Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community.

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson's chi-square test of association, Student's t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient's outcome.

Splenic Hamartoma: A Case Report and Literature Review.

BACKGROUND Splenic hamartoma (SH) is a benign vascular lesion, usually found incidentally on abdominal images or at autopsy. Only around 200 cases have been reported since 1861, when SH was first described by Rokitansky. Although it is very rare, it is important to be familiar with it, as it may be a diagnostic challenge to distinguish SH from other mass lesions of the spleen based solely on preoperative investigations. CASE REPORT We describe a case of symptomatic, isolated, single splenic hamartoma in a 19-year-old, otherwise healthy young man who presented with upper abdominal pain, nausea, and vomiting for a few months. The examination was unremarkable. The patient has been previously evaluated with abdominal ultrasonography, which found a suspicious splenic hyperechoic lesion. Computed tomography revealed a heterogeneous 5×7 cm enhancing lesion in the spleen, concerning for splenic hamartoma. The patient underwent laparoscopic splenectomy and recovered well. The histopathology examination confirmed the diagnosis of splenic hamartoma. CONCLUSIONS Splenic hamartoma is a rare benign vascular lesion of debated etiology. Most cases are asymptomatic and are found incidentally on images, in splenectomies performed for other reasons, or at autopsy. Radiologic findings may suggest the diagnosis and new modalities have shown accuracy in distinguishing splenic hamartomas. However, resection with formal or partial splenectomy is usually still needed since the differential diagnosis is wide, from benign to aggressive lesions, and histopathology remains the criterion standard for diagnosis. Given its benign nature, we found no cases of recurrence or metastasis in the literature.

Kikuchi-Fujimoto disease in the Eastern Mediterranean zone.

Kikuchi-Fujimoto disease (KFD) is a rare benign and self-limiting syndrome. We aim to review cases of KFD at our institution as a rare illness in the Arab ethnic descent and to analyse reports from most countries in the East Mediterranean zone. This is a retrospective study in which the histopathology database was searched for the diagnosis of KFD. A full review of KFD patients' medical records was done. Data regarding demographic features, clinical presentation, laboratory findings, comorbidities, and management protocols were obtained. Published KFD cases from east Mediterranean countries were discussed and compared to other parts of the world. Out of 1968 lymph node biopsies studied, 11 (0.6%) cases of KFD were identified. The mean age of patients with KFD was 32 years (4-59). 73% (8/11) were females. The disease was self-limiting in 5 patients (45%); corticosteroid therapy was needed in 4 patients (34%). One patient was treated with methotrexate and one with antibiotics. One patient died as a consequence of lymphoma. Jordanians and Mediterranean populations, especially those of Arab ethnic background, seem to have low rates of KFD. The genetic susceptibility theory may help to explain the significantly higher disease prevalence among East Asians. Early diagnosis of KFD-although challenging-is essential to reduce the morbidity related to this illness.

Intractable Biliary Candidiasis in Patients with Obstructive Jaundice and Regional Malignancy: A Retrospective Case Series.

BACKGROUND: Candida species are infrequently grown in bile cultures. An association between biliary candidiasis and regional malignancy may exist. The role of fungus membranes in frequent biliary stent occlusion is also presented in this case series. METHODS: We retrospectively identified patients who underwent percutaneous trans-hepatic cholangiogram (PTC) for obstructive jaundice between January 2014 and January 2019. The results of bile cultures - obtained by PTC - for all patients were analyzed, and patients with fungus growth were determined; their medical records were reviewed. RESULTS: A total of 71 patients with obstructive jaundice underwent PTC between January 2015 and January 2019. Five patients (all male; mean age 55.8 years) had candida species growth in bile cultures. Two patients were diagnosed with cholangiocarcinoma, one with adenocarcinoma of the head of the pancreas, one with gallbladder cancer, and one with locally advanced gastric adenocarcinoma. Formation of fungal balls predisposed to frequent PTC drain clogging. Eradication of Candida was achieved in 4 patients after 10 days to 3 weeks of antifungal therapy. CONCLUSION: We present a case series of biliary candidiasis in patients with obstructive jaundice and regional malignancy. We suggest that patients with obstructive jaundice and regional malignancy should be screened for biliary candidiasis. Persistent cholestasis may be caused by the recurrent formation of fungal membranes (balls).

Mesenteric cystic lymphangioma: A case report.

INTRODUCTION AND IMPORTANCE: Mesenteric cystic lymphangiomas are rare benign lesions of the abdominal cavity characterized by lymphatic vessels malformation with an unknown etiology. Despite the silent clinical course of mesenteric cystic lymphangiomas, they are considered as clinically tricky lesions with an immense spectrum of presentations. CASE PRESENTATION: We present a case of abdominal mesenteric cystic lymphangioma in a 1-year 9-month-old female patient, who complained of fever and abdominal pain for 10 days duration. Laboratory investigations, abdominal X-ray, ultrasonography, computed tomography and histopathological examination were all used to establish the diagnosis. CLINICAL DISCUSSION: A trial of true-cut biopsies performed by an interventional radiologist was not informative, so a multidisciplinary team decision was made to excise the mass. Intraoperative findings include multiloculated fused cystic lesion (8.0 × 5.0 × 4.0 cm) on the descending mesocolon. Histopathological examination revealed the diagnosis of a mesenteric cystic lymphangioma. The postoperative period was not complicated. CONCLUSION: Mesenteric cystic lymphangiomas are mostly asymptomatic in nature, yet predisposed to life threating events. Surgical excision is the modality of treatment characterized by low recurrence rate and a non-complicated postoperative period.