Acute severe gouty arthritis secondary to isotretinoin toxicity in a young male: a case report.

Acute gouty arthritis is a recognized complication of hyperuricemia and one of the most common forms of inflammatory arthritis in adults. Drug-induced hyperuricemia is increasingly prevalent in clinical practice. Diuretics, antitubercular medications, and immunosuppressants are the common drugs associated with hyperuricemia. Oral isotretinoin is the drug of choice for different forms of severe acne and is rarely associated with hyperuricemia. We present the case of a 30-year-old male with severe acne vulgaris who was prescribed isotretinoin and later presented with acute gout. The patient developed hyperuricemia and swelling of the right first metatarsophalangeal joint within two months of isotretinoin commencement. There was a second episode of similar joint swelling three months later, parallel to the isotretinoin rechallenge. The dose of isotretinoin was reduced with the addition of febuxostat. The patient did not develop further episodes and remained symptom-free without urate-lowering therapy.

Limb Salvage Surgery in an Enormously Large Pelvic Malignant Bone Tumor.

Introduction: Malignant transformation of pelvic osteochondroma is a rare entity. Large size and late presentation impose threat to life as well as limb. We report a case of limb salvage surgery in an enormously large secondary chondrosarcoma arising from pelvic bone. Case Report: A 60-year-old male presented with a colossal swelling at groin reaching up to distal thigh. He was walking with a wide-based gait due to pain and discomfort. 30 year back, the patient first reported this swelling of pea size, for which he was advised surgery but due to fear of surgery and economic reason he refused. Swelling gradually increased in size and reached up to distal thigh in the past 30 years. It was hard and non-tender up to 6 months back, when suddenly a change in consistency from hard to soft in distal area was noticed. On examination, a large soft cystic swelling was hanging from his pubic area. Tumor was fixed at base on proximal end. On magnetic resonance imaging, size of tumor was 281 mm in length, 263 mm in width, and 250 mm in anteroposterior diameter. Tumor was arising from superior and ischiopubic rami. However, no intra-articular extension was seen. A radiographic skeletal survey and bone scan did not reveal any other lesion. On biopsy, chondrogenic tumor composed of lobules of chondroid material with no cellular atypia or evidence of malignancy was reported. Considering the age of patient, rapid progression in recent months, size and duration of tumor, and type 3 pelvic resection was planned. Using utilitarian pelvic incision with perineal extension, separating long adductor muscles and deep femoral artery tumor, tumor excised with osteotomy at pubic symphysis, and on superior and inferior pubic rami. With minor wound complications, wound healed in 3 weeks. Post-operative biopsy reported as Grade 1 chondrosarcoma. At 3-year follow-up, the patient has no complains and no sign of recurrence noticed. Conclusion: Limb salvage surgery is a suitable option even in enormously large musculoskeletal malignancy. Proper counseling and tracking of patients are must to avoid future complications.

Unmasking of systemic lupus erythematosus in a patient with hemophagocytic lymphohistiocytosis- macrophage activation syndrome (HLA-MAS) and diffuse alveolar hemorrhage.

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome caused by macrophages and cytotoxic T cells with aberrant activation. The primary (genetic) form, which is caused by mutations that affect lymphocyte cytotoxicity and immune regulation, is most prevalent in children, whereas the secondary (acquired) form is prevalent in adults. Secondary HLH is commonly caused by infections or cancers, but it can also be caused by autoimmune disorders, in which case it is known as macrophage activation syndrome (MAS; or MAS-HLH). A 25-year-old female presented with a high-grade fever that lasted for two weeks. His laboratory results revealed pancytopenia, neutropenia, hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Based on the clinical presentation and laboratory findings, a provisional diagnosis of HLH has been made. A HLH protocol was utilized to treat the patient. During the course of hospitalization, systemic lupus erythematosus (SLE) was identified as the underlying cause. She improved dramatically after receiving an immunosuppressive regimen of etoposide, cyclosporine, and dexamethasone according to HLH protocol-2004 with individualized modifications. The clinician should be aware that HLH may be the initial manifestation of underlying SLE. Early diagnosis and aggressive, individualized treatment are the key to improving outcomes.

Schwannoma of the Median Nerve at Mid Forearm Level.

INTRODUCTION: Schwannomas are also known as neurilemmoma that usually originate from Schwann cells located in the peripheral nerve sheaths. It usually occurs in the age group of 20 to 70 years. These are the commonest tumors of the peripheral nerves, 5% of which occur in the adults and 19% of the tumors occur in upper extremities. Schwannomas are generally presented as an asymptomatic mass. Discomfort may be the only presenting complaint of the patient. Paresthesia may be elicited on tapping the swelling. Magnetic resonanceimaging, and ultrasound are helpful in the diagnosis. Surgical removal is usually curative. CASE PRESENTATION: A 28-year-old male came to our hospital for a lump located at the volar side of the right mid forearm for 10 years with discomfort and paresthesia in median nerve distribution of hand which appeared in last two years. Total excision was performed for the lesion. Histopathological examination of the mass revealed typical features of schwannoma. At two months follow-up, the patient was symptom free with mild paresthesia in his index and middle fingers. CONCLUSION: Benign tumours involving peripheral nerves of the upper extremity are uncommon. Schwannomas are theoretically removable because they repulse fascicular groups without penetrating them, thus allowing their enucleation while preserving nerve continuity, as reported in our patient.