Fibrocartilaginous embolism: a rare cause of cervical spine infarction

Introduction and importance

One of the uncommon causes of ischaemic myelopathy is fibrocartilaginous embolisation, which results from the intersomatic disc nucleus pulposus becoming embolised into the spinal vasculature during Valsalva-like manoeuvres.

Case presentation

A 29-year-old female patient presented to the authors' emergency department with general weakness, dizziness, and an inability to move her right hand after a minor trauma. These symptoms deteriorated suddenly until the patient became quadriplegic. The clinical picture and MRI led to a diagnosis of fibrocartilaginous embolism.

Clinical discussion

Fibrocartilaginous embolism is a rare cause of spine infarction. There is still little understanding of the underlying cause of FCE. Most cases occur sporadically in people without a family history of the disease, such as the authors' case, and diagnosis is based on imaging of the spinal cord and ruling out other causes of a blockage in the vascular system within the spinal cord, infectious and inflammatory causes.

Conclusion

When a practitioner suspects that a patient may have fibrocartilaginous embolism (FCE), they should take the patient's history and do a neurological examination. An MRI is required since it is thought to be the most accurate method of diagnosing FCE.

Central retinal artery occlusion in a child with ADA2 deficiency: a case report

Introduction and importance

Deficiency of ADA2 (DADA2) is the first molecularly described monogenic vasculitis syndrome. During the past decade, DADA2's clinical spectrum has expanded significantly as the number of reported cases has increased.

Case presentation

A 5-year-old boy with DADA2 who experienced sudden onset left-sided vision loss due to unilateral central retinal artery occlusion. The patient had a history of recurrent fever and arthralgia with high inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Brain MRI showed mild limbic encephalitis, and MRA was normal. His gene sequencing results demonstrated substitutions mutation in ADA2, and the diagnosis of DADA2 was eventually confirmed.

Clinical discussion

Central retinal artery occlusion (CRAO) in paediatrics is a very rare condition. Typically, DADA2 presents in childhood as systemic inflammation, vasculitis, humoral immunodeficiency, and/or haematologic abnormalities. The most common phenotype described in the literature is vasculitis, which typically affects the skin and central nervous system, but other systems can also be affected. Ophthalmic manifestations are less common and highly variable.

Conclusions

DADA2 manifests rarely with central retinal artery occlusion; therefore, physicians should be aware of this manifestation.

Fear of a new pandemic: perception and prediction of monkeypox among the middle east general population

Background

Monkeypox is a zoonotic disease caused by the monkeypox virus, an Orthopox virus. The 2022 monkeypox outbreak provoked fear among the public. Public awareness about the disease could be an important factor in its control. The authors conducted this study to assess the perception and prediction of monkeypox among the Middle East public.

Methods

This cross-sectional study was conducted in August 2022. Data were conveniently collected from eight Middle Eastern countries using an online self-administered questionnaire distributed through educational and social media platforms. Statistical analysis was conducted using R software.

Results

Approximately 11 016 individuals participated in this study. The participants' overall knowledge score indicated poor knowledge about monkeypox. Most of the participants knew the causative organism (66.7%). However, numerous participants were not aware of the disease mode of transmission, symptoms, complications, and vaccination. Participants' awareness was mostly gained from social media (61.8%). The majority predicted acquiring monkeypox when protective measures are not taken (72.7%), progression to a pandemic with economic consequences (50.8 and 52%, respectively), and the ability of the Ministry of Health to control the epidemic (51.5%).

Conclusion

In the Middle East, public knowledge about monkeypox is poor. Raising awareness about monkeypox would be of benefit in controlling the epidemic. This study constitutes evidence upon which health education programs could be designed.

Rare occurrence of hemoglobin Lepore variant in a Palestinian patient: a case report and brief literature review

Introduction

In hemoglobinopathies, a basic lesion alters the rate of globin synthesis or the structure of the globin in healthy hemoglobin (Hb). Genetic instructions are used to synthesize the polypeptide chains that make up globin chains. The kind and extent of the structural aberration of the Hb molecule are closely related to the clinical features. Hematologically, the heterozygous form of the Lepore syndrome has a pattern resembling minor thalassemia, and electrophoretically, it is characterized by aberrant Hb Lepore fractions at a rate of 5-15% and a decreased percentage of HbA and mildly increased HbF. Clinically speaking, Hb Lepore heterozygotes patients are asymptomatic and resemble the clinical picture of patients with mild thalassemia.

Case Presentation

A 28-year-old female came to our attention for assessment of generalized weakness and fatigue for a 4-month duration. Laboratory evaluation, including complete blood count, showed mild microcytic hypochromic anemia with parameters resembling the thalassemia trait. Iron profile studies were normal. Abdominal ultrasound showed mild splenomegaly. Hb electrophoresis was performed and showed an abnormal high-performance liquid chromatography pattern with an abnormal Hb band, mild elevated HbF, and mild reduction in HbA. The interpretation of the Hb electrophoresis curve suggested heterozygosity for beta chain variant Hb Lepore.

Discussion and Conclusion

Hb Lepore is one of the structural Hb variants with a characteristic fusion gene between the delta and beta chains. Hematologically, the heterozygous form of the Lepore syndrome has a pattern resembling the thalassemia trait. In Palestine, the prevalence of Hb Lepore, either homozygous or homozygous state, is unknown.

Genotype Mutations in Palestinian Children with Familial Mediterranean Fever: Clinical Profile, and Response to Colchicine Treatment: A Retrospective Cohort Study

Background

Familial Mediterranean fever is a hereditary autoinflammatory disease affecting mainly Arabs, Turks, Armenians, and Jews with genotype-phenotype heterogeneity, presenting as recurrent episodes of fever along with polyserositis and rash. To date, more than 370 mutations in the MEFV gene have been recognized to cause the disease.

Methods

We conducted a retrospective cohort study involving 124 patients in Hebron, Palestine, diagnosed with FMF at the Al-Ahli, and Palestinian Red Crescent Society (PRCS) Hospitals.

Results

The median age of diagnosis was five years, presenting as abdominal pain (76.6%), fever (67.7%), joint pain and arthritis. Regarding MEFV gene mutations, we had 62 patients (50%) with heterozygous genotypes, 40 patients (32.3%) with homozygous phenotypes, 21 patients (16.9%) with compound heterozygous genotypes, and one was a missing state. Regarding variant frequencies, M694V was the most common one (43.4%), followed by E148Q (15.6%), V726A (5.7%), A744S (4.1%), and R202Q (4.1%). Positive family history was detected in 59 patients (54.6%), and there was no significant difference in zygosity regarding characteristics, consanguinity, and family history.

Conclusions

We affirm in this study of 124 children with FMF, abdominal pain, followed by fever, joint pain and arthritis were the main manifestations. Further, M694V, E148Q, V726A, A744S, and R202Q were the most frequent mutations, and carrying the M649V mutations is associated with a predisposition to other comorbidities. We believe that this study gives a pervasive overview of FMF in Palestinian patients. Looking forward, future studies on a larger number of patients could precisely highlight the genotype-phenotype association among FMF patients.

Radiological identification of neuromyelitis optica in a patient presented with unexplained weight loss and generalized weakness: a case report and literature review

Central nervous system (CNS) inflammatory demyelinating disease known as neuromyelitis optica spectrum disorder (NMOSD) is characterized by recurrent inflammatory events that primarily affect the optic nerves and spinal cord; it may also affect the hypothalamus, area postrema, and periaqueductal gray matter. The NMOSD-specific aquaporin-4 antibody (AQP4-IgG) is available. Myelin oligodendrocyte glycoprotein antibodies (MOG-IgG) have recently been discovered in a group of patients who do not have AQP4-IgG.

Case presentation

A 29-year-old female presented to the hospital with the complaint of blurry vision in her right eye and left eye ptosis for 2 days. Two months ago, the patient had a history of generalized fatigue with continuous documented fever with an average of 38.5°C, which was relieved by acetaminophen and ibuprofen. She also complained of continuous hiccups that increased at night and interfered with her sleep pattern and breathing; they lasted for 3 weeks and disappeared suddenly. She had also developed episodes of vomiting and could not tolerate food intake due to which she lost 6 kg within 3 weeks. She was later diagnosed with neuromyelitis optica (NMO) using radiological neuroimaging.

Clinical discussion

Early and correct diagnosis, followed by urgent treatment for acute exacerbations and the prevention of further relapses, are essential for treating NMO spectrum illnesses since they entail significant morbidity and, occasionally, fatality.

Conclusion

The patient mentioned here represents a typical example of NMO disease. This case emphasizes the presence of this disease in our environment and the importance of accurately diagnosing this ailment, even in a context with minimal resources, to prevent disability.

Activated phosphoinositide 3-kinase delta syndrome 2 associated with Kikuchi-Fujimoto disease: a rare Palestinian case report

Histiocytic necrotic lymphadenitis (HNL), also known as Kikuchi-Fujimoto disease (KFD), is a rare local lymphadenopathy with a benign course and clinical manifestations such as fever, lymphadenopathy, rash, hepatosplenomegaly, central nervous system (CNS) symptoms, and hemophilic cell syndrome. It was first identified by Japanese pathologists Kikuchi and Fujimoto. KFD damages the meninges, the brain parenchyma, and peripheral nerves in addition to the CNS. Neurological symptoms may even be the most obvious clinical manifestations or initial symptoms of the disease.

Case presentation

We present a unique case of a 7-year-old male patient who was diagnosed with activated phosphoinositide 3-kinase delta syndrome 2 (APDS 2) associated with KFD, a HNL during a workup for fever without a focus and cervical lymphadenopathy.

Conclusion

Highlighted the unique relationship between two uncommon conditions and stressed the significance of adding KFD to the list of possible diagnoses for lymphadenopathy in APDS 2. Furthermore, we demonstrate that patients with APDS 2 may exhibit low immunoglobulin M levels.

Rare coexistence of primary renal cell carcinoma and primary adrenal adenoma in a cushingoid patient: A case report

Pituitary or adrenal lesions can cause Cushing syndrome, which has an incidence of 10-15 per million people. A growing variety of tumor subtypes make up the heterogeneous illness known as renal cell carcinoma (RCC). Herein, we described a case with renal clear cell carcinoma and an adrenal adenoma. As was mentioned, it is recommended that these patients routinely have their pituitary-adrenal axis evaluated. The primary etiology of these two illnesses occurring simultaneously is extremely rare.

Rare diagnosis of coexistent antiphospholipid syndrome and systemic lupus erythematosus in a male patient with successful management: a case report

Antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) are two autoimmune disorders that can develop together or separately. Similarities in the pathogenesis have been discovered, including the production of autoantibodies that target subcellular antigens and shared elevated risk of cardiovascular morbidity, which may be caused by common pathologic pathways.

Case presentation

A 28-year-old male, referred to our hospital for the assessment of chest pain. Past medical history was significant for extensive deep venous thrombosis despite the appropriate management with a therapeutic dose of direct-acting oral anticoagulant. Prolonged partial thromboplastin time was not corrected by mixing study along with positive lupus anticoagulant, anticardiolipin, and B-2 glycoprotein antibodies. In addition, antinuclear antibodies, anti-DNA antibodies, and direct Coombs were positive with decreased levels of C3. The patient was diagnosed with SLE with brain, heart, and kidney involvement in the setting of antiphospholipid antibody syndrome. He was treated successfully with full recovery.

Discussion

SLE and APS both have sneaky ways of manifestation. Ineffective diagnosis and therapy could cause irreversible organ damage. Clinicians should have a high index of suspicion for APS, particularly in young patients who approach with spontaneous or unprovoked thromboses or unexplained recurrent early or late pregnancy loss. Anticoagulation, modifying cardiovascular risk factors, and identifying and treating any underlying inflammatory diseases are all part of the multidisciplinary care that is needed for management.

Conclusion

Although male affection is rare, SLE and APS should be considered in male patients as these conditions tend to be more aggressive than in the female.

Unusual location of gouty arthritis with shoulder joint involvement in an elderly male patient: A rare case report

Gout is a metabolic disease characterized by recurrent episodes of acute arthritis. Gout has been reported in many locations but is rarely localized in the shoulder joint.

Case presentation

A 73-year-old man who visited an outpatient clinic with the main complaint of a right shoulder ache lasting 2 weeks came to our attention. The patient reports his discomfort as being of an unbearable character, happening largely at night and preventing him from falling asleep. In the previous 6 months, he had two episodes of the same ailment that lasted around 3-5 days each and spontaneously resolved. Due to the pain's continuance without improvement, the patient now seeks medical assistance. Gout with right shoulder involvement was identified as the cause. Prednisolone 40 mg/day for 10 days, allopurinol 300 mg/day, and colchicine 0.5 mg/day were all prescribed for the patient. After 6 months of follow-up, the patient had significantly improved.

Discussion and conclusions

The condition of gout affecting the shoulder joint is quite rare. According to past medical history and clinical manifestations, doctors and orthopedic surgeons should take gouty shoulder arthritis into consideration when there is serious erosion.

Primary tracheal carcinoid tumor misdiagnosed as asthma: a rare case report

About 2% of all lung malignancies are pulmonary carcinoid tumors, a family of neuroendocrine tumors. Rarely does a typical tracheal carcinoid of the trachea manifest as an endoluminal polypoidal tumor.

Case presentation

The author describe a 61-year-old nonsmoker who complained of growing nonexertional shortness of breath 5 years ago. She also had a wheezy chest and a dry cough. The results of the chest radiography and electrocardiogram revealed no noteworthy abnormalities. The results of the pulmonary function test supported the diagnosis of bronchial asthma. A patient's treatment has not advanced. After performing a bronchoscopy, a biopsy was taken and sent for pathological analysis. The endobronchial lining was found to have a subepithelial tumor infiltrate made up of nests of homogeneous bland cells with central nuclei and mild granular cytoplasm, according to histopathologic analysis. Considering all of these findings, the patient was diagnosed with a primary tracheal carcinoid tumor, which was misdiagnosed and treated as bronchial asthma.

Discussion and conclusion

People with stridor or trepopnea symptoms should undergo a computed tomography scan since central airway tumors can mimic the symptoms of bronchial asthma while a chest radiograph may be normal. Tracheal carcinoid that has not progressed to the mediastinum can be successfully removed with flexible bronchoscopy and electrocautery, but the excision site needs to be continuously watched for recurrence.

Corrigendum to “Successful radiological detection and surgical management of type 3 choledochocele: A case report” [Radiol Case Rep 2023;18:1502–6]

[This corrects the article DOI: 10.1016/j.radcr.2023.01.029.].

Successful radiological detection and surgical management of type 3 choledochocele: A case report

According to Todani's classification, a choledochocele is a cystic dilatation of the distal section of the common bile duct that protrudes into the duodenal lumen. It is also known as a type III choledochal cyst. There are not many cases, and the cause is still unknown. Typically, it is misdiagnosed as a peptic ulcer, as was the case with the patient in this case study. For choledochocele diagnosis, multislice spiral computed tomography and magnetic resonance cholangiopancreatography may be equivalent to endoscopic retrograde cholangiography. Both endoscopic therapy and open surgical care are risk-free possibilities, and the cyst's size influences which strategy should be used. A 35-year-old woman admitted to the hospital with upper abdominal pain caused by a large choledochocele was successfully treated by open surgical management. In this case study, we outline the specifics of her situation and talk about the most recent research on similar cases and how to treat them therapeutically. There is ongoing debate regarding the best course of action. However, to achieve a successful outcome, open surgical care for choledochocele of large size (ie, > 3 cm in diameter) is advised.

Osteoid osteoma of the rib masquerading as pain due to trauma: Removed by rib resection using preoperative CT-scan guidance

Osteoid osteomas (OO) are benign bone tumors that are prevalent in young adults. The typical clinical picture of the disease is pain that worsens at night, which may be alleviated by Non-Steroidal Anti Inflammatory Drugs (NSAIDs). The most common imaging finding of OO is a lytic lesion, known as a nidus, with variable intralesional mineralization, accompanied by bone sclerosis, cortical thickening and surrounding bone marrow edema, as well as marked post-contrast enhancement. The most commonly affected sites are the long bones of the lower limbs, but the ribs are rarely reported sites. The present study describes a case of osteoid osteomas located in the rib which was removed by rib resection using CT-scan guidance.

A report of presacral epidermoid cyst in perimenopausal women: An extremely rare site and an unusual cause of chronic constipation

BACKGROUND

Epidermoid cyst is rare congenital lesion of ectodermal origin that arises from the remnants of the embryonic tissues. Although epidermal cysts are frequently observed throughout the body, they are rarely found in the presacral regions. It more commonly occurs in women of reproductive age as an asymptomatic, incidental finding during routine physical examination or imaging studies, or during obstetric and gynecologic events.

CASE PRESENTATION

A 48-year-old female patient presented with intermittent constipation, lower abdominal and pelvic pain that had developed progressively during the previous six months, which was temporarily relieved with regular laxatives. Magnetic resonance imaging showed a presacral cystic tumor with a high signal intensity on T1-weighted images and, low signal on T2-weighted images with no significant enhancement post-contrast administration. The mass pushed the rectum laterally by external compression. This tumor was diagnosed as a developmental cyst, and total mass resection with negative margins was performed. After that, tumor was histopathologically diagnosed as an epidermoid cyst.

DISCUSSION AND CONCLUSION

Epidermoid cyst is a common entity but is rare at presacral space. Also, an epidermoid cyst is an uncommon entity among cystic pathologies found in the presacral region, which includes benign and malignant pathologies. Due to the potential of subsequent infection or cancer, a meticulous clinical examination with correlated radiographic imaging, followed by total mass excision and histopathological evaluation are crucial.

Emergency repair of traumatic avulsion of the right main stem bronchus using biliary stent in a 6-year-Old girl: A case report

Introduction

Pediatric thoracic trauma is a rare condition, but results in high levels of morbidity and mortality. These injuries are often more devastating in the pediatric population due to differences in children's anatomy and physiology relative to adult patients. Tracheobronchial injuries secondary to blunt trauma are difficult to diagnose compared to penetrating trauma. So, a high index of suspicion is of utmost importance.

Case presentation

We report a case of a 6-year-old girl who experienced complete avulsion of the right main bronchus. The patient presented with extensive emphysema and severe respiratory distress with bilateral tension pneumothorax. Endotracheal intubation and two thoracostomy tubes were applied. Pneumothorax and a massive air leak persisted on the right side. After thoracotomy, right main bronchus avulsion was present and then repaired by end-to-end anastomosis and muscle flap. minimal air leaks from right chest tubes and partially expanding right lung on chest X-ray are seen after that. So, reinforcement by biliary (instead of bronchial) stent was performed because unavailability of bronchial stent with the desired size at that time.

Discussion

Traumatic tracheobronchial damage occurs in just 0.05-3% of all pediatric thoracic traumas. It's fatal condition especially in first hour. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.

Conclusion

Biliary stent placement could be a reasonable treatment option for tracheobronchial damage.

Late onset hyperornithinemia, hyperammonemia, and homocitrullinuria syndrome, presenting as recurrent metabolic encephalopathy, A case report

Introduction

and importance: Hyperornithinemia, hyperammonemia, and homocitrullinuria (HHH) syndrome (OMIM 238970) seems to be an autosomal recessive disorder caused by a mitochondrial ornithine transporter 1 deficiency, which results in urea cycle dysfunction. HHH is the most uncommon of the urea cycle diseases, with less than 100 cases recorded.

Case presentation

A previously healthy 29 year old male presented to the emergency department complaining of decreased level of consciousness. CT scan, Cerebro-spinal-fluid analysis and toxicology screen were non-significant. Extended serum analysis showed elevated levels of ammonia. Urgent amino acid level analysis showed elevated ornithine. Follow up genetic testing showed that the patient is homozygous for the mutation c.44delG in exon 3 of SLC25A15 gene.

Clinical discussion

In this case, HHH syndrome presented as a late-onset metabolic encephalopathy. For diagnosis; elevated levels of ammonia, ornithine accompanied by the abovementioned genetic mutation confirms the diagnosis. Treatment focuses on reduction of the ammonia levels using sodium benzoat, citrulline or arginine, and low protein diet.

Conclusions

HHH syndrome, which is a urea cycle disorder, can present as a late-onset metabolic encephalopathy. High suspicion for genetic causes of metabolic encephalopathy should be maintained even for older patients without prior diagnosis in childhood/adolescence.

Hereditary Folate Malabsorption presenting as neutropenic fever in a newborn from the first Palestinian family with the novel SLC46A1-mutation, A-case-report

Introduction and importance

Hereditary Folate Malabsorption (HFM) is an extremely rare autosomal recessive disorder with in the existence of only 30 families world-wide. It presents with hematological, gastrointestinal, and neurological problems.

Case presentation

Three-month-old-boy with a familial history of HFM presented to the clinic due to persistent fatigue, yellowish discoloration, feeding refusal, and pancytopenia. The patient received 3 packs of Red Blood Cells (RBCs). Five days after received 3 packs of RBCs, the patient presented with a fever of 38.3 Celsius with pancytopenia. The patient had low level of all immunoglobulins. He was started on broad-spectrum antibiotics. Testing for the HFM's SLC46A1 gene mutation, was positive. The patient was started on Leucovorin and Respirm.

Clinical discussion

In this case, HFM presented as a neutropenic fever, hypoimmunoglobulinemia, low serum folate, elevated homocysteine, and a positive mutation on the SLC46A1. HFM has a wide-spectrum of presentations which includes hematological, neurological, immunological and gastrointestinal. Treatment involves the administration of folinic acid in either oral or intramuscular injections.

Conclusion

HFM can present as neutropenic fever. High index of suspension is to be maintained when the presenting symptoms of the patients vary over a large number of systems. Genetic counseling is needed for parents when both are carrying an autosomal recessive allele.

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Hereditary Folate Malabsorption is rare, but fatal.

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Diagnosis is based on a low folate level, elevated homocysteine, and positive SLC46A1 gene mutation.

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Management is dependent on the usage of folinic acid not folic acid.

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Genetic counseling is pivotal for disease prevention in mutation positive families.