Primary extraskeletal intradural Ewing sarcoma with acute hemorrhage: a case report and review of the literature.

BACKGROUND: Spinal cord tumors present a challenge in diagnosis and treatment due to their varied histopathological characteristics. While Ewing sarcoma is a rare malignant tumor typically originating from skeletal bone, cases of primary intradural extraskeletal Ewing sarcoma are exceptionally rare. The similarity of its presentation to other spinal tumors further complicates its identification and management. CASE PRESENTATION: We report a case of a 58-year-old Palestinian male with intradural extraskeletal lumbar Ewing sarcoma. The patient initially presented with lower back pain and bilateral S1 radiculopathy, with more severe symptoms on the left side. Magnetic resonance imaging revealed a 7 cm oval-shaped mass with homogeneous contrast enhancement, obstructing the spinal canal from L3/L4 to L5/S1 levels. Initially, a myxopapillary ependymoma was suspected, but the patient's sensory and motor functions suddenly deteriorated during hospitalization. Repeat magnetic resonance imaging indicated heterogeneous contrast enhancement, indicating acute intratumoral hemorrhage. Consequently, the patient underwent emergent L3-L5 laminotomy, with successful gross total resection of the tumor. Histopathological and immunohistochemical analyses confirmed the diagnosis of intradural extraskeletal Ewing sarcoma. Adjuvant therapy was administered to minimize the risk of local recurrence or distant metastasis. A systematic review of relevant literature, along with retrospective analysis of medical records, operative reports, radiological studies, and histopathological findings of similar cases, was also conducted. CONCLUSIONS: Intradural extraskeletal Ewing sarcoma is an infrequently encountered condition in adult patients, emphasizing the importance of considering it in the differential diagnosis of spinal tumors. Surgeons must possess a comprehensive understanding of this rare entity to ensure accurate staging and optimal management, particularly in the early stages when prompt intervention may improve prognosis.

An Undiagnosed Shone Complex in a 52-Year-Old Female: A Case Report.

Shone complex (SC) is a rare congenital heart disease characterized by four obstructive anomalies, including parachute mitral valve (PMV), left atrial supra-valvular ring, subaortic stenosis, and coarctation of the aorta. Typically, SC manifests early in life. However, we encountered a 52-year-old female with a history of hypertension diagnosed at 26 years and left-sided weakness poststroke. She presented with worsening dyspnea and palpitations, prompting a thorough investigation. Echocardiography revealed a heavily calcified bicuspid aortic valve with severe aortic stenosis and parachute mitral valve with severe mitral stenosis and preserved ejection fraction, raising suspicions regarding the presence of SC. Cardiac catheterization, aortic-angiography, and noncontrast chest computed tomography (CT) revealed abrupt occlusion of the postductal aorta, giving a picture of aortic coarctation with well-established collateral vessels including prominent right and left internal mammary arteries. So, she was diagnosed with an incomplete SC at the age of 52. Shone complex is a rare congenital heart disease that typically presents in early childhood, but late presentations due to misdiagnosis or incomplete work up are possible. This case emphasizes the rarity of late presentations of SC and highlights the importance of early diagnosis and intervention to improve outcomes. An incomplete SC should be considered in adult patients presenting with left-sided obstructive lesions.

A Case Series of Median Arcuate Ligament Syndrome With Varied Presentations.

Median arcuate ligament syndrome (MALS) is characterized by the constriction of the celiac trunk caused by fibrous connections originating from the median arcuate ligament (MAL) and diaphragmatic crura. It presents with symptoms often leading to misdiagnosis. In this study, we present three cases of MALS, with distinct manifestations. These cases were diagnosed through comprehensive investigations and managed successfully using laparoscopic decompression. The diagnosis of MALS poses challenges due to its variable presentations and overlap with other conditions. Diagnostic imaging techniques such as Doppler ultrasound, computed tomography (CT) scans and angiography play a role in confirming the diagnosis. Laparoscopic decompression has proven to be a treatment option that relieves symptoms and restores blood flow. This series highlights the importance of considering MALS as a cause for abdominal pain cases. Early detection and the use of diagnostic techniques can result in favorable outcomes.

Gonococcal endocarditis in a 32-year-old male: a rare presentation of an underrecognized disease - case report.

Introduction and importance: Disseminated gonococcal infection (DGI) is an infrequent but serious complication of gonorrhea that can exhibit atypical symptoms. While rare, it can lead to infective endocarditis (IE), a condition that affects the heart valves and can result in severe and potentially life-threatening outcomes. Case presentation: We present a case of Neisseria gonorrhoeae-caused IE confirmed by blood culture and direct isolation from the aortic valve vegetation. Our patient experienced complications, including glomerulonephritis, respiratory failure, and positive troponin. Urgent surgery successfully removed a large vegetation, replaced the aortic valve, and improved cardiac function. Follow-up showed symptom resolution. Clinical discussion: DGI can present atypically with a triad of tenosynovitis, polyarthralgia, and rash, even without genitourinary symptoms. However, it can also present with nonspecific symptoms, leading to a later diagnosis of IE, as observed in our patient, who developed an aortic valve abscess and aortic regurgitation. Conclusion: This case provides important insights into the diagnosis and management of gonococcal endocarditis, emphasizing the significance of early recognition, timely intervention, and multidisciplinary collaboration in improving patient outcomes. It is imperative to have a high level of suspicion for this rare entity, given its high virulence and potential for severe complications.

Gray Platelet Syndrome-Unusual Presentation with Spontaneous Splenic Rupture: A Case Report and Literature Review.

Gray platelet syndrome (GPS) is a rare hereditary hemorrhagic disorder characterized by macrothrombocytopenia and the absence of alpha-granules in platelets. Clinically, mild-to-moderate bleeding is the main manifestation, often accompanied by thrombocytopenia, splenomegaly, and myelofibrosis. Here, we present a case of a 15-year-old male patient with a history of hepatosplenomegaly, and thrombocytopenia for 8 years, who presented with sudden generalized abdominal pain. Despite initial suspicion of gastroenteritis, diagnostic imaging revealed an extensive hemoperitoneum. Subsequent genetic testing confirmed the diagnosis of GPS, which had not been previously identified. This case highlights the importance of considering inherited platelet disorders should be considered in adolescents with long-standing thrombocytopenia, and emphasizes the need for thorough evaluation in patients with suggestive symptoms.

Takotsubo cardiomyopathy prevalence and associated factors in patients presenting with a clinical picture of acute myocardial infarction in Palestine.

BACKGROUND: Takotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction. Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine. RESULTS: A retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2-93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0-86.7%) and dyspnea (20.4%, 95% CI 16.3-24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2-75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8-89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20-49.9 to 59-76% within a mean time of 7-37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5-2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8-98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation. CONCLUSIONS: TC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study's results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.

Interrupted inferior vena cava syndrome discovered incidentally after minimally invasive mitral valve repair in a 31-year-old female patient: A case report.

INTRODUCTION: Femoral cannulation is a technique used in minimally invasive cardiac surgery (MICS) for accessing the heart through the femoral artery and vein. However, the presence of an interruption in the inferior vena cava (IVC) can pose challenges during the procedure. Understanding the patient's venous anatomy is crucial to ensure successful cannulation. PRESENTATION OF CASE: We present the case of a 31-year-old female patient scheduled for minimally invasive mitral valve repair. During the procedure, femoral vein cannulation was unsuccessful. Subsequent diagnostic Computed Tomography (CT) revealed an interrupted IVC with azygos continuation. DISCUSSION: The interruption of the IVC can make cannulation through the femoral vein difficult or impossible due to the absence of the femoral vein or the presence of a collateral, necessitating alternative approaches. Preoperative imaging, such as CT, plays a significant role in identifying IVC interruptions and guiding surgical planning. CONCLUSION: Our case highlights the challenges associated with IVC interruptions during femoral cannulation in MICS. Preoperative imaging is essential for identifying anatomical variations and determining the most appropriate cannulation approach.

Rosai-Dorfman disease presenting as autoimmune hemolytic anemia in a male child in Palestine: a case report.

Rosai-Dorfman disease (RDD) is a rare, benign non-Langerhans cell histiocytosis predominantly affects lymph nodes and skin. Despite its benign nature, RDD can cause serious hematological complications. A 14-year-old male, presented with 3-month history of hemolytic anemia, lymphadenopathy, hepatosplenomegaly and rash. After thorough investigation, RDD was diagnosed by mediastinal lymph node biopsy that revealed presence of S100 and CD68-positive cells with absence of CD1a confirming the diagnosis of RDD. Treatment involved combination of steroids and Rituximab, which proved to be highly effective. The patient had dramatic improvement and entered remission, with follow-up period of 2 years. It is important to note that although RDD is a rare disease, it causes severe complications, as evidenced by the patient's parameters. Thus, prompt diagnosis and treatment are paramount. Histological diagnosis is of great value, as it helps confirming and guiding treatment decisions. With the right treatment, patients can experience great recovery and quality of life.

Unveiling follicular thyroid carcinoma by solitary spinal metastasis causing severe neurological deficit in a 67-year-old female: A case report.

INTRODUCTION AND IMPORTANCE: Follicular thyroid carcinoma (FTC) exhibits the ability to metastasize hematogenously to distant organs. Spinal metastasis is an unusual site for metastasis that even when it does, spinal metastasis manifests late in the course of the disease and is frequently linked to advanced disease and a bad prognosis. Until 2019, the literature only showed 29 cases of FTC with spinal metastasis as the first presenting feature. CASE PRESENTATION: We present a case of a 67-year-old female who presented with an acute onset of severe neurological deficit that ended up bedridden. Magnetic resonance imaging of the spine revealed a spinal lesion causing severe spinal cord compression. Urgent surgical decompression was performed, and the histopathology confirmed metastatic FTC. Subsequent comprehensive evaluation, unveiled a primary thyroid tumor. CLINICAL DISCUSSION: FTC accounts for 1 % of all malignancies, Therefore, regardless of how irrelevant symptoms may appear at first, it is important to understand all risk factors, screening recommendations, diagnostic techniques, treatment, and the vast range of potential presenting symptoms. Just like our patient, who had incontinence and abrupt loss of motor and sensory function in her lower limbs to be diagnosed with spinal cord compression by metastatic FTC. CONCLUSION: This instance emphasizes how crucial it is to consider FTC as a possible differential diagnosis in cases with spinal metastasis, even when there is no known primary thyroid cancer. Prompt diagnosis, comprehensive staging, and multidisciplinary management are crucial in optimizing outcomes.