Introduction: Spontaneous coronary artery dissection (SCAD) is a tear or separation within the coronary artery wall forming an intraluminal hematoma reducing downstream blood flow leading to myocardial ischemia (MI)(Figure 1A-C)1 . Intraluminal hematomas may develop from ”inside-out” due to endothelial-intimal injury or ”outside-in” due to injury within the vasa vasorum leading to bleeding in the wall. The subsequent false lumen from either mechanism can extend and compress the true lumen to cause MI [2]. Unlike other luminal etiologies of MI, SCAD is not caused by atherosclerotic plaque rupture, coronary intervention, or trauma [3]. With significant MI from intraluminal hematoma, patients can present with signs and symptoms that mimic MI including chest pain with and without radiation, dyspnea, nausea and vomiting. It can also include elevated troponin with electrocardiogram (ECG) changes consistent with ST segment elevation or non-ST segment elevation MI. The diagnosis is made when other etiologies of acute coronary syndrome (ACS) are ruled out and there is an angiographic evidence of non-iatrogenic or non-atherosclerotic radiolucent intimal flap and contrast staining [1]. Left anterior descending (LAD) artery is the most commonly affected branch of the left main coronary [4]. Severe stenosis can lead to heart failure as well as cardiogenic shock amongst other post-MI complications including ventricular arrhythmias, ventricular free wall or septal wall rupture. If angiography is inconclusive, then intracoronary imaging with optical coherence tomography or intravascular ultrasound may be considered before repeat angiography [5].The etiology of SCAD is thought to be multifactorial without a clear underlying cause. Risk factors associated include fibromuscular dysplasia (FMD), peri and postpartum period, hormonal fluctuations, and arteriopathies. SCAD is a rare cause of ACS, although when present, there is a higher prevalence in young females without cardiac risk factors [6]. Stable patients are treated conservatively with medication while percutaneous coronary intervention (PCI) and coronary artery bypass graft are reserved for severe stenosis and acute change in hemodynamics. Use of antiplatelet therapy remains controversial as medications such as acetylsalicylic acid (i.e. aspirin) and P2Y12 receptor blockers can worsen intraluminal hematoma. Dual antiplatelet therapy is recommended for those who undergo stent placement [5]. Similarly, guideline directed medical therapy is initiated for new onset of heart failure. Review of literature reveals 90% recovery within one month with coronary computed tomography angiography [5]. Many cases of SCAD have been reported in young females with ischemic symptoms and angiographic findings in the distal LAD but only few cases highlight proximal coronary involvement. We present a case of a young woman with extensive left main and proximal LAD SCAD requiring intervention.

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Title PageCase report title: Chronic Myelomonocytic Leukaemia Primarily Presenting as Life-Threatening Pericardial Effusion, Eldoret, Kenya: A Case reportAuthors: Victor M. Wauye1*, Evangeline Njiru1, Angela K. Amadi1, Mildred N. Hagembe2, Gabriel Kigen3

A document by Aasir Suliman. Click on the document to view its contents.

Introduction The Soft tissue sarcomas (STS) are exceptionally rare mesenchymal derived tumors accounting for only 1% of all malignancies. Leiomyosarcoma (LMS) include 5-10% of STS cases that displays heterogeneous subtype of malignant mesenchymal tumor originated from smooth muscle tissues 1. The LMS Commonly diagnosed in the fifth and sixth decades of life, and it can be detected every anatomic site, including the uterus, retroperitoneum, extremities, and vasculature 2. The two primary categories of LMS contains uterine LMS (uLMS) and extrauterine (euLMS) types, the first is commonest subtype of uterine sarcoma, while metastatic euLMS are not well described in terms of treatment, outcomes and prognostic factors3. The treatment of this tumor is controversial. However, regardless the site of origin, surgical resection is cornerstone treatment for localized LMS 2,4. The standard surgical procedure includes a complete excision with wide negative margins that gives the best chance of cure 2. Pelvic external beam radiation therapy with or without brachytherapy are recommended for locally resected tumors, especially for advance metastatic disease, chemotherapy considered as an option2,4. In the euLMS is not clear that the choice of specific agent or sensitivity to first-line systemic therapy affects the response rate and clinical outcomes 5.The molecular heterogeneity of leiomyosarcoma is uknown also targeted therapy not available now, detection of different molecular subtypes is urgent to weigh novel therapeutic options. Two diagnostic immunohistochemical markers newly detected in formalin-fixed, paraffin-embedded tissues; are LMOD1 (Leiomodin 1) in subtype I and ARL4C (ADP-ribosylation factor-like protein 4C) in subtype II leiomyosarcoma 6,7. Acording leiomyosarcoma tissue microarray and considering clinical outcome, specified that subtype I leiomyosarcoma is associated with good outcome in extrauterine leiomyosarcoma nonetheless, subtype II is related to poor prognosis in uterine and extrauterine leiomyosarcoma 7.Due to rarity and few confirmed cases reported in the literature, this case report presents a young female patient with euLMS, invading the ovary, uterus, small intestine, sigmoid colon, rectum, omentum and pancreas, which were treated with radical surgery and adjuvant chemotherapy.

A document by ShyamKumar Sriram. Click on the document to view its contents.

Ischemic stroke in a 4 year child resulting from scorpion envenomation: A case report from Nepal.Authors : Bhatta Sunil1, Awasthi Pusp Raj21-Department of Anesthesia and Critical Care, Nisarga Hospital and Research Center Pvt. Ltd.2-Department of Pediatric Critical Care, Nisarga Hospital and Research Center Pvt. Ltd.Data availability statement : Data described to support the findings is openly accessible in the article.

A document by mujtaba waris. Click on the document to view its contents.

Case report: Actinomyces in Hand: An Unusual Cause of OsteomyelitisAlireza Khosravi 1, Alireza Ghanadan2, Alireza Hadizadeh 3, Mohammadsadegh Talebi Kahdouei 4, Fatemeh Aghaei5, Faezeh Salahshour6, Zahra Saffarian7*1. Mycology Research Center, Faculty of Veterinary Medicine, University of Tehran, Tehran, [email protected]. Professor of pathology department of dermatopathology, Razi hospital, department of pathology, cancer institute, Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, [email protected]. Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago, Northshore University HealthSystem, Skokie, IL, USA4. Medical School, Tehran University of Medical Science, Tehran, [email protected]. Medical School, Tehran University of Medical Science, Tehran, [email protected].  Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences and Liver Transplantation Research Center, Imam Khomeini Hospital complex, Tehran University of Medical Sciences (TUMS), Tehran, [email protected] [email protected] [email protected]. Assistant professor of dermatology, Dermatology Department of Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, [email protected]*Co-responder author:Assistant professor of dermatology, Dermatology Department of Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, [email protected]

Right heart failure after pericardiectomy: a case report

IntroductionCoccidioidomycosis, known as Valley Fever, is the disease caused by the inhalation of arthroconidia from the soil-dwelling dimorphic fungi,Coccidioides immitis and Coccidioides posadasii [1]. In the United States, coccidioidomycosis is endemic to the southwestern part of the country, with most cases located in the San Joaquin Valley of California and Southern Arizona. The incidence of coccidioidomycosis is approximately 10,000 cases reported annually [1,2]. Coccidioidomycosis may affect any demographic, but primarily affects those aged 40-60 years old and has a slight male predominance. Clinical manifestations range from asymptomatic to disseminated infection depending on the patient’s immune status.Cutaneous manifestations in coccidioidomycosis can be classified as reactive or organism-containing lesions in secondary or primary cutaneous infection [3]. Sweet syndrome, or acute febrile neutrophilic dermatosis, is an inflammatory, non-infectious skin reaction rarely observed as one of the reactive skin manifestations of coccidioidomycosis. Patients with Sweet syndrome clinically present with fever, leukocytosis with neutrophilia, and painful erythematous papules, plaques, pustules, and nodules commonly appearing on the upper limbs, trunk, head, and neck [4]. Here, we present a case of coccidioidomycosis associated with Sweet’s syndrome.

INTRODUCTIONPleural effusion is an abnormal collection of fluid within pleural space usually resulting from excess fluid production and or decreased lymphatic absorption. Pleural effusion is rare during neonatal period with the estimated prevalence of 0.06%1. Neonatal pleural effusion may be due to antenatal congenital causes or postnatal acquired causes. Antenatal pleural effusion may be due to hydrops fetalis, congenital chylothorax, congenital heart disease (CHD), chromosomal anomalies, pulmonary anomalies or infection like congenital herpes simplex viral (HSV) and Paro virus infection. Postnatal acquired causes include extravasation of peripherally inserted central catheters, parapneumonic effusion or traumatic chylothorax.As neonatal pleural effusion can cause significant respiratory distress, vigilant delivery room management is required. Identifying the underlying cause is important as it leads to specific therapeutic measures. Diagnostic chests tap for pleural fluid analysis is important for diagnosis and its consequent management.2Similarly, echocardiography, karyotyping and other investigations are also indicated for identifying subsequent etiology.Here, we report a case of neonatal pleural effusion; which on evaluation; pulmonary sequestration-extra lobar type was found as the cause of effusion. Extra lobar pulmonary sequestration associated with pulmonary effusion is a very rare entity.3 The purpose of this case report is to familiarize clinician regarding lung sequestration as the cause of neonatal pleural effusion and prevent subsequent morbidity and mortality.

Sydenham’s chorea in a female child with rheumatic fever in Bhutan: a case reportTshering Penjor1, Thinley Dorji1, Sangay Wangchuk11Department of Internal Medicine, Central Regional Referral Hospital, Gelephu, BhutanAddress of corresponding author: Dr Tshering Penjor, MD. Department of Internal Medicine, Central Regional Referral Hospital, Gelephu, Bhutan.

INTRODUCTIONThis case reports a rare case of adult ileocolic intussusception secondary to an inflammatory fibroid polyp (IFP). Intussusception is an uncommon adult surgical condition, representing 5-16% of all cases of intussusception, and only 1-5% of all causes of adult intestinal obstruction (1). Up to 90% of cases are secondary to an underlying pathology, with approximately 65% being secondary to benign or malignant neoplasms (2). The diagnostic uncertainty of the underlying lead point highlights the need to surgically intervene on these lesions promptly.The inflammatory fibroid polyp, which is also known as the Vanek tumour, was first described by Vanek in 1949 and then proposed by Helwig and Ranier in 1953 (2). It is now defined as a benign tumour arising from the submucosa of the gastrointestinal tract. The most common site from which IFPs arise is the gastric antrum in 66-75% of cases, followed by the small bowel in 18-20% of cases (2). The ileal segment, however, is the most common site where they occur. Historically, aetiology was thought to be an inflammatory response to a submucosal granuloma usually associated with an irritating stimulus such as Helicobacter pylori , trauma, tuberculosis, etc. However, activating mutations of the proto-oncogene platelet derived growth factor alpha (PDGFRA) gene have been recently reported as a potential underlying true neoplastic origin (3).The appropriate surgical management of adult intussusception remains debatable when deciding on a primary en bloc resection versus an initial reduction followed by a limited resection. Here, we report a case of a laparoscopic ileocolic resection.

A document by Maciej Antkiewicz. Click on the document to view its contents.

A document by tianjie han. Click on the document to view its contents.

Title :Leiomyoma beyond the uterus

Title: Hemoptysis Secondary to Anomalous Origin of Right Pulmonary Artery from Ascending Aorta in a Young Male: A Case Report