Gonococcal endocarditis in a 32-year-old male: a rare presentation of an underrecognized disease - case report

Introduction and importance

Disseminated gonococcal infection (DGI) is an infrequent but serious complication of gonorrhea that can exhibit atypical symptoms. While rare, it can lead to infective endocarditis (IE), a condition that affects the heart valves and can result in severe and potentially life-threatening outcomes.

Case presentation

We present a case of Neisseria gonorrhoeae-caused IE confirmed by blood culture and direct isolation from the aortic valve vegetation. Our patient experienced complications, including glomerulonephritis, respiratory failure, and positive troponin. Urgent surgery successfully removed a large vegetation, replaced the aortic valve, and improved cardiac function. Follow-up showed symptom resolution.

Clinical discussion

DGI can present atypically with a triad of tenosynovitis, polyarthralgia, and rash, even without genitourinary symptoms. However, it can also present with nonspecific symptoms, leading to a later diagnosis of IE, as observed in our patient, who developed an aortic valve abscess and aortic regurgitation.

Conclusion

This case provides important insights into the diagnosis and management of gonococcal endocarditis, emphasizing the significance of early recognition, timely intervention, and multidisciplinary collaboration in improving patient outcomes. It is imperative to have a high level of suspicion for this rare entity, given its high virulence and potential for severe complications.

Interrupted inferior vena cava syndrome discovered incidentally after minimally invasive mitral valve repair in a 31-year-old female patient: A case report

INTRODUCTION

Femoral cannulation is a technique used in minimally invasive cardiac surgery (MICS) for accessing the heart through the femoral artery and vein. However, the presence of an interruption in the inferior vena cava (IVC) can pose challenges during the procedure. Understanding the patient's venous anatomy is crucial to ensure successful cannulation.

PRESENTATION OF CASE

We present the case of a 31-year-old female patient scheduled for minimally invasive mitral valve repair. During the procedure, femoral vein cannulation was unsuccessful. Subsequent diagnostic Computed Tomography (CT) revealed an interrupted IVC with azygos continuation.

DISCUSSION

The interruption of the IVC can make cannulation through the femoral vein difficult or impossible due to the absence of the femoral vein or the presence of a collateral, necessitating alternative approaches. Preoperative imaging, such as CT, plays a significant role in identifying IVC interruptions and guiding surgical planning.

CONCLUSION

Our case highlights the challenges associated with IVC interruptions during femoral cannulation in MICS. Preoperative imaging is essential for identifying anatomical variations and determining the most appropriate cannulation approach.

An Undiagnosed Shone Complex in a 52-Year-Old Female: A Case Report

Shone complex (SC) is a rare congenital heart disease characterized by four obstructive anomalies, including parachute mitral valve (PMV), left atrial supra-valvular ring, subaortic stenosis, and coarctation of the aorta. Typically, SC manifests early in life. However, we encountered a 52-year-old female with a history of hypertension diagnosed at 26 years and left-sided weakness poststroke. She presented with worsening dyspnea and palpitations, prompting a thorough investigation. Echocardiography revealed a heavily calcified bicuspid aortic valve with severe aortic stenosis and parachute mitral valve with severe mitral stenosis and preserved ejection fraction, raising suspicions regarding the presence of SC. Cardiac catheterization, aortic-angiography, and noncontrast chest computed tomography (CT) revealed abrupt occlusion of the postductal aorta, giving a picture of aortic coarctation with well-established collateral vessels including prominent right and left internal mammary arteries. So, she was diagnosed with an incomplete SC at the age of 52. Shone complex is a rare congenital heart disease that typically presents in early childhood, but late presentations due to misdiagnosis or incomplete work up are possible. This case emphasizes the rarity of late presentations of SC and highlights the importance of early diagnosis and intervention to improve outcomes. An incomplete SC should be considered in adult patients presenting with left-sided obstructive lesions.

An Unusual Presentation of Succinic Semialdehyde Dehydrogenase Deficiency: A Fatal Case of Severe Progressive Seizures in a Four-Month-Old Infant

Succinic semialdehyde dehydrogenase (SSADH) deficiency is a rare genetic condition with approximately 450 patients reported worldwide, inherited in an autosomal recessive manner affecting gamma-aminobutyric acid (GABA) metabolism, characterized by varied clinical features. We report a fetal case of a four-month-old female infant presenting with severe, progressive seizures leading to fatality. Despite aggressive medical interventions, including multiple antiepileptic medications and a ketogenic diet, the patient's condition deteriorated rapidly. Genetic testing revealed a homozygous mutation in the aldehyde dehydrogenase 5 family member A1 (ALDH5A1) gene. This present case emphasizes the difficulties in controlling SSADH deficiency and emphasizes the necessity for additional studies on successful therapy approaches.

Primary extraskeletal intradural Ewing sarcoma with acute hemorrhage: a case report and review of the literature

BACKGROUND

Spinal cord tumors present a challenge in diagnosis and treatment due to their varied histopathological characteristics. While Ewing sarcoma is a rare malignant tumor typically originating from skeletal bone, cases of primary intradural extraskeletal Ewing sarcoma are exceptionally rare. The similarity of its presentation to other spinal tumors further complicates its identification and management.

CASE PRESENTATION

We report a case of a 58-year-old Palestinian male with intradural extraskeletal lumbar Ewing sarcoma. The patient initially presented with lower back pain and bilateral S1 radiculopathy, with more severe symptoms on the left side. Magnetic resonance imaging revealed a 7 cm oval-shaped mass with homogeneous contrast enhancement, obstructing the spinal canal from L3/L4 to L5/S1 levels. Initially, a myxopapillary ependymoma was suspected, but the patient's sensory and motor functions suddenly deteriorated during hospitalization. Repeat magnetic resonance imaging indicated heterogeneous contrast enhancement, indicating acute intratumoral hemorrhage. Consequently, the patient underwent emergent L3-L5 laminotomy, with successful gross total resection of the tumor. Histopathological and immunohistochemical analyses confirmed the diagnosis of intradural extraskeletal Ewing sarcoma. Adjuvant therapy was administered to minimize the risk of local recurrence or distant metastasis. A systematic review of relevant literature, along with retrospective analysis of medical records, operative reports, radiological studies, and histopathological findings of similar cases, was also conducted.

CONCLUSIONS

Intradural extraskeletal Ewing sarcoma is an infrequently encountered condition in adult patients, emphasizing the importance of considering it in the differential diagnosis of spinal tumors. Surgeons must possess a comprehensive understanding of this rare entity to ensure accurate staging and optimal management, particularly in the early stages when prompt intervention may improve prognosis.

Renal Vein Thrombosis as an Initial Presentation for Systemic Lupus Erythematosus in a 32-Year-Old Sudanese Male: A Case Report in Palestine

Systemic lupus erythematosus (SLE) is a complex autoimmune disease known for its diverse clinical presentations, and one severe complication is lupus nephritis (LN), which significantly contributes to morbidity and mortality. While LN often presents within the first 5 years of SLE diagnosis, renal vein thrombosis (RVT) is a rare vascular complication with a high risk of mortality and morbidity. This case report discusses the rare occurrence of RVT as the initial presentation of SLE in a 32-year-old Sudanese male patient, currently working in Palestine, presenting with flank pain, hematuria, fever, and lower limb edema. The case details the patient's symptoms, examination findings, and extensive laboratory and imaging workup leading to the diagnosis. This report highlights the rare association between RVT and SLE, emphasizing the importance of maintaining a high index of suspicion for SLE in patients with multisystem involvement, especially in males, where the diagnosis may be overlooked due to its lower prevalence. Early recognition can improve patient outcomes and reduce the risk of complications. Further research is needed to better understand the connection between RVT and SLE and to develop more effective treatment strategies.

Gray Platelet Syndrome-Unusual Presentation with Spontaneous Splenic Rupture: A Case Report and Literature Review

Gray platelet syndrome (GPS) is a rare hereditary hemorrhagic disorder characterized by macrothrombocytopenia and the absence of alpha-granules in platelets. Clinically, mild-to-moderate bleeding is the main manifestation, often accompanied by thrombocytopenia, splenomegaly, and myelofibrosis. Here, we present a case of a 15-year-old male patient with a history of hepatosplenomegaly, and thrombocytopenia for 8 years, who presented with sudden generalized abdominal pain. Despite initial suspicion of gastroenteritis, diagnostic imaging revealed an extensive hemoperitoneum. Subsequent genetic testing confirmed the diagnosis of GPS, which had not been previously identified. This case highlights the importance of considering inherited platelet disorders should be considered in adolescents with long-standing thrombocytopenia, and emphasizes the need for thorough evaluation in patients with suggestive symptoms.

Unveiling follicular thyroid carcinoma by solitary spinal metastasis causing severe neurological deficit in a 67-year-old female: A case report

INTRODUCTION AND IMPORTANCE

Follicular thyroid carcinoma (FTC) exhibits the ability to metastasize hematogenously to distant organs. Spinal metastasis is an unusual site for metastasis that even when it does, spinal metastasis manifests late in the course of the disease and is frequently linked to advanced disease and a bad prognosis. Until 2019, the literature only showed 29 cases of FTC with spinal metastasis as the first presenting feature.

CASE PRESENTATION

We present a case of a 67-year-old female who presented with an acute onset of severe neurological deficit that ended up bedridden. Magnetic resonance imaging of the spine revealed a spinal lesion causing severe spinal cord compression. Urgent surgical decompression was performed, and the histopathology confirmed metastatic FTC. Subsequent comprehensive evaluation, unveiled a primary thyroid tumor.

CLINICAL DISCUSSION

FTC accounts for 1 % of all malignancies, Therefore, regardless of how irrelevant symptoms may appear at first, it is important to understand all risk factors, screening recommendations, diagnostic techniques, treatment, and the vast range of potential presenting symptoms. Just like our patient, who had incontinence and abrupt loss of motor and sensory function in her lower limbs to be diagnosed with spinal cord compression by metastatic FTC.

CONCLUSION

This instance emphasizes how crucial it is to consider FTC as a possible differential diagnosis in cases with spinal metastasis, even when there is no known primary thyroid cancer. Prompt diagnosis, comprehensive staging, and multidisciplinary management are crucial in optimizing outcomes.

Takotsubo cardiomyopathy prevalence and associated factors in patients presenting with a clinical picture of acute myocardial infarction in Palestine

BACKGROUND

Takotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction. Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine.

RESULTS

A retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2-93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0-86.7%) and dyspnea (20.4%, 95% CI 16.3-24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2-75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8-89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20-49.9 to 59-76% within a mean time of 7-37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5-2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8-98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation.

CONCLUSIONS

TC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study's results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.

Rosai-Dorfman disease presenting as autoimmune hemolytic anemia in a male child in Palestine: a case report

Rosai-Dorfman disease (RDD) is a rare, benign non-Langerhans cell histiocytosis predominantly affects lymph nodes and skin. Despite its benign nature, RDD can cause serious hematological complications. A 14-year-old male, presented with 3-month history of hemolytic anemia, lymphadenopathy, hepatosplenomegaly and rash. After thorough investigation, RDD was diagnosed by mediastinal lymph node biopsy that revealed presence of S100 and CD68-positive cells with absence of CD1a confirming the diagnosis of RDD. Treatment involved combination of steroids and Rituximab, which proved to be highly effective. The patient had dramatic improvement and entered remission, with follow-up period of 2 years. It is important to note that although RDD is a rare disease, it causes severe complications, as evidenced by the patient's parameters. Thus, prompt diagnosis and treatment are paramount. Histological diagnosis is of great value, as it helps confirming and guiding treatment decisions. With the right treatment, patients can experience great recovery and quality of life.

Very rare Palestinian case report of PRUNE1 p.Asp106Asn mutation: a mutation of global developmental delay

Introduction and importance

The PRUNE1 gene (prune exopolyphosphatase 1), situated on chromosome 1q21.3, encodes a protein crucial for early fetal brain development, regulating processes like the polymerization of microtubules, migration of cells, and proliferation. Common features of Neurodevelopmental disorder with microcephaly, hypotonia, and variable brain anomalies (NMIHBA) include progressive microcephaly, hypotonia, spastic quadriparesis, intellectual disability, and abnormal brain magnetic resonance imaging findings.

Case presentation

A 4-month-old male infant, born at 39 weeks and 2 days via Cesarean, prenatal ultrasound findings were positive for ventricular dilation (hydrocephalus). Postnatally, the infant required admission for transient tachypnea of the newborn. Developmental delays and limb stiffness were evident by 2 months of age, prompting neurological evaluation. Examination at 4 months revealed dysmorphic features, including frontal bossing, low-set, malformed ears, and dolichocephaly, alongside axial hypotonia, spasticity, and knee contractures. Genetic testing confirmed a c.316G>A mutation in the PRUNE1 gene, establishing the diagnosis of NMIHBA.

Clinical discussion

PRUNE1-related NMIHBA is a rare neurodevelopmental disorder characterized by profound developmental delays, microcephaly, and variable neurological findings. This case emphasizes the importance of early recognition and genetic testing in infants with suggestive dysmorphic and neurological features. While management remains supportive, early diagnosis aids in family counseling and long-term care planning.

Conclusion

This report describes a rare presentation of NMIHBA in a Palestinian infant with a PRUNE1 gene mutation, contributing to the limited literature on this disorder. Further studies are required to understand the phenotypic spectrum and molecular mechanisms underlying PRUNE1-related disorders.

Impact of Sinus Rhythm Restoration on Mitral Regurgitation in Patients With Atrial Fibrillation: A Comparative Echocardiographic Study

INTRODUCTION

Mitral regurgitation (MR) is a common valvular abnormality that can be exacerbated by atrial fibrillation (AF). Mitral regurgitation is classified based on mitral leaflet motion and can be either primary (organic) or secondary (functional). This study investigates the relationship between AF and functional MR, specifically assessing whether cardioversion to sinus rhythm influences MR severity and echocardiographic indices.

METHODS

This retrospective cohort study included 417 patients with AF and significant MR (Grade III or IV) who were hospitalized for cardioversion. Patients underwent echocardiography during AF and again within six months after successful cardioversion. The primary outcome was the change in MR severity post cardioversion. Secondary outcomes included changes in left atrial size, left ventricular ejection fraction, and mitral valve anatomy. Statistical analysis involved chi-square tests for categorical variables, Student's t-tests for continuous variables, and multivariate logistic regression to assess the impact of sinus rhythm restoration on MR severity.

RESULTS

Of the 417 patients, 61% (n = 254) returned to sinus rhythm after cardioversion. Among these, 28.4% (n = 72) showed a two-grade or greater improvement in MR severity. Patients who returned to sinus rhythm also exhibited significant reductions in left ventricular and left atrial dimensions and improved transvalvular gradients. The multivariate analysis indicated that conversion to sinus rhythm was independently associated with MR improvement.

CONCLUSIONS

Restoration of sinus rhythm is associated with significant improvement in functional MR, potentially reducing the need for surgical intervention. These findings suggest that rhythm control should be considered in managing patients with AF and significant MR, as it may lead to improved cardiac function and better clinical outcomes. Further large-scale prospective studies are needed to determine the most effective management strategy for functional MR in the context of AF.