Atezolizumab plus bevacizumab (Atez/Bev) is the standard first-line systemic therapy for unresectable hepatocellular carcinoma (HCC). We report HCC with intrahepatic progression during Atez/Bev in which selective conventional transarterial chemoembolization (cTACE) to a single lesion was followed by non-target lesion shrinkage. An 82-year-old woman with metabolic dysfunction-associated steatotic liver disease was diagnosed with BCLC stage B hepatocellular carcinoma in segments 5/7. After TACE, residual viable tumor persisted in segment 5, and Atez/Bev was initiated. After 4 cycles, a new intrahepatic lesion appeared in segment 8, and after 7 cycles, lesions in segments 5/7/8 enlarged, meeting the mRECIST progressive disease criteria. Systemic therapy continued, and selective cTACE for the segment 5 lesion was added. At 3 months post-cTACE, segment 5 viability decreased, but overall mRECIST remained progressive disease. At 6 months (November 20XX + 1), arterial enhancement in segment 5 resolved and non-target segment 7/8 lesions became hypovascular and shrank, achieving partial response.
Auto-Brewery Syndrome (ABS) is a rare metabolic condition characterized by endogenous ethanol production through fermentation of ingested carbohydrates by intestinal microorganisms. Clinical manifestations resemble alcohol intoxication, including ataxia, dysarthria, gastrointestinal symptoms, and altered mental status, despite the absence of alcohol intake. We report a case of a patient in his mid-40s who developed ABS reactivation following treatment with Amoxicillin/Clavulanic acid for community-acquired pneumonia. The patient was successfully managed with targeted antimicrobial therapy, dietary carbohydrate restriction, and probiotic supplementation, resulting in clinical improvement. This case highlights a rare instance of antibiotic-associated ABS relapse and underscores the diagnostic challenge of this unrecognized microbial condition.
Endoscopic submucosal dissection (ESD) for colorectal lesions becomes particularly challenging in the presence of the muscle-retracting sign (MRS), and the risk of perforation is further increased when a diverticulum underlies the lesion. We report a case of ESD for a 25-mm Paris type 0-Is tumor in the sigmoid colon surrounded by multiple diverticula. During ESD, a broad MRS obscured the appropriate submucosal plane. Careful dissection revealed a diverticulum directly beneath the lesion, indicating a focal defect of the muscularis propria. Subsequently, an intraoperative perforation occurred but was immediately detected and successfully closed using endoscopic clips, allowing completion of en bloc resection. Postoperative computed tomography demonstrated minimal free air, and the patient recovered uneventfully with conservative management. This case highlights that even in an extremely high-risk situation involving both an MRS and an underlying diverticulum, careful dissection and prompt endoscopic closure may avoid surgery and achieve curative resection.
Sarcoidosis may closely mimic disseminated malignancy on FDG-PET/CT because active granulomatous inflammation can demonstrate intense multisystem FDG uptake. We report a 59-year-old woman with previously diagnosed pulmonary sarcoidosis who presented with acute dyspnea and right leg pain and was found to have segmental and subsegmental pulmonary emboli on CT pulmonary angiography. FDG-PET/CT demonstrated extensive intensely hypermetabolic mediastinal, hilar, abdominal and pelvic lymphadenopathy with pulmonary, hepatic, splenic and multifocal osseous involvement, including a right iliac lesion (SUVmax 12.3), raising strong suspicion for disseminated metastatic malignancy or lymphoproliferative disease. CT-guided biopsy of the iliac lesion revealed non-necrotizing granulomatous inflammation without evidence of malignancy or infection, confirming multisystem sarcoidosis with osseous involvement. This case highlights the importance of histological confirmation when FDG-PET/CT findings in sarcoidosis mimic metastatic disease.
Minimal change nephrotic syndrome (MCNS) is a major cause of nephrotic syndrome in children and adults. Recent studies identified circulating anti-nephrin antibodies in 30%-50% of patients, linking them to severe proteinuria and frequent relapses. We describe a Japanese woman in her 40s with steroid-dependent nephrotic syndrome (SDNS). Anti-nephrin antibodies were identified in serum obtained at disease onset by immunoprecipitation and ELISA, and kidney biopsy showed punctate IgG colocalizing with nephrin. Before rituximab (RTX), she experienced relapses accompanied by increased anti-nephrin antibody reactivity. A low-dose RTX regimen (200 mg every 6 months for seven doses) enabled maintenance of complete remission and discontinuation of prednisolone and cyclosporine, with B-cell depletion confirmed by CD19 monitoring. She has maintained remission for two years after RTX discontinuation, without re-elevation of anti-nephrin antibody reactivity. This case supports a possible role of anti-nephrin antibodies in disease activity and suggests that low-dose RTX may contribute to durable remission.
Crossed renal ectopia is a rare congenital anomaly, with non-fused variants being exceptionally uncommon. The management of nephrolithiasis in such kidneys is challenging due to the abnormal anatomy, malrotation, and altered ureteral course. We report a case of a non-fused left crossed ectopic kidney with a 21 × 14.5 mm with density of 1250 HU renal calculus successfully managed with retrograde intrarenal surgery (RIRS), achieving complete stone clearance (SC). This case highlights the feasibility of RIRS, even in complex renal anomalies with a significant stone burden. A review of the existing literature further supports the expanding role of RIRS in anomalous kidneys.
We retrospectively reviewed histopathological and immunohistochemical data from patients with mixed exocrine-neuroendocrine intraductal papillary mucinous neoplasms (IPMNs) of the pancreas identified at a single centre between December 2023 and June 2026. Surgical specimens underwent detailed evaluation, including mucin profiling (MUC1, MUC2, MUC5AC) and neuroendocrine markers (synaptophysin, chromogranin A). Ten patients (median age 68.5 years, range: 31-78 years; 6 male) presented mainly with abdominal pain, weight loss, or jaundice. Most lesions were intestinal type IPMNs with focal or interspersed neuroendocrine components. Mucin expression patterns aligned with established subtype profiles, and neuroendocrine differentiation was confirmed immunohistochemically. Only one of the lesions met the World Health Organization (WHO) criteria for mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) due to the non-invasive IPMN component. This case series highlights a distinct subset of mixed non-invasive IPMN-neuroendocrine tumours not currently recognized in WHO classifications. We propose recognition of this entity to improve diagnostic precision and guide management.
Background:Radioactive iodine therapy (RAIT) is a definitive treatment for hyperthyroidism, but parathyroid effects are often underrecognized. Case Presentation:A 66-year-old woman with a 30-year history of Graves' disease underwent RAIT (555 MBq 131I) after long-term treatment with thiamazole and briefly with propylthiouracil without achieving remission. Two weeks after RAIT, she developed paresthesia and muscle cramps, progressing to hospitalization one week later with positive Chvostek's and Trousseau's signs. Laboratory tests showed severe hypocalcemia (ionized calcium 0.70 mmol/L), vitamin D deficiency, and low parathyroid hormone levels, consistent with parathyroid dysfunction (CTCAE Grade 3 hypocalcemia). She required intravenous and oral calcium plus vitamin D, with gradual improvement. At 9-month follow-up, calcium levels remained stable on supplementation, suggesting prolonged recovery of parathyroid function. She later developed post-RAIT hypothyroidism. Conclusion:This case highlights the importance of considering transient parathyroid dysfunction in patients with symptomatic hypocalcemia after RAIT and supports long-term biochemical monitoring and supplementation.
Choroidal melanoma is globally the most common primary intraocular malignancy in adults; however, it remains rarely reported in the Middle East. We report the case of a 38-year-old Iraqi woman who was diagnosed with choroidal melanoma. Five years later, she developed persistent gastric discomfort despite negative regular surveillance CT findings; however, further evaluation with linear endoscopic ultrasound revealed a hypoechoic lesion in the gastric fundus. And the metastatic melanoma was confirmed through histopathological examination, supported by immunohistochemical staining. The age at diagnosis in Asian populations is often younger. It was postulated that the age at presentation might likely get lower with implementation of improved screening strategies. In Asian nations Choroidal melanoma are detected late due to inadequate screening and reduced reporting. Moreover, the diagnosis of gastric melanoma can be challenging, as these metastases often remain clinically masked and CT/PET imaging studies have many pitfalls.
Immune-related hepatitis can interrupt effective PD-1 therapy, and evidence guiding within-class retreatment after recurrent toxicity remains limited. An 82-year-old woman with remote resected lung cancer later developed PD-L1-high metastatic squamous non-small cell lung cancer with thoracic and hepatic disease. After 4 pembrolizumab doses, mixed liver injury developed despite normal baseline liver chemistries. Viral hepatitis serologies were negative, liver ultrasound was unrevealing, and acetaminophen exposure remained a non-significant competing factor. Liver tests improved with corticosteroids but recurred after 2 pembrolizumab rechallenges, including a grade 3 event, prompting permanent discontinuation. Nivolumab was started after biochemical recovery and was tolerated for more than 3 years without recurrent hepatotoxicity. Follow-up PET-CT demonstrated durable metabolic resolution of thoracic and hepatic disease.
Primary small cell neuroendocrine carcinoma (SCNC) of the bladder is an exceptionally aggressive malignancy. We report the case of an 80-year-old male, a chronic smoker, presenting with an 8-month history of intermittent total hematuria. Cystoscopy revealed a 72 mm mass infiltrating the bladder dome, posterior, and lateral walls. Histopathological analysis of transurethral resection specimens demonstrated a necrotic diffuse proliferation of monomorphic small cells infiltrating the muscularis propria. Immunohistochemistry showed positivity for synaptophysin, chromogranin A, CD56, and TTF1, whereas GATA3 and p63 were negative. The Ki-67 index exceeded 90%. Systemic staging (cT3bN0M0) confirmed the primary bladder origin. Although multimodal management, including neoadjuvant chemotherapy and radical cystoprostatectomy, was recommended, the patient-initiated chemotherapy but declined surgery. Primary bladder SCNC is a highly invasive entity requiring early diagnosis and multidisciplinary care. The diagnosis is strictly anatomopathological. Differentiating this entity from primary pulmonary small cell carcinoma is a critical challenge, making systemic radiological staging mandatory.
Guillain-Barré syndrome (GBS) is an acute immune-mediated polyneuropathy characterised by rapidly progressive weakness, sensory disturbance, and autonomic dysfunction, often requiring intensive supportive care. While most cases follow gastrointestinal or respiratory infections, rare cases have been reported after vaccination. A 72-year-old man developed progressive symmetrical weakness and areflexia three weeks after receiving an mRNA COVID-19 vaccine. His condition deteriorated to bulbar dysfunction and respiratory failure, requiring intubation, tracheostomy, and prolonged ventilatory support. Cerebrospinal fluid analysis demonstrated albuminocytologic dissociation, while neuroimaging excluded structural pathology. Intravenous immunoglobulin was initiated promptly, followed by intensive multidisciplinary rehabilitation, including hydrotherapy. He gradually improved, was successfully decannulated, and transferred to a rehabilitation facility. This case highlights a rare possible post-vaccination association while emphasising that causality remains uncertain. Early recognition, close respiratory monitoring, and comprehensive rehabilitation are essential, as meaningful recovery is achievable even after severe disease.
Introduction:Dedifferentiated endometrial carcinoma (DEC) is a rare and aggressive uterine malignancy composed of low-grade endometrioid carcinoma admixed with an undifferentiated component and is associated with a poorer prognosis than conventional high-grade endometrioid carcinoma. Its synchronous occurrence with uterine leiomyosarcoma as a collision tumour is exceptionally rare. Case Presentation:A 74-year-old postmenopausal woman presented with abnormal uterine bleeding. Imaging revealed an endometrial mass, and she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histopathological examination demonstrated DEC with subclonal mismatch repair (MMR) deficiency and a morphologically distinct leiomyosarcoma. Immunohistochemistry showed loss of MLH1 and PMS2 expression in approximately 40% of tumour cells within the dedifferentiated component, with retained expression in the low-grade component. MLH1 promoter hypermethylation analysis demonstrated a methylation level of 55%, supporting a sporadic origin. A morphologically and immunophenotypically distinct uterine leiomyosarcoma was identified within the same specimen, consistent with a true collision tumour. The diagnosis was confirmed through comprehensive morphological, immunohistochemical, and molecular analyses. Postoperative imaging demonstrated nodal disease, and the patient subsequently received adjuvant therapy. At 1-year follow-up, she remained in complete remission. Conclusion:This rare collision tumour highlights the importance of integrated histopathological and molecular evaluation, particularly in recognising subclonal MMR deficiency and tumour heterogeneity.
Background:E-cigarette or vaping product use-associated lung injury (EVALI) is characterized by acute respiratory failure and bilateral pulmonary infiltrates. It presents a significant diagnostic challenge, particularly when it mimics common postpartum complications. Case Presentation:We describe a 28-year-old female who developed severe hypoxemic respiratory failure four days after a normal vaginal delivery. While initial clinical suspicion focused on obstetric etiologies like flash pulmonary edema or pneumonia, the patient's eventual disclosure of resumed vaping led to a diagnosis of EVALI. Following the administration of systemic corticosteroids, she experienced rapid and complete clinical recovery. Conclusion:This case, one of the first cases of EVALI in the immediate postpartum period, highlights the importance of obtaining comprehensive social history, particularly in a clinical context which broadens the differential diagnosis for unexplained respiratory failure.
Daptomycin is an effective antibiotic for resistant gram-positive infections, including MRSA and VRE, but can rarely cause daptomycin-induced eosinophilic pneumonia (DIEP). We present a 73-year-old woman treated for prosthetic joint infection who developed acute hypoxemic respiratory failure and peripheral eosinophilia after 21 days of daptomycin therapy. Chest imaging showed bilateral upper lobe consolidations. Symptoms resolved rapidly after stopping daptomycin, without corticosteroid use. This case highlights the need for early recognition of DIEP in patients presenting with new respiratory symptoms and eosinophilia during daptomycin therapy, enabling timely discontinuation and reducing potential morbidity.
Severe dilutional hyponatraemia is a recognised complication of transurethral resection of the prostate (TURP syndrome) caused by systemic absorption of hypotonic irrigation fluid, but similar events outside the operative setting are rarely reported. We describe a 77-year-old White male with radiation cystitis who underwent 12 days of sterile water bladder washouts alongside continuous 0.9% saline bladder irrigation for persistent haematuria. Serum sodium declined from 132 to 112 mmol/L and improved only after bladder washouts and irrigation were discontinued. Cystoscopy confirmed radiation cystitis with mucosal ulceration. The clinical course strongly suggests that systemic absorption of electrolyte-free sterile water caused the profound hypotonic hyponatraemia, whereas concurrent absorption of isotonic saline contributed to extracellular volume expansion. This case highlights that prolonged sterile water bladder washouts may produce a TURP-like syndrome in the absence of surgery. Early recognition, serial electrolyte monitoring and prompt source control are essential to prevent potentially life-threatening complications.
Burkitt lymphoma (BL) is a highly aggressive B-cell malignancy that rarely presents primarily in the breast. Its rapid progression and inflammatory features can mimic breast cancer or mastitis, leading to a delay in diagnosis. A 26-year-old nulliparous North African woman presented with a painful, rapidly growing breast mass that had appeared within the last four weeks. Clinical examination revealed an 8 cm mass accompanied by orange-peel skin. Imaging suggested a likely benign lesion (BI-RADS 3). However, histology showed a classic 'starry sky' pattern, a Ki-67 rate of 100% and positivity for CD20/CD10/BCL6 with negativity for BCL2/CD5/EBER. PET-CT revealed a solitary hypermetabolic lesion (SUV 32) without systemic involvement (stage IE, BL-IPI 1). Treatment with R-COPADM was initiated within 48 hours, resulting in complete remission. This case highlights that an early biopsy is essential in the presence of any atypical inflammatory breast mass, even when imaging appears reassuring.
Background:Purpureocillium lilacinum is a ubiquitous environmental fungus widely utilized as an agricultural biocontrol agent, but it is increasingly recognized as an opportunistic human pathogen. While invasive fungal infections caused by this microorganism have been documented globally, disseminated systemic presentations in pediatric oncology remain exceptionally rare and carry high mortality rates. Case Description:We report the case of an 11-year-old female patient with a high-grade osteosarcoma who developed high-risk febrile leukopenia during chemotherapy. Blood cultures from both a subcutaneous port and peripheral blood turned positive for both yeast-like and hyphal structures, which were further identified by DNA barcoding (ITS and EF1a regions) as P. lilacinum. The patient exhibited concurrent multiorgan dissemination, including hyperchromic scaling skin lesions in the perianal region and limbs, as well as diffuse bilateral pulmonary micronodules confirmed via video-thoracoscopy biopsy. Despite initial treatment with amphotericin B and fluconazole, clinical resolution was successfully achieved only after optimizing the antifungal regimen with oral voriconazole. The patient fully recovered and remains stable. Conclusions:To our knowledge, this represents the first clinical isolation and reported case of disseminated systemic P. lilacinum infection in a pediatric oncological patient in Ecuador. This case highlights the aggressive nature of this pathogen in immunosuppressed children, the challenge of its diagnosis due to the lack of specialized infrastructure for antifungal susceptibility testing, and the critical importance of a multidisciplinary approach and prompt, targeted first-line therapy with voriconazole to ensure survival.
Fluvastatin is extensively metabolized by CYP2C9, which is induced by rifampin over several weeks, leading to a concentration decline. However, since rifampin is a potent inhibitor of the primary first-pass hepatic statin uptake transporter, the organic anion transporting polypeptide 1B1 (OATP1B1), simultaneous administration has been shown to significantly increase statin exposure. We report a previously fluvastatin-tolerant 63-year-old woman with nonalcoholic steatohepatitis who developed statin-induced rhabdomyolysis four weeks after the initiation and co-administration of rifampin for tuberculosis. After both medications were stopped, the patient showed clinical and biochemical improvement. While this report is the first to describe a clinical outcome of this interaction, multiple pharmacokinetic studies have demonstrated opposing, time-dependent rifampin effects on statin concentrations. Safe management of this challenging interaction includes statin dose reduction and/or separate administration upon rifampin initiation until the anticipated onset of CYP induction, followed by careful and gradual dose titration with monitoring of both effectiveness and toxicity.
