Prevalence of hysterectomy and its determinants in northern Iran: enrollment results of the Tabari cohort study.

BACKGROUND: To the best of our knowledge, no population-based studies have provided insights into the prevalence of hysterectomy and its risk factors among northern Iranian females. Thus, the present study aimed to investigate the prevalence and sociodemographic determinants of hysterectomy in a large cohort of northern Iranian females. METHODS: This cross-sectional study included data from the enrollment phase of the Tabari cohort study (TCS). The TCS consists of 10,255 adults (4,149 males and 6,106 females) aged 35-70 years who reside in Sari, Mazandaran, Iran, of which 6103 females were included in the study. Multiple logistic regression analysis was used to search for hysterectomy determinants. RESULTS: Our results revealed that the prevalence of hysterectomy among northern Iranian females was 9.7% (595/6103). Additionally, 50-59 (OR: 4.63, 95% CI: 3.57-6.01) and 60-70 (OR: 5.83, 95% CI: 4.28-7.95) age groups, higher socioeconomic levels (OR: 1.66, 95% CI: 1.13-2.42), a history of tubectomy (OR: 1.27, 95% CI: 1.05-1.53), and more gravida (OR: 5.35, 95% CI: 1.62-17.63) were found to increase the odds of hysterectomy, whereas living in mountainous areas (OR: 0.57, 95% CI: 0.43-2.75) and having a job (OR: 0.62, 95% CI: 0.45-0.86) were found to decrease the odds of hysterectomy. CONCLUSION: Older age groups, living in urban areas, higher socioeconomic levels, not having a job, a history of tubectomy, and more gravida were found to increase the odds of hysterectomy.

Biliary co-infection by multidrug-resistant Candida glabrata and Candida albicans in a case of pancreatic cancer with cholangitis: A case report and review of literature.

Herein, we report a case of pancreatic cancer with acute cholangitis secondary to biliary obstruction. Empirical antibiotic therapy did not change the clinical presentation. Blood cultures were sterile; however, bile culture was positive for yeasts. Our laboratory analysis revealed a biliary coinfection by multidrug-resistant C. glabrata and C. albicans. The patient was successfully treated with endoscopic biliary drainage.

Rectal gastrointestinal stromal tumor (GIST) in a patient with Crohn's disease: a rare coincidence case report and brief literature review.

Gastrointestinal stromal tumors (GISTs) are the most common type of gastrointestinal mesenchymal tumors. The most common site for developing these neoplasms is the stomach and small intestine. In contrast, anorectal GISTs are very rare. Population-based studies have shown an increased risk of colorectal cancers (CRC) in patients with Crohn's disease (CD). As in sporadic CRC, adenocarcinomas are the most commonly observed tumor. Accordingly, it is expected that rectal mass in CD patients to be an adenocarcinoma. Some reports have presented CD cases with GISTs along the gastrointestinal tract; however, to the best of our knowledge, a rectal GIST has not been reported in CD. Herein, we report a 41-year-old woman with CD who presented with 8 weeks of constipation and was diagnosed with rectal GIST and briefly review existing reports regarding GIST in IBD.

Improvement in right heart function following kidney transplantation in esrd patients: insights from speckle tracking echocardiography analysis.

Chronic kidney disease (CKD) is commonly associated with unfavorable cardiovascular outcomes and remains the leading cause of mortality in individuals with end-stage renal disease (ESRD). Despite substantial knowledge about the impact of CKD on the left heart, the right heart, which holds significant clinical relevance, has often been overlooked and inadequately assessed in ESRD patients who have undergone kidney transplant (KTx). This study aimed to evaluate the effects of KTx on the right heart chambers in ESRD patients. 57 adult KTx candidates were enrolled in this prospective longitudinal study, while 49 of them were included in the final assessment. Patients underwent a comprehensive cardiac assessment, including conventional echocardiography, speckle tracking echocardiography, and three-dimensional heart modeling both before and after surgery. Echocardiographic assessments showed significant increases in right ventricular (RV) ejection fraction, RV fractional area change (RVFAC), tricuspid annular plain systolic excursion, RV fractional shortening, right atrial (RA) reservoir, conduit, and booster strains, and RV global longitudinal strain (RVGLS). Moreover, significant reductions in RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV stroke volume, RV end-diastolic diameter (RVEDD) in mid-cavity view, systolic pulmonary artery pressure was observed (all P values < 0.05). However, no significant difference was found in S velocity, as well as RVEDD in basal and apex-to-annulus view. Moreover, pre-KTx measurements of RVGLS, RVEDD (apex-to-annulus diameter), RV fractional shortening, and S velocity were predictors of RVGLS after KTx. RA conduit strain was also identified as a predictor of RA conduit strain after KTx. Additionally, age, RVEDV, RVESV, RVFAC, and RA reservoir strain before KTx were identified as independent predictors of RA reservoir strain after KTx. The findings of this study demonstrate a significant improvement in right heart function following KTx. Furthermore, strain analysis can provide valuable insights for predicting right heart function after KTx.

The prevalence and determinants of diabetes mellitus and thyroid disorder comorbidity in Tabari cohort population.

Studies have shown that the co-occurrence of diabetes mellitus (DM) and thyroid dysfunction (TD) exacerbates diabetes complications and imposes a financial burden on the healthcare system. Therefore, this study aimed to investigate the prevalence of TD-DM comorbidity and its associated risk factors. This cross-sectional study was conducted on enrollment phase data of the TABARI cohort population which consisted of 10,255 adults aged between 35 to 70 years old residing in Sari, Mazandaran, Iran from 2015 to 2017. A total of 9939 out of 10,255 individuals (96.92%) entered the study. The prevalence of TD among T2DM patients was 13.2%. The prevalence of T2DM among patients with TD was 9.2%. Furthermore, the prevalence of TD-DM comorbidity in the overall population was 2.2%. Logistic regression analysis revealed that the odds of TD-DM comorbidity was significantly higher in women (OR 2.85; 95% CI 1.58-5.11), in the age group of 60-70 years (OR 9.62; 95% CI 3.69-25.10), in smokers (OR 2.32; 95% CI 1.19-4.52), in individuals with high waist circumference (WC) (OR 2.22; 95% CI 1.32-3.75), in individuals with low high-density lipoprotein (HDL) (OR 1.60; 95% CI 1.20-2.14), in individuals with high total cholesterol (TC) (OR 1.71; 95% CI 1.21-2.41), in individuals with high triglycerides (TG) (OR 1.79; 95% CI 1.27-2.51), and significantly lower in individuals with higher physical activity (PA) (OR 0.67; 95% CI 0.49-0.93). The present study demonstrated a prevalence of 2.2% in patients with both TD and T2DM. Additionally, female gender, older age, smoking, high WC, low HDL, high TC, high TG, and low PA were predictors of TD-DM comorbidity.

Effects of oral montelukast on pulmonary function and clinical symptoms in acute asthma exacerbations: a randomized, double-blind, placebo-controlled trial.

Introduction: Montelukast is a leukotriene receptor antagonist that helps treat chronic asthma and allergic rhinitis by reducing inflammation and bronchoconstriction. However, oral montelukast's effectiveness in managing acute asthma attacks has yet to be completely identified. Methods: This randomized, double-blind, placebo-controlled trial investigated the efficacy of oral montelukast in acute exacerbations of asthma. Seventy patients between 18 and 65 years of age with a primary diagnosis of asthma attack were included in the study and were randomly assigned to receive 10 mg of montelukast orally daily or placebo. Symptoms, signs, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate (PEFR) were evaluated. Results: Our findings showed a statistically significant difference between montelukast and placebo regarding FEV1 (78.05 ± 7.84 vs. 72.05 ± 12.00, P = 0.016), PEFR (322.86 ± 28.95 vs. 290.86 ± 44.21, P = 0.003), and wheezing (P = 0.022) on the fifth day of treatment. Additionally, FEV1 and PEFR values were compared in two subgroups of patients, ICS users (ICSU) and non-ICS users (NICSU), in both the montelukast and placebo groups. In the montelukast group, while PEFR improved significantly for day 5 in both the ICSU (P = 0.007) and NICSU (P = 0.027) subgroups, FEV1 only improved in the ICSU (P = 0.009) subgroup compared to placebo. Conclusion: The present study demonstrated that oral montelukast administered in acute asthma exacerbation could lead to better values of PEFR and FEV1 on pulmonary function and improvement of wheezing in terms of symptoms.

Assessing renal function as a predictor of adverse outcomes in diabetic patients undergoing percutaneous coronary intervention.

BACKGROUND: Cardiovascular diseases remain a leading cause of global mortality, particularly among diabetic patients undergoing percutaneous coronary intervention (PCI). Chronic kidney disease (CKD) poses an additional risk in this population. Yet, its specific impact on major adverse cardiovascular events (MACEs), mortality, and triple vessel disease (TVD) post-PCI remains a topic of debate, specifically in patients with type 2 diabetes mellitus (T2DM). OBJECTIVE: This study aimed to examine the impact of renal function on MACE, mortality, and TVD among diabetic patients undergoing PCI. METHODS: Diabetic patients undergoing PCI were analysed for renal function and outcomes. Participants were stratified by glomerular filtration rate (GFR). Logistic regression and receiver operating characteristic (ROC) analysis assessed associations and predictive capabilities. RESULTS: A total of 505 patients enrolled in the study. A significant difference was observed regarding age, creatinine levels, and number of culprit vessels between diabetics with and without CKD. Severe CKD was associated with higher odds of 1-month mortality (OR: 15.694, p value <.001), 1-month MACE (OR: 7.734, p value <.001), and TVD (OR: 3.740, p value <.001). Patients with severe CKD also had significantly higher odds of 6-months mortality (OR: 12.192, p value <.001) and 6-months MACE (OR: 3.848, p value: .001). Moreover, GFR showed significant predictive accuracy for mortality at one- and six-months follow-up (AUC: 0.77 and 0.71, respectively). CONCLUSIONS: Renal dysfunction, particularly severe CKD, significantly elevates risks of MACE, mortality, and TVD. Strategies to optimise renal function and tailor cardiovascular management could mitigate adverse outcomes in this high-risk population.

Left atrial and ventricular deformation: alterations and predictive value of echocardiography parameters in end-stage renal disease patients after kidney transplantation.

Aims: End-stage renal disease (ESRD) patients are prone to alterations in cardiac haemodynamics specifically on the left ventricle (LV) and left atrial (LA) functions usually due to factors like uraemia, fluid overload, and inflammation. While studies on LV function in ESRD exist, research on LA function is limited. Successful kidney transplant (KTx) is believed to reverse pathological cardiac remodelling, and monitoring changes in cardiac strain before and after transplantation may guide pre- and post-transplant care. This study has two main objectives: to investigate alterations in LA and LV strain and other echocardiographic parameters after KTx and to identify independent factors predicting impaired strain parameters post-KTx. Methods and results: We conducted a prospective cohort study of 49 ESRD patients who underwent KTx. Echocardiography was performed at baseline and at 3 months after KTx. LV end-diastolic volume, LV end-systolic volume, LV end-diastolic diameter, LV ejection fraction (LVEF), E/e', maximum LA volume index (LAVi), LV global longitudinal strain (LVGLS), and all LA strain values, including booster (LASb), conduit (LAScd), and reservoir (LASr), improved significantly after KTx (P < 0.05). Regarding independent predictors of impaired LA and LV strains, pre-KTx values of LVEF, LAVi, and NT-proBNP were associated with LVGLS impairment after KTx; pre-KTx values of LAVi and LVEF were associated with LASr impairment after KTx. Conclusion: The present study provided valuable evidence on the effects of KTx on uraemic cardiomyopathy demonstrated by LA strain and LV strain improvements and indicated pre-KTx LVEF and LAVi as significant independent predictors of LVGLS and LASr impairment after KTx.

Correlation between coronary artery calcification and COVID-19.

Background: Coronary heart disease (CHD) is an underlying cardiac condition contributing to increased COVID-19 mortality and morbidity which can be assessed by several diagnosis methods including coronary artery calcification (CAC). The goal of this study was to find out if there were potential links between CAC, clinical findings, severity of COVID-19, and in-hospital outcomes. Methods: This retrospective study evaluated 551 suspected patients admitted to teaching hospitals of the Babol University of Medical Sciences, Babol, Iran, from March to October 2021. Data included previous diseases, comorbidities, clinical examinations, routine laboratory tests, demographic characteristics, duration of hospitalization, and number of days under ventilation were recorded in a checklist. Results: Findings of current study provide evidence of a significant relationship between coronary artery calcification (CAC) and in-hospital mortality. Additionally, we observed significant correlations between CAC and several clinical parameters including age, duration of hospitalization, pulse rate, maximum blood pressure, erythrocyte sedimentation rate (ESR), blood urea nitrogen (BUN), neutrophil count, white blood cell (WBC) count, and oxygen saturation. However, we did not observe a significant association between CAC and the severity index of COVID-19. In addition, logistic regression tests did not find a significant value of CAC to predict in-hospital mortality. Conclusion: Our findings showed a significant relationship between CAC and in-hospital mortality.

Diagnostic Performance of Ultrasonography for Identification of Small Bowel Obstruction; a Systematic Review and Meta-analysis.

Introduction: Small bowel obstruction (SBO) is known as a common cause of acute abdominal complaints in the emergency department (ED). The modality of choice for the diagnosis of SBO has not yet been established. This systematic review and meta-analysis aimed to investigate the accuracy of ultrasonography for the diagnosis of SBO. Methods: Systematic search was performed on five electronic databases including Medline, Scopus, Web of Sciences, Embase, and Cochrane Library, and the retrieval period was from the inception of each database to November 2023. The quality of the included studies were investigated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). The pooled values of diagnostic characteristics for ultrasonography were estimated using meta-Disc and Stata statistical software. Results: Twenty-one studies with a total of 1977 patients were included in the meta-analysis. The pooled estimate for sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary ROC curve of ultrasonography for diagnosing SBO were 0.93 (95% CI: 0.91-0.95), 0.8 (95% CI: 0.77-0.83), 5.69 (95% CI: 3.64-8.89), 0.1 (95% CI: 0.07-0.16), 83.51 (95% CI: 18.12-182.91) and 0.96, respectively. Conclusion: The findings of this meta-analysis showed that the utilization of ultrasonography holds promise as a diagnostic imaging for SBO with high accuracy. However, additional worldwide studies are essential to get more evidence on the value of ultrasonography for the diagnosis of SBO.

Transient lateral rectus palsy associated with acute coronary syndrome treated with percutaneous coronary intervention: a case report.

BACKGROUND: Patients who experience angina and acute myocardial infarction often receive diagnostic coronary angiography and percutaneous coronary intervention. CASE PRESENTATION: A 54-year-old Persian man with acute coronary syndrome was admitted to the hospital and underwent elective percutaneous coronary intervention. Two hours after the procedure, the patient experienced ophthalmoplegia and diplopia. The diagnosis was abducens nerve palsy resulting in transient lateral rectus palsy. The cause is presumed to have been an ischemic event affecting the unilateral abducens nerve. This could have occurred owing to the microembolism during the percutaneous coronary intervention, which resulted in left lateral rectus palsy. Within 1 month, the diplopia was relieved completely, and the physical examination was normal. CONCLUSION: The occurrence of neuro-ophthalmic complications that may arise from percutaneous coronary intervention is extremely rare. To our knowledge, this is the second reported case of unilateral rectus palsy associated with percutaneous coronary intervention.

Therapeutic Effects of Low-Level Laser on Male Infertility: A Systematic Review.

Introduction: The objective of this study was to assess the effectiveness and safety of photobiomodulation (PBM) in the treatment of male infertility. Methods: We searched Google Scholar, PubMed, and the reference sections of relevant papers published from January 1, 2000 to September 23, 2022. We retrieved all publications related to the impact of PBM on male infertility. After reviewing the titles, abstracts, and full texts, we included fifteen papers in the research. The studies involved 477 semen samples (in vitro studies) and 70 male participants (randomized clinical trials). Results: All 14 in vitro studies that evaluated effectiveness reported that PBM was successful in increasing the proportion of progressive sperms in semen samples. Various methods were used to evaluate the safety. One study with a sample size of 58 concluded that PBM was not a safe treatment, whereas the other ten studies confirmed its safety. Only one clinical trial evaluated the effect of laser acupuncture on male infertility and found improvements in sperm progressive motility without any serious adverse effects. Conclusion: All 15 studies evaluating effectiveness reported that the low-level laser was effective for increasing the proportion of progressive sperm in semen samples and that it was safe to use. However, due to the heterogeneity of population characteristics, source characteristics, duration of exposure, sample size, and instruments for measuring safety and efficacy, we cannot conclude that the positive results obtained from the reviewed studies are solely attributable to the low-level laser on the sperm samples.

The importance of intraoperative echocardiography in the early detection of mitral regurgitation as a postsurgical sequel of aortic valve replacement: a case report.

BACKGROUND: Mitral leaflet perforation (MLP) can rarely be a consequence of aortic valve replacement (AVR), resulting in mitral regurgitation (MR). Determining the cause and severity of MLP following AVR is crucial in preventing hemodynamic consequences, such as pulmonary hypertension and biventricular remodeling. However, the diagnosis of this rare complication requires detailed echocardiographic evaluations. CASE PRESENTATION: In this paper, we report a 37-year-old Persian male with progressive dyspnea on exertion diagnosed with severe MR caused by anterior MLP following AVR and discuss the importance of intraoperative transesophageal echocardiography (TEE) in the proper and on-time diagnosis of this rare complication. CONCLUSION: During AVR procedure, an evaluation with TEE could be beneficial for identifying and treating such condition. Echocardiography is beneficial in providing real-time guidance during surgery, early detection of potential complications, treatment of such complications if present, and prevention of adverse outcomes.

A case report of clubbing as the initial sign of systemic sclerosis sine scleroderma: A rare possible presentation.

Key Clinical Message: Even in the absence of characteristic cutaneous symptoms of scleroderma, systemic sclerosis should be considered in the differential diagnosis of patients initially diagnosed with idiopathic interstitial lung disease. Abstract: Systemic sclerosis (SSc) is an idiopathic connective tissue disorder characterized by multisystem involvement. Although skin thickening is a hallmark manifestation of SSc, a subset known as systemic sclerosis sine scleroderma (ssSSc) presents with internal organ involvement and positive serologic markers in the absence of significant cutaneous manifestations. We report the case of a 36-year-old Iranian woman who presented with clubbing as an initial symptom of ssSSc. Notably, clubbing as the sole initial sign of the disease has not been previously reported. Timely diagnosis of ssSSc is crucial to facilitate appropriate treatment and prevent disease progression. Physicians should adopt a comprehensive approach when evaluating patients presenting with limited clinical features, as they might be indicative of underlying ssSSc.

Trivalvular nonbacterial thrombotic endocarditis in a patient with colon adenocarcinoma: a case report.

BACKGROUND: Nonbacterial thrombotic endocarditis is a rare complication of prothrombotic states such as neoplasms that can cause valvular dysfunction and life-threatening complications. Nonbacterial thrombotic endocarditis usually affects the left-sided valves; however, only a minority of cases involving the tricuspid valve have been reported in medical literature. CASE PRESENTATION: The current report describes trivalvular involvement by nonbacterial thrombotic endocarditis in a 54-year-old Azeri female patient with metastatic colorectal carcinoma. This case underlines the necessity of evaluating nonbacterial thrombotic endocarditis as a possible consequence in cancer patients. When thromboembolic events are found in the presence of a hypercoagulable state (such as malignancy) and no growth on blood cultures, nonbacterial thrombotic endocarditis could be suspected as the cause. CONCLUSION: It is critical to achieve early diagnosis in such a setting to initiate treatment plans and prevent further complications rapidly.

Giant parathyroid adenoma presenting with multiple pathologic fractures: A case report.

Key Clinical Message: Hyperparathyroidism is a common endocrine disorder, which must be suspected in patients presenting with fatigue, history of pathologic fracture and the diagnosis can be confirmed by elevated calcium and PTH levels, and the preferred treatment option. Abstract: Primary hyperparathyroidism (PHPT), a common endocrine condition, with elevated parathormone production causes increased blood calcium levels. Parathyroid adenomas cause the majority of PHPT cases. Significant hypercalcemia can result from giant parathyroid adenomas. A calcium crisis may not always arise in these individuals, despite enormous parathyroid adenomas and high parathyroid hormone levels, and the masses may first be mistaken for a thyroid mass. In this article, we discuss the case of a 57-year-old Iranian man who suffered from PHPT due to a massive parathyroid adenoma and had a history of extreme fatigue and several traumatic fractures. As specialists, we should have a strong clinical suspicion of giant parathyroid adenoma as reason of hyperparathyroidism. In patients with multiple bone problems such as pain and multiple pathological fractures and elevated levels of calcium and PTH, the diagnosis of GPA must be considered and their preferred treatment is surgery.

Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review.

The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low-molecular-weight heparin. Heparin-induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6-week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy-related HIT. HIT is a pro-coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.

Evaluation of myocardial viability by a secondary delayed 99mTc-MIBI nuclear scanning in ST-elevation myocardial infarction patients with delay in referral and nonviable myocardium in the first scintigraphy: a preliminary cohort study.

OBJECTIVE: In the management of ST-segment elevation myocardial infarction (STEMI), if the treatment has not been initiated within the first 24 h and the patient no longer exhibits any symptoms, the decision to begin revascularization therapy is based on myocardial viability. If the tissue is nonviable, current guidelines advise against further revascularization therapy; however, collateral vessels represent an alternative source of blood supply and may help the damaged tissue to resume function; though at first, this tissue may not be considered viable. Thus, in patients whose first myocardial perfusion scintigraphy (MPS) revealed nonviable myocardium, a secondary MPS to assess viability may be beneficial and alter the course of treatment strategies. METHODS: This prospective cohort study was conducted on 30 STEMI patients referred to Mazandaran Heart Center. If no myocardial viability was found using 99mTc-MIBI MPS, the patient was referred for a secondary MPS after 3 months. RESULTS: In total, out of 30 patients, 3 became viable. There was no significant relationship between the viability of different Rentrop classes. Comparison of viability between patients with different numbers of occluded vessels showed no significant relationship. Three patients (17%) among 17 patients with Rentrop class nonzero became viable in the second MPS. Also, among four patients (13.3%) with Rentrop class three, one patient (25%) became viable and among seven patients (23.3%) with Rentrop class one, two patients (28.6%) became viable. CONCLUSION: Considering the results of this study, although nonsignificant, this subject requires further investigation to reach a definite conclusion.

Unusual presentation of transthyretin (ATTR) cardiac amyloidosis: A case report of pruritus as a possible initial symptom and challenging diagnosis.

Key Clinical Message: This case emphasizes the significance of cardiac amyloidosis as a potential diagnosis in individuals manifesting with lesion-free pruritus and normal liver tests. Abstract: Amyloidosis is a complex disorder in which misfolded proteins accumulate in various organs of the body. Cardiac amyloidosis (CA) can lead to heart failure, cardiac arrhythmia, sudden cardiac death, and deposition of proteins in coronary arteries. Diagnosing CA can be difficult, as the cardiac manifestations of amyloidosis can be similar to more prevalent etiologies. In addition, the accumulation of proteins in soft tissues, including the skin, can cause pruritus. In this paper, we present a 70-year-old man with generalized pruritus and no skin lesions, later diagnosed as CA after detecting ascites fluid. This case underscores the importance of considering amyloidosis in patients presenting with nonspecific symptoms, particularly those affecting the skin, and highlights the need for increased awareness of this disease among clinicians.

Waldenström's macroglobulinemia with necrotic extremities: A case with challenging diagnosis.

Key Clinical Message: Waldenström's macroglobulinemia may begin with constitutional symptoms that are common in primary care settings and it is crucial for physicians to be aware of the potential complications of hyperviscosity syndrome and to employ the appropriate diagnostic methods in order to achieve better outcomes. Abstract: Waldenström's macroglobulinemia (WM) refers to a type of lymphoplasmacytic lymphoma distinguished by the hyperproliferation of plasma cells, lymphocytes, and plasmacytoid lymphocytes. The disease is primarily diagnosed by increased monoclonal immunoglobulin M (IgM) levels and lymphoplasmacytic cell infiltration into the bone marrow. Individuals exhibit a high risk for hyperviscosity syndrome (HVS) as immunoglobulin levels increase. In addition to constitutional symptoms (fever, night sweats, and unintentional weight loss), clinical findings such as cytopenia, hepatosplenomegaly, and lymphadenopathy, this condition may cause hyperviscosity-related organ failures. Here we discuss a patient with WM who presented with neurological complaints and blurry vision and developed necrosis at distal portions of his body during the 6-month course of the disease.