Median arcuate ligament syndrome: A rare case report from Nepal.

INTRODUCTION: Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, leading to a typical symptom triad: postprandial abdominal pain, weight loss, nausea, and vomiting. CASE PRESENTATION: A 41-year-old female patient presented to our center with mild postprandial abdominal pain over the epigastric region, and bloating sensation. Ultrasonography of the abdomen showed multiple stones in the gall bladder lumen, and the computed tomography scan showed median arcuate ligament impingement along the proximal aspect of the celiac trunk causing moderate narrowing with post-stenotic dilation. Laparoscopic release of the median arcuate ligament with laparoscopic cholecystectomy was performed. DISCUSSION: The diagnosis of Median Arcuate Ligament Syndrome is based on the classical post-prandial symptoms and abdominal imaging technologies like Doppler ultrasonography, computed tomography angiography, or magnetic resonance angiography. Exclusion of other intestinal disorders should be considered before making the diagnosis. Celiac artery decompression through different means is the principle of treatment of this condition. CONCLUSION: The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have an established etiology. Celiac artery decompression by releasing the median arcuate ligament is the treatment.

Chylolymphatic mesenteric cyst: A rare differential diagnosis of cystic mass in abdomen: A case report.

INTRODUCTION: Mesenteric cysts are the rare benign intraperitoneal tumor, which are common in the mesentery of the terminal ileum. Though mesenteric cysts are frequently seen, chylolymphatic mesenteric cysts in children are rare entities. CASE PRESENTATION: Our case is a case of a 3-year-old female child presenting to our center with a complain of abdominal pain. Ultrasonography (USG) of the abdomen revealed a cystic lesion in the right upper abdomen, and computed tomography (CT) scan showed a large homogenous fluid density lesion in the right upper abdomen, giving a provisional diagnosis of mesenteric cyst. She was managed surgically: the cyst was excised, the involved segment of bowel was resected and the remaining was anastomosed. On histopathology, the final diagnosis of a chylolymphatic mesenteric cyst was made. DISCUSSION: Clinical presentations may vary from asymptomatic abdominal lump to features of acute abdomen. Imaging modalities like ultrasonography and computed tomography scans are the mainstay of investigations. Surgical management with excision of cyst, and resection of the involved bowel segment is the treatment of choice, as done in our patient. The final diagnosis is made after the histopathologic examination of the excised specimen. CONCLUSION: Chylolymphatic mesenteric cysts are rare, and have varied clinical presentations. Although rare, chylolymphatic mesenteric cysts should be considered a differential diagnosis in patients presenting with cystic masses in the abdomen.

Multidermatomal herpes zoster triggered by psychological stress in an immunocompetent young adult: a rare case report and clinical insights.

Introduction and Importance: Herpes zoster (HZ), a reactivated varicella zoster virus infection arising from dormant viral latency after initial chickenpox, manifests as localized skin rashes along dermatomes. Multidermatomal involvement, especially in immunocompetent individuals, is rare. The potential link between psychological stress and HZ reactivation remains underexplored. The authors present a case of multidermatomal HZ triggered by psychological stress in a young immunocompetent adult. Case presentation: A 26-year-old male presented with vesicular lesions spanning C5, C8, T1, and T2 dermatomes, triggered by psychological stress. The disease exhibited a unique midline-crossing presentation. The Varicella zoster virus IgM test result was positive. Treatment included acyclovir, pain management, and stress reduction strategies, yielding complete resolution within 3 weeks. Clinical discussions: The case highlights a distinctive multidermatomal HZ presentation, defying conventional dermatomal restrictions. Psychological stress potentially influenced viral reactivation. Immunocompetence and stress interplay merit further exploration. Multidermatomal HZ necessitates prompt clinical recognition and comprehensive evaluation. Antiviral therapy and integrated stress management may contribute to successful outcomes. Conclusion: This case underscores the rare occurrence of multidermatomal HZ in an immunocompetent young adult triggered by psychological stress. The atypical presentation and potential role of stress in viral reactivation emphasize the complex interaction between the nervous and immune systems. Integrated clinical management, stress reduction strategies, and antiviral therapy were effective in resolving the condition. Further research is warranted to elucidate the mechanisms underlying stress-induced viral reactivation and its clinical implications.

Jejunal duplication cyst in a female neonate: a case report.

Introduction and importance: Duplications are the abnormal portion of the intestine, either externally attached to the intestine or intrinsically placed within the bowel lumen. Their prevalence is noted to be around one in 25 000 deliveries. The rare gastrointestinal tract duplication may be located in any part of the gastrointestinal system from the oral cavity to the anus. The most common site of enteric duplication cyst (DC) is the terminal part of the ileum. Hence, duplications in jejunum are rare. Case presentation: Hereby, the authors report a case of jejunal DC in a female neonate which was managed successfully via surgery and adequate post-operative care without any complications. Clinical discussion: Duplications are more frequently single. They are usually located in the mesenteric border of the associated native bowel and may vary in shape and size. Most of them are cystic, followed by tubular and mixed type, with or without other congenital anomalies. More than 80% of the cases present before the age of 2 years as an acute abdomen or bowel obstruction, but many duplications remain silent unless complications occur, and therefore may not be diagnosed until adulthood. Complications of enteric DC include volvulus, bleeding, and, rarely, malignant degeneration. Conclusion: It is important for paediatric surgeons to include DC in the differential diagnosis if a neonate presents with features of intestinal obstruction.

Prevalence of methicillin-resistant Staphylococcus aureus carriage among healthcare workers in South Asia in non-outbreak settings: A systematic review and meta-analysis.

BACKGROUND: This study aimed to estimate the pooled prevalence and sub-group-specific prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among Healthcare Workers (HCWs) in South Asia. METHODOLOGY: We considered prospective and cross-sectional studies published in the English language with participants ≥50 by searching different electronic databases to locate the relevant articles that reported the epidemiology of MRSA. The participants were healthy South Asian nationality HCWs (asymptomatic for any infectious disease) of any age and gender with a definitive diagnosis of MRSA carriage. The result was synthesized for the pooled prevalence of MRSA carriers among HCWs using 95% confidence interval (CI) with DerSimonian and Laird random-effects models. RESULTS: The pooled prevalence of MRSA carriage among HCWs was 9.23% (95%CI; 6.50%, 12.35%) with a range from 0.67% to 36.06%. The prevalence in India, Nepal, Pakistan, Sri Lanka, and Bangladesh was 5.65% (95%CI; 3.65%, 8.03%), 8.83% (95%CI; 6.77%, 11.11%), 17.20% (95%CI; 10.70%, 24.85%), 22.56% (95%CI; 4.93%, 47.83%), and 4.93% (95%CI; 1.88%, 9.20%) respectively. The pooled prevalence of MRSA carriage among nurses and doctors was 8.90% (95%CI; 6.00%, 12.24%) and 6.53% (95%CI; 3.63%, 10.06%) respectively. CONCLUSION: The findings from our study suggests that if the propagation of MRSA continues, then it can lead to a situation of an outbreak. Hence, proper preventive measures are to be adopted to prevent this outbreak.

Radiologic finding of intraosseous gas: A rare case of emphysematous osteomyelitis of the foot.

Emphysematous osteomyelitis is a rare but potentially life-threatening infection which is characterized by presence of intraosseous gas. It is a very rare form of osteomyelitis which is complicated by infection with gas forming organisms. In majority of the cases, it has been found to be associated with comorbidities like immunosuppressive therapies, diabetes mellitus, alcohol use, and several others. Early identification on radiologic imaging is necessary to enable implementation of prompt treatment plan.

A case of scar endometriosis in cesarean scar: A rare case report.

INTRODUCTION: Scar endometriosis is a rare entity characterized by presence of functional endometrial tissue in the site of surgical scar. Cesarean section scar is the most common reported site. We herein report a case of cesarean scar endometriosis in a 43-years-old female patient. CASE PRESENTATION: A 43 year old female, with history of lower segment cesarean section 8 years back, presented to our center with complains of pain and palpable lump during menstruation, at the site of cesarean scar. On ultrasonography she was said to have some pathology in her previous surgical scar site. On MRI, a soft tissue mass measuring 25 × 35 mm within the subcutaneous tissue of anterior abdominal wall on the left side was seen. She was planned for surgical removal of the tissue. DISCUSSION: Scar endometriosis is a rare entity. The iatrogenic implantation of the hormone sensitive endometrial tissue into the edge of the wound during surgery best explains its occurrence. They usually present as a painful nodule in the site of surgical scar that undergoes cyclic variation with the menstrual cycle. Diagnosis can be confirmed by radiography. Treatment options can be medical and surgical, the latter being more effective and the preferred one. CONCLUSION: Scar endometriosis often mimics with variety of clinical conditions, so high degree of suspicion is necessary. Efforts should be aimed at minimizing the transfer of endometrial tissue into the subcutaneous area. Gloves replacement prior to closure can avoid the implantation of endometrial tissue into the abdominal wall.

A case of huge ovarian cyst in second trimester: A rare case report.

Introduction: Large cystic masses are rare in pregnancy. Corpus luteum cysts and theca lutein cysts are common are most common among all. Ovarian masses are usually discovered as an incidental finding during routine obstetric ultrasonography. Management depends upon the size of the mass, and the symptoms produced by the mass. Case presentation: Our case describes an incidental finding of a large ovarian cyst during the second trimester, in a 24-year-old female patient. Per abdominal examination revealed a huge mass in the epigastrium, left hypogastrium, and left lumbar region, along with 20 weeks sized uterus. Ultrasonography revealed a cystic mass of 11.9 cm × 11.7 cm X 15.9 cm, with multiple septations and cystic areas. After other baseline investigations, she was planned for surgical removal of the mass. Upon histopathologic examination after surgical excision, the mass was found to be mucinous cystadenoma. Discussion: Large ovarian masses are uncommon during pregnancy. The most common complications of ovarian masses in pregnancy are torsion, rupture, infection, or malpresentation of the fetus. Surgical management can be done if the mass presents with acute symptoms like torsion, or if the size of the mass is greater than 5 cm. Non-obstetric surgery for cyst removal can be done electively during the second trimester, or irrespective of the period of gestation if there are acute symptoms. Conclusion: Large ovarian masses are usually rare during pregnancy. It is necessary to properly evaluate the case of ovarian masses during pregnancy, to decide the appropriate line of management.

Right breast schwannoma in a male: A rare case report.

INTRODUCTION: Schwannoma are benign neoplasms of peripheral nerve sheath. They usually occur in the head, neck and the extremities. Breast is a rare location of Schwannoma. CASE PRESENTATION: Our case describes the occurrence of Schwannoma in the right breast, in a 60-year-old male, who has had a breast lump since the last 6 years. After ultrasonography (showed 3.4 × 2.3 × 2.0 cm heteroechoic mass in the upper outer quadrant of the right breast), and mammography (showed 2.5 × 3.2 cm sized high density mass in upper outer quadrant of right breast), an excisional biopsy was performed, and on histopathologic examination, the diagnosis of breast schwannoma was confirmed. DISCUSSION: Clinical and pathological features resemble that of other benign tumors. On ultrasonography they present a well-defined, solid, hypoechoic mass, with some degree of posterior acoustic enhancement. Diagnosis is usually based on histopathologic examination. Microscopically, it exhibits hypercellular antony A areas along with hypocellular antony B areas. Treatment is usually surgical excision. CONCLUSION: Though Schwannomas in breast are rare, they must be considered as differential diagnoses in patients presenting with breast lumps.

Bilateral ovarian mucinous carcinoma (stage III) with omental involvement and incidental hydronephrosis: A rare case report.

INTRODUCTION: Though ovarian malignancies are common, mucinous ovarian carcinomas of high grade are rare. They usually occur in a young female under 40 years of age. Here, we present a case of mucinous ovarian carcinoma (stage III), with omental involvement and incidental hydronephrosis in a 67-year-old female patient. CASE PRESENTATION: A 67-year-old female patient presented to us with a history of lower abdominal pain for 2 months and per-vaginal discharge for the last 6 days. On deep palpation of the abdomen, a nodular mass occupying the suprapubic region was found. Bimanual palpation revealed a mass on the right and left adnexa. After visualization of septate cystic mass bilaterally on CECT, she was planned for staging laparotomy with bilateral salpingo-oophorectomy (BSO) with infra-colic omentectomy with peritoneal cytology. Incidentally, a horseshoe-shaped kidney with right mild hydronephrosis was found. After surgery and histopathologic examination, mucinous ovarian carcinoma (stage III), with omental involvement was confirmed. DISCUSSION: Mucinous ovarian carcinomas are rare malignancies, with different natural history, molecular profile, and prognosis as compared to other epithelial tumors of the ovary. These carcinomas can be either primary or secondary (those metastasized to the ovary from elsewhere), and this differentiation is essential. The therapeutic approach to the patients depends upon the stage at which these carcinomas are diagnosed. CONCLUSION: Mucinous ovarian carcinomas are rare and have unique features among the epithelial ovarian carcinomas. Appreciation of these features will surely make a positive impact in improving the management and thus the prognosis of these carcinomas.

Isolated bilateral clavicular fracture: A case report.

Bilateral clavicle fractures are uncommon and are mostly associated with polytrauma. The presence of concurrent serious injuries diverts the doctor's attention and causes the clavicular injury to be overlooked. Our report presents a 39-year-old male patient with bilateral clavicle fracture whom we managed surgically by open reduction and internal fixation.

Right-sided paraduodenal hernia with malrotation - A case report.

INTRODUCTION: Paraduodenal hernia is a rare cause of internal hernia. It is the herniation of small bowel through a peritoneal sac in the duodenum. It occurs due to incomplete rotation and fixation abnormalities of the primitive midgut during fetal development. We report a case of right sided paraduodenal hernia in an adult male. CASE PRESENTATION: This is a case of 36-year-old gentleman who presented with complaints of abdominal fullness and upper abdominal pain for 1.5 months and 7 to 8 episodes of vomiting. CT scan of abdomen gave an impression of right-sided paraduodenal hernia. Exploratory laparotomy with hernia repair was performed and patient was discharged without complications. DISCUSSION: Right sided paraduodenal hernia is the protrusion of viscera through the fossa of Waldeyer. It is frequently associated with malrotation and strangulation. Its diagnosis is frequently delayed. Symptoms are non-specific and may need laparotomy for diagnosis. Technique of choice for surgical management remains inconclusive. CONCLUSION: Paraduodenal hernias are frequently diagnosed late or incidentally because of vague symptoms. They are rarer and carry higher lifetime risk of strangulation and bowel obstruction. Surgical management is necessary after diagnosis.

Kikuchi-Fujimoto disease: A rare case report from Nepal.

Clinicians and pathologists must be aware of the occurrence of Kikuchi-Fujimoto Disease, as one of the differential diagnoses of cervical lymphadenopathy.

Forshal type IE appendiceal intussusception: A case report.

INTRODUCTION: Appendiceal intussusception is a rare condition. Clinical features are not specific for it. Patients may present with abdominal pain and vomiting. These symptoms represent a variety of abdominal pathology. Preoperative diagnosis is difficult because of the non-specific clinical features. We present a case report of a child who initially presented with ileocolic intussusception. CASE PRESENTATION: This is a case report of a 5-years-old boy with abdominal pain and vomiting. He had an ileocolic intussusception 2 days back, and was successfully managed by hydrostatic reduction and discharged. On ultrasonography, an intussusception was identified in the ileocaecal region. Hydrostatic reduction failed this time and laparotomy was performed. On laparotomy, there was complete intussusception of the appendix with normal ileocaecal junction. Appendectomy was performed. Post-operative period was uneventful. DISCUSSION: Appendiceal intussusceptions are mostly diagnosed intra-operatively. The clinical features may mimic various other acute and chronic abdominal conditions. Type IE appendiceal intussusception, as described by Forshal, is a rare condition. Appendectomy with a rim of the caecum is the procedure of choice. CONCLUSION: Though ileocaecal intussusceptions are common in children, appendiceal intussusceptions are rare and are usually diagnosed during the operative procedure. Radiologists and pediatric surgeons should be aware of this rare entity. Appendectomy is the treatment of choice in most of the appendiceal intussusceptions.

Myopericytoma in right inguinal region: A rare case report from Nepal.

INTRODUCTION: Myopericytoma is a rare mesenchymal soft tissue tumor that originates from perivascular myoid cells and mostly benign in nature. With a slight male predisposition, it occurs more commonly in the lower extremities with an insidious and painless presentation. Contrary to the usual, our patient was with a rare presentation in the inguinal region with a dull aching pain. CASE PRESENTATION: We herein report a case of a 64-year-old female patient with myopericytoma, the first of its kind reported in Nepal, present in the right inguinal region and surgically removed. The mass was single with dull aching pain, non-tender, globular, smooth, mobile, covered with skin and, had been slowly growing for 1 year and had started bleeding for 4 days. On complete surgical excision and subsequent biopsy, a nodule with thin-walled blood vessels and spindle-shaped cells having indistinct cell border, eosinophilic cytoplasm, and oval to spindle-shaped nucleus was observed, features consistent with those of myopericytoma. DISCUSSION: Myopericytoma can occur in different sites in the body. Its differential diagnoses in the inguinal region include inguinal hernia, lipoma, or an inguinal lymphangioma. Histopathological analysis and immunohistochemistry (IHC) staining are used for diagnosis and confirmation. CONCLUSION: Myopericytomas are rare and have a substantial propensity to be misdiagnosed as other soft tissue tumors such as sarcomas due to significant overlap in their presentation and histological features. Complete surgical excision of mass is the curative therapy.