Benign duodenojejunal junction stricture: a case report.

Introduction: Duodenojejunal stricture is a rare entity that has been attributed to peptic stricture, malignancy, chronic pancreatitis, Crohn's disease and other benign causes. Case presentation: The authors present a case of a 67-year-old male who presented with upper abdominal pain for 2 weeks, 2 episodes of bilious vomiting, and inability to pass stool and flatus for 1 day. He had a history of chronic upper abdominal pain over the last 40 years and pulmonary tuberculosis 50 years back.Computed tomography (CT) scan of the abdomen and pelvis showed short segment narrowing in the fourth segment of the duodenum with dilated first, second and third segment duodenal loops. Resection and end-to-end duodenojejunal anastomosis was performed and the outcome was normal. Discussion: Benign duodenojejunal can be treated with balloon dilatation, stenting, strictureplasty and resection anastomosis. Treatment should be offered considering efficacy, availability, complications of these modalities and aetiology. Conclusion: Anterograde push enteroscopy and CT scan can aid in preoperative diagnosis of duodenojejunal stricture. Even in older age groups without prior surgical history, benign duodenojejunal stricture can be the cause of intestinal obstruction. Resection and end-to-end duodenojejunal anastomosis can be safe and effective treatment modalities for duodenojejunal junction stricture.

Acute abdomen due to perforated jejunal gastrointestinal stromal tumor: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, with jejunal GISTs being particularly uncommon. Jejunal GISTs causing perforation and acute diffuse peritonitis is rare. CASE PRESENTATION: A 53-year-old female with a history of hypertension presented with severe, acute abdominal pain and vomiting. Examination revealed abdominal distension, tenderness, and guarding, with imaging suggestive of gastrointestinal perforation. Emergency laparotomy revealed a 9 cm × 8 cm mass with perforation in the jejunum, which was resected which on histopathological examination confirmed a low-grade GIST. The postoperative course was complicated by a wound infection, managed with antibiotics and secondary suturing. At one-year follow-up, the patient remained disease-free without the need for adjuvant therapy. CLINICAL DISCUSSION: The most common symptoms of jejunal GISTs include vague abdominal pain or discomfort, early satiety, obstruction or hemorrhage. Preoperative diagnosis and confirmation of GIST is difficult due to nonspecific symptoms and none of the radiographic procedures can establish the diagnosis with certainty. The surgical excision of the tumor along with infiltrated tissues is the treatment of choice for GIST. CONCLUSION: This case underscores the necessity of considering GISTs in differential diagnoses of acute abdomen and the critical role of prompt surgical management and multidisciplinary care in achieving favorable outcomes.

Coexistence of cecal duplication cyst and Meckel's diverticulum presenting as intestinal obstruction: A case report.

INTRODUCTION: Enteric duplication cysts (EDC) are rare anomalies of the gastrointestinal tract, with only 0.4 % occurring in the cecum. Meckel's diverticulum (MD) is a common congenital anomaly affecting up to 2 % of the population. The simultaneous occurrence of these two conditions is rare with no existing guideline on treatment. CASE PRESENTATION: An 11-month-old boy presented with fever, vomiting, and abdominal distension. A contrast-enhanced computed tomography scan confirmed the diagnosis of an enteric duplication cyst causing intestinal obstruction. The patient underwent exploratory laparotomy, during which a cecal duplication cyst measuring 30 × 20 mm was found along with MD in the distal ileum. Right limited hemicolectomy was performed. Histopathological examination revealed features consistent with an enteric duplication cyst and the presence of gastric mucosal heterotopia. CLINICAL DISCUSSION: Differentiating EDC from MD is a significant challenge, as both can present with similar symptoms and be positive on a Tc-99 m radionuclide scan. The final diagnosis of EDC and MD can only be made by correlating the imaging findings with the surgical findings and pathological features. CONCLUSION: Cecal duplication cysts should be considered a differential diagnosis in infants who present with intestinal obstruction. Although their presentation may resemble that of Meckel's diverticulum, both conditions can coexist. Excision of duplication cysts in children is considered a safe and efficient treatment approach.

Emergency surgery for acute rectal bleeding in a newly diagnosed case of fulminant ulcerative colitis.

INTRODUCTION: The incidence of ulcerative colitis is rising among Asian population. Massive bleeding per rectum is an uncommon, but serious, complication of UC accounting for 0.1-1.4 % of admissions. CASE PRESENTATION: A 22-year-old male, reported persistent abdominal pain, bloody diarrhea, and intermittent vomiting for one week. Physical examination revealed signs of dehydration and pallor. Laboratory tests showed elevated inflammatory markers. CT and colonoscopy confirmed ulcerative colitis, refractory to corticosteroids, leading to a subtotal colectomy followed by Ileal Pouch-Anal Anastomosis. The patient was symptom free at a 24-month follow-up. DISCUSSION: Bleeding that occurs during the initial stages of the disease or in cases where the diagnosis of ulcerative colitis hasn't been confirmed makes it challenging for patients to accept the need for extensive surgery and the creation of a stoma. Conservative procedures are advised in such settings. CONCLUSION: Acute severe bleeding in ulcerative colitis is rare but demands a multidisciplinary approach for timely diagnosis and treatment. In resource and expertise limited situation, where patients are noncompliant to regular follow-ups surgical treatment can still be intervention of choice for these cases.

Richter supraumbilical hernia managed with invagination: a case report.

Introduction and importance: Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias. Case presentation: A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done. Clinical discussion: Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation. Conclusion: Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.

Hepatic angiomyolipoma masquerading as abdominal pain: A case report.

INTRODUCTION AND IMPORTANCE: Hepatic angiomyolipoma (HAML) is a rare liver tumor composed of blood vessels, smooth muscle, and fat cells. HAML occurs across a wide age range, with symptoms including abdominal discomfort, bloating, and weight loss. Diagnosis is challenging due to varied imaging appearances, but histopathological examination supplemented by immunohistochemical analysis, particularly using HMB-45, is definitive. CASE PRESENTATION: A 33-year-old man presented with a two-year history of right upper quadrant abdominal pain, occasionally relieved with analgesics but worsening over the past month and a half. Examinations revealed a soft, non-distended abdomen with a palpable liver. Laboratory tests, including viral markers and tumor markers were normal. Contrast-enhanced CT revealed a well-defined oval mass in liver segment III with heterogeneous enhancement leading to provisional diagnosis of HAML. The patient underwent a successful en bloc excision with no intraoperative or postoperative complications. CLINICAL DISCUSSION: Surgical resection is recommended for symptomatic cases or inconclusive biopsies, with stringent follow-up necessary due to the potential for recurrence and association with other malignancies. CONCLUSION: HAML may present with prolonged nonspecific abdominal symptoms. CT imaging aids in diagnosing cases with abundant fatty tissue. En bloc tumor excision proves safe and effective in treating symptomatic presentations.

Incidentally discovered intestinal malrotation during evaluation for blunt abdominal trauma: A case report.

INTRODUCTION AND IMPORTANCE: Intestinal malrotation is a congenital abnormality predominantly diagnosed in children, with only a few cases reported in adults. Patients may be incidentally identified during unrelated surgical procedures or postmortem examinations. It is crucial to promptly recognize this condition to prevent severe complications such as bowel ischemia and potential fatality. CASE PRESENTATION: A 40-year-old male presented to the Emergency Department after a child jumped on his abdomen with complaints of acute left upper quadrant abdominal pain progressing to be generalized. Examination showed pallor, abdominal tenderness without guarding or rigidity, and intact bowel sounds. Preoperative diagnostic tools revealed intestinal malrotation confirmed during the laparotomy, prompting the performance of Ladd's procedure to address the malrotation. CLINICAL DISCUSSION: Disruption in the normal embryological development of bowel is the cause of intestinal malrotation. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated. CONCLUSION: Intestinal malrotation is rare in adults and often found incidentally during evaluation for unrelated medical conditions. Timely identification and surgical intervention usually result in positive outcomes. Our case underscores the incidental discovery of malrotation during the evaluation of blunt abdominal trauma, treated with Ladd's procedure. This is particularly significant due to geographical constraints associated with the patient's rural origin, as untreated malrotation could lead to complications in future occurrences.

Thiosulfinate Tolerance Gene Clusters Are Common Features of Burkholderia Onion Pathogens.

Burkholderia gladioli pv. alliicola, B. cepacia, and B. orbicola are common bacterial pathogens of onion. Onions produce organosulfur thiosulfinate defensive compounds after cellular decompartmentalization. Using whole-genome sequencing and in silico analysis, we identified putative thiosulfinate tolerance gene (TTG) clusters in multiple onion-associated Burkholderia species similar to those characterized in other Allium-associated bacterial endophytes and pathogens. Sequence analysis revealed the presence of three Burkholderia TTG cluster types, with both Type A and Type B being broadly distributed in B. gladioli, B. cepacia, and B. orbicola in both the chromosome and plasmids. Based on isolate natural variation and generation of isogenic strains, we determined the in vitro and in vivo contribution of TTG clusters in B. gladioli, B. cepacia, and B. orbicola. The Burkholderia TTG clusters contributed to enhanced allicin tolerance and improved growth in filtered onion extracts by all three species. TTG clusters also made clear contributions to B. gladioli foliar necrosis symptoms and bacterial populations. Surprisingly, the TTG cluster did not contribute to bacterial populations in onion bulb scales by these three species. Based on our findings, we hypothesize onion-associated Burkholderia may evade or inhibit the production of thiosulfinates in onion bulb tissues. [Formula: see text] Copyright © 2024 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license.

Maternal exposure to folate antagonists and susceptibility to congenital heart disease in offspring: A systematic review and meta-analysis.

AIMS: The objective of this meta-analysis was to determine whether maternal exposure to folate antagonists is associated with increased rates of congenital heart disease in offspring. METHODS: A comprehensive search for articles in the MEDLINE (PubMed) and EMBASE databases published up to 21 August 2023 was performed. The search strategy was not limited by study design but only for articles in the English language. RESULTS: Analysis of 6 cohort studies and 5 cross-sectional studies, published between 1976 and 2020, showed significant increase in rate of congenital heart disease (odds ratio 1.55, 95% confidence interval, 1.28-1.87) when exposed to folate antagonists compared with the control. Further subgroup analysis showed the increased rate for exposure to both dihydrofolate reductase inhibitors and antiepileptic drugs separately. No differences were observed when analyses were stratified by timing of study. CONCLUSION: Administration of folate antagonists within the 12-week period preceding conception and throughout the second and third months of gestation exhibited a statistically significant elevation in the susceptibility to congenital heart diseases. Notably, the protective effect of folic acid supplementation was reported in cases of congenital heart disease linked to dihydrofolate reductase inhibitors but not that associated with antiepileptic drugs.

De novo subgaleal abscess complicated by spontaneous osteomyelitis and epidural abscess: a case report and review of literature.

Introduction and importance: A subgaleal abscess is a collection of pus in a potential space between the galea aponeurotica and pericranium. De novo subgaleal abscesses are a subset of subgaleal abscesses that develop in the absence of identifiable risk factors such as head trauma or procedures. However, these have rarely been reported in the literature. Case presentation: We present the case of a 65-year-old woman who presented with a headache for two and a half months, followed by swelling of the right parieto-occipital scalp. She denied any history of trauma, procedures, or anticoagulant use. A diagnosis of subgaleal abscess complicated by osteomyelitis and epidural abscess was made after obtaining a computed tomography of the head. Surgical treatment consisting of drainage, debridement, and craniectomy was performed, and the disease was successfully treated with a 6-week course of antibiotics. Clinical discussion: It is uncommon to have a de novo subgaleal abscess with spontaneous osteomyelitis and an epidural abscess as concurrent complications. The symptoms can be subtle, such as chronic headaches which can lead to delayed hospital visits. Computed tomography of the head is sufficient to make a definitive diagnosis. Appropriate antibiotic therapy and surgical intervention are necessary, which may encompass incision, drainage, debridement, and occasionally a craniectomy in order to achieve full resolution. Conclusions: One should be vigilant when evaluating scalp swelling for possible underlying abscesses. Prompt diagnosis and appropriate surgical treatment with adequate antibiotics are preferred treatment options for de novo subgaleal abscesses.

Prevalence and Clinical Types of Tremor in Multiple Sclerosis and its Associated Disability: A Systematic Review.

Objective: To describe the state of literature regarding prevalence, clinical types of tremor in Multiple Sclerosis and associated disability. Background: Tremor has long been recognized as an important symptom of multiple sclerosis. This can be intention and postural tremor that affects the upper limbs. Patients with multiple sclerosis who experience tremor of any severity typically retire early or lose their jobs due to disability. Methods: This systematic review was performed up to September 9, 2022. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The search strategy was not limited by study design but only for articles in the English language. Results: A total of nine full-text articles were included in the analysis. Six studies were cross-sectional studies; one each was a prospective observational study, a case-control study, a community-based cohort. The prevalence of tremor in the multiple sclerosis (MS) population among studies ranged widely, between 12.5% and 68.9%. The presence of severe tremor ranged from 3% to 33%. Younger age was a significant predictor of tremor in two studies. The most common tremor subtype was action tremor. Upper extremities were the most common site involved in the majority of our studies, followed by head and neck. Conclusions: Prevalence of tremor ranged from 12.5% to 68.9% in the MS population with severe tremor being an infrequent complication. Severity of tremor correlated with increasing disability. Upper limb action tremor was the most common with rare occurrences of resting and rubral tremor.

Guillain-Barre Syndrome following lower segment caesarean section under spinal anesthesia: A case report.

Symptoms of Guillain-Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro-inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures.

Pegcetacoplan in paroxysmal nocturnal hemoglobinuria: A systematic review on efficacy and safety.

Introduction: Pegcetacoplan, a pegylated penta-decapeptide, targets complement C3 to control both intravascular and extravascular hemolysis. This systematic review aims to study the efficacy and safety of pegcetacoplan in paroxysmal nocturnal hemoglobinuria (PNH). Methods: We performed a comprehensive and systematic literature search for all studies on PubMed, Google Scholar, Cochrane Library, and clinicaltrials.gov. The studies were searched using keywords "paroxysmal nocturnal hemoglobinuria" or "PNH," "Pegcetacoplan" or "Empaveli." The primary outcomes included change in hemoglobin level, transfusion independence, absolute reticulocyte count, and lactate dehydrogenase (LDH) level after pegcetacoplan therapy. The safety outcomes included the proportion of deaths and adverse effects. Results: We included a total of three studies. The total number of patients with PNH was112. 59.83% were female. In the PADDOCK study and study by Hillmen et al., the average increase in hemoglobin was 3.68 g/L and 2.37 g/L, respectively. In the study by de Castro et al., the hemoglobin level increased from below the lower limit of normal and stayed in the normal range (11.1-15.9 g/L). Absolute reticulocyte count and LDH levels decreased in all patients receiving pegcetacoplan. In the study by de Castro et al., LDH level remained stable, and within <1.5× upper limit of normal, whereas in the study by Hillman, the mean change of LDH from baseline was -15 ± 43 U/L. Two of six, seven of 23, and seven of 41 patients reported adverse events in the study by de Castro et al., PADDOCK, and Hillmen et al., respectively. Conclusion: Pegcetacoplan effectively improves hemoglobin level and transfusion requirements in patients with PNH, including those unresponsive to eculizumab.

Guillain-Barré syndrome following coronavirus disease vaccine: First report from Nepal.

ChAdOx1 nCoV-19 is an effective and well-tolerated coronavirus disease 2019 vaccine. However, rare cases of serious adverse events have been reported with it. We report a patient who did not have active or prior coronavirus disease 2019 infection, who developed Guillain-Barré syndrome 7 days following the first dose of ChAdOx1 nCoV-19 vaccination. He was treated with intravenous immunoglobulin, with stabilization of the disease. Proper monitoring and prompt reporting of such cases are required to ensure the safety of the vaccine.

Synovial Chondromatosis of Hip Joint in a Patient with Ankylosing Spondylitis: A Case Report.

Synovial chondromatosis in association with ankylosing spondylitis is extremely rare and has been reported only once before and this case report is presenting a similar case. The knee is the preferential site of involvement with involvement of the hip being reported sparsely. We herein report a case of a 52-year-old male who came with complaints of the lower back pain for 5 years and left hip pain for 1.5 years who was diagnosed with synovial chondromatosis of the hip joint with axial ankylosing spondylitis and was managed operatively. We here review briefly the clinical manifestations, pathogenesis, diagnosis, previously reported cases as well as treatment of synovial chondromatosis in patients with immune-mediated inflammatory arthritides. There should be a high index of suspicion to diagnose synovial chondromatosis in association with inflammatory arthritides. We also believe that surgical management is an effective method of treatment of an established synovial chondromatosis of the hip joint. Keywords: ankylosing spondylitis; case reports; hip joint; synovial chondromatosis.

Optic neuropathy induced by ethambutol: A rare case from Nepal.

Introduction: Ethambutol is a drug used against tuberculosis and causes side effects like problems with vision, which may lead to optic neuropathy. It has a low prevalence of 1% and typically develops after 4-12 months of its medications. Case presentation: Here, we report a case of a 42-year-old male with ethambutol-induced optic neuropathy after six weeks of initiations of ethambutol. Discussion: Nutritional and tobacco/alcohol, ischemia, compressive, demyelinating, and genetic optic neuropathies were all ruled out as differential diagnosis for toxic optic neuropathy. Because our patient did not have vasculopathy and his vision loss was progressive on follow up and bilateral, rather than acute and unilateral, as is more usual with an ischemic disease, ischemic optic neuropathy was ruled out. Finally, because hereditary optic neuropathy usually manifests at a younger age and is expressed in many generations which was not the case in our patient, it was effectively ruled out as the cause of optic neuropathy. Conclusion: This case highlights that ethambutol toxicity is rare in cases of new onset pulmonary tuberculosis where ethambutol has been administered for only 2 months.

Pseudomonas alliivorans sp. nov., a plant-pathogenic bacterium isolated from onion foliage in Georgia, USA.

This study provides a taxonomic characterization of three bacterial strains isolated from onion seedlings in Georgia USA. Yellow-colored colonies were isolated, and a diffusible fluorescent pigment was visible under ultraviolet light on King's medium B. Preliminary analysis of the basic phenotype tests and 16S rRNA gene sequence analysis indicated the onion strains were closely related to Pseudomonas viridiflava with the highest similarity to P. viridiflava DSM 6694T (99.6%). The phylogenomic analyses based on whole genome sequences showed that the onion strains formed a separate monophyletic clade from other species with P. viridiflava as the closest neighbor. When the onion strains and the P. viridiflava type strain were compared, the average nucleotide identity values was 91.6%. Additionally, the digital DNA-DNA hybridization values of the onion strains were 45.8% or less when compared to the type strains of their close relatives, including P. viridiflava. In addition, biochemical, physiological features, and cellular fatty acid compositions were determined for a polyphasic taxonomic analysis. The results supported that the three onion strains represented a novel Pseudomonas species. We propose a new species as Pseudomonas alliivorans sp. nov., with 20GA0068T (=LMG 32210T = CFBP 8885T) as the type strain. The DNA G + C content of the strain 20GA0068T is 59.1 mol%.

Paraparetic Guillain-Barre syndrome: An uncommon diagnosis of acute flaccid paralysis of the lower limbs.

Apart from the usual differentials of transverse myelitis and cord compression, paraparetic GBS should be considered when sudden, flaccid paralysis of the lower limbs occurs, as prompt diagnosis and management can minimize sequel and unnecessary procedures. We do report a case wherein we managed a similar situation without the use of an immunomodulatory therapy.

Taxonomy and Phylogenetic Research on Ralstonia solanacearum Species Complex: A Complex Pathogen with Extraordinary Economic Consequences.

The bacterial wilt pathogen, first known as Bacillus solanacearum, has undergone numerous taxonomic changes since its first description in 1896. The history and significance of this pathogen is covered in this review with an emphasis on the advances in technology that were used to support each reclassification that finally led to the current separation of Ralstonia solanacearum into three genomic species. Frequent name changes occurred as methodology transitioned from phenotypic, biochemical, and molecular studies, to genomics and functional genomics. The diversity, wide host range, and geographical distribution of the bacterial wilt pathogen resulted in its division into three species as genomic analyses elucidated phylogenetic relationships among strains. Current advances in phylogenetics and functional genomics now open new avenues for research into epidemiology and control of the devastating bacterial wilt disease.

Development of a robust, field-deployable loop-mediated isothermal amplification (LAMP) assay for specific detection of potato pathogen Dickeya dianthicola targeting a unique genomic region.

Destructive maceration, a wide host range, and longevity in non-plant substrates has established Dickeya dianthicola (blackleg of potato) as a significant threat to potato industries worldwide. To protect these businesses, a specific and sensitive point-of-care D. dianthicola detection tool is necessary. We have developed a loop-mediated isothermal amplification (LAMP) assay for specific, sensitive, and rapid detection of D. dianthicola, which can be streamlined for point-of-care use. The developed LAMP assay targets a unique gene, alcohol dehydrogenase, of D. dianthicola. Assay specificity was assessed using strains present in inclusivity (16 D. dianthicola strains) and exclusivity panels (56 closely related, potato pathogenic, and other bacterial strains). Amplification with strains of inclusivity panel occurred, and cross-reactivity with non-target DNA was not observed. The limit of detection (LOD) was 10 CFU/ml when dilutions were made before isolating the genomic DNA; however, LOD was determined as 1 pg using 10-fold serially diluted D. dianthicola genomic DNA. Similar LOD of 1 pg was observed when serially diluted target genomic DNA was mixed with host genomic DNA. LOD (1 pg) was also calculated with 10-fold serially diluted synthetic DNA fragments containing primer target sites. Naturally and artificially inoculated plant samples were used for field adaptability tests with the field-deployable Optigene Plant Material Lysis Kit and a heat block (65°C); the results were obtained within 20 minutes. Despite the lack of method precision, no false positives or false negatives were observed. Therefore, with prepared reactions and a steady heat source, this assay can be used for rapid point-of-care detection, which is imperative for quarantine, eradication, disease management, and border protection.