Periodontal therapy for hopeless mandibular anterior teeth: a retrospective case report with a multidisciplinary approach and a 20-year follow-up

Introduction: This case report presents the intentional periodontal maintenance of two periodontal hopeless lower central incisors with a multidisciplinary approach and 20-year follow-up. Case presentation: A 36-year-old male, in 2001, was diagnosed with aggressive periodontitis, gingival swelling, bleeding, and mandibular central incisors with mobility and poor prognosis. Following periodontal therapy (phase I), root canal treatment, and occlusal adjustment, #31 and #41 were gently extracted to remove the granulation tissues, calculus, and infected cementum from the root surface. Then, tetracycline-HCl was applied for 5 minutes on the root surfaces. The teeth were repositioned into the sockets and splinted with a lingual bar. At 3 months, the bar was removed, and a free gingival autogenous graft was done to improve the local keratinized tissue width. Mobility scores, pocket depths, and clinical attachment levels were recorded, and radiographs were taken at 1, 5, and 20 years. The 5-year follow-up showed that the teeth were clinically and radiographically in function. There was a reduction in probing depth and a gain in clinical attachment and radiographic alveolar bone levels. After 20 years, #41 was stable, but #31 had external root resorption, leading to a new treatment plan (dental implants) and extraction. Conclusion: The clinical result of this case was satisfactory for 20 years. Intentional periodontal maintenance of the teeth may be an alternative treatment, even considering the high level of complexity.

Hemoglobin and total bilirubin may affect tacrolimus clearance in liver transplant patient following the early postoperative period: a case report.

BACKGROUND: Tacrolimus is a potent calcineurin inhibitor (CNI) that is principally used as a first-line immunosuppressant for the prophylaxis of allograft rejection in liver transplantation (LT) patients. In clinical practice, prescribing the optimal tacrolimus dosage is complicated by its narrow therapeutic index and high pharmacokinetic variability. Thus, performing therapeutic drug monitoring (TDM) of only tacrolimus may not provide optimal drug levels. However, other influential clinical factors affecting tacrolimus levels, such as hemoglobin (Hb), hematocrit, and total bilirubin (TBIL), should be considered while adjusting tacrolimus levels. This case report aims to introduce clinicians and their teams to taking the pharmacokinetic prediction equation into consideration for a better understanding of tacrolimus dosage adjustment during the early postoperative LT. CASE PRESENTATION: In this case report, an 18-year-old male patient of Thai ethnicity was admitted for orthotropic liver transplantation, and tacrolimus was prescribed as a cornerstone immunosuppressive agent. In the immediate postoperative period, which is the most challenging period in liver transplantation, the population pharmacokinetics predictive equation was clinically used to assist in dosage adjustment of tacrolimus by considering the significant clinical factors in this case. Hemoglobin and total bilirubin levels were deemed significant clinical factors affecting the oral clearance (CL/F) of tacrolimus. First, a decrease in the Hb concentration increases the free drug concentration and therefore increases the CL/F of tacrolimus. Second, an elevated TBIL decreases the biliary excretion of tacrolimus, resulting in a decrease in the CL/F of tacrolimus. Thus, dose optimization of tacrolimus would be accurate when taking the pharmacokinetic prediction equation into consideration. Moreover, the results may contribute to a better understanding of tacrolimus pharmacokinetic variability in each transplant patient during the immediate postoperative course. CONCLUSIONS: Hemoglobin and total bilirubin were significant clinical factors influencing the oral clearance of tacrolimus early after liver transplantation. A decrease in the hemoglobin concentration would increase the free drug concentration and therefore increase the oral clearance of tacrolimus. An elevated total bilirubin decreases the biliary excretion of tacrolimus, resulting in a decrease in the oral clearance of tacrolimus.

Helsmoortel-Van der Aa syndrome in a 13-year-old girl with autistic spectrum disorder, dysmorphism, a right solitary kidney, and polycystic ovaries: a case report.

BACKGROUND: Helsmoortel-Van der Aa syndrome was officially documented in 2014. Helsmoortel-Van der Aa syndrome is an extremely rare complex neurodegenerative disorder characterized by reduced intellectual capacity, motor dysfunction, facial dysmorphism, impaired development, and an increased predisposition to autism spectrum disorder. In addition, many patients also present with neuropsychiatric disorders, including attention deficit hyperactivity disorder, anxiety disorders, and various behavioral abnormalities. Helsmoortel-Van der Aa syndrome is challenging to identify solely on the basis of symptoms, and genetic investigations, including exome sequencing, may facilitate diagnosis. CASE PRESENTATION: We report a case of 13-year-old Saudi patient who presented with dysmorphic features as illustrated in Fig. 1, severe mental retardation, autism spectrum disorder, and attention deficit hyperactivity disorder. Initial genetic testing was unremarkable; thus, a clinical exome analysis was performed to identify the genetic basis of the condition. CONCLUSIONS: Clinical exome analysis indicated an autosomal dominant Helsmoortel-Van der Aa syndrome with a likely pathogenic de novo variant within the activity-dependent neuroprotector homeobox (ADNP) gene not previously reported in Helsmoortel-Van der Aa syndrome. The patient had a right-sided solitary kidney and polycystic ovaries, conditions that were not previously associated with HVDAS.

A More Aesthetically Pleasing Smile: A Case Report on the Impact of Scalpel Technique on Gingival Depigmentation.

Gingival hyperpigmentation can significantly affect how the smile looks cosmetically, leading patients to seek treatment. This case report addresses the use of a scalpel approach combined with bur abrasion for gingival depigmentation in a 19-year-old female patient who was displeased with her "black" gums. A local anesthetic was required for the surgical removal of the pigmented epithelium and a thin layer of connective tissue. Post-operative care included antibiotics and analgesics, with chlorhexidine mouthwash use for optimal healing. Follow-up examinations showed successful depigmentation without complications. This simple method is a good choice for gingival pigmentation management since it provides satisfactory cosmetic results and patient satisfaction.

Pigmented Bowen's Disease: A Case Report in Saudi Arabia.

Bowen's disease (BD) is an in situ squamous cell carcinoma of the epidermis with multiple etiologies and a high incidence among Caucasians. It commonly occurs in photo-exposed areas of the skin, although other sites can also be affected. Most lesions are solitary, and their morphology can vary based on the lesion's age, origin, and degree of keratinization. A 50-year-old female from Saudi Arabia presented to the dermatology clinic with a three-year history of slowly enlarging skin lesions on the left side of her chest. Initially, the lesion appeared three years ago, but she observed changes and a darkening in color over the past year, accompanied by mild pain and itching. On examination, the lesion was a 2 × 2 cm, well-defined, unevenly pigmented brown-black plaque with a dispersed pigment pattern and irregular borders with globularity on the left side of the upper chest. A 4 mm punch biopsy was taken from the most pigmented area and sent for histopathological examination, which confirmed the diagnosis of pigmented BD.

Sclerotherapy with absolute alcohol in a child with spinal aneurysmal bone cyst: A case report.

Aneurysmal bone cyst (ABC) is a benign and locally proliferative vascular disorder in the form of a non-neoplastic bone lesion commonly found in children and young adults. Several treatments and therapeutic options are available. Percutaneous sclerotherapy is an alternative treatment for ABC with less morbidity than other therapies. An 11-year-old girl presented with a lump in her left flank since 10 months ago with paresthesia, and leg weakness. The patient was unable to raise her legs and walk. The patient underwent posterior surgical and stabilization procedures with tumor extirpation. Three months postsurgery, the lump progressively increased and tenderness. MRI showed an expansile destructive lytic lesion, firm borders, regular margins, and multiple septa with clear transition zones, without periosteal reactions, forming a picture of a "soap bubble appearance" surrounding the lumbar paravertebral. The patient underwent sclerotherapy using 5 ml of absolute alcohol under visual fluoroscopy guidance. After the sclerotherapy, the patient showed clinical improvement and decreased lump size. No side effects or massive bleeding were experienced postsclerotherapy. Thoracolumbar x-ray post sclerotherapy showed a decreased mass size in the posterior lumbar area. This case demonstrates that sclerotherapy presents a secure alternative for pediatric patients in contrast to spinal ABC surgery. It offers minimal invasiveness and reduced morbidity. The percutaneous administration of absolute alcohol proves effective in treating spinal ABC. In this case, the patient experienced clinical improvement, leading to a decrease in lump size. There were no instances of significant bleeding around the lump postsclerotherapy.

Potential therapeutic option for EGFR-mutant small cell lung cancer transformation: a case report and literature review.

Transformation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) is rare and is associated with poor prognosis. However, the standard treatment protocols for patients with SCLC transformation remain unknown. Here, we report the case of a patient with advanced EGFR exon 19 deletion (19del) NSCLC who underwent SCLC transformation during targeted therapy. Biopsies and genetic testing were performed to adjust treatment regimens accordingly. The patient responded favorably to a combined treatment regimen comprising etoposide plus cisplatin chemotherapy and adebrelimab plus osimertinib. This case highlights the critical importance of acknowledging tumor heterogeneity in clinical decision-making and identifying potentially effective treatment options for patients with SCLC transformation. Additionally, we reviewed cases of the transformation of NSCLC to SCLC from 2017 to 2023.

Polymicrobial purulent pericarditis and peritoneal effusion in an immunocompromised patient with Staphylococcus aureus bacteraemia: a case report.

Background: Polymicrobial pericarditis is an extremely rare and lethal form of pericarditis. Prompt initiation of appropriate antimicrobial treatment and pericardial drainage are crucial. Case summary: A 57-year-old immunocompromised male patient presented to the emergency department due to dyspnoea, chest pain, and fever lasting for 7 days. Following clinical, laboratory, and imaging work-up, he was found to have pericardial effusion with signs of tamponade. After pericardiocentesis through subxiphoid and apical approaches, 800 mL of gross purulent fluid was obtained. Blood and pericardial fluid cultures confirmed the diagnosis of polymicrobial purulent pericarditis (Staphylococcus aureus and Bacteroides vulgatus). Further work-up revealed minor peritoneal effusion, and paracentesis fluid culture revealed the presence of S. aureus and, additionally, Candida albicans. After treatment initiation with intravenous antibiotics, pericardial, drainage and supportive measures, the patient's condition initially improved despite the development of constrictive pericarditis. However, he suddenly deteriorated after 37 days of hospitalization and passed away after 51 days of hospitalization. Discussion: To the best of our knowledge, this is the first report of purulent pericarditis and purulent peritoneal effusion in the settings of S. aureus bacteraemia with an absent primary infection focus. Clinicians should be aware of treatment options for purulent pericarditis and consider intrapericardial fibrinolysis, especially in patients not suited for more invasive pericarditis treatment.

A novel case report of isolated cardiac myxedematosus.

Background: Cardiac mucinous deposits are a rare entity only previously described in the setting of scleromyxedema, a disorder characterized by cutaneous and systemic mucin deposits, fibroblastic proliferation, and monoclonal gammopathies. Case summary: A 41-year-old woman was transferred to our hospital after a month-long hospitalization with worsening cardiogenic shock requiring ionotropic support. Cardiac magnetic resonance imaging revealed a left ventricular ejection fraction of 23%, prior right coronary artery infarct, full-thickness late gadolinium enhancement in the left ventricle basilar wall, global abnormal parametric mapping parameters of both native T1, T2, and extracellular volume, and severe biventricular dysfunction concerning for infiltrative cardiomyopathy. Endomyocardial biopsy demonstrated heavy deposits of interstitial mucin, confirmed by electron microscopy; a Congo red stain was negative for amyloid. She was treated with an aggressive decongestive strategy, oral guideline-directed medical therapy, and intravenous immunoglobulin (IVIg); she was discharged home off inotropic support. Subsequently, she had three additional hospitalizations for heart failure exacerbation in a span of 6 months, and her overall prognosis remains guarded. Discussion: We report a first known case of isolated cardiac myxedematosus associated with a severe systolic and diastolic cardiomyopathy. Our patient did not have any clinical evidence of systemic scleromyxedema or paraproteinemia, both of which have been reported in association with cardiac mucin deposits. Mucinosus has been described in patients with systemic lupus erythematous; however, cardiac deposits have not been reported. While IVIg has been used as a treatment in previously reported cases of cardiac scleromyxedema, its clinical benefit remains unclear in isolated cardiac myxedematosus.

Coexistence of Pulmonary Thromboembolism, Pulmonary Tuberculosis and Granulomatosis with Polyangiitis: A flimsy triple dribble.

Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease with multi-system involvement. It involves the upper respiratory tract, lungs and kidneys. A 36-year-old female patient presented to a tertiary care referral hospital in Central India in 2023 with complaints of low-grade fever, dry cough and loss of appetite initially followed by dyspnoea, purpuric skin lesions, right lower limb swelling with pain and redness. Her chest radiograph revealed right upper lobe cavitary lesion with consolidation in the right lower lobe. Mycobacterium tuberculosis was detected in sputum and broncho alveolar lavage via cartridge based nucleic acid amplification assay. Later, computed tomography pulmonary angiography revealed bilateral pulmonary artery thromboembolism. Furthermore, her cytoplasmic-antineutrophil cytoplasmic antibody test was positive, serum creatinine was rising, urine microscopy had red cell casts and lower limb venous doppler revealed deep venous thrombosis. Histopathological examination of the skin lesion revealed vasculitis. Based on these findings, the patient was diagnosed with GPA. The patient improved with pulse steroids, cyclophosphamide, anticoagulants and anti-tuberculous therapy.

Successful Treatment of Angiolymphoid Hyperplasia with Eosinophilia Associated with Scalp Demodicosis Using Cryotherapy and Topical Metronidazole.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare, benign, vasoproliferative tumour. We report a 25-year-old female patient who reported in 2021 to a dermatology clinic in Rustaq, Oman, with multiple, grouped, erythematous dome-shaped papules and nodules of 6 months duration on the left temporo-occipital region. Biopsy findings were consistent with a diagnosis of ALHE with evidence of Demodex mite infestation in the sebaceous ducts. The patient demonstrated significant improvement following 7 weeks of treatment with multiple cryotherapy sessions and topical application of metronidazole gel. This case suggests that scalp demodicosis may represent a novel trigger for the development of ALHE.

Adrenocorticotropic Hormone-Secreting Pituitary Microadenoma Presenting with Acute Psychosis, Delirium and Paroxysmal Sympathetic Hyperactivity.

Adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas are known to be associated with behavioural changes but acute presentation including psychosis and delirium are less common. We report the case of a 42-year-old female patient with a known medical history of hypertension and diabetes mellitus, presenting with acute onset behavioural changes suggestive of psychosis to a tertiary care centre in Muscat, Oman in 2022. Further evaluation revealed an ACTH dependent Cushing's disease with a pituitary microadenoma. The patient was admitted for endoscopic resection of the adenoma. During the peri-operative period, she experienced worsening of psychosis in addition to delirium. She also developed episodes of unresponsiveness, posturing, severe diaphoresis and dyspnoea accompanied by tachycardia and hypertension which were managed with midazolam and levetiracetam. A seizure work-up and computed tomography brain scan were unremarkable. At follow-up, she showed full resolution of symptoms with good blood pressure and glycaemic control.

Erdheim-Chester Disease Presenting as Bilateral Facial Masses: A case report and review of literature.

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis with unknown aetiology. It is recently recognised to be neoplastic with genetic mutations affecting the mitogen-activating protein kinase pathway. We report a 49-year-old female patient who initially presented in 2012 to a tertiary care centre in Muscat, Oman, with bilateral facial masses. These were removed but later recurred over a period of 10 years. She then presented with xanthelasmas, bone lesions, secondary infertility due to hypothalamic hypogonadism, diabetes insipidus and Hashimoto's hypothyroidism. The facial masses were biopsied and they showed classic morphological features in the form of diffuse infiltration by foamy histiocytes with scattered Touton type of giant cells, patchy lymphocytic infiltrates and dense fibrosis. The patient is stable and is being followed-up. The presented ECD case is particularly interesting due to the recurrent bilateral facial masses. To the best of the authors' knowledge, this is the first documented case in Oman.

Adrenal gland haemangioma, a rare entity difficult to differentiate from malignancy.

Adrenal haemangioma is a rare benign vascular lesion, which is usually asymptomatic and it is typically discovered incidentally on radiographic imaging. Differential diagnosis from other benign or malignant adrenal neoplasms may be challenging, and in many cases, the diagnosis is only possible after surgical resection. We present a case of a 39-year-old female with abdominal pain in the upper right quadrant, who was referred to our hospital after incidentally discovering a mass above the right kidney on abdominal ultrasonography. MRI revealed an adrenal mass, with features not indicative of adenoma and suggestive of adrenal haemangioma, without ruling out other possible diagnoses such us phaeochromocytoma and adrenal cortical carcinoma. Biochemical tests did not reveal any endocrine dysfunction. The patient underwent adrenalectomy, and histopathological analysis confirmed a venous haemangioma. Adrenal gland haemangioma is an unusual vascular lesion, typically diagnosed incidentally during abdominal imaging. Certain radiologic features may raise suspicion for malignancy, making it difficult to distinguish them from a primary adrenal cortical carcinoma. They may also grow large, compressing surrounding structures and causing abdominal pain, or may rupture, leading to retroperitoneal haemorrhage. For these reasons, some authors recommend excision of all suspected adrenal haemangiomas, and in many cases, the final diagnosis is made only after surgical removal.

IC-ECG guided PICC tip location in a dextrocardia: A case report.

INTRODUCTION: Mirror people have difficulty with PICC placement due to inversion of organs. Intracavitary electrocardiography (IC-ECG) guided peripherally inserted central catheter (PICC) tip location technique has been widely applied in clinical practice. CASE DESCRIPTION: Herein, we admitted a 59-year-old man diagnosed with esophageal cancer (EC). Chest X-ray and computed tomography (CT) revealed that the patient was with a mirror-image dextrocardia and situs inversus totalis: the heart and stomach located in the right side of the body, whereas the liver located in the left side. Echocardiography suggested that the apex of the heart pointed toward the right, while the left and right chambers were inverted. The relationship of the heart chambers, structure, and function were normal: left ventricular ejection fraction was 0.67, left atrial diameter was 31 mm, and heart output was 4.7 L/min. Surface ECG showed typical features of a dextrocardia: P-wave inverted on lead I. Amplitude of the R-wave and S-wave decreased gradually on lead chest from V1 to V5. Compared with the normal ECG image, the waves completely exchanged on lead II and III, so as on aVR and aVL. METHODS: Column of saline technique can assist operator estimate the tip position in real-time according to P-wave changes. When the height of P-wave reaches to its highest, it means that the tip of catheter has advanced to the target position of cavo-atrial junction (CAJ). OUTCOMES: Patient was inserted catheter and no adverse events were reported. CONCLUSIONS: Measuring the predicted length of catheter is still an indispensible procedure to help precisely adjusting the tip position in IC-ECG guided PICC. Our work provides both supplement for clinical data to facilitate further research and better understanding of special types of PICC to clinicians.

Wernicke encephalopathy in a patient with medullary infarctions: a case report.

Wernicke encephalopathy (WE) is an acute life-threatening neurological condition caused by thiamine (vitamin B1) deficiency. Patients with WE often present with a triad of symptoms consisting of ophthalmoplegia, gait ataxia, and mental confusion. If WE is not treated in a timely manner, it can lead to serious complications such as confusion, coma, or death. Although alcohol abuse is the most commonly reported cause of WE, nonalcoholic causes-although rare-do exist. Herein, we present the case of a nonalcoholic woman with medullary infarctions who presented with intractable vomiting. Her clinical state subsequently progressed to include ophthalmoplegia and gait ataxia. A diagnosis of WE was suspected based on her clinical presentation; this was confirmed by brain magnetic resonance imaging (MRI) and the finding of decreased serum thiamine levels. Brain magnetic resonance imaging demonstrated the complete resolution of abnormal hyperintensities during a follow-up visit, 6 months after treatment.

Mature Cystic Teratoma of Anterior Mediastinum in a Child: A Case Report and Literature Review.

Mediastinal mature cystic teratomas are rare benign germ cell tumors that predominantly affect children. Despite their low incidence, they present unique diagnostic and management challenges. Early recognition and appropriate surgical intervention are crucial for optimal outcomes. This case report aims to highlight the importance of prompt diagnosis and management of mediastinal mature cystic teratomas in pediatric patients. We present the case of a 10-year-old female patient who presented with persistent chest pain and dyspnea. Imaging studies, including a chest X-ray and contrast-enhanced chest CT scan, revealed a large, well-circumscribed anterior mediastinal mass with calcifications. The patient underwent a right thoracotomy, resulting in the excision of a 6 × 5 × 5 cm mature cystic teratoma. Histopathological examination confirmed the diagnosis. The patient had an uneventful recovery and was discharged in stable condition. Mediastinal mature cystic teratomas pose diagnostic challenges due to their nonspecific symptoms and heterogeneous imaging characteristics. Differential diagnosis includes other mediastinal masses containing fat and calcifications. Surgical excision is the preferred treatment, although complete removal can be challenging due to adhesions to neighboring structures. Close follow-up is necessary to monitor for recurrence and complications. Mediastinal mature cystic teratomas are rare tumors with variable clinical presentations. Early detection and surgical intervention are crucial for optimal outcomes. These tumors should be included in the list of differential diagnoses for mediastinal masses in pediatric patients.

Vein of Galen Aneurysmal Malformation Presenting As Persistent Pulmonary Hypertension in a Newborn: A Case Report.

We present a case of a newborn infant with a vein of Galen aneurysmal malformation (VOGM) who was admitted to our neonatal intensive care unit (NICU) with the diagnosis of persistent pulmonary hypertension of the newborn (PPHN). Further work-up at our institution, which included an echocardiogram and cranial ultrasound revealed VOGM. The patient was transferred to a children's center for further management of the vascular malformation where the patient subsequently died from high cardiac output heart failure. This study highlights the importance of considering a VOGM as a rare cause of PPHN in an infant.

Transverse Sinus Stenosis as an Underdiagnosed Cause of Chronic Headache: A Case Report.

Transverse sinus stenosis (TSS) is an abnormality in the cerebral venous system in which the narrowing of the transverse sinus of the brain leads to obstructed cerebral venous outflow. It is an infrequent, incidental radiological finding. However, it is not uncommon among patients with chronic headaches of unclear cause, particularly those that remain unexplained after initial evaluation or those that are refractory to medical treatment. Its diagnosis frequently eludes the initial workup, and a high degree of suspicion should be maintained since its identification can lead to potentially curative treatment. This report describes the case of a 36-year-old female with a history of chronic headache who was found to have TSS. This paper discusses its etiology, pathophysiology, clinical presentation, radiological findings, and management.