A Rare Case of Acute Pancreatitis as an Initial Presentation of Acute Myeloid Leukemia.

Acute pancreatitis is a rare manifestation of acute myeloid leukemia which can be a presentation at the initial diagnosis or during or after the onset of the disease. Acute myeloid leukemia occurs due to the abnormal proliferation of undifferentiated hematopoietic stem cells in the bone marrow which alter the normal hematopoiesis. We report the case of a 32-year-old male admitted with a one-month history of fever and backache, followed by 15 days of blackish stool discoloration and two days of abdominal pain and reduced urine output. On clinical examination, he was hypoxic with respiratory distress with epigastric tenderness. Blood investigations and imaging were consistent with acute pancreatitis. A complete blood count with peripheral smear showed severe normocytic normochromic anemia and an increased myeloid series containing 50% myeloblasts and 30% monoblasts. Additionally, some cells displayed cytoplasmic vacuolations, with a reticulocyte count of 2%. These findings were suggestive of acute myeloid leukemia M5. Due to the poor Glasgow Coma Scale (GCS), he was intubated and placed on mechanical ventilation. Unfortunately, he did not improve despite treatment and succumbed to the illness.

Valproate-induced hyperammonemia, neuroleptic sensitivity, and cerebellar atrophy-A clinical conundrum in the management of bipolar disorder.

OBJECTIVE: Treatment of bipolar disorder (BD) involves complexities especially when patients come with significant sensitivity to various psychotropic medications and comorbidities. The following cases aim to recapitulate and discuss some of such situations. CASES: Case 1: A 36-year-old man with intellectual development disorder and BD experienced catatonia, seizures, and hyperammonemia following valproate administration. Treatment involved electroconvulsive therapy (ECT) and a tailored medication regimen, ultimately leading to stability. Case 2: A 63-year-old man with long-standing BD exhibited resistance to lithium and valproate of late, having co-existing essential tremors and cerebellar atrophy. Multiple medication trials led to side effects, requiring ECT for symptom improvement, followed by a carefully adjusted maintenance regimen. CONCLUSION: Medication side effects can pose major challenges in treatment of BD. Comprehensive evaluation and monitoring are essential. ECT can prove valuable in such cases. There is pressing need to develop more safer treatment alternatives, especially considering the progressively ageing society.

Hyperbaric Oxygen Therapy in the Management of Zygomatic Bone Osteomyelitis.

INTRODUCTION: Zygomatic bone osteomyelitis is a rare condition having an incidence of 1.42%. Zygomatic osteomyelitis can be due to haematogenous infection with tubercle bacillus, facial bone fractures or very rarely due to an unknown aetiology like in our case. If surgically managed alone, it would lead to complete loss of zygomatic bone, causing high morbidity to the patient in terms of function and aesthetics like loss of globe support causing dystopia, loss of facial projection causing facial asymmetry. Restoration of facial symmetry and globe support would require extensive procedures such as non-vascular bone grafting or patient-specific implant placement or microvascular bone flap transfer. MATERIALS AND METHODS: Hyperbaric oxygen therapy (HBOT) was used to try and preserve the zygoma by promoting revascularisation. The patient received 100% oxygen at 2.5 absolute atmospheric pressure for 90 min, one session per day for 5 days in a week using a mask system in a multiplace chamber. The patient was reviewed clinically and radiologically after each 5 dives of HBOT sessions. After a total of 30 dives of HBOT, CT examination was repeated. There was partial reconstitution of cortical bone without any additional residual bone lesion. Minimal residual sequestra were noted. At this stage, the patient underwent conservative sequestrectomy in contrast to extensive surgery if HBOT was not contemplated. CONCLUSION: HBOT has the potential to be a very useful adjunct in the treatment of osteomyelitis in head and neck surgery; however, there is a need for carefully designed trials, avoiding methodological bias due to the great variability of patients, infectious agents, antibiotic resistance, host factors, to broaden the evidence of this therapeutic modality.

Virtual Surgery Planning in Orthomorphic Correction of Mandibular Dysmorphology.

Three-dimensional virtual surgery programs are widely available for orthognathic surgery. The advent of imaging software programs has proved to be useful for diagnosis, treatment planning, outcome measurement, and three-dimensional surgical simulation. Complex maxillofacial malformations continue to present challenges in analysis and correction beyond modern technology. Orthomorphic correction for mandibular dysmorphology refers to basal bone movement without any change in dental component. The purpose of this paper is to present a virtual surgery planning for surgeons to perform the orthomorphic surgery with precision and quantification. Moreover, it provides an essential educational tool for patients to foresee predicted surgical outcome.

Le Fort I Disassembly for the Management of Juvenile Ossifying Fibroma Extending To the Skull Base.

Ossifying fibroma is a rare benign osteogenic neoplasm arising from undifferentiated cells of the periodontal ligament. Ossifying fibroma have a well-defined border that differentiates it from fibrous dysplasia clinically; these tumors manifest as a round or ovoid, expansile, painless, slow-growing mass may displace the roots of adjacent teeth and also cause root resorption. A variety of approaches for resection of the maxilla have been described. Most involve the use of facial and lip-splitting incisions to gain wide access. Surgical approach specifically to the ossifying fibroma located in the midface includes the Le Fort I approach, Caldwell-Luc access, lateral rhinotomy with medial or total maxillectomy, external ethmoidectomy, and endoscopic surgery. The access through Le Fort I disassembly is a versatile approach not only because of the aesthetic potential in using intraoral incision but also due to its minimal invasiveness, lesser complications and gives the possibility of reconstruction in a single operation. Le Fort I disassembly followed by an excision appears to be a versatile, secure, and satisfactory option.

Fabrication of Patient Specific Titanium Implants for Correction of Cranial Defects: A Technique to Improve Anatomic Contours and Accuracy.

Hard tissue cranial defects may result from traumatic or iatrogenic etiology and warrants adequate reconstruction to provide protection to the underlying brain and cosmesis. Various techniques have been described in the literature for fabrication of patient specific titanium cranial implants. The process of fabrication of titanium patient specific implants (PSI) can be broadly classified into indirect and direct techniques. With the improvements in the medical imaging and computational modeling, direct technique of computer assisted prefabricated patient specific implants have gained popularity. However indirect method of PSI fabrication hold some specific advantage. Here we describe a technique for fabrication of titanium PSI by combining the principles of direct and indirect methods for reconstruction of cranial defects.

Custom made orthotic device for maintaining skull architecture during the postoperative period in infants undergoing craniosynostosis surgery.

AIM: To fabricate a cost effective, indigenous and simple orthotics helmet for post-operative cranial molding in patients with craniosynostosis surgery. METHODS: We present a case of 15 month old infant with secondary cranial vault deformity. Cranial vault remodeling surgery involving the posterior skull was planned and executed to increase the posterior gap, so that brain growth would be facilitated towards this empty space. Materials such as thermoplastic sponge, thermoplastic ionomer resin sheet, soft sponge and Velcro straps are used to fabricate a cranial orthotics helmet. RESULTS: We have successfully used the above materials to fabricate the orthotics helmet for post-operative cranial molding. CONCLUSION: The technique described in this article is simple and cost effective. It can be custom made according to the demands of the surgical technique and the type of synostosis. It favors an individualistic prognosis, and proves worthwhile as every synostosis requires a unique treatment plan. It is an excellent adjuvant to craniosynostosis remodeling surgery.

Invasive aspergillosis presenting as swelling of the buccal mucosa in an immunocompetent individual.

Fungi are ubiquitous in nature but have low virulence and cause disease usually when the host defenses are compromised. Fungal infections of the central nervous system are rare and are usually seen in immunocompromised patients. However, in recent years, there has been an increase in the number of central nervous system fungal infections in immunocompetent individuals. Intracranial fungal granulomas are rare space-occupying lesions. Among these, Aspergillus granuloma is the most common. Craniocerebral involvement by aspergillosis usually occurs via the hematogenous route or through contiguous spread from the paranasal sinuses. Predominant symptoms associated with cranial fungal granuloma include headache, vomiting, proptosis, and visual disturbances. Common signs include papilledema, cranial neuropathy, hemiparesis, and meningismus. We present a case of invasive Aspergillus granuloma in an immunocompetent individual, who presented with a palpable mass in the buccal mucosa following removal of an impacted mandibular third molar but with no other characteristic signs and symptoms of invasive fungal granuloma. To our knowledge, there is no documentation of aspergillosis presenting as a swelling in the buccal mucosa. Unexplained swellings in the buccal mucosa should be viewed with a high degree of suspicion and investigated thoroughly at the earliest.

Subdural hygroma after craniosynostosis remodeling surgery.

Craniosynostosis is defined as the premature fusion of the cranial sutures and can cause functional impairment or cosmetic deformity. Surgical techniques for the correction of craniosynostosis have changed overtime, as so have the intraoperative and postoperative complications. Extensive surgeries involving fronto-orbital unit repositioning and cranial vault remodeling are associated with various complications. Intraoperative and postoperative hemorrhage, venous infarct, air embolism, hydrocephalus, cerebrospinal fluid leak, as well as meningitis are a few complications associated with cranial vault remodeling surgery. Postoperative complications can increase the morbidity and mortality associated with these procedures. Identification of the complications and their timely management should be a part of every craniofacial reconstruction team's training program.In this article, we report a case of subdural hygroma in an infant after cranial vault remodeling procedure. Subdural hygroma is a known complication following head injuries and represents 5% to 20% of posttraumatic intracranial mass lesions. However, subdural hygroma developing after a cranial procedure is rare and has not been reported in the literature. Identification of the complication, close monitoring of the change in subdural fluid volume, and tapping of the fluid through the craniotomy site if indicated form the mainstay of management of subdural hygroma that develops after cranial vault remodeling surgery.