Reports — Clinical Practice and Surgical Cases

Background and Clinical Significance: Lymphoepithelial cysts are uncommon benign lesions of the head and neck, rarely encountered within the oral cavity and exceedingly infrequent in the palatine tonsils. Their nonspecific clinical presentation and ability to mimic more common benign entities often render diagnosis challenging. Case Presentation: We report the case of a 68-year-old woman with a four-year history of persistent foreign-body sensation in the oropharynx despite multiple normal otolaryngologic examinations. Flexible nasoendoscopy was non-diagnostic, as the lesion was deeply concealed within the superior tonsillar pole between the palatine pillars. Targeted tonsillar manipulation ultimately revealed a small pedunculated mass and contrast-enhanced computed tomography demonstrated a well-circumscribed, non-enhancing cystic lesion confined to the tonsillar parenchyma. Surgical excision under general anesthesia confirmed an oral lymphoepithelial cyst on histopathologic analysis. The patient remained asymptomatic with no recurrence at four months. Conclusions: This case underscores the rarity of tonsillar lymphoepithelial cysts, highlights the diagnostic limitations of endoscopic evaluation for cryptic superior-pole lesions and emphasizes the importance of meticulous dynamic oropharyngeal examination. Complete surgical excision is both definitive and curative, with an excellent prognosis. Full article

Background and Clinical Significance: Anaplastic thyroid cancer (ATC) is a rare and aggressive malignancy with a poor prognosis, where median survival typically ranges from 4 to 10 months. Advances in genetic profiling, particularly the identification of BRAF mutations, offer new opportunities for targeted therapy. Case Presentation: This case report details the journey of a woman in her late 50s diagnosed with symptomatic ATC. Initial immunohistochemistry (IHC) testing for BRAF mutations returned negative results, leaving the patient with limited treatment options and prompting her to pursue medical assistance in dying (MAiD). However, next-generation sequencing (NGS) confirmed a ^V600EBRAF mutation, and a basis for targeted therapy. The patient began treatment with dabrafenib-trametinib, followed by pembrolizumab as second-line therapy, ultimately extending her life by nearly seven months. Conclusions: This case underscores the importance of rapid and comprehensive diagnostic approaches, particularly the higher sensitivity of NGS over IHC for detecting BRAF mutations. The complexities of accessing newer therapies in Canada’s single-payer healthcare system are also emphasized. The utilization of newer rapid diagnostic technologies can have a direct impact on directing treatment for ATC and other aggressive malignancies. Full article

Background and Clinical Significance: Upadacitinib, a selective Janus kinase 1 (JAK1) inhibitor, is increasingly prescribed for autoimmune and inflammatory diseases. Although its therapeutic safety profile is well established, fatal intoxications have not been reported to date. Case Presentation: We describe the first fatal case of upadacitinib overdose in a 13-year-old girl. Following ingestion of approximately 600 mg (40 × 15 mg tablets Rinvoq^®), the patient presented with deep coma, profound bradycardia (~40 bpm) with third-degree atrioventricular block, conduction delay, hypotension, hypothermia, and metabolic acidosis. Laboratory tests showed hyperglycemia (17.8 mmol/L) and only minimal elevations in cardiac biomarkers (CK 57.03 U/L, CK-MB 30.64 U/L, troponin 0.003 ng/mL). Despite advanced resuscitation, the patient succumbed within a few hours. Forensic toxicology revealed extremely high concentrations of upadacitinib, 1.84 µg/mL (~1840 ng/mL) in blood and 70.3 µg/mL in gastric contents, far exceeding reported therapeutic plasma levels (Cmax 36.0 ± 8.8 ng/mL). This case establishes the first reported value for a lethal upadacitinib concentration in humans. The combination of conduction abnormalities, refractory shock, and minimal biomarker changes is consistent with an acute electrophysiological and hemodynamic collapse rather than myocardial infarction. Conclusions: The toxicity of upadacitinib in this case is characterized by profound central nervous system depression, severe cardiovascular (electrophysiological and hemodynamic) disturbances, and metabolic abnormalities (acidosis and hyperglycemia). These findings provide essential reference data for clinical and forensic toxicology, highlight the fatal potential of upadacitinib in overdose, and underscore the importance of secure medication storage and pharmacovigilance in households with adolescents. Full article

Background and Clinical Significance: This case presents immediate implant placement combined with PRF (A-PRF+) and a photogrammetry-based workflow, illustrating predictable full-arch implant-supported rehabilitation. Case Presentation: Main clinical findings included compromised abutment teeth and patient dissatisfaction with aesthetics. Interventions included extractions, immediate implants, PRF socket management, and digital provisional and definitive restorations. Outcomes demonstrated stable occlusion, satisfactory aesthetics, and high patient satisfaction. Conclusions: Immediate placement with PRF and photogrammetry provides reliable outcomes in complex full-arch cases. Full article

Background and Clinical Significance: Statins are widely prescribed for cardiovascular risk reduction and generally demonstrate a favorable safety profile. While myalgia and elevations in liver enzymes are well-recognized adverse effects, headaches are less commonly reported and often underrecognized in clinical practice. This may result in unnecessary diagnostic evaluations, increased healthcare costs, and delayed identification of the underlying cause. Case Presentation: We describe an adult patient who developed intractable headaches that emerged after many years of statin therapy. The headaches persisted despite conventional analgesic treatment and resolved completely following discontinuation of the statin. Secondary causes were excluded, and comorbid conditions were systematically ruled out. Statin-associated headache is uncommon but clinically relevant. Proposed mechanisms include nitric-oxide-mediated vasodilation, central effects of lipophilic statins, and mitochondrial involvement. In this case, the patient was taking metoprolol succinate, lisinopril, simvastatin, clopidogrel, and tamsulosin. Except for lisinopril, none of the other comedications are strongly linked to new-onset headaches. Holding it did not resolve his headache, making simvastatin the most plausible contributor. This was confirmed by resolution of headache through its discontinuation. Because such headaches may be overlooked, clinicians should consider a statin-related cause when symptoms begin after initiation and may manage this by switching to a hydrophilic statin or using alternative lipid-lowering therapy. Conclusions: Clinicians should remain vigilant about the possibility of statin-induced headache, even in long-term users. Early recognition can prevent unnecessary diagnostic investigations, expedite symptom resolution, and support optimal management of both cardiovascular risk and treatment-related adverse effects. Full article

Background and Clinical Significance: Hemiplegia following a cerebrovascular accident (CVA) disrupts gait symmetry and efficiency, compromising functional independence. The integration of surface electromyography (sEMG) and inertial measurement units (IMU) enables quantitative assessment of muscle activation and segmental dynamics, providing objective data for therapeutic planning. Case presentation: A 57-year-old male with chronic right hemiplegia, eight years post-ischemic stroke of the left middle cerebral artery. The patient ambulated independently without assistive devices, exhibiting right lower-limb circumduction. Clinical assessment revealed the following scores: Barthel Index 85/100, Tinetti Performance-Oriented Mobility Assessment (POMA) 16/28, Timed Up and Go (TUG) test 13 s, and Modified Ashworth Scale (MAS) scores of 1 (upper limb) and 1+ (lower limb). Methods: Multichannel sEMG (Miotool 800^®, 8 channels) was recorded form the lumbar erectors, gluteus medius and maximus, vastus medialis, vastus intermedius, vastus lateralis, biceps femoris, tibialis anterior, medial gastrocnemius, and lateral gastrocnemius. Ag/AgCI electrodes were positioned according to SENIAM recommendations: sampling rate: 1000 Hz; band-pass filter: 20–500 Hz; notch filter: 60 Hz; normalization to %MVC. Simultaneously, IMU signals (Xsens DOT^®, 60 Hz) were collected from both ankles during slow, medium and fast walking (20 s each) and compared with a healthy control subject. Results: The patient exhibited reduced sEMG amplitude and increased peak irregularity on the affected side, particularly in the gluteus medius, tibialis anterior, and gastrocnemius, along with agonist desynchronication. IMU data revealed decreased range of motion and angular pattern irregularity, with inconsistent acceleration peaks in the right ankle compared to the control, confirming neuromuscular and kinematic asymmetry. Conclusions: The combined sEMG-IMU analysis identified deficits in selective motor control and propulsion on the affected hemibody, providing essential information to guide physiotherapeutic interventions targeting pelvic stability, dorsiflexion, and propulsive phase training, enabling objective follow-up beyond specialized laboratory settings. Full article

Background and Clinical Significance: Henoch–Schönlein purpura (HSP), also known as Immunoglobulin A (IgA) vasculitis (IgAV), is a common systemic vasculitis in children characterized by palpable purpura, abdominal pain, and joint and kidney involvement. While respiratory tract viral or bacterial infections are the most common causes of HSP, parasitic infections, such as giardiasis, are occasionally reported. Giardia lamblia is the most common parasite infecting humans and a major cause of infectious diarrhea, which can lead to post-infection complications. To our knowledge, this is the first report in Greece describing a pediatric patient with HSP secondary to giardiasis. A review of pediatric HSP cases caused by parasitic infections is also included. Case presentation: An 8-year-old girl presented with a purpuric rash, joint tenderness, severe abdominal pain, and bloody diarrhea, raising suspicion of HSP. Laboratory tests revealed elevated IgA levels, and stool analysis tested positive for Giardia lamblia antigen. The diagnosis of HSP secondary to giardiasis was confirmed, and the patient was successfully treated with supportive care, metronidazole, and corticosteroids. Conclusion: This case report and literature review highlight parasitic infections as an underrecognized but important trigger of pediatric HSP. Although giardiasis is linked to various post-infectious complications, its association with HSP is rarely reported. Pediatricians should maintain a high level of suspicion for underlying infectious diarrhea, such as giardiasis, in patients with HSP, especially in children with prominent gastrointestinal symptoms. Early recognition can reduce complications and facilitate faster recovery. Further research is needed for the immunopathogenic mechanisms linking parasitic infections and HSP in children. Full article

Background and Clinical Significance: Cutaneous lupus erythematosus (CLE) is an autoimmune condition characterized by a wide range of cutaneous manifestations, classified into three major subtypes—chronic (CCLE), subacute (SCLE), and acute (ACLE)—based on clinical morphology and lesion duration. Discoid lupus erythematosus (DLE), the most common form of CCLE, predominantly affects sun-exposed areas and presents as erythematous macules that progress to well-demarcated, disc-shaped plaques. If left untreated, DLE may lead to scarring and permanent alopecia. Diagnosis is primarily clinical, with skin biopsy performed when indicated. Management includes photoprotection and topical corticosteroids, with systemic immunosuppressive therapy reserved for severe cases. Case Presentation: We report a case of a 38-year-old female patient presenting with confluent lesions with indurated borders and multiple pustules, initially raising suspicion of cutaneous infection. A broad differential diagnosis was considered, including fungal and bacterial infections, demodicosis, and cutaneous tuberculosis, all of which were excluded through comprehensive clinical and laboratory investigations. Ultimately, DLE was diagnosed based on serologic and histopathologic findings. During the course of immunosuppressive therapy, her condition deteriorated, and she developed pulmonary tuberculosis. Conclusions: The presented case underlines the rarity and broad differential diagnosis of DLE as well as the possibility of complications. Full article

Background and Clinical Significance: Urothelial carcinoma is one of the most commonly diagnosed malignant diseases. However, it has a much more favorable prognosis than other significantly less common malignancies. This statement, however, is true only for conventional urothelial carcinomas, not for those with divergent differentiation or a special type of urothelial carcinoma. Case Presentation: Herein, we present a case report of an 80-year-old female patient with multiple predominantly cardiovascular comorbidities and vascular dementia, who presented to our institution with genital bleeding. Clinical and diagnostic tests were difficult due to patient noncooperation; however, abdominal computer tomography and cystoscopy showed an advanced tumor originating from the ventral bladder wall. Histology of the tumor showed an invasive urothelial malignancy with foci of clear-cell (glycogen-rich) variant and dispersed, pleomorphic cells, which were immunohistochemically positive for beta-human chorionic gonadotropin. Hence, the diagnosis of high-grade urothelial carcinoma with clear-cell (glycogen-rich) morphology and divergent trophoblastic differentiation was established. Patient outcome was poor. Conclusions: While conventionally having a somewhat favorable prognosis, special subtypes and divergent differentiation in urothelial carcinomas, which warrant a high-grade diagnosis are not only rare but also highly aggressive conditions. Further challenges arise in their differential diagnosis with other advanced malignancies, which can develop in adjacent organs in both genders Full article

Background and Clinical Significance: Inflammatory fibroid polyp (IFP), also known as Vanek’s tumor, is a rare, benign mesenchymal lesion of the gastrointestinal (GI) tract that frequently mimics neoplastic conditions due to its submucosal location and radiologic appearance. Although most commonly found in the gastric antrum, IFPs may occur throughout the GI tract and present with a range of symptoms, from incidental findings to obstruction or bleeding, depending on size and location. Case Presentation: This article presents two distinct cases of gastric IFP managed at the University Hospital of Messina: one endoscopically resected polyp in a 70-year-old man and one surgically excised infiltrative lesion in a 64-year-old woman with high-grade obstruction. Histological analysis in both cases confirmed the diagnosis of IFP, demonstrating spindle cell proliferation with eosinophilic infiltrates and a characteristic perivascular “onion-skin” pattern. Immunohistochemical staining showed strong CD34 positivity and absence of CD117 and DOG1, aiding in differentiation from gastrointestinal stromal tumors (GISTs). Conclusions: Recent evidence suggests a neoplastic origin for IFPs, supported by the presence of PDGFRA mutations and telocyte involvement, prompting a reevaluation of their pathogenesis. These cases underscore the diagnostic challenges posed by IFPs and highlight the importance of histological and immunohistochemical analysis in guiding appropriate treatment. While endoscopic resection is preferred for localized lesions, surgical intervention remains necessary in complex or obstructive cases. Understanding IFPs’ molecular profile and cellular origin may refine future diagnostic and therapeutic approaches. Full article

Background and Clinical Significance: Visual agnosia and speech production deficits are well-described sequelae of neurosurgical interventions, but their selective dissociation remains rare. This report presents an unusual combination of postoperative deficits following awake resection of a left frontal low-grade glioma. Case Presentation: We present the case of a right-handed female with left hemisphere language dominance who had a left frontal low-grade glioma. Preoperatively, she exhibited anomia and dysexecutive syndrome, including difficulty completing everyday goal-directed tasks such as sending emails and paying for parking. Following awake tumor resection, she developed two rare, dissociated deficits: (1) speech restricted to infinitive verb forms and (2) selective visual agnosia for static images, with preserved recognition of dynamic stimuli. Conclusions: This uncommon clinical constellation highlights the vulnerability of left frontal language and ventral visual processing networks during surgery and supports the dual-stream model of vision and language production. We describe a selective form of static visual agnosia affecting static images with relative preservation of dynamic and object recognition, for which we use the descriptive label “astatopsia”. This peculiar clinical condition is rarely documented in this particular combination and has not, to the best of our knowledge, previously been denominated in such a manner in the literature. Full article

Background and Clinical Significance: Splenic artery pseudoaneurysm (SAP) is a rare but life-threatening complication of chronic pancreatitis. Although endovascular embolization achieves high technical success, recurrence and delayed rupture may occur, particularly in patients with ongoing pancreatic inflammation or alcohol use disorder (AUD). Case Presentation: A 47-year-old woman with alcohol-associated chronic pancreatitis presented with hematochezia, melena, and syncope. CT angiography revealed a 3.6 cm SAP adjacent to a 4.2 cm pancreatic head pseudocyst, and she underwent successful coil embolization. Despite initial stability, she relapsed into heavy alcohol use, experienced recurrent pancreatitis flares, and developed progressive multisystem comorbidities. Surveillance imaging up to three months post-embolization showed pseudocyst fluctuations without early recanalization, but long-term follow-up lapsed. Eight months after embolization, she presented in hemorrhagic shock from recurrent SAP rupture and died despite massive transfusion and emergent splenic artery ligation. Conclusions: Fatal SAP rupture may occur months after technically successful embolization. Sentinel bleeding, AUD relapse, and progressive systemic decline are critical warning signs. Structured post-embolization imaging and multidisciplinary management are essential to improve long-term outcomes. Full article

Background: Recent advancements in regenerative medicine have introduced mesenchymal stem cell–derived exosomes (MSC-Exos) as a novel therapeutic approach. Exosomes are extracellular vesicles containing proteins, lipids, and RNAs capable of modulating cellular behavior and promoting tissue regeneration. A systematic review of human studies is warranted to summarize outcomes, assess therapeutic value, and guide clinical applications. Objectives: This systematic review synthesizes current evidence on mesenchymal stem cell–derived exosomes for cutaneous scars, aging, and hyperpigmentation, with a focus on functional and aesthetic outcomes. Method: A comprehensive search of PubMed, Scopus, Embase, Web of Science, and Google Scholar (January 2010–July 2025) was performed following 2020 PRISMA guidelines. Eligible studies included studies that were randomized controlled trials, pilot studies, case series, and case reports involving human participants treated with MSC-Exos. Outcomes assessed were scar remodeling, pigmentation, skin regeneration, recurrence, and adverse events. Data extraction and bias assessment were conducted independently. Result: Six studies (n = 99; age 19–72 years) from diverse regions, including the United States, the Republic of Korea, and México, were included. MSC-Exos therapy showed promising improvements in reducing scar thickness (32.5% vs. 19.9%, p < 0.01), wrinkle parameters were reduced by 1 (2.4–14.4% vs. 6.6–7.1%, p < 0.05), and elasticity was enhanced (+11.3% vs. −3.3%, p = 0.002) Additional benefits included hydration (+6.5% vs. +4.5%, p = 0.37) and reduced melanin index (−9.9% vs. −1%, p = 0.44). The Global Aesthetic Improvement Scale score showed significant improvement (p = 0.005). Using the Investigator Global Assessment, 16 out of 25 areas treated with exosomes showed significant improvement (grade ≥ 2), compared to 12 out of 25 areas in the control group (p = 0.02), indicating that exosome treatment led to more visible improvement. Complete resolution of icepick scars, partial improvement of boxcar/rolling scars, and no recurrence of keloids (18/21) were reported. Adverse events were mild and transient. Conclusions: Early human evidence suggests that MSC-Exos may offer potential therapeutic benefits for scars, hyperpigmentation, and skin aging, with favorable short-term safety profiles. However, the current evidence remains preliminary due to small sample sizes, heterogeneous study designs, and limited follow-up durations. Larger, well-designed randomized trials are needed to confirm long-term efficacy and safety. Full article

Background and Clinical Significance: Cesarean scar pregnancy (CSP) is a rare complication that can occur after cesarean delivery, potentially exposing the patient to severe and life-threatening complications. This case report aimed to illustrate the evolution of CSP cases following initial conservative surgical treatment. Case Presentation: We present two cases involving pregnant women aged 29 and 36 years, both diagnosed with type 2 CSP based on ultrasound findings between 6 and 8 weeks of gestation. In these cases, we initially performed an aspirative curettage after administering systemic Methotrexate (MTX) or Mifepristone. Unfortunately, both patients experienced severe bleeding during the aspirative curettage, which necessitated emergency abdominal hysterectomy along with bilateral salpingectomy. Additionally, we provide an updated review of the related literature. Conclusions: For optimal outcomes, treatment must be tailored to various factors, including gestational age at diagnosis, gestational sac size, anterior myometrial thickness, and the presence of embryonic cardiac activity. Full article

Inferior vena cava (IVC) disruption with continuation of the azygos is a rare congenital vascular abnormality that can be detected prenatally via high-resolution ultrasound. We present a case of isolated discontinuation of IVC, diagnosed during a routine abnormal scan of the second trimester, confirmed by fetal echocardiography, with an uneventful neonatal outcome. In accordance with the literature, we discuss the diagnostic approach, clinical significance and long-term implications of this vascular variant. We want to emphasize the importance of recognizing this anomaly and differentiating isolated cases from those associated with other congenital malformations. Full article

Background and Clinical Significance: Cryotherapy, particularly with the CryoBalloon Focal Ablation System (CbFAS), has emerged as a minimally invasive modality delivering targeted ablation through liquid nitrous oxide. While its role in treating Barrett’s esophagus and dysplasia is well established, its application in early esophageal adenocarcinoma (EAC) salvage treatment remains limited. Case Presentation: We report the case of an 84-year-old male with Barrett’s esophagus and multiple comorbidities who underwent endoscopic submucosal dissection (ESD) for a 3 cm esophageal adenocarcinoma (pT1bN0M0). Histology revealed deep submucosal invasion, perivascular infiltration, and positive margins, rendering the resection non-curative. Given surgical ineligibility, the patient underwent cryoballoon ablation six months later for recurrent intramucosal carcinoma proximal to the ESD scar. At three months, surveillance endoscopy showed residual Barrett’s esophagus with low-grade dysplasia. Conclusions: This case highlights the feasibility and safety of cryoballoon ablation as salvage therapy after non-curative ESD in inoperable EAC. To our knowledge, this represents the first report of salvage CbFAS in T1bN0M0 EAC, underscoring the need for further studies to define its role in the multimodal management of EAC. Full article

Background and Clinical Significance: Atrial fibrillation is a rare disorder in the pediatric population in the absence of underlying heart disease. A specific arrhythmia, known as lone pediatric atrial fibrillation, can occur without identifiable structural heart abnormalities. Case Presentation: We report a case of a 12-year-old obese child with symptomatic hypertension and atrial fibrillation diagnosed through an electrocardiogram (ECG). Conclusions: The patient was rapidly managed with intravenous metoprolol, and he subsequently started cardiologic treatment and clinical follow-up. This case underlines the possibility of performing routine ECGs in the follow-up of obese children. Full article

Orthopedic and lower limb fracture surgeries are among the most frequent emergency procedures and are commonly performed under general anesthesia (GA). Background and clinical significance: Epidemiologically, postoperative coma after GA is rare (0.005–0.08%), but delayed awakening (2–4%) and postoperative delirium or postoperative cognitive dysfunction (POCD) (15–40%) remain significant. These neurological complications increase markedly in vulnerable brain patients with psychiatric, cerebrovascular, or neurodegenerative disorders. Methods: This mechanistic narrative review synthesizes evidence from clinical and experimental studies (1990–2025) comparing the effects of general versus Regional (RA)/local (LA) or spinal anesthesia in vulnerable neuropsychiatric populations “with pre-existing brain illness” undergoing orthopedic surgery. Domains analyzed include neuropsychiatric medications effects and interactions with the GA process and with general anesthetic agents, alongside alterations in neurotransmitter modulation, cerebrovascular autoregulation, mitochondrial dysfunction, oxidative stress, redox imbalance, and neuroinflammatory activation. The review summarizes evidence on how the choice of anesthesia type influences postoperative brain outcomes in patients with known neurological conditions. Results: From previous studies, patients with psychiatric and/or chronic brain illness have a 3–5-fold increased risk of delayed emergence and up to 60% incidence of postoperative delirium. Pathophysiological mechanisms involve GABAergic overinhibition, impaired perfusion, mitochondrial energy failure, and inflammatory amplification. Regional/local and spinal anesthesia may offer physiological advantages, preserve cerebral perfusion, and lower neurological complication rates. Conclusions: General anesthesia may exacerbate pre-existing brain vulnerability, converting reversible neural suppression into irreversible dysfunction. Therefore, whenever possible, regional/local or spinal anesthesia with or without sedation should be prioritized in those neurologically vulnerable patients to reduce the length of hospital stay (LOS) and to lower postoperative neurological complications and risks in psychiatric and neurologically unstable patients. Full article

Rapid methadone metabolism in patients with opioid use disorder could complicate methadone treatment. Toxicology screenings to monitor methadone levels may show negative for methadone, even with regular adherence to a regimen. A patient receiving treatment for opioid use disorder tested negative for methadone in 11 out of 22 toxicology screenings (50.0%). We hypothesized that the patient was a rapid methadone metabolizer. After tapering doses to a maintenance level and using supervised urine collection, the patient was negative for methadone in seven out of seven tests (100.0%), but positive for cocaine in five out of seven tests (71.4%) near the end of the maintenance period. Chronic cocaine use and genetic factors, particularly CYP2B6 polymorphisms, have been found to cause rapid methadone metabolism. Clinicians should be vigilant for unusual metabolic reactions and modify dose and monitoring schedules accordingly. More investigation into the physiological and genetic aspects of methadone metabolism is needed. Full article