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.

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.

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.

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.

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.

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.

Extradural abscess following synthetic fabric duraplasty.

BACKGROUND: Duraplasty refers to the neurosurgical process of reconstructing dural defect. Variety of materials is used for such reconstruction, including natural, semisynthetic, and synthetic materials. Although synthetic materials are readily available and easy to apply, these are associated with foreign body reaction which may lead to serious consequences in some cases. We describe one such rare instance of extradural abscess after polypropylene synthetic fabric duraplasty. CASE DESCRIPTION: Our patient is a 33-year-old lady who suffered road traffic accident leading to massive brain laceration, contusion of bilateral frontal lobes, and anterior skull base fractures. Emergency craniotomy was carried out and dural defect repaired with polypropylene (G-Patch; G. Surgiwear® Ltd.) synthetic fabric as the duraplasty material. Three months later, the patient presented with discharging wound at the incision site. Neuroimaging showed ring enhancing lesion in frontobasal extradural space with cutaneous extension. The lesion failed to heal despite intravenous antibiotics and surgery was planned. Intraoperatively, abscess was found between G-Patch and dura. Histopathology showed granulomatous foreign body reaction. The lesion healed after synthetic dura removal and abscess drainage. CONCLUSION: Although various materials are used for duraplasty, there is no clear consensus on what material should be used for dural repair. Synthetic materials are bio-inert, offer good handling and malleability. Polypropylene has been used safely for both single- and double-layered duraplasty. However, foreign body reaction may occur and very rarely present as extradural abscess. Randomized trials should be done to establish the safety and efficacy profile of commonly used duraplasty materials.

Endoscopic intranasal control of hemorrhage from unexpected ethmoidal hemangioma during conchoplasty: A case report.

INTRODUCTION AND IMPORTANCE: Hemangiomas of paranasal sinuses are rare. Unexpected hemangiomas of this region can bleed profusely leading to operative morbidity and mortality. Hemangiomas of paranasal sinuses may be associated with concha bullosa. CASE PRESENTATION: We report a case of 41-year-old female who presented with difficulty in nose breathing and headache since two years. She was diagnosed with concha bullosa with deviated nasal septum and was planned for endoscopic septoplasty and conchoplasty. During the procedure, profuse, unexpected hemorrhage resulted from the undiagnosed hemangioma which was managed by endoscopic intranasal cauterization of anterior ethmoidal artery. DISCUSSION: Hemangiomas of paranasal sinuses such as ethmoidal sinus are rare. These are slow growing tumors and may be radiologically silent. Due to high vascularity of these lesions, it may be very difficult to manage associated bleeding. A sound knowledge of vascular anatomy of this area is important in managing intraoperative complications. Until now, only a few cases of ethmoidal hemangiomas have been reported in association with concha bullosa. Screening for these lesions may be important in patients with concha bullosa. CONCLUSION: Sound knowledge of surgical anatomy forms the basis of managing intraoperative complications in endoscopic sinus surgery. Further research should be carried out to find out the association between concha bullosa and ethmoidal hemangioma and patients with concha bullosa should be screened with advanced imaging techniques for such vascular lesions where feasible.

Pituitary hyperplasia due to Himalayan endemic hypothyroidism.

Pituitary hyperplasia due to hypothyroidism can be treated medically. This condition should not be mistaken for adenoma and surgery should be avoided.

Pituitary hyperplasia in childhood primary hypothyroidism: a review.

INTRODUCTION: Pituitary hyperplasia following primary hypothyroidism in pediatric age group population is considered rare with reports of unnecessary neurosurgical intervention for this medically treatable condition. Given the paucity of information on this topic, it is timely to provide clinicians with a comprehensive summary of available research. METHODS: A search of published studies in Pubmed, PsychInfo and Cochrane Database with the terms "pituitary hyperplasia" or "pituitary hypertrophy" and "hypothyroidism" was performed and the results filtered for English language, pediatric (0-18 years) population and CT or MRI confirmed findings. 55 studies met the inclusion criteria. Data for a total of 110 patients with pituitary hyperplasia following primary hypothyroidism were extracted. The study population included 29 males and 81 females (M: F= 0.35:1). Patient age varied from 3 weeks to 18 years with a mean age of 10.22 years. RESULTS: The most common clinical presentations included growth retardation, constipation and features of myxedema which were present in 78, 36 and 18 percent of children included in our review. Neuroimaging showed the mean (SD) pituitary height being 13.48 mm (4.72 mm). All of the patients achieved resolution of their pituitary mass and clinical as well as biochemical abnormalities 1 to 26 months after initiation of thyroid hormone replacement therapy, with an average time interval of 7.22 months. Our review has tried to delve in the pathophysiology as well as clinical, biochemical and radiological aspects of pediatric pituitary hyperplasia secondary to primary hypothyroidism and provide recommendations for treatment and follow-up. This may help anyone concerned gain a substantial knowledge on this topic.

Providencia rettgeri infection complicating cranial surgery: illustrative cases.

BACKGROUND: Providencia rettgeri is a rare cause of nosocomial infection in humans. These organisms are capable of biofilm production and are intrinsically resistant to commonly used antibiotics, leading to high rates of morbidity and mortality. P. rettgeri may very rarely cause postneurosurgical infection. OBSERVATIONS: In this report, the authors describe two patients in whom P. rettgeri infection complicated the postoperative course. Both the patients underwent craniotomy at approximately the same time under similar environments. The organism isolated was resistant to most of the commonly used antibiotics, and therapy tailored to the results of susceptibility testing led to resolution of infection in both cases. LESSONS: P. rettgeri is a rare cause of postneurosurgical nosocomial infection. Timely identification and early tailoring of antibiotic therapy based on susceptibility testing is the key to treatment. Every effort should be made to identify the source of infection and rectify it so that mortality, morbidity, and financial burden are reduced. Contact isolation and use of sterile gloves after each patient contact are effective in preventing its spread, as in most cases of nosocomial infection.

Acute on Chronic Bilateral Subdural Hematoma in a Woman with a Remote History of Previous Subdural Hematoma Managed by Trephination: A Case Report.

Bilateral chronic subdural hematoma are not that common. It may be recurrent and rarely superimposed by acute bleed leading to rapid progression and poor clinical outcomes. We report the case of a seventy six years old lady with a history of traumatic subdural hematoma evacuated by trephination twenty years back, presenting at our hospital with a history of persistent headache and acute onset of several episodes of vomiting. A non-contrast head CT revealed bilateral chronic subdural hematoma with acute on chronic bleed on one side. Trephination was done initially unilaterally, but the symptoms persisted and bilateral trephination was performed. The patient developed bilateral pneumocephalus and chest infection post-surgery. Bilateral, recurrent subdural hematoma with acute superimposition of bleed is a rare entity that presents with signs of increased intracranial pressure as opposed to unilateral SDH. A single burr hole trephination can be an effective intervention in these cases.