Al Assad University Hospital

Pleural tuberculosis is a common manifestation of extrapulmonary tuberculosis; however, its diagnosis remains challenging in paucibacillary disease, where clinical presentation may be atypical and microbiological tests frequently yield negative results. We report the case of a 27-year-old Syrian male who presented with a one-year history of left-sided pleuritic chest pain and unintentional weight loss. Imaging studies revealed left-sided pleural-based subpleural nodules with mild metabolic activity. Repeated sputum acid-fast bacilli smears, polymerase chain reaction testing for Mycobacterium tuberculosis, and bronchoscopy were all negative. Due to persistent clinical suspicion, thoracoscopic exploration was performed, revealing multiple subpleural nodules on both the parietal and visceral pleura. Histopathological examination demonstrated necrotizing granulomatous inflammation with caseous material, consistent with pleural tuberculosis. The patient was treated with a standard six-month antituberculous regimen and showed favorable clinical recovery. Pleural tuberculosis represents a diagnostic challenge due to its frequent paucibacillary nature and nonspecific clinical presentation, which often results in low sensitivity of conventional microbiological and molecular tests such as direct smears using Ziehl-Neelsen and Auramine staining. In this case, prolonged pleuritic chest pain with minimal systemic symptoms and repeatedly negative sputum smears and PCR delayed microbiological confirmation. Definitive diagnosis was achieved only through thoracoscopic pleural biopsy and histopathological examination. This highlights the limitations of noninvasive investigations in pleural TB and underscores the importance of early escalation to pleural biopsy when clinical suspicion persists despite inconclusive results. This case highlights pleural tuberculosis presenting as subpleural nodules as a diagnostic challenge in the setting of negative microbiological tests. Maintaining a high index of suspicion and early escalation to tissue diagnosis are essential to ensure timely treatment and prevent misdiagnosis.

Stroke is the second-leading cause of death worldwide, including in Syria, and the third-leading cause of death and disability combined. With approximately 90% of strokes worldwide linked to modifiable risk factors, identifying and quantifying these factors within a specific population is essential for effective prevention. This is the first study to investigate primary risk factors for stroke in Syria. This study included the six primary stroke centres across four major cities in Syria. Data was collected through case files and a questionnaire answered by the cases or their proxies through personal interviews, as well as selected controls. A total of 411 cases were recruited, comprising 363 ischemic strokes (IS) and 48 haemorrhagic strokes, and with a matched ratio of 1:1 for age and sex. IS was significantly associated with multiple chronic conditions including atrial fibrillation AF [AOR 5.04 (2.64-9.62)], high body mass index (overweight [AOR 2.09 (1.28-3.40)], obesity [AOR 4.17 (2.32-7.50)]), hypercholesterolemia [AOR 2.10 (1.34-3.28], hypertension HTN [AOR 1.83 (1.23-2.73)], and diabetes mellitus DM [AOR 1.79 (1.18-2.71)]. Moreover, several lifestyle risk factors contributed to IS: Alcohol consumption [AOR 4.80 (1.72-13.41)], a diet lacking fruits and vegetables [AOR 2.04 (1.28-3.23)], and low physical activity PA [AOR 1.75 (1.01-2.86)]. Notably, over 40% of the population exhibited medication nonadherence. IS showed no significant association with cigarette smoking, heart failure (HF), ischemic heart disease (IHD), or a family history of stroke (p > 0.05). In contrast, haemorrhagic stroke was linked to higher BMI, HTN, DM, and AF (p < 0.05), but not to hypercholesterolemia, cigarette smoking, IHD, or HF (p > 0.05). This first nationwide multicentre case-controlled study in Syria identified critical modifiable risk factors for stroke, including hypertension, diabetes, atrial fibrillation, and obesity, with high rates of medication non-adherence, especially among hypertensive patients, complicating stroke risk. These findings underscore the urgent need for targeted health interventions promoting lifestyle modifications, medication adherence, and public health policies tailored to Syria's current resource-limited context to reduce the stroke burden and improve population health.

Pulmonary sequestration is a rare congenital lung anomaly, accounting for 0.15-6.4% of all congenital lung malformations. The celiac artery, a rare source of blood supply for pulmonary sequestration, is found in about 21% of instances. A 16-year-old male presented with recurrent hemoptysis, fever, weight loss, and night sweats. The patient had a significant family history of tuberculosis, as the patient’s mother and brother were undergoing anti-tuberculosis treatment for proven Koch’s bacillus in sputum, and his father has died 3 months ago due to massive hemoptysis resulting from a proven tuberculosis infection. Initial investigations, including chest X-ray and sputum culture, confirmed tuberculosis, and the patient was started on anti-TB treatment. Despite clinical improvement, hemoptysis persisted, prompting further evaluation. Bronchoscopy revealed significant bleeding, and a contrast-enhanced chest CT identified a wedge-shaped enhancement in the left lower lobe with an aberrant arterial supply from the celiac artery, consistent with intralobar pulmonary sequestration. Surgical management involved left thoracotomy, ligation of the aberrant artery, and resection of the extensively damaged lower lobe. Histopathology confirmed pulmonary sequestration with granulomatous lesions indicative of tuberculosis. Follow-up showed no recurrence. Pulmonary sequestration involves nonfunctioning lung tissue without communication with the bronchial tree, often supplied by aberrant blood vessels. Infections are common, with Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus being frequent pathogens. Tuberculosis is rarely reported in pulmonary sequestration, especially in celiac artery-supplied cases, which is also a rare occurrence. Tuberculosis colonizes sequestered lungs due to high oxygen-rich blood flow, complicating diagnosis. Surgical resection is the primary treatment for Pulmonary sequestration.

Introduction and significanceGanglion cysts in the thigh area are uncommon, typically occurring in the wrist and ankle. These cysts are usually painless but may compress nearby structures, causing discomfort. Ultrasound is a valuable tool to differentiate ganglion cysts from hematomas and lipomas. It also helps identify the fluid-filled cyst walls. Treatment typically involves surgical removal, with complete resection being the goal.Case presentationWe present a case of a woman who experienced a gradual increase in size of a lump in her groin area. The lump was later diagnosed and completely removed. Histological analysis revealed the presence of a ganglion cyst.Clinical discussionClinical examination is crucial for diagnosing superficial ganglion cysts. It allows us to assess their separation from the skin and connection to deeper structures. It's important to consider ganglion cysts as part of the differential diagnosis for cystic lesions in the groin area during routine medical practice. This can help avoid unnecessary and expensive tests like MRI scans in some cases.ConclusionDeveloping a thorough differential diagnosis for uncommon lesions in specific anatomical areas is essential in clinical practice. This aids in choosing appropriate diagnostic methods and surgical intervention, if necessary, to prevent recurrence of the condition.

INTRODUCTION:Primary small bowel melanoma (PSBM) is a rare form of melanoma that originates from the intestinal mucosa. It is typically asymptomatic; however, it can present with non-specific symptoms, which pose challenges in accurately diagnosing the condition. In rare cases, it may manifest as small bowel obstruction, further adding challenges with diagnosis and management.CASE PRESENTATION:A 57-year-old male presented to the hospital with complaints of chronic constipation, abdominal pain, and abdominal enlargement. Computed tomography (CT) scan revealed thickening of the jejunum wall, while endoscopy and biopsy revealed nothing. During surgery, surgeons identified and excised a jejunal mass. Subsequent pathological analysis confirmed the diagnosis of melanoma, and post-surgical examination failed to identify primary cutaneous melanoma.DISCUSSION:PSBM is a rare and aggressive tumor often misdiagnosed due to non-specific symptoms and challenging imaging interpretations. Obstruction and intussusception are uncommon presentations. Surgical resection offers symptom control and improved prognosis, but achieving negative margins can be challenging. Early recognition and diagnosis are crucial for optimal management.CONCLUSION:The lack of data in the literature presents challenges in identifying and selecting the optimal approach for managing PSBM. Physicians should increase their awareness of this specific type of tumor to facilitate early-stage diagnosis and provide appropriate care for patients.