BACKGROUND Cerebral venous thrombosis (CVT) is an uncommon form of stroke with highly variable clinical manifestations. Although headache and focal neurological deficits are typical presenting features, isolated psychiatric symptoms as an initial manifestation are exceptionally rare and may substantially delay diagnosis. CVT most commonly affects young adults and women with identifiable prothrombotic risk factors. CASE REPORT We report the case of a 37-year-old previously healthy woman with no identifiable thrombotic risk factors who presented with acute behavioral disturbances characterized by insomnia, agitation, emotional lability, and aggressive behavior. There was no history of prior psychiatric illness. Initial investigations, including brain magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and infectious workup, were unremarkable, with no evidence of structural abnormalities on early neuroimaging. She was admitted with a working diagnosis of acute polymorphic psychotic disorder and started on psychiatric treatment. Six days later, she developed sudden loss of consciousness followed by generalized tonic-clonic seizures, prompting urgent neuroimaging. Imaging revealed a right high-parietal intracerebral hemorrhage, and subsequent venous imaging confirmed CVT involving the superficial superior cerebral vein. The patient was treated with antiepileptic therapy and anticoagulation, leading to gradual neurological and psychiatric improvement. CONCLUSIONS This case highlights an unusual presentation of CVT with isolated psychiatric manifestations, absence of classical risk factors, and initially normal neuroimaging findings, all of which contributed to delayed diagnosis. Abrupt neurological deterioration can occur despite non-specific early investigations. Early consideration of cerebral venous imaging may be warranted in atypical acute psychiatric presentations to avoid delayed diagnosis and potentially life-threatening complications.
BACKGROUND Aortic cross-clamping is usually required to clearly visualize the surgical field in mini-thoracotomy because cardiac surgery without aortic cross-clamping can be challenging. However, certain patients may require alternative strategies for cardiovascular surgeries. CASE REPORT We report the case of a 73-year-old woman with prior valve replacement who underwent left atrial thrombectomy under cardiopulmonary bypass without aortic cross-clamping using rapid ventricular overdrive pacing. She was referred to our hospital for an evaluation of elevated C-reactive protein levels. Computed tomography coronary angiography revealed a large non-mobile mass in the left atrium that did not decrease after anticoagulation therapy. A high degree of adhesion was observed around the aortic root, making median sternotomy and aortic cross-clamping hazardous. Thrombectomy during perfused ventricular fibrillation was an option but is associated with other potential complications such as coagulopathy, arrhythmia, hyperglycemia, and disordered electrolytes that could further increase the total risk. Therefore, rapid ventricular overdrive pacing was selected to achieve temporary circulatory arrest, combined with a mini-thoracotomy approach. Rapid ventricular overdrive pacing was successfully maintained throughout the thrombectomy, and the patient was easily weaned from cardiopulmonary bypass. She was extubated in the operating room at the end of the surgery. She recovered without complications and was discharged walking independently. CONCLUSIONS Rapid ventricular overdrive pacing to achieve temporary circulatory arrest during cardiovascular surgery may be a new therapeutic option in patients with high risks associated with reoperation.
BACKGROUND Cardiac tamponade caused by intrapericardial contrast extravasation is a rare but life-threatening iatrogenic complication associated with central venous access devices (CVADs) during power injection. CVADs, including implanted ports (port-a-caths), are susceptible to fibrin sheath formation and mural thrombosis over time, which can tether the catheter tip against the vessel wall and predispose it to erosion or perforation. When high-pressure contrast is injected through a compromised device, contrast may bypass the vessel lumen entirely and accumulate within the pericardial sac, producing acute obstructive shock. CASE REPORT We report a 61-year-old woman with a history of diabetes mellitus, cerebrovascular accident, and an indwelling port-a-cath who underwent computed tomography (CT) angiography because of difficult peripheral venous access. Immediately after contrast administration, she developed sudden cardiovascular collapse and cardiac arrest. CT imaging demonstrated a large hyperdense pericardial effusion with superior vena cava thrombosis adjacent to the catheter tip, suggesting catheter-related vessel wall injury and direct contrast extravasation into the pericardial sac. Bedside echocardiography confirmed tamponade physiology with right ventricular diastolic collapse and chamber compression. Emergent pericardiocentesis drained 1 L of contrast-containing serosanguinous fluid and resulted in immediate hemodynamic recovery after cardiac arrest. CONCLUSIONS Contrast extravasation through a long-term indwelling port-a-cath is a rare but catastrophic cause of acute cardiac tamponade. Sudden cardiovascular collapse during or after contrast-enhanced CT in a patient with a long-term central venous device should prompt immediate suspicion for this diagnosis. Additionally, echocardiography enables rapid confirmation, and emergent pericardiocentesis is life-saving.
BACKGROUND Takotsubo cardiomyopathy is a transient stress-induced cardiomyopathy that can mimic acute coronary syndrome (ACS) but typically occurs without obstructive coronary disease. Reverse takotsubo is an uncommon variant characterized by basal hypokinesis with preserved apical contraction. We report an atypical case in which acute respiratory failure, rather than an abrupt emotional stressor, appeared to be the primary trigger. CASE REPORT A 69-year-old woman with coronary artery disease status after prior left anterior descending artery stent, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) presented with severe respiratory distress and became unresponsive, requiring emergency intubation. She tested positive for coronavirus OC43 and was managed in the intensive care unit (ICU) for COPD exacerbation with ventilator-dependent respiratory failure. High-sensitivity troponin rose from 56 ng/L to 937 ng/L initially, later peaking at 1928 ng/L after catheterization with ST-T changes on EKG, prompting cardiac evaluation. Transthoracic echocardiography revealed new segmental wall motion abnormalities consistent with stress cardiomyopathy and an estimated ejection fraction of 40%. Urgent coronary angiography demonstrated no obstructive coronary disease with a patent LAD stent; left ventriculography showed severe basal hypokinesis with preserved apical contraction, confirming reverse takotsubo. Further history-taking revealed ongoing grief after her sister's death 3 months earlier. CONCLUSIONS Reverse takotsubo should be considered in patients with ACS-like presentations during acute critical illness, including respiratory failure, even when emotional stressors are chronic rather than sudden. Recognizing basal hypokinesis with preserved apical function can help avoid misdiagnosis and guide appropriate supportive management and follow-up imaging.
BACKGROUND Endo-periodontal lesions (EPL), particularly those manifesting as primary periodontal lesions with secondary endodontic involvement, pose unique clinical challenges when accompanied by odontogenic maxillary sinusitis (OMS). Furthermore, limited case reports document the nonsurgical management of such complex conditions in maxillary molars exhibiting rare multi-rooted and multi-canal variations (prevalence <0.103%). CASE REPORT A 31-year-old woman presented with pain and grade III mobility in the right maxillary first molar, with an intact crown, a deep palatal periodontal pocket, and a negative cold testing response on clinical examination. Periapical radiography indicated multi-rooted anatomy and extensive bone loss, and cone beam computed tomography (CBCT) confirmed 4 separate roots (mesiobuccal, distobuccal, mesiopalatal, distopalatal), a fifth centrally located pulp chamber canal orifice, a periapical lesion communicating with a periodontal defect, and ipsilateral maxillary sinus mucosal thickening. Nonsurgical root canal treatment for all 5 canals was performed under a dental operating microscope with ultrasonic activation (3% NaOCl) and bioceramic sealer, combined with concurrent supportive periodontal therapy. At the 8-month follow-up, the tooth was asymptomatic with reduced mobility and probing depths; CBCT revealed marked reduction in periapical lesions and significant improvement in maxillary sinus mucosal thickening (ENT consultation advised). CONCLUSIONS This case unequivocally demonstrates that meticulous nonsurgical endodontic treatment with ultrasonic activation and bioceramic sealer, in conjunction with targeted periodontal therapy and occlusal management, is a highly effective tooth-preserving strategy for maxillary molars with complex anatomic variations complicated by primary periodontal lesions with secondary endodontic involvement and secondary OMS, achieving excellent clinical and radiological outcomes.
BACKGROUND The coexistence of multiple oncogenic drivers in non-small cell lung cancer (NSCLC) is a rare and diagnostically challenging molecular configuration. Conventional polymerase chain reaction (PCR)-based testing may fail to detect co-occurring genomic alterations, potentially limiting therapeutic options, particularly in resource-constrained settings. CASE REPORT We describe the case of a 54-year-old non-smoking woman diagnosed with Stage IIIA lung adenocarcinoma in 2020. Initial PCR-based molecular testing was negative for EGFR mutations. Following disease progression with brain metastases and severe chemotherapy toxicity, stepwise molecular profiling in a resource-limited setting identified HER2 (ERBB2) amplification via fluorescence in situ hybridization (FISH). The patient achieved 23 months of clinical and radiological stabilization on trastuzumab. Subsequent next-generation sequencing (NGS) analysis of archived tissue revealed a previously undetected estimated glomular filtration rate (EGFR) L858R mutation. In late April 2025, new lesions appeared in the lungs, indicating disease progression. Based on the previously verified EGFR L858R mutation, the treatment strategy was revised and gefitinib was initiated in May 2025. CONCLUSIONS This case illustrates that co-occurring EGFR and HER2 alterations can remain undetected following initial limited molecular testing, and that stepwise molecular profiling in a resource-constrained setting can facilitate identification of therapeutically actionable targets. The sequential clinical responses observed are consistent with the biological relevance of both alterations, although broader conclusions regarding diagnostic strategy or driver hierarchy cannot be drawn from a single observation.
BACKGROUND The therapeutic margin of colchicine is narrow, and toxicity occurs easily. No standard treatment exists because its toxicokinetics are poorly understood. Symptoms are usually gastrointestinal, and dehydration occurs easily. Few reports have monitored serum and urinary colchicine levels. CASE REPORT A man in his 20s presented with nausea, vomiting, diarrhea, drowsiness, and dyspnea. He ingested 2 dried Colchicum autumnale bulbs (estimated colchicine: 6.24-15.6 mg) with an energy drink. Activated charcoal with laxative was administered at 27 hours post ingestion (h-PI), followed by multiple-dose activated charcoal (MDAC) every 6 hours (13 doses, 27-101 h-PI), high-volume fluid infusion (Ringer's acetate), and blood purification (hemodialysis [HD] at 48-52 h-PI; hemodiafiltration [HDF] at 71-75 and 98-102 h-PI). Serum colchicine was measured at 16 time points and urine at 11 time points. Serum colchicine at 27 h-PI was 50.3 ng/mL, and was temporally associated with a rapid decrease to 21.2 ng/mL at 35 h-PI, coinciding with initiation of infusion and activated charcoal. A secondary rise to 17.74 ng/mL occurred at 77 h-PI, approximately 2.4 hours after HDF1 completion. Urine colchicine was 110.0 ng/mL at 29 h-PI, then gradually decreased. Serum colchicine changed modestly (12.16 to 5.46 ng/mL) during HD. CONCLUSIONS In this case of severe colchicine poisoning, serial serum and urine concentration monitoring provided a time-resolved profile across concurrent interventions. The observed temporal associations support hypothesis generation regarding the potential roles of renal elimination and MDAC-mediated interruption of enterohepatic recirculation in colchicine clearance, while recognizing that concurrent therapies preclude attribution of effects to any single intervention.
BACKGROUND Anterior cutaneous nerve entrapment syndrome is an underrecognized cause of abdominal wall pain and may be overlooked, particularly in patients with advanced cancer, in whom abdominal pain is often attributed to malignancy-related causes. Failure to identify coexisting non-cancer-related pain mechanisms can result in inadequate pain control and functional decline. CASE REPORT A 51-year-old woman with advanced sigmoid colon cancer and peritoneal metastasis presented with severe movement-related abdominal pain that was refractory to high-dose opioid therapy. Although tumor lesions were present near the umbilicus, she reported minimal pain at rest, with marked exacerbation during sitting and ambulation. Physical examination revealed multiple localized tender points along the lateral borders of the rectus abdominis muscle and a positive Carnett's sign, suggesting abdominal wall pain. Based on these findings, anterior cutaneous nerve entrapment syndrome was suspected. Ultrasound-guided bilateral rectus sheath blocks were performed at the tender points, resulting in immediate pain relief. Although the initial analgesic effect was transient, repeated blocks led to sustained pain reduction beyond the expected duration of local anesthetic action, enabling recovery of mobility and activities of daily living. CONCLUSIONS This case shows that anterior cutaneous nerve entrapment syndrome can coexist with cancer-related pathology and is a treatable cause of refractory abdominal pain in patients with advanced cancer. Careful assessment of pain characteristics and physical examination, even in the presence of tumor lesions at the pain site, can facilitate recognition and treatment of non-cancer-related pain and improve functional outcomes and quality of life in palliative care settings.
BACKGROUND Septic abortion is a serious, life-threatening uterine infection that can occur before, during, or after a miscarriage or termination, and when it is associated with an intrauterine fetal death (IUFD), the retained fetal tissue can be a focus for bacterial infection. This report describes the case of a 34-year-old woman with septic abortion associated with IUFD at 8 weeks of gestation, complicated by myometritis and bilateral psoas muscle abscess. CASE REPORT A 34-year-old female patient presented with severe lower back pain radiating to the right lower extremity. Diagnostic workup initially ruled out neurological lesions but identified an impending septic spontaneous abortion due to IUFD at 8.7 weeks. Following cervical ripening with misoprostol and subsequent uterine curettage, she developed persistent fever and methicillin-resistant Staphylococcus aureus bacteremia. Abdominal and pelvic computed tomography (CT) documented fluid collections involving both iliopsoas muscles bilaterally at their distal insertion, alongside smaller collections in the right external obturator and thigh musculature. No surgical drainage was required due to the limited size of the abscesses. Targeted treatment consisting of a 28-day course of intravenous vancomycin resulted in full clinical and radiographic resolution. CONCLUSIONS Iliopsoas abscess is a complex clinical entity whose diagnosis can be challenging, even more in a pregnancy context. Very few cases of psoas abscess during pregnancy have been reported in the literature, and even fewer have been bilateral. Timely diagnosis and broad-spectrum antibiotic coverage are the cornerstones of treatment.
BACKGROUND Radiation therapy is critical for treating many solid tumors but increases the risk of secondary malignancies due to DNA damage. Radiation-associated sarcomas (RAS) occur in 0.03% to 0.8% of irradiated patients, typically 5 to 20 years after treatment. Undifferentiated pleomorphic sarcoma (UPS) is a common RAS subtype with poor 5-year survival (12%-14%). Risk rises with doses ≥50 Gy and is especially concerning in previously irradiated head and neck regions, where surgery is challenging. Germline mutations in DNA repair genes (eg, ATM) further increase susceptibility. CASE REPORT A 54-year-old man treated in 2003 for multifocal medullary thyroid carcinoma (thyroidectomy, bilateral neck dissection, adjuvant 59.4 Gy radiation) presented 22 years later with a painless neck mass. Imaging showed a 1.9-cm enhancing lesion within the prior radiation field. Excision revealed a 4-cm, FNCLCC grade 3 intramuscular UPS meeting the modified Cahan criteria for RAS. Immunohistochemistry excluded recurrent thyroid carcinoma. Margins were positive, but re-excision and re-irradiation were not feasible. The sarcoma tumor board recommended close surveillance and germline testing. This case involved high-grade UPS arising 2 decades after neck irradiation. Compared with sporadic UPS, RAS-associated UPS has worse disease-specific survival (~52% vs 76%) and higher local recurrence (~55% vs 24%), emphasizing the importance and difficulty of achieving negative margins in previously irradiated fields. CONCLUSIONS As cancer survival improves, lifelong vigilance for RAS remains essential. New masses in irradiated areas require prompt evaluation. Multidisciplinary management and consideration of genetic testing are critical, as treatment options are often limited by prior therapy.
BACKGROUND Renal angiomyolipoma (AML) is a typically benign mesenchymal tumor with an indolent clinical course. Rarely, AML demonstrate aggressive vascular invasion, most commonly in association with tuberous sclerosis complex (TSC). Intracardiac extension, particularly into the right ventricle, is exceptionally uncommon in sporadic cases and presents significant diagnostic and surgical challenges. CASE REPORT A 36-year-old woman with a history of rheumatoid arthritis presented with progressive left upper-quadrant abdominal pain, nausea, and back discomfort. Cross-sectional imaging revealed a massive left renal angiomyolipoma measuring 19.5×18.0×10.5 cm, with a contiguous tumor thrombus extending from the left renal vein through the inferior vena cava into the right atrium, intermittently prolapsing across the tricuspid valve into the right ventricle. Echocardiography confirmed a mobile intracardiac mass without evidence of valvular obstruction. Genetic testing was negative for TSC1 and TSC2 mutations, consistent with a sporadic angiomyolipoma. The patient underwent successful en bloc left radical nephrectomy with complete venous thrombectomy and inferior vena cava reconstruction through a coordinated multidisciplinary approach. Final pathology confirmed complete excision with negative margins and absence of epithelioid features. CONCLUSIONS This case was an exceptionally rare presentation of sporadic renal angiomyolipoma with extensive intracardiac extension into the right ventricle. It demonstrates that significant vascular and cardiac involvement can occur even in the absence of TSC-associated genetic mutations or epithelioid histology, thereby challenging traditional assumptions regarding AML behavior. These findings underscore the importance of early recognition, comprehensive imaging, and individualized operative planning in the management of complex AML presentations. Given the potential for aggressive progression in otherwise benign tumors, close long-term radiographic surveillance remains essential.
BACKGROUND Coronary-subclavian steal syndrome (CSSS) is a rare but clinically significant cause of myocardial ischemia in patients with prior coronary artery bypass grafting (CABG), particularly when the left internal mammary artery (LIMA) is used as a conduit. Proximal subclavian artery stenosis can lead to reversal of LIMA graft flow, resulting in compromised myocardial perfusion that can mimic progression of native coronary disease. CASE REPORT A 63-year-old man with a history of multi-vessel coronary artery disease, prior PCI, and CABG with a LIMA-to-LAD graft presented with progressive exertional chest pain and left upper-extremity paresthesia. Physical examination revealed a diminished left radial pulse and inability to obtain blood pressure in the affected arm, raising suspicion for a proximal inflow lesion. CTA subsequently identified high-grade stenosis of the proximal left subclavian artery, and coronary angiography confirmed underfilling of the LIMA-LAD graft consistent with CSSS physiology. After evaluating medical therapy, redo surgical revascularization, and endovascular intervention, percutaneous stent placement was selected due to its lower procedural morbidity and favorable reported outcomes. A balloon-expandable stent was successfully deployed, restoring antegrade flow with immediate improvement in graft perfusion. CONCLUSIONS This case emphasizes the importance of recognizing coronary-subclavian steal syndrome in post-CABG patients presenting with recurrent angina and upper-extremity vascular findings. Targeted vascular imaging and bedside examination facilitated the diagnosis, and endovascular subclavian revascularization proved safe and effective in restoring graft perfusion. A practical diagnostic flowchart is also presented to support clinical evaluation and management in similar cases.
BACKGROUND Left ventricular summit ventricular tachycardia (LVSVT) originates in the epicardium of the superior left ventricular wall, between the origins of the main coronary arteries, with characteristic findings on 12-lead electrocardiogram (ECG) that can guide ablation. This report describes a 66-year-old man with dizziness and palpitations diagnosed with LVSVT using ECG and managed with radiofrequency ablation. CASE REPORT A 66-year-old man presented with 24 hours of dizziness and palpitations. He was hemodynamically stable, and the initial ECG showed frequent premature ventricular complexes with left bundle branch block-like morphology, inferior axis, and early precordial transition. Continuous monitoring and 24-hour Holter recording documented a high ventricular ectopic burden (~65%), with episodes of sustained and nonsustained monomorphic ventricular tachycardia of identical morphology. Echocardiography showed preserved left ventricular systolic function, and coronary angiography and cardiac magnetic resonance imaging excluded obstructive coronary disease, myocardial fibrosis, and scar. Because symptoms and arrhythmia burden persisted, an electrophysiological study was performed on day 4. Isoproterenol infusion induced ventricular tachycardia, activation mapping localized the earliest ventricular activation to the left ventricular summit, and radiofrequency ablation was performed from the great cardiac vein and adjacent left ventricular outflow tract and left coronary cusp sites after coronary angiography confirmed a safe distance from the coronary arteries. Ventricular ectopy was immediately suppressed, and no arrhythmia was inducible after ablation. At 30-day follow-up, the patient remained asymptomatic without recurrent ventricular arrhythmia on Holter monitoring. CONCLUSIONS Systematic ECG interpretation can localize LVSVT and guide effective catheter ablation.
