Biliary co-infection by multidrug-resistant Candida glabrata and Candida albicans in a case of pancreatic cancer with cholangitis: A case report and review of literature.

Herein, we report a case of pancreatic cancer with acute cholangitis secondary to biliary obstruction. Empirical antibiotic therapy did not change the clinical presentation. Blood cultures were sterile; however, bile culture was positive for yeasts. Our laboratory analysis revealed a biliary coinfection by multidrug-resistant C. glabrata and C. albicans. The patient was successfully treated with endoscopic biliary drainage.

Improvement in right heart function following kidney transplantation in esrd patients: insights from speckle tracking echocardiography analysis.

Chronic kidney disease (CKD) is commonly associated with unfavorable cardiovascular outcomes and remains the leading cause of mortality in individuals with end-stage renal disease (ESRD). Despite substantial knowledge about the impact of CKD on the left heart, the right heart, which holds significant clinical relevance, has often been overlooked and inadequately assessed in ESRD patients who have undergone kidney transplant (KTx). This study aimed to evaluate the effects of KTx on the right heart chambers in ESRD patients. 57 adult KTx candidates were enrolled in this prospective longitudinal study, while 49 of them were included in the final assessment. Patients underwent a comprehensive cardiac assessment, including conventional echocardiography, speckle tracking echocardiography, and three-dimensional heart modeling both before and after surgery. Echocardiographic assessments showed significant increases in right ventricular (RV) ejection fraction, RV fractional area change (RVFAC), tricuspid annular plain systolic excursion, RV fractional shortening, right atrial (RA) reservoir, conduit, and booster strains, and RV global longitudinal strain (RVGLS). Moreover, significant reductions in RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV stroke volume, RV end-diastolic diameter (RVEDD) in mid-cavity view, systolic pulmonary artery pressure was observed (all P values < 0.05). However, no significant difference was found in S velocity, as well as RVEDD in basal and apex-to-annulus view. Moreover, pre-KTx measurements of RVGLS, RVEDD (apex-to-annulus diameter), RV fractional shortening, and S velocity were predictors of RVGLS after KTx. RA conduit strain was also identified as a predictor of RA conduit strain after KTx. Additionally, age, RVEDV, RVESV, RVFAC, and RA reservoir strain before KTx were identified as independent predictors of RA reservoir strain after KTx. The findings of this study demonstrate a significant improvement in right heart function following KTx. Furthermore, strain analysis can provide valuable insights for predicting right heart function after KTx.

Rectal gastrointestinal stromal tumor (GIST) in a patient with Crohn's disease: a rare coincidence case report and brief literature review.

Gastrointestinal stromal tumors (GISTs) are the most common type of gastrointestinal mesenchymal tumors. The most common site for developing these neoplasms is the stomach and small intestine. In contrast, anorectal GISTs are very rare. Population-based studies have shown an increased risk of colorectal cancers (CRC) in patients with Crohn's disease (CD). As in sporadic CRC, adenocarcinomas are the most commonly observed tumor. Accordingly, it is expected that rectal mass in CD patients to be an adenocarcinoma. Some reports have presented CD cases with GISTs along the gastrointestinal tract; however, to the best of our knowledge, a rectal GIST has not been reported in CD. Herein, we report a 41-year-old woman with CD who presented with 8 weeks of constipation and was diagnosed with rectal GIST and briefly review existing reports regarding GIST in IBD.

Diagnostic Performance of Ultrasonography for Identification of Small Bowel Obstruction; a Systematic Review and Meta-analysis.

Introduction: Small bowel obstruction (SBO) is known as a common cause of acute abdominal complaints in the emergency department (ED). The modality of choice for the diagnosis of SBO has not yet been established. This systematic review and meta-analysis aimed to investigate the accuracy of ultrasonography for the diagnosis of SBO. Methods: Systematic search was performed on five electronic databases including Medline, Scopus, Web of Sciences, Embase, and Cochrane Library, and the retrieval period was from the inception of each database to November 2023. The quality of the included studies were investigated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). The pooled values of diagnostic characteristics for ultrasonography were estimated using meta-Disc and Stata statistical software. Results: Twenty-one studies with a total of 1977 patients were included in the meta-analysis. The pooled estimate for sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary ROC curve of ultrasonography for diagnosing SBO were 0.93 (95% CI: 0.91-0.95), 0.8 (95% CI: 0.77-0.83), 5.69 (95% CI: 3.64-8.89), 0.1 (95% CI: 0.07-0.16), 83.51 (95% CI: 18.12-182.91) and 0.96, respectively. Conclusion: The findings of this meta-analysis showed that the utilization of ultrasonography holds promise as a diagnostic imaging for SBO with high accuracy. However, additional worldwide studies are essential to get more evidence on the value of ultrasonography for the diagnosis of SBO.

Transient lateral rectus palsy associated with acute coronary syndrome treated with percutaneous coronary intervention: a case report.

BACKGROUND: Patients who experience angina and acute myocardial infarction often receive diagnostic coronary angiography and percutaneous coronary intervention. CASE PRESENTATION: A 54-year-old Persian man with acute coronary syndrome was admitted to the hospital and underwent elective percutaneous coronary intervention. Two hours after the procedure, the patient experienced ophthalmoplegia and diplopia. The diagnosis was abducens nerve palsy resulting in transient lateral rectus palsy. The cause is presumed to have been an ischemic event affecting the unilateral abducens nerve. This could have occurred owing to the microembolism during the percutaneous coronary intervention, which resulted in left lateral rectus palsy. Within 1 month, the diplopia was relieved completely, and the physical examination was normal. CONCLUSION: The occurrence of neuro-ophthalmic complications that may arise from percutaneous coronary intervention is extremely rare. To our knowledge, this is the second reported case of unilateral rectus palsy associated with percutaneous coronary intervention.

Trivalvular nonbacterial thrombotic endocarditis in a patient with colon adenocarcinoma: a case report.

BACKGROUND: Nonbacterial thrombotic endocarditis is a rare complication of prothrombotic states such as neoplasms that can cause valvular dysfunction and life-threatening complications. Nonbacterial thrombotic endocarditis usually affects the left-sided valves; however, only a minority of cases involving the tricuspid valve have been reported in medical literature. CASE PRESENTATION: The current report describes trivalvular involvement by nonbacterial thrombotic endocarditis in a 54-year-old Azeri female patient with metastatic colorectal carcinoma. This case underlines the necessity of evaluating nonbacterial thrombotic endocarditis as a possible consequence in cancer patients. When thromboembolic events are found in the presence of a hypercoagulable state (such as malignancy) and no growth on blood cultures, nonbacterial thrombotic endocarditis could be suspected as the cause. CONCLUSION: It is critical to achieve early diagnosis in such a setting to initiate treatment plans and prevent further complications rapidly.

A case report of clubbing as the initial sign of systemic sclerosis sine scleroderma: A rare possible presentation.

Key Clinical Message: Even in the absence of characteristic cutaneous symptoms of scleroderma, systemic sclerosis should be considered in the differential diagnosis of patients initially diagnosed with idiopathic interstitial lung disease. Abstract: Systemic sclerosis (SSc) is an idiopathic connective tissue disorder characterized by multisystem involvement. Although skin thickening is a hallmark manifestation of SSc, a subset known as systemic sclerosis sine scleroderma (ssSSc) presents with internal organ involvement and positive serologic markers in the absence of significant cutaneous manifestations. We report the case of a 36-year-old Iranian woman who presented with clubbing as an initial symptom of ssSSc. Notably, clubbing as the sole initial sign of the disease has not been previously reported. Timely diagnosis of ssSSc is crucial to facilitate appropriate treatment and prevent disease progression. Physicians should adopt a comprehensive approach when evaluating patients presenting with limited clinical features, as they might be indicative of underlying ssSSc.

Therapeutic Effects of Low-Level Laser on Male Infertility: A Systematic Review.

Introduction: The objective of this study was to assess the effectiveness and safety of photobiomodulation (PBM) in the treatment of male infertility. Methods: We searched Google Scholar, PubMed, and the reference sections of relevant papers published from January 1, 2000 to September 23, 2022. We retrieved all publications related to the impact of PBM on male infertility. After reviewing the titles, abstracts, and full texts, we included fifteen papers in the research. The studies involved 477 semen samples (in vitro studies) and 70 male participants (randomized clinical trials). Results: All 14 in vitro studies that evaluated effectiveness reported that PBM was successful in increasing the proportion of progressive sperms in semen samples. Various methods were used to evaluate the safety. One study with a sample size of 58 concluded that PBM was not a safe treatment, whereas the other ten studies confirmed its safety. Only one clinical trial evaluated the effect of laser acupuncture on male infertility and found improvements in sperm progressive motility without any serious adverse effects. Conclusion: All 15 studies evaluating effectiveness reported that the low-level laser was effective for increasing the proportion of progressive sperm in semen samples and that it was safe to use. However, due to the heterogeneity of population characteristics, source characteristics, duration of exposure, sample size, and instruments for measuring safety and efficacy, we cannot conclude that the positive results obtained from the reviewed studies are solely attributable to the low-level laser on the sperm samples.

Giant parathyroid adenoma presenting with multiple pathologic fractures: A case report.

Key Clinical Message: Hyperparathyroidism is a common endocrine disorder, which must be suspected in patients presenting with fatigue, history of pathologic fracture and the diagnosis can be confirmed by elevated calcium and PTH levels, and the preferred treatment option. Abstract: Primary hyperparathyroidism (PHPT), a common endocrine condition, with elevated parathormone production causes increased blood calcium levels. Parathyroid adenomas cause the majority of PHPT cases. Significant hypercalcemia can result from giant parathyroid adenomas. A calcium crisis may not always arise in these individuals, despite enormous parathyroid adenomas and high parathyroid hormone levels, and the masses may first be mistaken for a thyroid mass. In this article, we discuss the case of a 57-year-old Iranian man who suffered from PHPT due to a massive parathyroid adenoma and had a history of extreme fatigue and several traumatic fractures. As specialists, we should have a strong clinical suspicion of giant parathyroid adenoma as reason of hyperparathyroidism. In patients with multiple bone problems such as pain and multiple pathological fractures and elevated levels of calcium and PTH, the diagnosis of GPA must be considered and their preferred treatment is surgery.

The importance of intraoperative echocardiography in the early detection of mitral regurgitation as a postsurgical sequel of aortic valve replacement: a case report.

BACKGROUND: Mitral leaflet perforation (MLP) can rarely be a consequence of aortic valve replacement (AVR), resulting in mitral regurgitation (MR). Determining the cause and severity of MLP following AVR is crucial in preventing hemodynamic consequences, such as pulmonary hypertension and biventricular remodeling. However, the diagnosis of this rare complication requires detailed echocardiographic evaluations. CASE PRESENTATION: In this paper, we report a 37-year-old Persian male with progressive dyspnea on exertion diagnosed with severe MR caused by anterior MLP following AVR and discuss the importance of intraoperative transesophageal echocardiography (TEE) in the proper and on-time diagnosis of this rare complication. CONCLUSION: During AVR procedure, an evaluation with TEE could be beneficial for identifying and treating such condition. Echocardiography is beneficial in providing real-time guidance during surgery, early detection of potential complications, treatment of such complications if present, and prevention of adverse outcomes.

Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review.

The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low-molecular-weight heparin. Heparin-induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6-week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy-related HIT. HIT is a pro-coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.

Unusual presentation of transthyretin (ATTR) cardiac amyloidosis: A case report of pruritus as a possible initial symptom and challenging diagnosis.

Key Clinical Message: This case emphasizes the significance of cardiac amyloidosis as a potential diagnosis in individuals manifesting with lesion-free pruritus and normal liver tests. Abstract: Amyloidosis is a complex disorder in which misfolded proteins accumulate in various organs of the body. Cardiac amyloidosis (CA) can lead to heart failure, cardiac arrhythmia, sudden cardiac death, and deposition of proteins in coronary arteries. Diagnosing CA can be difficult, as the cardiac manifestations of amyloidosis can be similar to more prevalent etiologies. In addition, the accumulation of proteins in soft tissues, including the skin, can cause pruritus. In this paper, we present a 70-year-old man with generalized pruritus and no skin lesions, later diagnosed as CA after detecting ascites fluid. This case underscores the importance of considering amyloidosis in patients presenting with nonspecific symptoms, particularly those affecting the skin, and highlights the need for increased awareness of this disease among clinicians.

Evaluation of myocardial viability by a secondary delayed 99mTc-MIBI nuclear scanning in ST-elevation myocardial infarction patients with delay in referral and nonviable myocardium in the first scintigraphy: a preliminary cohort study.

OBJECTIVE: In the management of ST-segment elevation myocardial infarction (STEMI), if the treatment has not been initiated within the first 24 h and the patient no longer exhibits any symptoms, the decision to begin revascularization therapy is based on myocardial viability. If the tissue is nonviable, current guidelines advise against further revascularization therapy; however, collateral vessels represent an alternative source of blood supply and may help the damaged tissue to resume function; though at first, this tissue may not be considered viable. Thus, in patients whose first myocardial perfusion scintigraphy (MPS) revealed nonviable myocardium, a secondary MPS to assess viability may be beneficial and alter the course of treatment strategies. METHODS: This prospective cohort study was conducted on 30 STEMI patients referred to Mazandaran Heart Center. If no myocardial viability was found using 99mTc-MIBI MPS, the patient was referred for a secondary MPS after 3 months. RESULTS: In total, out of 30 patients, 3 became viable. There was no significant relationship between the viability of different Rentrop classes. Comparison of viability between patients with different numbers of occluded vessels showed no significant relationship. Three patients (17%) among 17 patients with Rentrop class nonzero became viable in the second MPS. Also, among four patients (13.3%) with Rentrop class three, one patient (25%) became viable and among seven patients (23.3%) with Rentrop class one, two patients (28.6%) became viable. CONCLUSION: Considering the results of this study, although nonsignificant, this subject requires further investigation to reach a definite conclusion.

Paraneoplastic acute eosinophilic pneumonia due to carotid angiosarcoma: A rare case.

Key Clinical Message: This case report emphasizes that we should analyze a patient's signs and symptoms as a whole rather than relying exclusively on a common pattern to diagnose the condition and indicates that thorough histological investigation and sample collection are needed to accurately diagnose this malignancy. Abstract: Angiosarcoma is a rare, fatal, and poorly understood malignant tumor of vascular endothelial cells which is a challenging disease to diagnose in the clinical settings and requires early diagnosis to achieve a favorable prognosis. Paraneoplastic syndromes associated with angiosarcoma can include hypercoagulability, thrombocytopenia, anemia, fever, weight loss, and night sweats. In some cases, the paraneoplastic syndrome can be the first sign of the underlying malignancy. Here, we present a 47-year-old individual with angiosarcoma over the right scapula accompanied by hemoptysis and other pulmonary complaints whom at first was thought to be metastatic polmunary involvement. However, the patient's dramatic response to corticosteroids, in addition to further imaging and paraclinical studies, led us to an acute eosinophilic pneumonia (AEP) diagnosis which is an eosinophilic infiltrations of alveolar spaces. The patient received chemotherapy for angiosarcoma and radiation, since the brachial nerve network was disrupted, leaving the tumor unresectable. After 3 years of continuous follow-up, the patient is now completely cured.

Waldenström's macroglobulinemia with necrotic extremities: A case with challenging diagnosis.

Key Clinical Message: Waldenström's macroglobulinemia may begin with constitutional symptoms that are common in primary care settings and it is crucial for physicians to be aware of the potential complications of hyperviscosity syndrome and to employ the appropriate diagnostic methods in order to achieve better outcomes. Abstract: Waldenström's macroglobulinemia (WM) refers to a type of lymphoplasmacytic lymphoma distinguished by the hyperproliferation of plasma cells, lymphocytes, and plasmacytoid lymphocytes. The disease is primarily diagnosed by increased monoclonal immunoglobulin M (IgM) levels and lymphoplasmacytic cell infiltration into the bone marrow. Individuals exhibit a high risk for hyperviscosity syndrome (HVS) as immunoglobulin levels increase. In addition to constitutional symptoms (fever, night sweats, and unintentional weight loss), clinical findings such as cytopenia, hepatosplenomegaly, and lymphadenopathy, this condition may cause hyperviscosity-related organ failures. Here we discuss a patient with WM who presented with neurological complaints and blurry vision and developed necrosis at distal portions of his body during the 6-month course of the disease.

Molecular proof for Lophomonas infection in a patient with history of breast cancer.

We report a 52-year-old patient with a history of breast cancer (BC) referred to the clinic of Afzalipour Hospital, in Kerman, eastern Iran, with a 1-week complaint of restless dyspnea. A chest computed tomography scan revealed consolidations in the upper lobes of both lungs. The patient had no history of smoking or underlying diseases that would predispose her to consolidation, including pneumonia. Then, bronchoscopy was performed for the patient, and bronchoalveolar lavage fluid was sent to the Iranian National Registry Center, where the Lophomonas parasite was detected in the sample and confirmed using a polymerase chain reaction test. Finally, her symptoms improved by receiving oral metronidazole three times a day for 3 weeks.