Neuromucormycosis of Posterior Tibial Nerve: A Rare Presentation of Mucormycosis.

Opportunistic fungal infections are known to occur in immunocompromised patients. Mucormycosis is one of the most common opportunistic fungal infections with significant mortality rates. In this article, we present a case of an adult female, a known diabetic who presented with fever and pus discharge from the amputation site of toes in the left foot with blackening of the foot. Examination revealed gangrenous changes of the left foot with no distal pulses palpable. Computed tomography angiogram revealed no flow of blood in distal vessels of the left lower limb. Left below knee guillotine amputation was done. Intraoperative biopsy of the neurovascular bundle revealed invasive neuromucormycosis. She was started on liposomal amphotericin B. The wound started granulating after a few days with serial dressings and the patient was planned for split skin grafting.

Solitary lower limb cutaneous metastasis in a case of esophageal adenocarcinoma: a rare presentation.

Esophageal cancer is the ninth most common cancer all over the world and is sixth in the list of cancer-related mortality. Here in this report, we present an elderly male with solitary subcutaneous metastasis to right thigh 2 years following esophagectomy for esophageal adenocarcinoma. Operative notes revealed inadequate margins on frozen section analysis during initial resection, which were subsequently revised. Postoperative histopathology showed ypT3N0M0 Grade 3 mucin-secreting adenocarcinoma. A wedge biopsy from the thigh growth revealed metastatic mucinous adenocarcinoma. Positron Emission Tomography (PET) was done, which showed a higher tracer uptake in the ulcero-proliferative lesion arising from the subcutaneous plane in the right thigh with no evidence of any other metastasis or recurrence at the primary site. As the reported incidence of distant unexpected metastases is growing, careful physical examination with a preoperative PET-CT is indispensable. Further knowledge on options on treatment of such isolated cutaneous metastasis needs to be studied by the scientific community.

A Rare Case of HIV-Associated Plasmablastic Lymphoma of Anal Canal.

Plasmablastic lymphoma, an acquired immunodeficiency syndrome defining malignancy, is a subtype of diffuse large B-cell lymphoma. It is classically described in the oral cavity, the extraoral presentation being rare. Owing to its rarity and aggressiveness, plasmablastic lymphoma poses a diagnostic and therapeutic challenge to the treating physician. A 40-year-old male, recently diagnosed with HIV infection, presented with bleeding per rectum and spurious diarrhea. Examination revealed proliferative growth in the anal canal. Biopsy of the lesion was diagnostic of plasmablastic lymphoma. Computed tomography and magnetic resonance imaging were done to stage the lesion and assess the local extent, respectively. A multidisciplinary board discussion was done, and the patient was instituted on antiretroviral therapy and chemoradiotherapy. Following six cycles of chemotherapy and 25 fractions of radiotherapy, he achieved complete remission.

Comparison of Postoperative Port-Site Pain After Gallbladder Retrieval From Epigastric Versus Umbilical Port in Patients of Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis: A Randomized Controlled Trial.

Introduction Gallbladder (GB) retrieval is an important cause of postoperative pain (POP) after laparoscopic cholecystectomy (LC). Retrieval is through the epigastric or umbilical port based on the surgeon's preference. There is limited evidence to support the superiority of one port over the other in terms of POP. This study was done to compare POP between epigastric and umbilical ports after GB retrieval in LC for symptomatic cholelithiasis.  Material and methods All patients who underwent elective LC for symptomatic cholelithiasis were randomized for GB retrieval either through the umbilical (n = 15) or epigastric (n = 15) port. Postoperatively, the retrieval difficulty score by the operating surgeon, visual analog scale (VAS) scores for pain, and surgical site infection (SSI) by postoperative day (POD) 10 and 30 were assessed. Results The mean visual analog scores at the umbilical port at 1, 6, 12, 24, and 36 hours postoperatively were 5.20 ± 0.86, 4.60 ± 0.74, 4.00 ± 0.53, 3.40 ± 0.08, and 2.73 ± 0.82, which were significantly less than the visual analog scores at the epigastric port at the same time intervals, measuring 6.06 ± 1.34, 5.87 ± 1.30, 5.27 ± 1.16, 4.73 ± 1.10, and 3.93 ± 1.03, respectively. The difference was statistically significant between the two arms (p-value < 0.05). The mean retrieval difficulty score was significantly less for the umbilical port (4.40 ± 0.74) when compared with the epigastric port (5.13 ± 0.55). The overall SSI rate in the present study was 10%, and three (20%) patients in the epigastric port group developed SSI by POD 10, while none in the umbilical port group developed SSI. Conclusion GB retrieval from the umbilical port is associated with less POP, SSI, and retrieval difficulty when compared with GB retrieval from the epigastric port after elective LC for symptomatic cholelithiasis. Titration of analgesic use can also be done appropriately, reducing the dose of analgesics after 12-24 hours.

Omphalic Bleed.

Portosystemic collateralization is usually seen in patients with portal hypertension. Bleeding from the ectopic varices is reportedly rare. We present a case of a 55-year-old gentleman who presented with complaints of bleeding from the umbilicus. On examination, he was tachycardic, hypotensive, and in hypovolemic shock. Bleeding was suspected to be from the umbilical varices. Contrast-enhanced computed tomography of the abdomen with abdominal angiography revealed a cirrhotic liver with partial thrombosis of the portal vein with collaterals in the perigastric, lower esophageal, peripancreatic, splenic and mesenteric, umbilical and paraumbilical collaterals with recanalization of the umbilical vein. The bleeder was identified to be the collateral at the umbilical region from the superior mesenteric vein. The patient was treated with a Doppler-guided injection of a sclerosant into the collateral, thereby achieving successful hemostasis.

A Rare Case of Primary Anorectal Malignant Melanoma.

Malignant melanoma affecting the anorectum is very rare. We present a 63-year-old female who presented with features of bleeding per rectum and painful defecation. On examination, the patient had a palpable mass on the right side of the anorectum, with predominant exophytic growth and intraluminal extension. Biopsy and imaging studies were diagnostic of malignant melanoma. The patient was discussed on the tumor board and planned for abdominoperineal resection. Postoperatively, the patient was started on chemotherapy. The patient was followed up for two years, and there was no evidence of any recurrence.

Strangulated Falciform Hernia.

Internal hernias are rare, and a delayed diagnosis can lead to dangerous complications. A 75-year-old male with no previous surgical history presented with right upper abdominal pain and vomiting. On examination, he had guarding in the right hypochondrium with a positive Murphy's sign. However, ultrasonography of the gall bladder was normal with dilated bowel loops. Contrast-enhanced CT (CECT) revealed a falciform hernia with evidence of obstruction. Segmental resection of the gangrenous ileum was done with a double-barrel stoma. Later on, stoma reversal was also done with no complications.

Feasibility of Laparoscopic Closed Cystectomy for Hepatic Hydatid Cyst in Segments VI, VII, and VIII.

Background Laparoscopic closed cystectomy of the hepatic hydatid cyst (HHC) is increasingly being performed as it has improved postoperative recovery and reduced morbidity. However, laparoscopic closed cystectomy of HHC is difficult when located in segments VI, VII, and VIII. This study aimed to assess the laparoscopic closed cystectomy feasibility of the HHC when cysts are located at the difficult access site. Methodology Seven patients out of 13 patients of HHC treated laparoscopically in the surgery department from 2014 to 2018 were included. These patients had cysts located in segments VI, VII, and VIII of the liver. All patients received perioperative albendazole, underwent ultrasonography (USG) and contrast-enhanced computed tomography for diagnosis. We noted the demographic character of all the patients, cyst's location, cyst size, type of the cyst, mean operative time, intraoperative and postoperative complications, duration of the hospital stay, and recurrence of the cyst.  Results All patients underwent laparoscopic closed cystectomy of HHC. One patient had a conversion to open procedure, and one patient had an additional thoracoscopic approach added. The mean operative time was 191.86 minutes. There were no intraoperative complications. One patient had developed a surgical site infection, and three had a minor bile leak postoperatively. The hospital stay's mean duration was four days, and there was no recurrence in the 21 months follow-up. Conclusion The laparoscopic closed cystectomy of HHC located at segments VI, VII, and VIII is feasible, safe, and cost-effective. A thorough preoperative evaluation, preparation, and radiological planning of the procedure should be done.

A Diagnostic Dilemma of Bleeding Gastric Tumor or Bleeding Pancreatic Tumor.

Gastrointestinal stromal tumors are the most common nonepithelial tumors of the gastrointestinal tract. The stomach is the most common site of occurrence. Most of the tumors are asymptomatic. Many patients may present with mass per abdomen, gastrointestinal bleed. Tumors arising from the stomach's posterior wall may grow large, and on imaging, it may create confusion of the site of origin. We present a case of gastrointestinal stromal tumor arising from the stomach's posterior wall, growing large and creating a confusion of site of origin.

Perforation of the Meckel's Diverticulum Following Blunt Trauma to the Abdomen.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Most of the patients are asymptomatic and very few develop symptoms. Hemorrhage, obstruction, perforation, and inflammation are the complications that can occur in an MD. Even though hollow viscus perforation is common, perforation of the MD following blunt abdominal trauma is rare. We report a case of perforation of the MD in a 60-year-old man following a blunt abdominal trauma due to a fall from a bike, which was diagnosed promptly and managed successfully by timely operative intervention.

A non-resolving splenic 'abscess' in an elderly male - An unusual manifestation of splenic lymphoma.

Splenic abscess is a relatively uncommon condition, posing a diagnostic and therapeutic challenge for the treating physician. It occurs due to haematogenous spread from endocarditis or other septic foci, especially in immune-compromised individuals and diabetics. We describe an elderly male who presented with splenomegaly and low-grade fever with no predisposing factors. Examination revealed a tender splenomegaly. Ultrasonography (US) showed a hypoechoic area within the spleen from which guided aspiration of pus grew Staphylococcus aureus and Klebsiella pneumoniae. Percutaneous drainage and culture-based antibiotics failed to resolve the abscess, obligating surgical drainage. Intraoperative biopsy from the abscess wall was reported as splenic marginal lymphoma. This unusual presentation of lymphoma needs to be considered in splenic abscess without known risk factors.

Emphysematous cystitis - An uncommon yet fatal urinary tract infection.

Emphysematous cystitis is an uncommon form of complicated urinary tract infection mostly caused by Gram-negative organisms in elderly, debilitated or immune-compromised patients. It has a varied spectrum of clinical manifestations ranging from asymptomatic to generalised sepsis. Radiological investigations such as conventional abdominal radiography and computed tomography are quintessential for diagnosis. Treatment with culture-specific antibiotics forms the mainstay of management. We present the case of an elderly patient who presented with gastric carcinoma and, during his stay, developed an unexplained fever with rapid clinical deterioration. Emphysematous cystitis was diagnosed radiologically, and urinalysis revealed Klebsiella pneumoniae. Culture-specific antibiotics were started after obtaining the culture report, and despite early and aggressive management, the patient succumbed to generalised septicaemia. Although Emphysematous cystitis is known to have lower mortality compared to other gas-forming infections of the urinary tract, high degrees of clinical suspicion and early management are of paramount importance in obtaining a favourable outcome.

Xanthogranulomatous adrenalitis masquerading as a functioning adrenocortical malignancy: a case report.

INTRODUCTION: Xanthogranulomatous adrenalitis (XA) is a rare chronic inflammatory disease of the adrenal glands and resembles adrenal neoplasm in clinical and radiologic characteristics. There is no report on XA presenting as a functioning adrenal mass in the literature. We present a case of XA mimicking a functioning adrenocortical carcinoma. CASE REPORT: A 52-year-old man presented with right flank pain, fever, vomiting, and loss of appetite for 2 weeks. He had signs of dehydration and elevated blood glucose level. Ultrasonography revealed a right adrenal mass. Contrast-enhanced computed tomography showed lobulated and necrotic mass replacing the right suprarenal gland and encasing the right renal vein, adjacent inferior vena cava, psoas, and diaphragm. There was loss of fat planes with liver and upper pole of the right kidney. Biochemical evaluation indicated increased serum and urine cortisol levels. As a sequel to hypercortisolism-induced hyperglycemia, he developed spontaneous chest wall abscess and bilateral sudden vision loss due to vitreous hemorrhages. Pus and blood culture grew methicillin-sensitive Staphylococcus aureus. Adrenal suppressant ketoconazole was administered for better glycemic control. With a diagnosis of locally advanced adrenocortical malignancy, right radical adreno-nephrectomy was performed, and cut section revealed a pus collection of around 100 mL. Histopathology examination showed xanthogranulomatous inflammation involving adrenal gland, Gerota's fascia, psoas, and lymph nodes. Postoperatively, the patient recovered satisfactorily with favorable glycemic control. CONCLUSION: XA can mimic adrenal neoplasms both clinically and radiologically and is associated with staphylococcal infection. It warrants surgical excision and culture-based antibiotics and is mostly diagnosed on postoperative histopathology.