Al Mouwasat University Hospital

Introduction: Sinonasal mucosal melanoma (SNMM) is an aggressive subtype of melanoma that represents <5 % of head and neck melanomas and constitutes less than 1 % of systemic melanoma cases. Case presentation: A 54-year-old female presented with a 5-month history of unilateral recurrent epistaxis, anosmia, and nasal obstruction. Nasal endoscopy showed a bleeding fleshy lesion occupying the right nasal cavity, extending to the nasal floor and nasal septum. Pathological examination and immunohistochemistry (IHC) findings confirmed the diagnosis of SNMM. Conclusion: SNMM in the head and neck region can manifest with nonspecific symptoms. The diagnosis often requires a combination of clinical, pathological, and IHC studies.

Introduction:Acute lymphoblastic leukaemia (ALL) is an aggressive hematologic malignancy, with T-cell ALL (T-ALL) accounting for approximately 25% of adult cases. Renal infiltration is recognized but rarely presents as isolated bilateral nephromegaly with acute kidney injury (AKI) in adults. Case description:A 32-year-old previously healthy man presented with progressive bilateral flank pain, abdominal heaviness, fatigue, intermittent fever, night sweats, and unintentional weight loss. Physical examination revealed large bilateral flank masses without peripheral lymphadenopathy. Laboratory tests initially showed normal blood counts but significant renal impairment (creatinine 3.5 mg/dl, urea 82 mg/dl). Imaging demonstrated massive bilateral kidney enlargement (~20 × 20 cm). Percutaneous renal biopsy revealed diffuse infiltration by medium-sized lymphoblasts expressing CD3 and TdT, confirming T-ALL. Within 1-week, hematologic abnormalities developed, including leucocytosis, anaemia, and thrombocytopenia, alongside worsening renal function and tumour lysis syndrome, necessitating dialysis and allopurinol therapy. The patient was started on a pre-phase corticosteroid regimen followed by intensive hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin [Adriamycin], and dexamethasone) induction chemotherapy. Initial radiologic improvement occurred; however, the clinical course was complicated by neutropenic sepsis, ultimately resulting in death. Conclusion:This case highlights a rare adult presentation of T-ALL in which renal involvement preceded hematologic abnormalities. Clinicians should consider hematologic malignancy in adults presenting with unexplained bilateral nephromegaly and AKI, even if initial blood counts are normal. Early recognition and timely intervention are critical to improve renal and overall outcomes. LEARNING POINTS:Renal infiltration is recognized but rarely presents as isolated bilateral nephromegaly with acute kidney injury (AKI) in adults.This report underscores the importance of considering underlying hematologic malignancy in adults presenting with unexplained bilateral nephromegaly and AKI, even when initial hematologic investigations are normal.

Introduction:Cardiac myxomas (CMs) are the most common benign primary heart tumors. CMs can present with diverse symptoms including embolic events and neurological signs. Diagnosis relies heavily on imaging modalities like transthoracic echocardiography. Surgical excision is the definitive treatment due to the high risk of embolism. Case presentation:A 19-year-old woman presented with dyspnea, palpitations, and dizziness. Echocardiography revealed a right atrial mass. Surgical excision via sternotomy confirmed a 2 cm CM. Eighteen months later, the patient presented with symptomatic recurrence. Following a redo sternotomy, she developed a permanent iatrogenic phrenic nerve injury, resulting in diaphragmatic paralysis and significant respiratory morbidity. Discussion:This report details a 19-year-old woman presenting with non-specific symptoms, who was ultimately diagnosied with CM. This case is noteworthy due to the patient's young age - as CMs typically occur in middle-aged individuals - the sporadic recurrence of the tumor, and the associated post-surgical complications. We outline the diagnostic pathway for CMs identification and emphasize the rarity of recurrence in sporadic cases following initial resection. Additionally, we discuss the iatrogenic phrenic nerve injury and its long-term impact on the patient's respiratory health. Conclusion:CMs management requires precise surgical strategy and long-term follow-up, particularly in redo cases. This report highlights the significant risk of iatrogenic phrenic nerve injury during re-intervention, emphasizing the need for specialized perioperative care to optimize clinical outcomes.

Hydatid disease, caused by various Echinococcus species, is endemic in developing countries and most commonly affects the liver and lungs. Approximately 7.4% of cases involve intrathoracic extrapulmonary locations, with pleural involvement usually resulting from rupture of adjacent hepatic or pulmonary cysts. However, primary pleural hydatid cysts are extremely rare, representing less than 1% of extrapulmonary cases, and may cause compressive symptoms depending on size and location. Diagnosis is guided by serologic testing and imaging, while surgical excision remains the mainstay of treatment. A 26-year-old Middle Eastern female presented to the emergency department with exertional dyspnea, right-sided pleuritic chest pain, low-grade fever, and night sweats. Physical examination revealed decreased breath sounds, dullness to percussion, and increased tactile fremitus on the right side, while imaging confirmed a moderate-to-large right pleural effusion with adhesions and fibrinous strands. Laboratory tests showed a lymphocytic exudative effusion with elevated adenosine deaminase, initially suggesting tuberculous pleuritis. However, negative cultures and positive anti-Echinococcus antibodies redirected the diagnosis to hydatid disease. Video-assisted thoracoscopic surgery (VATS) revealed dense adhesions and granulomatous inflammation on biopsy. Due to restricted lung expansion, right thoracotomy was performed, excising a cystic mass from the mediastinal pleura. Histopathology confirmed a hydatid cyst. The patient recovered well and was discharged on oral Albendazole. This case emphasizes the rarity of primary pleural hydatid cysts, the diagnostic challenges they pose, and the importance of considering parasitic infections in pleural effusions for timely surgical and medical management.

Introduction: Acquired thrombotic thrombocytopenic purpura (aTTP) is a severe microangiopathic hemolytic anemia (MAHA) characterized by profound ADAMTS13 deficiency. MAHA can also manifest as a paraneoplastic syndrome, particularly in advanced malignancies, with cancer-associated MAHA (CA-MAHA) linked to signet ring cell carcinoma being exceptionally rare. Case description: We present the case of a 42-year-old Arab male who initially presented with classic features of aTTP, including severe MAHA, profound thrombocytopenia, and renal and neurological dysfunction, confirmed by an ADAMTS13 activity level of 6%. Despite standard TTP therapy including plasma exchange, his atypical response and rapid deterioration prompted further investigation, leading to the diagnosis of aggressive, metastatic signet ring cell carcinoma. Tragically, he passed away less than a week after first presentation. Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for occult malignancies in patients with atypical thrombotic microangiopathy presentations, especially those with an incomplete response to conventional TTP therapies. It emphasizes the need for comprehensive diagnostic workup and a multidisciplinary approach to manage these complex and often fatal conditions, as early identification of underlying cancer is crucial for guiding appropriate, often tumour-directed, therapy and improving patient outcomes.