Sarcoid-like reaction and hypothyroidism induced by PD-1 inhibitor treatment in metastatic renal cell carcinoma: a case report and literature review.

BACKGROUND: Pembrolizumab is among the approved treatments for a variety of cancer types, including clear cell renal cell carcinoma (ccRCC). It has contributed to enhancing the prognosis of renal cell carcinoma. However, it is essential to be aware of the numerous potential immune-related side effects associated with its use. CASE PRESENTATION: A 69-year-old patient with a history of metastatic renal cell carcinoma has been undergoing treatment with Pembrolizumab, an immune checkpoint inhibitor. The medication has led to the development of a sarcoid-like reaction, initially misinterpreted as cancer recurrence and progression. Additionally, the patient has experienced new-onset hypothyroidism, which has been attributed to the immunotherapy. CONCLUSION: Clinicians, including oncologists, endocrinologists, and radiologists, should maintain a high level of suspicions and awareness regarding the potential adverse events associated with newly introduced immunotherapies like pembrolizumab. This knowledge is crucial for the accurate diagnosis and appropriate management of patients receiving these treatments.

Identification of Risk Factors for the Development of Diabetic Retinopathy Among Palestinian Adults With Type 2 Diabetes Mellitus: A Cross-Sectional Study.

INTRODUCTION: Although risk factors linked to diabetic retinopathy (DR) among patients with Type 2 diabetes mellitus (T2DM) have been extensively studied globally, the specific determinants of these factors in relation to DR in Palestine are presently not well understood. METHODS: This retrospective cross-sectional study included patients who underwent DR screening with a fundus camera (VersaCam a). The study included patients aged ≥18 with T2DM, excluding those with other types of diabetes or a history of malignancies. Univariable and multivariable logistic regressions were used to identify factors associated with DR. RESULTS: A total of 1163 patients with T2DM were included in this study. Of these, 211 (18.1%) patients were classified in the DR group, 761 (65.4%) in the no DR group and 191 (16.4%) were ungradable. Among the included patients, 434 (37.3%) were male. A secondary level of education or higher and a BMI ≥30 kg/m2, compared with <25 kg/m2, were independently and inversely associated with DR, with odds ratios (ORs) of 0.46 (p < 0.001) and 0.58 (p = 0.046), respectively. A 5-year increase in the duration of T2DM correlated with 45% higher odds of having DR (p < 0.001). Patients with DR were more likely to have HbA1c >7%, be physically inactive and use insulin, with ORs of 1.63 (p = 0.02), 2.05 (p < 0.001) and 1.53 (p = 0.03), respectively. Age, gender, occupational status, hypertension and hyperlipidaemia were not independent predictors of DR (p < 0.05). CONCLUSION: Longer duration of T2DM, HbA1c >7%, physical inactivity and insulin use were all independently associated with the presence of DR. Furthermore, a secondary or higher educational level and obesity demonstrated independent and inverse associations with the development of DR.

Successful management of large incarcerated inguinal hernia: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Hernias containing organs like the cecum, appendix, sigmoid colon, ureter, and omentum are less common compared to typical inguinal hernias involving the small intestine. Patients typically present with inguinoscrotal swelling. CASE PRESENTATION: A 53-year-old male with ischemic heart disease, diabetes, and hypertension presented with vomiting and no bowel movement for 24 h. He had a long-standing left inguinoscrotal hernia and recently underwent cardiac catheterization. Examination showed a massive hernia and an empty rectum. Imaging confirmed a small bowel obstruction. Surgery revealed an incarcerated hernia containing multiple organs, which were reduced, and hernioplasty was performed. Postoperatively, he developed abdominal compartment syndrome, necessitating decompressive laparotomy. His abdomen was closed on day 13, and he was discharged on day 30. CLINICAL DISCUSSION: Hernias, particularly when they become incarcerated, pose significant risks to patients. If untreated, they can progress to strangulated hernias, leading to bowel ischemia and potentially fatal outcomes. CONCLUSION: Inguinal hernias are diagnosed primarily through clinical examination. It is rare for these hernias to contain the cecum, appendix, sigmoid colon, ureter, and omentum, and such cases are typically associated with intestinal obstruction.

Successful treatment of pseudomyxoma peritonei (PMP) through cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC): A case report and literature review.

INTRODUCTION AND IMPORTANCE: Pseudomyxoma peritonei (PMP) is characterized by the accumulation of mucinous fluid in the abdominal cavity, typically originating from mucin-producing tumors, most commonly arising in the appendix. CASE PRESENTATION: A 63-year-old male patient presented to the hospital with complaints of abdominal pain, significant weight loss, a palpable mass in the right iliac fossa, and evidence of ascites. A diagnosis of PMP was proposed based on findings from a computed tomography (CT) scan, which was subsequently confirmed through histopathological examination of a biopsy. The patient underwent successful treatment with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). CLINICAL DISCUSSION: Diagnosing PMP presents challenges due to its rarity and the potential for extensive spread throughout the peritoneal cavity, necessitating a multidisciplinary approach for successful treatment. CONCLUSION: Pseudomyxoma peritonei is a rare yet medically significant condition. Documenting a case of this ailment in Palestine has the potential to advance medical understanding, raise awareness, and improve patient care standards within the local healthcare system. By documenting this uncommon condition, healthcare practitioners in Palestine can gain valuable insights into its manifestations, diagnostic processes, and treatment modalities. This contribution not only enriches the global medical literature but also promotes collaboration in addressing the challenges associated with rare diseases.

The impact of vitamin D treatment on pregnancy rate among endometriosis patients: a systematic review and meta-analysis.

Background: Vitamin D supplementation is supposed to have an important role in the management of several endometriosis-related aspects, offering potential relief to affected individuals. Herein, the authors aim to evaluate the impact of vitamin D on pregnancy rates and clinical symptoms in women with endometriosis. Methods: The authors extensively searched PubMed, Cochrane Library, EMBASE, Ovid MEDLINE, and CINAHL from their inception to 20 July 2023. Results: Three randomized controlled trials involving 167 patients were included in this meta-analysis. The findings demonstrated that vitamin D supplementation exhibits efficacy in alleviating dysmenorrhea associated with endometriosis, as evidenced by a meta-analysis showing a significant reduction in dysmenorrhea (mean difference -1.41, 95% CI -2.61 to -0.22, P = 0.02). However, the impact on dyspareunia was inconclusive, with a non-significant mean difference of -0.2 (95% CI -1.62 to 1.22, P = 0.78). In contrast, dyschezia significantly decreased with vitamin D supplementation (mean difference -1.10, 95% CI -2.22 to 0.02, P = 0.05 However, the meta-analysis did not show a significant effect of vitamin D on chronic pelvic pain associated with endometriosis. Conclusion: While antioxidant vitamin D supplementation demonstrates general effectiveness in alleviating endometriosis symptoms, such as dysmenorrhea, dyspareunia, and dyschezia, the existing literature lacks direct investigations into the specific impact of vitamin D on enhancing pregnancy rates among endometriosis patients. This observation prompts various hypotheses, suggesting that the positive effects of vitamin D supplementation on endometriosis-related symptoms may indirectly contribute to improved pregnancy outcomes and enhanced fertility.

The level of medical students' knowledge regarding the prevention of cervical cancer.

Background: In Palestine, cervical cancer is the third most common gynaecological cancer, exhibiting higher mortality rates compared to regional counterparts. Late-stage diagnosis and limited awareness contribute to this disparity. This study aims to assess the awareness of Palestinian medical students regarding cervical cancer prevention. Methods: A questionnaire-based survey involving 532 medical students from various Palestinian universities was conducted between October 2023 and December 2023. The survey encompassed closed-ended quantitative and demographic questions distributed through social media. Results: The study was carried out on a group of 532 medical students (66.3% women and 33.6% men), (average age 21.7 years). Most students (77.7%) knew that the main risk factor for cervical cancer was human papillomavirus (HPV) infection. Participants doing the internship had the greatest knowledge, whereas students from the first year had the poorest knowledge about the main risk factors for cancer of the cervix. Only about half, 50.2% of all students, knew that in Palestine, there is no screening program. 84.4% of students correctly indicated that the cervical cancer screening test is a pap smear test. 41.4% of respondents knew that microscopic evaluation of the exfoliated cells from the vaginal part of the cervix is the screening test for cervical cancer which is used. Only about half of the students (45.1%) knew that there were no specific early symptoms of cervical cancer. Conclusions: This study highlights the need for enhanced education, particularly regarding screening program awareness, among Palestinian medical students. Addressing these knowledge gaps is crucial for effective preventive strategies.

Waugh syndrome: A rare coexistence of intussusception and intestinal malrotation: Case report and literature review.

INTRODUCTION: Waugh's syndrome, characterized by the concurrent presence of acute intussusception and gut malrotation, is a rare clinical entity. The relationship between these conditions is not well-explored, and the true incidence may be underreported. CASE PRESENTATION: A 4 month old male infant, with an uneventful medical history, presented to the pediatric emergency department due to irritability and rectal bleeding lasting one day. The infant had a history of bilious vomiting and dark bloody rectal discharge. Physical examination revealed a hypoactive, dehydrated child with a palpable mass in the left lower abdomen. Abdominal ultrasound indicated Colo-colonic intussusception, and attempts at hydrostatic reduction were unsuccessful. Subsequent CT scan revealed malrotation with ileo-Colo-rectal intussusception. The patient underwent a two-step operation, involving manual reduction and Ladd's procedure, with a successful recovery and no post-surgical complications. CLINICAL DISCUSSION: Reviewing the cases, we explore the unique features of Waugh's syndrome, its diverse age presentation, and the challenges in timely diagnosis. Diagnostic modalities, including abdominal ultrasound and contrast studies, are discussed, emphasizing the importance of recognizing malrotation in conjunction with intussusception for appropriate management. CONCLUSION: Our experience highlights the potential underrecognition of Waugh's syndrome and emphasizes the need for a high index of suspicion. The rarity of laparoscopic interventions in documented cases is noted, emphasizing the prevailing reliance on open surgical approaches. A call for prospective studies is made to determine the actual incidence of intussusception in intestinal malrotation cases and to enhance understanding for optimal patient management.

Comparing pyridoxine with dopaminergic agonists (cabergoline and bromocriptine): Unveiling the strategy for lactation inhibition - A systematic review of clinical trials.

This systematic review aims to evaluate the efficacy and safety of Pyridoxine compared to Dopaminergic agonists (cabergoline and bromocriptine) in post-partum lactation inhibition. Cochrane Central, PubMed/MEDLINE, Cochrane Central, ScienceDirect, ClinicalTrials.gov, Web of Science, CINAHL and Google Scholar, covering the period from inception to November 2023. Additionally, the bibliographies of included articles and previous meta-analyses were screened for any relevant articles. The systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The outcomes of interest encompassed inhibition of lactation, breast pain/tenderness, breast engorgement, milk secretion, fever, mastitis, prolactin level and adverse events related to pyridoxine, cabergoline and bromocriptine. Methodological quality assessment was conducted using the Cochrane risk of bias assessment tool for rigorous evaluation. Three clinical trials assessed the effectiveness of pyridoxine and dopaminergic agents (cabergoline and bromocriptine) for lactation inhibition. It was assessed by using different assessment methods such as a scale for milk secretion, serum prolactin levels, and questionnaires for assessing breast engorgement, breast pain, and milk leakage. On the global assessment of the therapeutic efficacy of dopaminergic agents, it was found that there was significant inhibition of lactation as compared to pyridoxine (p < 0.001). In conclusion, this systematic review contributes significant insights into lactation inhibition interventions. Dopaminergic agonists, specifically cabergoline and bromocriptine, stand out as more effective and tolerable choices compared to Pyridoxine. These findings provide a foundation for informed clinical decisions and underscore the need for careful consideration of lactation inhibition strategies in diverse clinical contexts.

A single center experience with a rare clinical entity of idiopathic granulomatous mastitis: Case series and review of the literature.

INTRODUCTION AND IMPORTANCE: Idiopathic granulomatous mastitis (IGM), also called autoimmune mastitis or granulomatous lobular mastitis is a benign, rare disease of the breast lobules. It is characterized by chronic non-caseating granulomatous sterile inflammation of the breast lobules. It is a disease of middle-aged women. CASE SERIES PRESENTATION: Herein we report six cases of IGM the General Surgery Department at Palestinian Medical Complex (PMC) with a good response to treatment and significant improvement. The patients were followed-up for an average of 4-month period. DISCUSSION: Pathophysiology is uncertain. It has a wide differential diagnosis and malignancy should be ruled out. Its diagnosis is highly challenging and is only made by biopsy. Treatment options include medical and surgical therapy. Patients are usually started with a low dose prednisolone, other options include immunosuppressive agents, antibiotics, NSAIDs, colchicine and minimally invasive surgery. IGM has a high recurrence rate up to 40 % and long term follow up is advised. CONCLUSION: IGM is a rare breast pathology that evolves in an unpredictable manner over time. Clinical and radiological aspects vary and pose a diagnostic challenge, particularly in breast cancer. The pathological examination is still the most important component of certain diagnoses. The clinically correlated treatment is still debatable.

Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study.

Background: Telemedicine has proven to be a boon in the field of medical sciences, as it provides a platform for all health-care personnel to assist patients remotely through digital technology advancements. It brings hope to the lower middle-income regions of the world. Thus, the study was conducted to explore the perceptions regarding telemedicine among healthcare professionals (HCP) in rural Sindh, Pakistan. Methodology: Overall, 19 in-depth interviews were conducted and this comprised of HCP working in the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences (PAQSJIMS) and Peoples University of Medical and Health Sciences for Women (PUMHSW) being involved in providing online consultations and practicing telemedicine. The interviews were conducted and audio recorded in Sindhi and Urdu and were later transcribed in to English, coded for themes and sub-themes, and were analyzed using content analysis. Results: The opportunities perceived with the use of telemedicine services were reducing nosocomial infections, facilitating the healthcare in remote areas, handling telemedicine tools, application of telemedicine services on the ground and reducing stress. However, inadequate awareness regarding telemedicine, difficulty in physical examination, the need for training, lack of compliance, and concerns regarding accuracy in diagnosis and treatment were identified as the perceived barriers to the use of telemedicine services. Conclusion: HCP had perception toward telemedicine as have numerous opportunities favoring implementation as well as various barriers are needed to overcome to promote the usage of telemedicine. Increased awareness, training programs, and technological advancements are key to overcome these challenges.

Acute coronary syndrome in young (≤45 years) patients: a multi-centre observational study.

Introduction: Acute coronary syndrome (ACS) in young individuals (≤45 years) is increasingly recognized as a significant health concern, yet research in this demographic remains limited, particularly within the Palestinian context. This study aims to bridge this gap by comprehensively investigating the clinical characteristics, age-specific profiles, gender disparities, treatment modalities, and angiographic patterns of ACS in young patients compared to their older counterparts. Materials and methods: A multi-centre observational study was conducted, enroling 468 participants aged 18-55 diagnosed with ACS and admitted to three prominent Palestinian hospitals. Data were collected from medical records, and statistical analysis was performed to assess demographic characteristics, clinical presentations, risk factors, treatment strategies, and outcomes. Results: The majority of participants were male (87%), with a higher proportion in the older age group (>45 years). Clinical presentations varied, with non-ST segment elevation myocardial infarction (NSTEMI) being the most common diagnosis (48%). Risk factors such as smoking, hypertension, and diabetes were prevalent, with notable gender and age-specific differences. Percutaneous coronary intervention (PCI) was the predominant treatment strategy (83%), with consistent medication use across age groups. Conclusion: ACS in young patients poses a significant public health challenge in Palestine, necessitating tailored preventive strategies and comprehensive management approaches. Understanding the unique demographic and clinical characteristics of young ACS patients is crucial for informing targeted interventions and policies aimed at reducing the burden of cardiovascular disease in this population. These findings contribute valuable insights to the existing literature and underscore the importance of further research in this area to improve outcomes and mitigate the impact of ACS in young individuals globally.

Very rare metastatic phenomena of biliary tract cancer to the cerebellum: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: The occurrence of brain metastasis due to cholangiocarcinoma is an exceedingly uncommon phenomenon, documented in only a few numbers of published cases. Recent studies indicated an incidence rate of just 0.15 % for brain metastases in connection with this condition, which was also linked to a reduced survival rate. CASE PRESENTATION: A 58-year-old woman with a history of hepatobiliary cholangiocarcinoma presented with a recent onset of unsteady walking, dizziness, vomiting, and worsening occipital headaches. Her medical history included successful chemotherapy treatment for her cholangiocarcinoma. Neurological examination revealed right-sided cerebellar deficits, and imaging indicated a sizable lesion in the right cerebellar hemisphere with surrounding vasogenic edema. A PET scan revealed a liver lesion but no other significant abnormalities. The recommended approach was surgical excision of the cerebellar lesion to relieve symptoms, halt deterioration, and obtain a tissue sample for analysis. After comprehensive discussions with the patient and her family, they opted for the surgical procedure. CLINICAL DISCUSSION: The major contributors to brain metastases include lung cancers, breast cancers, testicular cancers, melanomas, and renal tumors. In contrast, brain metastases originating from gastrointestinal cancers are less frequent, accounting for fewer than 4 % of cases, with notable impact on 1 % of colorectal cancers, 0.62 % of gastric cancers, and 0.33 % of pancreatic cancers. However, brain metastases are extremely rare. CONCLUSION: This study underscores the significance of anticipating and identifying brain metastases in biliary tract cancers, even in the face of their low incidence and the limited amount of available literature on the subject.

The clinical significance of laparoscopy in the differentiation of inclusion cysts from ovarian masses: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Peritoneal inclusion cysts (PICs) are infrequently encountered cysts within the abdominal and pelvic regions, typically observed in perimenopausal women. They frequently pose a diagnostic challenge as they can be clinically misinterpreted as ovarian-related lesions, owing to their resembling clinical presentations and radiological features. CASE PRESENTATION: A 30-year-old female patient without significant medical or surgical history sought medical attention for mild left lower abdominal discomfort lasting two days. Initial evaluation ruled out pregnancy, and further tests showed no abnormalities in her blood work. Pelvic ultrasound revealed a 4.5 cm cystic mass in her left ovary while her right ovary and uterus appeared normal. A laparoscopic ovarian cystectomy was planned. During the procedure, it was discovered that the mass was not connected to the left ovary but was, in fact, a peritoneal inclusion cyst. CLINICAL DISCUSSION: previous intraperitoneal surgeries performed within a timeframe ranging from 6 months to 20 years, intraperitoneal inflammation, pelvic inflammatory disease, peritoneal tuberculosis, leiomyoma, tubo-ovarian abscess, among others. However, the absence of these predisposing factors does not minimize the possibility of PICs. CONCLUSION: This case highlights the diagnostic challenges and the value of laparoscopy in accurately identifying and differentiating such cystic cases.

Brain abscess as a complication of nasopharyngeal COVID-19 swab testing: Two case reports and a literature review.

INTRODUCTION AND IMPORTANCE: The nasopharyngeal swab, which has experienced a marked increase in utilization during the COVID-19 pandemic and is considered the gold standard for COVID-19 testing due to its high diagnostic accuracy and sensitivity, The procedure is generally safe and well-tolerated, with pain, discomfort, and the urge to cough or sneeze being the most common complications. Though it is occasionally associated with serious complications. CASE PRESENTATION: we report two cases of brain abscess as a complication of nasopharyngeal COVID-19 testing. The first case was of a 47-year-old male diabetic patient with a positive medical history for immune thrombocytopenic purpura (ITP) who developed a frontal brain abscess one week after the swabbing procedure and was treated with systemic antibiotics followed by a successful functional endoscopic sinus surgery. The second case involved a hypertensive female patient in her 40s who also developed a frontal brain abscess on the same side as painful nasal COVID-19 testing. Systemic antibiotics were used to treat the patient. CLINICAL DISCUSSION: Serious adverse events from nasopharyngeal COVID-19 testing were reported to occur rarely, with incidences ranging from 0.0012 to 0.026 %. Retained swabs, epistaxis, and CSF leakage were commonly reported complications, which were frequently associated with high-risk factors such as septal deviations, pre-existing basal skull defects, and sinus surgeries. However, brain abscess complications are considered one of the extremely rare complications, with only a few cases reported in the literature. CONCLUSION: Appropriate approaches that depend on adequate anatomical knowledge are necessary for practitioners to perform nasopharyngeal COVID-19 testing.

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.

The new wave of Congo virus in Pakistan: emerging threat.

Congo virus, or Crimean-Congo hemorrhagic fever (CCHF), is a tick-borne disease caused by a single-stranded RNA virus (genus nairovirus, Bunyaviridae family). It spreads through infected ticks' bites or contact with viremic individuals or livestock. Factors supporting its spread include hot, humid climates, limited pesticide use, poor animal control, inadequate irrigation during monsoons, and vector control deficiencies. Nosocomial transmission in under-resourced hospitals poses a threat to healthcare workers. Decades of CCHF cases persist in Pakistan due to these factors, with six deaths reported by June 2023. To combat the epidemic, Pakistan should raise awareness, improve irrigation, establish surveillance systems, and implement livestock quarantine and vaccination.

Metastasis of incidentally diagnosed renal cell carcinoma to the sacrum 7 years after partial nephrectomy: Case report and literature review.

INTRODUCTION: After undergoing partial nephrectomy for renal cell carcinoma (RCC), approximately 20-40 % of patients may develop either distant metastatic disease or locally recurring disease. Delayed occurrence of metastasis is an important aspect to consider in the management and monitoring of patients with renal cell carcinoma. CASE PRESENTATION: A 69-years-old male who had been followed up for liver hemangioma, an incidental enhancing right renal mass was discovered which then revealed to be renal cell carcinoma on computed tomography scan. The patient underwent a partial nephrectomy in 2016without any reported complications, complaints, adverse event and/or re-admissions. Seven years following the surgery, the patient began experiencing left hip pain, leading him to seek medical advice which is then confirmed to be a cancerous metastasis of the renal origin. CLINICAL DISCUSSION: Advocating for extended surveillance protocols is important to ensure that patients receive optimal care and that any disease progression is identified promptly. Early detection and intervention may lead to better treatment outcomes and improved patient survival. Therefore, continued vigilance and close monitoring of patients with RCC, even after long periods of disease-free survival, are essential components of comprehensive cancer care. CONCLUSION: This case highlights the challenges in predicting and detecting the occurrence of metastases in renal cell carcinoma despite regular surveillance and follow-up examinations. The delayed appearance of the metastatic lesion underscores the importance of continued vigilance and thorough monitoring even in cases where initial imaging and blood tests appear unremarkable in patients with renal cell carcinoma.

Unique clinical entity: Infective endocarditis with ruptured MCA mycotic aneurysm presented as fever of unknown origin: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Fever of unknown origin (FUO) in children poses a complex challenge for doctors. It involves a broad spectrum of potential diagnoses, with infectious diseases being the predominant culprits, followed by connective tissue disorders and malignancies. CASE PRESENTATION: A 4-year-old boy with a prior diagnosis of a congenital bicuspid aortic valve was admitted to our hospital after experiencing two months of intermittent high-grade fever, severe nighttime headaches, and episodes of nausea and vomiting. His condition deteriorated rapidly with a drop in hemoglobin, elevated inflammatory markers, and the discovery of a large intracerebral hematoma. Further evaluation revealed infective endocarditis and a ruptured cerebral mycotic aneurysm associated with the bicuspid aortic valve infection. The aneurysm was successfully treated through cerebral endovascular catheterization, and the patient received six weeks of intravenous antibiotics. Cardiac surgery for valve repair was planned for a later date. CLINICAL DISCUSSION: Among the infectious causes, infective endocarditis (IE) is a notable contributor, accounting for 1-5 % of all FUO cases. IE can lead to severe complications, with a small fraction of patients experiencing neurological issues such as stroke, encephalopathy, or the development of cerebral mycotic aneurysms. CONCLUSION: The presented case serves as a stark reminder that FUO can be caused by serious underlying conditions, such as infective endocarditis. The rapid progression from fever and neurological symptoms to a ruptured cerebral mycotic aneurysm highlights the potentially life-threatening nature of these cases.

Life-saving intervention following spontaneous rupture of splenic vein in a young patient: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: The spontaneous rupture of the splenic vein is indeed a rare occurrence, and it carries a high risk of mortality. To date, only a very limited number of documented cases of splenic vein rupture attributed to hepatic cirrhosis have been reported. CASE PRESENTATION: A 17-year-old male patient was urgently referred to our hospital due to sudden severe abdominal pain. Upon admission, the patient displayed critical signs, including abdominal tenderness and shock. Lab results revealed low red blood cell count and elevated creatinine levels. A CT scan uncovered a substantial abdominal fluid accumulation and a ruptured splenic vein alongside a dilated superior mesenteric vein. Emergency exploratory surgery revealed extensive intraperitoneal bleeding due to the splenic vein rupture, leading to a total splenectomy and vein ligation. Surprisingly, histological findings confirmed liver cirrhosis, although the patient had shown no liver-related symptoms prior to surgery. Over six months of careful monitoring, the patient displayed significant improvement in health with no complications or readmissions. CLINICAL DISCUSSION: The rupture of the splenic vein is an uncommon condition that should be taken into consideration when evaluating the potential causes of intra-abdominal hemorrhage, particularly in cirrhotic patients and pregnant women. The appropriate treatment typically involves controlling the hemorrhage and performing the ligation of the splenic vein, often necessitating an urgent splenectomy. CONCLUSION: This case underscores the critical importance of considering uncommon sources of sudden intraperitoneal hemorrhage, such as splenic vein rupture. It also emphasizes the vital role of prompt surgical intervention in such cases.

Successful pregnancy-preserving laparoscopic adnexectomy for complicated ovarian torsion during late pregnancy: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: A rare disorder called ovarian torsion (OT) during pregnancy can harm both the mother and the fetus. Predisposing variables for the condition include enlarged ovaries, free mobility, and a long pedicle, despite the fact that its genesis is not entirely understood. When ovarian stimulation is used to treat infertility, the disease's incidence rises. Magnetic resonance imaging and ultrasound are examples of diagnostic imaging modalities (MRI). CASE PRESENTATION: A 26-year-old woman with a 33-week pregnancy presented to our emergency department with acute, severe left groin pain. Laboratory evaluation was unremarkable except for leukocytosis (18.800/µL) with neutrophil shift. A radiologist used ultrasound to examine the abdomen and pelvis, and the results revealed a bulk enlargement of the left adnexa. The patient underwent a non-enhanced MRI in order to obtain a conclusive diagnosis, which revealed a massive enlargement and torsion of the left ovary with large areas of necrosis. The patient underwent a successful laparoscopic adnexectomy with preservation of the pregnancy. She delivered a healthy baby and had an uneventful follow up period. DISCUSSION: The etiology of OT is largely unknown. Any tendency to rotate the infundibulopelvic and utero-ovarian ligaments should be considered as a possible etiology. The prevalence of OT among pregnant women is underreported and determined by small limited studies. CONCLUSION: Ovarian torsion should be included in the differential diagnosis of patients with suspected acute abdomen in advanced stages of pregnancy. In addition, MRI should be used as an alternative diagnostic modality in patients with normal sonographic findings.