Clinical evaluation and surgical intervention for diaphragmatic eventration mimicking peritoneopericardial hernia in a cat

A 2-year-old spayed female British Shorthair cat presented with an increased frequency and duration of cough since infant period. Based on radiographic, ultrasonographic, and computed tomography findings, peritoneopericardial diaphragmatic hernia was considered so that repair surgery was planned. During celiotomy, lax diaphragm was identified instead of defect. Transabdominal diaphragmatic plication was performed to resolve lax diaphragm and to prevent recurrence by overlapping relatively normal part of diaphragm. Diagnosed with diaphragmatic eventration postoperatively, the cat showed improvement in clinical signs and imaging results. Transabdominal diaphragmatic plication is a suitable treatment; the patient maintained normally during a 14-month follow-up period.

Paraneoplastic movement disorder due to suspected metastatic Leiomyosarcoma of tongue: A case report

Paraneoplastic movement disorders, though rare, can be the initial symptoms of malignancies like leiomyosarcoma, as in our case. Clinicians should keep malignancies in their differential diagnosis in cases of unexplained movement abnormalities.

Optic nerve haemangioblastoma in association with von Hippel-Lindau syndrome: case report and literature review

Optic nerve haemangioblastoma (ONH) is an uncommon, benign, non-meningothelial, mesenchymal tumour of unclear origin. Most are associated with von Hippel-Lindau (VHL) syndrome (71%), and only 40 cases have been reported in the medical literature. Most of the patients develop non-specific visual symptoms, including decreased visual acuity and/or loss of visual fields, exophthalmos, trigeminal neuralgia, and retroorbital pain. Optic nerve sheath meningioma and optic nerve glioma are among the differential diagnoses that may be considered in this location. Contrast-enhanced MRI is considered an optimal diagnostic tool, which helps to determine some characteristics that guide towards an adequate diagnosis and treatment. We present a 42-year-old patient with a history of VHL syndrome in whom a cerebellar lesion and optic nerve lesions were evidenced, and we did a review of the literature and case analysis.

A 40-Year-Old Man with a 7-Year History of Polyarthritis and a Late Diagnosis of Whipple Disease: A Journey to Resolve the Mystery

BACKGROUND Whipple disease (WD) is rare, with an incidence of only a few patients per million. It is caused by infection with the gram-positive bacterium Tropheryma whipplei, and presents with symptoms that include joint pain, fever, diarrhea, and weight loss. This report is of a 40-year-old man with a 7-year history of polyarthritis and a late diagnosis of Whipple disease. The atypical nature of his symptoms led to misdirection and misdiagnosis for years. CASE REPORT A middle-aged white man with seronegative migratory polyarticular arthritis underwent 7 years of treatment with steroids, disease-modifying anti-rheumatic drugs (DMARDs), and a TNF (tumor necrosis factor)-alpha inhibitor, all without any clinical improvement. Throughout this period, he had persistent loose stools and iron-deficiency anemia. Extensive diagnostic investigations for various possibilities yielded negative results. However, after 7 years, he began displaying clinical signs of malabsorption. This prompted further evaluation, including an upper-gastrointestinal endoscopy and biopsy, which revealed the presence of PAS (periodic acid-Schiff)-positive Treponema whipplei, which led to the diagnosis of WD. Following initiation of appropriate treatment, the patient experienced complete resolution of symptoms. Retrospectively, all the pieces of this puzzle fell into place, providing a comprehensive understanding of the prolonged medical challenge the patient faced. CONCLUSIONS This case illuminates the diagnostic challenge faced when dealing with migratory polyarticular inflammatory arthritis and fever. This report has highlighted that Whipple disease can be associated with multiple symptoms and signs, which can result in a delay in diagnosis. However, once the diagnosis is confirmed, antibiotic treatment is effective.

Utilization of dapsone and hemoglobin in the epithelial skin regeneration therapy of cutaneous loxoscelism: A case report and integrative literature review

BACKGROUND

Loxosceles spp are arthropods found worldwide. Its bite may produce cutaneous loxoscelism (necrotic or edematous) or cutaneous-visceral loxoscelism. Depending on their severity and location, cutaneous forms are managed with local cold application and systemic administration of antihistamines, corticosteroids, antibiotics, polymorphonuclear inhibitors, and analgesics.

OBJECTIVE

This study aimed to report a case of cutaneous loxoscelism and to identify the main dermatological manifestations associated with the Loxosceles spp bite.

DESIGN AND SETTING

This case report and literature review was conducted in a Mexican university.

METHODS

A detailed report on the medical management of a patient with cutaneous loxoscelism treated at the emergency department of a public hospital was published. Scopus, PubMed, Web of Science, and Google Scholar databases were searched to identify articles reporting cutaneous loxoscelism. The following keywords were used during the database search: "loxoscelism" OR "spider bite," OR "loxosceles" OR "loxosceles species" OR "loxosceles venom" OR "loxoscelism case report" AND "cutaneous" OR "dermonecrotic arachnidism."

RESULTS

A 62-year-old female patient with cutaneous loxoscelism was treated with systemic dapsone and local heparin spray. Eighteen studies with 22 clinical cases were included in this systematic review. Of the 22 patients, 12 (54.5%) were men. L. rufescens was the predominant spider species.

CONCLUSIONS

The administration of dapsone and heparin for the management of cutaneous loxoscelism demonstrated success in this case, with no sequelae observed. In general, the literature review indicated favorable outcomes in patients treated with antimicrobials and corticosteroids, with continuous healing of skin lesions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42023422424 (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422424).

Identifying in-market application of Pelargonium root extract EPs 7630 for the treatment of COVID-19: analysis of pharmacovigilance data

Introduction: Phytopharmaceutical products are successfully used for acute respiratory infections and may therefore be promising candidates for adjuvant symptomatic treatment of COVID-19. In vitro and clinical studies suggest that the proprietary Pelargonium sidoides DC. root extract EPs 7630 has antiviral and immunomodulatory properties, and effects on SARS-CoV-2 propagation have been shown in vitro. Medicinal products containing the extract have been approved for the symptomatic treatment of acute viral respiratory tract infections. Methods: We present a retrospective review of case reports submitted spontaneously to the pharmacovigilance database of the manufacturer of EPs 7630 and containing information on the off-label use of the extract for the treatment and prophylaxis of COVID-19 and of post-COVID-19 syndrome. Eligible case reports were identified by automated database searches. Results: Forty-four case reports filed between December 2019 and February 2023 were eligible for analysis. More than ¾ described the use of EPs 7630 for treatment of COVID-19 while the remaining reports referred to the treatment of post-COVID-19 syndrome or to COVID-19 prophylaxis. 15/22 cases which reported on treatment duration indicated an intake of EPs 7630 for up to 7 days. Five case reports indicated the use of EPs 7630 as COVID-19 monotherapy while 14 indicated a combination treatment with other drugs. All 28 cases that reported on treatment outcome characterized the patients as improved. Thirty case reports (68%) did not indicate any complications. The most frequent suspected adverse reactions were gastrointestinal complaints and hypersensitivity reactions, both of which may occur as known adverse effects of EPs 7630. No unexpected adverse reactions were observed. Conclusion: Reported cases confirm that there was a certain off-label use of EPs 7630 for COVID-19 in the market. Even though no formal conclusions about the efficacy of EPs 7630 in COVID-19 can be drawn, a beneficial effect would be explainable by the pharmacological profile of the extract. Further assessment of the effects of EPs 7630 in COVID-19-related indications therefore appears to be both justified and promising, particularly as the available case reports did not give rise to any safety concerns also in this patient group.

Thyroid Metastases from Breast Cancer Case Report and Literature Review

BACKGROUND

Thyroid metastasis arising from primary breast cancer is a rare phenomenon, with only a handful of cases documented in both national and international literature. The management approach and prognosis of this occurrence have sparked debates and uncertainties.

CASE PRESENTATION

Herein, we report the case of a 55-year-old woman with breast cancer. She previously underwent extensive excision of the breast lesion with adjuvant chemotherapy and endocrine therapy. After 9 years, she presented with neck discomfort and examination suggested right thyroid metastasis and lymph node metastasis in the neck. Imaging showed pulmonary and bone metastases. Furthermore, the patient received endocrine therapy. After 7 months of follow- up, the patient survived without any new distant metastases. Thyroid metastases originating from breast cancer often unfold with a subtle, intricate nature, making early detection challenging. They tend to emerge inconspicuously, intertwining with widespread systemic metastases, hinting at a less favorable prognosis.

CONCLUSION

Given the unusual clinical indicators, identifying heterochronic thyroid metastases in patients with tumors poses a distinct challenge, requiring clinicians to navigate the follow-up process with heightened sensitivity. The key lies in timely detection and early intervention, factors that can significantly enhance the overall quality of life for patients.

Successful Antiviral Treatment for Chronic Adenoiditis Caused by Herpes Virus in a Pediatric Patient: A Case Report

BACKGROUND The adenoids are lymphatic tissue located in the nasopharynx and play a role in upper-airway immunity. Inflammation of the adenoids is called adenoiditis, which can cause a variety of symptoms. This is a common condition and is due to acute viral or bacterial infection. Most patients experience mild symptoms of upper-respiratory tract infection with a self-limiting course. CASE REPORT A 5-year-old female patient was brought into the clinic by her parents with concerns regarding hearing and sleep. Clinical assessment was consistent with persistent otitis media with effusion and sleep-disordered breathing. She was scheduled for surgery, including nasendoscopy, adenoidectomy, and bilateral grommet insertion. During surgery, direct visualization of the postnasal space showed complete obstruction by hypertrophic, inflamed adenoids covered in a thick, white film. A biopsy was taken, which detected herpes virus cytopathic effect. A diagnostic workup excluded a neoplastic process and other bacterial or fungal infections. A trial of oral antiviral medication was successful and follow-up nasendoscopy showed resolution of adenoid hypertrophy. CONCLUSIONS Direct visualization of the postnasal space, with a transoral mirror or 120-degree endoscope, prior to adenoidectomy can aid diagnosis. Adenoiditis may be caused by a wide range of organisms, including herpes virus. Active mucopurulent discharge should raise concern for infection by bacteria, fungi, or virus. Previous research on viral infection of the adenoids have been in asymptomatic patients with presumed latent infection and undergoing elective adenoidectomy. To our knowledge, this is the first paper to report on successful treatment with antiviral medication alone.

Ovarian cancer with intestinal wall invasion and hyperamylasemia: a case report

Numerous studies have suggested a robust association between amylase and ovarian cancer. however, few amylase-producing ovarian cancers have been reported because amylase is a rare product of ovarian cancer. A case of an elderly female patient with an upper abdominal unfitness, intestinal wall along with uterine adnexal invasion, and high serum and urinary amylase is summarized in this article. The patient was initially suspected of having a gastrointestinal tumor. Initial laboratory findings showed markedly significantly raised serum and urinary amylase levels. Imaging showed invasion of the intestinal wall and uterine adnexa, and histology of the specimen taken through the abdominal wall lump and electron colonoscopy showed ovarian cancer. The patient's blood amylase levels decreased to normal after 4 cycles of neoadjuvant chemotherapy with paclitaxel and carboplatin. Following this, she underwent interval debulking surgery, which included total hysterectomy, bilateral adnexectomy, great omentectomy, appendectomy, resection of pelvic and abdominal lesions, and partial rectal resection. Postoperative pathology and immunohistochemistry staining confirmed a diagnosis of high-grade serous ovarian cancer. This case suggests that in female patients, hyperamylasemia may indicate the presence of ovarian cancer. It is necessary to perform a multisite, multipoint histologic examination to identify the tumor's origin in patients with multiple sites of invasion.

Successful Conservative Management of Hepatic Portal Venous Gas Following Percutaneous Endoscopic Gastrostomy: A Case Report

BACKGROUND Hepatic portal venous gas (HPVG) is a rare radiologic finding mostly associated with life-threatening diseases like bowel necrosis, but can also be benign; its overall mortality rate is 39-75%. In rare cases HPVG is associated with endoscopic procedures such as percutaneous endoscopic gastrostomy (PEG) placement. However, due to the rarity of this condition, there is no recommendation about its management. The aim of this case report was to describe a successful conservative management of HPVG without antibiotic administration based on the clinical presentation. CASE REPORT A 78-year-old male patient known for a history of esophageal cancer treated with radio- and chemotherapy, complicated by a post-radiation esophageal stenosis requiring a PEG tube placement 1 month prior was admitted to our Emergency Department for vomiting and abdominal pain. A contrast-enhanced abdominal CT scan showed small-bowel dilatation without obstruction, as well as gastric wall pneumatosis and HPVG. We opted for a conservative approach. The PEG was put to suction for 2 days. The clinical evolution was favorable, with resolution of abdominal pain and a restored transit on day 2. A follow-up CT scan at day 5 showed resolution of HPVG. Nutrition through the PEG was restored at day 6 without complication. CONCLUSIONS HPVG can be a benign finding after a PEG tube placement. Conservative management without antibiotics can be used in oligosymptomatic and hemodynamically stable patients after life-threatening associated diseases like bowel necrosis have been ruled out.

Oral manifestations after vaccinations: A systematic review of observational studies

OBJECTIVE

This study aimed to assess the prevalence and types of oral adverse events following immunization (AEFIs) in people who received at least one dose of any type of vaccine.

MATERIALS AND METHODS

We conducted a bibliographic search about oral AEFIs in MEDLINE, Embase, PubMed, and Ovid from database inception to November 07, 2022. Risk of bias was assessed using the MURAD or the Quality In Prognosis Studies tools. Random-effects proportional meta-analysis was applied.

RESULTS

A total of 119 studies involving 343 people were eligible. These reported AEFIs occurred following administration of the coronavirus disease 2019 vaccine, anti-influenza vaccine, hepatitis B vaccine, and anti-smallpox vaccine. The most common to be affected in vaccinated people were buccal mucosa (63.1%; 95% confidence interval (CI) 33.4-88.2) and lips (55.7%; 95% CI, 41.1-69.8). The most prevalent oral AEFIs were ulceration (55.2%; 95% CI 24.4-84.0), swelling (65.2%; 95% CI 34.9-89.8), and burning sensation (18.3%; 95% CI 7.9-31.8).

CONCLUSIONS

The mechanisms underlying oral AEFIs should be further investigated to promptly recognize oral manifestations and provide optimal management for people undergoing vaccination.

Emergent Management of Gastric Outlet Obstruction Post-Intragastric Balloon: A Case Report Highlighting the Importance of Preoperative Assessments and Postoperative Monitoring in Obesity Management

BACKGROUND Obesity is a global epidemic often managed through surgical interventions, such as intragastric balloons. Despite the minimally invasive appeal of intragastric balloons, severe complications, such as gastric outlet obstruction, can occur with their use. The most recent guidelines recommend metabolic and bariatric surgery for specific body mass index categories but rarely discuss the potential complications and required postoperative monitoring. Guidelines encourage metabolic and bariatric surgery for patients with a body mass index of 30-34.9 kg/m² and presence of metabolic disease, or body mass index ≥35 kg/m², regardless of co-morbidities. CASE REPORT We report a case of a 35-year-old woman with severe nausea, vomiting, electrolyte imbalance, and chest pain, leading to ICU admission just 2 weeks after intragastric balloon placement in Mexico. Testing and diagnostics were concerning for metabolic imbalance and heart rhythm changes. Imaging and endoscopic investigations confirmed gastric outlet obstruction, necessitating emergent endoscopic balloon deflation and removal. Following the procedure, her symptoms resolved, and she was discharged with appropriate medication and scheduled follow-up. CONCLUSIONS Given the increasing prevalence of obesity and a corresponding surge in surgical interventions, this case serves as a cautionary tale. Selection of a type of metabolic and bariatric surgery should be patient specific, with the patient involved in the decision making. Rigorous preoperative assessments and sustained postoperative monitoring are imperative. This study aims to guide future research toward enhanced patient selection and prevention of severe complications, thus influencing practice and policy in obesity management.

An AQP-4-IgG-Positive Patient with Neuroimaging Findings Suggestive of Multiple Sclerosis

BACKGROUND Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSDs) are 2 similar but distinct diseases. These diseases were difficult to distinguish from each other until aquaporin-4-IgG (AQP-4-IgG) was discovered. The accurate identification of these 2 diseases is crucial for appropriate drug treatment in clinical practice. Herein, we report a case of AQP-4-IgG seroconversion with magnetic resonance imaging (MRI) findings suggestive of MS. CASE REPORT A 54-year-old woman developed weakness in her right lower extremity that gradually returned to normal 4 years ago. Recently, she was admitted to the hospital for numbness and weakness of both lower limbs and the right upper limb for more than 10 days. The clinical and MRI features of the patient suggested a high susceptibility for misdiagnosis of MS. However, careful observation of the MRI revealed the presence of atypical MS lesions ("red flag" signs), indicating the possibility of other diagnoses in this patient. After further examination, serum AQP-4-IgG was detected, suggesting the potential presence of another disorder, NMOSD, in the patient. CONCLUSIONS Attention should be given to the identification of MS MRI "red flag" signs. Even for patients with a high suspicion of MS, it is necessary to conduct antibody tests for AQP-4-IgG, MOG-IgG and other relevant markers to screen for associated diseases because MS disease-modifying therapy approaches may lead to a deterioration in the state of NMOSD patients. Analyzing this case can help us to further distinguish the differences between these 2 types of diseases, which has important practical clinical value.

Disseminated appendicular lymphoma presenting as acute appendicitis: a case report

Introduction and importance

Acute appendicitis is a common surgical emergency marked by appendix inflammation, presenting as acute abdominal pain and typically treated with appendectomy. The authors report a rare case of disseminated appendicular lymphoma presenting as acute appendicitis. Acute appendicitis is a common surgical emergency.

Case presentation

This case involved a 75-year-old male patient who underwent appendectomy, revealing an enlarged appendix with lymphomatous nodules.

Clinical discussion

Lymphoma involvement in the appendix is extremely rare, and lymphomas presenting as acute appendicitis are even more exceptional. Imaging investigations, including ultrasound and CECT scan of the abdomen, are recommended to aid in diagnosis. On computed tomography, appendiceal lymphoma is characterized by markedly diffuse mural soft-tissue thickening with preserved vermiform morphology and occasional aneurysmal dilatation of the lumen.

Conclusion

This case underscores the importance of considering unusual etiologies in atypical appendicitis presentations.

Differences in Symptoms Following Acupuncture Treatment in Three Case Presentations of Bipolar Disorder: Type 2, Comorbid Anxiety Disorder, and Rapid Cycling Type

Background

This study reports the effects of acupuncture treatment on depression and anxiety symptoms for 3 different bipolar disorder (BD) pathologies.

Case

Case 1: A 35-year-old man was diagnosed with BD type 2. His depressive symptoms appeared 17 years ago. He did not meet the diagnostic criteria for anxiety disorder (AD) in the Mini International Neuropsychiatric Interview (MINI). Case 2: A 32-year-old woman was diagnosed with BD type 2 with AD. Her depressive symptoms appeared 5 years ago. MINI indicated panic-, social anxiety-, and generalized AD. Case 3: A 42-year-old woman was diagnosed with rapid cycling BD. She developed depressive and hypomanic symptoms and visited our hospital 18 years ago. Acupuncture treatment was performed weekly for 12 weeks. Depression and anxiety symptoms were evaluated using the Himorogi Self-Rating Depression Scale (HSDS) and Himorogi Self-Rating Anxiety Scale (HSAS), respectively.

Results

Case 1: The HSAS score did not improve significantly, but the HSDS score decreased from 22 points at baseline to 9 points at the 12th visit. Case 2: The HSDS score did not improve, and the HSAS score remained high from 26 points at baseline to 25 points at the 12th visit. Case 3: During the acupuncture period, both HSDS and HSAS scores fluctuated greatly, and the patient experienced repeated episodes of depression and hypomania.

Conclusions

The response to acupuncture treatment may differ according to the classification and pathology of BD, and it may be desirable to perform the acupuncture treatment after evaluating the pathology and estimating the prognosis.

Complications of lymphangioleiomyomatosis in pregnancy: a case report and review of the literature

Lymphangioleiomyomatosis is a rare cystic lung disease primarily affecting premenopausal females and may be exacerbated by pregnancy. We conducted a literature review of lymphangioleiomyomatosis during pregnancy with a specific focus on related maternal morbidity and obstetrical outcomes. We also report a case of lymphangioleiomyomatosis that presented as an acute spontaneous pneumothorax in the third trimester of pregnancy, followed by significant maternal morbidity. A 37-year-old primigravid woman who presented at 29 weeks 5 days gestation with chest pain was diagnosed with spontaneous pneumothorax. Further imaging demonstrated cystic lung lesions and renal angiomyolipomas. She developed severe abdominal pain concerning for placental abruption that led to an urgent cesarean delivery at 30 weeks 2 days gestation. Her course was complicated by recurrent pneumothorax, superimposed preeclampsia, and significant ileus and bowel dilation complicated by bowel perforation. For patients with a clinical suspicion of lymphangioleiomyomatosis in pregnancy, prompt recognition, diagnosis, and referral to appropriate multidisciplinary subspecialists is critical to mitigate complications and optimize outcomes both during and after pregnancy.

Three cases of systemic lupus erythematosus presenting with ischemic stroke as the initial symptom: Case reports and literature review

BACKGROUND

Ischemic stroke constitutes a grave complication within the context of systemic lupus erythematosus (SLE), typically manifesting several years postdiagnosis of SLE. Incidents where ischemic stroke precedes and acts as an initial symptom of SLE are comparatively rare in its early stages, and such presentations are frequently misdiagnosed as ischemic cerebrovascular diseases, posing significant diagnostic challenges.

CASE REPORTS

This article presents three cases of young females in whom ischemic stroke emerged as the initial manifestation of SLE. It incorporates a review of 17 case reports published over the past two decades, focusing on patients with SLE where ischemic stroke was a primary symptom. This discussion encompasses the clinical presentation, outcomes, and therapeutic approaches for these patients.

CONCLUSION

In young patients, particularly females presenting with ischemic stroke and especially in cases accompanied by hematologic or multisystemic involvement, there should be heightened vigilance for SLE-induced ischemic stroke. Early diagnosis and treatment significantly enhance patients' quality of life and survival rates.

Myocardial infarction with nonobstructive coronaries (MINOCA) following rabies postexposure prophylaxis: A case report

Key Clinical Message

This case underscores the importance of considering myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients experiencing acute chest pain following rabies vaccination, emphasizing the need for heightened awareness and further research into the association between MINOCA and Rabies vaccination.

Abstract

Rabies is a vaccine-preventable deadly viral disease prevalent in Asia and Africa that causes thousands of deaths annually. Rabies pre (PrEP) and postexposure prophylaxis (PEP) is highly effective in annulling rabies-associated deaths. The adverse reactions following rabies vaccination are typically mild. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare condition, and its association with rabies vaccination is unprecedented. We present a case of a 43-year-old male with MINOCA following Rabies PEP. A 43-year-old male, nonsmoker and nonalcoholic, presented to the ER with complaints of acute onset left sided chest pain following the completion of the third dose of intradermal rabies vaccine, whose clinical features, ECG changes and lab reports were suggestive of acute presentation of inferior wall MI. Coronary angiography was performed, which however revealed normal coronaries with only slow flow being noted in the left anterior descending (LAD) artery. Echocardiography later showed a normal study with no other relevant diagnosis unveiled on further investigations. Hence a diagnosis of vaccine-induced MINOCA was made. Treatment included antiplatelet therapy, statins, and beta-blockers. MINOCA following rabies vaccination is an unprecedented finding. The clear etiology behind this couldn't be ascertained. The patient's treatment was conventional, emphasizing the need for further research and clinical trials in MINOCA diagnosis and management. This case highlights the need for clinicians to consider MINOCA in patients with acute chest pain post-rabies vaccination. Further research is essential to unravel the association between MINOCA and rabies vaccination, paving the way for optimal management strategies.

Unique combination of hyaluronic acid and amino acids in the management of patients with a wide range of moderate-to-severe chronic wounds: Evidence from international clinical practice

The availability of new products and strategies to manage wounds has taken a quantum leap in recent years. Healthcare professionals now have an extensive range of products to choose from, but while positive this also raises dilemmas in real-world clinical practice to decide on the most appropriate treatment for a given patient. Clinical trials confirm the effectiveness of the unique combination of hyaluronic acid and amino acids (Vulnamin®) in a range of wounds, but are these results replicated in real-world clinical practice? International experts presented their clinical experience with the use of the combination in difficult-to-treat wounds. The objective was to reach a consensus on how and when to use the unique combination products to provide a cost-effective, convenient option, in all healthcare settings that improves QoL for patients and their carers.

Uncovering the Unknown: Granulomatous Peritonitis After Right Ovarian Cystectomy at a Tertiary Care Center in South India-A Case Report

Background. Granulomatous peritonitis is a rare postoperative complication caused by a delayed hypersensitivity reaction to foreign substances. It can be challenging to diagnose owing to its vague presentations, and its possibility is often overlooked. Tubercular peritonitis and peritoneal carcinomatosis are the 2 crucial differential diagnoses that need to be taken into account. However, making a clinical differentiation between these 2 entities is challenging and necessitates a careful histopathological and microbiological analysis. Case Presentation. In this report, we present the case of a 28-year-old female who developed granulomatous peritonitis following a right ovarian cystectomy. The diagnosis was confirmed by histopathological examination. Conclusion. We must be aware of this rare entity, which, if left untreated, could have serious consequences, and consider its possibility in cases where the patient complains of abdominal pain after any abdominal procedure. We hope to provide insights into the importance of histopathological examination in aiding a confirmatory diagnosis of this entity.

Intrahepatic Cholangiocarcinoma in Wilson's Disease: A Case Report

BACKGROUND Wilson's disease is a rare autosomal recessive disorder characterized by excessive accumulation of copper in the liver, brain, and kidneys. Although it affects only approximately 1 in 30 000 individuals, it leads to progressive liver damage and neurological issue. Wilson's disease presents a wide spectrum of clinical manifestations related to hepatic disease, ranging from asymptomatic cases to acute liver failure. The occurrence of hepatobiliary malignancies, including intrahepatic cholangiocarcinoma, is relatively uncommon in Wilson's disease, even among patients with cirrhosis. Only 14 cases have been published so far, including the present report, and its etiology remains unclear. CASE REPORT We report the successful treatment of intrahepatic cholangiocarcinoma in a 39-year-old woman with Wilson's disease. Twenty-two years after being diagnosed with Wilson's disease, intrahepatic cholangiocarcinoma was diagnosed. She had an intrahepatic mass that was found to be a 4.3-cm ill-defined hypodense lesion in liver segment 3/4, with features suggesting infiltrative intrahepatic cholangiocarcinoma rather than hepatocellular carcinoma. Laboratory results showed slightly elevated liver enzymes and tumor markers. There was no evidence of metastasis on chest computed tomography or positron emission tomography, and the tumor was resectable, so surgery was the first-choice treatment option. Left hepatectomy was performed successfully, and the final pathology confirmed adenocarcinoma with clear resection margins. The patient received adjuvant chemotherapy with capecitabine. To date, the patient has been doing well without evidence of recurrence or metastasis. CONCLUSIONS Despite limited knowledge regarding hepatic malignancy in Wilson's disease, it is crucial to prioritize careful monitoring and develop suitable treatment strategies upon diagnosis to achieve favorable outcomes, considering the potential occurrence of intrahepatic cholangiocarcinoma in Wilson's disease.

A case of digoxin intoxication caused by short-term massive overdose: Case report

RATIONALE

Digoxin is a frequently prescribed medication for the management of both acute and chronic cardiac insufficiency. The overdose ingestion of digoxin can result in a range of arrhythmias, with severe cases potentially leading to malignant arrhythmias and fatal outcomes. To date, there is a lack of documented cases related to acute digoxin intoxication resulting from the administration of massive digoxin overdose in the short term.

PATIENT CONCERNS

A 37-year-old female patient was admitted to the emergency department following a suicide attempt involving the administration of 330 tablets of digoxin (each tablet containing 0.25 mg). The patient exhibited symptoms of confusion, nausea, and vomiting for around 30 minutes. The patient had a history of depression.

DIAGNOSES

The patient was diagnosed with digoxin intoxication.

INTERVENTIONS

The patient underwent many medical interventions including stomach lavage, administration of laxatives, correction of cardiac arrhythmias, provision of myocardial nutrition, diuresis, correction of acid-base balance, and management of electrolyte disturbances, among others.

OUTCOMES

Following a treatment of 9 days, the patient exhibited no signs of discomfort, maintained consciousness, and the serum concentration of digoxin was indeterminable. Upon reevaluation of the electrocardiogram, it was determined that no arrhythmia was present. Consequently, the patient was authorized to be discharged from the hospital.

CONCLUSIONS

There is currently no documented evidence of cases involving a significant overdose of digoxin resulting in intoxication. The patient had a comprehensive treatment regimen consisting of stomach lavage, administration of a laxative, correction of cardiac arrhythmias, provision of myocardial nutrition, fluid replacement, diuresis, and supportive therapy, resulting in successful outcomes.

LESSONS

There have been no known cases of intoxication resulting from a significant overdose of digoxin, specifically with the consumption of 330 tablets (0.25 mg/tablet). However, in the event of ingesting excessive amounts of digoxin, it is imperative to promptly administer stomach lavage, administration of a laxative, and arrhythmia correction. The administration of temporary pacemaker therapy is recommended for patients presenting with high atrioventricular block, whereas hemoperfusion is advised for patients with renal insufficiency as a means to eliminate digoxin from the body.

A 3-Year-Old Girl with Brain Imaging Findings Suggesting Arachnoid Cyst, and Biopsy Diagnosis of Extra-Axial Multicystic Pilocytic Astrocytoma

BACKGROUND Arachnoid cysts and pilocytic astrocytomas are distinct intracranial entities with differing clinical presentations, origins, and management strategies. Arachnoid cysts are benign fluid-filled sacs associated with congenital or acquired causes, while pilocytic astrocytomas are low-grade brain tumors, primarily affecting pediatric and young adult populations, originating from astrocytes. However, diagnosing pilocytic astrocytomas can be challenging due to their radiological features, sometimes resembling more common intracranial lesions, such as arachnoid cysts. This case underscores the need for vigilance and a multidisciplinary approach when confronted with neuroimaging findings that diverge from typical patterns. CASE REPORT We present a case of a 3-year-old girl who presented with persistent headaches, vomiting, and difficulty walking. Initial radiological assessment suggested an arachnoid cyst, given the patient's symptoms and imaging characteristics. Subsequently, the patient underwent a craniotomy, with intraoperative findings revealing a cystic lesion without a solid mural nodule, which was excised completely. Postoperatively, histopathological examination confirmed a diagnosis of extra-axial pilocytic astrocytoma. The patient's symptoms resolved, and she was discharged without neurological deficits. CONCLUSIONS Diagnosing extra-axial pilocytic astrocytomas presents challenges, due to their radiological similarities with more common intracranial lesions, like arachnoid cysts. This case underscores the importance of histopathological examination to confirm the diagnosis accurately. Surgical resection remains the primary treatment for extra-axial pilocytic astrocytomas, often resulting in a favorable prognosis.

Brown spiders (Loxosceles) are taking hold in Pernambuco, Brazil: a case series, 2018-2022

OBJECTIVE

To describe accidents involving brown spider (genus Loxosceles) bites notified by the Pernambuco Poison Information and Care Center (CIATox-PE), Brazil, from January 2018 to December 2022.

METHODS

This was a case series study of brown spider bites notified by the CIATox-PE.

RESULTS

The study included 22 cases with median age of 35 years, the majority being female (13); the cases occurred in rural and urban areas (12 versus 10), at night (10); Petrolina was the municipality with the highest number of notifications (6); spider bites occurred mainly in the lower (11) and upper (9) limbs, almost exclusively inside households (21); specific serum therapy was not indicated for 8 cases because the time for its effectiveness had already elapsed.

CONCLUSION

Loxoscelism cases occurred more frequently in females, in both rural and urban areas and mainly at home, with delays in seeking medical care.

MAIN RESULTS

The 22 cases described represent an alert for the presence of a venomous species not reported in previous studies in Pernambuco. The severity of cases may be associated with delays in seeking medical care, especially due to the population's lack of information.

IMPLICATIONS FOR SERVICES

Identify the presence of brown spiders in households in the region and the potential severity of poisonings. Alert health professionals to recognize the clinical picture with a view to appropriate early treatment.

PERSPECTIVES

Develop research on poisoning by venomous animals and educational actions alerting the population to prevent these accidents and updating health professionals on care.