Nutrition and Health in Arab Adolescents (NaHAR): Study protocol for the determination of ethnic-specific body fat and anthropometric cut-offs to identify metabolic syndrome.

The prevalence of adolescent obesity in the Middle-East is considered among the highest in the world. Obesity in adolescents is associated with several cardiometabolic abnormalities, the constellation of which is referred to as the metabolic syndrome (MetS). This multi-country cross-sectional study aims to determine the optimal cut-off values for body fat (BF); body mass index (BMI) z-score; waist circumference (WC) percentile, and mid-upper arm circumference (MUAC) for the prediction of MetS among adolescents from Kingdom of Saudi-Arabia (KSA), Kuwait, Jordan, Lebanon and Syria. A secondary objective is to examine the validity of Bioelectrical Impendence Vector Analysis (BIVA) in estimating BF against the deuterium dilution technique (DDL). In each country, a sample of 210 adolescents will be recruited. Data collection will include demographics, socioeconomic, lifestyle and dietary data using a multi-component questionnaire; anthropometric measurements will be obtained and body composition will be assessed using the DDL and BIVA; blood pressure and biochemical assessment will be performed for the identification of the MetS. Receiver operating characteristic analyses will be undertaken to determine optimal cut-off values of BMI, WC, MUAC and BF in identifying those with MetS. Odds ratios (OR) and their respective 95% confidence interval (CI) for the association of the anthropometric measurements with MetS will be computed based on multiple logistic regression analysis models. The Bland and Altman approach will be adopted to compare BIVA against the reference DDL method for the determination of body composition parameters. This study responds to the need for ethnic-specific anthropometric cut-offs for the identification of excess adiposity and associated cardiometabolic risks in the adolescent population. The adoption of the generated cut-offs may assist policy makers, public health professionals and clinical practitioners in providing ethnic-specific preventive and curative strategies tailored to adolescents in the region.

A decade in focus: mixed germ cell tumors with choriocarcinoma components.

Introduction: This 10-year registry review aimed to investigate the clinical behaviour and outcomes of mixed germ cell tumours with choriocarcinoma components, a rare and aggressive subtype of testicular cancer, in Saudi Arabia. The study explores the demographic characteristics of affected patients, tumour profiles, and the mortality rate associated with this malignancy. Methods: Utilizing data from the Saudi Cancer Registry, the authors identified 33 cases of mixed germ cell tumours with choriocarcinoma components among 1001 testicular cancer cases recorded between 2008 and 2017. Demographic information, including age, marital status, region of residency, year of diagnosis, and 10-year survival status, were collected. Tumour factors, such as the basis of diagnosis, origin site, behaviour, grade, extension, and laterality, were also analyzed. Results: The majority of cases (78.8%) occurred in the young age group (18-45 years), and most tumours (97%) originated in normally descended testes. Grade IV (undifferentiated anaplastic) tumours and distant metastasis were present in 45.5% of patients. All cases exhibited malignant tumour behaviour. The overall mortality rate was 15%, with a mean time from diagnosis to death of 7.72 months (range: 0.5-21.5 months). Conclusion: Mixed germ cell tumours with choriocarcinoma components are rare and tend to affect younger populations. These tumours demonstrate aggressive clinical behaviour, with a significant proportion presenting with high-grade lesions and metastasis at diagnosis. The observed mortality rate underscores the poor prognosis associated with this malignancy. Our study provides essential insights into the clinical characteristics of this rare tumour subtype in the Saudi Arabian population, emphasizing the need for further research to identify prognostic factors and optimize management strategies for affected patients.

Persistent Median Artery, Bifid Median Nerve, and Reversed Palmaris Longus Encountered During Cadaveric Dissection: The First Reported Case.

The median artery is a transient embryological structure that normally disappears with the development of the radial and ulnar arteries. In rare instances, though, it persists as the persistent median artery (PMA). The superficial and deep palmar arches are formed through the anastomoses of the radial and ulnar arteries, giving hand and digits their main blood supply. This complex network of vessels and their anastomoses are prone to anatomical variations based on how the anastomosis occurs and which arteries contribute to this anastomosis. While it normally forms through the anastomosis of the radial and ulnar arteries, the superficial palmar arch (SPA) may also form differently, as in our case here, where the median artery persisted and branched off the radial artery, anastomosing with the ulnar artery to give rise to the SPA. This may also interfere with the normal compartmental architecture within the hand, possibly contributing to various clinical pathologies like carpal tunnel syndrome (CTS). Notably, in addition to the persistent median artery, our findings revealed a reversed palmaris longus and a bifid median nerve. These two additional variations can potentially exacerbate the risk of CTS. Alone, the coexistence of the PMA and the reversed palmaris longus is deemed a rare anomaly, only reported once in the literature. The addition of a third variation to the existing ones, like the bifid median nerve, is first reported by us and calls for more investigation for a possible genetic mutation. In this case, we report a persistent median artery, reversed palmaris longus muscle, and bifid median nerve in the forearm of a male cadaver found during a routine anatomy teaching session.

Reversed Palmaris Longus: A Rare Anatomical Phenomenon Discovered.

The palmaris longus (PL) muscle is considered by many to be a vestigial muscle due to it having little to no functional significance on the upper limb. This, however, made it highly valuable in surgical procedures, especially as a graft in plastic and reconstructive cases. Variations in the muscle's morphology were discussed in the literature, but some are more rare than others. Those variations may have clinical implications on different pathologies such as Guyon's syndrome or Carpal tunnel syndrome based on the nerves and vessels surrounding it, and thus demand a proper understanding of the variation's anatomy. Here, we report a case of one of the rarer variations, a unilaterally reversed palmaris longus muscle in the left forearm of a 55-year-old male cadaver, discovered in a routine teaching session. Throughout the case, we will discuss the normal anatomy, the variation, and the clinical implications this variation may have.

A Rare Case Report of a Vertebral Artery Variant Arising From the Aorta With Its Clinical Significance: An Uncommon Anatomy Unveiled.

The vertebrobasilar (VB) system, comprising two vertebral arteries and one basilar artery, is responsible for providing vital vascular supply to the central nervous system structures. Disruption in this network can lead to fatal neurologic outcomes, and variations in the origin of vessels may contribute to unexplained symptoms of clinical relevance. Therefore, an extensive understanding of the VB system's anatomy and its variations is crucial for diagnosing neurological disorders. Here, we report a case of a vertebral artery variant arising from the aortic arch proximal to the left subclavian artery in the cadaver of a 50-year-old male, discovered incidentally during a teaching dissection session. We also discuss the clinical pathophysiology and the relevance of the neurological symptoms in relation to the anomaly.

The Clinical Significance of CD163+ Tumor-Associated Macrophages (TAMs) in Laryngeal Squamous Cell Carcinoma.

Background and objective The tumor's microenvironment is currently considered an important indicator of the tumor's prognosis, treatment failure, and recurrence. CD163+ tumor-associated macrophages (TAMs) are a marker of poor prognosis in many types of human cancers. In the present study, the expression of CD163+ TAMs was analyzed in laryngeal squamous cell carcinomas (LSCCs) using immunohistochemistry, and this expression was correlated with the clinical and pathological characteristics of LSCC patients. Materials and methods One commercial human larynx microarray with 80 cases of LSCCs, was used for this study. For comparison with normal laryngeal mucosa, a second microarray carrying normal tissues from all human anatomical sites, including normal laryngeal tissues, was used. Immunohistochemical staining was performed, and the primary antibody was a mouse monoclonal against human CD136. The absence of the primary antibody was used as a negative control. The percentage of positive cells was categorized into five scores: 0 (0%); 1, (1%-10%); 2, (11%-50%); 3, (51%-80%); and 4, (>80%). A case was scored as positive for CD163 with a score >= 1. The χ2 test was used to assess the CD163 expression in LSCC cases (N=80). A statistically significant difference was defined as P 0.05. Results The human larynx microarray containing 80 cases of LSCCs was used for this study. The age of the cancer patients in this array was in the range of 39 to 72, with a median of 53. LSCC grades were distributed as follows: 25 patients were designated as grade I, 43 were designated as grade II, and 6 were designated as grade III. Two tumors' (2/80) cores were missing from the microarray. Six tumors on the microarray did not have a grade designation reported by the manufacturer of the array. The expression of CD163 in normal, benign, unmatched laryngeal tissue was absent. In cancer cases, on the other hand, a significant number of LSCCs had TAMs that were positive for CD163 (87% positive tumors, with an IHC score ranging from 1 to 4, χ2=30.634; p<0.001). The rest of the LSCC cases (10 in total) had negative CD163 expression (score of 0). Conclusion A significant majority of LSCCs were found to have CD163+ TAMs expression using tissue microarrays (TMAs). This expression is positively correlated with the tumor's grade, clinical manifestation, and TNM staging. Morphologic evidence shows that the majority of LSCCs express the highest range of immunohistochemistry (IHC) scores for CD163 protein in the membranes and cytoplasm of their TAMs. This study provides evidence of the clinical significance of CD163+TAMs in LSCCs and proposes further studies to pinpoint the exact role of these cells in LSCC patients.

MINOCA mimic: Type 2 myocardial infarction due to severe aortic stenosis complicated by cardiogenic shock.

Acute myocardial infarction without significant obstructive coronary disease presents a challenging clinical entity that requires timely intervention. The term myocardial infarction with nonobstructive coronary arteries (MINOCA) describes a working diagnosis attributed to varying etiologies in patients with a presumed ischemic cardiac condition. Several overlapping etiologies can be classified as type 2 myocardial infarction (MI). The 2019 AHA statement established diagnostic criteria and clarified the associated confusion, aiding in appropriate diagnosis. In this report, we present a case of demand-ischemia MINOCA and cardiogenic shock in a patient with severe aortic stenosis (AS).

Stress cardiomyopathy as a cardiovascular manifestation of COVID-19.

Patients with coronavirus disease 2019 (COVID-19) may present with a broad spectrum of clinical manifestations, affecting several organ systems. Predominant cardiac manifestations include myocardial injury, heart failure, cardiogenic shock, and arrhythmias. Stress (takotsubo) cardiomyopathy, characterized by apical ballooning of the heart leading to acute left ventricular dysfunction, is rarely seen in patients with COVID-19. We present a case of COVID-19-associated stress cardiomyopathy in a female in her sixties.

Parotid Gland Tuberculosis: A Case Report and Literature Review.

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that primarily affects the lungs. Although TB can affect many organs, involvement of the head and neck is extremely rare and involvement of the salivary glands is even rarer. Clinical diagnosis is challenging and may be misdiagnosed, as it mimics neoplasms on physical exams and imaging. In this paper, we present a case of parotid tuberculosis in a 28-year-old man who presented with a painful left parotid mass, loss of appetite, fever, and weight loss for six months. Suspicion of infection arose, and treatment began with intravenous antibiotics, followed by oral antibiotics, with no improvement. A biopsy of the patient's left parotid gland was performed, and a diagnosis of parotid TB with jaw osteomyelitis due to Mycobacterium tuberculosis infection was made. The patient was started on isoniazid for one week, followed by isoniazid, ethambutol, and rifampicin for six months. Follow-up after six months showed full resolution of the swelling.

Thrombotic Thrombocytopenic Purpura and Metastatic Malignancy-Like Presentation Secondary to Hypervirulent Strain of Klebsiella pneumoniae: A Case Series.

Thrombotic thrombocytopenic purpura (TTP) is a rare and potentially fatal disease. The majority of cases are caused by a significant enzyme deficiency in the blood called the von Willebrand factor (VWF) cleaving protease (also called ADAMTS13). TTP is classified as a hematologic emergency because of the high mortality rate. The diagnosis is difficult due to the extensive overlap in the clinical manifestations of TTP and other illnesses. Klebsiella pneumoniae infection can in very rare instances present with TTP and/or a metastatic-like presentation where the patient might have prostate, liver, brain, and lung abscesses mimicking late-stage solid organ malignancy. In this paper, we report a case of TTP secondary to Klebsiella pneumoniae infection in a 38-year-old male patient, who presented with fever, cough, and shortness of breath for five days. On examination, he was vitally unstable, confused, and not oriented, with a Glasgow Coma Scale (GCS) of 9/15. Complete blood count (CBC) showed a high white blood cell (WBC) count, very low platelet count, increased reticulocyte count, and significant elevation of schistocytes on peripheral blood film. Sputum and blood cultures were positive for Klebsiella pneumoniae. Computerized tomography (CT) scan chest showed bilateral lung parenchymal nodules. An abdominal ultrasound (US) scan detected a right hepatic lobe lesion that was both cystic and solid. The patient was initially started on meropenem, vancomycin, and levofloxacin due to shock presentation which was de-escalated to ceftriaxone later. The patient had five therapeutic plasma exchange sessions and was started on methylprednisolone for three days. The patient's situation gradually improved, and he was discharged later on. The second case is a 63-year-old-male patient who presented with fever, dry cough, night sweats, and dysuria for seven days. He was vitally stable, conscious, alert, and oriented. His hemoglobin was 9.6 g/dl. He was scheduled for an urgent colonoscopy to rule out colon cancer along with computed tomography (CT) scan of the chest, abdomen, and pelvis. The CT scan showed complex cystic lesions involving the right hepatic lobe, lungs, adrenal glands, and prostate. The clinical picture was suggestive of hyper-mucoid Klebsiella pneumoniae infection showering to the liver, adrenal glands, and prostate. A drained prostate collection and urine cultures confirmed the diagnosis. The patient was managed with surgical drainage of the collection in addition to ceftriaxone and metronidazole. The patient was discharged in good health on ciprofloxacin with follow-up as an outpatient.

Painless Left Scrotal Mass: A Rare Case of Paratesticular Angiofibroma.

Angiofibromas, also known as angiomyofibroblastoma-like tumors or AMF-like tumors, refer to a collection of rare, benign yet highly cellular tumors of the vulva, scrotum, perineum, or inguinal region. In this paper, we present a 34-year-old Saudi man who presented with findings of a testicular tumor on physical examination and imaging and tested negative for all the markers associated with testicular tumors.

A Case of Cytomegalovirus Colitis in an Immunocompetent COVID-19 Patient.

Cytomegalovirus (CMV) is a double-stranded DNA virus that belongs to the herpesvirus family. In the immunocompetent host, CMV infection is usually mild and goes unnoticed. Patients become prone to CMV infection as a result of immunosuppressive drugs or disorders that weaken cellular immunity. In severe COVID-19 infection, the patient experiences a drop in his T lymphocytes and becomes prone to opportunistic infections such as CMV colitis. In this paper, we presented a rare case of CMV colitis in a 54-year-old female with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) polymerase chain reaction. The patient was admitted to the intensive care unit and intubated due to the severity of her presentation. The patient received high-dose dexamethasone followed by a tapering dose of prednisolone. Fifteen days post-admission, the patient started to have melena with a drop in her hemoglobin. Sigmoidoscopy revealed ulcerated lesions that extended 5 cm proximally, and multiple biopsies confirmed the diagnosis of CMV colitis. The patient was started on ganciclovir 5 mg/kg intravenously for 21 days. The patient's symptoms improved to the point where she no longer complained of melena, and her hemoglobin level normalized. The patient was discharged home in stable condition, to be followed later in the outpatient clinic.

Acute Abdomen Secondary to Granulomatous Appendicitis: A Rare Case of Complicated Appendicitis.

Acute appendicitis is one of the most common surgical presentations seen in the emergency department, usually presenting as a case of fever, anorexia, and abdominal pain. Curative treatment is an appendectomy with histological examination of the surgical specimen to diagnose the subtypes or causes of appendicitis. One of these subtypes, granulomatous appendicitis, is an uncommon form of appendicitis. This condition can be caused by a multitude of mechanisms, including tuberculosis infections, parasitic infections, fungal infections, mechanical obstruction, or systemic diseases such as Crohn's disease, sarcoidosis, among others. Investigations and management should be tailored according to the histologic findings, and patient follow-up should be advised.

Acquired Hemophilia A Post-COVID-19 Vaccination: A Case Report and Review.

Acquired hemophilia A (AHA) is an inhibitory coagulopathy that represents a rare variant of hemorrhagic syndromes. We present a case of idiopathic AHA in a 75-year-old male patient with a cutaneous hematoma that could be attributed to a recent COVID-19 vaccination. The aim of this report is to raise awareness of a possible association between AHA and COVID-19 vaccination and to review similar reported cases and management plans to prevent the development of possible morbidity and debilitating complications. This case illustrates an exceptionally rare side effect of the COVID-19 vaccination. The advantages of obtaining the COVID-19 vaccine outweigh the risks.

A Strange Occurrence of Hematohidrosis: A Case Report From Saudi Arabia.

Hematohidrosis is a rare disorder of blood excretion from the eccrine sweat gland not associated with an injury or trauma. Although several hypotheses exist to explain such a condition, the etiology of hematohidrosis remains unknown. Psychological stress is strongly linked to the condition, yet patients may present completely healthy with no identifiable etiology. The diagnosis of hematohidrosis can be difficult and requires the exclusion of bleeding disorders, vasculitis, and other disorders. Here, we present a case of hematohidrosis in a 20-year-old female who had almost weekly bloody tears, as well as gum bleeding, ear bleeding, and epistaxis for the past four months. During hospitalization, the patient was thoroughly investigated for an etiology, but no identifiable cause was found. The patient was diagnosed with hematohidrosis and treated with propranolol. Her condition had improved significantly on follow-up.

Fruitful Pregnancy Outcome in a Case of Eisenmenger Syndrome With Severe Pulmonary Hypertension: A Rare Case Report.

Eisenmenger syndrome (ES) is considered an absolute contraindication for pregnancy. ES is characterized by a congenital heart abnormality that results in a significant anatomical shunt. Hemodynamic forces generate a left-right shunt, leading to severe pulmonary arterial hypertension (PAH). Eventually, the shunt will become a right-to-left shunt due to increased pulmonary vascular resistance, leading to significant hypoxemia and cyanosis. Pregnant women with ES experience volume overload as a result of the syndrome and the physiological response of pregnancy. The decrease in systemic vascular resistance that occurs during pregnancy also increases the right-to-left shunt, resulting in left ventricular failure. Due to the significant risk to both the mother and the fetus, women are advised to terminate their pregnancy during the first trimester. However, with all the odds, very few cases show positive neonatal and maternal outcomes. Appropriate management of ES includes a multidisciplinary team assembled to monitor and manage the patient carefully and thoroughly. In this paper, we present a case of ES secondary to an atrial septal defect with severe PAH in a 32-year-old woman who underwent a cesarean section at 33 weeks of gestation. She delivered a healthy baby girl. On the seventh postoperative day, she was discharged with no complications.

Unusual Lower Lip Swelling: A Rare Case of Lip Schwannoma.

Schwannoma (neurilemmoma) is a benign neoplasm that arises from the nerve sheath's Schwann cells. Between 25% and 40% of all schwannomas are discovered in the soft tissues of the head and neck area, but they are infrequently detected in the oral cavity, with the lips being the most unusual site of involvement. Peripheral nerves in the intraoral cavity originate only 1% of schwannomas despite the fact that lips and oral cavity are heavily innervated anatomical areas. Schwannomas are more common in people between the third and fifth decades of life, and there is no predilection based on gender or race. Here, we report a case of lip schwannomas in a 22-year-old female. The lesion was affecting her lower lip and growing steadily for the past two years. The mass measured 1.5 x 1 cm, involving the lower lip with surface telangiectasia. The patient underwent surgical removal of the lower lip mass, and the mass was sent for histopathological correlation that showed completely excised encapsulated schwannoma with free margins. The patient did not have any postoperative complications and was discharged home on the same day. The patient was followed up in the outpatient clinics, and she made full recovery and was pleased with the outcome.

A Challenging Case of Persisting Hypokalemia Secondary to Gitelman Syndrome.

There are several causes of hypokalemia, including transcellular shift, renal loss, gastrointestinal loss, and decreased oral intake. Sometimes it is challenging to know the source of the problem; however, with detailed history, physical examination, and appropriate laboratory investigations, the physician should be able to narrow down the differentials diagnosis to reach the right one. One of the rare causes of hypokalemia is Gitelman syndrome, which is a salt-losing tubulopathy that manifests as renal potassium wasting, metabolic alkalosis, hypokalemia, hypomagnesemia, hypocalciuria, and hyperreninemic hyperaldosteronism. This disorder is inherited in an autosomal recessive pattern with an incidence of 25 instances per million population. We report a challenging case of persistent hypokalemia in a 30-year-old woman who presented with a history of palpitation, bilateral upper and lower limbs numbness, nausea, diarrhea, and generalized fatigue for three days. After history and physical examination, the patient was diagnosed with an episode of enteritis, and laboratory workups revealed low potassium and magnesium levels, and it was thought that these electrolyte abnormalities were secondary to gastrointestinal loss. Therefore, the patient was mainly treated supportively along with potassium and magnesium replacement. However, after one week of replacement, the patient still had low potassium and magnesium levels in spite of being diarrhea-free, so renal loss was suspected. Urine electrolytes revealed high renal potassium loss with low-normal blood pressure, arterial blood gases revealed metabolic alkalosis with a pH of 7.49 and bicarbonate level of 29 mEq/L. Repeated urine chemistry was done to check for chloride level and turned out to be high, and 24-hour urinary excretion of calcium was very low. Therefore, the patient was diagnosed with Gitelman syndrome and was managed with potassium and magnesium replacements intravenously, and was encouraged to consume a diet rich in these electrolytes. After complete resolutions of the symptoms and correction of potassium and magnesium levels, the patient was discharged home in stable condition.

Acute Transverse Myelitis Following COVID-19 Infection: A Rare Case From Saudi Arabia.

Respiratory viral illnesses can lead to a wide variety of neurological complications. However, only a few cases of acute transverse myelitis (ATM) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in the literature. Here, we report a case of ATM following SARS-CoV-2 infection in a 57-year-old male patient. The patient presented to the emergency room with lower abdominal pain, urinary retention, bilateral lower limbs weakness, and allodynia for the last four days. One week earlier, he had experienced fever, cough, and shortness of breath. On physical examination, he was vitally stable with sensory loss from the nipples down to the lower limbs bilaterally. His nasopharyngeal polymerase chain reaction for SARS-CoV-2 was positive. MRI of the spine showed an abnormal cord signal extending from the level of the D2 vertebra down to the conus medullaris. The main differential diagnosis was transverse myelitis, and the patient was started on pulse steroids for seven days. After the therapy, the condition of the patient improved with the restoration of power and sensory sensation in his lower limbs. A new MRI of the whole spine one month later showed normal morphology and signal intensity without any abnormal enhancement. The patient was discharged home with almost complete resolution of his symptoms for later follow-up in the clinic.

Toxic Epidermal Necrolysis Post COVID-19 Vaccination - First Reported Case.

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of acute, delayed-type hypersensitivity reactions that affect the skin and the mucous membranes. Medications are the culprit cause of these disorders in addition to infections and in very rare instances vaccinations. We report a case of TEN in a 49-year-old woman with no previous medical history. The disorder developed one week after receiving the first dose of COVID-19 vaccine with no other identifiable causes. The patient received two doses of tumor necrosis factor-alpha inhibitor (etanercept) and she stopped developing new lesions after two days of the initial dose; complete healing was observed after 22 days and no side effects were observed in our patient. This case demonstrates an extremely rare complication to the COVID-19 vaccine. The benefits of receiving the COVID-19 outweigh the potential risk.