Reports, Volume 9, Issue 2 (June 2026) – 55 articles

Background and Clinical Significance: Acute retinal pigment epitheliitis is a retinal disorder considered as part of a larger group named idiopathic choroidopathies. Little gray round macular lesions at the retinal pigment epithelium can be found, which are self-limited, resolving within 6–12 weeks. It can decrease best corrected visual acuity (BCVA), but visual quality has not been studied yet. Case Presentation: A 17-year-old Caucasian boy who came to our ophthalmology department and presented with acute retinal pigment epitheliitis in his right eye (OD). BCVA under mesopic lighting was 0.18 logMAR in his OD and −0.18 in his OS. With a neutral density filter, it was 0.52 and 0.04, respectively. Contrast sensitivity was assessed with the CSV-1000E test, but OD outcomes were worse only in the case of mesopic lighting. Chromatic discrimination was assessed with the Farnsworth–Munsell 100 test and revealed marked impairment of both red-green and yellow-blue axes. No central scotoma was detected on a 10.2 visual field, nor was any halo perception detected with the Halometer test. Conclusions: BCVA under low illumination and color perception in the yellow-blue axis may be affected in patients with acute retinal pigment epitheliitis to a greater extent than previously described. Contrast sensitivity may also be altered, but to a lesser extent. Full article

Background and Clinical Significance: Dermato-neuro syndrome is a rare, potentially fatal complication of scleromyxedema, characterized by a prodrome of flu-like symptoms, and a triad of fever, confusion, and seizures. Intravenous immunoglobulin (IVIG) has become first-line treatment for both scleromyxedema and dermato-neuro syndrome based on case reports and case series data showing variable treatment responses. Case Presentation: In this report, we describe a Black, female patient with scleromyxedema and lambda-restricted IgG monoclonal gammopathy who developed suspected dermato-neuro syndrome within a week of her first round of IVIG infusions. Conclusions: To our knowledge, this is the second case report of dermato-neuro syndrome temporally linked to a recent IVIG infusion, a paradoxical reaction that may complicate clinical decision making. Furthermore, we highlight the dermatologic manifestations of scleromyxedema in dark skin tones and emphasize the need for heightened clinical suspicion of dermato-neuro syndrome in patients with scleromyxedema presenting with acute neurological symptoms. Full article

Objectives: The aim of this study was to compare a widely applied table-top digital non-mydriatic camera (Topcon TRC-NW-8) with a handheld digital non-mydriatic camera (Optomed Aurora IQ) regarding the quantitative assessment of the retinal microcirculation using established biomarkers: central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE) and arterio-venous ratio (AVR). Methods: The present cross-sectional study included 26 randomly selected participants (51 eyes) who underwent retinal imaging of both eyes with the two devices and were analyzed using a static retinal vessel analyzer. Results: The mean differences in CRAE, CRVE and AVR between the two devices (Topcon/Aurora) were 24.96 ± 11.7, 22.7 ± 11.7 and 0.026 ± 0.045, respectively. Strong correlations were observed between devices (r = 0.84 for CRAE, 0.75 for CRVE and 0.83 for AVR; all p < 0.001), with high agreement as indicated by ICC values (0.91, 0.85, and 0.90, respectively). Bland–Altman plots indicated evidence of systemic bias (95% within 2 SD) with no proportional bias, as the differences were consistently distributed across the range of average values. Regression-based equations were derived to approximate the transformation of measurements between devices. Conclusions: The handheld fundus camera demonstrates strong correlation and good relative agreement with the table-top device; however, a consistent device-dependent bias limits the direct interchangeability of absolute measurements. The derived transformation equations may facilitate approximate cross-device comparison, although external validation is required. These findings support the complementary use of handheld devices and highlight the need for calibration strategies when integrating measurements across platforms. Full article

Background and Clinical Significance: Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related death. Skeletal muscle metastases are extremely rare and typically occur in advanced or poorly differentiated tumors. In selected oligometastatic cases, surgical excision can provide symptom relief and requires a multidisciplinary approach. Case Presentation: We report a 73-year-old female patient with colonic adenocarcinoma treated with right hemicolectomy and side-to-side mechanical anastomosis, followed by adjuvant CAPOX chemotherapy. The tumor was characterized by MSI-H (microsatellite instability-high) status. During adjuvant treatment (less than 6 months after surgery), she developed progressive right thigh pain, later diagnosed as an intramuscular skeletal muscle metastasis measuring approximately 16 × 13 × 8 cm. The patient underwent en bloc resection of the tumor, followed by adjuvant chemotherapy after metastasectomy. Upon disease progression, first-line chemotherapy in combination with targeted therapy (bevacizumab) was administered. Conclusions: Skeletal muscle metastases from colorectal adenocarcinoma are rare. This case emphasizes the importance of recognizing atypical metastatic patterns and suggests that, in selected oligometastatic cases, surgical excision combined with a multidisciplinary approach may improve symptom control and clinical outcomes. Full article

Uterine fibroids are among the most common benign tumors affecting women, with a prevalence reaching up to 50–60% in those over 40 years of age, although often underestimated due to asymptomatic cases. Radiofrequency ablation (RFA) represents a minimally invasive alternative to surgery for selected patients. We report the case of a 41-year-old woman with symptomatic uterine fibroids (FIGO type 4, size of 5 cm) treated with transvaginal RFA. One month post- treatment, the fibroid showed partial volume reduction. Two months after the procedure, the patient presented with foul-smelling discharge and heavy bleeding. Ultrasound confirmed complete fibroid migration into the cervical canal. Vaginal removal was performed without complications. Fibroid expulsion after RFA is a rare event that may represent either a complication or a therapeutic outcome. A balanced interpretation and appropriate clinical management are required. Further studies are needed to clarify its clinical significance. Full article

Background: The term “pseudo-signet ring cell” in the gastrointestinal and biliary tract refers to benign cells with signet ring-like morphology that resemble the malignant counterpart seen in poorly differentiated adenocarcinomas; Clinical Significance: Given this close resemblance to malignant cells, they can pose a diagnostic challenge for pathologists. Awareness of this diagnostic pitfall is crucial to avoid misdiagnoses and overtreatment of patients; Case Presentation: Herein, we provide an overview of an array of clinical presentations of pseudo-signet ring cells, particularly focusing on the three most frequent clinical scenarios, and briefly discuss the possible etiologies for this phenomenon; Conclusions: Pseudo-signet ring cells are a rare but important diagnostic pitfall that require careful morphological evaluation, contextual awareness, and clinicopathologic correlation to avoid misdiagnosis. Full article

Background and clinical significance: Autoimmune hepatitis (AIH) and ankylosing spondylitis (AS) are distinct immune-mediated disorders that only rarely coexist. Diagnostic interpretation becomes especially challenging when the liver biochemistry is not classically hepatocellular and the histology is unavailable. Case presentation: We report a 51-year-old man with inflammatory back pain, polyarthralgia, weight loss, fatigue, night sweats and fever. Laboratory tests showed marked systemic inflammation, anemia and a cholestatic-predominant liver profile with associated aminotransferase elevation. Imaging demonstrated bilateral sacroiliitis and syndesmophytosis. Liver workup excluded viral, obstructive, metabolic, hereditary and inflammatory bowel disease-associated cholangiopathic causes. Antinuclear antiboidies (ANA) and anti liver cyotsole 1 antiboidies (anti-LC-1) were positive, IgG was mildly elevated, magnetic resonance cholangio-pancreatography (MRCP) was negative for primary sclerosing cholangitis and the simplified AIH score was six. A liver biopsy was proposed but refused. The patient received a short course of prednisone for rheumatologic flare control, followed by nonsteroidal anti-inflammatory treatment and sulfasalazine, with normalization of liver tests during follow-up. Conclusions: This case is suggestive, but not diagnostic, of autoimmune hepatitis in a patient with ankylosing spondylitis. In the absence of histology and in the setting of a cholestatic-predominant biochemical profile, the findings may be more appropriately interpreted as an autoimmune hepatitis-like syndrome. The main teaching point is that abnormal liver tests in AS warrant structured evaluation beyond drug toxicity and viral hepatitis, particularly when autoimmune serology is positive, even in a cholestatic-predominant presentation. Full article

Background: Erectile dysfunction (ED) is a common complication of type 2 diabetes and obesity and significantly affects patients’ quality of life. Nursing care for patients with metabolic multimorbidity requires a holistic, structured approach. The International Classification for Nursing Practice (ICNP^®) enables standardized formulation of nursing diagnoses, interventions, and outcomes and supports structured and individualized ICNP^®-based care planning. Aim: This study aimed to develop and present an ICNP^®-based nursing care plan for a patient with erectile dysfunction associated with type 2 diabetes and obesity and to demonstrate the applicability of ICNP^® in holistic nursing management of chronic disease. Methods: A descriptive single-case study was conducted in 2025 in a cardiology ward in Poland. Data were collected using a nursing interview, observation, medical documentation analysis, and standardized tools (IIEF-5, SF-36v2). Based on a comprehensive assessment of physical, psychological, and social status, nursing diagnoses, interventions, and expected outcomes were formulated according to ICNP^® terminology. Results: The patient presented with poorly controlled diabetes, class I obesity, moderate erectile dysfunction, reduced testosterone levels, and decreased quality of life, particularly in psychosocial domains. Key ICNP^® nursing diagnoses included erectile dysfunction, deficient knowledge, obesity, disturbed psychological status, impaired endocrine function, impaired cardiovascular function, and impaired adaptation. Individualized ICNP^®-based interventions focused on metabolic control, lifestyle modification, sexual health support, education, and psychosocial support. Implementation of the care plan was associated with improvements in health behaviors, disease knowledge, and psychological well-being. Conclusions: ICNP^® provides a useful framework for structured and comprehensive nursing care in patients with diabetes-related erectile dysfunction and multimorbidity. Case-based ICNP^® care planning supports holistic management, interdisciplinary collaboration, and quality improvement in chronic disease nursing. Full article

Background and Clinical Significance: Osmotic demyelination syndrome (ODS) and pituitary apoplexy are rare but potentially severe neurological and endocrine complications that can arise in the context of profound metabolic stress. Case Presentation: We describe the case of a previously healthy 34-year-old man who developed severe symptomatic hyponatremia shortly after receiving his second dose of an mRNA COVID-19 vaccine. Initial laboratory findings and clinical assessment were consistent with syndrome of inappropriate antidiuretic hormone secretion. Following correction of serum sodium, the patient experienced neurological deterioration with gait disturbance, dysarthria, and cognitive impairment. Follow-up brain MRI demonstrated extrapontine osmotic demyelination involving the basal ganglia and thalamus, despite initially normal imaging. During subsequent endocrinological follow-up, pituitary MRI revealed pituitary apoplexy in a previously unrecognized adenoma, accompanied by evolving partial hypopituitarism. The patient was managed with careful electrolyte control and long-term hormone replacement therapy, including hydrocortisone, levothyroxine, and recombinant growth hormone, resulting in gradual functional and cognitive improvement. Conclusions: This case highlights the interaction between severe hyponatremia, osmotic stress, and pituitary vulnerability, and emphasizes the need for cautious sodium correction, careful interpretation of temporal associations, and continued clinical vigilance in the context of COVID-19 vaccination programs. Full article

Background and Clinical Significance: Migraine is a common yet debilitating condition that significantly impacts personal lives, productivity, and the healthcare system. Pharmacological interventions provide relief for some migraine sufferers, but for others, are ineffective or accompanied by side effects. Emerging evidence implicates autonomic nervous system dysfunction in migraine pathophysiology, suggesting that mind–body interventions may offer a simple, cost-free therapeutic option. Case Presentation: A 61-year-old woman presented with severe daily migraines that had persisted for years despite medication and dietary changes. Upon starting a regular 10 min slow diaphragmatic breathing practice, her migraines ceased immediately. At a 12-month follow-up, she had only experienced two minor headaches and reported improvements in both daily functioning and quality of life. Conclusions: These findings underscore the potential role of autonomic imbalance in chronic migraine and the preliminary feasibility of breathing interventions as an accessible, low-risk treatment that may, for some, surpass medication in efficacy. Breathing practices may offer a viable alternative to pharmaceutical interventions that benefits both patients and healthcare systems alike. Full article

Background and Clinical Significance: Dupuytren’s disease (DD) typically affects the palmar fascia and proximal digital structures, with distal interphalangeal joint (DIPJ) involvement considered rare. True extension of DD into the volar pulp has not been previously documented. Distal lesions may be misdiagnosed as neoplastic or inflammatory masses, and optimal management of isolated distal cords remains uncertain. We present the first histologically confirmed case of DD extending beyond the DIPJ into the volar pulp, accompanied by a systematic review of reported DIPJ-dominant DD. Case Presentation: A 30-year-old right-hand-dominant male presented with a two-year history of progressive flexion deformity of the little finger. Examination demonstrated a 90° proximal interphalangeal joint and 55° DIPJ contracture. Ultrasound and MRI showed a well-circumscribed soft-tissue lesion along the radial middle phalanx but did not suggest DD. Open exploration via an ulnar digital approach revealed a discrete DD cord extending distally beyond the DIPJ into the volar pulp, closely associated with the ulnar neurovascular bundle. Limited fasciectomy achieved full correction without neurovascular compromise. Histopathology confirmed classic DD. At the twelve-month follow-up, the patient maintained full extension and function with no recurrence. Conclusions: This study reports the first confirmed case of DD extending into the volar pulp and highlights that atypical distal DD can occur even in young patients. Imaging may fail to identify DD in uncommon sites, reinforcing the importance of clinical suspicion. Limited fasciectomy remains safe and effective in the distal phalanx. Recognition of this phenotype or histopathological examination may improve diagnostic accuracy and guide tailored operative planning. Full article

Background and Clinical Significance: Guillain–Barré syndrome (GBS) can rarely progress to fulminant paralysis with loss of brainstem reflexes, mimicking coma or brain death despite preserved cortical function. Case Presentation: A 38-year-old man developed rapidly progressive weakness following a diarrheal illness, culminating in quadriplegia, areflexia, respiratory failure, and complete loss of brainstem reflexes within 72 h. Neuroimaging was unrevealing. EEG demonstrated preserved cerebral activity with an alpha coma pattern. Despite initial intravenous immunoglobulin therapy, neurological deterioration continued, prompting escalation to plasma exchange. Gradual recovery of brainstem reflexes and motor function ensued, followed by substantial functional improvement over nine months. This case highlights the diagnostic and prognostic challenges of fulminant GBS at the interface of peripheral and brainstem dysfunction. Neurophysiologic assessment and disciplined exclusion of central etiologies are essential. Timely immunotherapy and supportive care can lead to meaningful recovery even in extreme presentations. Conclusions: Fulminant GBS should be recognized as a potentially reversible cause of apparent coma, underscoring the importance of early diagnosis and aggressive treatment. Full article

Background and Clinical Significance: Early loss of pacing capture after pacemaker generator replacement is an uncommon but potentially life-threatening event, especially in pacemaker-dependent patients. In this setting, device malfunction is often initially attributed to intrinsic lead damage, prompting consideration of invasive lead revision or extraction. However, not all early failures reflect true structural lead dysfunction. Careful interpretation of device interrogation findings, particularly in relation to pacing configuration, may uncover reversible causes and support a more targeted diagnostic and management approach; Case Presentation: A 61-year-old man with complete atrioventricular block presented with recurrent syncope six days after elective pacemaker generator replacement. The electrocardiogram showed absence of effective ventricular pacing with a slow escape rhythm. Device interrogation revealed loss of ventricular capture in bipolar configuration associated with markedly elevated impedance, initially raising concern for lead malfunction. However, switching to unipolar pacing restored effective capture with normal electrical parameters, suggesting preserved lead integrity and prompting reconsideration of the underlying mechanism. Further diagnostic evaluation, including imaging and intraoperative assessment, was therefore undertaken to clarify the cause and guide management; Conclusions: Early pacing failure should not automatically be equated with lead damage. Beyond documenting a reversible lead–header interface problem, this case highlights the diagnostic value of a stepwise approach integrating pacing configuration behavior, targeted imaging, and intraoperative header-independent testing. Such an approach may facilitate rapid localization of reversible defects and help avoid unnecessary lead revision. Full article

Background and Clinical Significance: Chondroid syringoma is a very rare tumor arising from the sweat glands, with an incidence described in the literature of 0.01% of all primary skin tumors. Case presentation: This paper aims to present the case of a patient treated in our clinic for a large cyst located at the inner corner of the left eye, which appeared two years ago and progressively increased in size. The patient presented for cosmetic reasons and discomfort, especially when wearing glasses. The diagnosis of chondroid syringoma is generally established clinically. The differential diagnosis includes other benign cutaneous lesions (pleomorphic adenoma, lipoma, neurofibroma, a dermoid cyst, dermatofibroma, pleomorphic adenoma of the salivary glands, a sebaceous cyst, or hemangioma) or malignant lesions (basal cell carcinoma, squamous cell carcinoma, or adenocarcinoma). Additional imaging investigations—CT and MRI—are rarely required and would mainly assess the extent of the lesion. Dermoscopy is an early differential diagnostic method, especially for small lesions of 1–3 mm, such as xanthelasma, milia, or basal cell carcinoma. Chondroid syringoma may be treated using minimally invasive methods such as fractional CO₂ laser, radiofrequency, or electrocautery, but only when the lesion is superficial and small. For larger and deeper tumors, such as in our case, multiple treatment sessions would be required, increasing the cost, and complete removal would not be guaranteed. Conclusions: The chosen treatment is surgical excision with oncologic margins, followed by histopathological and immunohistochemical examination to prevent recurrence and assess the risk of malignancy. Full article

Background and Clinical Significance: Over recent decades, percutaneous nephrolithotomy (PCNL) has emerged as a primary treatment, firmly establishing itself as the cornerstone approach for managing large kidney stones. Postoperative bleeding commonly stems from an arteriovenous fistula (AVF), a connection between a damaged artery with high flow and a damaged vein with low flow, or from a pseudoaneurysm (PA), which involves arterial blood leaking into the tissue, causing a localized hematoma. The preferred technique for addressing such vascular complications is selective trans-arterial angioembolization, widely regarded as the gold standard. Case Presentation: In this article, we present the case of a 42-year-old woman who experienced delayed bleeding eight years after PCNL and a previous angioembolization. The patient presented with macroscopic hematuria, and further investigations, including cystoscopy, contrast-enhanced abdominal-pelvic CT, and angiography, were performed. To stop the bleeding, we identified and performed selective angioembolization (SAE) of a small arterial branch arising from an inferior branch of the right renal artery. Conclusions: To the best of our knowledge, this is the initial documented instance of delayed bleeding manifesting eight years post-PCNL and angioembolization. This occurrence is exceptionally rare, given that the patient exhibited no urological signs or symptoms over the intervening years, and no predictive or risk factors were identified. Full article

Background and Clinical Significance: Revascularization of the circumflex territory remains technically challenging because of its anatomical position and the frequent need for distal branch grafting. Case presentation: We report the case of a 76-year-old man in whom the proximal circumflex trunk was used as the target for an in situ right internal thoracic artery routed through the transverse sinus during combined coronary and ascending aortic surgery. This approach allowed antegrade perfusion of the circumflex territory while avoiding multiple distal anastomoses. In this selected anatomical setting, the technique proved feasible and was associated with excellent intraoperative flow and 1-year radiological patency. Conclusions: Direct grafting of the circumflex trunk is not a new concept, but this case revisits it using a contemporary total arterial revascularization strategy. This approach may represent a useful adjunctive option in carefully selected patients with favorable circumflex anatomy. Full article

Background and clinical significance: Autoimmune encephalitis (AE) is an inflammatory brain disorder that manifests through a diverse, unspecific range of neuropsychiatric symptoms. When AE occurs alongside a primary neurodegenerative disorder, the shared symptoms can create a mixed clinical profile, making diagnosis more difficult and potentially postponing effective management and treatment. Case presentation: We describe the case of a 58-year-old female with a one-year history of progressive behavioral and personality changes who presented a subacute confusional state, psychomotor retardation alternating with psychomotor agitation, apathy, visual hallucinations, and motor symptoms. Examination revealed Parkinsonian symptoms and frontal lobe signs. Neuroimaging showed frontotemporal atrophy, while cerebrospinal fluid analysis excluded infection but demonstrated elevated phosphorylated tau, supporting an underlying neurodegenerative process. An electroencephalogram revealed asymmetric temporal slowing without overt epileptiform activity. An initial diagnosis of behavioral variant frontotemporal dementia (bvFTD) was established. Due to rapid clinical deterioration and fluctuating cognition, autoimmune testing was expanded to a full antibody panel, which identified elevated serum anti-glutamic acid decarboxylase 65 (anti-GAD65) antibodies (60 UI/mL, reference range 0–5 UI/mL), establishing a possible coexisting diagnosis of anti-GAD65 autoimmune encephalitis. Initial treatment with intravenous immunoglobulin produced minimal improvement; however, therapeutic plasma exchange led to the remission of psychosis and significant improvement in rigidity, bradykinesia, and attention, with modest amelioration in global cognition. Conclusions: This case highlights the diagnostic challenges posed by overlapping AE and bvFTD clinical pictures, especially when neurodegenerative features obscure an underlying autoimmune process. Early, panel-based neural antibody testing—and consideration of AE even in patients already diagnosed with a major neurocognitive disorder—is critical for avoiding delays in immunotherapy. Prompt recognition and treatment of AE may substantially improve clinical outcomes, even in complex cases with suspected overlap. Full article

Background: Low-dose CT scanning is a key tool in lung cancer screening, enabling the detection of clinically significant abnormalities in asymptomatic individuals and often prompting further diagnostic evaluation. Case Presentation: We describe the case of an 80-year-old man with a heavy smoking history who was found to have a new right middle lobe collapse on screening CT. Subsequent positron emission tomography-computed tomography (PET/CT) imaging demonstrated mild fluorodeoxyglucose (FDG) uptake (SUVmax 2.7), raising concern for a low-grade endobronchial malignancy versus mucoid impaction. Flexible fiberoptic bronchoscopy revealed a large exophytic endobronchial mass occluding the airway. Histopathologic examination of the biopsy sample unexpectedly revealed vegetable material, consistent with chronic foreign-body aspiration. Discussion: Unrecognized aspiration events are relatively common in elderly adults and can mimic malignancy on imaging. This case highlights an important diagnostic pitfall: inflammatory endobronchial processes, including foreign-body granulomas, can demonstrate FDG uptake and mimic malignancy. Conclusion: Clinicians should maintain a broad differential diagnosis when evaluating PET-avid endobronchial lesions, especially in elderly patients. Full article

Background and Clinical Significance: The management of large benign ovarian cysts in women of reproductive age requires balancing minimally invasive surgery with oncologic safety and preservation of ovarian function. Laparoscopic cystectomy for large cysts is technically challenging and carries an increased risk of intraoperative rupture and spillage; Case Presentation: We describe a novel hybrid laparoscopic–extracorporeal technique in which controlled cyst decompression is performed using a balloon-tipped trocar through a suprapubic port under direct laparoscopic visualization. The ovary is then carefully mobilized and exteriorized through the same incision, allowing extracorporeal cystectomy and ovarian reconstruction before returning the adnexa to the abdominal cavity. This approach was applied in a series of six patients with large benign-appearing ovarian cysts, including one 42-year-old patient with an 18 cm multilocular mature cystic teratoma. There were no intraoperative or postoperative complications, no conversions to laparotomy, and all patients were discharged on postoperative day 1. Follow-up at six weeks and subsequent imaging at nine months demonstrated preserved ovarian architecture, normal menstrual function, and high patient satisfaction; Conclusions: The hybrid laparoscopic–extracorporeal approach appears feasible and may offer a safe surgical option in carefully selected patients, allowing fertility preservation while minimizing the risk of spillage. Further studies are needed to evaluate reproducibility, oncologic safety, and long-term reproductive outcomes. Full article

Oral squamous cell carcinoma (OSCC) typically develops in individuals with established risk factors such as tobacco and alcohol use, yet an increasing number of cases occur in young non-smoking, non-drinking (NSND) patients. We report a case of oral tongue OSCC in a 33-year-old woman who is a never-smoker and never-drinker without identifiable environmental or local risk factors. The patient underwent surgical treatment followed by adjuvant radiotherapy and remains disease-free 15 months after therapy. Whole-exome sequencing (WES) revealed a pathogenic truncating TP53 mutation together with additional somatic alterations affecting genes involved in DNA repair, hypoxia adaptation, mitochondrial function, and epigenetic regulation. The heterogeneous mutational profile suggests branched tumor evolution and the involvement of non-classical tumorigenic pathways. This report contributes to the growing evidence that OSCC in young NSND patients represents a biologically distinct subgroup and demonstrates the value of comprehensive genomic profiling for improving understanding of tumor heterogeneity and potential molecular drivers in the absence of traditional carcinogenic exposures. Full article

Background and Clinical Significance: Nonbacterial thrombotic endocarditis (NBTE) is a sterile fibrin-platelet valvular condition associated with malignancy and hypercoagulable states. It produces friable vegetations prone to systemic embolization, often presenting as multifocal ischemic stroke. While modestly linked to advanced adenocarcinomas, its association with melanoma is exceedingly rare; Case Presentation: We present a 43-year-old man with recently diagnosed metastatic melanoma who presented with fever, confusion and abdominal pain. Brain magnetic resonance imaging (MRI) revealed multifocal bilateral acute infarcts. Additional imaging demonstrated splenic and bilateral renal infarcts. Transesophageal echocardiography (TEE) revealed an 8 mm × 7 mm multilobar lesion on the posterior mitral valve leaflet. Blood cultures remained persistently negative; autoimmune and infectious workup were unrevealing, and positron emission tomography-computed tomography (PET-CT) showed no cardiac hypermetabolism. Despite empiric antibiotics for suspected infective endocarditis (IE), progressive embolic infarcts occurred. After exclusion of infection, NBTE was considered, and therapeutic enoxaparin was initiated, resulting in clinical stabilization without hemorrhagic conversion; Conclusions: Distinguishing NBTE from IE remains challenging due to overlapping and nonspecific imaging findings. TEE is the preferred diagnostic modality because of its high sensitivity for detecting small valvular vegetations. Adjunctive imaging modalities such as brain MRI and PET-CT may support the diagnosis by demonstrating embolic patterns or excluding metabolically active infectious vegetations. Management primarily relies on systemic anticoagulation, while percutaneous vegetation aspiration may represent a potential diagnostic and therapeutic strategy. Clinicians should maintain high suspicion of this condition in patients with advanced melanoma and other malignancies presenting with multifocal embolic phenomena and negative cultures to enable timely anticoagulation. Full article

Background: Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated necrotizing vasculitis primarily affecting small and medium-sized vessels. The typical presentation commonly includes upper and/or lower respiratory tract and renal involvement. GPA has a particularly strong association with proteinase-3 (PR3) ANCA. Though well defined, GPA may be clinically difficult to recognize, particularly in early disease. Initial presentations may include nonspecific symptoms, including but not limited to fatigue, fever, and sinus congestion or sinusitis, which may be mistaken for infection. Though initial ANCA testing is useful, it is not definitive as early stages of disease may be negative, thus delaying diagnosis; Clinical Significance: This case highlights the importance of including GPA in the differential diagnosis of patients with unremitting upper or lower respiratory and constitutional symptoms despite negative ANCA testing. Though atypical, GPA cases may lack renal involvement and even have negative ANCA serologies, leading to a delay in diagnosis and increased morbidity. ANCA positivity can be as low as 60% in limited GPA cases, and less than 20% of individuals have renal involvement at presentation. If GPA suspicion is high, repeat testing and biopsy are warranted; Case Presentation: A woman in her 50s initially presented to the emergency department with recurrent/persistent fever with nonspecific sinus symptoms that remained unresolved despite multiple outpatient treatments and tests. Infectious work-up was negative. She was found to have multiple pulmonary nodules on various scans. Initial testing on admission was unremarkable or nondiagnostic, including anti-neutrophil cytoplasmic antibody (ANCA) serologies. The patient’s hospital course was complicated by acute hypoxic respiratory failure with distributive shock during bronchoscopy. Repeat serological testing was positive for PR3-ANCA, and lung biopsy demonstrated necrotizing granulomatous vasculitis consistent with a diagnosis of granulomatosis with polyangiitis (GPA). The patient demonstrated clinical improvement with avacopan, glucocorticoids, and rituximab; Conclusions: The diagnosis of GPA should be suspected in all patients with nonspecific constitutional symptoms along with clinical evidence of upper/lower respiratory tract involvement, regardless of renal function. Physicians with a strong suspicion of an autoimmune disease, such as GPA, should utilize a thorough clinical history, physical exam, and other labs in the setting of a negative autoimmune marker and/or negative imaging. Clinical judgment is required to not rule out GPA despite a negative workup when other more serious causes have been excluded, as the diagnosis may be life-threatening. Full article

Background and Clinical Significance: Intrapericardial ectopic thyroid tissue is extremely rare and can mimic vascular mediastinal or cardiac lesions. Case Presentation: We describe a 62-year-old woman with dyspnea, palpitations, and flushing for several months, progressively worsening, associated with nonspecific ST-segment abnormalities on ECG. Contrast-enhanced CT revealed a small, highly vascularized epicardial mass anterior to the ascending aorta. 18F-FDG PET/TC findings were inconclusive, and biopsy was not feasible due to the anatomical location. Surgical excision via upper ministernotomy was performed, leading to resolution of symptoms. Histology confirmed benign ectopic thyroid tissue. Conclusions: With fewer than ten similar intrapericardial cases reported in the English-language medical literature, this presentation underlines the diagnostic difficulty of such lesions and the importance of including ectopic thyroid tissue among the less common differential diagnostic considerations for intrapericardial masses, particularly in patients with prior thyroid disease. Full article

Background and Clinical Significance: Angiotensin-converting enzyme inhibitors (ACE-Is) are commonly used for treatment of hypertension and are well known among primary care specialists. ACE-I-induced angioedema is a rare, yet possible side effect. It should not be taken lightly, as it can be life-threatening. It is characterized by erythematous or skin-coloured, self-limiting, localized, non-pitting swelling of the submucosal and/or subcutaneous layers of tissue. Usually, it develops in the first year of using the medication, although it can also start several years after using it. Herein, we describe a late-onset ACE-I-induced angioedema, which developed 7 years after using the ACE-I. This case report depicts the challenges of diagnosing ACE-I-induced angioedema, especially if it is late-onset. It highlights the importance of actively asking patients questions about possible side effects of medication even several years after using it and the patients themselves not having any complaints. Case Presentation: We present a 61-year-old Caucasian male with recurring swelling of the lips, tongue and an uncomfortable feeling in the throat, which started 7 years after using an ACE-I: perindopril. There was no airway obstruction or urticaria in any of the episodes. Hereditary angioedema was ruled out by blood analysis. Based on the clinical presentation, images and blood analysis, it was diagnosed as late-onset ACE-I-induced angioedema. After discontinuing the ACE-I, there were two more episodes of angioedema reported, which were a lot milder in symptoms and lasted a shorter time period. Since then, there have been no other episodes of angioedema. Conclusions: It is important to keep in mind angioedema as a possible side effect for patients on ACE-Is. Patients should be regularly and actively questioned about side effects, even if the medication has been started several years ago and no complaints are brought up by the patient. Full article

Background and Clinical Significance: Conventional hard sockets are reported to result in skin breakdown for almost half of transtibial prosthesis users. Adjustable sockets have been developed to better accommodate residual limb shape and volume changes. They have demonstrated optimal skin health in prospective adult clinical studies. Case Presentation: We present the case of a 57-year-old male with a transtibial amputation who enrolled in a research study at the University of Pennsylvania. In the year before enrollment, he experienced frequent, near-constant skin breakdown of the distal residual limb at the anterior tibia due to limb volume fluctuations and excessive pressure from a conventional hard socket and was frequently unable to use his socket due to skin breakdown. The subject was fit with an adjustable, immediate fit transtibial prosthesis (iFIT Prosthetics^®). After a two-week home trial, he rated the adjustable prosthesis 62 out of 70 on an adapted Prosthetic Evaluation Questionnaire, compared with a score of 20 for his conventional prosthesis. Due to improved comfort, he discontinued the use of his conventional device. The subject was followed for over one year and wore the adjustable prosthesis exclusively without a recurrence of skin breakdown. Residual limb volume changes commonly lead to poor socket fit and skin irritation in conventionally fabricated hard sockets, often progressing to skin breakdown. In individuals with diabetes, wound healing can be prolonged and functionally limiting. In this case, an adjustable prosthesis successfully eliminated anterior tibial skin breakdown in a subject predisposed to this injury when using conventional hard sockets. Conclusions: Adjustable sockets can prevent skin breakdown in individuals with transtibial limb loss. Full article

Background and Clinical Significance: Mechanical complications and intracavitary thrombus are both recognized causes of clinical deterioration following acute myocardial infarction, yet they require fundamentally different therapeutic approaches. Distinguishing between these entities is critical, as misdiagnosis may lead to unnecessary surgical intervention or delayed anticoagulation with serious consequences. Left ventricular (LV) thrombus typically appears as a well-defined mass; however, atypical and highly mobile morphologies may closely mimic catastrophic post-infarction mechanical complications, creating significant diagnostic uncertainty. This case highlights the pivotal role of contrast-enhanced echocardiography in resolving such ambiguity and guiding appropriate management in a high-stakes clinical setting. Case Presentation: A 60-year-old man presented with acute dyspnea and pulmonary edema ten days after an anterior myocardial infarction treated with percutaneous coronary intervention, complicated by ischemic stroke. Transthoracic echocardiography demonstrated severe LV systolic dysfunction with moderate-to-severe mitral regurgitation and an unexpected, highly mobile, irregular mass protruding into the LV apex. The mass exhibited a shredded, tissue-like appearance, raising urgent concern for post-infarction mechanical complications, including papillary muscle rupture or apical myocardial disruption, and prompting immediate consideration of surgical intervention. Contrast-enhanced echocardiography was performed and revealed a mobile LV apical thrombus. Surgical management was avoided, and systemic anticoagulation was initiated, followed by transition to rivaroxaban in combination with ongoing dual antiplatelet therapy. The patient demonstrated rapid clinical improvement with optimized heart failure treatment and was discharged after four days, with planned follow-up imaging to assess thrombus resolution. Conclusions: Left ventricular thrombus may present with atypical, misleading morphologies that closely resemble life-threatening mechanical complications after myocardial infarction. Full article

Background and Clinical Significance: Multiligamentous knee injuries (MLKIs) are uncommon but severe injuries associated with instability, neurovascular compromise, and long-term functional impairment. Irreducible knee dislocations are a distinct subgroup requiring urgent intervention because soft-tissue interposition may prevent closed reduction and place the limb at risk of skin necrosis and vascular compromise. This report reviews current concepts in MLKI management and presents a complex KD-IV irreducible knee dislocation treated with a staged surgical strategy. Case Presentation: A 56-year-old woman presented 24 h after a skiing injury with a grossly deformed knee, multidirectional instability, and an anteromedial “pucker sign”. Magnetic resonance imaging demonstrated a KD-IV injury with complete rupture of the anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament, associated with capsular disruption and intra-articular soft-tissue interposition causing irreducibility. Urgent open reduction was performed. The first stage included reduction of the incarcerated capsule, capsular repair, and reconstruction of the posteromedial corner and medial collateral ligament using a semitendinosus autograft. Delayed reassessment at 6 months demonstrated satisfactory stability, minimal residual anterior laxity, and no subjective instability; therefore, anterior cruciate ligament reconstruction was not performed. At final follow-up, the patient had near-full range of motion, no significant valgus instability, and no arthrofibrosis or vascular complications. Conclusions: Management of MLKIs should be individualized according to reducibility, soft-tissue condition, neurovascular status, and functional demands. Irreducible KD-IV dislocations with a pucker sign require urgent open reduction. In selected patients, staged reconstruction may reduce postoperative stiffness and allow selective omission of cruciate ligament reconstruction when satisfactory functional stability is achieved. Full article

Background and Clinical Significance: Endoscopic third ventriculostomy (ETV) is a well-established cerebrospinal fluid (CSF) diversion technique for treating obstructive hydrocephalus. Here, the complication of post-ETV hyponatremia is rare. Separately, aqueductal web as a cause of obstructive hydrocephalus is also an uncommon occurrence. We present an unusual case of an adolescent who presented with late symptoms of obstructive hydrocephalus secondary to an aqueductal web and developed a delayed onset of post-operative hyponatremia after a successful ETV procedure. Pertinent aspects of the case are discussed in corroboration with the recent literature. Case Presentation: A previously well 14 year old presented with symptoms of raised intracranial pressure. Neuroimaging demonstrated progressively enlarging ventricles associated with an aqueductal web. She underwent an uneventful ETV and was discharged home. However, she was readmitted for symptomatic hyponatremia that was investigated and most likely attributed to Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). She was managed with fluid restriction with good clinical improvement. Conclusions: We herein report a case of delayed onset of obstructive hydrocephalus secondary to an aqueductal web, treatment challenges faced and the patient’s unexpected occurrence of hyponatremia after a technically successful ETV. This emphasizes that clinicians need to be mindful of this potential post-operative complication and the ability to discern subtle symptoms in a patient whose clinical signs may not be straightforward. Full article

Background and Clinical Significance: Nodular fasciitis is a benign, self-limited myofibroblastic proliferation that frequently mimics malignant soft-tissue tumors both clinically and radiologically. Although it has been well described in the extremities, its uncommon occurrence in the submandibular region poses a diagnostic challenge. Case Presentation: We report the case of a 22-year-old male patient, presenting with a rapidly enlarging painless swelling in the left submandibular region. Ultrasound demonstrated a well-defined subcutaneous lesion, while magnetic resonance imaging revealed heterogeneous enhancement with diffusion restriction, suggesting inflammatory or neoplastic pathology. Fine-needle aspiration cytology showed spindle-cell proliferation with pseudosarcomatous features, warranting histological examination to exclude malignancy. Surgical resection was performed. Histopathological examination demonstrated a myofibroblastic proliferation with tissue culture-like morphology. Immunohistochemistry showed diffuse SMA positivity while many other immunohistological markers were negative, arguing against several histologic mimics. Fluorescence in situ hybridization confirmed USP6 gene rearrangement, establishing the diagnosis of nodular fasciitis. Conclusions: This case highlights the diagnostic challenges posed by nodular fasciitis in the head and neck region and emphasizes the importance of correlating imaging, cytology, histopathology, and molecular findings to avoid overtreatment. The literature review further supports the benign clinical course of this rare entity in the submandibular region and underscores the value of including it in the differential diagnosis of submandibular masses. Full article

A 34-year-old male presented with persistent medial knee pain and mechanical symptoms three months after a rotational injury, with limited knee extension on examination. Magnetic resonance imaging demonstrated the double posterior cruciate ligament (PCL) sign, produced by a displaced bucket-handle tear of the medial meniscus with the fragment lying anterior and parallel to the intact PCL within the intercondylar notch. Coronal sequences confirmed displacement and loss of normal meniscal configuration. Arthroscopy verified the diagnosis, and arthroscopic partial meniscectomy was performed due to chronic displacement and poor healing potential. Following structured rehabilitation, the patient returned to full athletic activity without symptoms at one-year follow-up. This case underscores the importance of recognizing the double PCL sign as a highly specific MRI finding enabling prompt diagnosis and appropriate management of displaced bucket-handle meniscal tears, while also highlighting its radiologic–arthroscopic correlation and the clinical implications of delayed presentation on treatment strategy, and provides a clear illustrative example of this classic imaging sign for educational purposes. Full article