Severe and rapidly changing hypophosphatemia in cannabinoid hyperemesis syndrome: a case report.

The increasing prevalence of cannabis worldwide requires awareness of a potential, less recognized, paradoxical entity, the cannabinoid hyperemesis syndrome (CHS). This includes cyclic episodes of nausea, vomiting, and compulsive hot water bathing for alleviation in individuals with chronic cannabis use. An 18-year-old male with daily and prolonged cannabis use has excessive nausea and vomiting, is diagnosed with CHS, and is further complicated by severe and rapidly fluctuating hypophosphatemia. He was successfully managed with intravenous (IV) antiemetic (metoclopramide) and IV normal saline in the emergency department. Hypophosphatemia was treated with IV phosphorous. Although hypophosphatemia in CHS is a rare encounter, the authors share their experience to promote broader recognition and insight into successful management.

Retroperitoneal Castleman's disease in a young Nepalese girl: A rare cause of childhood abdominal mass.

Introduction: Castleman's disease (CD), or benign angio-follicular lymph node hyperplasia, is an uncommon condition in childhood. When a child presents with a huge retroperitoneal mass and inconclusive findings on clinico-radiological evaluation or tissue sampling, management becomes exceedingly difficult. CD herein becomes an uncommon presentation of an uncommon diagnosis. Case presentation: A six-year-old girl with no past medical problems presented to the office with a slowly progressive, painless mass over the right lumbar region for a year. Abdominal ultrasound showed a well-defined oval mass in the right periumbilical region, further evaluation of which with a computed tomography scan suggested lymphoma. A preoperative core-cut biopsy could not confirm the findings and suggested a neoplastic lesion, probably an inflammatory myofibroblastic tumour or small round cell tumour. She underwent an exploratory laparotomy with in-toto excision of the mass. Intraoperatively, a solid retroperitoneal tumour measuring 8×8×6 cm was found. Histopathology and immunohistochemistry confirmed a unicentric CD of the hyaline-vascular type. At two years of follow-up, she remained asymptomatic and disease-free. Conclusion: While CD in children is rare, retroperitoneal localization of the same can further add to the diagnostic conundrum. However, if carefully considered, an en-bloc surgical resection offers complete treatment.

Uncommon presentation of cutaneous leishmaniasis: late-onset facial involvement after a decade-a rare case report.

Leishmaniasis is a parasitic infection that can involve the skin, mucosal membranes, and internal organs. It is endemic to the tropics. A forty-three-year-old male, diagnosed and treated for visceral leishmaniasis 15 years ago, presented with a complaint of a progressively growing lesion on his face for five years. A detailed history, clinical examination, and histopathological examination were done to reach a diagnosis of cutaneous leishmaniasis (CL). Treatment with oral fluconazole 300 mg daily for six months, followed by 50 mg miltefosine three times a day for another two months, led to complete resolution of symptoms, and the lesion on the face was cured. Early diagnosis is crucial to averting unwarranted treatment and potential complications. This case aims to inform clinicians of the high index of suspicion when diagnosing CL; given the delayed presentation, the previous medical history and the natural course of the lesion are of utmost importance.

Liver fluke in a young Nepalese girl: A rare diagnostic puzzle.

Key Clinical message: Fascioliasis poses diagnostic challenges to clinicians for its broad spectrum of hepatobiliary symptoms and lower detection rates. Timely and precise identification avoids long-standing hepatic complications. Abstract: Fasciola hepatica, a trematode parasite, inhabits snails and sheep. Human hepatic fascioliasis is a neglected tropical disease with no specific tests. In this instance, the significance of clinical awareness, appropriate imaging, and serological investigations is demonstrated. A young Nepalese girl was diagnosed and managed successfully.

Concurrent occurrence of acute pancreatitis and intracerebral hemorrhage as presenting manifestations in lupus: a case report.

Systemic lupus erythematosus (SLE) is a rare autoimmune condition that may affect almost every organ system and has a wide range of disease severity. It is characterized by a spectrum of clinical manifestation, a plethora of autoantibodies, and immune complex formation. The symptoms can come from any organ system, alone or in a group, and they can be of any severity, which makes diagnosis and prognosis difficult. Case presentation: The authors hereby present the case of an 18-year-old female with chief complaints of fever, abdominal pain, headache, vomiting, and loss of vision. She was diagnosed with acute pancreatitis (AP) and intracerebral hemorrhage (ICH) with an etiology linked to SLE. SLICC criterion was used to diagnosed SLE while ATLANTA criteria for AP and neuro-radiological findings for ICH. Emergency temporo- parietal-occipital-osteoplastic craniotomy was done for ICH as well as started with immunosuppressive therapy for SLE. On the 18th day of admission, she was discharge with maintenance medications for SLE. While the vision took over a month to come to a premorbid state, she was clinically improved within 2 weeks of admission. Clinical discussion: Clinical manifestation of SLE vary greatly. AP and intracranial bleeding are few of the rare presentation of SLE. Acute presentation of both conditions in an otherwise healthy individual in the initial course of disease left the clinician with a wide array of differentials. Literature shows very little evidence of co-occurrence of ICH and pancreatitis as an initial manifestation in SLE patients. The exclusive diagnosis of these potentially fatal condition is made holistically with clinical, biochemical, and radiological parameters. Conclusion: SLE may present with atypical, life-threatening initial manifestations. Early diagnosis and timely intervention in therapy can lead to successful management. The treating physician must consider, SLE when a straightforward diagnosis is associated with inexplicable multiple concomitant abnormalities, especially in young women.

Infantile choledochal cyst presenting with an epigastric bilioma: An iceberg phenomenon.

INTRODUCTION: Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation, can account for 1.8-7% of cases. In an infant with non-specific abdominal complaints and a vaguely palpable upper abdominal mass, a perforated CC may be overlooked, leading to a delayed or misdiagnosis and a detrimental outcome. CASE PRESENTATION: We describe a 10-month-old girl who presented to the office with upper abdominal pain and associated fullness for two weeks. An abdominal ultrasonogram revealed perihepatic collections and an evident dilatation of the common bile duct. The bile aspirated from the collections prompted pigtail drainage as an emergency. Magnetic resonance cholangiopancreatography later revealed a spontaneously perforated CC with residual bilioma. Elective resection after six weeks, followed by bilio-enteric reconstruction, resulted in an uneventful recovery. CLINICAL DISCUSSION: Biliary peritonitis and localized biliomas are rare forms among the wide range of findings that can accompany CC. Satisfactory outcomes can be achieved with a two-stage procedure that entails biliary drainage with sepsis control, followed by resection of the CC and bilio-enteric reconstruction a few weeks later. CONCLUSION: It is important to be aware of the spectrum of findings that CC may present. We discussed our experience successfully treating a perforated type IVa CC.

A cystic non-Wilms renal tumor in a Nepalese boy: A rare case of clear cell sarcoma.

INTRODUCTION: Clear cell sarcoma of the kidney (CCSK) is an uncommon childhood malignancy known for its aggressive behavior and tendency to recur and metastasize to the brain and bones. CASE PRESENTATION: We report a four-year-old boy evaluated for non-specific abdominal pain with an incidental radiological finding of a right lower pole cystic renal mass initially thought to be cystic Wilms' tumor. A pretherapy core biopsy of the mass suggested a clear cell tumor. An open transperitoneal radical nephroureterectomy with aortocaval lymph node sampling was done. Based on histopathological findings and immunohistochemical analysis, CCSK was diagnosed. Appropriate chemotherapy and radiotherapy were instituted postoperatively. At six years follow-up, he was tumor-free and doing well. CLINICAL DISCUSSION: The workup for CCSK includes diagnostic and metastatic imaging, histopathology, and immunohistochemistry analysis. Diagnostic segregation of CCSK and Wilms' tumor is imperative to institute optimal oncological management and improve overall treatment outcomes. CONCLUSION: Considering the age of presentation and clinico-radiological appearance, CCSK can be mistaken for Wilms' tumor, which is much more common in occurrence despite the distinguishable histopathological features, treatment modalities, and prognosis.

Liver injury at admission and outcomes in patients with COVID-19 disease: a prospective cohort study.

The liver is one of the common extrapulmonary organs involved in the coronavirus disease 2019 (COVID-19) infection. We aimed to find the prevalence of liver injury at hospital admission and its effects on outcomes. Methods: This is a single-center prospective observational study. All consecutive patients with COVID-19 admitted during the months of May to August 2021 were included in the study. Liver injury was defined as at least 2 times elevation of aspartate transaminase, alanine transaminase, alkaline phosphatase, and bilirubin above the upper limits on normal. The predictive efficacy of liver injury was measured as its effects on outcome variables, that is duration of hospital stay, requirement of ICU admission, mechanical ventilation, and mortality. Presence of liver injury compared with existing biomarkers markers of severe disease, that is lactate dehydrogenase, D-dimer, and C-reactive protein. Results: A total of 245 consecutive adult patients with COVID-19 infection were included in the study. Liver injury was present in 102 (41.63%) of patients. There was a significant association between the presence of liver injury and duration of hospital stay (10.74 vs. 8.9 days; P=0.013), the requirement of ICU admission (12.7 vs. 10.2%; P=0.018), mechanical ventilation (10.6% vs. 6.5%; P=0.003), and mortality (13.1% vs. 6.1%; P<0.001). Liver injury was significantly associated (P<0.001) with the corresponding elevation of serum biomarkers of severity. Conclusion: The presence of liver injury in patients with COVID-19 infection at the time of hospital admission is the independent predictor of poor outcomes and can also be used as the marker of disease severity.

Laparoscopic anatomical segmentectomy: A paradigm shift towards minimally invasive liver surgery in Nepal: A cohort study.

Laparoscopic liver resection is taking stride in slowly replacing open surgeries for various hepatic pathologies in many developed countries. However, due to high cost and lack of expertise, there are only a handful of centres in the low-medium income countries who perform advanced laparoscopic liver resections regularly. In this study, a prospective analysis was carried out to assess and report the outcomes of laparoscopic anatomical segmentectomy (LAS) from a single centre in Nepal. Methods: The clinical data of all patients who underwent LAS between 1 October 2021 to 30 September 2022 were prospectively recorded. Demographics, pathological diagnoses, types of resections performed, perioperative parameters, postoperative length of stay, postoperative complications data and IWATE score were collected and analyzed. All operations were performed using the extrahepatic Glissonean technique with the use of indocyanine green dye as an adjunct during the intraoperative period. Results: In the study period, a total of 16 LAS were performed in our centre for various indications. The mean age of the patients in the series was 41.6 years, and seven of 16 patients were male. The majority of the cases were segment 2/3 resection indicated for various pathologies and segment 4b/5 indicated for carcinoma gallbladder. The median hospital stay was 6 days and only two cases developed major complication. There were no mortalities in our series. Conclusions: Taking into account the results produced from a single centre in a low-medium income country, laparoscopic anatomical segmentectomy is technically feasible with an acceptable safety profile.

Long COVID Syndrome and Cardiovascular Manifestations: A Systematic Review and Meta-Analysis.

(1) Background: Long COVID syndrome is a significant cause of morbidity in COVID-19 patients who remain symptomatic with varied clinical presentations beyond three weeks. Furthermore, the relevance of considering cardiovascular outcomes in post-COVID-19 syndrome is important in the current COVID-19 pandemic; (2) Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this systematic review and meta-analysis. Systematic searches were conducted from multiple databases without language restrictions until October 8, 2022, to find studies evaluating cardiovascular outcomes such as arrhythmias, myocardium and pericardium diseases, coronary vessel disease, and thromboembolic disorders in post-COVID cases. The pooled odds ratio (OR), and standard mean difference (SMD) with their corresponding 95% confidence intervals (CI) were computed to find the association; (3) Results: Altogether, seven studies with a total of 8,126,462 (cases: 1,321,305; controls: 6,805,157) participants were included in the meta-analysis. Pooled odds ratios of cardiovascular outcomes were significantly higher in post-COVID cases (OR > 1, p < 0.05) than in controls. However, the mortality (OR: 4.76, p = 0.13), and heart rate variability (SMD: -0.06, p = 0.91) between cases and controls were not statistically significant; (4) Conclusions: Significant cardiovascular sequelae in long COVID syndrome highlight the importance of careful cardiac monitoring of COVID-19 patients in the post-COVID phase to address cardiovascular complications as soon as possible; larger-scale prospective studies are required for accurate estimation.

The stone beneath my skin: Pilomatricoma in a young Nepalese girl.

Introduction: Pilomatricoma is a rare and benign tumor affecting children and adolescents. It originates from the matrix cells of hair follicles, the usual sites being head-neck and upper extremities. Due to its rarity, it is often misdiagnosed delaying definitive treatment. We report a case of pilomatricoma over the left gluteal region in a young Nepalese girl that was initially thought to be a calcified granuloma. Case presentation: A six-year-old girl presented with a painful swelling over the left buttock for one year that was gradually increasing in size. On examination, a solitary, well-circumscribed, tender swelling with hard consistency and a bumpy irregular surface measuring 3 × 2 cm was noted over the subcutaneous plane of the left gluteal region. Surgical excision of the mass was done which demonstrated features of pilomatricoma on histopathological examination (HPE). She recovered and remained disease-free at one year follow-up. Conclusion: This case highlights one of the handful presentations of pilomatricoma involving the buttock. Pilomatricoma is rarely considered a differential diagnosis of benign masses, the diagnosis of which is ascertained mostly after an HPE of the excised specimen. Surgical excision with clear margins is not only diagnostic but therapeutic in most situations.

Breast abscess in two Nepalese newborns: An unusual series.

Background: Breast abscess in newborns is an exceedingly rare pyogenic inflammation that usually starts as mastitis neonatorum. Although mastitis can respond to antibiotic therapy in the initial stages, once advanced into a purulent collection, decompression may be indicated either in the form of needle aspiration or even surgical drainage. We present two newborns with breast abscesses managed surgically with successful outcomes. Case presentation: Case 1: A 13-day-old boy presented with swelling and redness over the left breast for a day. Local examination revealed a warm, indurated swelling with redness and fluctuation. Needle aspiration confirmed pus. Intravenous (IV) antibiotics were started right away followed by pus drainage, the culture of which yielded Methicillin-Sensitive Staphylococcus aureus (MSSA). Regular wound care subsequently resulted in complete recovery.Case 2: A 15-day-old boy presented with swelling, redness and milky discharge from the right breast for two days. The swelling was erythematous, tender and indurated but not cystic or fluctuant. Ultrasonogram was suggestive of an abscess. Once again, IV antibiotics were administered followed by drainage. Pus yielded MSSA. Following regular wound dressings, satisfactory healing was achieved. Conclusion: Neonatal mastitis and breast abscess are uncommon. Early recognition followed by appropriate antibiotic therapy and drainage of the abscess is the mainstay of treatment.

Borderline tuberculoid leprosy misdiagnosed as Cheilitis Granulomatosa Miescher: A case report.

Macrocheilia, as an initial manifestation of leprosy, is uncommon. We present a case of a 50-year-old female, with lower lip swelling, initially diagnosed as Cheilitis Granulomatosa Miescher. Unresponsiveness to local intralesional corticosteroids necessitated further evaluation. Repeat tissue sampling yielded a confirmatory diagnosis of borderline tuberculoid leprosy, which was managed successfully.

Eosinophilic gastritis without peripheral eosinophilia and atopy: A case report.

Eosinophilic gastritis (EG) is characterized by eosinophilic infiltration of any gastric layers. We report a 65-year-female presenting with abdominal pain and vomiting for two months. Chronic gastritis not responding to empirical treatment interrogated further investigations. In the absence of atopy and peripheral eosinophilia, successful treatment of a large solitary antral ulcer with steroids upheld the diagnosis of EG.

Suppurative complications following BCG vaccine in 2 Nepalese children.

Background: The Bacillus Calmette-Guérin (BCG) vaccine is one of the most common vaccines administered worldwide and awareness regarding its usual and adverse reactions is important. Local and systemic complications require accurate identification for timely therapy. We hereby report two patients with rare suppurative local complications of BCG. Case presentation: Case 1: A nine-month-old boy presented with swelling over the right deltoid for one month with low-grade fever and purulent discharge for two days. The active discharge occurred from the same site of previous BCG inoculation, the regression of which was achieved conservatively. Case 2: The second case was a 14-month-old boy who presented with a swelling over the lower part of the right axilla for one year, later diagnosed as a tuberculous lymph nodal abscess. Needle aspiration was done and anti-tubercular therapy was started based on positive Gene Xpert reports. Both the cases resolved completely without complications. Conclusion: Pharmacovigilance surveillance of BCG scar reactions and occurrence of suppurative complications should be known by clinicians for correct identification and management.

Chilaiditi syndrome in a Nepalese girl - A potential mislead!

INTRODUCTION: Chilaiditi's Sign (CS) is a radiological finding on an abdominal radiograph due to colonic interposition between the liver and the diaphragm giving a false impression of free intra peritoneal air. When accompanied by abdominal symptoms, a syndrome with the same name is diagnosed. As elusive a finding, it can be a source of diagnostic misinterpretation causing an alarming illusion of a deceptive emergency. CASE PRESENTATION: We report a four-year-old girl presenting with an acute abdomen in a background of long-standing constipation and an illusory radiograph suggesting left-sided, free sub diaphragmatic air. Further imaging with a CECT confirmed mesenteric lymphadenitis without free peritoneal air and chronic constipation as a cause of symptoms. Expectant management resulted in gradual clinical improvement. DISCUSSION: Chilaiditi's syndrome or CS is more often described in adults and more frequently over the right side, nevertheless, can occur in children too. Knowledge of its occurrence can avoid unnecessary surgical intervention. CONCLUSION: While evaluating a child with acute abdomen, if the finding of a radiographic free sub diaphragmatic air is discordant with clinical signs, further imaging to rule out CS is important to avoid unnecessary exploration.

An unusual case of subacute small bowel obstruction - Gallstone ileus.

INTRODUCTION AND IMPORTANCE: Gallstone ileus is caused by an impaction of one or more gallstones within the gastrointestinal tract, leading to mechanical intestinal obstruction. It is a rare complication of cholelithiasis leading to the formation of a cholecystoenteric fistula and is associated with high mortality rates. We report a case of atypical subacute small bowel obstruction due to gallstone ileus. PRESENTATION OF CASE: An 82-year-old man, with previously diagnosed cholelithiasis, presented with abdominal pain and vomiting for nine days. The contracted gallbladder with distended bowel loops was visualized on abdominal ultrasound. Computed tomography of the abdomen and pelvis revealed dilated loops of the small intestine with a gallstone in the proximal ileum, causing intestinal obstruction with pneumobilia, suggesting gallstone ileus with cholecystoduodenal fistula. The patient underwent an emergency laparotomy and enterolithotomy to remove the impacting gallstone. The cholecystoduodenal fistula was left undisturbed due to the significant risk of duodenal injury. The patient had an uneventful postoperative recovery. CONCLUSION: Gallstone ileus almost always requires surgical management. However, performing an interval biliary surgery is based on the clinical judgment of the surgeon. In our case, the patient's clinical status determined the treatment in which an enterotomy with stone extraction alone was largely sufficient, and has supported the literature. Gallstone ileus is an important differential diagnosis in elderly patients with gallstone disease, untreated or undiagnosed, presenting with features of small bowel obstruction.

Self-inflicted stab injury with abdominal evisceration: A case report.

INTRODUCTION AND IMPORTANCE: Self-inflicted abdominal stab injury with an intention of self-harm is uncommon. Moreover, self-inflicted injury leading to avulsion of the colon has rarely been reported in the literature. We report a case of a 42-years-female with schizoaffective disorder who presented with self-inflicted stab injury on the abdomen resulting in abdominal evisceration. PRESENTATION OF CASE: A 42-years-female with schizoaffective disorder (F25) for 10 years presented to the emergency department with multiple, self-inflicted injuries on the abdomen. A large free portion of the omentum and segment of the bowel were brought in a plastic carry bag. Examination revealed multiple transverse hesitation cuts in the epigastrium and a single deep penetrating transverse cut resulting in the evisceration of the omentum and colon. Intra-operatively, avulsion of a large portion of the greater omentum and missing segment of the mid transverse colon was observed. The patient underwent an immediate abdominal exploration and side-to-side colo-colic anastomosis along with diversion ileostomy. At three months following primary surgery, ileostomy closure was done. CONCLUSION: Patients with schizophrenia spectrum psychosis are at risk of self-harm and in our case a schizoaffective patient presented with self-inflicted injuries that required an emergency abdominal exploration and repair. This case highlights a multi-disciplinary approach for the management of these cases and mandates clinicians and caregivers to be more vigilant to restrict injuries in the future.

Incidental finding of Langerhans cell histiocytosis of temporoparietal bone - A case report.

INTRODUCTION AND IMPORTANCE: Langerhans cell histiocytosis (LCH) is a rare haematological disorder affecting infants and young children and has an estimated incidence of 2-5 cases per million people per year. LCH invades the reticuloendothelial system and causes the proliferation of Langerhans cells and mature eosinophils. LCH involving the temporoparietal bone has rarely been reported in the literature. PRESENTATION OF CASE: A ten-year-old boy presented to the Neurosurgical outpatient clinic with a swelling on the right temporoparietal region following a fall from his bicycle. Local examination revealed a single, 3 × 3 cm, non-tender, cystic, immobile swelling in the right temporoparietal region. On evaluation for recent head trauma, an incidental finding of eosinophilic granuloma was discovered on a CT scan. The FNAC was suggestive of a histiocytic lesion pertaining to a diagnosis of LCH. The patient underwent wide excision of the mass and cranioplasty. A one-month follow-up CT scan of the head had no evidence of residual or recurrent disease. DISCUSSION: Eosinophilic granuloma is one of the three variants of LCH and has a relatively better prognosis. Clinical diagnosis can be challenging and mandates tissue sampling for histopathological examination. Treatment modalities including surgery, radiotherapy, chemotherapy, and steroid injection are used alone, or in combination, depending on the extent and severity of the disease. CONCLUSION: Examining a swelling in the temporoparietal region with no other characteristic symptoms could be a case of LCH. The timely diagnosis and surgical excision with other adjuvant treatment options of this rare pediatric disease would help in a better outcome.

Multiple jejunal gastrointestinal stromal tumors and Neurofibromatosis type 1: A rare association.

INTRODUCTION AND IMPORTANCE: The association between gastrointestinal stromal tumor (GIST), mesenchymal tumor arising from the interstitial cells of cajal and Neurofibromatosis type 1 (NF1), an autosomal dominant disease has been reported in the literature. GIST in NF1 patients are multiple and located in the small intestine. Tumorigenesis in NF1 associated GIST is different to that of sporadic GIST and hence the treatment. Here we report a rare case of an NF1 patient with multiple jejunal GISTs. CASE PRESENTATION: We here present a rare case of a 57-year-old male diagnosed with NF1 30 years back, presented in our emergency department with complaints of black, tarry stools later diagnosed to have multiple GIST in jejunum. Contrast enhanced computed tomography (CECT) of the abdomen showed a large 10.1 × 7.33 × 6.2 cm heterogeneous, exophytic, solid mass with cystic areas originating from the jejunum. The microscopic examination of the specimen showed spindle shaped tumor cells while immunohistochemistry showed CD117 (c-KIT) and DOG-1 positivity. The primary treatment was complete surgical excision of the tumor. CLINICAL DISCUSSION: The incidence of GISTs in NF1 patient is around 6-7%; however, concomitant presence of multiple GISTs is rare. CECT of abdomen along with histopathological and immunohistochemistry studies are diagnostic. The management of GIST includes surgical and adjuvant therapy methods based on the tumorigenesis and recurrent risk stratification. CONCLUSION: Early clinical suspicion and imaging aids in early detection of the tumor in patients with NF1 presenting with gastrointestinal symptoms. Postoperatively, screening for recurrence with radiology is of utmost importance.