2-year History Research Articles

Unravelling the Diagnostic Dilemma of Juvenile Scleroderma: A Case Report

Juvenile scleroderma (JS) is a rare and often overlooked connective tissue disease in Paediatric populations. Its diagnosis is particularly challenging due to its multi-systemic involvement, and in developing countries like ours, the lack of diagnostic tools further complicates timely identification. We present the case of an 11-year-old male who presented to our children’s emergency room with a 2-year history of progressive skin thickening, flexion contracture and immobility of the right thumb. There was generalized body pain and swelling of the right upper limb. Additionally, the patient experienced recurrent cough, night sweats, easy fatigability, and occasional palpitations, though without significant weight loss. After an initial misdiagnosis and several ineffective treatments, the suspected diagnosis of JS led to a trial treatment with methylprednisolone and methotrexate, to which the patient responded favourably. This case underscores the importance of a high index of suspicion for the prompt diagnosis and management of rare childhood rheumatic diseases, as delay in diagnosis can exacerbate morbidity and increase mortality.

May-Hegglin, another Cause of Cataract: Case Report and Review

May-Hegglin anomaly (MHA) is a rare autosomal dominant genetic disorder characterized by the presence of large, abnormally shaped platelets (macrothrombocytes), thrombocytopenia, and distinctive leukocyte inclusions known as Döhle-like bodies. First described by the German physician Heinrich May in 1909 and further characterized by Swiss hematologist Otto Hegglin in 1945, MHA is part of a group of disorders collectively referred to as the MYH9-related diseases, which also include Sebastian syndrome, Fechtner syndrome, and Epstein syndrome. A 41-year-old male presents with a 10-year history of thrombocytopenia and a recent development of bilateral cataracts over the past three years. The patient reports that the thrombocytopenia has been resistant to corticosteroid treatment. He has experienced occasional episodes of mild bleeding, including easy bruising, epistaxis, and petechiae, but no severe hemorrhagic events. He denies any history of significant trauma, surgeries, or other major medical conditions. There is no known family history of similar hematological or ophthalmological issues. One of the primary ophthalmological concerns in MHA is the increased risk of retinal hemorrhages. Thrombocytopenia, a hallmark of MHA, predisposes patients to bleeding complications due to insufficient platelet numbers [3, 4]. The retinal vasculature, being highly sensitive to changes in hemostasis, is particularly vulnerable. Retinal hemorrhages can manifest as dot-blot hemorrhages or more extensive preretinal hemorrhages, potentially leading to vision impairment. Regular ophthalmologic examinations are crucial for early detection and management of these hemorrhages to prevent permanent vision loss. This case underscores the importance of considering MYH9-related disorders in patients presenting with thrombocytopenia resistant to standard treatments and associated with atypical clinical features, such as cataracts and leukocyte inclusions. Comprehensive diagnostic evaluations, ...

Herpes vegetans mimicking penile malignancy in a patient living with human immunodeficiency virus.

A 51-year-old man with human immunodeficiency virus (HIV) infection presented to the dermatology clinic with a 2-year history of recurrent penile ulceration and a large, fungating, exophytic mass with ulceration. Histopathology revealed no evidence of malignancy, hepes simplex viruses 1 and 2 were detected on polymerase chain reaction (PCR) and a diagnosis of herpes vegetans was made. The patient was treated succesfully with oral valaciclovir resulting in complete resolution of lesions.

Non-Ketotic Hyperglycemia Induced Hemichorea-Hemiballism May Represent Glioma-Like Pattern on Multimodal Magnetic Resonance Imaging: Can 1H Spectroscopy Help in the Differentiation?

Abstract Nonketotic hyperglycemia (NKH) induced hemichorea-hemiballismus (HC-HB) is an infrequent reversible condition observed in individuals with poorly controlled diabetes. In this report, we present a case of NKH-induced HC-HB exhibiting distinctive morphological and functional alterations on conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and 1H magnetic resonance spectroscopy (MRS), followed by subsequent monitoring. A 70-year-old male with a 20-year history of diabetes presented with severe unilateral involuntary movement. Computer tomography revealed heightened attenuation in the left putamen and caudate nucleus. The conventional MRI revealed the presence of focal T2-hyperintensity, noticeable mass effect, and ring-like enhancement, which are indicative of glioma. Additionally, the DWI showed unrestricted diffusion of water molecules within the lesion. MRS analysis further demonstrated significantly elevated lactate (Lac) and lipids (Lip), minimal increased choline (Cho), basically stable creatine (Cr), and modest decreased N-acetylaspartate (NAA) levels (which remained larger than both Cho and Cr peaks), leading to a diagnosis of NKH-induced HC-HB. This report emphasizes the significance of acknowledging that NKH-induced HC-HB can manifest with imaging features that bear resemblance to those of glioma. The presence of a slightly elevated Cho/NAA ratio alongside a notable increase in Lac/Lip peak on MRS may aid in ruling out neoplastic conditions.

Utilizing Upadacitinib for the Management of Hailey-Hailey Disease

Hailey-Hailey Disease (HHD) is a rare disease associated with mutation of the ATP2C1 gene characterized by skin blistering and erosion. Here, we report a case of a patient with HHD who significantly improved after treatment with upadacitinib. A 55-year-old male with biopsy-confirmed Hailey-Hailey disease presented with a 20-year history of ill-defined, brightly erythematous, painful patches initially on the neck and subsequently involving the penile shaft. Following treatment with 30mg of upadacitinib, the patients neck ulcers gradually re-epithelized. This case adds to the growing body of literature supporting the use of Janus kinase inhibitors as a therapeutic modality for this condition.

Middle fossa approach for a petrous apex bony spur causing trigeminal neuralgia: illustrative case.

Trigeminal neuralgia (TN) can arise from trigeminal nerve compression at the root entry zone due to neurovascular conflict, which most often presents in the 6th decade of life. The authors report the case of a young patient with TN with a petrous apex bony spur near the entrance of Meckel's cave, causing compression of the proximal trigeminal nerve. A 21-year-old woman presented with a 5-year history of progressive right-sided TN. Axial T2 sampling perfection with application optimized contrast using different flip angle evolution magnetic resonance imaging (MRI) did not reveal vascular compression of the trigeminal nerve. However, sagittal reformats demonstrated a prominent bony ridge along the petrous apex, causing compression of the right trigeminal nerve at the porus trigeminus. Removal of the bony spur via a middle fossa approach completely resolved the patient's symptoms. Although TN is most frequently caused by neurovascular compression, it is vital to examine the entire course of the trigeminal nerve on MRI to identify alternative causes of nerve compression in the absence of neurovascular conflict. Bony compression is a rare cause of TN that should be considered, particularly in younger patients. The presence of prominent osseous structures along the course of the trigeminal nerve can be evaluated reliably on sagittal MRI. https://thejns.org/doi/10.3171/CASE24321.

Telerehabilitation with a Patient Diagnosed with Acromegaly and Bilateral Total Loss of Vision Secondary to Pituitary Macroadenoma: A Case Report

Coronavirus disease 2019 (COVID-19) caused unprecedented disruptions in the lives of people, inducing a change in social behavior because of quarantine and physical distancing measures for health safety. It greatly affected not only the general population but also the healthcare system, forcing healthcare providers and consumers to adjust from the traditional mode of in-person consultation to telemedicine to enable safe and prompt delivery of adequate and efficient patient care. A 35-year-old female was diagnosed with acromegaly secondary to pituitary macroadenoma, presenting as a 10-year history of weight gain, amenorrhea, hand and feet enlargement, coarse facial features, and bilateral vision loss. Patient then underwent craniotomy, right petrosal cranialization of frontal sinus, and tumor excision during the height of the pandemic in a COVID-19 referral center. Post-operatively, she was assisted in all activities of daily living. She was discharged after a few days of in-patient rehabilitation in order to decrease risk of contracting COVID-19. Telerehabilitation was then done using both asynchronous and synchronous methods while the patient stayed at home. Given the patient’s functional and visual disabilities, it was a challenge to do the traditional telerehabilitation techniques that highly rely on intact visual senses. We hereby share our experiences in providing virtual care amid these challenges towards achieving the patient’s optimal rehabilitation goals.

Split hand and minipolymyoclonus in spinocerebellar ataxia type 3: a case report

BackgroundSpinocerebellar ataxia type 3 (SCA3), also known as Machado–Joseph disease, is an autosomal dominant neurodegenerative disorder caused by CAG repeat expansion in exon 10 of ATXN3. Extra-cerebellar manifestations, including external ophthalmoplegia, dystonia, Parkinsonism, and peripheral neuropathy, are predominantly present in SCA3 cases. Here, we report a case of SCA3 presenting with a split hand and minipolymyoclonus.Case presentationA 73-year-old female patient presented with a 5-year history of ataxic gait. Neurological examination revealed cerebellar ataxia and minipolymyoclonus in the digits on both sides and muscle atrophy in the right hand, consistent with the split hand pattern. Electrodiagnostic studies demonstrated decreased amplitude of compound muscle action potentials and neurogenic motor unit potentials, indicating lower motor neuron involvement.ConclusionsOur patient’s case indicated a split hand and minipolymyoclonus in SCA3. Clinicians should consider these extra-cerebellar manifestations in patients with SCA3. Although neither split hand nor minipolymyoclonus are likely to directly result in a specific etiological diagnosis, a common pathophysiological mechanism for both may be lower motor neuron involvement. This extracerebellar manifestation contributes to narrowing down the diagnostic possibilities for cases presenting with progressive cerebellar ataxia.

Barriers and enablers of life cycle assessment in small and medium enterprises: a systematic review

AbstractBusinesses are facing increasing pressure from multiple stakeholders to integrate sustainability into their practices and business models. Although Small and Medium-sized Enterprises (SMEs) represent at least 90% of businesses worldwide and contribute approximately 60% of environmental impacts, assessing and improving their sustainability performance is not a priority for them. SMEs can address sustainability issues through the application of the different Life Cycle Assessment (LCA) approaches. LCA focuses solely on the environment; however, other forms, such as social, costing, sustainability, and organizational LCA, enable practitioners to assess impacts across the entire life cycle of the studied system, each with different scopes and approaches. However, LCA remains in the domain of large companies. This article aims to identify the main barriers and enablers of LCA in SMEs for wider use as a tool to improve sustainability performance. Through a systematic review of the scientific literature on LCA among SMEs applying the Standardized Technique for Assessing and Reporting Reviews of LCA data, a sample of 61 articles provides a 20-year history. Our results characterize the application of LCA in SMEs through six main aspects. Our main conclusions identify three main barriers to the application of LCA among SMEs: lack of trained personnel, lack of data, and high costs. To overcome these barriers, we found that narrowing down the scope using simplified methods in clusters can increase the use of LCA among SMEs. A simplified SME cluster-elaborated LCA can be used to qualitatively identify sustainability hotspots, develop suitable strategies to improve sustainability performance, and respond to market requests.

A 5-year natural history cohort of patients with facioscapulohumeral muscular dystrophy determining disease progression and feasibility of clinical outcome assessments for clinical trials.

The number of clinical trials in facioscapulohumeral muscular dystrophy (FSHD) is expected to increase in the near future. There is a need for clinical outcome assessments (COAs) that can capture disease progression over the relatively short time span of a clinical trial. In this study, we report the natural progression of FSHD and determine the feasibility of COAs for clinical trials. Genetically confirmed FSHD patients underwent various COAs at baseline and after 5 years. COAs consisted of the Motor Function Measure (MFM), manual muscle testing using the Medical Research Council score, six-minute walk test, quantitative muscle strength assessment of the quadriceps muscle, clinical severity score, and FSHD evaluation score (FES). Statistical significance and the minimal clinically important difference (MCID) were calculated and power calculations were performed. One hundred fifty-four symptomatic FSHD patients were included, with a mean (SD) age of 51.4 (14.6) years old. All COAs showed a minimal, yet statistically significant progression after 5 years. MCID was reached for the MFM Domain 1, MFM total score, and FES. These three COAs showed the lowest sample size requirements for clinical trials (185, 156, and 201 participants per group, respectively, for a trial duration of 2 years). The captured FSHD disease progression rate in 5 years was generally minimal. The COAs in this study are not feasible for clinical trials with a duration of 2 years. Extended trial durations or novel outcome assessments might be necessary to improve trial feasibility in FSHD.

Looking to the past: Investigating 10-year place histories as a determinant of home food environments in the Healthy Communities Study

Emerging research suggests there is a need to consider the importance of place histories in studying neighborhood effects. Guided by a life course of place framework, the objective of this study is to investigate the relationship between two place history exposures and three contemporary home food environment outcomes. Exposures included 10-year neighborhood socioeconomic status (SES) histories and multi-year nutrition community programming and policy (CPP) histories. Outcomes included the availability of healthy foods in the home, the availability of unhealthy foods in the home, and household food insecurity. Associations are investigated using cross-sectional and retrospective data on 4210 US families in the national, observational Healthy Communities Study (2013–2015). Multilevel regression models, adjusted for household income and other factors, were fit for each exposure and outcome. Households residing in neighborhoods with intermittently low, consistently moderate, intermittently high, and consistently high SES histories had greater availability of healthy foods in the home than households in neighborhoods with consistently low SES histories (adjusted βs: 0.11 [95% CI: 0.02, 0.20], 0.13 [95% CI: 0.06, 0.21], 0.23 [95% CI: 0.13, 0.34], and 0.24 [95% CI: 0.15, 0.33], respectively). Households in consistently high SES neighborhoods also had a lower likelihood of household food insecurity than those in consistently low SES neighborhoods (adjusted OR: 0.54 [95% CI: 0.42, 0.71]). Neighborhood SES histories were not significantly associated with the availability of unhealthy foods in the home. Nutrition CPP histories were not significantly associated with food insecurity or the availability of unhealthy foods in the home. However, more intense nutrition CPP histories were significantly associated with greater availability of healthy foods in the home. Moreover, effect estimates increased with more long-term historical accounts of CPPs (adjusted βs: 1-year CPP histories, 0.21 [95% CI: 0.03, 0.39]; 3-year CPP histories, 0.22 [95% CI: 0.03, 0.41]; 6-year CPP histories, 0.25 [95% CI: 0.04, 0.46]; 10-year CPP histories, 0.28 [95% CI: 0.05, 0.50]). To curb food insecurity and promote the availability of healthy foods, the findings suggest considering how neighborhoods develop and evolve over time with respect to SES and nutrition CPP implementation.

A case of indeterminate cell histiocytosis with ETV3-NCOA2 translocation.

Indeterminate cell histiocytosis (ICH) is a rare histiocytic disorder characterized by a proliferation of CD1a+ and CD207/langerin- cells. Recent molecular analyses have identified ETV3-NCOA2 translocation as a possible aetiopathogenesis of ICH. Herein, we describe the first Japanese case of ICH with ETV3-NCOA2 translocation. A 79-year-old Japanese man presented with a 1-year history of pruritic erythematous papules and nodules on his trunk and extremities. Histological examination revealed a dense and diffuse sheets-like infiltration of medium-sized histiocyte-like cells from the epidermis to the deep dermis. Immunohistochemically, the atypical cells were positive for CD1a but negative for CD207/langerin. Fluorescence insitu hybridization using NCOA2 break-apart probes confirmed a chromosomal break occurring on NCOA2 monoallele in the tumor cells. Furthermore, ETV3 exon 4-NCOA2 exon 14 translocation was identified in formalin-fixed paraffin-embedded skin samples using reverse transcription polymerase chain reaction and subsequent direct DNA sequencing. He also presented with interspersed eczematous plaques on his trunk and reactive dermatopathic lymphoadenopathy without any infiltration of ICH. He was treated with topical corticosteroids and narrowband UVB phototherapy. Four months later, his ICH skin eruptions, eczematous plaques, and lymphoadenopathy gradually regressed. Our case supports the notion that the detection of ETV3-NCOA2 translocation can be useful for diagnosis of ICH.

Desmoplastic Fibroblastoma (Collagenous Fibroma) of the Knee: A Case Report and Literature Review.

Desmoplastic fibroblastoma, also known as collagenous fibroma, is a rare benign mesenchymal neoplasm that primarily arises in the subcutaneous tissue of upper extremities and limb girdles. The knee is an uncommon location for desmoplastic fibroblastoma. Recent studies have demonstrated the presence of immunoreactivity for FOS like 1 (FOSL1) and rearrangements of FOSL1. A 70-year-old woman presented with a 1-year history of a palpable mass in the medial aspect of the right knee. Physical examination revealed a 4-cm, elastic hard, mobile, nontender mass. Magnetic resonance imaging (MRI) showed a well-defined mass with prominent low signal intensity on all pulse sequences. Contrast-enhanced MRI demonstrated mild internal enhancement with rim enhancement. After an open biopsy, the lesion was successfully treated by complete excision. Histologically, the tumor was composed of bland spindle or stellate-shaped cells embedded in an abundant collagenous stroma. Immunohistochemically, the tumor cells showed diffuse nuclear positivity for FOSL1. These findings were consistent with a diagnosis of desmoplastic fibroblastoma. The patient was asymptomatic and there was no evidence of local recurrence eight months after surgery. Desmoplastic fibroblastoma is a distinctive benign soft-tissue tumor with FOSL1 immunoreactivity and should be clearly distinguished from more biologically aggressive mesenchymal neoplasms.

Zolpidem-related euphoria, addiction and detoxification: A case report and review of the literature.

Zolpidem, a non-benzodiazepine sedative-hypnotic, is considered safer for the treatment of insomnia compared to benzodiazepines. However, in recent years, there have been growing reports of Zolpidem dependence, addiction, and withdrawal symptoms. We reported a case of Zolpidem addiction and successful detoxification, reviewed similar cases in the literature, and proposed a potential mechanism underlying Zolpidem addiction. The patient was a 46-year-old Tibetan woman who had been using Zolpidem intermittently to treat insomnia for at least 8 years. She was overweight, with a BMI of 28.04 kg/m², and had hypertension, diabetes, a 20-year smoking history, and several years of alcohol abuse, often seeking instant gratification. She voluntarily increased both the dosage and frequency of Zolpidem, experiencing euphoria, anxiolysis, and increased appetite at higher doses, which led her to gradually escalate her dosage to 280 mg per day in divided doses. However, upon stopping Zolpidem, she experienced withdrawal symptoms, including insomnia, tension, and palpitations. She was diagnosed with a combination of hypnotic use disorder, anxiety disorder, hypertension, and diabetes. She underwent diazepam replacement therapy, along with antianxiety medications and mindfulness-based cognitive therapy, to address Zolpidem addiction. After 13 days of inpatient treatment, the patient successfully quit Zolpidem. During a 3-month follow-up, she returned to work and remained free from Zolpidem use. We speculate that Zolpidem addiction is likely linked to the drug's euphoric effects and certain patient characteristics, such as sensation-seeking behavior. A comprehensive approach, involving both pharmacological and psychological interventions, is essential for an effective detoxification strategy for Zolpidem addiction.

Can metformin be used as a treatment for unresponsive oral ulcers? A case report

Introduction: Aphthae are common lesions that occur inside the mouth on the mucous membrane, often associated with various diseases. The causal pathogenesis generally depends on the accompanying condition, but there is usually no serious underlying cause. Case presentation: This case report describes a 33-year-old male patient with a 10-year history of recurrent oral ulcers and impaired glucose tolerance. The patient had previously been treated with glucocorticoids, which provided temporary relief. Laboratory tests and immune profiles were normal. After 1 week of treatment with metformin at a dose of 500 mg twice daily, the lesions were relieved, and the patient required further metformin treatment for three years without any recurrence. Discussion: Metformin has been shown to have anti-inflammatory effects in preclinical studies, making it a potential treatment option for mucocutaneous manifestations. This case report highlights the clinical effectiveness of metformin in treating oral ulcers and suggests its potential as an alternative treatment option for this condition. Conclusion: Further studies are needed to confirm the efficacy and safety of metformin in treating mucocutaneous manifestations.

Exploring Typologies of Domestic Violence Perpetrators: Insights into Male Patterns and Behaviours

Research into domestic violence has typically focused on the victims, who are usually female. However, shifting the focus to the male perpetrators creates opportunities for earlier intervention to stop the violence. By recognizing the early warning signs, police, community-based supports and governments can target interventions to prevent domestic violence before it escalates or even occurs. This policy brief examines the 10-year history of Calgary Police Service interactions with 934 Calgary men, aged 18 and above, who were eventually charged in domestic violence incidents in 2019. Based on their criminal and domestic encounters with police, the perpetrators fell into four typologies. Of the four groups, one had no history with police and the second had a criminal history but no non-criminal domestic encounters before the 2019 charge. The third group had a history of non-criminal domestic encounters, but no criminal history with police, while the fourth group had a record of both criminal charges and non-criminal domestic encounters with police. Only 27 per cent of the men in this study had no previous interactions with police. These trajectories and typologies reveal discernible increases in criminal activity and domestic encounters with police culminating in domestic violence charges. This information can help to focus legislation, policies and practices which can lead to preventing domestic violence, thus improving on the current model in which police and community organizations often respond to domestic violence only after the fact. Increased police interactions prior to a criminal conviction involving domestic violence mean there is a point at which early intervention may prevent a criminal incident of domestic violence from happening. Interventions can include providing access to counselling and supports while making online resources accessible to men at risk of becoming perpetrators and who are struggling with their behaviour in their intimate relationships. Other prevention efforts could include school-based programs and targeting male-dominated workplaces with domestic violence prevention efforts in order to avert potential first offences. The approach to domestic violence must shift. The victims’ responsibility to keep themselves safe needs to be augmented by a focus on stopping the individuals who perpetuate harm. Our ongoing research agenda is investigating the extent to which police, government and policy-makers may be able to use information about the behaviours and trajectories of offenders to intervene proactively and so prevent incidents of domestic violence from happening.

Erythematous indurated plaques on the palate in a middle-aged adult.

A 45-year-old male presented with a 2-year history of erythematous indurated plaques on the right palate and adjacent palatobuccal mucosa, accompanied by dull pain and loosening of the third molar, necessitating extraction. Radiological imaging revealed soft tissue density with cortical bony erosions in the bilateral upper alveolar ridge. A single sub-centimetric right cervical lymph node was palpable. Biopsy showed an upper dermal infiltrate composed of cells with nuclear grooving and abundant eosinophilic cytoplasm. Through this case, we highlight a rare manifestation of a systemic disease.

Soft-tissue keratocyst: report of 3 new cases from Brazil.

To describe the clinicopathological features of 3 new cases of soft-tissue keratocyst (STK) of the buccal mucosa from Brazil. Clinical data from 3 patients diagnosed with STK were obtained from the archives of the Laboratory of Oral Pathology at the Federal University of Rio de Janeiro- Brazil from 2020 to 2023. Two oral pathologists reviewed conventional hematoxylin and eosin-stained slides of each case. Immunohistochemical stainings for CK19, Bcl-2, CD138, D2-40, EMA, and Ki-67 were performed in all cases. Case 1 was a 58-year-old man with a 2-year history of painless swelling of the right buccal mucosa, measuring approximately 5cm. Case 2 was of a 44-year-old man with a painful swelling in the left buccal mucosa lasting 3 years with drainage to the oral cavity. Case 3 was of a 74-year-old woman with a painful swelling in the left buccal mucosa of unknown duration. Microscopic evaluation of all 3 cases revealed a cyst lined with a few cell layers composed of columnar palisading basal cells and a corrugated parakeratin surface. The capsule comprised fibrous connective tissue with variable amounts of blood vessels with hemorrhage, nerve bundles, fat tissue, striated muscle fibers, and the absence of pilosebaceous units. No recurrence was observed after complete surgical removal. All epithelial layers of the 3 cases expressed positivity for CK19 and CD138, the basal cells were positive for Bcl-2 and D2-40, and the superficial epithelial layer was positive for EMA. All cases demonstrated a low proliferation index by Ki-67. This study represents a series of 3 cases of STK that affected the posterior buccal mucosa of middle-aged patients from Brazil, sharing histopathological and immunohistochemical features with odontogenic keratocyst.

Chronic appendicitis misdiagnosed as a periappendiceal orifice polyp: a case report

BackgroundUnlike acute appendicitis, chronic appendicitis is characterized by nonspecific abdominal pain and intermittent course. This may lead to late diagnosis or misdiagnosis, with the possibility of serious complications.Case reportA male patient of Arab origin aged 55 years had a 2-year history of recurrent episodes of mild pain in the right lower quadrant of the abdomen. The episodes were associated with nausea, chills, and abdominal bloating but no vomiting, rectal bleeding, or weight loss. On examination, the patient showed soft and lax abdomen with mild tenderness in the right lower quadrant, with no organomegaly or abdominal masses. Laboratory findings showed normal complete blood count and C-reactive protein. The patient underwent colonoscopy to rule out malignancy, which showed appendiceal orifice polyp that required resection. The computed tomography scan showed an enlarged appendix with multiple intraluminal dense appendicoliths. The largest stone at the appendiceal orifice measured 1.5 cm × 0.9 cm and was partially protruding within the cecal lumen. The diagnosis of chronic appendicitis was confirmed. The patient underwent appendectomy and was asymptomatic a few days after discharge.ConclusionsWe are reporting a patient with chronic appendicitis presented with multiple appendicoliths. The patient was initially misdiagnosed as periappendiceal orifice polyp. The current finding highlights the importance of imaging, especially computed tomography in confirming the diagnosis in patients with atypical appendicitis presentation.

Recurrent balanitis and oral blistering in a young man.

A 35-year-old veterinarian presented to the outpatient dermatology with a clinical history of recurrent blisters on genital skin and oral mucosa. Lesions had started three years previously over the glans penis with painful swelling, blistering and sloughing and a 2-year history of alternating activity/remitting diseases. Painless blisters had developed on his hard palate in the past year. Additionally, he has experienced painful eyes for 3 years.