Subarachnoid hemorrhage mimicking an acute migraine attack: A case report.

Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common cause. Subarachnoid hemorrhage is often misdiagnosed in the emergency department and mortality rates range from 8% to 67%. It may be the manifestation of the chronicity of the migraine. The difference in severity or quality compared to previous headaches, and other symptoms, particularly neck stiffness, but also seizure, syncope, focal neurological deficit, and vomiting are the key factors differentiating subarachnoid hemorrhage from the migraine. We report a case of a 37-year-old female with a previous history of migraines who presented with acute onset of excruciating headaches in the occiput associated with nausea, vomiting, and photophobia in whom a non-contrast computed tomography scan of the head showed hyper-densities involving the bilateral cerebral cortical sulcus and Sylvian fissure and the cerebral angiography showed a complex aneurysm in anterior communicating artery.

Cardiac complications (arrhythmias and heart failure) in patients with ischemic stroke: A meta-analysis.

BACKGROUND: In patients with ischemic stroke (pwIS), cardiac complications have been observed in observational studies. We conducted a systematic review and meta-analysis to investigate the arrhythmias and heart failure in pwIS. METHODS: Up until September 2023, we searched for case-control, cross-sectional, or cohort studies in 4 databases. For case-control/cross-sectional studies, odds ratios (OR) were determined using a random-effects model meta-analysis, while hazard ratios (HR) were calculated for cohort studies, and 95% confidence intervals (CIs) were pooled in the meta-analysis. RESULTS: In the meta-analysis, we incorporated 5 studies: 2 cohort studies, 2 case-control studies, and 1 cross-sectional study. In all, 81,181 controls and 25,544 pwIS were included in this investigation. The combined OR for case-control studies of arrhythmias was estimated to be 1.86 (95% CI: 0.70-4.94, P = .21), HR for cohort studies of arrhythmias to be 4.2 (95% CI: 1.49-12.01, P < .05), and for cohort studies of heart failure to be 2.9 (95% CI: 2.65-3.18, P < .05), suggesting that pwIS may be more likely to experience cardiac complications. CONCLUSION: Our results revealed that there is a comparatively higher risk of cardiac complications in pwIS; however, more research is needed to evaluate the risk of cardiac complications in pwIS.

Renal vein thrombosis in a patient secondary to high-grade rhabdoid renal cell carcinoma: a case report and review of literature.

Introduction: Renal cell carcinoma, a common kidney tumour which is often incidentally discovered on imaging, can manifest with atypical symptoms. Renal cell carcinoma with rhabdoid features is a rare occurrence and even rarer in case of adults. Renal cell carcinoma has the tendency to form thrombus that can migrate to renal vein, inferior vena cava and even right atrium. Case presentation: The authors report a case of an 81-year-old male with rhabdoid renal cell carcinoma presenting with persistent cough for 6-7 months. with tumour thrombus extending into the renal vein and hepatic inferior vena cava. The patient was found feeble for the surgery and hence was treated on anticancer drugs pembrolizumab and axitinib. Conclusion: Renal cell carcinoma has the tendency to form tumour thrombus in renal vein and inferior vena cava. Prognosis without surgical intervention in these conditions is very poor.

Cutaneous drug reaction secondary to antitubercular regimen: A case report from Nepal.

Cutaneous adverse drug reactions are known side effects of first-line antitubercular therapy, which ranges from mild pruritus to life-threatening toxic epidermal necrolysis. Severe cutaneous adverse drug reactions can lead to antitubercular therapy discontinuation and further complicates tuberculosis treatment. Here we present the case of a 49-year-old obese male who developed a generalized maculopapular rash within 24 hours of initiation of therapy followed by bullae over palms in 3 days. Antitubercular therapy was immediately discontinued, and he was managed with antihistamines, intravenous fluid, and electrolyte supplementation. He was discharged on antihistamines, a short course of systemic steroids, moxifloxacin, and bedaquiline (second-line antitubercular therapy (ATT)). Proper guidelines about rechallenge therapy will enormously aid in managing cutaneous adverse drug reactions, and efficient treatment of tuberculosis in these patients, and ceasing its progression to multisystemic complications. This article aims to discuss the presentation and management of cutaneous adverse drug reactions in the setting of Nepal.

Partial annular pancreas as an incidental finding in a patient with intermittent bowel obstruction: A case report.

Complete annular pancreas (AP) is a congenital anomaly, in which the duodenum is either completely or partially encircled by the ring of pancreatic tissue, which eventually becomes continuous with the head of the pancreas. The incidence of AP is estimated to be around 0.02%. Reports from endoscopic retrograde cholangiopancreatography show an incidence of 0.4%. Partial AP (PAP) is a rarer entity, in which a band of pancreatic tissue in continuity with the head of the pancreas, incompletely encircles the duodenum. It may be asymptomatic or may present later in life with complications. We report a case of a 72-years old male with features of intermittent bowel obstruct which was later found to be having PAP on contrast-enhanced computed tomography imaging at the level of renal hilum characterized by "crocodile-jaw appearance." The possibility of PAP should also be considered at the back of mind of the treating physician, if a patient presents with a long-term history of postprandial abdominal discomfort.

Diagnostic pitfalls in young onset parkinsonism and its unique challenges: A case report from rural Nepal.

Parkinson's disease is a neurodegenerative disease resulting from the loss of dopamine-secreting neurons present in the substantia nigra of the brain. Parkinson's disease is classified as early-onset and late-onset disease based on the time of its presentation. Since young patients with Parkinson's disease have an atypical clinical presentation and have to deal with their careers, raising families, or both at the time of diagnosis and also have a higher risk of drug-related side effects, it poses unique challenges for the patient, clinical team, and community. We present the case of a 40-year-old female with young onset Parkinson's disease from rural Nepal and the challenges faced during and after the disease in a resource-limited setting.

Bilateral thalamic infarct involving artery of Percheron: a case report.

Introduction and importance: The thalamus and the midbrain have marked variations and overlapping in their blood supply; one of those variations is the artery of Percheron. Artery of Percheron occlusion is a rare cause of infarction in the bilateral thalamus and midbrain. Case presentation: In this case, a 60-year-old female with chronic hypertension presented with unconsciousness, motor impairments, and oculomotor disorders. Clinical discussion: Due to highly variable clinical manifestations and possible negative findings during initial imaging, these conditions are often overlooked, causing delays in therapeutic intervention and leading to bad patient prognosis. Various imaging techniques can be used for diagnosis and treatment should be started early. The treatment aims to promote recanalization as soon as possible and prevent future episodes. The involvement of the midbrain is unfavourable. Conclusion: Early clinical assessment and neuroimaging are vital for timely diagnosis and early administration of therapeutic measures for better patient prognosis.

Unilateral proptosis in a patient with thyroid eye disease: A case report.

Unilateral proptosis is an abnormality in which one eye sticks out forward more than the other. Bulging of the eye is commonly seen in Graves' ophthalmopathy, but it's mostly bilateral. Thyroid eye disease presents as the most common extrathyroidal manifestation of Graves' disease, and rarely leads to unilateral proptosis. A 25-year-old female with a history of weight loss, menstrual irregularities, and palpitations presented with progressive right eye bulging, which was further confirmed by magnetic resonance imaging and biochemical investigations. Magnetic resonance imaging of the orbit revealed unilateral extraocular muscle enlargement and enhancement with sparing of the tendons. Timely therapy is crucial for reversing the ocular manifestations of thyroid eye disease.

Intestinal tuberculosis can masquerade as Crohn's disease: A teachable moment.

Intestinal tuberculosis and Crohn's disease are chronic granulomatous diseases with similar clinical presentations and can mimic one another. Their treatment modalities are completely different; however, sometimes it is challenging to differentiate them. We report a case of a 51-year-old female presenting with abdominal pain and on-and-off diarrhea for 4 years with weight loss. Clinical symptoms along with multiple aphthous ulcers in the terminal ileum and negative tuberculin test favored the diagnosis of Crohn's disease. The patient did not respond to steroids. A repeat colonoscopy with acid-fast bacilli stain showed Mycobacterium tuberculosis. This case highlights that acid-fast bacilli culture and tuberculosis polymerase chain reaction to confirm or rule out the diagnosis of intestinal tuberculosis in all patients suspected of Crohn's disease.

A case report on agenesis of dorsal pancreas with insulin-dependent diabetes mellitus: a rare entity.

Agenesis of the dorsal pancreas (ADP) is a clinically rare entity that occasionally presents with abdominal pain. It is also association with various disorders of glucose metabolism. Case presentation: A 23-year-old male presented with continuous epigastric pain for 4 h and intermittent vomiting. He has a history of experiencing recurrent abdominal pain and diarrhoea for the past 5 years. Additionally, he has been diagnosed with type 1 diabetes mellitus for 15 years. Contrast-enhanced computed tomography of the abdomen showed the absence of body and tail of the pancreas. Discussion: ADP is caused by unknown factors, but may be linked to genetic mutations or changes in signalling pathways related to retinoic acid and hedgehog. Symptoms can be absent, but may include abdominal pain, pancreatitis, and hyperglycaemia due to beta-cell dysfunction and insulin deficiency. Imaging modalities, such as contrast tomography or magnetic resonance cholangiopancreatography, or endoscopic retrograde cholangiopancreatography, are crucial in the diagnosis of ADP. Conclusion: It is important to consider ADP as a differential diagnosis in patients with glucose metabolism disorders and associated symptoms such as abdominal pain, pancreatitis, or steatorrhea. It requires the combined use of imaging modalities such as ultrasound, contrast tomography, magnetic resonance cholangiopancreatography, or endoscopic retrograde cholangiopancreatography, as ultrasound alone may not provide a complete diagnosis.

Traumatic retroclival hematoma complicated with hyponatremia and delayed traumatic intracranial hematoma in an adult: A case report.

Intracranial hematoma is a common variety of brain insults in trauma. However, posterior fossa hematoma in the retroclival location is quite unusual. There are limited numbers of case reports regarding traumatic retroclival hematoma. Some are managed with surgery in this condition. We present a traumatic retroclival hematoma in a 34-year-old gentleman who sustained brain trauma in a motor vehicle accident. His condition was further complicated by hyponatremia and delayed traumatic intracerebral hematoma in a distant location. The only symptom he had later was severe headache which could be attributed to delayed traumatic intracerebral hematoma and hyponatremia. He was managed conservatively and discharged on the 12th day from the hospital.

Hepatitis-E-induced cholestasis in a child: a case report.

Hepatitis E virus (HEV) is a major cause of epidemic water-borne hepatitis in tropical and subtropical countries in areas with poor sanitary conditions. The infection by HEV in children is frequent but typically asymptomatic or manifested only as a very mild disease without jaundice, and usually, it often goes undiagnosed. In this case report, the authors describe a case of hepatitis-E-induced cholestasis in a child. Case presentation: An 8-year-old male child presented to a Pediatrics emergency with fever and features of acute cholestasis. On abdominal examination, there was non-tender hepatomegaly. The rest of the systemic examinations were normal. Ultrasonography findings were suggestive of acute hepatitis. The liver biopsy report showed hepatic cholestasis and hepatitis. The serological test for hepatitis E IgM was positive. The child was managed symptomatically. Conclusion: Although cholestasis is uncommon in children with HEV infection, it should be considered for non-improving clinical status in children with hepatitis. Also, patients with jaundice and Hepatitis E should be followed up by treating physicians until resolution occurs. To the authors' knowledge, this is the first case report from Nepal describing cholestasis in a child due to HEV infection.

Salmonella meningitis, an unusual complication of salmonella species: a case report from Nepal.

Salmonella meningitis, caused by a Gram-negative bacillus of the Enterobacteriaceae family, is an uncommon but serious complication of Salmonella infection that can result in high mortality rates, significant neurological damage, and a high relapse rate, and has become a leading cause of Gram-negative bacterial meningitis in the developing world. Case presentation: A 16-year-old boy presented with high-grade fever and altered sensorium for 2 days associated with vomiting, headache, and photophobia. Case discussion: After invading the abdominal barrier, Salmonella can enter bloodstream and rarely present with meningitis. Cerebrospinal fluid analysis and culture supported with other investigations can diagnose bacterial meningitis and its causative agent. Adequate treatment is essential to completely cure and prevent relapse. Conclusion: Given its invasive nature and potential serious consequences, such as relapse and antibiotic resistance, prompt, and appropriate treatment of Salmonella meningitis is essential.

Meckel's diverticulum causing acute intestinal obstruction: A case series.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Most cases are asymptomatic and when symptomatic, preoperative diagnosis of MD is poor. Intestinal obstruction, Malena or hematochezia, and inflammation are major symptoms. We report three cases of 18-month, 2-year, and 9-year old male patients presenting with intestinal obstruction.

Acute psychosis unveiling diagnosis of hypothyroidism: A case report.

Introduction: Hypothyroidism is a common condition in the general population that presents a wide array of medical, neurological and psychiatric symptoms. However, hypothyroidism rarely leads to acute psychosis, termed myxedema psychosis (MP) and is often missed by many physicians. Case presentation: Here we report a case of a 36-years-old female who presented with a one-week history of abnormal behavior, delusions and hallucinations. Investigations revealed a high thyroid-stimulating-hormone (TSH)of 78.60 mlU/mL and low free thyroxine (FT4) of 0.64 pmol/L. Diagnosed with hypothyroidism, she was treated with oral thyroid hormone replacement (l-thyroxine 75 µg/day) with antipsychotics and her symptoms settled within days. She was discharged off antipsychotics and advised to adhere to thyroxine replacement and to follow up for Thyroid function test (TFT). Discussion: Myxedema psychosis is an uncommon manifestation of the common endocrine disease hypothyroidism. The atypical nature of presentations occasionally complicates diagnostics. When approaching a 'first-episode psychosis,' it is essential to perform a complete organic screen consistently. Conclusion: Acute myxedema madness should be considered in the differential diagnosis of acute psychosis in patients with hypothyroidism.

Duodenal gastrointestinal stromal tumor: A case report.

Introduction: Gastrointestinal tumor (GIT) is an uncommon gastrointestinal tumor most commonly arising in the stomach. Duodenum is an uncommon site accounting for only about 3-5% of cases. Case presentation: In this case report, we present a case of high-risk duodenal GIST and review its management strategies. Discussion: An abdominal mass and gastrointestinal (GI) bleeding are its usual presentation, however it may be lost among the long list of differentials of an abdominal mass and GI bleeding, if a high index of suspicion is not maintained. Surgery, with or without tyrosine kinase inhibitors like imatinib mesylate, has been the cornerstone in management of GIST. Conclusion: This case underlined the importance of duodenal GIST as a cause of GI bleed and abdominal mass as well as shone light upon historical developments, current updates and managements of GISTs.

Diclofenac induced anaphylaxis: A case report from Nepal.

Introduction: Diclofenac is considered a generally safe medication, and cause few side effects like dyspepsia, diarrhea/constipation, nausea, and vomiting, stomach bleeding, rash, urticaria, photosensitivity reactions, acute renal failure, analgesic nephropathy, bone marrow and liver diseases. Rarely, it causes anaphylactic reaction. Case presentation: We report a case of 40 years male who developed anaphylactic reaction after intravenous infusion with diclofenac. Discussion: Both the pulmonary embolism and anaphylaxis guidelines emphasize the importance of a thorough evaluation when making a diagnosis. Mast cells secrete tryptase, a neutral protease that is specifically concentrated in the secretory granules of human mast cells (but not basophils), along with histamine, as a marker of mast cell activation. Conclusion: Although intravenous diclofenac sodium is a safe and often used medicine, it can cause severe and perhaps fatal anaphylactic responses.

A case report on role of hypertonic saline solution in management of parotid fistula.

Introduction: Parotid fistula is an uncommon consequence of surgical or non-surgical trauma to the parotid gland or the area surrounding it. To treat it, a variety of pharmacological medicines and surgical techniques are used, each with their own set of benefits, drawbacks, and patient preferences. Case Presentation: We present the successful care of a young female with post-traumatic parotid fistula using hypertonic saline injections into the parotid substance, which is a simple yet efficient approach of treating this abnormality. Discussion: Thermodynamic and physicochemical calculations suggest that hypertonic saline solutions work to close parotid fistula by causing conformational denaturation of the cell membrane proteins in situ and saline can be diluted to a point where there will be no cellular toxicity. It is advised that temperature of the saline should be raised above body temperature to enhance the fibrosing property of physiologic saline. Conclusion: The use of hypertonic hot saline injections combined with compression dressing is a cost-effective, patient-friendly, and almost complication-free approach of treating parotid fistulas with promising results.

A case report on atypical spindle cell lipomatous tumor: A rare entity.

Introduction: Atypical spindle cell lipomatous tumor (ASPLT), a separate entity for the group of benign/low grade adipocytic neoplasm that is characterized by adipocyte adequacy and the presence of lipoblast-like cells and spindle cells at varying degrees. Case presentation: Here, we report a rare case of 60 years old male with atypical spindle cell lipomatous tumor in the anterior abdominal wall. Discussion: Histopathology is the gold standard for establishing the diagnosis and grade of soft tissue tumor and consistent radiology-pathology correlation is essential to avoid any diagnostic pitfalls [1]. Ultrasound is preferred as an initial investigation for superficially located lesions. Conclusion: ASPLT show a wide variety of microscopic features, and differential diagnosis is important and difficult. Recognition of morphologic clues and immunohistochemistry/molecular tests to confirm the diagnosis.

A case report of anaphylaxis induced by topical use of extract of Cynoglossum wallichii var. golchidiatum.

Introduction: Cyanoglossum wallichii var. golchidiatum is a perennial plant that contains pyrrolizidine alkaloids of many types and used as traditional medicine for wounds, burns, and infections. Case presentation: We report the first diagnosed case of 50 years old male who presented with anaphylaxis after the use of local herbal remedies ( Cyanoglossum wallichii var. golchidiatum ) in his cut injury. Discussion: Without seeing a doctor, individuals in our region of the world administer herbal plants for conditions like burn healing, infections, and wound healing. As a result, there is a delay in the course of treatment, and the herbal therapies have a number of negative side effects. Numerous academic studies have demonstrated the numerous advantages of herbal plants, but despite these advantages, there is a lack of sufficient scientific evidence and knowledge regarding their use and potential drawbacks. Conclusion: Non-judicial use of Cyanoglossum wallichii var. golchidiatum may lead to potentially life-threatening condition like anaphylaxis.