery was uneventful, with a full range of motion achieved at six months. At one year, the DASH score and MEPS were 86 and 75, respectively. Conclusions: Humeral NPPIFs are challenging and require individualized, biomechanically sound strategies. This case reinforces the importance of intraoperative assessment and careful implant selection in humeral fracture management. Full article

Background and Clinical Significance: Local anesthetic injections, routine in dental practice, ensure pain control during procedures like root canal treatments. Though generally safe, they can occasionally cause hematomas, localized blood accumulations in tissue planes. Rapidly expanding hematomas in the head and neck are exceptionally rare but dangerous due to anatomical complexity, potentially threatening the airway. This case report emphasizes the critical need for the prompt recognition and management of such complications to prevent life-threatening outcomes, highlighting vigilance in routine dental procedures. Case Presentation: A 63-year-old male presented with rapidly enlarging right buccal swelling four hours post-local anesthetic injection for a root canal on a right maxillary molar. Examination showed warm, erythematous edema and buccal ecchymosis; a CT scan confirmed a 3.8 cm × 8.4 cm × 5.5 cm buccal space hematoma. His medical history revealed controlled type 2 diabetes and hyperlipidemia, and his coagulation was normal. Conservative management failed as the hematoma progressed, limiting mouth and eye opening. Urgent surgical decompression under general anesthesia evacuated clots and ligated facial and angular arteries. ICU monitoring ensured airway stability, with discharge on day three with antibiotics and follow-up. Conclusions: This case highlights the rare potential for dental anesthetic injections to cause rapidly progressive hematomas, requiring urgent surgical intervention and multidisciplinary care to prevent airway compromise. Early recognition, imaging, and decisive management are vital in achieving favorable outcomes in such serious complications. Full article

Background and Clinical Significance: Ventricular septal defect (VSD) is a rare but serious complication following myocardial infarction (MI) that can lead to cardiogenic shock and carries a high mortality rate. Acute mitral regurgitation (MR) is another severe complication of MI with additional risks of mortality. The optimal timing of surgical intervention for VSD with MR is still being debated, and delaying surgery in medically manageable patients has been associated with improved survival. However, managing these patients in the intensive care unit (ICU) presents unique challenges. Case Presentation: In this paper, we present the case of a 52-year-old male with comorbidities who developed post-MI VSD with severe MR and underwent successful delayed surgical repair and mitral valve replacement. Our aim is to highlight the clinical characteristics, diagnostic approach, and management strategies of this rare complication in the critical care setting. The patient presented in cardiogenic shock and acute pulmonary edema. After stabilization using an intra-aortic balloon pump, pre- and afterload reducing pharmacotherapy and non-invasive mechanical ventilation, a watchful waiting strategy was employed, and surgery was performed on day 21 after hospital admission. Surgery was performed under general anesthesia, and the patient did not develop any complications related to the intra-aortic balloon pump or novel organ dysfunction. Conclusions: This case highlights the importance of a multidisciplinary approach to managing post-MI VSD with MR and emphasizes the need for careful patient selection and timing of surgical intervention in the critical care setting. Clinicians should be aware of the potential benefits of delaying surgical intervention in medically manageable patients, while also considering the unique challenges of managing these patients in the ICU. Full article

Background and Clinical Significance: This case presents a rare variation in mesenteric and pelvic vasculature that holds relevance for endovascular procedures. Limited published cases of the testicular artery arising off the inferior mesenteric artery exist in the literature and play an important role in clinical outcomes. Case Presentation: An 89-year-old male presented with gastrointestinal bleeding from diverticulosis. During an arteriogram to locate and assess sigmoid arteries for embolization, an unusual anatomical variant of the left testicular artery was discovered. Typically, the left testicular artery originates from the abdominal aorta below the renal arteries. However, in this patient, the left testicular artery was found to directly branch off the inferior mesenteric artery, while the superior rectal artery was absent from the inferior mesenteric artery. Conclusions: Awareness of such vascular variations is essential for interventionalists to optimize procedural success and minimize complications. Recognizing potential vascular anomalies, such as those presented in this case, is essential for effective pre-procedural planning and intraoperative management to improve patient outcomes. Full article

Background and Clinical Significance: Kidney transplantation remains the most effective method of renal replacement therapy. Living donor transplantation offers several advantages—reduced cardiovascular risk, better graft survival, and preemptive intervention. However, donor obesity is a growing concern, as it is usually associated with perioperative and long-term complications, which can affect donor eligibility. Bariatric surgery is a standard recommendation for patients with a BMI over 35 kg/m². There are limited data on the use of pharmacological agents for weight reduction in kidney donors. This case presents a successful conservative treatment with GLP-1 receptor agonist in an obese woman wishing to donate a kidney to her son. Case Presentation: We are presenting the case of a 63-year-old woman with grade II obesity who was initially denied being a kidney donor to her son because of her weight. Under these circumstances, she underwent comprehensive lifestyle modification in the cardio-obesitology clinic (caloric restriction, physical activity, and pharmacological treatment with liraglutide). During the 3-month follow-up, she decreased her BMI to 33.4 kg/m², and subsequent examinations confirmed no surgical contraindications to donating a kidney. Despite hematuria, biopsy and genetic testing revealed a benign carrier condition of Alport syndrome, which, without proteinuria or renal impairment, allowed successful kidney donation. Conclusions: This case demonstrates that conservative pharmacological treatment for body weight reduction with GLP-1 receptor agonists may be an alternative to bariatric surgery for selected obese kidney donor candidates. The presented case highlights the importance of a multidisciplinary and personalized approach. Full article

This case study presents the long-term management of a 14-year-old male diagnosed with 18q deletion syndrome, also known as de Grouchy Syndrome, highlighting the challenges of treating rare chromosomal disorders in rural Romania. Background and Clinical Significance: 18q deletion syndrome, also known as de Grouchy syndrome, is a chromosomal disorder caused by the deletion of a part of the long arm of chromosome 18. This syndrome is seen in one out of 10,000 live births. The main features of the syndrome are short stature, hearing loss, hypotonia, mental retardation, endocrine disorders, and autoimmunity. Case Presentation: The patient’s condition was initially suspected at birth due to abnormal features and was later confirmed through genetic testing, revealing a 46,XY,del(18) karyotype. Key clinical features include craniofacial dysmorphism, delayed growth, congenital cardiac anomalies, developmental delay, severe neurological impairment, and multiple comorbidities such as endocrine dysfunction, dental anomalies, and orthopedic deformities. Despite early interventions such as cardiac surgery, the patient’s management has been challenged by limited access to specialized care. Conclusions: The case underscores the importance of timely genetic testing, early multidisciplinary care, and the role of family support in managing complex disorders. This report also addresses the gaps in healthcare accessibility in rural settings and emphasizes the need for improved infrastructure and genetic services. By comparing this case with the existing literature, the study explores the variability in clinical presentations of 18q deletion syndrome and advocates for more precise genetic testing to better understand its phenotypic spectrum. The patient’s ongoing challenges with medical and socio-economic factors emphasize the critical need for coordinated care and family support in managing rare genetic conditions. Full article

Background: Deep vein thrombosis (DVT) management remains challenging despite standard anticoagulation therapy. This study evaluated the comprehensive benefits of combining rivaroxaban with Aescuven (CAV) compared to rivaroxaban monotherapy (SAT) in DVT treatment. Methods: A retrospective analysis was conducted on DVT patients (2018–2023) using multi-method propensity score matching and ensemble weighting. Outcomes included improvement rate (IPR), daily improvement rate (DIR), cost-effectiveness ratio (CER), daily improvement cost (DIC), cost–LOS efficiency (CLE), and length of stay (LOS). Counterfactual analysis was implemented to estimate causal effects. Results: The CAV group demonstrated superior outcomes compared to SAT: IPR increased by 6.39 percentage points (95% CI: 5.61–7.39), DIC substantially reduced by 3323.38 CNY (95% CI: 2887.95–3758.81), and CLE improved by 136.97 CNY per day (95% CI: 122.31–151.64), with minimal LOS increase (0.15 days, 95% CI: 0.12–0.18). Network analysis revealed significant correlations between baseline coagulation parameters and treatment outcomes, particularly between APTT and economic benefits. Conclusions: The CAV regimen achieved significant clinical and economic advantages over standard monotherapy without substantially increasing resource utilization. These findings support integrating venoprotective agents into conventional anticoagulation strategies for optimized DVT management. Full article

Background and Clinical Significance: Gastrointestinal bleeding is a critical medical emergency, with upper gastrointestinal bleeding occurring approximately five times more frequently than lower gastrointestinal bleeding (LGIB). The incidence of LGIB tends to increase with age, likely due to a greater prevalence of vascular and diverticular diseases among older patients. However, there are rare or extremely rare causes of LGIB that demand significant diagnostic and therapeutic efforts, some of which may pose unexpected challenges during surgery. Case report: We present the case of a 75-year-old woman, previously treated for a cecal neoplasm 15 years ago, who was hospitalized due to intermittent lower gastrointestinal bleeding over the past three months. Initially, the patient declined a colonoscopic examination, and the bleeding stopped spontaneously. She was then discharged at her own request in stable condition. However, she returned with a recurrence of the bleeding. While preparing for a colonoscopy, she experienced subocclusive symptoms, abdominal distension, and vomiting. During emergency surgery, a floating coprolith, which was attached to one of the anastomosis sutures, was sensed through palpation and later confirmed via colotomy. The coprolith was removed, and hemostasis was achieved in situ, leading to a favorable postoperative recovery and normalization of intestinal transit. A literature review identified 24 articles that met the eligibility criteria concerning rare causes of LGIB. Appendiceal bleeding (due to erosions, arteriovenous malformations, or endometriosis) was the most common cause, whereas the rarest causes included jejunal hemangiomas and rectal ulcers resulting from mucormycosis. Diagnosing these conditions is often challenging, typically requiring CT scans, colonoscopy, and angiography, with surgical treatment being the primary method to ensure hemostasis. In conclusion, the diagnosis and management of LGIB present significant challenges for clinicians, and successful outcomes are usually achieved through a collaborative multidisciplinary team approach. Full article

Background and Clinical Significance: Osteomas of the mastoid process are extremely rare tumors. In their development, they are usually asymptomatic, they can manifest with cosmetic deformity, pain, hearing loss, and weakness of the facial nerve. Case Presentation: We present a clinical case of a 13-year-old girl with complaints of swelling in the area behind the left pinna, which was painless but created a cosmetic defect and an unpleasant sensation. She reported no pain in the ear and no hearing loss. An otorhinolaryngological examination, an audiometry of the patient, and a computed tomography of the head, temporal bones, and middle and inner ear were performed. The test results showed that hearing was not affected, and the tumor in the area of the mastoid process was approximately 3 cm in diameter, sitting “on top” of the mastoid process. Extirpation of the osteoma was performed with a retroauricular approach. The patient had a short postoperative period without any complications. Conclusions: Mastoid osteomas are rare, benign, slow-growing, and frequently asymptomatic bone tumors. Other bone lesions of the mastoid region should be ruled out in the differential diagnosis. Surgery is the treatment of choice and should be performed in the presence of symptoms or for cosmetic reasons. Full article

Background and Clinical Significance: Altered pain perception is a diagnostic challenge for patients with a history of trauma and substance use. Familial dysautonomia (Riley-Day syndrome) may further complicate the sensory profiles. Case Presentation: We describe a male in his late twenties, originally from Central America, with a history of severe childhood trauma and chronic cannabis use, who reported diminished pain perception despite multiple injuries. Despite the absence of nociceptive pain (nociceptive hypoesthesia), abnormal sensations, such as tingling and itching (paresthesia), and occasionally unpleasant burning sensations (dysesthesia) were common symptoms in this case. Diagnosis: Clinical suspicion of familial dysautonomia was raised based on altered pain perception and minor autonomic signs. However, no genetic testing or neurological evaluation was performed. Psychological assessment revealed high levels of neuroticism, depression, and maladaptive coping. The Central Sensitization Inventory (CSI) and the Symptom Severity Scale (SS) further supported the presence of psychological symptoms suggestive of possible central sensitization. Outcome: Functional improvement was observed after a reduction in substance use and implementation of self-directed physical and cognitive rehabilitation. No standardized follow-up or formal interventions were recorded. Conclusions: This case illustrates the complexity of pain modulation in trauma-affected individuals and emphasizes the need for an integrative, interdisciplinary evaluation of atypical pain presentations. Full article

Background and Clinical Significance: The deer horn sign is an ultrasonographic (US) finding suggesting congestive hepatopathy. It is composed of dilated intrahepatic inferior vena cava (IVC) representing the deer’s head and dilated hepatic veins (HVs) representing its horns. Case Presentation: A 72-year-old female patient presented with a one-week history of dull pain in the right upper abdominal quadrant. Her medical records showed that she had previously experienced cardiovascular problems; however, she is without any recent heart failure symptoms. The transabdominal US demonstrated the deer horn sign and hemodynamic changes in the hepatic venous drainage, which is suggestive of congestive hepatopathy. An echocardiogram revealed congestive heart failure with a preserved ejection fraction, mild-to-moderate mitral and tricuspid valve insufficiency, and severe aortic valve stenosis with mild aortic valve insufficiency. Conclusions: The definite diagnosis of heart failure is based on clinical and laboratory features; however, this sign may be helpful for diagnosis in emergency settings. Full article

Background and Clinical Significance: Solitary fibrous tumors (SFTs) arising from the lung parenchyma without any relation to the pleura are rare. Case Presentation: We report a case of highly aggressive intraparenchymal SFT of the lung in a 52-year-old woman with rapid distant metastasis to the brain, lungs, and bones within one year post-operation. Chest computed tomography (CT) showed a 5.5 cm-sized, round, but partially lobulated mass with ambiguous enhancement in the right upper lobe. Positron emission tomography/computed tomography (PET/CT) demonstrated strong homogeneous FDG uptake. Unfortunately, the patient succumbed to the disease within one year of diagnosis. Conclusions: Among intrapulmonary SFT, the cellular variant may appear as a cystic mass due to accompanying hemorrhage, coagulation necrosis, and myxoid degeneration. In the absence of mediastinal metastatic adenopathy, it can be mistaken for a benign cystic mass, making PET/CT findings a crucial tool for suggesting a malignancy. Furthermore, as cellular-type intrapulmonary SFT can exhibit aggressive distant metastasis, understanding the CT and PET/CT findings in this condition is essential for accurate diagnosis and treatment planning. Full article

Background and Clinical Significance: Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder caused by mutations in the CYP27A1 gene, leading to impaired bile acid synthesis and systemic cholesterol deposition. The condition presents with a broad spectrum of symptoms affecting multiple organs and systems, including the eyes, central nervous system, tendons, and skeletal muscles. Due to its heterogeneous and often ambiguous clinical manifestations, CTX is frequently misdiagnosed or remains undiagnosed for years. Case Presentation: We report the case of a 37-year-old male who was admitted to our university hospital with a long-standing history of progressive muscle weakness in the arms and legs. His medical history revealed bilateral cataract surgery in childhood, cognitive decline, epilepsy, and bilateral round swellings of the Achilles tendons, suspected to be xanthomas. A clinical diagnosis of CTX was established, and sequencing analysis confirmed the presence of a homozygous pathogenic variant in the CYP27A1 gene. Despite the unavailability of chenodeoxycholic acid (CDCA) therapy in Bulgaria, symptomatic management was provided. Conclusions: This case underscores the diagnostic challenges associated with CTX and highlights the prolonged diagnostic journey faced by patients with rare neurogenetic disorders. It also emphasizes the need for increased awareness and early recognition of such conditions to improve patient outcomes. Full article

Background and Clinical significance: Apical fenestration is a rarely reported clinical finding that may be associated with apical periodontitis. However, its diagnosis can often be complicated by overlapping clinical and radiographic features. While management traditionally involves a combination of endodontic and surgical interventions, there is limited documentation regarding successful outcomes achieved through non-surgical treatment alone. Therefore, further reporting and investigation of such cases are warranted to enhance clinical understanding and inform decision-making. Case Presentation: This case report describes the non-surgical management of a 20-year-old patient presenting with symptomatic apical periodontitis and a labial apical fenestration in a previously treated maxillary left central incisor (tooth #21) exhibiting an open apex. Diagnosis was confirmed using cone-beam computed tomography (CBCT), which revealed a bone defect in the facial cortical plate. The treatment protocol involved conservative canal debridement, intracanal placement of calcium hydroxide, and final obturation using an apical plug of calcium silicate-based hydraulic cement (CSBHC) and the monoblock technique. Over a follow-up period of two years and eight months, clinical and radiographic assessments demonstrated resolution of symptoms, healing of the sinus tract, and complete regeneration of the buccal cortical bone. Conclusions: This case highlights the potential for complete healing of apical fenestration associated with apical periodontitis in an open apex tooth through non-surgical endodontic treatment alone. Full article

Background and Clinical Significance: Twin pregnancies are associated with an increased risk of congenital malformations. One of them is rare but lethal—acrania—which belongs to the group of neural tube defects. The pathogenesis of acrania is not fully understood. It is presumed that the underlying mechanism of its development is a disorder of migration of mesenchymal tissue. The presence of an acrania in one of the twins may lead to complications such as polyhydramnios, preterm labor, or, in severe cases, an intrauterine death in one or both twins. Case Presentation: A 30-year-old woman (G4P4) was admitted to the Labor Department of a tertiary hospital in 30+3 weeks due to preterm labor. The patient was in a dichorionic diamniotic twin pregnancy with a single lethal fetal anomaly and severe polyhydramnios of a second twin. Hence, the caesarean section was immediately performed. Both twins were admitted to the Neonatology Department. The healthy neonate was hospitalized and discharged after 42 days in good condition. Palliative care for the twin with acrania was provided. Conclusions: Early detection of acrania in twin pregnancies is critical. It allows the implementation of appropriate management and targeted counseling, thereby minimizing the risk of complications both for unaffected twins and the mothers. Our case is a good model of action where a twin pregnancy with a diagnosed lethal defect in an ambulatory setting was managed, providing holistic specialized care. Full article

Background and Clinical Significance: The coexistence of spinal hemangiomas and dural arteriovenous fistula (SDAVF) is uncommon. Unclear imaging and progressive neurological impairment require early surgical management. Case Presentation: A 76-year-old woman presented with progressive thoracolumbar pain and worsening bladder dysfunction. Magnetic resonance imaging (MRI) of the thoracic spine revealed a round-shape expansive lesion at T11 with spinal cord edema and homogeneous contrast enhancement. Despite a chronic presentation, the subacute progression of bladder dysfunction and spinal cord edema warranted timely intervention. Intraoperatively, a vascular malformation resembling a dural arteriovenous fistula (SDAVF), unrecognized at pre-operative imaging, was found in association, and histological examination confirmed the diagnosis of hemangioma. The mechanism of coexistence remains unclear, although venous hypertension due to fistula could induce vascular malformations. Conclusions: This case emphasizes the importance of thorough imaging, timely intervention and intraoperative assessment in patients presenting with a suspicion of spinal hemangioma; it may also provide awareness of potentially associated concurrent lesions such as SDAVFs, unrecognized at pre-operative imaging, and technical insights during surgery. Full article

Background: Idiopathic duodenal hematoma is a rare clinical condition, typically associated with trauma, anticoagulation therapy, gastrointestinal procedures, or coagulopathies. We present a unique case of spontaneous duodenal hematoma in a patient without identifiable risk factors. Case presentation: We present the case of a 60-year-old Asian woman who presented to the emergency room (ER) with a 10-day history of progressive abdominal pain, early satiety, nausea, and vomiting. She had no history of trauma, anticoagulant use, or underlying predisposing conditions. On clinical evaluation, she was hemodynamically stable, and the initial laboratory results were unremarkable except for signs of dehydration and inflammation. A computed tomography (CT) scan revealed a heterogeneous lesion in the second portion of the duodenum, initially raising suspicion of a duodenal tumor. Further evaluation with magnetic resonance imaging (MRI) confirmed a duodenal hematoma with compression of the adjacent pancreas. Management and Outcome: The patient was managed conservatively with bowel rest, nasogastric decompression, intravenous (IV) fluid, and a proton pump inhibitor (PPI). Serial imaging demonstrated gradual hematoma resolution, with progressive improvement in her symptoms. She was discharged in stable condition and returned to normal activity after three weeks with complete hematoma resolution as seen on follow-up imaging. Conclusions: This case highlights the importance of considering spontaneous hematoma in the differential diagnosis of abdominal pain, even without risk factors. Early diagnosis and conservative treatment remain the mainstay of management and can lead to full recovery in uncomplicated cases. Full article

Background and Clinical Significance: Scimitar Syndrome is a rare congenital cardiopulmonary anomaly characterized by partial anomalous pulmonary venous return, often requiring early surgical correction. It may coexist with other congenital or acquired cardiovascular anomalies, including valvular diseases such as mitral regurgitation. When surgical correction of Scimitar Syndrome is combined with mitral valve annuloplasty, the proximity to the atrioventricular node may potentially predispose patients to late-onset conduction disturbances, although causality remains speculative. Case Presentation: We describe the case of a 53-year-old male who developed paroxysmal atrial fibrillation, atrial flutter, and intermittent second-degree AV block decades after undergoing surgical correction of Scimitar Syndrome with concomitant mitral annuloplasty. Multimodal echocardiographic evaluation revealed preserved left atrial volume, normal intra-atrial conduction time, mildly reduced strain, and maintained atrial synchrony. The patient was treated with direct oral anticoagulants and beta-blockers and underwent the implantation of a ventricular leadless pacemaker. Conclusions: This case highlights the supportive role of atrial function imaging in assessing atrial health and informing rhythm management and procedural choices in surgically corrected congenital heart disease. Full article

Background and Clinical Significance: Uterine fibroids affect up to 25% of women of reproductive age and can lead to significant symptoms or impact fertility, often requiring surgical management. While hysteroscopic myomectomy is suitable for intracavitary fibroids, intramural and subserosal fibroids typically necessitate open or minimally invasive surgery (MIS). Laparoscopic approaches offer notable advantages, including reduced postoperative pain and faster recovery. However, MIS is frequently avoided in cases of very large fibroids due to technical difficulty and concerns about safe tissue extraction. Power morcellation, previously used for specimen removal, has fallen out of favor due to the risk of disseminating occult malignancies, especially in women over 35. Therefore, establishing the feasibility of MIS without morcellation in such cases is essential. Case Presentation: A woman of reproductive age presented with a symptomatic uterine fibroid measuring approximately 4 kg (1500 cm³). Laparoscopic myomectomy was performed using a modified trocar entry technique and contained tissue fragmentation, avoiding morcellation. The operation was completed successfully without complications. Postoperative recovery was uneventful, and the patient was discharged on postoperative day two. Histopathological examination confirmed a benign leiomyoma. Conclusions: This case highlights the feasibility of laparoscopic removal of an exceptionally large uterine fibroid without morcellation. Through careful patient selection, strategic trocar placement, and controlled tissue fragmentation, MIS can be safely performed in select high-volume cases. These findings support reconsidering the size limitations of laparoscopic myomectomy when conducted by experienced surgeons using appropriate techniques. Full article

Background and clinical significance: Polymorphous adenocarcinoma of the oral cavity is predominantly located in the palate. It is characterized by a slow rate of growth and thus may be misdiagnosed as a benign tumor. Its histology is intricate with other salivary malignancies, thus necessitating specific immunohistochemical stains. Our case report illustrates an adenocarcinoma localized in the palate of a 61-year-old female patient. Case presentation: The patient came to the postgraduate clinic of Oral Medicine and Pathology, Department of Oral Medicine and Pathology, School of Dentistry, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece and provided written informed consent for the subsequent examination. The patient complained about the presence of a mass on the palate, which was otherwise asymptomatic, without being able to pinpoint when the tumor initially emerged. The lesion was biopsied and the histology suggested the immunophenotype p63+/p40- which constitutes an important diagnostic clue for polymorphous adenocarcinoma. The patient was referred to the Department of Oral and Maxillofacial Surgery. Conclusions: The standard therapeutic approach primarily involves surgical excision. The goal is to achieve optimal patient outcome while minimizing unnecessary morbidity. As surgical techniques and understanding of the disease continue to advance, it is crucial for healthcare providers to stay informed and integrate these developments into practice to improve treatment outcomes for patients. Full article

Background and Clinical Significance: Pancreatic cancer was the third leading cause of cancer-related mortality in the United States in 2020 after lung and colorectal cancers. The prevalence of pancreatic cancer has been increasing and is projected to continue rising through 2040, with an estimated 355,317 additional cases expected. We present the case of an 81-year-old patient with metastatic pancreatic ductal adenocarcinoma (PDAC) who tolerated NALIRIFOX for a year with grade 1 adverse events. Case presentation: An 81-year-old Asian male presented with abdominal pain associated with weight loss and fatigue. An abdominal computed tomography (CT) scan showed a mass in the body of the pancreas measuring 3.5 cm with an infiltrative appearance invading the retroperitoneum and encasing the splenic artery. A biopsy confirmed poorly differentiated PDAC. The patient received 13 cycles of NALIRIFOX in a palliative setting over the course of one year, demonstrating excellent tolerance aside from minor toxicities, including worsening of pre-existing macrocytic anemia, treatment-related grade 1 neuropathy, diarrhea, and thrombocytopenia. A subsequent CT scan revealed disease progression, and the patient was switched to second-line therapy. However, per his preference, the patient was referred to hospice care and passed away a few days later. Conclusions: This case highlights the excellent tolerability of NALIRIFOX in an elderly patient, with minimal adverse events observed, which is uncommon among similar patient populations. Full article