Effectiveness of an ultrasound basic cancer training program through on-site training and virtual case discussions in rural Tanzania: a proof-of-concept study.

Introduction: Cancer rates are rising in low- and middle-income countries. While point-of-care ultrasound is now available globally and could serve to mitigate against this rise, its use in diagnosing cancers is inconsistent in lower-resourced healthcare contexts. This proof-of-concept study investigates the feasibility of an ultrasound training concept in a low-resource setting. It evaluates whether this educational concept led to improved knowledge and application of ultrasound diagnostics, cancer screening and staging and patient care. Material and methods: The curriculum was developed through expert exchange and is based on the World Health Organisation's Manual of Diagnostic Ultrasound. It consisted of two didactic components: an on-site training phase across 5 days for a total of 24 hours, and a digital follow-up phase involving the meeting of a bi-weekly tumor board online. The learning objectives of the on-site training were normal imaging and recognition of common pathologies of the abdominal organs, vessels, lymph nodes, female breasts and lungs. The virtual tumour boards met to discuss cases and ultrasound findings, thus aiding continuing professional development after the training sessions had concluded. The face-to-face course component was accompanied by tests given before and after training as well as an evaluation sheet (Likert-scale with 1 = 'completely/very good' and 7 'not at all/very poor'). Results: Of 20 participants from a rural hospital in Tanzania, a total of 16 were included in the analysis (clinical officers n = 6; medical officers n = 10). A significant increase in knowledge (p < 0.01) was measured both in the subjective self-assessment and in the theoretical competence tests. In multivariate linear regression, the status 'medical officers yes' (ß = 5.4; p = 0.04) had a significant influence on theory test results at T2. During the 24 virtual tumour board meetings, 28 cases were discussed and a continuous improvement in image acquisition quality was observed. Conclusion: The ultrasound education concept comes with a sustainable increase in clinical competence and improved oncological ultrasound screening locally. There is potential for the transfer of the concept to other locations, which can be explored in the future.

A rare case of pulmonary embolism in a Mt. Kilimanjaro recreational hiker: A case report with review of literature.

Pulmonary embolism is one of the rarest complications of high-altitude sickness that can coexist with high altitude pulmonary edema. The risk of developing this phenomenon increases significantly with prolonged stay in high altitudes especially above 5000 m. Given the fatality of the condition, early screening and management is crucial; however, there is no gold standard approach in diagnosis. A 44-year-old male, a Tanzanian tourist first time hiking Mt. Kilimanjaro developed difficulty in breathing on the 4th day of ascending on a route that takes 6 days to summit whereby he was saturating at 38% on room air at the height of 4775 m. He was admitted with the clinical diagnosis of high altitude pulmonary edema. However, in the course of treatment for 72 h with no improvement, further investigations including computed tomography scan were suggestive of pulmonary embolism whereby he was treated with full recovery. Pulmonary embolism case reports are increasingly rising with the difficult to notice among high altitude pulmonary edema patients given their presentation similarities. A high index of suspicion based on clinical examination and investigations should prompt a clinician to include or exclude it.

A case of corrosive tracheoesophageal fistula: A complication of button battery ingestion.

Key Clinical Message: Button battery ingestion has been a common condition encountered by otorhinolaryngologists. Impaction in the esophagus can lead to serious and fatal complications such as tracheoesophageal fistula. Management involves a multidisciplinary team and varies from supportive therapy to surgical intervention. Abstract: Ingestion of button batteries has been seen with increasing frequency over the past decade. In several small numbers of reported cases, their impaction in the esophagus has led to severe, sometimes fatal, complications. The management of these cases has varied from expectant, supportive therapy to early surgical intervention. We report a case of button battery ingestion that was diagnosed late and resulted in a complication of tracheoesophageal fistula with migration to the thorax which was managed by open surgery.

Colon Lipoma Causing Colo-Colic Intussusception in an Adult: A Case Report from Tanzania.

Intussusception is rarely seen in adulthood but is commonly seen in the pediatric age group. Causes of intussusception in adults are commonly due to tumors and inflammatory diseases. Intussusception in adults accounts for less than 5% of intestinal obstruction. Colonic lipomas are usually asymptomatic and are mostly managed surgically with promising outcomes as seen in our case.

Successful treatment of early bioprosthetic mitral valve fusion in a patient on VA ECMO with balloon valvuloplasty via direct cannulation of pulmonary vein.

We present a case of a 57-year-old male who underwent bioprosthetic mitral valve replacement (MVR) and developed postoperative cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and Impella 5.5 (Abiomed) hemodynamic support.

A case report of atypical presentation of a solitary brain metastasis from a primary lung cancer in a low resource setting.

INTRODUCTION AND IMPORTANCE: Brain metastasis is the most common associated consequence of primary lung cancers, and it has a major detrimental influence on patients' survival and quality of life. Modern imaging modalities such as brain MRIs and PET scans are preferred for assessing these lesions. Complete surgical resections have been shown to enhance survival. CASE PRESENTATION: We present the case of a 59-year-old male patient who had a history of progressive left-sided weakness and right-sided headaches with no respiratory symptoms. A solitary brain lesion was noticed, prompting a surgical resection. Histology findings confirmed brain metastases, and a thoracic CT scan revealed a primary lung tumour. The patient was scheduled for chemotherapy. DISCUSSION: Primary lung tumors often disseminate to the brain. The brain metastatic lesions in advanced lung cancer are often numerous and smaller in size, based on MRI imaging. The patient's symptomatology obscured the existence of an underlying lung tumour, delaying focused therapy. The early symptomatology and scans of our patient indicated the probability of a solitary brain tumour, necessitating a surgical excision. CONCLUSION: Prompt management of brain metastatic lesions is crucial. Yet, some patients emerge with atypical characteristics of the lesions that hint to a primary brain lesion and conceal the presence of a lung tumour. Enhancing these patients' prognoses necessitates a targeted therapy that includes a comprehensive examination, radiological imaging, and recognition of the distinctive brain patterns in patients with lung cancer. The merits of complete or incomplete resections for multiple brain metastatic lesions might be a fascinating subject of discussion.

Isolated cerebellar tuberculoma mimicking a malignant posterior cranial fossa tumor in a healthy child: A rare case report from Tanzania.

INTRODUCTION: Tuberculosis (TB) is one of the leading causes of mortality and morbidity in the world, especially in developing countries that account for 98 % deaths among TB cases. Although TB is primarily a disease of the lungs, extrapulmonary manifestations have been reported. Although CNS tuberculoma mostly affects immunocompromised people, it also affects healthy people at extremes of age. Imaging of intracranial tuberculoma may look like neurocysticercosis, and other ring-enhancing lesions hence imposing a diagnosis dilemma. CASE PRESENTATION: A 13-year-old female presented with headache, convulsions, blurry vision, and gait disturbance for six months. Brain imaging showed a left cerebellar lesion with obstructive hydrocephalus. She underwent ventriculoperitoneal shunting on admission, then sub-occipital craniotomy with tumor resection one week later. Histology confirmed a diagnosis of tuberculoma. She was given anti-tuberculosis medications and she was discharged home healthy without any of the symptoms she had on admission. DISCUSSION: Although only about 1 % of active tuberculosis cases presents as CNS TB, 5-10 % of intracranial space-occupying lesions in developing countries are tuberculomas. Provisional diagnosis of tuberculoma can be made through clinical history, examination, and neuroimaging. However, it is challenging because neurocysticercosis also appears as a ring-enhancing lesion in the brain and has almost similar prevalence in low-income settings. Being immunocompetent with no history of tuberculosis or constitutional symptoms, a diagnosis of tuberculoma was only confirmed by histology. CONCLUSION: A high index of suspicion for CNS tuberculomas in TB endemic areas should be kept in patients presenting with features of intracranial space-occupying lesions regardless of the absence of risk factors.

Etiologic Investigation of Patients Diagnosed with Bacteriologically Unconfirmed Tuberculosis in Tanzania.

Globally, half of patients with pulmonary tuberculosis (PTB) are diagnosed clinically without bacteriologic confirmation. In clinically diagnosed PTB patients, we assessed both the proportion in whom PTB could be bacteriologically confirmed by reference standard diagnostic tests and the prevalence of diseases that mimic PTB. We recruited adult patients beginning treatment of bacteriologically unconfirmed PTB in Moshi, Tanzania, in 2019. We performed mycobacterial smear, Xpert MTB/RIF Ultra, and mycobacterial culture, fungal culture, and bacterial culture on two induced sputum samples: fungal serology and computed tomography chest scans. We followed participants for 2 months after enrollment. We enrolled 36 (63%) of 57 patients with bacteriologically unconfirmed PTB. The median (interquartile range) age was 55 (44-67) years. Six (17%) were HIV infected. We bacteriologically confirmed PTB in 2 (6%). We identified pneumonia in 11 of 23 (48%), bronchiectasis in 8 of 23 (35%), interstitial lung disease in 5 of 23 (22%), pleural collections in 5 of 23 (22%), lung malignancy in 1 of 23 (4%), and chronic pulmonary aspergillosis in 1 of 35 (3%). After 2 months, 4 (11%) were dead, 21 (58%) had persistent symptoms, 6 (17%) had recovered, and 5 (14%) were uncontactable. PTB could be bacteriologically confirmed in few patients with clinically diagnosed PTB and clinical outcomes were poor, suggesting that many did not have the disease. We identified a high prevalence of diseases other than tuberculosis that might be responsible for symptoms.

Button battery ingestion: A serious pitfall of diagnosis of ingested foreign bodies in children from resource-limited settings - A case report.

INTRODUCTION AND IMPORTANCE: Button battery ingestion and impaction in the oesophagus can result in severe morbidity and even fatality if not diagnosed and managed urgently. Delayed or missed diagnosis due to the sometimes-vague symptomatology and limited investigations in resource-limited settings further increases the complications rate. CASE PRESENTATION: Case 1: A 2 years old male child presented with a nine months history of recurrent respiratory tract infections not responding well to medical treatment. A radio-opaque round foreign body (FB) was incidentally seen in the chest. Rigid esophagoscopy and removal were done, but the child had developed a trachea oesophagal fistula. The fistula was managed conservatively by retaining a nasogastric tube until spontaneous fistula closure happened. Case 2: A 2 years old female child presented with a one-year history of poor feeding, vomiting, difficulty in breathing and persistent wet cough, and fever. He underwent tonsillectomy with no improvement. A radio-opaque round FB was incidentally seen in the oesophagus near the carina by a chest x-ray. A thoracotomy had to be done after two failed removal attempts by rigid esophagoscopy. CLINICAL DISCUSSION: The similarity in the symptomatology of common aerodigestive conditions with FB ingestion compounded with low chances of witnessing the ingestion creates a possible pitfall for clinicians when resulting in a missed or a delayed diagnosis, further raising the complications rate of FB impaction in the oesophagus, such as tracheoesophageal fistula formation or the need for a massive surgery such as thoracotomy to remove the button battery. CONCLUSION: Complications of foreign body ingestion in the paediatric population can have serious complications. High morbidity and mortality may be attributed to delayed diagnosis and intervention.

Viscus perforation as an initial presentation of plexiform fibromyxoma: A case report and review of the literature.

INTRODUCTION: Plexiform fibromyxoma (PF) is a rare benign mesenchymal neoplasm of stomach recognized by the WHO. The tumor often arises in the antrum and pyloric region of the stomach. Morphologically, PF tumors display bland spindle cells in myxoid or fibromyxoid stroma and can be misdiagnosed as gastrointestinal stromal tumor (GIST). PRESENTATION OF CASE: A-21-year old female presented to emergency department with peritonitis due gastric tumor leading to gastric perforation and pus collection in the abdomen. Partial gastrectomy was performed. Histopathology, immunohistochemical (IHC) and fluorescent in-situ hybridization assessment of the specimen confirmed the diagnosis of PF. One year postoperative, the patient remains symptoms free. CLINICAL DISCUSSION: A great majority of gastric mesenchymal tumors are GIST. Histopathologically, PF tumors display a multinodular and plexiform architecture with arborizing vasculature. Cytologically these tumors show bland spindle cells in myxoid or fibromyxoid stroma with a rare or no mitotic figures. Thus, PF may easily be under recognized or misinterpreted without the pathologists' knowledge of this entity. Misinterpreting PF as GIST can lead to inappropriate treatment including unnecessary surgery and/or chemotherapy, which is an expensive. Recommended treatment is surgical excision. Metastases and recurrence following complete excision have not been described. This case highlights unexpected presentation in a young female where other competing diagnoses were more plausible before considering PF diagnosis which could not have been established without advanced diagnostic techniques. CONCLUSION: PF is a rare mesenchymal tumor with nonspecific clinical characteristics. It is principally located in the gastric antrum and prepyloric regions, however other parts of the body may be affected. PF tumors should be separated from GIST, nerve sheath tumors, and other fibromyxoid neoplasms. The worth in writing lies in epidemiological custodianship for such a unique presentation of a rare gastric neoplasm.

Idiopathic fibrosing mediastinitis with esophageal varices: A case report.

Fibrosing mediastinitis (FM) is a rare cause of lung fibrosis with multiple etiologies ranging from infectious to autoimmune to idiopathic. Common causes of FM include histoplasmosis and a relatively new cause of IgG4-related disease. We present a 55-year-old male with symptoms of esophageal varices, intractable hiccups, and progressive difficulty in breathing. A chest X-ray showed right lung fibrosis with pleural effusion and loss of lung volume, which was originally thought to be the sequelae of SARS-CoV-2 or metastasis, but computed tomography of the chest revealed FM. His variceal bleeding was controlled, and he was discharged home. However, treatment for FM was not pursued because the cause was not identified. Using corticosteroids may not cease the progression of the disease, and surgical options are available when symptoms persist. Idiopathic FM requires laboratory and radiological findings to exclude relevant differential diagnoses.

Huge primary retroperitoneal mature cystic teratoma mimicking adrenal incidentaloma: A case report and literature review.

INTRODUCTION: Teratomas originating from extra-gonadal account for 15 % of all teratomas, while retroperitoneal site being the least site for teratoma 1-11 %, extremely rare adrenal teratoma is less than 4 % of the retroperitoneal teratomas. Usually, patients are asymptomatic and the tumours are detected incidentally during imaging. PRESENTATION OF CASE: A case of a 29 years old female, presented with intractable pain for four weeks. Computed tomography scan study of the abdomen showed an avascular septate cystic lesion measuring 11.6 × 11.4 14.5 cm (cranial-caudal x transverse x anterior-posterior) with central fat density and large punctate calcification in the right suprarenal region displacing the inferior vena-cava laterally, abutting the gall bladder, pancreas and duodenum. Impressions of right adrenal teratoma and less likely adrenal myelipoma were suggested. She remarkably improved one day post operation. During clinic visit a month later, she was completely recovered and resumed her daily activities. DISCUSSION: In adults primary retroperitoneal mature cystic teratoma are uncommon, mostly are secondary tumours and very rare will occur in adrenal gland. Adrenal incidentaloma have been seldom reported mimicking primary mature cystic teratoma. Biochemical and Imaging studies are of great importance in diagnosing and showing relationship of the tumour and other organs. This work has been reported in line with the SCARE criteria (Agha et al., 2018 [1]). CONCLUSION: Primary retroperitoneal tumours are rare and surgery is the main stay of treatment whether it be open or laparoscopic, the latter being best for small lesion for it offers early recovery and complete excision gives excellent prognosis of 100 %.

An unusual presentation of penetrating bladder injury with vesicocutaneous fistula: a case report.

BACKGROUND: Blunt trauma to the urinary bladder is common with penetrating injury being a rare occasion. Most common entry pint for penetrating injuries includes buttock, abdomen and perineum with thigh being rare. There are a number of complications that may develop as a result of penetrating injury with vesicocutanous fistula being a rare occurrence that usually presents with typical sign and symptoms. CASE PRESENTATION: We present a rare case of penetrating bladder injury through medial upper thigh as an entry point that had complicated into vesicocutaneous fistula with atypical presentation of long-standing pus discharge that had been managed by incision and drainage several times with no success. MRI demonstrated a presence of fistula tract and a foreign body (piece of wood) in-situ confirmed the diagnosis. CONCLUSION: Fistulas are a rare complication of bladder injuries and can cause negative impact on the quality of life of patients. Delayed urinary tract fistulations and secondary thigh abscesses are uncommon therefore a high index of suspicion is needed for early diagnosis. This case emphasizes the importance of radiological tests in aiding the diagnosis and ultimately proper management.

Papillary thyroid carcinoma arising from ectopic thyroid tissue in a neck branchial cyst.

A 35-year-old man presented with a right lateral neck mass for 6 years. Thyroid function test was within normal limits. Computed tomography scan of the neck was suggestive of branchial cyst, tuberculous lymphadenopathy and normal thyroid gland. Fine needle aspiration cytology of cervical lymph node was suggestive of metastatic carcinoma. Branchial cystectomy spearing the thyroid gland was undertaken. Histopathology analysis of the resected specimen confirmed it to be papillary thyroid carcinoma originating from ectopic thyroid tissue in a branchial cyst. The patient was scheduled for total thyroidectomy and neck dissection. Unfortunately, he was lost to follow-up. A brief review of the literature regarding this unusual presentation of thyroid cancer has been provided.

Thymoma: a fatal case report of recurring pneumonia from Tanzania.

Thymomas present either concurrently with myasthenia gravis, with local pressure symptoms, or asymptomatically as a mediastinal mass. Due to its variable presentation, the incidence is low, as not all cases would be identified. Thymomas can present with a rare entity of combined T-cell and B-cell immunodeficiency in adults. Thymectomy is the most important prognostic factor, including preventing autoimmune manifestations of thymoma, but immunodeficiency may persist after thymectomy. Case presentation: The authors report a case of thymoma with evidence of immunodeficiency, manifesting as recurrent pneumonia and respiratory distress in an HIV-seronegative 62-year-old man with a suspected diagnosis 3 years before admission. During his bouts of pneumonia, blood cultures revealed methicillin-resistant Staphylococcus aureus, which was initially treated with vancomycin and then with clindamycin. Although hypogammaglobulinemia was not established in our low-resource setting, there was a reduced CD4-cell count with an abnormal CD4/CD8 ratio. The patient responded well to the first course of antibiotics. However, the second attempt was unsuccessful, which led to his demise. Conclusion: Clinicians should be aware that thymoma can cause immunodeficiency. Clinical suspicion should be raised in patients who present with recurrent infections, particularly in thymoma cases with adult-onset immunodeficiency.

A giant metanephric adenoma in a young male.

Metanephric adenoma is an uncommon renal tumor with almost exclusively benign behavior, which can clinically and radiologically imitate malignancy. The histological examination is therefore crucial in diagnosis. Herein, we report a case of an 18-year-old male with a huge left renal mass. Histopathology and immunohistochemistry of nephrectomy resection specimen confirmed it to be metanephric adenoma. We present our experience with this rare tumor entity and literature review with focusing on differential diagnosis.

Sclerosing epithelioid fibrosarcoma of the foot: A case report.

Sclerosing epithelioid fibrosarcoma (SEF) is a rare and distinctive variant of fibrosarcoma. To date, about 100 cases only have been documented. Histopathologically, it resembles a variety of benign, pseudosarcomatous and other malignancies. Early diagnosis and treatment are vital for improving the treatment outcomes.

Long COVID? Fatal case report of ischemic stroke and pulmonary embolism post COVID-19 infection.

Coronavirus disease 19 (COVID-19) may lead to post-COVID syndrome a few weeks to months after the infection with various symptoms. Post-COVID thromboembolic syndrome may be a result of coagulopathy that occurs in both the arterial and venous circulation. Apart from direct cellular infection, post-COVID syndrome may occur due to immune system dysregulation, endothelial injury, and hypercoagulability, leading to thrombosis. We present a 32-year-old man who was diagnosed with mild symptoms of COVID-19 infection 4 months before an acute ischemic stroke and an asymptomatic pulmonary embolism. A COVID-19 antigen test was negative. An analysis of prothrombotic factors was negative. He could not receive any therapeutic intervention before his demise. The extent of COVID-19 infection after the onset of symptoms is a mystery and poses a fatal concern due to the increasing number of complications. The long-term complications after COVID-19 infection are still not understood. Clinicians need to be aware of any signs and symptoms that may arise months after COVID-19 infection and its possible causal relationship.

Ocular, scrotal and abdominal trauma in a secondary blast injury.

Blast injuries are subjected to high morbidity and mortality in the general population. They cognate to single or multiple organ-related injuries that may be life-threatening. The unique injury patterns of blast injuries make treatment therapy complex. An adult male patient presented to our setting with multiple severe deep burn wounds resulting from a dynamite explosion. His computed tomography (CT) scan revealed numerous sharp shards around his body and a ruptured hemiscrotum with exposed testicles. Surgery was immediately done and with a good post-operative outcome. The severity of these injuries escalates in relation to the proximity of the explosions. A CT scan is an imperative diagnostic imaging modality. Treatment involves resuscitation, optimization, excision of non-viable tissues and damage control surgery. Delays in management may have detrimental consequences. Therefore, for physicians to manage the diverse injury manifestations that these patients may present with, they must grasp the pathophysiological patterns of blast injuries.

Chylous ascites: Our experience from a resource-limited setting.

INTRODUCTION AND IMPORTANCE: Chyle is a lipid-rich, milky-appearing fluid originating from lymph tissues. Chylous ascites is the collection of chyle in the peritoneal cavity and is a rare pathology. CASE PRESENTATION: In this case report we share our experience of successfully managing chylous ascites conservatively from a resource-limited setting. CLINICAL DISCUSSION: There are numerous causes hence management includes treating the cause. Generally responds well to conservative management however some cases require surgical intervention. CONCLUSION: Ascitic tapping is an effective diagnostic and therapeutic tool is chylous ascites.