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A very unusual, interesting, and challenging case of a 24-year-old female who was born with three openings in the neck. The patient had chronic abdominal gaseous distention, recurrent abdominal pain, and constipation since early infancy. The patient presented in emergency with acute painful red, hot, and tender swelling in the left upper cervical area. Laboratory studies showed high inflammatory markers and a provisional diagnosis of abscess with a sinus was made. The patient underwent an emergency incision and drainage. Sinus recurred and a sinogram showed it to be a residual cyst in the left submandibular salivary gland. The total cyst excision was attempted with resultant recurrence and grade IV facial nerve palsy. Post-operatively recurrent infections caused by Methicillin-resistant Staphylococcus aureus (MRSA) required several courses of oral and intravenous broad-spectrum antibiotics with several hospital admissions with no resolution in sight. Subsequent ultrasound and magnetic resonance imaging showed a residual infected cyst, cutaneous sinus, and a fistula opening in the left ear canal. A diagnosis of branchial cyst type II of the first brachial cleft remnant with a fistula was established with bilateral branchial fistulas of the second branchial remnants and the associated colorectal hypoganglionosis based on radiological studies. The patient refused any further operative interventions. Therefore, the option of conservative treatment of hypoganglionosis with holobiotics consisting of prebiotics, probiotics and postbiotics, laxatives, dietary changes, lifestyle modifications, and dietary supplements started. All antibiotics were stopped. These therapies resulted in the resolution of residual first branchial remnants and recurrent MRSA infections with the improvement in the facial nerve palsy from grade V to grade III-IV together with an excellent cosmetic and functional result. The patient is doing well at follow-ups being infection-free for 18 months and repeat contrast-enhanced computed tomogram (CECT) has shown complete resolution of the residual cyst, sinus, and fistula with fibrosis.

Background: Neonatal hypoglycemia is known to cause significant neuronal damage and poor neurodevelopmental outcomes. Consensus guidelines are lacking for the management of persistent neonatal hypoglycemia and hyperinsulinism which often requires high concentrations of dextrose and medications. Although used in the pediatric population with persistent hypoglycemia, only a few case reports are published regarding the use of Maltodextrin supplementation in persistent neonatal hypoglycemia due to transient hyperinsulinism. Objective: To audit the use of Maltodextrins in the management of persistent neonatal hypoglycemia due to transient hyperinsulinism in neonates. Audit design: A retrospective chart review (CERNER electronic data) of all cases with persistent neonatal hypoglycemia who received Maltodextrin supplementation for a period of 3½ years between July 2018 and December 2021. Results: A total of 18 neonates received Maltodextrin supplementation for neonatal hypoglycemia during the audit period. 16/18 (89%) neonates who received Maltodextrin supplementation were weaned off from intravenous dextrose within 1 week without major side effects or severe rebound hypoglycemia. Two out of 18 babies who received Maltodextrin needed Diazoxide supplementation for persistent hypoglycemia.  Conclusion: The results of our audit are promising, yet further research and randomized controlled studies are needed to systematically evaluate the findings of this audit regarding Maltodextrin supplementation for the management of neonatal hypoglycemia with transient hyperinsulinism.

Septic arthritis is a serious inflammatory infectious state of the joint secondary to microbial infection. In the pediatric population the most common route of infection is haematogenous spread. Less than fifty percent of patients with septic arthritis will yield positive culture results with a mortality rate of up to 42% in some cases. Due to the challenge in obtaining culture and identification of the causative organism the management of septic arthritis has been more of empirical in nature with the chosen antibiotic synchronized with the epidemiological data. Here is a case of a 14 months old female patient presenting at our hospital with a left knee and lower thigh swelling for three days with failure to bare weight on the limb. In addition, she had fever and diarrhea for three days. Upon evaluation clinical, laboratory and radiological findings supported septic arthritis expect for her blood, pus and synovial fluid culture of which all came back negative. She had poor response to intravenous ceftriaxone, gentamycin, metronidazole, ampicillin- cloxacillin and amoxicillin clavunate. Over the course of therapy, she developed septic shock, severe anemia and acute liver failure and was admitted to the intensive care unit. Afterwards she was initiated vancomycin and developed a hypersensitivity reaction with generalized edema which prompted cessation of the drug. Due to her critical state and poor response a triple therapy regimen composing of meropenem, ciprofloxacin and metronidazole was selected and maintained for three weeks followed by an oral clindamycin course for another three weeks of which she responded. In addition, surgical debridement arthrotomy, irrigation and drainage were done. Physiotherapy for rehabilitation is ongoing with patient recovering well.

A 51-year-old female with a history of multinodular goitre presented with vomiting, abdominal discomfort, and generalized tiredness. Investigations revealed hypercalcemia (ionized calcium 1.41 mmol/L), hypokalaemia, suppressed parathyroid hormone, and significantly elevated free thyroxine (> 7.77 ng/dL) with a suppressed thyroid-stimulating hormone level consistent with hyperthyroidism. Further, the workup confirmed Graves’ disease as the underlying aetiology. Hyperthyroidism is occasionally associated with mild to moderate hypercalcemia, but severe hypercalcemia or hypercalcaemic crisis is an extremely rare complication. Prompt recognition and treatment are crucial to prevent life-threatening complications. The patient was treated with intravenous fluids, a low-calcium diet, zoledronic acid, carbimazole, and a beta-blocker, leading to improvement in her condition. This case highlights a rare occurrence of hypercalcaemic crisis in a patient with thyrotoxicosis due to Graves’ disease. Hyperthyroidism-induced hypercalcemia requires prompt recognition and multidisciplinary management involving endocrinologists, internists, and critical care specialists to prevent potentially life-threatening complications. Healthcare providers should consider the hypercalcaemic crisis in the differential diagnosis of hypercalcemia in the context of hyperthyroidism.

Background: Idiopathic intracranial hypertension (IIH or pseudotumor cerebri) has two major morbidities: papilledema with visual loss and disabling headache. Intracranial Venous Hypertension (IVH) is a fundamental mechanism of IIH. Although traditionally considered limiting to the central nervous system, evidence suggests IIH as a systemic disease associated with cardiorespiratory disorders, which has been far less comprehended. Case Report: A 60-year-old female with Chronic Obstructive Pulmonary Disease (COPD) was admitted for dyspnea and developed a coma with a pH of 7.01 and pCO2 of 158 mmHg. She was intubated and had persistent nuchal rigidity, a brief myoclonus episode with a negative electroencephalogram, and negative CT head studies. A Lumbar Puncture (LP) revealed elevated opening pressure (35 cmH2O) with normal Cerebral Spinal Fluid (CSF) studies. Her nuchal rigidity improved after the removal of 40 mL CSF. The ophthalmology examination the next day after her the large volume LP didn’t show visual loss or papilledema. The patient improved clinically and was extubated two days later. Her echocardiogram showed a dilated right ventricle with pulmonary hypertension. The patient was discharged home.Discussion: IIH is different from hypercapnic encephalopathy and characterized by increased intracranial pressure with papilledema, vision loss, and debilitating headache. Hypercapnia-induced increased intracranial venous flow and pulmonary hypertension-caused elevated central venous pressure with consequent outflow resistance lead to IVH. In hypercapnic encephalopathy, the presentation is mostly cognitive changes. In this case, nuchal rigidity with a negative CT head scan triggered the investigation of IIH. Conclusion: A deep understanding of the relationship between COPD and IIH is vital. There is insufficient evidence to recommend routine eye examinations in COPD patients for papilledema and to conduct a pulmonary function test for a newly diagnosed IIH patient. However, we highly suggest a timely ophthalmology exam prior to performing an LP in COPD patients with suspecting IIH to avoid unnecessary procedures and meanwhile improve clinical outcomes.

Mesenchymal stem cell (MSC) transplantation may be an alternative to liver transplantation for patients with end-stage liver disease. A 24-year-old patient with Hepatic Encephalopathy due to alcoholic liver cirrhosis underwent UCMSC transplantation because there were no donors available for liver transplants involving adult deceased and living individuals. The patient was given allogeneic Umbilical cord-derived MSCs, which were then cultured following accepted practices. Subsequently, the UCMSCs were infused through the intravenous route 3 times at the interval of 30 days. Serum bilirubin, globulin, and ammonia levels were improved after the infusion and the morphology of the liver and spleen had also improved.

Verrucous hyperplasia is a wart-like lesion that can develop on amputation stumps, often due to poor-fitting prostheses, venous stasis, friction, and bacterial infections. While surgical excision is sometimes necessary for intractable cases, many instances can be managed non-surgically. We present the case of a 35-year-old male with a slowly growing verrucous plaque on his amputated stump that had caused repeated infections. His prosthesis was loose, allowing the stump to hang loosely inside the socket. After histological confirmation of verrucous hyperplasia, he was advised to change his prosthesis and use compression bandaging. Over 5 months, the lesion resolved without surgery. Early recognition and non-surgical management, including proper prosthetic fit, compression, and hygiene, can often successfully treat verrucous hyperplasia of amputation stumps. This avoids the need for excision in many cases. Patients and clinicians should be aware of this condition and the importance of prosthetic fit and limb care to prevent and treat it.

Venous Thromboembolism (VTE) is a major public health concern, affecting approximately 900,000 people annually in the United States. In rare cases, a Patent Foramen Ovale (PFO) may allow a venous thrombus to cross into the arterial circulation, causing a paradoxical embolism. This case report presents a 46-year-old male who developed left renal artery stenosis after a paradoxical embolism, likely triggered by a prolonged flight and binge alcohol consumption. The patient was found to have a moderate-sized PFO and renal infarction, confirmed by imaging studies. Despite initial anticoagulation therapy and a planned stenting procedure, intraoperative findings revealed only mild stenosis, leading to cancellation of the stent placement. The patient ultimately underwent PFO closure with an Amplatzer Talisman device. This case underscores the diagnostic challenges in managing paradoxical embolism and the need for individualized treatment, particularly concerning anticoagulation duration, the decision for PFO closure, and post-procedural antithrombotic therapy. Further research is required to establish optimal management strategies for cryptogenic embolic events.

Introduction: Busulfan (Bu)-based regimens are crucial for myeloablative conditioning in pediatric allogeneic stem cell transplantation. Despite its efficacy, Intravenous Bu has a narrow therapeutic index and variable pharmacodynamics especially in children, heightening the risk of adverse events. This study explores Bu dosing and related organ toxicities in pediatric patients at a tertiary center in Saudi Arabia.Methodology: This retrospective study at King Fahad Specialist Hospital in Dammam (KFSH-D), Saudi Arabia, included pediatric patients (≤16 years) treated with intravenous Bu before bone marrow transplantation from 2010 to 2022. Pharmacokinetic dose adjustments were based on AUC targets of 900-1350 µMol-min. Descriptive measures included mean, Standard Deviation (SD), median, minimum-maximum values, counts, and percentages. Statistical analyses used Kruskal-Wallis, Chi-square, and Fisher’s exact tests. Ethical approval was obtained from KFSH-D.Results: We identified 44 pediatric patients who underwent Bu prior to HSCT. Mean age was 4.95 ± 2.49 years, with a female majority (56.8%). Primary diseases included Beta Thalassemia (34.09%), Neuroblastoma (29.55%) among others. There was no significant difference in the cohort’s demographic and clinical features of the cohort. Nonetheless, higher infections were found in the Low-AUC group (66.7%) compared to the Target-AUC (40.0%) and Higher-AUC groups (0.0%) (p = 0.015).Conclusion: This study emphasizes the need for therapeutic drug monitoring and individualized Bu dosing in pediatric HSCT to minimize toxicity and improve outcomes. Larger multicenter studies are recommended to refine dosing strategies and enhance the safety and efficacy of Bu-based regimens.

Stroke is a clinically defined syndrome of acute focal neurological deficit attributed to vascular injury (infarction, hemorrhage) of the central nervous system. Stroke is the second leading cause of death and disability worldwide. Stroke is not a single disease but can be caused by a wide range of risk factors, disease processes and mechanisms. Approximately 15% of strokes worldwide are the result of intracerebral hemorrhage, which can be deep (basal ganglia, brainstem), cerebellar or lobar. A minority (about 20%) of intracerebral hemorrhages are caused by macrovascular lesions (vascular malformations, aneurysms, cavernomas), venous sinus thrombosis or rarer causes.

Objective: To investigate the clinical significance of preoperative lower extremity venography in patients with varicose veins.Methods: From February 2019 to July 2023, 498 patients (583 diseased lower limbs) with lower limb varicose veins as the first symptom were selected and admitted to the Seventh People’s Hospital of Chongqing. Paracentesis of the deep veins of the lower extremities was performed in all affected limbs to observe the morphology of the deep veins from the ankle to the pelvis, the patency of the deep veins, and the reflux of contrast medium when the patients performed the Valsalva manoeuvre. The aetiology of varicose veins was analysed according to the imaging manifestations and individualised treatment plans were formulated according to the different aetiologies.Results: The imaging success rate of 583 diseased lower limbs was 100%, of which 285 (48.9%) were primary lower limb deep vein valve insufficiency, 186 (32%) were simple superficial varicose veins, 63 (10. 8%) were iliac vein compression syndromes, 41 (5%) were post-thrombotic syndromes of the deep veins of the lower limbs and the others (primary deep vein avascularity of the lower limbs, bifemoral venous malformations, congenital varicose vein osteohypertrophy syndrome, tumour compression, etc.) 8 articles (1.37%).Conclusion: The advantages of lower extremity deep vein bypass angiography are simple operation, low trauma, and high specificity, which can help to diagnose the aetiology of lower extremity varicose veins and guide the clinical treatment.

Background: Methemoglobinemia is an uncommon hematological condition in which hemoglobin contains iron in an oxidized (Fe³+) state with limited oxygen-carrying ability. It can be congenital or acquired. Anesthetic management of methemoglobinemia poses a great challenge, as there is a risk of refractory hypoxemic crisis in the perioperative period. Case: Here, we present a case of a 24-year-old female with congenital methemoglobinemia who presented with gallstone disease for laparoscopic cholecystectomy under general anesthesia. She had a deficiency of cytochrome B5 reductase, which contributed to 26% of methemoglobin levels on co-oximetry. Despite taking considerable precautions to avoid hypoxemic episodes and metabolic acidosis, an episode of desaturation happened at the end of the procedure, which was managed with intravenous methylene blue. The patient recovered without any hypoxemic insult. Conclusion: Anesthetic management of patients with moderate (20% - 30%) methemoglobinemia can be successful with extreme precautions to avoid events that can increase the methemoglobin levels and adequate preparation and availability of intravenous methylene blue.

Introduction: Menarche, the onset of a girl's first menstrual cycle, often introduces menstrual taboos in certain eastern cultures. These taboos may manifest as social isolation, dietary restrictions, and exclusion from religious spaces, which can adversely affect health and promote gender inequality.Case history: A 10-year-old girl developed gastroenteritis while in cultural confinement after reaching menarche. Her parents strictly adhered to traditional customs that limited her interactions with the outside world and deprived her of healthy foods. They believed that her fatigue was a result of hormonal changes associated with menarche. Although her condition worsened over four days, they did not seek medical treatment. The child succumbed upon admission. The autopsy revealed extensive cyanosis in the left hand due to multiple thrombotic occlusions of the brachial vein. Microscopic examination confirmed the presence of brachial venous thrombi. The cause of death was determined to be Multiple Organ Dysfunction Syndrome (MODS) as a consequence of hypovolemic shock.Discussion: Key medico-legal issues in this case include parental negligence and failure to provide medical care under Section 308A of the Penal Code, potentially leading to criminal liability for negligence-related death under Section 298. Violations of the child's rights, protected by the Children and Young Persons Ordinance (CYPO) and the Protection of Children's Rights Act, form the legal framework for child protection in Sri Lanka. The ISD has interviewed family members and collected witness statements from neighbors and teachers, referring the case to the police for further investigation and notifying the National Child Protection Authority for an additional inquiry. Additionally, Sri Lanka is a signatory to the United Nations Convention on the Rights of the Child (UNCRC), which guarantees children's fundamental rights.

Dural Venous Sinus Thrombosis (DVST) is a rare although serious clinical entity that causes approximately 0.5% of all stroke cases. Head trauma with skull base fracture, aneurysm, CNS infection, thrombophilia, and vasculitis may be identified as a possible cause of DVST. Vernet’s Syndrome is characterized by a constellation of unilateral cranial nerve palsies involving the 9th, 10th, and 11th cranial nerves due to compression or narrowing of the jugular foramen. We herein present a case of 33 years old Bangladeshi worker from Malaysia who had history of severe Traumatic Brain Injury (TBI) following road traffic accident with multiple skull bone fracture and extradural hematoma 3 months back, presented with acute dysphagia, dysphonia, fever and cough for 6 days. Neurologic examination revealed deviation of uvula to the left side and features of consolidation over right upper chest. Magnetic Resonance Venography (MRV) revealed thrombosis involving right transverse sinus, sigmoid sinus extending up to right internal jugular vein. The diagnosis of vernet syndrome with aspiration pneumonia was made. Later thrombophilia screen showed protein S deficiency. He was treated with broad spectrum antibiotics and started anticoagulation with dabigatran. After 6 months of anticoagulation he recovered fully with no residual neurological deficit.