Metaplastic Breast Cancer with Squamous Differentiation: Beyond the Recognized Statistics.

Background: Metaplastic breast cancer is a clinically rare subtype of breast carcinomas, accounting for less than 1% of all breast neoplasms, and was not officially recognized till the end of the 20th century as an independent pathological diagnosis. Objective: In this paper, we report a case of metaplastic breast cancer with squamous differentiation in a 51-year-old female, with a succinct review of the literature. Case Report: The patient presented to our outpatient department with a complaint of left breast mass for 2 months duration with a diagnostic workup found to be grade three metaplastic carcinoma with squamous differentiation. The management decision was to proceed with neoadjuvant chemotherapy, followed by surgical intervention based on the tumor cell response to neoadjuvant therapy. Conclusion: Metaplastic breast cancer represents a rare clinical entity, encountered in a minority of patients. The clinical presentation of metaplastic carcinomas in general is similar to other breast cancers, however, metaplastic breast cancer tend to present in later stages as a rapidly growing mass with poor prognosis. The recognized poor prognosis along with rarity necessities having a high index of suspicion for early detection and appropriate management of metaplastic breast cancer.

Giant Sclerosing Hepatic Hemangioma Presenting as Bornman-Terblanche-Blumgart Syndrome: a Case Report and Review of the Literature.

Background: Hepatic hemangioma represents the most frequent benign tumor originating from the liver. When the tumor exceeds 10 cm, and in some studies 4 or 5 cm, it is considered giant, which accounts for 10% of all hemangiomas arising from the liver. Histologically, Sclerosing hepatic hemangioma, in particular, is an exceedingly rare subtype of hemangioma. Clinically Bornman-Terblanche-Blumgart syndrome is a very rare complication of hepatic hemangioma. Objective: The aim of this case presentation was to contribute to the literature by documenting a case of giant sclerosing hemangioma diagnosed in a 36-year-old female presenting with Bornman-Terblanche-Blumgart syndrome, along with a brief review of the literature. Case report: The current paper documents two rare clinical and histological features of hepatic hemangioma. Bornman-Terblanche-Blumgart syndrome is complicated a giant hepatic hemangioma found histologically to be sclerosing in nature. Knowledge about the uncommon complications of liver hemangioma permits the implementation of appropriate interventions in a timely manner and, in turn, can enhance the patient's quality of life and minimize rates of associated mortality.

Dilemma of Blunt Abdominal Trauma in Patients with Crohn's Disease, Can Intestinal Perforation be Missed?

Background: Isolated intestinal injury after blunt abdominal trauma is a rare challenging clinical entity. Patients with Crohn's disease (CD) are considered more prone to spontaneous intestinal perforation rather than normal population However, spontaneous intestinal perforation remains rare. In the literature, there are few cases reports discussing intestinal perforation after blunt abdominal trauma in CD patients. Objective: Herein, we report a young male patient with CD who had missed traumatic intestinal perforation along with literature review of similar cases. Case Presentation: A young male patient, known to have CD, was brought to the emergency department after a road traffic accident. He had mild tenderness over his right iliac fossa with no signs of peritonitis. His chest X-rays revealed right-sided pneumothorax. His pan-computed tomography revealed thickened terminal ileum and minimal collection between the intestinal loops that were interpreted as interval regression of his Crohn's disease. On the second day, he remained hemodynamically-stable with no signs of peritonitis but his chest X-rays showed air under diaphragm. A repeated CT showed pneumoperitoneum, air foci around the terminal ileum and mild free fluid. An ileal perforation was found around 25 cm from the ileo-cecal valve. The involved ileal segment was completely resected with double-barrel ileostomy. Conclusion: Traumatic intestinal injury in patients with Crohn's disease represent both diagnostic and management dilemma. Inaccurate interpretation of radiological signs may lead to a delayed or missed diagnosis and surgical intervention. Abdominal CT scan should be routinely repeated, within 24 hours, for such patients, regardless absence of symptoms or signs suggestive of intestinal perforation.

Reconstruction of Infected Mediastinal Wound with an Omental Flap Harvested Laparoscopically After Cardiac Surgery: Report of Two Cases and Literature Review.

Background: Deep sternal wound infection and dehiscence are two serious complications after open cardiac surgery. Omental flap harvesting is recognized as one of the management options, with traditionally non-favorable outcomes due to laparotomy stress on patients. Objective: Herein, however, we report our experience with two patients who have developed a mediastinal wound infection following coronary artery bypass grafting and were reconstructed with omental flaps harvested laparoscopically. Case Presentation: Two 74-year-old females, who were known to have multiple comorbidities, developed a sternal wound infection after coronary artery bypass graft. Several operative trials and non-operative measures have been attempted to manage the infections and/or reconstruct the wound but failed. Both patients then underwent laparoscopic omental flap harvesting for reconstruction and exhibited significant clinical improvement postoperatively. Discussion: Omental flap is considered a feasible option for reconstruction of sternal wound dehiscence developing after open cardiac surgery because it is usually well-vascularized, contains a large number of immunologically active cells and has the ability to absorb wound secretions. The traditional method of harvesting is conventional laparotomy, but it carries high rates of morbidity. Therefore, laparoscopic harvesting can be utilized as an alternative with better outcomes. Conclusion: Laparoscopic omental flap harvesting is considered a feasible and safe procedure to manage sternal wound dehiscence after open cardiac surgery, with satisfactory surgical outcomes.

COVID-19 and Malignancy: What is the Association? A Case Report and Review of the Literature.

Background: After more than two years since Coronavirus disease 2019 (COVID-19) was first identified as a global pandemic, we still observe a variety of clinical presentations. From asymptomatic carriers to severely ill patients. Most patients infected with COVID-19 present with respiratory symptoms. Objective: However, case reports of different presentations were published, none of them highlighted the potential of COVID-19 to facilitate the manifestation of hidden malignancy, particularly, gallbladder carcinoma. Case presentation: In this report, we present a case of a 77-year-old Saudi lady with multiple comorbidities, presented with an acute confusional state after one month of having asymptomatic COVID-19 infection. Significantly, she was completely functional prior to her presentation and did not manifest any symptoms such as weight loss or fever. Her clinical assessment demonstrated severe abdominal tenderness and guarding on palpation. Computed tomography scans of the abdomen showed perforated gallbladder cancer. Conclusion: Among multiple clinical presentations related to COVID-19 infection, gastrointestinal manifestations are the most common extrapulmonary symptoms, ranging from mild to more severe symptoms. Acute abdomen with perforated viscus should be kept in mind as a differential diagnosis when dealing with COVID-19 infected patients who present with severe abdominal pain. The current case report highlights one of unusual presentations of COVID-19 infection.

The Effectiveness of Nigella sativa and Ginger as Appetite Suppressants: An Experimental Study on Healthy Wistar Rats.

Background: Obesity is a global pandemic that is associated with high morbidity and mortality. Natural herbs are commonly used for weight reduction and appetite suppression. Therefore, we aim to investigate the role and mechanism of Nigella sativa (NS) and ginger on weight reduction and appetite regulation. Methods: This experimental study was performed at Imam Abdulrahman Bin Faisal University. Twenty-five female rats were distributed into 5 groups: NS (oral 1000mg/kg), Ginger (500 mg/kg), NS-ginger (both interventions), a positive control (intraperitoneal 50 µg/kg Liraglutide), and a negative control. Each intervention was given for 9 weeks. Food intake and body weight were assessed weekly. Serum lipid profile and peptides involved in appetite control (cholecystokinin (CCK), glucagon-like peptide 1(GLP-1), gastric inhibitory polypeptide (GIP), ghrelin, peptide YY, and orexin) were assayed at the end of the experiment. Results: None of the interventions showed a statistically significant difference regarding food consumption or weight gain (p > 0.05). However, the three interventions significantly reduced total cholesterol (TC), NS and NS-ginger significantly increased HDL, NS increased ghrelin and ginger increased orexin. Conclusion: The present dose and duration of NS, ginger, or in combination did not demonstrate a significant change in body weight or food consumption in comparison to the negative or positive controls. However, NS or ginger has improved the lipid profile by reducing TC and increasing HDL. In addition, NS or ginger can influence some of the peptides involved in appetite regulation such as the increase in ghrelin induced by NS and the reduction of orexin induced by ginger. We believe that these latter effects are novel and might indicate a promising effect of these natural products on appetite regulation.

Synchronous Malignant Peritoneal Mesothelioma and Sigmoid Adenocarcinoma: a Challenging Clinical Entity.

Background: Malignant peritoneal mesothelioma (MPM) represents a rare clinical entity. The synchronous existence of MPM with other malignancies as colonic adenocarcinoma have been rarely reported. Its diagnosis and management are challenging given its complexity and rarity. Objective: Herein, we report a case of epithelioid subtype of MPM occurring synchronously with sigmoid colonic adenocarcinoma, along with review of the literature. Case presentation: An elderly female patient was referred as case of rectosigmoid mass. She reported history of abdominal pain, per-rectal bleeding, anorexia, and significant weight loss. Her computed-tomography scan of the abdomen revealed a fistulizing sigmoid mass and multiple enlarged lymphnodes with omental nodulation. The colonoscopy revealed a large fungating mass and the endoscopic biopsies were reported as colonic adenocarcinoma. The patient was scheduled laparoscopic low anterior resection. However, the diagnostic laparoscopy revealed several nodules disseminated all over the peritoneum, suggestive of peritoneal mesothelioma. Therefore, the decision was changed to create transverse colostomy after examination obtaining multiple biopsies from the omental and peritoneal nodules. The histopathological revealed MPM and the final diagnosis was sigmoid adenocarcinoma with synchronous MPM. The patient was started on palliative chemotherapy (capecitabine) without active management of MPM because of her general condition. She was followed up with a good clinical course. Conclusion: MPM is an overlooked entity with vague clinical presentation. Synchronous MPM with colorectal cancer is rare with only few published case reports. Its diagnosis is challenging, and its management should be tailored according to the patient. This case is the first reported case in Saudi Arabia and the Middle East.

Foreign body ingestion: Is intervention always a necessity?

Introduction: Intentional and accidental foreign body ingestion are commonly encountered in clinical practice. In adults, intentional foreign body ingestion is frequently observed among individuals with psychiatric disorders and prisoners. Controversies exist regarding the management of sharp or pointed objects. We contribute to this existing controversy by presenting a case of a 43-year-old male who accidently ingested a metallic screw and was managed successfully through endoscopic retrieval. Case presentation: We discuss a case of a 43-year-old male presented to our emergency department after accidently swallowing a metallic screw, 1 h and a half prior to his presentation. He was initially asymptomatic then started to complain of vague abdominal symptoms. X-rays of the chest and abdomen demonstrated the presence of a metallic screw at the mid-abdomen. Computed tomography scan of the abdomen then confirmed its presence within the gastric lumen, with no evidence of gastric or bowel perforation. The patient was managed via esophagogastroduodenoscopy in which the ingested screw was extracted. He was discharged after 24 hours in a good condition. Clinical discussion: A limited number of epidemiological studies have shed light on the prevalence and incidence of foreign body ingestion among adult individuals. Probability of spontaneous passage depends on several factors including the size, shape and composition of the impacted item, as well as the age of patient and duration of ingestion prior to presentation. Conclusion: Considering the variation of ingested objects and the availability of several therapeutic approaches, a patient-tailored management plan should always be established.

Recurrent Non-Lactational Fungal Abscesses in a Systemic Lupus Erythematosus Patient: Causation or Mere Association? A Case Report and Literature Review.

Background: Systemic lupus erythematosus is a multisystemic autoimmune disorder that can present in many different ways that can be debilitating for many patients. These patients are at risk for developing infections following the introduction of immunosuppressive therapy. Breast infections, particularly of the fungal type, in nonlactating patients who are not in an immunosuppressive state are extremely rare. Objective: We report a case of recurrent right breast fungal infections manifesting in the form of multiple abscesses in a systemic lupus erythematosus patient. Case report: A 39 years old female patient presented with recurrent fungal breast abscesses. She was diagnosed with systemic lupus erythematosus nine years ago and was in remission being maintained with an antimalarial agent without the use of immunosuppressive therapy. Fluconazole was started for her prior to her visit to us, and she had no active complaints. She was not breastfeeding nor pregnant currently nor during any of the previous episodes. Examination was unremarkable, however cultures of samples from her previous lesions demonstrated growth of Candida albicans. A decision to manage her conservatively with the continuation of her antifungal therapy was made. Conlusion: Lactation and breastfeeding are well-known risk factors for infectious mastitis and there is sparse literature regarding this condition in the absence of these risk factors. Studies evaluating other risk factors, particularly systemic lupus erythematosus, need to be conducted to determine any relationship and how to best manage this condition in such patients.

Diabetic mastopathy: A rare clinicopathologic entity with considerable autoimmune potential.

INTRODUCTION AND IMPORTANCE: Diabetic mastopathy is a rare entity affecting diabetic patients. It has been previously linked to type 1 diabetes mellitus; however, due to the several accompanying conditions, a theory of autoimmune factors contributing to the origin of this condition has been on the rise. In this paper, we report a case of diabetic mastopathy associated with several autoimmune diseases to highlight the immunological potential of this condition. CASE PRESENTATION: A 25-year-old female, known to have type 1 diabetes mellitus, hypertension, hypothyroidism, adrenal insufficiency, dilated cardiomyopathy and end-stage renal disease, was referred to our clinic for a breast lump. Radiological investigations showed a dense mass with irregular borders in the retroareolar area of the left breast. A core biopsy was obtained which revealed keloid-like fibrosis along with lymphocytes infiltrated, suggestive of lymphocytic mastopathy. CLINICAL DISCUSSION: Fibrous mastopathy has been merely attributed to a long-standing use of insulin therapy by diabetic patients; recent observations, however, proved the major contribution of immunity to etiopathogenesis. Even though human leukocyte antigen (HLA) association has not been supported in the literature, the histological changes of breast lymphocytic infiltrate are seen in patients who not only have T1DM, but also thyroiditis, systemic lupus erythematosus, Sjogren's syndrome, and Addison's disease. The frequent presence of several possible autoimmune conditions has promoted the theory of an autoimmune process affecting connective tissues, however, these claims are yet to be proven by future studies. CONCLUSION: Recent observations have proved the major contribution of immunity to etiopathogenesis of diabetic mastopathy. We shed light on the role of the immune system in triggering the disease process by reporting a case of diabetic mastopathy with a cluster of autoimmune diseases. Future studies should explore the genetic background of the condition as it would potentially have several clinical implications. The discussed pathophysiologic explanations raise the possibility of autoimmunity as a key driver in pathogenesis and indicate the need to change the nomenclature of this condition.

Pleural Empyema as a Complication of Pyogenic Liver Abscess: Can the Minimum Achieve the Optimal? A Comparison of 3 Approaches.

BACKGROUND Pyogenic liver abscess is an uncommon entity that is potentially lethal. Pleural empyema and mediastinal collection are 2 rare complications of hepatic abscess that negatively impact the prognosis. CASE REPORT Herein, we report 3 cases of pyogenic liver abscesses complicated by pleural empyema, each approached differently, along with a succinct review of the literature. Case 1: A 29-year-old man diagnosed with Crohn's disease presented with Crohn's disease-associated hepatic abscess complicated by pleural empyema and concurrent mediastinal collection. The patient demonstrated significant improvement after administration of intrapleural fibrinolytic therapy. Case 2: A 42-year-old man with unremarkable past medical history presented with abdominal pain and dyspnea. Upon investigation, he was found to have massive pleural empyema secondary to liver abscess. In contrast to case 1, case 2 required pleural debridement via video-assisted thoracoscopic surgery followed by formal decortication through a posterolateral thoracotomy. Thereafter, a dramatic clinical improvement was observed. Case 3: A 26-year-old man with history of brucellosis 6 months before was transferred to our facility as a case of pleural empyema secondary to transdiaphragmatic extension of liver abscess. Unlike case 1 and 2, this patient was managed by drainage of hepatic and pleural collections under radiological guidance only, without the need for intrapleural fibrinolytic therapy or surgical intervention. CONCLUSIONS The current paper sheds light on one of the uncommon complications of hepatic abscess and contributes to this scant literature by summarizing pertinent publications. Adequate drainage remains the cornerstone of any pus collection management despite the complexity of some encountered cases.

Giant Esophageal Leiomyoma: Diagnostic and Therapeutic Challenges.

BACKGROUND Leiomyoma is a rare, benign, esophageal tumor that does not often measure >10 cm. Here, we report a case of giant esophageal leiomyoma in a 24-year-old man. CASE REPORT A 24-year-old man who smoked and had primary hypertension and glucose-6-phosphate dehydrogenase deficiency presented with a history of shortness of breath and productive cough with yellowish sputum, a long history of dysphagia to solid food, and a weight loss of 7 kg over 2 months. A chest X-ray revealed a mediastinum with a width >8 cm. Computed tomography of the patient's chest revealed a multilobulated mass that originated from the upper and middle thoracic esophagus, caused severe narrowing of his esophageal lumen, and was compressing his trachea and right main bronchus. Resection of the tumor was performed and, because of the large defect after the surgery and the mucosal necrosis, the patient underwent an Ivor-Lewis esophagectomy. His postoperative course was uneventful. He had no symptoms when he was seen in the outpatient clinic for follow-up and fully recovered. CONCLUSIONS Giant esophageal leiomyoma (GEL) is a rare oncological entity that presents several diagnostic and therapeutic challenges because of the scarcity of information in the medical literature on surgical management. The descriptions of techniques for surgical resection of GEL do not include ways to effectively perform subsequent reconstruction. The aim of the present paper was to contribute to this scant information by reporting our experience with performing an Ivor-Lewis esophagectomy to manage a case of GEL.

Organ transplantation in Arabian Gulf countries: ethical and legal practice and beyond.

Almost half a century ago, organ transplantation was introduced to Arabian Gulf countries. The criteria for diagnosing brain death among these countries is relatively similar, in which the main area of discrepancy is the number of physicians required to diagnose and their required specialties. Regarding the organs and tissues allowed for transplantation, they must possess an intrinsic regenerative ability if they are harvested from a living donor to avoid jeopardizing their health. To donate, Arabian Gulf countries follow an opt-in consent system, requiring the donor's informed consent before organ procurement. Live donors can be related or unrelated to the recipient, although the latter is subjected to variable restrictions among Arabian Gulf countries and prohibition in one of them. This is due to its implication in commercial trade. Furthermore, the Gulf Health Council was established to coordinate different health initiatives and programs between Gulf states, including organ transplantation, in an attempt to improve the health sector of all of its member states. Although organ trafficking is illegal in all Arabian Gulf countries, their penalty systems vary from barring physicians, subjecting them to fines or even imprisonment. As for the attitudes of people towards organ transplantation, the willingness to donate varies among these countries. The rate of organ transplantation remains low. This article aims to cover the history of organ transplantation, brain death diagnosis protocols, organ donation enrollment policies and conditions, as well as the issue of organ trafficking in Arabian Gulf countries.