Search Results (52)

Background: Invasive aspergillosis (IA) is a severe complication after solid organ transplantation, especially in patients receiving long-term immunosuppressive therapy. Pulmonary artery involvement caused by Aspergillus fumigatus is extremely rare and may mimic pulmonary artery thrombosis or malignancy, resulting in diagnostic challenges. Case Presentation: A 61-year-old male developed fatigue, intermittent fever, cough, and chest discomfort seven months after orthotopic heart transplantation. Computed tomography pulmonary angiography revealed a mass-like filling defect involving the main pulmonary artery and left pulmonary artery, which was initially suspected to represent pulmonary artery thrombosis or tumor. Whole-blood next-generation sequencing identified Aspergillus fumigatus and Streptococcus mitis. The patient was treated with voriconazole, anticoagulation therapy, and adjustment of immunosuppressive therapy. Follow-up imaging demonstrated progressive regression of pulmonary artery lesions and disappearance of pulmonary nodules without evidence of graft rejection. Conclusions: Pulmonary artery aspergillosis should be considered in heart transplant recipients presenting with pulmonary artery-occupying lesions, particularly when imaging findings are atypical. Early pathogen identification combined with appropriate antifungal therapy, individualized immunosuppression adjustment, and careful monitoring may improve clinical outcomes. Full article

Endovascular aneurysm repair (EVAR) has become a widely adopted treatment for abdominal aortic aneurysms, offering lower perioperative morbidity and mortality than open surgical repair. Nevertheless, long-term imaging surveillance remains essential because procedure-related complications may occur years after treatment. Among these, endoleaks represent the most frequent and clinically relevant finding, particularly Type II endoleaks, which are sustained by retrograde collateral perfusion and may be associated with persistent aneurysm sac filling and sac enlargement. Computed tomography angiography (CTA) remains the reference standard for anatomical assessment after EVAR, providing detailed evaluation of endograft integrity, aneurysm sac morphology, and vascular anatomy. However, repeated CTA examinations involve cumulative radiation exposure and iodinated contrast administration and may be limited in the detection of low-flow or intermittent endoleaks. Contrast-enhanced ultrasound (CEUS) provides real-time hemodynamic assessment, improves detection of slow-flow endoleaks, and avoids both ionizing radiation and nephrotoxic contrast agents. Nevertheless, CEUS may be affected by operator dependency and limited anatomical overview. CT–ultrasound fusion imaging combines pre-acquired CTA datasets with real-time ultrasound through spatial co-registration and probe tracking, enabling simultaneous evaluation of vascular anatomy and flow dynamics. This narrative review critically synthesizes current evidence regarding CTA, CEUS, and CT–ultrasound fusion imaging in post-EVAR surveillance, with particular emphasis on the incremental clinical value of fusion imaging beyond standalone CTA and CEUS. Particular attention is devoted to diagnostic performance, technical implementation, clinical applicability, current limitations, and future perspectives of CT–CEUS fusion imaging. Full article

Background/Objectives: Human breathing occurs through either the nasal or the oral route. Nasal breathing is the physiological mode of ventilation and contributes to nitric oxide delivery, upper-airway regulation, and efficient pulmonary gas exchange. In contrast, chronic oral breathing has been associated with upper-airway dysfunction, impaired nocturnal oxygenation, and chronic intermittent hypoxia, conditions increasingly associated with cardiovascular, metabolic, respiratory, neurocognitive, and oncological diseases. To determine whether adults with cancer exhibit structural and functional craniofacial characteristics associated with oral breathing patterns and altered nocturnal oxygenation. Methods: We conducted an exploratory case–control study including adults with cancer and matched controls. Participants underwent a standardized multidimensional airway assessment comprising symptom evaluation using the STOP-BANG questionnaire, structured clinical examination of upper-airway and orofacial characteristics, craniofacial assessment, cone-beam computed tomography (CBCT), and home respiratory polygraphy to characterize upper-airway phenotype and nocturnal oxygenation patterns. Results: Adults with cancer exhibited impaired nocturnal oxygenation despite comparable apnea–hypopnea index values. They also exhibited a higher prevalence of structural and functional upper-airway abnormalities, including restricted tongue mobility, anterior open bite, and reduced maxillary transverse dimensions. Conclusions: This exploratory study identifies a distinct upper-airway phenotype in adults with cancer, characterized by craniofacial and functional features associated with impaired nocturnal oxygenation. These findings suggest that upper-airway anatomy and nocturnal oxygenation may contribute to systemic disease vulnerability and warrant further investigation. Full article

Background: Inferior vena cava (IVC) graft–enteric fistula is an exceptionally rare but potentially fatal complication of caval reconstruction. Case Presentation: A 22-year-old woman with previous IVC and right renal vein reconstruction presented with an 18-month history of intermittent abdominal pain, diarrhea, and progressive anemia. On admission, contrast-enhanced computed tomography demonstrated a thrombosed IVC graft with perigraft gas and fluid, loss of the fat plane between the graft and adjacent bowel, and a multiloculated right psoas abscess. Escherichia coli was isolated from blood and drainage cultures. Upper gastrointestinal endoscopy directly visualized prosthetic graft material protruding into the descending duodenum, confirming a graft–enteric fistula. After targeted antimicrobial therapy and stabilization, the patient underwent complete graft explantation, resection of the involved duodenal and jejunal segments, duodenojejunal reconstruction, and extensive retroperitoneal debridement. She remained free of recurrent infection, fistula, and gastrointestinal bleeding at 5-year follow-up. Conclusions: In patients with previous caval reconstruction, persistent gastrointestinal symptoms, unexplained anemia, bacteremia, or retroperitoneal infection should raise suspicion for a graft–enteric fistula. Computed tomography may identify suggestive perigraft changes, whereas endoscopy can provide direct confirmation of luminal erosion. Full article

Background: Perforation associated with intrauterine devices (IUDs) occurs in approximately 1 in 1000 insertions and may be either partial or complete. Perforation may be primary, occurring during device insertion, or secondary, developing after the device has remained in situ for more than eight weeks. Typical symptoms of IUD perforation include chronic pain and intestinal obstruction. Rarely, the device is found either completely within the rectal lumen or partially embedded in the rectal wall with partial intraluminal extension. Removal of the device may require colonoscopy, laparoscopy, or a combination of both. Case: A 45-year-old woman was referred for evaluation of intermittent rectal bleeding. Initial outpatient evaluation included contrast-enhanced computed tomography (CT), which demonstrated two intrauterine devices: one appropriately positioned within the uterine cavity and another located within the rectouterine pouch. A multidisciplinary discussion involving gastroenterologists, gynecologists, and colorectal surgeons was subsequently conducted. Under general anesthesia, laparoscopy was initiated. Upon entering the abdominal cavity, a free IUD string was visualized embedded within the pelvic peritoneum. Using simultaneous colonoscopic guidance with transillumination, a targeted peritoneal incision was made overlying the IUD. The arms were removed laparoscopically. Subsequent colonoscopy removed the remaining segment of the IUD traversing the rectal wall. Conclusions: Although uterine perforation and migration of intrauterine devices are uncommon, they may result in severe and potentially life-threatening complications. Early diagnosis, careful documentation, routine follow-up, and timely removal of misplaced devices remain essential to minimizing morbidity and preventing adverse outcomes. Full article

Background/Objectives: Intermittent ureteropelvic junction obstruction (UPJO), classically termed Dietl’s crisis, may be missed when imaging is obtained outside symptomatic periods. The challenge is amplified in duplicated collecting systems, where the obstructed moiety may not be recognized on screening ultrasonography. Case Presentation: A 14-year-old boy presented with recurrent severe right flank pain triggered by heavy fluid intake, associated with nausea and vomiting and separated by symptom-free intervals. An initial renal ultrasound performed between attacks was normal. One week later, the same pain pattern recurred together with a febrile urinary tract infection. Computed tomography urography (CTU) demonstrated an incomplete right duplex collecting system with a bifid ureter, marked hydronephrosis of the lower moiety, delayed contrast excretion, and focal narrowing at the lower-moiety ureteropelvic junction adjacent to one crossing artery and one crossing vein. Diuretic ^99mTc-mercaptoacetyltriglycine (MAG3) renography documented obstructive drainage, with a post-furosemide drainage half-time (T1/2) > 20 min, differential renal function of 51% on the right, and split moiety function of 31% (upper) and 20% (lower). The patient underwent transperitoneal robot-assisted dismembered Anderson–Hynes pyeloplasty of the lower moiety with the reconstructed ureteropelvic junction repositioned anterior to the crossing vessels; a 6 Fr × 26 cm double-J stent was placed and subsequently removed at 4 weeks postoperatively. Total skin-to-skin operative time was 75 min, estimated blood loss < 100 mL, and the postoperative course was uneventful. At early 3-month follow-up, the patient remained free of Dietl-type episodes, and ultrasonography showed marked reduction in lower-moiety hydronephrosis. Selective postoperative CTU, obtained because of the unusual bifid anatomy, demonstrated patent drainage. Conclusions: A normal interval ultrasound should not exclude intermittent UPJO when the history is stereotypical, and cross-sectional plus functional imaging is decisive when duplex anatomy and crossing vessels coexist. Full article

Background and Clinical Significance: Heerfordt syndrome (uveoparotid fever) is an uncommon extrapulmonary expression of sarcoidosis defined by parotid enlargement, uveitis, low-grade fever, and facial nerve palsy. It is identified in fewer than 1% of patients with biopsy-confirmed sarcoidosis, and the co-occurrence of bilateral seventh-nerve palsy with calcitriol-driven obstructive kidney injury has been reported only sporadically. Recognizing this metabolic-renal phenotype is clinically important because it is readily reversible yet easily missed when the chest radiograph is normal. Case Presentation: A 30-year-old man presented with four months of progressive bilateral parotid swelling, sicca symptoms, and intermittent blurred vision, preceded by a self-limited episode of bilateral simultaneous peripheral facial weakness; renal colic developed one month before admission. Evaluation showed parathyroid-hormone-independent hypercalcemia (peak corrected calcium 13.1 mg/dL), a serum angiotensin-converting enzyme level above 100 U/L, and acute kidney injury (creatinine 2.1 mg/dL) caused by bilateral upper-ureteric calculi with hydronephrosis. Posterior uveitis was confirmed ophthalmologically. Chest radiography and high-resolution thoracic computed tomography were unremarkable, with no hilar lymphadenopathy. Parotid gland biopsy demonstrated non-caseating epithelioid granulomas. Bilateral ureteric stenting and oral prednisolone 40 mg daily produced rapid normalization of serum calcium, recovery of renal function, and regression of parotid enlargement. Conclusions: This report characterizes a phenotype that combines bilateral simultaneous facial-nerve involvement, calcitriol-mediated hypercalcemia, and obstructive nephrolithiasis without coexistent pulmonary disease. It argues for early consideration of sarcoidosis whenever hypercalcemia, parotid enlargement, and cranial neuropathy occur together, and reinforces the reversibility of sarcoidosis-related renal injury when corticosteroids are introduced promptly. Full article

Grade IV lateral patellar luxation is an advanced orthopedic condition that may be associated with severe skeletal deformities, chronic soft-tissue contracture, and irreversible loss of normal stifle function. Although reconstructive procedures are considered the treatment of choice in most dogs, some end-stage cases may not be amenable to conventional correction. This report describes the clinical presentation, surgical management, and long-term outcome of a young dog with severe bilateral grade IV lateral patellar luxation treated with single-stage bilateral stifle arthrodesis. A 1-year-old, 42-kg intact female Romanian Shepherd Dog was presented with chronic severe hindlimb dysfunction, crouched posture, and permanent bilateral patellar luxation. Orthopedic and radiographic examination revealed severe femoral valgus, proximal tibial varus, external tibial torsion, absence of a functional trochlear groove, marked caudal thigh muscle contracture, and severely restricted stifle extension. Computed tomography was considered but not performed because of financial limitations. Based on the severity of the deformities and the limited preoperative range of motion, conventional reconstructive procedures were considered unlikely to restore functional joint motion. Bilateral stifle arthrodesis was therefore performed during a single anesthetic event using tibial tuberosity osteotomy, temporary Kirschner-wire fixation, and bilateral 3.5-mm locking compression plates. Due to severe chronic soft-tissue contracture, final arthrodesis angles of 95° and 99° were achieved. Progressive clinical improvement and radiographic bone union were observed throughout follow-up. At 12 months, complete bilateral arthrodesis and implant stability were confirmed radiographically. At 24 months, the dog remained independently ambulatory with a markedly improved quality of life despite persistent mechanical gait abnormalities, including circumduction and intermittent bunny-hopping. This case suggests that bilateral stifle arthrodesis may represent a salvage option in carefully selected dogs with end-stage bilateral grade IV lateral patellar luxation when conventional reconstructive procedures are unlikely to restore useful limb function. Full article

Background and Clinical Significance: Streptococcus pyogenes (group A Streptococcus, GAS) can cause rapidly progressive invasive infections, including necrotizing soft tissue infection (NSTI) and streptococcal toxic shock syndrome (STSS). Although invasive GAS disease is often associated with skin barrier disruption, severe infection may also follow blunt trauma without visible skin injury. Case Presentation: A 22-year-old woman presented with persistent right hip and groin pain four days after a blunt fall during recreational sports activity, without disruption of skin integrity. On admission, she was hypotensive, tachycardic, and intermittently hypoxemic, with local hematoma, swelling, and inflammatory infiltration of the right groin. Laboratory tests showed marked inflammation, acidosis, acute kidney injury (AKI), elevated lactate, creatine kinase, and myoglobin levels. She was admitted to the intensive care unit with septic shock. Empirical antimicrobial therapy was initiated with piperacillin/tazobactam, clindamycin, and linezolid. Computed tomography showed inflammatory changes extending from the right groin to the thigh fascia. On day 3, the patient’s condition deteriorated with respiratory failure necessitating endotracheal intubation and mechanical ventilation. Surgical incision revealed inflamed and necrotic subcutaneous tissue with superficial muscle involvement. Deep tissue cultures yielded GAS, whereas blood and urine cultures remained negative; probable STSS was diagnosed. Therapy was de-escalated to penicillin plus clindamycin. Continuous renal replacement therapy with an adsorptive acrylonitrile 69 surface-treated (AN69ST) membrane was initiated for AKI. The patient gradually improved and was transferred to the surgical ward on day 16. Conclusions: Minor blunt trauma without skin disruption may precede life-threatening invasive GAS infection. Rapid recognition, surgical source control, antitoxin antimicrobial therapy, and intensive organ support are essential in suspected STSS. Full article

Background: Cracked teeth may present with variable and atypical symptoms, sometimes mimicking non-odontogenic orofacial pain conditions, making diagnosis challenging, particularly when cracks appear limited to enamel. Case presentation: A 36-year-old woman presented with intermittent pain in a mandibular molar radiating to the ipsilateral temporal region. Clinical examination identified a crack line on the lingual surface of the mandibular first molar. Pulp sensibility testing (cold test and electric pulp test), occlusal loading tests, and cone-beam computed tomography (CBCT) were performed. CBCT was used primarily to exclude vertical root fracture and periapical pathology, and no radiographic abnormalities were identified. Differential diagnosis was conducted using structured diagnostic frameworks, including the International Classification of Orofacial Pain and the International Classification of Headache Disorders (3rd edition). Diagnostic local anaesthesia eliminated both biting pain and referred pain, supporting an odontogenic source. Collectively, the findings suggested that the enamel crack was the most likely source of odontogenic pain, although a definitive causal relationship could not be established. Because pulp sensibility remained normal, conservative management was selected. Crack sealing with a methyl methacrylate-based adhesive resin resulted in complete symptom resolution that was maintained throughout a 3-year follow-up period without the need for root canal treatment. Conclusions: Although the diagnosis remained probabilistic, the structured diagnostic approach, together with the favourable clinical response after crack sealing, supported the enamel crack as the most likely source of odontogenic pain. Full article

Background/Objectives: External apical root resorption (EARR) is a recognized biological consequence of orthodontic tooth movement. Although clear aligner therapy has been hypothesized to reduce EARR due to staged and intermittent force delivery, existing evidence remains heterogeneous, particularly with respect to imaging modality. This systematic review and meta-analysis aimed to compare EARR between clear aligners and fixed orthodontic appliances using exclusively quantitative cone-beam computed tomography (CBCT)-based linear root length measurements. Methods: A systematic search was conducted in PubMed/MEDLINE, Scopus, Web of Science, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, and Google Scholar (inception to January 2026). Comparative clinical studies reporting CBCT-based linear root length changes (mm) in clear aligner and fixed appliance groups were included. Random-effects meta-analysis (DerSimonian–Laird method) was performed to calculate pooled mean differences (MD = CA − FA). Heterogeneity was assessed using Cochran’s Q and I² statistics. Risk of bias was evaluated using the ROBINS-I tool, and certainty of evidence was assessed with GRADE. Results: Six studies involving 392 patients met the inclusion criteria and were included in the quantitative synthesis. Random-effects meta-analysis demonstrated significantly lower EARR in the clear aligner group compared with fixed appliances (MD = −0.50 mm; 95% CI −0.79 to −0.21; p < 0.001). Between-study heterogeneity was moderate (I² = 60.8%). Subgroup analysis suggested a larger reduction in extraction-based protocols, although data were limited. Sensitivity analyses confirmed the robustness of the overall effect. The certainty of evidence was rated as low. Conclusions: Clear aligner therapy was associated with lower CBCT-measured external apical root resorption compared with fixed orthodontic appliances; however, this finding should be interpreted with caution due to the limited number of studies, moderate heterogeneity, and potential residual confounding inherent to non-randomized designs. The results should be considered exploratory rather than definitive. Full article

Background: Valproic acid (VPA) poisoning has a dynamic clinical course and may require extracorporeal toxin removal (ECTR) in severe cases. Intermittent hemodialysis is the preferred ECTR technique; however, clinical experience with expanded hemodialysis (HDx) using medium cut-off (MCO) membranes in acute VPA intoxication is scarce. We describe a case of severe VPA poisoning managed with intermittent HDx and outline the clinical rationale and kinetic response. Case Report: A 54-year-old woman presented to the emergency department after accidental presumably ingesting approximately 4 g of VPA, with depressed consciousness (Glasgow Coma Scale 7) and metabolic acidosis (pH 7.10, HCO₃⁻ 13 mmol/L, PCO₂ 50 mmHg, lactate 2.8 mmol/L, ionized calcium 0.8 mmol/L, elevated anion gap). Initial plasma VPA was 262.99 µg/mL, ammonia was 14 µmol/L, and cranial computed tomography showed no acute abnormalities. ECTR was initiated in the intensive care unit as intermittent HDx using an MCO dialyzer for 4 h. Serial VPA concentrations were obtained before treatment, at 2 h, and at the end of the session to guide real-time prescription adjustment, with an increase in blood flow from 200 to 230 mL/min. Results: VPA decreased from 262.99 µg/mL pre-HD to 141.48 µg/mL at 2 h (46.2% reduction) and 97.81 µg/mL at 4 h (62.8% reduction), with clear improvement in the level of consciousness. A mild post-dialysis rebound was observed (100.07 µg/mL at 14 h). The patient recovered without additional ECTR and was discharged with normalized VPA levels on follow-up. Conclusions: In this patient, intermittent HDx with an MCO membrane was feasible, well tolerated, and associated with rapid VPA clearance and neurological recovery. Serial drug monitoring enabled bedside optimization of the dialysis prescription and post-treatment evaluation. A single HDx session was sufficient, and VPA therapy was safely reintroduced under close monitoring. Full article

Background: Chronic subdural hematoma is commonly managed with surgical evacuation when significant mass effect or herniation features are present. Although middle meningeal artery embolization has emerged as an effective adjunctive therapy, evidence supporting its use as standalone treatment in patients with radiological herniation remains limited. Case Presentation: We report a 51-year-old man who presented with a three-week history of progressive headache, intermittent confusion, and mild left-sided weakness. Magnetic resonance imaging demonstrated a right-sided chronic subdural hematoma with marked cortical compression and subfalcine herniation. Despite radiological severity, the patient remained neurologically stable. After multidisciplinary discussion, middle meningeal artery embolization was performed as sole therapy via right radial access using a liquid embolic agent. Selective angiography demonstrated pathological neovascular supply from the right middle meningeal artery, which was completely obliterated following embolization without procedural complications. The post-procedural course was uneventful, with progressive clinical improvement. Follow-up non-contrast computed tomography at eight months demonstrated near-complete resolution of the hematoma with normalization of midline structures, and no surgical evacuation was required. Conclusions: Standalone middle meningeal artery embolization may represent a feasible therapeutic option in carefully selected clinically stable patients with chronic subdural hematoma and radiological herniation features, though further studies are required to define optimal selection criteria and long-term outcomes. Full article

Background and Clinical Significance: A paratubal leiomyoma is an exceptionally rare benign smooth muscle tumor arising from paratubal tissue, with only sporadic cases reported in the literature. Case Presentation: We present the case of a 72-year-old postmenopausal woman with intermittent spotting for three months. A pelvic examination revealed a retained intrauterine device, which was removed along with an old sanguineous discharge. A transvaginal ultrasound demonstrated a complex left adnexal mass with calcifications, and computed tomography (CT) confirmed a 7.8 × 5.5 × 4.7 cm lesion suggestive of an ovarian malignancy. Tumor markers showed mildly elevated CA-125 and carcinoembryonic antigen (CEA) levels. Endometrial sampling using a hysteroscopy and curettage revealed hyperplasia without atypia. The patient underwent a total laparoscopic hysterectomy with a bilateral salpingo-oophorectomy. A diagnostic laparoscopy revealed a well-circumscribed solid mass arising from the mesosalpinx, separate from the ovary and fallopian tube and consistent with a paratubal mass, which was successfully excised laparoscopically. Frozen sections suggested a fibroma, and the final pathology confirmed a paratubal leiomyoma with hyalinization, accompanied by adenomyosis and simple endometrial hyperplasia. The patient recovered uneventfully, and the 6-month follow-up showed no recurrence. This case highlights the diagnostic challenge of differentiating paratubal leiomyomas from ovarian tumors based on imaging alone. Histopathological examination is essential for confirmation. Conclusions: Awareness of paratubal leiomyomas as a differential diagnosis may prevent overtreatment and guide the appropriate surgical management of postmenopausal women presenting with adnexal masses. Full article

Background: Though neoplasms in pigs are increasingly recognized, there are no previous clinical descriptions of nasal squamous cell carcinoma. Case Presentation: A 4-year-old 71 kg Vietnamese Pot-bellied pig barrow presented with a history of mild intermittent epistaxis. A mass was identified in the left nasal passage during computed tomography. Rhinoscopic guidance biopsy confirmed squamous cell carcinoma. Surgical excision via dorsal rhinotomy was performed. Nasal swelling prompted repeated computed tomography 1 year later. Mass recurrence was detected, and the pig underwent a second surgical excision with adjunctive cryotherapy. The patient developed a small permanent nasocutaneous fistula, with no evidence of tumor recurrence 1 year following the second surgery. Conclusion: This is the first reported case of a Vietnamese Pot-bellied pig undergoing treatment for nasal squamous cell carcinoma. A multimodal diagnostic and therapeutic approach was applied, including advanced imaging, rhinoscopy, surgical intervention, and vigilant post-operative monitoring, which resulted in successful management and a favorable long-term outcome. Neoplasia should be considered as a differential diagnosis in pigs presenting with nonspecific nasal signs. Full article