Delayed Presenting Gastric Duplication Cyst Mimicking a Left Adrenal Cyst in a Young Female: A Case Report with a Literature Review.

Introduction: Gastric duplication cyst (GDC) is a rare congenital anomaly of the gastrointestinal tract. Though GDC is often misdiagnosed, misidentification as an adrenal cyst has rarely been reported. Herein, we report a case of GDC in a young female mimicking an adrenal cyst. Case Presentation: A 17-year-old female presented with chronic epigastric pain, nausea, and intermittent vomiting. Physical examinations revealed mild tenderness in the epigastric region. Esophagogastroduodenoscopy showed no abnormality. Ultrasound, contrast-enhanced computed tomography scan, and MRI of the abdomen and pelvis showed an oval-shaped left adrenal cystic lesion measuring 33 × 26 mm. Preoperative blood investigations and hormonal assessments were normal. Laparoscopy showed that the cyst originated from the greater curvature of the stomach. The left adrenal gland was normal. After an intraoperative consultation with a gastrointestinal surgeon, a wedge resection of the cyst was performed. Histopathology confirmed the gastric duplication cyst. Conclusion: GDCs are rare congenital malformations that may become symptomatic during adulthood. They can mimic adrenal cysts and lead to misdiagnosis.

Carcinoma arising from thyroglossal duct remnants.

Thyroglossal duct cysts (TGDCs) are unusual remnants of the thyroid gland that are rarely observed in association with carcinoma. The present study aimed to showcase the clinical characteristics, diagnosis and management of patients with TGDC carcinoma. It was a single-center study conducted from February 2016 to February 2020. The study involved the retrospective analysis of a series of cases with TGDC carcinoma. A total of 10 patients were included in the study, of whom eight (80%) were females. Their age ranged from 25 to 48 years with a mean age of 39.1 years. A total of five cases (50%) underwent only Sistrunk's procedure, four patients (40%) underwent total thyroidectomy along with Sistrunk's procedure and one patient (10%) was treated by Sistrunk operation and lobectomy. In all of the cases (100%), histopathological examination confirmed papillary thyroid carcinoma in TGDCs. In addition, in the thyroid tissue, 2 cases (20%) also had papillary thyroid carcinoma and 3 cases (30%) had papillary thyroid microcarcinoma. Radioiodine was administered in one patient (10%) with suppressive thyroxine. A three-year follow-up with ultrasound revealed no suspicious lesions in any of the cases. Although rare, carcinoma may develop in the thyroglossal cysts. In this situation, both the thyroid gland and different lymph node compartments should be evaluated for malignancy. Surgical intervention is the cornerstone of management.

X-Linked Familial Hypophosphatemia: A Case Report of 27-Year Old Male and Review of Literature.

X-linked hypophosphatemia (XLH) associated with short stature during childhood are mostly referred to the hospital and diagnosed as vitamin D deficiency rickets and received vitamin D before adulthood. A case is presented with clinical features of hypophosphatemia from childhood who did not seek medical care for diagnosis and treatment, nor did his mother or two brothers, who have short statures, bone pain, and fractures. The patient was assessed for sociodemographic, hematological, and biochemical parameters together with a genetic assessment. A DEXA scan and X-ray were done to determine the abnormalities and deformities of joints and bones despite clinical examination by an expert physician. All imaging, laboratory parameters, and the genetic study confirmed the diagnosis of XLH. A detailed follow-up of his condition was performed after the use of phosphate tablets and other treatments. X-linked hypophosphatemia needs a good assessment, care, and follow up through a complementary medical team including several specialties. Phosphate tablets in adulthood significantly affects clinical and physical improvement and prevention of further skeletal abnormality and burden on daily activity. The patients should be maintained with an adequate dose of phosphate for better patient compliance. More awareness is needed in society and for health professionals when conducting medical checkups during the presence of stress fractures, frequent dental and gum problems, rickets, short stature, or abnormality in the skeleton or walking to think of secondary causes such as hypophosphatemia. Further investigations including a visit to a specialist is imperative to check for the primary cause of these disturbances.

Hypogonadism among patients with transfusion-dependent thalassemia: a cross-sectional study.

Patients with thalassemia major are liable to have complications from blood transfusion and iron excess despite using iron-chelating agents. It is common to have endocrine complications in these patients. Hypogonadism is one of the most common complications in thalassemic patients. Early detection and treatment are essential to restore puberty and prevent complications from hypogonadism. Patients and methods: The authors conducted this cross-sectional study in the Kurdistan Region of Iraq, from 1 July 2022, to 1 December 2022. Eighty patients with ß-thalassemia major who were referred to the endocrinology clinic were enrolled. The patients were evaluated sequentially, starting with a history, followed by a clinical examination and laboratory tests related to endocrine disease. Those who met the inclusion criteria were enrolled in the study, while the others were excluded. Results: Out of 80 patients with major thalassemia who were referred to the endocrinology clinic, 53 (66.3%) were female, and 27 (33.7%) were male, with a mean (SD) age of 24.86±7.66 (14-59) years. Fifty-five (68.75%) of them had hypogonadism, three patients (3.8%) had hypothyroidism, while two (2.5%) had hypoparathyroidism. Five patients (6.3%) had diabetes. None of the patients had adrenal insufficiency. The mean ferritin level in thalassemic patients with hypogonadism and thalassemic patients without hypogonadism was 2326±2625 ng/ml vs. 1220±2625 ng/ml. Conclusion: To minimize the risk of endocrinopathy in patients with thalassemia major, they should receive blood transfusions regularly and initiate chelating agents early, because the leading cause of endocrinopathy in thalassemic patients is related to the severity of anemia and iron overload.

Pseudo­Wellens syndrome in an elderly female patient with pulmonary embolism: A case report.

Pseudo-Wellens syndrome refers to any electrocardiogram (ECG) pattern that mimics Wellens syndrome with no critical left anterior descending (LAD) artery-associated coronary artery disease. The present study describes a rare case of pseudo-Wellens syndrome associated with pulmonary embolism. A female patient presented with chest tightness for 72 h. The precordial examination and heart sounds were normal. A mild bilateral lower pitting leg edema with a superficial varicose vein was observed. The levels of C-reactive protein (98.80 mg/l) and D-dimer (7599.9 ng/ml) were abnormal. An electrocardiogram presented a biphasic inversion of the T-wave in precordial leads in the pain-free interval. Coronary angiography did not reveal any notable findings. A computed tomography pulmonary angiography demonstrated an acute pulmonary embolism. The patient received unfractionated heparin (20,000 IU) by intravenous infusion. She was discharged on rivaroxaban (15 mg) twice daily for 21 days. The inverted T-wave specificity, sensitivity and positive predictive values for LAD stenosis are 89, 69 and 86% respectively. This indicates that ECG alternations with the properties of Wellens syndrome do not always guarantee its occurrence, and in the presence of a normal coronary artery, the condition may be pseudo-Wellens syndrome. The case described herein suggests that clinicians need to carefully screen patients that have pulmonary embolisms with an abnormal electrocardiographic pattern in order to prevent unnecessary intervention.

Whole­body MRI for metastatic workup in patients diagnosed with cancer.

Early diagnosis and appropriate staging workup are crucial for cancer patients. Whole-body magnetic resonance imaging (WB-MRI) has been proposed as another practical whole-body approach for assessing local invasiveness and distant metastases in patients newly diagnosed with cancer. The current study aimed to evaluate the efficacy of WB-MRI in assessing metastasis in patients newly diagnosed with cancer using histopathologic data as the reference method. A prospective observational study was performed from April 2018 to July 2020. MRI sequences were utilized to acquire anatomical and functional images in three orthogonal planes. The discovery was classified as nodal, skeletal and visceral metastases. Patient-based analysis was used for visceral metastasis and region-based for skeletal, systemic and lymph node metastases. A total of 43 consecutive patients (mean age, 56±15.2 years) were assessed successively. In 41 patients, there was a concordance between the WB-MRI and histological confirmation. The most prevalent site of metastasis was the skeletal system (18 patients). There were 12 individuals with liver metastasis, 10 with lung metastasis and 4 with peritoneal metastasis, with just one brain metastatic lesion found. On WB-MRI, 38 lymph node groups were deemed positive. Out of the total, 66 skeletal locations contained metastases. The accuracy of WB-MRI for nodal, skeletal and visceral metastases was (98.45, 100 and 100%, respectively). In conclusion, WB-MRI in three orthogonal planes, including the diffusion-weighted MRI with background body signal suppression sequence, may be utilized efficiently and accurately for assessing metastasis staging and may thus be utilized in patients with newly diagnosed cancer.

Brucella epididymo-orchitis: A single-center experience with a review of the literature.

Brucella epididymo-orchitis (BEO) is a rare complication of brucellosis. Despite the high incidence of brucellosis in developing countries, few case series on BEO are available. This study focuses on the clinical presentations, diagnosis, and treatment of BEO with a review of the literature. This study included consecutive BEO patients diagnosed and treated at Smart Health Tower between 2021 and 2023. The required data were retrospectively collected from patients' profiles. The BEO diagnosis was established through scrotal Doppler ultrasound in cases with a positive Rose Bengal test and positive IgG and IgM results for brucellosis, in addition to scrotal pain and swelling. This study included 11 cases whose ages ranged from 22 to 55 years. Most of the cases presented with testicular pain (72.7%), followed by fever (63.6%) and arthralgia (63.6%). The right side (54.5%) was slightly more affected than the left side (45.5%). The major abnormal laboratory finding was an elevated C-reactive protein (82%). The treatment was conservative, in which a combination of gentamicin, doxycycline, and rifampicin was administered to the patients for about 6-8 weeks. One case underwent an orchiectomy due to the abscess formation. All the patients responded well to the treatment, with no recurrence. In the Middle East, brucellosis remains a concerning infectious disease. Early diagnosis, aimed at preventing abscess formation and other complications, takes first priority to avoid invasive interventions.

Myocardial infarction following COVID-19 vaccine administration; a systematic review.

Introduction: Covid-19 vaccines have been assessed in randomized trials, which are designed to establish efficacy and safety, but are insufficient in power to detect rare adverse outcomes. Among the adverse cardiac events associated with mRNA COVID-19 vaccines are inflammations (e.g., pericarditis or myocarditis), thrombosis, and ischemia. Objective: This systematic review aims to evaluate the reported cases of myocardial infarction (MI) after COVID-19 vaccinations. Method: Web of Science, MEDLINE on OVID, PubMed, and Google Scholar were searched for English-language papers published until March 25, 2022. Results: This study included 15 papers (10 case reports and 5 case series). In total, 20 individuals were included who had received COVID-19 vaccines and experienced MI. Males (55%) reported more adverse occurrences than females (45%) across the majority of event categories. The mean time from the administration of the vaccine to the onset of symptoms was 2 days (0-10 days). The AstraZeneca vaccine was responsible for more than half of the reported events. In the majority of cases, the event developed after receiving the first dose of vaccination. Conclusion: MI related to COVID19 vaccination is a rare, but serious and life-threatening condition. Chest discomfort should be regarded as a warning sign, particularly in people who have been administered a dose of the vaccine within the previous two days.

Hypocalcemia as a cause of reversible heart failure: A case report and review of the literature.

Introduction: In both pediatric and adult populations, hypocalcemia-induced heart failure is an extremely rare presentation. The aim of the current study is to report a case of reversible heart failure caused by severe hypocalcemia resulting from hypoparathyroidism, which was resolved by correcting the serum calcium level. Case report: A 29-year-old female presented with orthopnea, dyspnea on mild exertion, and bilateral lower limb swelling. She had a positive Trousseau's sign. Vital signs were stable except for tachycardia. On chest auscultation, there were bilateral basal fine inspiratory crackles. She was immediately treated as a case of pulmonary edema with intravenous furosemide and oxygen therapy. Subsequent treatment for correcting the hypocalcemia was then initiated. Discussion: Hypocalcemia has been proven to influence cardiac function, resulting in lower cardiac contractility as determined by decreased left ventricular work index, stroke index, and cardiac index. In rare circumstances, the clinical, biochemical (elevation of cardiac enzymes), electrocardiographic, and echocardiographic data may lead to an incorrect diagnosis of an acute ischemic attack. Conclusion: Hypocalcemia as a possible factor leading to heart failure should be considered in the differential diagnosis of all individuals with congestive heart failure.

Resistance to thyroid hormone in a child with thyroid agenesis: A case report with review of the literature.

Introduction: The coexistence of thyroid dysgenesis and resistance to thyroid hormone (RTH) is a very rare occurrence. The current study aims to report a unique case of thyroid agenesis with RTH in a pediatric patient. Case report: A 5-year-old male patient presented with poor feeding, excessive somnolence, and a noticeable umbilical hernia since the age of 2 months. He was initially diagnosed as a case of congenital hypothyroidism, and since then, he had been placed on thyroid replacement therapy. No further investigations were conducted until the age of 5 years. Recent laboratory findings revealed an elevated TSH level (42.41 µIU/mL). X-ray examination showed delayed bone age (30 months). Ultrasound (US) examination demonstrated the complete absence of thyroid lobes, isthmus, and ectopic thyroid tissue, but small 2.7 x 2.5-mm non-echoic, cystic, and hypo-vascular nodules were seen in the bed of the right thyroid lobe. The patient was kept on thyroid replacement therapy (levothyroxine) and under close follow-up. On follow-up, the patient's thyroid function status revealed resistance to exogenous thyroid hormone. Discussion: Thyroid agenesis is the complete absence of the thyroid gland. Meanwhile, RTH is a hereditary disease characterized by decreased sensitivity of body tissues to thyroid hormone. Most cases of RTH are due to mutations in the gene encoding for THRß. However, recently RTH due to THRα mutations has also been reported. The presentations of RTH cases in general and with thyroid dysgenesis are quite heterogenous. Conclusion: Although the combination is exceedingly rare, thyroid agenesis can coexist with RTH.

Acute intestinal pseudo-obstruction by pheochromocytoma: A case report with review of literature.

INTRODUCTION: Pheochromocytomas are rare tumors of the adrenal gland. Intestinal pseudo-obstruction is a very rare presentation of a functioning catecholamine-secreting tumor. We present a case of intestinal pseudo-obstruction due to a large functioning pheochromocytoma. CASE REPORT: A 29-year-old female presented with abdominal distension, pain, nausea, and vomiting with constipation for 3 weeks. She was hypertensive and diabetic and was on multiple medications. She reported frequent spells of severe headaches, palpitations, night sweats, and a 17 kg weight loss over 6 months. She had pallor, dyspnea, marked abdominal distension, and diminished bowel sounds. Her blood pressure was high at 200/120 mmHg. She had tachycardia (pulse 120 bpm) and tachypnea (35 pm). Serum metanephrine levels were significantly elevated, measuring 1203 pg/ml. Abdominal CT showed a heterogeneous, hyper-vascular mass near the upper pole of the left kidney, measuring 10.75 cm × 8.72 cm. Open left adrenalectomy was performed through an anterior subcostal approach to remove the tumor with the left adrenal gland. Histopathological examinations were consistent with pheochromocytoma. DISCUSSION: Some authors documented the correlation between tumor size and metabolic activity of catecholamine-secreting tumors with intestinal pseudo-obstruction by paralytic ileus. This case corresponds with these findings, with a tumor mass of 350 g and a serum metanephrine level of 1203 pg/ml. CONCLUSION: Although it is extremely rare, functioning pheochomocytoma could be a cause of instestinal obstruction or pseudo-obstruction.

Recurrent seasonal severe hypertriglyceridemia-induced acute pancreatitis; a case report.

Introduction: Acute pancreatitis (AP) is a serious inflammatory condition of the pancreas. Hypertriglyceridemia (HTG) is considered an uncommon cause of AP. The current study aims to present a unique case of recurrent seasonal severe HTG-induced AP (HTG-AP); treated with insulin and heparin. Case report: A 36-year-old male presented with recurrent attacks of severe upper abdominal pain that was radiating to the back and associated with repeated vomiting. The condition has being occurring every autumn-winter for the last three years. He had thalassemia minor and had a history of HTG-AP. His TG levels were relatively normal from February to August; however, from September to February, his TG levels highly elevated which has resulted in HTG-AP every year for the past three years. The condition was confirmed via a contrast-enhanced computerized tomography scan of the abdomen. To prevent the next HTG-AP, his TG level was monitored monthly. When TG levels spiked again, the patient was put on an insulin infusion with heparin, glucose, and potassium to rapidly reduce TG level. After two days, serum TG was dramatically reduced (<500 mg/dL). Discussion: Despite multiple theories being proposed, the pathogenesis of HTG-AP is yet to be understood. Usually, HTG-AP is a single episodic, and recurrent HTG-AP is considered uncommon finding. Previous reports are contradictory regarding TG level and seasonal variation. There is currently no standard management approach to treat HTG-AP cases. Conclusion: HTG-AP rarely reoccurs on an annual basis, and seasonal variation seems to play a major role in its onset. The condition can be managed with insulin, heparin, and glucose infusions.

Post COVID-19 pulmonary fibrosis; a meta-analysis study.

Introduction; Pulmonary fibrosis is a frequently reported COVID-19 sequela in which the exact prevalence and risk factors are yet to be established. This meta-analysis aims to investigate the prevalence of post-COVID-19 pulmonary fibrosis (PCPF) and the potential risk factors. Methods; CINAHL, PubMed/MEDLINE, Cochrane Library, Web of Science, and EMBASE databases were searched to identify English language studies published up to December 3, 2021. Results; The systematic search initially revealed a total of 618 articles - of which only 13 studies reporting 2018 patients were included in this study. Among the patients, 1047 (51.9%) were male and 971 (48.1%) were female. The mean age was 54.5 years (15-94). The prevalence of PCPF was 44.9%. The mean age was 59 years in fibrotic patients and 48.5 years in non-fibrotic patients. Chronic obstructive pulmonary disease was the only comorbidity associated with PCPF. Fibrotic patients more commonly suffered from persistent symptoms of dyspnea, cough, chest pain, fatigue, and myalgia (p-value < 0.05). Factors related to COVID-19 severity that were associated with PCPF development included computed tomography score of ≥18, ICU admission, invasive/non-invasive mechanical ventilation, longer hospitalization period, and steroid, antibiotic and immunoglobulin treatments (p-value < 0.05). Parenchymal bands (284/341), ground-glass opacities (552/753), interlobular septal thickening (220/381), and consolidation (197/319) were the most common lung abnormalities found in fibrotic patients. Conclusion, About 44.9% of COVID-19 survivors appear to have developed pulmonary fibrosis. Factors related to COVID-19 severity were significantly associated with PCPF development.

Simultaneous pituitary and adrenal adenomas in a patient with non ACTH dependent Cushing syndrome; a case report with literature review.

INTRODUCTION: Cushing syndrome is a rare disorder with a variety of underlying etiologies, that can be exogenous or endogenous (adrenocorticotropic hormone (ACTH)-dependent or ACTH-independent). The current study aims to report a case of ACTH-independent Cushing syndrome with adrenal adenoma and nonfunctioning pituitary adenoma. CASE REPORT: A 37-year-old female presented with amenorrhea for the last year, associated with weight gain. She had a moon face, buffalo hump, and central obesity. A 24-hour urine collection for cortisol was performed, revealed elevated cortisol. Cortisol level was non-suppressed after administering dexamethasone. MRI of the pituitary region revealed a pituitary microadenoma, and the CT scan of the abdomen with adrenal protocol revealed a left adrenal adenoma. DISCUSSION: Early diagnosis may be postponed due to the variety of clinical presentations and the referral of the patient to different subspecialists based on their dominant symptoms (gynecological, dermatological, cardiovascular, psychiatric); it is, therefore, critical to consider the entire clinical presentation for correct diagnosis. CONCLUSION: Due to the diversity in the presentation of CS, an accurate clinical, physical and endocrine examination is always recommended.

Thyroid collision tumors; A case series with literature review.

Background: Collision tumors are two histologically distinct types of malignancies within the same mass and organ. The aim of this study is to present a case series of thyroid collisions. Methods: This was a multicenter retrospective case series study. The participants were consecutive in order. Socio-demographic and clinical data were obtained from hospital records. Results: The study included eight cases comprising six (75%) females and two (25%) males. The patients had different presentations, including neck swelling, dyspnea, and dizziness. The pathology was successfully determined through fine-needle aspiration. Four patients (50%) underwent lobectomy, whereas the other half (four patients) underwent total thyroidectomy. Conclusion: Collision tumors of papillary thyroid cancer (PTC) and follicular thyroid carcinoma (FTA) or medullary thyroid carcinoma (MTC) and FTA are exceedingly rare phenomena that most commonly affect females. Complete or partial thyroidectomy is the ideal management of choice for these cases and is associated with good survival.

Topical corticosteroid-induced iatrogenic cushing syndrome in an infant; a case report with literature review.

INTRODUCTION: Cushing syndrome (CS) is an endocrinological abnormality that results from a high level of glucocorticoids in the blood. Iatrogenic CS due to the overuse of topical corticosteroids is rarely reported. The current study aims to present a rare case of topical corticosteroid induced iatrogenic CS in an infant. CASE PRESENTATION: A 4-month-old female infant presented with an insidious onset of face puffiness that progressed over a 2-month period. The mother reported to have used a cream containing Betamethasone corticosteroid 5-8 times a day for a duration of 3 months to treat diaper dermatitis. Laboratory findings revealed low levels of adrenocorticotrophic hormone (ACTH) and serum. Abdominal ultrasound showed normal adrenal glands. The topical corticosteroid was halted and physiologic topical hydrocortisone doses were administered. CLINICAL DISCUSSION: Infants are more likely to acquire topical corticosteroid induced iatrogenic CS due to their thin and absorptive skin, higher body surface area, and the high prevalence of conditions that necessitates the use of these medications. Most iatrogenic CS cases following topical steroid application have been reported in infants with diaper dermatitis that are most commonly treated with Clobetasol and Bethamethasone. CONCLUSION: Infants are susceptible to develop CS due to topical corticosteroid overuse. Hence, physicians need to consider this in infantile CS cases, and take appropriate measures to avoid their occurrence.

Post COVID-19 transverse myelitis; a case report with review of literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has emerged as severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Recently, various complications have been reported. The aim of the current study is to report a rare case of transverse myelitis after recovering from COVID-19. CASE REPORT: A 34-year-old lady, presented with inability to walk for one day duration due to the lower limb weakness. After two weeks from the recovery of COVID-19; she developed progressive intermittent leg pain, paresthesia and weakness on both sides. Brain and cervical MRI showed evidence of a short segment inflammatory enhancing lesion at upper cervical region (at C1 level). The patient was treated conservatively. DISCUSSION: Transverse myelitis has many different causes, it occurs as an autoimmune phenomenon post-infection and vaccination, or it may result from direct infection or acquired demyelinating disease like multiple sclerosis. CONCLUSION: Although it is a sporadic finding, SARS-CoV-2 can cause transverse myelitis. The condition responds to medical therapy.