case report

The authors describe the unusual case of subungual onychomycosis, due to fluconazole and itraconazole resistant Candida albicans after using the hybrid and acrylic lacquers and nail tips. The etiology of these atypical changes was supported by isolation of the fungus from the nail lesions, and its consistent identification by means of morphological and molecular diagnosis. In the presented case, topical treatment with ciclopirox 8% nail lacquer allow to fight the pathogenic fungus but did not restore the natural appearance of the nails.

Intraparenchymal cysts without communication to the ventricles or the subarachnoid space are named ependymal or epithelial cysts. The estimated ratio of their incidence compared with arachnoid cysts is 1:10. Neurologic deficit can occur when the cyst exerts mass effect on its surroundings. We report a case of cerebral ependymal cyst in a 75-year-old lady who presented with history of headache, vomiting and left incomplete homonymous hemianopsia. Neuroimaging studies showed a large right occipital cyst. She underwent the neurosurgical procedure of marsupialization. Histologic findings and the immunophenotype was consistent with a diagnosis of ependymal cyst. The patient made an excellent recovery after the procedure.

43-year-old lady presented with incidentally discovered liver lesions while she was being managed for her complaints of menorrhagia. CT and MRI showed hepatomegaly with multiple lesions in both lobes of the liver with vascular element in the background of diffuse fatty infiltration. Patient underwent laparoscopic core biopsy. Histopathology showed extensive steatosis, intracytoplasmic giant mitochondria and absence of portal tracts, features highly suggestive of hepatic adenomatosis. IHC staining showed membranous and cytoplasmic positivity in hepatocytes for B-catenin consistent with multiple hepatic adenomatosis. Hepatic adenomatosis is a new clinical entity in the hepatological practice characterized by the presence of 10 or more nodules in the liver known for its major complication of bleeding. Hepatic adenomatosis is managed by regular imaging and resection of large (> 5cm) superficial and painful adenomas along with liver function tests and tumor markers to rule out malignant transformation. However, the potential cure being the liver transplantation.

Pseudomyxoma peritonei (PMP) or Gelatinous Peritoneal Disease is a rare condition that refers to an anatomo-clinical entity characterized by ascites of variable abundance in the peritoneal cavity, viscous or mucinous, associated or not with neoplastic epithelial cells. It predominates in women. Diagnosis is guided by imaging and confirmed by histology. Prognosis is good in case of early management. We report the case of a male diagnosed with Pseudomyxoma peritonei revealed by isolated ascites.

Meigs’ syndrome is a rare condition characterized by the presence of a benign fibroma of the ovary, ascites and pleural effusion. Other benign cysts of the ovary (such as struma ovarii, mucinous cystadenoma, serous cystadenoma and teratomas), leiomyoma of the uterus, and secondary metastatic tumours to ovary if associated with hydro thorax and ascites are referred to as ‘Pseudo-Meigs” syndrome. It very uncommon and diagnosis is made difficult by symptoms that usually mimic disseminated malignancy or tuberculosis. The gold standard treatment is laparotomy and, by definition of the syndrome, after tumor removal, the symptoms resolves and the patients become asymptomatic. We presented an 18 years old girl with giant ovarian serous cystadenoma with associated pseudo-meigs syndrome, successfully managed in a low resources setting.

Puerperal acute uterine inversion is a rare obstetric condition observed as a serious complication during the third stage of labor. Reported as one of the causes of postpartum haemorrhage, it commonly requires quick diagnosis and surgical treatment in order to reduce morbidity and lethality. The authors describe a case of uterine inversion with hypovolemic shock after home birth, brought to Hospital Leonor Mendes de Barros. The purpose of this article is to describe a case of acute uterine inversion and its management and a review of aetiology, predictive and risk factors, diagnosis and treatment.

The lumbar epidural analgesia is commonly used for labour analgesia. The “loss of resistance to air” LORA technique is commonly used for recognition of epidural space. One of the rare complications of this technique is Pneumocephalus (PC). We want to present a case of Pneumocephalus which the mother developed during epidural analgesia in labour. The patient complained of severe headache immediately after attempt at epidural catheter insertion. The symptoms progressively worsened following delivery. A postnatal anaesthetic review was performed and an urgent CT scan of the brain was arranged that showed pneumocephalus. A conservative management pathway was followed with liberal analgesia, oxygen inhalation and keeping the patient mostly in supine position. Her symptoms regressed in severity over the next three days and subsided after one week. We believe that the amount of air used for LORA should be minimized; LORA should not be used after dural puncture and the use of normal saline would alleviate the risk.

Primary umbilical cutaneous endometriosis is a rare umbilical endometrioma that affects women who are within the reproductive age group. It may be associated with infertility and severe dysmenorrhea and can be difficult to diagnosed in an asymptomatic patient. We report a case of a 38-year-old nulliparous with seven years history of infertility and severe dysmenorrhea. Her hormonal profile assay and hysterosalpingogram results were normal while her husband semen analysis was also within normal range. She complained of monthly bleeding from a painful rubbery multilobate cutaneous nodule on the umbilicus of one year duration. She was diagnosed of cutaneous endometriosis. The diagnosis was confirmed histologically and she had surgical excision with good outcome.

Advanced technologies, such as electrochemical impedance spectroscopy (EIS), are a valuable tool which can enhance and simplify the industrial process monitoring if used correctly. State-of-the-art approaches for screening the cell growth of for example yeast during the brewing process still heavily rely on offline methods such as methylene blue or florescence dye-based staining, and/or the usage of flow cytometric measurements. These methods, while being accurate, are very time consuming and require heavy manual effort. Furthermore, the time span needed to obtain the counting result can lead to a time-delayed response signal and can impact the quality of the final product. In recent studies, applications of low-frequency EIS in the α-regime were used for the determination of cell counts and the metabolic state in Saccharomyces cerevisiae. This method has proven to be a reliable tool which has also shown high potential in industrial scale applications. The online biomass monitoring, as well as viable cell count, for feasibility study was performed in-house at Stiegl Brewery in Salzburg/Austria founded in 1492.

Background: Knowledge of pulmonary complications (PCs) in children after hematopoetic stem cell transplantation (allo-HSCT) is limited; most data are from adult studies. Case: We describe a 8 year old girl with high risk acute myeloid leukemia who developed graft versus host disease (GVHD) on Day 20, Cytomegalovirus (CMV) pneumonia on Day 50 and Cryptogenic organizing pneumonia (COP) on Day 170 after allo-HSCT. Discussion: Cryptogenic organizing pneumonia is a rare noninfectious PCs that can be idiopathic or have several risk factors as a secondary causes, such as viral respiratory infections, drugs, GVHD and allo-HSCT. Viral respiratory infections and alloimmune lung syndromes have been reported in a few patients who have undergone transplantation. Conclusion: Transplant physicians should be kept in mind for the development of alloimmune lung syndrome in the form of COP following CMV pneumonia in patients after allo- HSCT

An enquiry into the lack of attention awarded to serotonin antagonism in the treatment of arterial thrombosis revealed that the mode of action of serotonin and its platelet receptor antagonists was an action upon thrombus growth, and not, as with other anti-platelet drugs upon the initiation of thrombosis. This lack of effect could explain why this approach has been considered not to be effective. However under conditions of arterial stenosis in which there is platelet activation by increased shear stress, and during the growth phase of arterial thrombi, serotonin 5HT2A antagonism has been demonstrated to have great potentcy in dispersing thrombotic obstruction to blood flow. This mode of action, the lack of participation of serotonin in haemostasis, and the absence of serotonin in wounds accounts for the proven lack of effect of effect of pure specific 5HT2A antagonists (i.e., not those with other actions) on operative bleeding and skin bleeding times. This lack of effect on haemostasis solves the dosing problem encountered with other anti-thrombotic drugs, with which drug concentration cannot be controlled with single fixed doses, leading to the association between increased anti-thrombotic efficacy and increased bleeding complications. Thus 5HT2A antagonism appears to be the preferred approach, from the point of view of safety and lack of bleeding risk; this consideration applies particularly to thrombosis therapy in the context of traumatic accidents, surgical operations and invasive procedures such as angioplasty.

Background: Invasive fungal infections cause significant morbidity and mortality in patients with hematologic malignancies and in recipients of hematopoietic stem cell transplantation. Case: We report a patient with relapsed acute myeloid leukemia who developed disseminated Fusarium infection during the neutropenic period following the salvage cycle of chemotherapy given at King Fahad specialist Hospital in Dammam, Saudi Arabia. The invasive fungal infection was successfully managed with a combination of voriconazole and liposomal amphotericin-B. Discussion: Fusarium species can cause invasive infections that may become disseminated and life-threatening in patients with acute myeloid leukemia. Conclusion: Combined antifungal therapy and recovery of neutrophil count are essential to control invasive Fusarium infections

Background: Pure red cell aplasia is characterized by anemia, reticulocytopenia and diminished bone marrow erythroid precursors. It has multifactorial etiology and consequently several therapeutic interventions. Case: In August 2017, a young patient was diagnosed to have pure red cell aplasia. She was given immunosuppressive therapy for approximately two months but this treatment was stopped due to intolerance. Later on she developed herpes zoster infection that was treated with valacyclovir. Subsequently, it was noted that the patient became blood transfusion independent due to normalization of her hemoglobin and regeneration of the erythroid precursors in the bone marrow. Discussion: Varicella zoster virus behaves differently from other members of the herpes group of viruses such as cytomegalovirus and Epstein-Barr virus. Two retrospective studies, performed in patients with malignant hematological disorders and bone marrow failure, have shown that infection with the virus may cause stimulation of the three cell lines in the bone marrow and superior overall survival. Conclusion: The outcome of the patient presented confirms the findings of the two studies showing long-term beneficial effects of varicella zoster virus infections in immunocompromised individuals.

Introduction: Erdheim-Chester disease (ECD) is a rare and difficult-to-treat non-Langerhans cell histiocytosis characterized by the excessive production and accumulation of histiocytes. This study reports a case of ECD, emphasizing both its diagnosis, assessment and treatment of the pain associated with the disease. Case Report: Six years ago, a 39-year-old male patient presented with generalized pain of moderate intensity in the lower limbs that involved periods of greater intensity associated with ambulation. The diagnosis of histiocytosis associated with panhypopituitarism and adrenal insufficiency was proposed. For a specific diagnosis, a bone lesion biopsy was performed, revealing the presence of histiocytic proliferation that was CD1 negative, S100 protein positive, and CD68 negative. Therefore, the diagnosis of non-Langerhans histiocytosis known as ECD was confirmed. During the two years that followed, the patient presented with severe bone pain, particularly in the lower limbs and cranial vault, and the pain subsided to a certain extent with the use of tramadol and paracetamol. Because of the pain, the patient was unable to walk and became bedridden As the patient remained in severe pain, even after the administration of morphine, the opioid was changed from morphine (60mg/day) to oxycodone (30mg/day) for a convenient dosing schedule; furthermore, the oxycodone dosage was scheduled to increase to 40mg/day that same week. The patient experienced significant pain reduction, requiring rescue analgesia only once or twice a week. Conclusion: To the best of our knowledge, this is the first case report on the characterization and treatment of pain specific to ECD, and we highlight that the patient had a good response to treatment.

Celiac disease affects 1% of the world population; however it is under diagnosed in UAE. The disease has many clinical manifestations, ranging from severe malabsorption to minimally symptomatic or non-symptomatic presentation. Hypocalcaemia is a common finding in celiac disease and could be the only presentation of the disease; however hypercalcemia has been previously reported in patients with celiac disease either due to primary hyperparathyroidism or tertiary hyperparathyroidism due to prolonged hypocalcaemia. A normal calcium level on the other hand in patients with untreated celiac disease who also have primary hyperparathyroidism can be due to interplay of these two conditions and may delay the diagnosis of primary Hyperparathyroidism. We report the very first case from our practice in UAE with untreated celiac disease and normal calcium level at presentation, where a diagnosis of primary hyperparathyroidism was not entertained initially. Patient went on gluten free diet which then caused normalization of intestinal abnormalities and likely calcium absorption manifesting as hypercalcemia on subsequent labs. This led to further work up and finally the diagnosis of Primary hyperparathyroidism due to parathyroid adenoma.

Familial adenomatous polyposis is an autosomal dominant syndrome of variable penetration and constitutes the second frequent inherited syndrome enunciating the emergence of a colorectal carcinoma. The syndrome is accompanied by exemplification of defective adenomatous polyposis coli (APC) gene located upon chromosome 5q21 with a prototypic denomination of colonic adenomatous polyps usually exceeding a > 100. Incriminated individuals develop innumerable colonic and rectal polyps, particularly during early teenage years and are accompanied by an almost 100% possible emergence of colorectal carcinoma within 40 years in untreated subjects [1]. Prophylactic colectomy is advisable to substantially reduce possible occurrence of colorectal carcinoma. Familial adenomatous polyposis is concurrent with associated neoplasms such as gastric or duodenal cancer, hepatoblastoma or desmoid tumour along with a probable emergence of extra-colonic carcinomas [1,2].

Acute pancreatitis is inflammation of the pancreas that may be accompanied by a systemic inflammatory response which results in impairment of the functioning of various organs, systems. Pancreatitis associated vascular complications very often cause morbidity and mortality. There are various cardiovascular complications like shock, hypovolemia, pericardial effusion, and sometimes ST–T changes in the electrocardiogram (ECG) presenting as acute myocardial infarction (AMI). Acute myocardial infarction complicating acute pancreatitis has rarely been studied and the exact process of myocardial injury still remains unclear. We here report a case of Acute Pancreatitis associated with acute myocardial Infarction.

Hepatocellular carcinoma (HCC) is characterized by high morbidity, high recurrence, and high mortality rates. In China, the morbidity of HCC is fifth among all malignant tumors and HCC is the third most common cause of cancer-related deaths. Most HCC patients also have liver cirrhosis. Surgery is the sole curative method for HCC; however, many patients are diagnosed with HCC during its advanced stages so radical resection can no longer be performed. Therefore, the proportion of patients who undergo radical hepatectomy is less than 30%. Patients with mildly advanced HCC cannot undergo hepatectomy and thus transcatheter arterial chemoembolization (TACE) and/or biological targeted therapy are alternative options. However, data on the effects of TACE therapy or biological targeted therapy are limited. Therefore, an investigation of multimodal and individualized treatments is critical to ensure the best treatment. In June 2018, we treated an advanced HCC patient with multiple metastases and right portal vein tumor thrombus. The patient exhibited partial remission after undergoing treatment with TACE and crizotinib capsules for 1 month. The case and a literature review are reported here.

Background: Like other viruses, the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) appears to be responsible for several autoimmune complications. The occurrence of autoimmune hemolytic anemia has been described in several case reports. This AIHA was also noticeable by the important number of blood transfusions required for COVID-19 (coronavirus disease 2019) patients. By investigating RBC coating autoantibodies, this article attempts to clarify the autoimmune aspect of the anemia in the context of SARS-CoV-2 infection. Results: A large population of COVID-19 patients selected at Saint-Luc University Hospital showed an average of 44% DAT positivity. In this population, the intensive care patients were more prone to DAT positivity than the general ward patients (statistically significant result). The positive DAT appeared « transmissible » to other RBCs via COVID-19 DAT-positive patient’s plasma. Conclusion: The strongest hypothesis explaining this observation is the targeting of cryptic antigens by autoantibodies in COVID-19 patients.

Introduction: Forty-six per cent children have allergic rhinoconjunctivitis (Allergologica 2005). Working hypothesis: Ocular topical cyclosporine improves the quality of life for these patients. Material, methods, design: 2-year prospective study (2015-16), 40 patients with topical corticosteroids without improvement, followed 20 and 20 switched to corticosteroids cyclosporine 0.05%. Interview with Quality of Life Questionnaire in Children with rhinoconjunctivitis (PRQLQ) before and at the end of treatment. Mean age of 10.3 years with 60% male-40% female. Treatments were applied from January to March. There were 15 questions divided into two blocks. Children responded using a card with responses rated from zero (not bothered at all) to 6 (quite upset). Results: Before the 100% reported that, the itching was very bothersome. In the group of 40 children, 80% showed symptoms of epiphora and 60% showed symptoms of ocular inflammation. 100% complained of significant discomfort in rubbing their eyes, 30% did not like to take medications. Headaches affected 20%. 100% stated that they cannot play normally. 80% showed decreased concentration in class. Continuing with corticosteroids did not show statistically significant changes. Patients with cyclosporine improved the results by 3 points, with decreased itching, tearing, swelling, pain, eye rubbing, medication and headaches. In the 2nd questionnaire there was limited variation in the results related to fatigue, malaise, and irritability but with substantially improved balance of sleep, insomnia and concentration at school. Conclusion: Cyclosporine A is a cyclic polypeptide calcineurin inhibitor developed from the fungus Tolypocladium inflatum. The first dilution was 2% but it is currently used at a dilution of 0.05% and recent publications suggest nanosuspensions. Our study showed improvement in parameters related to symptoms, especially itching and lower improvement of psychological aspects, this achieves a better quality of life for children and more willingness to adhere to the treatment.