Low-grade malignant peripheral nerve sheath tumour presenting as retroperitoneal spindle cell neoplasm.

Retroperitoneal spindle cell neoplasms are diagnostically challenging. Malignant peripheral nerve sheath tumours (MPNSTs) can sometimes present as sporadic primary retroperitoneal tumours. MPNSTs are usually high-grade and highly aggressive tumours and are associated with a poor prognosis. Low-grade MPNSTs are very rarely described. This current case report describes a case of sporadic primary low-grade MPNST presenting as retroperitoneal spindle cell neoplasm. The diagnosis, imaging and immunohistopathological findings, as well as its successful surgical management, are presented.

Neuro-ophthalmic manifestations in traumatic brain injury: a hospital-based study from Nepal.

Objective: Neuro-ophthalmic manifestations occur frequently in patients with a traumatic head injury which are often ignored, leading to late presentation with permanent visual disability and visual field defects. This study aimed to find the various neuro-ophthalmic manifestations of traumatic brain injury and correlate them with the neurological status and neuroimaging abnormality. Methods: A hospital-based cross-sectional study was carried out among patients admitted to our centre with a diagnosis of traumatic brain injury for a period of six months from August 2020 to January 2021. Glasgow Coma Score was used to grade the severity of the head injury. Detailed ophthalmological examinations were documented in predesigned proforma. Descriptive statistics were used to describe the outcomes. Results: A total of 377 head injury patients underwent neuro-ophthalmic examination-271 (71.9%) were males and 106 (28.1%) were females. The mean age in our study population was 38.6 ± 16.8 years, their age ranging from 3 to 85 years. Time from injury to ophthalmologic examination ranged from 30 min to 12 days post-injury, the mean duration being 24.2 ± 34 h. Road traffic accidents were the most common cause of head injury, with 203 cases (53.8%). 38 (10.1%) patients had neuro-ophthalmic manifestations-16 (42.0%) had afferent pathway deficits and 22 (57.9%) had efferent pathway deficits. The most frequently encountered neuro-ophthalmic abnormality was optic neuropathy in 14 (36.8%) followed by trochlear, oculomotor, abducens nerve, and chiasmal injury. The presence of brain contusion was associated with traumatic optic neuropathy while skull fractures were associated with trochlear nerve palsy, these associations being statistically significant (P<0.05). Conclusion: Neuroimaging abnormalities, particularly brain contusions and skull fractures were significantly associated with neuro-ophthalmic deficits.

Kayser-Fleischer rings: The pathognomonic for Wilson's disease.

Wilson's disease is a genetic disorder of copper metabolism that primarily manifests with hepatic and neurological features. Kayser-Fleischer rings (KF rings) are pathognomonic of Wilson's disease and helps in establishing its diagnosis.

Assessment of severity and feto-maternal outcomes among COVID-19 infected pregnant females hospitalized at tertiary care center in western Nepal.

Objective: There is a paucity of data assessing the severity of coronavirus disease 2019 (COVID-19) infection and feto-maternal outcomes in pregnant women in Nepal, especially during the third wave of the pandemic with the Delta variant. This study aimed to severity as well as maternal-fetal outcomes among pregnant women with COVID-19 infection. Methods: In this cross-sectional study carried out amongst COVID-19 positive pregnant women visiting our institution for 6 months from January through June 2022, data surrounding COVID-19 severity and fetal outcomes were collected in a structured questionnaire. Disease severity was categorized based on the NIH (National Institutes of Health) severity classification. Descriptive statistics were used to describe the outcomes. Results: A total of 105 pregnant females infected with COVID-19 during the third wave were included in our study. The participants ranged from 16 through 40 years, mean gestational age being 36.6 weeks. Most of the women (40.55%) belonged to Brahmin and Chhetri ethnic backgrounds. About half (48.55%) of females were asymptomatic and four patients had severe disease requiring intensive care management. Only 13 pregnant females underwent vaccination. Of the 91 females that underwent delivery at our center, 77 (84.62%) were term. The rate of cesarean delivery was slightly higher (51.65%) than normal delivery. None of the babies born to COVID-positive pregnant females tested positive for COVID-19 and there were no stillbirths or any congenital anomalies. The majority of babies (68.14%) had normal fetal weight. Conclusion: Severe COVID-19 infection and adverse maternal-fetal outcomes during the third wave of COVID-19 infection with the Delta variant in Nepal were less than in other regions of the world despite low rates of vaccination.

Unusual cystic hygromas: Case report.

INTRODUCTION AND IMPORTANCE: Cystic hygromas are congenital lymphangiomas that arise from a developmental anomaly in the lymphatic system. Typically detected in early childhood, their incidence in adolescents and at the chest wall or axillary area is rare. CASE PRESENTATION: We report two cases, a 14-year-old male child (Case I) and a 1-year-old male infant (Case II), who presented with swelling in unusual locations, the right axillary region and the right anterolateral chest wall respectively. Local examination findings were indicative of a cystic hygroma in the first case, while in the second case, characteristic transillumination was not seen due to a complication: hemorrhage within the cyst. The diagnoses were established after a correlation of the patient's history, and clinical findings with radiological investigations. Both underwent surgical intervention and had no complications. Histopathology of the post-operative specimens confirmed the diagnoses. DISCUSSION: The diagnosis of cystic hygroma is made in the totality of thorough history taking, clinical examination, and radiological and histopathological investigations. Though most cases typically manifest before the age of two years and in the cervicofacial area, unusual locations and delayed presentation can occur. Surgical excision is a safe and effective treatment modality for these lesions. CONCLUSION: Although a rare entity, cystic hygroma should be considered a possible differential diagnosis of any swelling in the pediatric population.

An unusual case report of transverse vaginal septum presenting as primary amenorrhea.

INTRODUCTION AND IMPORTANCE: Outflow tract disorders are uncommon causes of primary amenorrhea. Transverse vaginal septum (TVS) is a rare cause of outflow tract obstruction. CASE PRESENTATION: A 15-year-old female presented to us with severe abdominal pain. Abdominal examination revealed a boggy mass in the suprapubic region. The diagnosis was made following a history of primary amenorrhea, lower abdominal pain, and pelvic examination which revealed a vaginal septum. She had surgical resection of the vaginal septum and a mold was left in situ to keep the vagina patent during the healing process. The procedure was uneventful and she was able to achieve menstrual flow following surgery, septoplasty being performed after three months. DISCUSSION: Transverse vaginal septum is an unusual cause of primary amenorrhea. These lesions, albeit rare, usually have a typical presentation and are amenable to surgical management. CONCLUSION: Although transverse vaginal septum is a rare diagnosis in our practice, it is important to establish early diagnosis and carry out proper management so as to preserve normal physiology and fertility as well as to prevent complications.

Vesicovaginal fistula associated with massive bladder calculi: An urogynecological case report.

In developing countries, VVF mainly occurs due to obstructed labor unlike developed countries where common causes are radiotherapy and malignancy. Due to social taboos, patients do not seek medical attention for problems like urinary incontinence and dysuria, thus presenting very late.

"You Sleep, You Die": A Rare Clinical Case of Ondine's Curse after Posterior Fossa Surgery.

Ondine's curse is a rare condition in which breathing is preserved while awake, but there is absence of autonomic control of ventilation. It is a potentially fatal complication that may result rarely from surgery in posterior fossa in area close to respiratory centers. We describe a patient with posterior fossa hemangioblastoma who underwent subtotal resection via telovelar approach and developed acquired Ondine's curse postoperatively. The patient's presentation and management are described. Besides that, Ondine's is a great example of how modern medicine is linked to ancient literature, and thus, its anecdotal history is also described.

Fatal toxicity due to locally produced unlabeled alcohol consumption: An illustrative case series from Nepal.

Locally prepared liquor, which is not standardized or regulated, though cheap can contain various toxic ingredients and even may be fatal. We report a case series of four adult males who died within 18.5 h due to the effect of local liquor consumption in a hilly district of Gandaki Province of Nepal. Methanol toxicity due to illicitly produced alcohol consumption should be managed with adequate supportive care and administration of specific antidotes such as ethanol or fomepizole. Liquor production should be standardized, and quality checks should be done before the sale for consumption.

Clinical profile and biochemical abnormalities in Scrub Typhus: A cross-sectional study.

Introduction: Scrub Typhus (ST) is an acute febrile illness caused by obligate intracellular bacteria of the family Rickettsia. It is often unrecognized and neglected but prevalent in tropical regions of endemic areas. The tragedy behind this diagnostic dilemma is non-specific clinical signs and symptoms, limited awareness, unavailability of diagnostic facilities, and low index of suspicion among the physicians. To address the knowledge gap, we tried to find out a proper panel of laboratory investigations to diagnose the disease and predict its progression because of the uncertainty of the course of the disease in a tertiary care hospital in western Nepal. Methods: This is a hospital laboratory-based prospective study conducted at Gandaki Medical College- Teaching Hospital (GMC-TH) for a period of two years. Among 988 cases of acute febrile illness, 40 seropositive cases of ST were enrolled in the study. We excluded those who did not give consent for the participation, those who were under 17 years of age, and those who had preexisting liver dysfunctions and other co-morbidities and dual seropositive with other infectious etiologies. We used descriptive statistics to analyze the data in terms of demography, clinical features, and laboratory parameters. Results: Out of 988 febrile patients, we included 40 confirmed cases of ST aged between 17 and 70 years during the study-period. Maximum seropositive cases were from Tanahun district 14 (35%), with predominance among the women (70%). The cases were prevalent in the age group 30-60 years, 19 (47.5%), and in the month of October 15 (37.5%). The commonest complaints were fever in 40 (100%), headache in 20 (50%), eschar in 11 (27.5%). Laboratory parameters showed anemia in 22 (55%), hypoalbuminemia in 11 (27.5%), leukopenia in 5 (12.5%), leukocytosis in 9 (22.5%), thrombocytopenia in 13 (32.5%), raised transaminase levels, SGPT in 21 (52.5%) and SGOT in 14 (26%) ST patients. Conclusion: We found clinical and laboratory profiles in patients with ST were varied and nonspecific. However, knowledge of these findings may evoke the recognition of ST and give a clue to the progression of the disease.

Clinical profile and biochemical abnormalities in brucellosis: A cross-sectional study.

Introduction: Brucellosis is the commonest zoonotic disease worldwide and a common public health problem in Nepal. Because of the highly variable clinical presentation and non-specific manifestations, it remains a big challenge for clinicians from developing countries. Brucellosis has a tropism for the reticuloendothelial system, the liver is frequently involved. There is a paucity of data about the laboratory and clinical findings of human Brucellosis from Nepal. To address this knowledge gap, we conducted this study to find out the clinical profile and biochemical abnormalities of patients with brucellosis at a tertiary-care teaching hospital in western Nepal. Methods: A cross-sectional study was carried out at Gandaki Medical College Teaching Hospital, Pokhara, Nepal. All patients admitted to the in-patient department of our hospital with probable or definitive diagnoses of brucellosis were included. We excluded those who did not consent to their participation in our study, those who were under 18 years of age, and those who had deranged liver function due to other pre-existing illnesses. Descriptive statistics were used to analyze the data in terms of demography, clinical manifestations, and laboratory parameters. Results: There was a total of 40 confirmed cases of Brucellosis (age: 18-66 years) during the study period. More than half (55%, n = 22) of the study participants were males and most of them lived in a rural setting (77.5%, n = 31). Most of them (70%, n = 28) gave history of ingestion of high-risk food. The commonest clinical findings were fever with/out chills (90%, n = 36) followed by nausea/vomiting (72.5%, n = 29), headache (40%, n = 16) and malaise (37.5, n = 15). Liver function was deranged in a majority of the patients, the common parameters being Alkaline phosphatase in 96% (n = 38) cases, followed by SGOT (62.5%, n = 25), leukocytosis (57.5%, n = 23), total bilirubin (52.5%, n = 21) and SGPT (37.5%, n = 15). Characteristic increment (more than two folds of the upper limit of normal) was observed for alkaline phosphatase. Conclusion: The reticuloendothelial system is frequently involved in brucellosis. Notable changes were observed in liver function and hematological parameters in a majority of the participants in our study. These findings highlight the need for the implementation of effective control programs to address this problem in the Nepalese context.

Neurosurgery in Nepal: Past, Present, and Future.

Neurosurgery in Nepal is now more than half a century old. Though Nepalese neurosurgical roots can be traced back to ancient times, modern services began in Nepal only after 1990 following the arrival of Dr. Upendra Devkota-the father of Nepalese neurosurgery. Contributions from many reputable global advisors as well as local leaders have yielded many changes to the field ever since. Despite these advancements, neurosurgical care in Nepal is mostly limited to the capital city of Kathmandu, and there remains a deficit of qualified neurosurgeons. Geographical dissemination of neurosurgical care, reappraisal of residency training programs, and initiation of subspecialty-based neurosurgical practices are the next steps to further improve the field in Nepal.

Endoscopic-assisted transantral-endonasal approach to large dentigerous cyst of maxillary sinus.

Dentigerous cysts are seen in the maxillary canine and third molars. We report a case of dentigerous cysts invading the maxillary sinus, which was managed surgically by endoscopic-assisted transantral and transnasal approach.

Urinoma following blunt renal trauma in a patient with anomalous solitary kidney: A case report.

INTRODUCTION AND IMPORTANCE: Blunt traumatic injury to the genitourinary system is uncommon. Urinoma formation may occur in patients with blunt trauma after high grade renal injuries. In such cases, the presence of solitary kidney must be ruled out as it may affect treatment decisions. CASE PRESENTATION: A 21 years old male presented to our facility with complaints of abdominal pain and frank hematuria following physical assault. Physical examination revealed tenderness at the right flank. Laboratory evaluation showed a decreased hemoglobin level and urinalysis showed proteinuria and marked hematuria. Imaging findings were consistent with AAST Grade IV right renal injury affecting the renal pelvis with urinoma formation and congenital megacalyces. Incidental finding of unilateral renal agenesis on the left side was also noted. Our patient underwent Ureteroscopy with double-J stenting. Subsequent ultrasonography after the procedure showed resolution of the perirenal collection. DISCUSSION: The presence of solitary kidney must be ruled out in cases of high grade renal trauma as operative procedures may lead to catastrophic consequences in such cases. Urinoma formation after renal trauma may occur if the renal pelvis is injured and should be managed preferably by urinary diversion in the form of ureteral stenting over other operative procedures, especially in patients with anomalous solitary kidney. CONCLUSION: Presence of bilateral kidneys should be confirmed before subjecting patients with high grade renal injury to operative procedures. Early ureteric stenting appears to be an effective method of urinary diversion for management of symptomatic urinomas in patients with anomalous solitary kidney.

Dicephalus parapagus conjoined twins.

Dicephalus parapagus are conjoined twins with two separate heads. Proper identification helps in patient counseling and timely referral to specialist centers.