Reports

Obstructive sleep apnea (OSA) may be linked to various factors that narrow the upper airways, such as obesity, adenotonsillar hypertrophy and craniofacial abnormalities. Hypothyroidism has also been described as a risk factor for OSA. However, the implication of goiter independently of thyroid function in the occurrence of OSA remains unclear. We present the case of a 66-year-old woman with a large compressive multinodular goiter for whom total thyroidectomy was indicated. During the preoperative assessment, the patient had a body mass index (BMI) of 37.8 kg/m² with symptoms of OSA. Respiratory polygraphy confirmed the diagnosis of severe OSA (apnea–hypopnea index (AHI) = 32), and treatment with continuous positive airway pressure (CPAP) was initiated prior to thyroid surgery. Surprisingly, after total thyroidectomy, OSA symptoms disappeared, and the patient abandoned CPAP therapy. Subsequent respiratory polygraphy after thyroidectomy showed a decrease in AHI to a normal value (AHI < 5). Interestingly, there was no change in BMI or other factors explaining the resolution of OSA, except for thyroidectomy. This case report suggests that goiter can be considered a risk factor for OSA. However, prospective studies are needed to accurately assess the effects of goiter on the occurrence of OSA according to its dimensions and local extension. Full article

Atypical teratoid/rhabdoid tumors (AT/RT) are highly aggressive tumors of the central nervous system (CNS), accounting for 1–3% of all pediatric CNS tumors. In general, AT/RTs are associated with biallelic inactivation of SMARCB1, resulting in the loss of expression of the integrase interactor 1 (INI1) protein. In this report, we describe the clinical course of an infant patient who presented with fatigue, postprandial vomiting, and disability of left side movement. Histological examination revealed classical features indicative of rhabdoid tumors, yet an atypical immunohistochemical profile with preserved INI1 expression was observed. Molecular diagnostics further elucidated the presence of a heterozygous frameshift variant, SMARCA4 c.2693del, p.(Asn898Thrfs*12), underscoring the distinctive genetic foundations of the case. Surgical resection of the tumor was administered with subsequent chemotherapy to the patient, but the condition worsened dynamically, and a decision was made to give the patient palliative therapy. We report on a patient with AT/RT caused by a rare mutation of the SMARCA4 gene and an aggressive course of disease to provide more information and characteristics of these tumors. Full article

Facial nerve palsy is most commonly idiopathic, but it can also result from infections, inflammatory and cerebrovascular disorders, tumors, and trauma. We report the case of a 68-year-old patient who developed iatrogenic facial nerve palsy subsequent to dermatological cryosurgery on the right cheek. Remarkably, a full recovery occurred within 8 weeks. Drawing upon the promising outcome of this case and the existing literature on neuropathies linked with cold application in sports injuries, we propose neurapraxia as the probable pathomechanism underlying cryotherapy-induced nerve damage. Full article

Background and objective: Lung cancer is increasingly common, and accurate diagnosis is important for personalized treatment. Ultrasound-guided percutaneous fine-needle aspiration (FNA) is a useful method to obtain a specimen for a histological diagnosis of peripheral lung lesions. The aim of this study is to evaluate the diagnostic accuracy and complication rate of the procedure performed by pulmonologists. The result is compared with that of ultrasound-guided core needle biopsy performed by radiologists. Methods: We retrospectively evaluated the diagnostic accuracy and complication rates of pulmonologist-performed ultrasound-guided FNAs of lung lesions in the period of 1 August 2019 to 30 June 2021 (pulmonologist group) and radiologist-performed ultrasound-guided core needle biopsies (CNBs) of lung lesions in the period of 1 January 2010 to 31 December 2014 (radiologist group). A logistic regression analysis was used to identify independent influence factors associated with diagnostic accuracy in the pulmonologist group and in the combination of both groups. Results: In a 23-month period, pulmonologists in a tertiary center performed 113 episodes of ultrasound-guided fine-needle aspiration for peripheral lung lesions. The diagnostic accuracy and complication rates were 80.4% and 5.3%, respectively, compared to 86.8% and 7.4% in a historical cohort consisting of 68 episodes of ultrasound-guided core needle biopsies performed by radiologists in the same hospital. Lung lesions located in the upper lobe were predictive of successful diagnoses. Conclusions: An ultrasound-guided fine-needle aspiration by a pulmonologist is an easily accessible and reliable method to obtain specimens for histological diagnoses. Full article

A rise in fungal infections has been observed worldwide among patients with extended hospital stays because of the severe infection caused by the new coronavirus pandemic. A 62-year-old female patient was admitted with a severe form of Coronavirus disease 2019 (COVID-19) and spent four weeks in the intensive care unit (ICU) requiring mechanical ventilation support before being moved to a tertiary hospital for further testing. Aspergillus fumigatus filamentous fungus, Candida spp., and positive bacteriology for multidrug-resistant Klebsiella pneumoniae and Proteus mirabilis were identified by bronchial aspirate cultures. The patient’s progress was gradually encouraging while receiving oral antifungal and broad-spectrum antibiotic therapy along with respiratory physical therapy; but ultimately, thoracic surgery was necessary. Long-lasting tissue damage and severe, persistent inflammatory syndrome were the two main pathophysiological mechanisms that led to significant outcomes regarding lung lesions that were rapidly colonized by fungi and resistant flora, cardiac damage with sinus tachycardia at the slightest effort, and chronic inflammatory syndrome, which was characterized by marked asthenia, myalgias, and exercise intolerance. Full article

The amnion rupture sequence is a rare condition occurring early in pregnancy, resulting in complex fetal anomalies by disrupting normal embryonic development. The prevalence of amnion rupture sequence is reported to be 1.16 in 10,000 live births. This article explores the uncommon case of early amnion rupture leading to fetal encephalocele, suspected in the first trimester. Despite the variable and intricate nature of anomalies associated with this condition, cranio-facial and abdominal defects are frequently observed. Genetic testing was conducted, with normal results supporting our theory of amnion rupture. The patient decided to terminate the pregnancy, and the anatomopathological results confirmed the findings. This article discusses the diagnostic challenges, emphasizing the importance of timely identification through advanced imaging techniques. Full article

West Nile Virus (WNV) is an arbovirus endemic to many countries and has caused over 56,000 cases, with 2776 deaths in the U.S. from 1999 to 2022. WNV occurs most often in the fall, typically affecting elderly populations in states like Nebraska and Arizona. Currently, supportive care is the only management for WNV. Our case is a female patient in her mid-70s in an intermountain state who presented in the fall with WNV meningoencephalitis and experienced a delay in care due to the unique clinical presentation. This demonstrates the importance of early inclusion of WNV in the differential for altered mental status, especially with WNV risk factors, and expedition of supportive care. Doing so could potentially reduce antibiotic duration and hospital costs. Full article

This case report provides us with insight on how blood glycemia affects refraction, vergence and accommodation in a single diabetic patient. A 21-year-old type I diabetic woman was the subject studied in this report. Refraction, near and far fusional vergence ranges, near point of convergence, monocular accommodative facility, amplitude of accommodation, lag of accommodation, and near and far phoria, were measured before and after controlled caloric intake and insulin injection. Measurements were taken a total of 10 times, once a week for 10 consecutive weeks. Blood glycemia levels were provided by a measuring device that was attached to the patient’s body at all times. Statistically significant differences were found in the glucose levels before and after lunch, p = 0.041, sphere refraction of the right eye, p = 0.016, but not in the left eye, p = 0.051. Accommodative facility in both right and left eyes, p = 0.019, p = 0.028, respectively, and amplitude of accommodation, p = 0.016, p = 0.019, right and left eyes, respectively were statistically different before and after insulin injection. In a 21-year-old subject with type I diabetes, a diminution in blood glucose levels influences refractive myopic state, and is associated with a decrease in accommodative facility and in amplitude of accommodation. Full article

Background: The greatest risk for the occurrence of the placenta accreta spectrum (PAS) is represented by uterine scars, which most frequently result after cesarean sections. Uterine rupture is a rare condition and appears mainly in the third trimester of pregnancy. The association between these two conditions is extremely rare in the first trimester of pregnancy. Methods: We performed a systematic review of abnormal placental adhesions and spontaneous uterine ruptures in the first trimester of pregnancy. We also reported a case of spontaneous uterine rupture in a 12-week pregnancy that presented with massive hemoperitoneum and hemorrhagic shock. Results: A 33-year-old patient with two previous cesarean sections, at the twelfth week of pregnancy at the time to this visit to the emergency room, presented with syncope and intense pelvic–abdominal pain. A clinical examination and ultrasound scan established the diagnosis of hemoperitoneum and hemorrhagic shock. Surgical exploration was performed, uterine rupture was identified, and hemostasis hysterectomy was necessary. The histopathological results showed placenta percreta. There have been eight reported cases of spontaneous uterine rupture in the first trimester of pregnancy associated with PAS. In these cases, it was found that 62.5% of the patients had undergone at least one cesarean section in the past; in 75% of the cases, hysterectomy was performed; and, in 87.5% of the cases, the presence of placenta percreta was confirmed. Conclusions: A high rate of cesarean sections determines the increase in the incidence of placenta accreta spectrum disorders. The possible life-threatening complications caused by this pathology can be observed in early pregnancies. Full article

A 58-year-old man with a history of diabetes type I and chronic coronary syndrome who underwent coronary artery bypass grafting (CABG) 7 years before was admitted to a cardiology unit for unplanned cardiac catheterization because of dyspnea and chest pain at rest. Femoral access was chosen because of the previous CABG and a vascular closure device (VCD) was used at the end of the procedure. Because of femoral artery rupture during VCD implantation, surgical vascular repair was performed. About 45 days later, the patient experienced a growing inguinal swelling at the site of vascular access in the absence of fever and clinical features of inflammation. The swelling became painful over time. Despite the most probable hypothesis of a hematoma, pseudoaneurysm, and inguinal abscess, a final diagnosis of lymphocele was made. Full article

We present an unusual case of uveitis secondary to avelumab and pembrolizumab in a 39-year-old Taiwanese male with stage IV clear cell renal cell carcinoma (ccRCC) and lung metastasis, who initially received pembrolizumab as his primary treatment. However, the patient experienced skin and liver immune-related adverse events (irAEs) after the seventh dose of pembrolizumab, which prompted a switch to avelumab. The patient began to experience gradual blurring of vision after completing the fifth cycle of avelumab immunotherapy. Ophthalmic examinations revealed findings consistent with bilateral anterior uveitis. Despite an initial lack of significant improvement with steroid treatment, the patient’s vision and inflammation improved upon discontinuation of avelumab. Due to the occurrence of uveitis, avelumab was switched back to pembrolizumab. However, three months after initiating pembrolizumab, the patient developed foggy vision and bilateral anterior uveitis with cystoid macular edema (CME). The administration of topical, oral, and subconjunctival steroids resulted in an improvement in vision and the resolution of CME, without the need to discontinue pembrolizumab. Over the subsequent eighteen months, there has been no recurrence of uveitis, and there is no evidence of relapse or further metastasis in his ccRCC. Full article

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are underrecognized. Ischemic stroke and thrombotic complications have been documented in patients with SARS-CoV-2 infection. Acute disseminated encephalomyelitis (ADEM) associated with coronavirus disease 2019 (COVID-19) is rare but can occur; the incidence of COVID-19-associated ADEM is still not clear due to the lack of reporting of cases. ADEM may have atypical stroke-like manifestations, such as hemiparesis, hemiparesthesia and dysarthria. The treatment strategies for ADEM and acute stroke are different. Early identification and prompt management may prevent further potentially life-threatening complications. We report a patient with SARS-CoV-2 infection presenting with stroke-like manifestations. We also make a comparison between demyelinating diseases, COVID-19-associated ADEM and acute stroke. This case can prompt physicians to learn about the clinical manifestations of SARS-CoV-2-associated ADEM. Full article

Vaccine- induced immune thrombocytopenia and thrombosis (VITT) is a rare adverse event occurring after immunization with adenoviral vector-based vaccines against SARS-CoV-2. This life-threatening condition is characterized by thrombocytopenia, systemic activation of coagulation, and anti-platelet factor 4 antibodies, often resulting in extensive venous thrombosis. Arterial thrombosis is less common and mainly affects the aorta, peripheral arteries, heart, and brain. Several cases of ischemic stroke have been reported in VITT patients, frequently being associated with large vessel occlusion (LVO). Here, we present a case of aggressive VITT in a 46-year-old woman with a past mild SARS-CoV-2 infection, who was admitted with a left-middle cerebral artery (MCA) territory stroke and thrombocytopenia eight days after her first dose of the ChAdOx1 nCoV-19 vaccine. The patient developed a diffuse arterial thrombosis with concomitant thrombotic events in the intrahepatic portal branches. The patient’s clinical condition worsened rapidly due to a significant enlargement of the ischemic cerebral lesion in the left hemisphere, cerebral herniation, and incipient hydrocephalus requiring decompressive neurosurgery with an unfavorable outcome. Our observations may be indicative of a stroke variant in VITT and highlight the diverse clinical manifestations of the syndrome. Full article

Laparoscopic cholecystectomy is the most common procedure performed for the management of symptomatic gallstone disease. This, however, can be complicated by the formation of fistulous communications between the biliary tree and the gastrointestinal tract. This abnormal communication allows for the flow of bile and bowel contents between two systems (biliary system and intestine), which can cause abdominal pain, nausea, vomiting, and biliary sepsis. We would like to present a rare case of fistulous communication between the cystic duct stump and duodenum and outline possible contributing factors. The literature review describes the most common interventions for the management of fistulas with emphasis on ERCP and stent preferences to eliminate transpapillary pressure gradient, which directly contributes to fistula closure. Full article

A 64-year-old man, who had no pre-existing health conditions, was admitted to the intensive care unit due to progressive shortness of breath resulting from COVID-19. Initially, the patient responded to non-invasive mechanical ventilation, which improved his breathing function. However, after six days, his respiratory function worsened significantly, requiring invasive ventilation. Out of nowhere, the person experienced spontaneous pneumomediastinum and extensive subcutaneous emphysema. The next day, a spontaneous pneumothorax occurred and was successfully drained later. It became evident that there was extensive subcutaneous emphysema also. The CT scan of the chest confirmed the presence of spontaneous pneumomediastinum, but it did not have any effect on the patient’s hemodynamics. The physicians performed a bronchoscopy and imaging with a contrast medium, which ruled out any lesions to the trachea or esophagus. No other issues related to the problem were identified during the examination. Unfortunately, microscopic bullae of interstitial emphysema, or micro air leaks, are visible when they are an adequate size on computed tomography. Recent literature and studies not available during the case report have shown that if the Macklin effect is detected on the baseline CT scan, it could predict the occurrence of pneumothorax or pneumomediastinum. Full article

(1) Background: Synchronous tumors are defined as tumors that occur at the same time, appearing within 2 months, according to the Surveillance Epidemiology and End Results Program, with a frequency of tertiary tumors of 0.5%. The purpose of this presentation is to report a case of three synchronous tumors of the female genital tract, given the fact that it represents a challenge both therapeutically and in demonstrating that the malignant lesions are completely different from each other. (2) Methods: We report the case of a 45 year-old patient diagnosed with three synchronous tumors developed in the genital tract: clear-cell ovarian carcinoma, uterine endometrioid adenocarcinoma, and cervical adenosquamous carcinoma. (3) Results: Total hysterectomy with bilateral anexectomy was performed and accompanied by a biopsy of the greater omentum. The evolution of the patient was favorable during chemotherapy, but she died two weeks after the completion of this treatment, from a cause secondary to the adverse effects determined by it, namely, severe thrombopenia which caused a massive lower digestive hemorrhage. (4) Conclusions: This case demonstrates the maximum importance of the involvement of adjuvant diagnostic techniques, especially when it comes to a diagnostic challenge with direct implications in the subsequent therapy of the patient. Full article

Hidradenitis suppurativa (HS), a challenging dermatological condition, can be described as a chronic, painful, follicular, occlusive disease that is characterized by painful nodules, abscesses, and sinus tracts generally located in the intertriginous skin areas. This disorder places a considerable burden on affected individuals and often leads to significant impairment in quality of life for those grappling with its persistent and recurrent nature. We present the case of a 20-year-old male patient known to have ulcerative proctitis and diagnosed with hidradenitis suppurativa in 2020, for which he underwent various topical and systemic treatments, with periods of remission and recurrent flares without managing to obtain complete remission of HS. In our dermatology service, the patient underwent two surgical unroofing procedures combined with punch debridement, with the wounds being allowed to heal by secondary intention. This choice of treatment delivered great results with favorable outcomes, without recurrence of the lesions, proving to be an effective method for managing HS. By presenting this case, we underline the role of surgical procedures in managing HS, and our desire is to emphasize the importance of comprehensive understanding of this enigmatic and complex condition for more effective management strategies in patients with refractory disease. Full article

Endoscopic methods are emerging as a possible adjunct to surgery in the management of gastroesophageal reflux disease. Initially, endoscopic treatment has failed because of inefficient suturing devices, and although over many years it proved to be safe, it still can result in serious adverse events. In this article, the authors present a rare case of a male patient who experienced severe reflux years following endoscopic fundoplication. Moreover, in this report, we discovered an interesting finding with the patient who was diagnosed and managed laparoscopically. Although considered minimally invasive, endoscopic fundoplication can have significant deleterious consequences, and early recognition of these complications is vital to limit associated morbidities. Full article

Background: The modern concept of pharmaceutical healthcare implies monitoring the pharmacotherapy outcomes and reporting adverse drug reactions. Objective: To present a suspected hematuria as the adverse rivaroxaban reaction in a patient with atrial fibrillation observed by pharmacists in a community pharmacy. Case presentation: A 69-year-old female patient came to a pharmacy with a prescription for cranberry-based supplement. She was diagnosed with a mild urinary infection after experiencing blood in her urine for about two weeks. The pharmaceutical anamnesis revealed that the patient was treated with irbesartan and rivaroxaban. Rivaroxaban was applied for atrial fibrillation, and the patient was treated for nine months. The patient was treated with omeprazole gastro-resistant capsules for mild dyspepsia and stomach ache over a three-week period. The pharmacist counselled the patient to contact the clinician who introduced rivaroxaban, further suggesting substitution with different anticoagulant. Although the urine culture was negative, the physician introduced ciprofloxacin, which was followed by blood in the patient’s stool. Thus, gastroscopy, colonoscopy, and gynecological examination were advised. All findings were normal. Four days after rivaroxaban was substituted with acenocoumarol, no blood in the urine or stool was detected. Conclusions: Rivaroxaban can cause spot urine blood even when applied in therapeutic doses among older female patients when applied with omeprazole. Possible rivaroxaban interaction with omeprazole metabolites is suspected and should be carefully monitored. Full article