Reports, Volume 9, Issue 3 (September 2026) – 64 articles

Background and Clinical Significance: Budd–Chiari syndrome (BCS) is a rare disorder characterized by hepatic venous outflow obstruction, often associated with underlying hypercoagulable states. Pregnancy represents a physiologic prothrombotic condition that may precipitate disease onset. Case Presentation: We report a case of de novo BCS diagnosed in the second trimester in a previously healthy 36-year-old multiparous patient. Evaluation revealed cirrhotic liver morphology, portal hypertension, and bleeding esophageal varices requiring emergent treatment. The patient’s course included a transjugular intrahepatic portosystemic shunt (TIPS) procedure with complications, anticoagulation, multidisciplinary care, and a work-up revealing a JAK2 mutation consistent with an underlying myeloproliferative disorder. Despite apparent maternal stabilization and reassuring fetal growth, the pregnancy resulted in intrauterine fetal demise at 34 weeks’ due to placental abruption, followed by postpartum hemorrhage. Conclusions: This case highlights the diagnostic and therapeutic challenges of BCS in pregnancy, and demonstrates that favorable maternal stabilization does not preclude severe obstetric complications. Full article

Background and Clinical Significance: Encephalitis is a rare neurological complication associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. In rare cases, focal neuroinflammation can manifest as a mass-like parenchymal lesion, creating profound diagnostic and treatment dilemmas by mimicking primary central nervous system neoplasms. Case Presentation: A 34-year-old female presented with cephalalgia, nausea, confusion, facial palsy, and a new onset of focal impaired awareness seizures (FIAS). Brain magnetic resonance imaging (MRI) revealed a prominent hyperintense lesion within the left temporal lobe with associated vasogenic edema and focal leptomeningeal enhancement highly suspicious of a low-grade glial neoplasm. Although nasopharyngeal RT-PCT was negative, the presence of serum anti-SARS-CoV-2 IgM and IgG suggested recent subclinical SARS-CoV-2 infection. To resolve diagnostic ambiguity and avoid empiric oncological overtreatment, a stereotactic brain biopsy was performed. Histopathology revealed acute neuroinflammation characterized by reactive gliosis, microglial hyperplasia, and perivascular lymphatic cuffing, with no evidence of neoplastic presence. Quantitative tissue RT-PCR confirmed the presence of SARS-CoV-2 (Ct33). Follow-up imaging demonstrated complete resolution of the abnormalities following conservative treatment with corticosteroids and antiepileptics, though mild clinical symptoms persisted for 12 months thereafter. Conclusions: Encephalitis presents a rare yet critical manifestation of SARS-CoV-2. Establishing definitive etiology remains challenging. Stereotactic biopsy is a valuable tool to guide appropriate treatment in cases of ambiguous imaging and clinical findings. Radiographic resolution may precede complete clinical recovery. Full article

Background and Clinical Significance: Implant rehabilitation of patients with acquired maxillofacial defects remains challenging, particularly following high-energy war-related trauma. Gunshot and mine blast injuries frequently result in extensive hard and soft tissue loss, often requiring complex reconstructive procedures. Although cortically anchored implants have been successfully used in patients with severe maxillary atrophy and selected traumatic defects, evidence supporting their use for the immediate rehabilitation of critical-size war-related maxillary defects remains limited. Cortically anchored single-piece implants used in conjunction with an immediate loading protocol may provide an alternative rehabilitation strategy for selected patients who decline, or are unsuitable for, conventional implants and bone-grafting procedures. Case Presentation: Two patients with critical-size maxillary defects (approximately 3 cm) resulting from gunshot and mine blast injuries are presented. Treatment consisted of extraction of non-restorable teeth, placement of cortically anchored single-piece implants, including tubero-pterygoid implants, followed by immediate loading with fixed hybrid metal–acrylic hybrid prostheses. Clinical and radiological evaluation was performed using panoramic radiography and cone-beam computed tomography. Conclusion: Successful implant-supported prosthetic rehabilitation was achieved in both patients. Cortically anchored implants engaging the basal bone of the maxilla provided stable support for immediately loaded fixed prostheses despite substantial hard and soft tissue loss. Functional and aesthetic outcomes were satisfactory. Immediate prosthetic rehabilitation was successfully completed in both patients. A 12-month clinical and radiographic follow-up was available for one patient and demonstrated stable implant function without biological or prosthetic complications. Long-term follow-up of the second patient was not available because of active military service. Cortically anchored implant-supported hybrid prostheses may represent a viable treatment option for selected patients with critical-size maxillary defects resulting from gunshot or mine blast injuries, enabling rapid restoration of oral function and facial aesthetics while avoiding extensive bone-grafting procedures. Full article

Background and Clinical Significance: The most common cause of liver toxicity with the use of immune checkpoint inhibitors (ICIs) is autoimmune hepatitis. As most patients with prior viral infections such as hepatitis B and hepatitis C were excluded in trials for the use of ICIs, the safety of ICIs in these patients with active or prior treated hepatitis is unknown. With expanded use of these medications in many malignancies, it is important to understand the risk of viral reactivation with these medications. There are only few case series and reports documenting hepatitis B reactivations with the use of ICIs. Case Presentation: We present a middle-aged woman with a history of treated hepatitis B who presented with metastatic gastric cancer. She was treated with two cycles of 5-FU, oxaliplatin and nivolumab followed by maintenance nivolumab. After 14 months of nivolumab, she developed marked transaminitis and was found to have reactivation of hepatitis B. As autoimmune hepatitis was the initial suspicion, the patient was initiated on prednisone 1 mg/kg with no improvement in transaminases. Due to the significant elevation of HBV DNA, she was diagnosed with hepatitis B reactivation. She was initiated on entecavir with normalization of transaminases and improvement in HBV DNA levels. She was successfully rechallenged with nivolumab with no evidence of recurrent transaminitis or worsening HBV DNA levels. Conclusions: There are case series of HBV reactivation with the use of ICIs. We believe that any patients with known history of HBV should get baseline viral titers prior to initiation of ICIs with serial monitoring of DNA levels. Prospective studies to evaluate risk of reactivation may need to be performed for us to get a better understanding of risks of viral reactivation and potential effects it may have on safety and efficacy of ICIs. Full article

Background and Clinical Significance: Metaplastic breast carcinoma (MBC) is a rare type of breast tumor with various subtypes. MBCs are typically high-grade and exhibit a particularly aggressive behavior, with a significant propensity for recurrence and specific chemoresistance, especially in neoadjuvant settings. One of its high-grade variants is the metaplastic carcinoma with heterologous mesenchymal differentiation (MCHMD). At present, the literature regarding the genetic predisposition of MBC and its connection with BRCA2 is limited. Hence, we present a rare case of a 51-year-old patient with a germline BRCA2 pathogenic variant affected by MCHMD. Case presentation: A 51-year-old Caucasian woman with a family history of breast cancer noticed a lump in her right breast. A needle biopsy of the mass resulted in a diagnosis of poorly differentiated (G3) invasive ductal carcinoma, associated with a dominant component of pleomorphic carcinoma with osteoclast-like cells. After surgery, the pathological report diagnosed a metaplastic carcinoma of the breast with heterologous mesenchymal differentiation (MCHMD) according to the WHO 2019 classification. Genetic testing revealed the presence of the pathogenic variant c.9676del of the BRCA2 gene. Conclusions: We report, to the best of our knowledge, the first case of a BRCA2 mutation in a woman with metaplastic carcinoma of the breast with heterologous mesenchymal differentiation. Full article

Background and Clinical Significance: The COVID-19 pandemic led to the rapid development of effective vaccination strategies. Although COVID-19 vaccines are generally safe, rare hematological adverse events have been reported, most prominently vaccine-induced immune thrombotic thrombocytopenia (VITT). Isolated cases of autoimmune cytopenias and bone marrow failure syndromes following COVID-19 vaccination have also been described. Case Presentation: We report the case of an 80-year-old male who developed subacute-onset severe normocytic anemia with reticulocytopenia and mild leukopenia following heterologous COVID-19 vaccination with ChAdOx1 nCoV-19 (AstraZeneca) and BNT162b2 (Pfizer–BioNTech). Seven days after the second vaccination, mild anemia was detected, progressing over the following weeks to symptomatic anemia requiring hospitalization. Extensive diagnostic evaluation revealed no evidence of hemolysis, nutritional deficiency, autoimmune disease, or viral infection, including SARS-CoV-2 and Parvovirus B19. Bone marrow examination demonstrated an erythroid maturation arrest at the proerythroblast stage, resembling a pure red cell aplasia (PRCA)-like pattern. Cytogenetic and molecular analyses excluded myelodysplastic syndromes. Treatment with erythropoietin resulted in complete hematologic recovery. Conclusions: This case suggests that, in rare instances, COVID-19 vaccination may be temporally associated with transient suppression of erythropoiesis. Further studies are required to elucidate underlying mechanisms and to guide diagnosis and management. Full article

Background and Clinical Significance: Dupuytren’s disease (DD) is characterized by abnormal myofibroblast proliferation and excessive collagen deposition, leading to the formation of pathological fibrous cords. It typically affects the palmar surface of the hand, where these contractile cords cause progressive flexion contractures of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Lesions involving the proximal interphalangeal (PIP) joint without significant flexion contracture may be misdiagnosed as soft-tissue tumors or inflammatory lesions based on imaging findings, including magnetic resonance imaging (MRI) and ultrasound; Case Presentation: We present a case of a soft-tissue mass located on the volar aspect of the proximal phalanx of the little finger, associated with a mild PIP joint contracture. The initial MRI findings suggested a giant-cell tumor of the tendon sheath; however, the diagnosis of Dupuytren’s disease was established only after histopathological examination; Conclusions: This case highlights the importance of considering DD in the differential diagnosis of peripheral soft-tissue lesions of the finger, particularly when presenting with only mild PIP joint contracture and atypical imaging features. Full article

Background and Clinical Significance: Scaphoid fractures and nonunion are uncommon in skeletally immature patients. Pediatric nonunion most often follows a missed or delayed diagnosis or failure of conservative treatment. Inferior-pole nonunion is particularly uncommon, and evidence guiding graft selection in children is limited. We report a case in which preoperative and intraoperative assessment of fragment viability supported the use of a non-vascularized graft. Case presentation: A 12-year-old boy sustained a right inferior-pole scaphoid fracture after falling onto an outstretched hand. The fracture was missed at the initial emergency-department visit. Thumb-spica immobilization was subsequently prescribed, but the patient repeatedly removed the cast, missed appointments, and was lost to follow-up. At referral six months after injury, radiographs and multiplanar CT demonstrated established inferior-pole nonunion. MRI showed preserved marrow fat signal in both fragments without osteonecrosis. Open reduction and internal fixation were performed through a dorsal approach using a 2.4 mm headless compression screw and approximately 1 cc of cancellous iliac-crest autograft. Intraoperatively, both fragments appeared viable, without cystic or sclerotic change. At two months, the patient was pain-free and radiographs showed progressing union. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score improved from 25 preoperatively to 10 at two months. CT at six months confirmed complete osseous union, with a QuickDASH score of 0. At 1.5 years, he remained pain-free, had full flexion with a 5° terminal extension lag, and had returned to table tennis without functional limitation. Conclusions: In this inferior-pole scaphoid nonunion, open reduction and internal fixation with iliac-crest cancellous autograft achieved CT-confirmed union and sustained functional recovery. MRI and intraoperative confirmation of viable bone supported selection of a non-vascularized graft. At 1.5 years, the patient was pain-free, had returned to sport without functional limitation, and had a QuickDASH score of 0. Full article

Background and Clinical Significance: Endoscopic ureterocele incision is the preferred initial treatment for ureteroceles associated with duplex collecting systems due to its capability for rapid decompression via a minimally invasive technique with generally favorable outcomes among pediatric patients. However, the postoperative trajectory in children with solitary functioning renal units remains inadequately characterized. We present a severe, yet reversible, case of postrenal acute kidney injury (AKI) following endoscopic ureterocele incision in an infant with a contralateral multicystic dysplastic kidney (MCDK). This case emphasizes the pathophysiological implications of failed ureterocele decompression and the vital importance of rigorous postoperative monitoring. Case Presentation: A female infant with a right MCDK and a left duplex collecting system featuring an upper pole ureterocele underwent transurethral endoscopic incision due to progressive hydronephrosis. Within 24 h following surgery, the patient exhibited oliguria, oedema, worsening hydronephrosis, hyponatremia (125 mmol/L), metabolic acidosis, and increasing serum creatinine levels, indicative of postrenal AKI. Arterial blood gas analyses indicated severe renal-driven metabolic acidosis with bicarbonate levels of 13.9 mmol/L, accompanied by respiratory compensation and normal lactate levels. Imaging studies revealed deteriorating hydronephrosis of the upper and lower poles of the left kidney. Emergency open nephrostomy placement in the lower pole, after failed jj insertion in the lower pole ureteral orifice, resulted in the immediate restoration of urinary drainage and progressive biochemical recovery. The patient required a brief period of intensive care monitoring, followed by hospitalization in pediatric and urological departments. Longitudinal imaging demonstrated persistent but stable upper pole dilatation with preserved parenchyma. Definitive management was later achieved through right nephrectomy of the non-functioning MCDK. Conclusions: In patients with solitary functioning renal units, the endoscopic ureterocele incision may result in postoperative local oedema, potentially leading to clinically significant obstructive AKI. This case underscores the necessity for intensified surveillance and individualized postoperative management strategies in anatomically complex pediatric patients. Full article

Background and Clinical Significance: Clavicular fractures account for approximately 2.6% of all fractures, with 80% of clavicular fractures occurring in the middle-third of the bone. The middle-third of the clavicle lies directly under the skin without any protection from soft tissue or muscle attachments. The purposes of this case report are as follows: (1) to represent the prosthesis and its operative implantation and (2) to assess the radiological and clinical outcomes of using the prosthesis after a 2.5-year follow-up of the patient; Case Presentation: We present the case of a midshaft clavicle fracture in a 26-year-old, right-handed, male patient following a failure of conservative and open reduction and internal fixation of the fracture. A three-dimensional (3D) customized prosthesis with polyamide was designed for the patient. The patient presented 2.5 years after surgery with a VAS score of 2 and a DASH score of 21, and radiographic evaluation revealed good prosthesis position and no evidence of a stress fracture or unanticipated complications; Conclusions: This is a single case with successful polyamide prosthesis fixation in the treatment of a midshaft clavicle fracture after the failure of plate fixation. Full article

Background and Clinical Significance: Carotid-cavernous fistulas (CCFs) are pathological communications between the carotid artery and the cavernous sinus, most commonly traumatic when direct and high-flow (Barrow type A). Bilateral traumatic CCFs are rare, occurring in approximately 1–2% of cases. Case Presentation: We report a 45-year-old male with polytrauma after a road traffic accident who presented with right-sided chemosis, pulsatile exophthalmos, and ocular bruit. Digital subtraction angiography revealed bilateral direct CCFs. The right fistula was treated with transarterial coil embolization combined with flow-diverter stent placement in the intracavernous internal carotid artery. Subsequent imaging demonstrated left-hemispheric ischemia while the contralateral high-flow CCF remained untreated; the underlying mechanism was considered potentially hemodynamic or thromboembolic. The left fistula was managed using the same technique. Final angiography confirmed complete bilateral occlusion. Despite transient postoperative epistaxis, the patient showed neurological improvement. Conclusions: This case highlights the effectiveness of combined flow diversion and coiling in managing rare bilateral traumatic CCFs. Full article

Background and Clinical Significance: The co-occurrence of Hashimoto thyroiditis (HT), Graves’ disease (GD), and papillary thyroid carcinoma (PTC) is an extremely rare event and offers a unique opportunity to examine how chronic autoimmune thyroid disease may interact with the process of thyroid cancer development. Case Presentation: We present the case of a 42-year-old female with long-standing autoimmune thyroid disorders who developed progressive Graves’-related orbitopathy that did not improve with corticosteroid therapy. Owing to persistent hyperthyroidism and worsening orbital symptoms, she underwent total thyroidectomy. A histopathological examination of the removed thyroid gland surprisingly found PTC developing within a background of chronic autoimmune inflammation. The patient’s postoperative course included stable thyroid hormone replacement, a significant decrease in serum levels of thyroid autoantibodies, and clinical improvement in her orbital symptoms following decompressive surgery, although partial visual impairment persisted. Conclusions: This case highlights how chronic thyroid autoimmunity may create a carcinogenic environment and emphasizes the importance of comprehensive histopathological assessment and multidisciplinary care for patients with complex autoimmune thyroid disease. Full article

Background and Clinical Significance: Periorbital ecchymosis, or “raccoon eyes,” often indicates a basilar skull fracture. When trauma is absent, clinicians should consider other causes, such as Valsalva maneuvers, bleeding disorders, or systemic inflammation. Spontaneous orbital hemorrhage is rare, and its appearance as a mass causing a secondary orbital roof blow-out fracture is even more unusual. This report presents a unique case of primary spontaneous orbital hemorrhage (PSOH) leading to a secondary orbital blow-out fracture; Case Presentation: A 60-year-old man with a history of ulcerative colitis (UC) presented with acute-onset, non-traumatic, and bilateral periorbital bruising, swelling, and right-sided vision loss. Computed tomography (CT) showed a mass lesion in the right orbit with an associated orbital roof fracture. Following excision, histological examination showed extravasated blood. Additional laboratory work-up helped rule out possible hematologic and inflammatory etiologies, confirming a diagnosis of PSOH with a secondary orbital roof fracture; Conclusions: This case demonstrates that PSOH can generate sufficient intra-orbital pressure (IOP) to cause a secondary blow-out fracture, a phenomenon not previously reported in the literature. Furthermore, it emphasizes the need for a systematic diagnostic approach to exclude potential systemic etiologies in patients presenting with spontaneous periorbital ecchymosis. In addition, this case highlights the critical importance of rapid decompression in managing orbital compartment syndrome (OCS) to prevent permanent visual loss. Full article

Background and Clinical Significance: Spina bifida occulta may be associated with occult spinal dysraphism, including a low-lying conus medullaris or tethered cord, which can increase the risk of neurological injury during neuraxial anesthesia. We report a case in which preoperative magnetic resonance imaging (MRI) and lumbar ultrasonography supported individualized planning for spinal anesthesia for cesarean delivery. Case Presentation: A 31-year-old woman at 37 weeks of gestation was scheduled for elective cesarean delivery because of marginal placenta previa. She had chronic low back pain, and previous lumbar radiography and computed tomography had demonstrated radiographic spina bifida occulta. Preoperative lumbar MRI confirmed that the conus medullaris terminated normally at L1 and showed no evidence of tethered cord, filum terminale thickening, spinal lipoma, or abnormalities at the planned L3/4 puncture site. Based on these findings and discussion with the patient, spinal anesthesia was selected. Immediately before the procedure, lumbar ultrasonography was used to identify the L3/4 interspace, visualize the posterior complex, and estimate needle depth. Spinal anesthesia was successfully achieved with a 27-gauge pencil-point needle and intrathecal hyperbaric bupivacaine, morphine, and fentanyl. Cesarean delivery was completed without new neurological deficits or major anesthetic complications. Conclusions: Preprocedural MRI and lumbar ultrasonography supported individualized anatomical assessment and anesthetic planning in this patient. Full article

In patients undergoing endotracheal intubation and mechanical ventilation, damage to the endotracheal tube or inflation line is a potential risk with life-threatening consequences. Although various devices and bite blocks have been developed to secure the endotracheal tube and prevent its dislodgement or damage, they are not suitable for children or newborns. We describe a 1-year-and-2-month-old girl who required long-term endotracheal intubation and mechanical ventilation. The eruption of the lower deciduous incisors caused damage to the inflation line. A mouthguard was not appropriate because her teeth had erupted only slightly, and the retention was insufficient. After collaborating with a dental technician to fabricate a protective device, we were able to provide the optimal treatment while minimizing invasiveness to the patient. It is necessary to collaborate with other professionals as a team to select the optimal medical care tailored to each patient. Full article

Background and Clinical Significance: Tenofovir disoproxil fumarate (TDF) is a widely prescribed nucleotide reverse transcriptase inhibitor (NtRTI) for HIV-1 infection. Though generally well-tolerated, proximal renal tubulopathy resulting in full-blown Fanconi syndrome remains a rare but severe complication (<0.1%). Case Presentation: We present the case of a 52-year-old female living with HIV-1 (diagnosed in 1999, CDC stage A3) who had been treated with a TDF-based antiretroviral regimen for 12 years. Upon admission, she complained of progressive bone pain and polyuria over the preceding six months. Laboratory investigations revealed profound hypokalemia, severe hypophosphatemia, hypouricemia, elevated alkaline phosphatase (ALP) and a decline in renal function (creatinine 1.3 mg/dL from a baseline of 0.7 mg/dL). Arterial blood gas (ABG) analysis showed a normal anion gap hyperchloremic metabolic acidosis alongside respiratory acidosis. Urinalysis demonstrated profound glycosuria in the setting of normal blood glucose levels, coupled with increased 24 h urinary excretion of potassium and phosphorus. A bone scintigraphy demonstrated a “super scan” pattern of metabolic etiology, establishing secondary osteomalacia driven by renal phosphate wasting. Secondary hyperparathyroidism and severe vitamin D3 deficiency were also recorded. The diagnosis of TDF-induced Fanconi syndrome was established. TDF was discontinued, and her antiretroviral regimen was modified to tenofovir alafenamide fumarate (TAF), emtricitabine (FTC), darunavir, and ritonavir, combined with vitamin D supplementation. Over a 6-month follow-up period, renal function normalized, electrolyte wasting resolved, and metabolic acidosis completely reversed. Conclusions: This case highlights that TDF-induced proximal tubulopathy can manifest even after a decade of uneventful therapy, particularly when co-administered with a boosted protease inhibitor. Full article

Background and Clinical Significance: Anti–myelin-associated glycoprotein (MAG) antibody polyneuropathy is a rare, chronic IgM-mediated demyelinating peripheral neuropathy predominantly affecting sensory nerves in older adults, commonly in association with monoclonal gammopathy of undetermined significance. Reports describing anesthetic management in patients with this condition remain extremely limited, and no specific guidelines currently exist regarding neuromuscular blocking agent (NMBA) use or neuromuscular monitoring in this population. Case Presentation: A 79-year-old man with anti-MAG antibody polyneuropathy (diagnosed in 2007) and IgM monoclonal gammopathy of undetermined significance developed disproportionate progressive lower-extremity weakness and became wheelchair-dependent following COVID-19 infection in 2020. Preoperative evaluation revealed mildly reduced left ventricular function (ejection fraction 49%), mild chronic kidney disease, and marked intrinsic hand muscle atrophy with absent deep tendon reflexes. He was scheduled for robot-assisted radical cystectomy with ileal conduit diversion under combined general and thoracic epidural anesthesia. Before NMBA administration, neuromuscular monitoring was systematically attempted at the ulnar nerve (electromyography and acceleromyography, up to 60 mA/300 μs) and the corrugator supercilii; despite visible muscle contractions following peripheral nerve stimulation, neither modality produced reliable responses at either site. Given the inability to establish reliable monitoring, the administration of NMBAs was considered to carry an unacceptable risk of a prolonged, undetectable blockade. Anesthesia was maintained with deep sevoflurane (2.0–2.5% end-tidal) and remifentanil infusion without NMBAs, titrated to a bispectral index of 40–60. Tracheal intubation was accomplished via video laryngoscopy without NMBA. The 7 h and 30 min surgery was completed without patient movement or surgical compromise. Postoperatively, the patient developed transient upper airway obstruction attributed to glossoptosis, managed successfully with head elevation and nasopharyngeal airway insertion; supplemental oxygen was required until postoperative day 3, and the patient was discharged from the high-dependency unit on postoperative day 5. Conclusions: No measurable quantitative neuromuscular response could be obtained in this patient with advanced anti-MAG antibody neuropathy, despite appropriate application of electromyography- and acceleromyography-based monitoring and the presence of visible muscle contractions following peripheral nerve stimulation. In such circumstances, avoiding NMBA administration in favor of deep volatile or intravenous anesthesia with opioid supplementation may represent a reasonable, hypothesis-generating approach in carefully selected patients; this observation does not establish the general superiority of an NMBA-free strategy, and caution is warranted before generalizing it to procedures such as robotic surgery, in which profound neuromuscular blockade is often considered desirable. Full article

Background and Clinical Significance: Blistering distal dactylitis is a localized infection of the distal phalanx, most commonly affecting children and adolescents and typically caused by group A β-hemolytic Streptococcus. Infections due to atypical organisms are rare. Involvement of atypical organisms such as Acinetobacter lwoffii is extremely rare; Case Presentation: We report an 18-month-old boy presenting with hemorrhagic crustation over bilateral big toes for 2 weeks; wound culture swab revealed Acinetobacter lwoffii. Patient was managed with 5 mL of trimethoprim–sulfamethoxazole twice daily for a week; Conclusions: This case highlights the rare involvement of Acinetobacter lwoffii in blistering distal dactylitis and emphasizes the importance of culture-guided diagnosis and treatment. Full article

Background/Objectives: Cardiac implantable electronic device (CIED) infections are infrequent but clinically significant, and Latin American—particularly Chilean—data remain scarce. We aimed to describe the clinical and microbiological profile, complications, mortality, and local infection burden of CIED infections at a tertiary center in southern Chile. Methods: This was a retrospective descriptive cohort study of all patients treated for CIED infection at Hospital Dr. Hernán Henríquez Aravena between January 2015 and December 2021. Crude per-procedure infection proportions were calculated using locally implanted devices (primary implants, generator replacements, and upgrades) as the denominator; because annual implant volumes and individual follow-up times were not retrievable, only exploratory approximate rates per 100 patient-years were derived under strong assumptions and were not used for formal comparison. Results: Fifty-four patients were included (77.8% men; mean age 69 ± 14 years). Predominant comorbidities were arterial hypertension (79.6%), heart failure (40.7%), atrial fibrillation (27.8%), and type 2 diabetes mellitus (24.1%). Pacemakers accounted for 59.3% of infections, and late-onset cases predominated (48.2%). The overall per-procedure infection proportion was 1.4% (95% confidence interval [CI] 1.1–1.9%) and was numerically higher for implantable cardioverter-defibrillators (ICDs; 5.5%) and cardiac resynchronization therapy (CRT) devices (4.3%) than for pacemakers (1.1%). Coagulase-negative Staphylococcus (43.2%) and Staphylococcus aureus (24.3%) were the leading isolates, although microbiological sampling was incomplete (available in 68.5%). Complete system extraction was attempted in all patients and achieved in all but one case; recurrence occurred in 9.3% and in-hospital mortality in 1.9%. Conclusions: The clinical and microbiological profile of CIED infections in this single-center southern Chilean cohort was broadly consistent with international series. Per-procedure proportions for ICDs and CRT devices were numerically higher than those for pacemakers, but the retrospective design, a procedure-based denominator including replacements and upgrades, and incomplete echocardiographic and microbiological workup preclude formal comparison with time-to-event registries; these device-specific findings should be regarded as exploratory and hypothesis-generating. The findings identify concrete, locally actionable targets: more systematic microbiological sampling, broader pre-procedural and diagnostic echocardiography (including transesophageal studies), and strengthened long-term follow-up of CIED carriers. Full article

Background and Clinical Significance: Foreign body aspiration is an important cause of morbidity and mortality in children younger than three years of age. Although laryngeal foreign bodies are uncommon, they may be life-threatening and are frequently misdiagnosed because of their variable clinical presentation. Eggshell aspiration is exceptionally rare, with only a few cases reported in the literature. We report a case of delayed diagnosis of a glottic eggshell foreign body in a toddler presenting with persistent upper airway symptoms. Case Presentation: A 16-month-old previously healthy girl was referred to our hospital for evaluation of persistent hoarseness and barking cough following a witnessed choking episode while eating boiled egg. The choking episode had occurred 15 days before presentation during an episode of viral upper respiratory tract infection. Initial symptoms were attributed to laryngitis and persisted despite medical treatment. Flexible laryngoscopy revealed a foreign body impacted at the glottic level, while neck radiography demonstrated a radiopaque calcified lesion corresponding to the foreign body. Microlaryngoscopy under deep sedation was performed, and an approximately 10-mm eggshell fragment was successfully removed. A small amount of granulation tissue was observed at the posterior commissure, corresponding to the site of foreign body impaction. The postoperative course was uneventful, and repeat endoscopic examination on postoperative day three demonstrated satisfactory laryngeal healing with regression of the granulation tissue. Conclusions: This case highlights the importance of considering a retained laryngeal foreign body in young children with persistent hoarseness or barking cough following a choking episode, even in the presence of concomitant respiratory infection. Early endoscopic evaluation is essential to avoid diagnostic delay and facilitate prompt treatment. In addition, this report emphasizes the importance of food choking prevention and caregiver education in children younger than three years of age. Full article

Odontoma is one of the most frequent odontogenic tumors, and most cases occur in pediatric patients. A panoramic examination of an 11-year-old boy presenting with a chief complaint of dental caries revealed delayed eruption of the maxillary right second molar and a radiolucency around the crown. In addition, cone-beam computed tomography revealed slight calcifications within a cystic lesion measuring 20 × 18 × 13 mm, and demonstrated root resorption of the first molar. Following root canal treatment of the first molar, the lesion was removed under general anesthesia. Histological findings of the resected lesion confirmed the diagnosis of a developing odontoma. This report highlights the importance of early detection of odontomas through radiographic examination. Full article

Background and Clinical Significance: Enfortumab vedotin combined with pembrolizumab has emerged as an effective first-line therapy for advanced urothelial carcinoma. While immune checkpoint inhibitors are associated with digestive tract toxicities, upper gastrointestinal involvement such as esophagitis remains rare, and its presentation in combination with enfortumab vedotin is not well characterized. Case Presentation: A 72-year-old man with metastatic urothelial carcinoma presented with generalized weakness, poor oral intake, odynophagia, dysphagia, anemia, and systemic symptoms following the second cycle of combination therapy of enfortumab vedotin and pembrolizumab. Endoscopic evaluation revealed diffuse circumferential ulcerative esophagitis involving the entire esophagus, with associated duodenitis. Infectious workup, including Clostridioides difficile, cytomegalovirus, and human immunodeficiency virus testing, was negative, and HSV-1 IgG was positive, consistent with prior exposure rather than active infection; however, tissue-based testing for active HSV infection was not performed. Lower gastrointestinal evaluation demonstrated nonspecific rectal inflammation. The patient was treated with high-dose intravenous corticosteroids (intravenous methylprednisolone 1 mg/kg/day) with rapid clinical improvement within 48–72 h, followed by a steroid taper and supportive care. Conclusions: This case represents a severe and diffuse manifestation of esophagitis associated with enfortumab vedotin and pembrolizumab therapy. While immune-mediated esophagitis is rare, the combination of antibody–drug conjugate therapy with immune checkpoint inhibition may contribute to synergistic mucosal injury. Early recognition and prompt initiation of immunosuppressive therapy are critical for favorable outcomes. Clinicians should be aware of severe esophagitis as a potential complication of enfortumab vedotin and pembrolizumab therapy. Timely diagnosis and management with corticosteroids can lead to rapid symptom resolution and may prevent serious complications. Full article

Background and Clinical Significance: Intrahepatic portosystemic venous shunts (IPSVSs) are rare hepatic vascular malformations that occur when there is an abnormal communication between the hepatic and portal veins. IPSVSs can be acquired or congenital, with the latter being the most common. Case Presentation: In this manuscript, we report two cases of symptomatic IPSVSs that were likely congenital in etiology and varied in presentation. The shunts were diagnosed using ultrasound, CT, and MRI, followed by successful treatments with transcatheter embolization procedures. Conclusions: This report highlights the high degree of symptomatic variance that can be seen in patients with symptomatic IPSVSs, as each case presented with different symptomatic features, while also reinforcing the notion that the use of ultrasound, CT, and MRI is of high importance when trying to diagnose IPSVSs. In addition, this article also adds to the existing literature that transcatheter embolization is a valuable therapeutic approach for symptomatic IPSVSs. Full article

Background and Clinical Significance: Iatrogenic aorto-ostial dissection is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), most commonly involving the right coronary artery. Although ostial stenting is generally considered the standard bailout strategy, failure of initial sealing may occur in selected anatomical settings and remains poorly understood. A focused narrative review of the literature was conducted through PubMed/MEDLINE, Scopus and Web of Science to identify reports of PCI-related aorto-coronary dissection with particular attention to dissection morphology, propagation mechanisms, bailout strategies, and outcomes after ostial stenting; Case Presentation: A 76-year-old man presented with non-ST-elevation myocardial infarction. Coronary angiography showed severe ostial right coronary artery (RCA) disease and significant left anterior descending artery stenosis. Following drug-eluting stent implantation in the RCA, extensive aorto-ostial dissection with retrograde extension into the sinus of Valsalva occurred. Initial ostial stenting failed to seal the dissection and was complicated by hyperacute stent thrombosis. After successful rewiring of the true lumen, a second overlapping drug-eluting stent was implanted using a stent-in-stent technique, followed by prolonged balloon inflation, achieving complete sealing and stabilization. Serial computed tomography angiography confirmed stability, and staged PCI of the LAD was successfully performed five days later; Conclusions: Failure of primary sealing may depend not only on procedural factors but also on dissection morphology. Transverse dissections with wide entry tears may be less effectively sealed by a single ostial stent, whereas overlapping stenting with prolonged balloon inflation may represent a more effective bailout strategy. Full article

Background and Clinical Significance: Gallstone ileus (GI) is a rare but serious complication of gallstone disease. This condition is characterized by migration of gallstones through a cholecystoenteric fistula, resulting in mechanical bowel obstruction. GI primarily affects older patients with multiple comorbidities. Case Presentation: Herein, we describe a case of 68-year-old Saudi woman with a history of end-stage renal disease, pulmonary hypertension, diabetes mellitus, bronchial asthma, and atrial fibrillation. She presented with acute calculous cholecystitis. Due to her condition, she was managed conservatively initially. The patient was recommended laparoscopic cholecystectomy but she declined due to fear of anesthesia-related complications. She re-presented after two months with abdominal pain, vomiting, distension, and constipation. Computed tomography (CT) scan showed a 3.2 cm ectopic gallstone impacted in the distal ileum with proximal bowel dilatation and segmental ischemia, confirming GI. Laparotomy showed bowel ischemia and localized perforation. The patient was managed with enterolithotomy, resection of 25 cm of distal ileum, and primary anastomosis. Post-surgery, the patient had favorable recovery. Conclusions: This case highlights need for early diagnosis and appropriate management of GI in patients with multiple comorbidities. Full article

Background and Clinical Significance: Alien hand syndrome (AHS) is a rare disorder of agency and complex motor control characterized by involuntary, apparently purposeful limb movements experienced as outside voluntary control. Pontine hemorrhage is an uncommon substrate, and its manifestations may overlap with sensory ataxia and other post-stroke movement disorders. Case Presentation: An 86-year-old right-handed man developed right-sided alien hand phenomena after a left pontine hemorrhage. Examination showed dysarthria, limited left gaze, diplopia, preserved muscle strength, marked right-sided proprioceptive impairment, a thalamic-hand-like posture, impaired spatial control, involuntary levitation, intermanual conflict, and purposeful-appearing rubbing movements when distracted. The diagnosis was based on loss of agency and autonomous limb behavior that could not be explained by sensory ataxia alone. Serial CT demonstrated an interval reduction in the size of the pontine hemorrhage; a representative thalamic level CT showed no evident thalamic hemorrhage or gross structural lesion, although a small CT occult ischemic lesion could not be excluded. Repeat MRI was not completed because of severe claustrophobia and anesthesia risk. EEG, formal neuropsychological testing, and standardized functional scales were unavailable. The NIHSS, assessed 15 days after admission to our hospital, was 6 points. No specific pharmacological treatment was initiated. Cognitive-behavioral rehabilitation was recommended, but transportation difficulties prevented regular attendance. Approximately three months after discharge, physician relatives reported resolution of abnormal movements and improved independent gait; no formal post-discharge examination was performed. Conclusions: Pontine hemorrhage may rarely be associated with mixed AHS phenomenology. Disruption of ascending proprioceptive and sensorimotor pathways is plausible, but the absence of advanced imaging and neurophysiological assessment precludes definitive anatomical or causal conclusions. Full article

Background and Clinical Significance: Patellar dislocation is considered uncommon in African populations, a finding often attributed to characteristically deeper femoral trochlear grooves that confer increased patellofemoral stability. Nevertheless, individual anatomical variations may predispose certain patients to instability despite population-based trends; Case Presentation: We report the case of a 12-year-old African pediatric patient who presented with a primary traumatic lateral patellar dislocation. Magnetic resonance imaging (MRI) demonstrated rupture of the medial patellofemoral ligament (MPFL) and a markedly increased sulcus angle of 159°, consistent with a shallow trochlear groove. The patient underwent MPFL reconstruction using a synthetic ligament to minimize the risk of physeal injury; Conclusions: This case shows the importance of individualized anatomical assessment in pediatric patellar instability. Even in populations generally considered to have lower anatomical risk, marked individual variation in trochlear morphology may influence treatment decisions. When surgical stabilization is selected in skeletally immature patients, physeal-sparing techniques should be carefully considered. Full article

Background and Clinical Significance: Cryptogenic multifocal ulcerating stenosing enteritis (CMUSE) is a rare idiopathic disorder of the small bowel which remains diagnostically challenging because it can closely mimic Crohn’s disease, celiac disease, and non-steroidal anti-inflammatory drug (NSAID)-induced enteropathy; Case Presentation: We report a 44-year-old man with Down syndrome, Hirschsprung’s disease, celiac disease, and multiple prior abdominal operations who developed recurrent small-bowel strictures of uncertain cause. Initial management involved endoscopic assessment and jejunal dilatation, but this became neither technically feasible nor durable as the disease progressed. He therefore underwent exploratory laparotomy with small-bowel resection to relieve obstruction and to obtain adequate tissue for diagnosis. On balance, the presence of multifocal ulceration, recurrent mucosa-predominant strictures, and non-transmural jejunitis supported a diagnosis of CMUSE; Conclusions: This case highlights the rarity and diagnostic difficulty of CMUSE, which may closely resemble Crohn’s disease in patients with recurrent small-bowel strictures and obstructive symptoms. Early and ongoing MDT coordination (surgery, gastroenterology, radiology, dietetics, and infectious diseases) supports anatomy definition, complication control, and coherent long-term management focused on function and quality of life. Full article

Background/Objectives: Helicobacter pylori infection is a major cause of chronic gastritis, peptic ulcer disease, and gastric cancer. Although accurate diagnostic tests are available, their cost, accessibility, and invasiveness may limit their routine use, particularly in resource-limited settings. Because dyspeptic symptoms are frequently used to guide testing decisions, identifying symptom patterns associated with H. pylori infection may improve patient selection for diagnostic testing. This study evaluated the association between gastrointestinal symptoms, particularly burning epigastric pain that worsens on an empty stomach, and H. pylori stool antigen positivity. Methods: This retrospective observational study included 589 adults who underwent H. pylori stool antigen testing at a private laboratory in Tehran, Iran, between May 2021 and June 2022. Patients were classified as H. pylori-positive (n = 353) or H. pylori-negative (n = 236) based on stool antigen test results. Gastrointestinal symptoms documented in patient records were compared between groups using chi-square analysis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of burning epigastric pain were also calculated. Results: Burning epigastric pain that worsens on an empty stomach was significantly more common in H. pylori-positive than H. pylori-negative patients (76.2% vs. 4.2%; p < 0.00001). Significant associations were also observed for bloating, persistent vomiting, dysphagia, diarrhea, constipation, and melena. Burning epigastric pain demonstrated a sensitivity of 76.2%, specificity of 95.8%, PPV of 96.4%, and NPV of 72.9%. Overall, 99.7% of H. pylori-positive patients reported at least one gastrointestinal symptom compared with 35.2% of H. pylori-negative patients. Conclusions: Burning epigastric pain that worsens on an empty stomach was strongly associated with H. pylori stool antigen positivity and may help clinicians identify patients who are more likely to benefit from diagnostic testing. However, symptoms alone are insufficient for diagnosis and should complement, rather than replace, established diagnostic methods. Prospective studies using standardized symptom assessment and multiple diagnostic modalities are needed to validate these findings. Full article