Systemic lupus erythematosus associated with erythema multiforme: A rare case report of Rowell's syndrome.

Key Clinical Message: Although it is very uncommon, SLE may initially present with recurrent episodes of EM-like rash. Despite the various possibilities underlying their association, prompt identification, and treatment of SLE in patients presenting with EM is important to prevent death or serious organ damage. Abstract: Rowell's syndrome (RS) is an uncommon presentation of systemic lupus erythematosus (SLE) with erythema multiforme (EM)-like lesions associated with specific serological changes, including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA), positive rheumatoid factor, or anti-La antibodies in the serum. Our case, a 41-year-old male, presented with features of EM. Upon investigation, we identified underlying systemic lupus erythematosus, marking a rare instance of SLE presenting for the first time as EM. Classical or true EM is precipitated by trigger factors such as infective agents like the herpes simplex virus, Mycoplasma pneumoniae, drugs like anticonvulsants, antibiotics, and non-steroid anti-inflammatory drugs, any underlying malignancy, or connective tissue disorders, and is not associated with any specific serological abnormalities. EM cases associated with LE lesions where an EM trigger factor is missing are considered an RS diagnostic criterion. In this case report, the importance of considering SLE in patients presenting initially with recurrent episodes of EM-like rash is emphasized. RS should be considered, especially when there is no evidence of triggering factors. Early diagnosis and prompt treatment of SLE are crucial to preventing death and irreversible organ damage.

Citrobacter freundii-associated osteomyelitis and thromboembolic events following Moderna COVID-19 vaccination: a rare case report from Nepal.

Introduction: Vaccination against coronavirus disease 2019 (COVID-19) is essential for controlling the ongoing cases of this disease. Citrobacter infections of the bones and joints are extremely uncommon. Thromboembolism and deep vein thrombosis (DVT) are very rare complications. Case presentation: The authors present a rare case of osteomyelitis, septic arthritis, deep venous thrombosis, and pulmonary embolism in a 15-year-old previously healthy boy occurring shortly after receiving the second dose of the Moderna COVID-19 vaccine. He experienced pain, swelling in the right leg, shortness of breath, and fever, followed by chest pain and leg edema. Treatment included anticoagulation, ketorolac for pain management, antipyretics, and intravenous antibiotics (Tazobactam/Piperacillin, Linezolid, Clindamycin) for osteomyelitis. Discussion: The risk of COVID-19 vaccine-related thrombotic events is minimal. Thrombotic events reported among mRNA is very rare. Citrobacter freundii bone and joint infections are very rare, accounting for a small percentage of cases. Some documented cases include cefotaxime-resistant strains causing necrotizing fascitis and osteomyelitis, including postarthroplasty infections. Due to the diverse range of susceptibility patterns and the widespread occurrence of drug resistance, personalized treatment based on culture and sensitivity testing is recommended. However, in rare cases, severe complications like DVT and joint infections associated with Citrobacter infection may occur and should be reported to the vaccine adverse events reporting system. Conclusion: Administering the COVID-19 vaccine to enhance natural antibodies is crucial, despite the low risk of infection, thromboembolism, and DVT. Healthcare providers should stay vigilant about adverse effects postvaccination and promptly report those cases.

Diagnostic challenges in tuberculous meningitis: a case report with negative genexpert result.

Introduction: Tuberculous meningitis (TBM) is a severe form of tuberculosis affecting the meninges, primarily caused by Mycobacterium tuberculosis. Diagnosis of TBM poses numerous challenges due to its nonspecific clinical presentation and the limitations of diagnostic tests like GeneXpert. Case presentation: The authors report a case of a 22-year-old female from Eastern Nepal presenting with acute-onset fever, headache, vomiting, and neck pain. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, low glucose levels, and cobweb coagulum indicative of TBM. However, the GeneXpert test revealed negative results. Discussion: In resource-limited settings like Nepal, where access to GeneXpert MTB/Rif is limited, CSF analysis and clinical algorithms play a crucial role in diagnosing TBM. Relying solely on GeneXpert results may lead to false negatives, so a high level of suspicion based on patient risk factors is essential. Prompt initiation of empirical antitubercular therapy is vital for a favorable outcome in TBM cases. Conclusion: Negative MTB PCR results from CSF can be misleading in diagnosis of tubercular meningitis. Therefore, comprehensive evaluations, including detailed patient history, physical examination, and CSF fluid analysis, are crucial in high tuberculous prevalence countries to ensure accurate and timely diagnosis.

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.

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.

Inferior conjunctival autografting for pterygium surgery: an alternative way of preserving the glaucoma filtration site in far western Nepal.

BACKGROUND: The purpose of this study was to evaluate the outcome of pterygium excision with inferior conjunctival autografting for primary pterygium. METHODS: This was a prospective noncomparative interventional case series study enrolling 50 eyes of 50 patients with primary pterygium between November 1, 2010 and October 30, 2011. All patients underwent the standard surgical technique for pterygium excision with inferior conjunctival autografting. The sampling method was purposive. The study variables were complications of surgery and recurrence rates during a follow-up period of 6 months. RESULTS: The mean age of the patients was 43 ± 7.97 (range 26-64) years. Grade 1 pterygium comprised 64% while grade 2 pterygium comprised 36% of cases. The mean size of pterygium was 3.2 ± 0.60 mm. Minor complications did occur, but only 4% required resuturing. Recurrence occurred in two eyes (4%) which we detected 3 months after surgery in both cases. We observed conjunctival scarring at the donor site in four eyes (8%); however, there was no symblepharon formation or restriction of upgaze. CONCLUSION: Inferior conjunctival autografting is an effective technique with a low recurrence rate. This is a useful technique when it is not possible or desirable to use the superior conjunctiva as a donor source. It is an especially good option for preserving the glaucoma filtration site for the future.