Present Case Research Articles

A case of invasive Aspergillus niger spondylodiscitis with epidural abscess following COVID-19 infection in an immunocompromised host with literature review

Introduction and Importance: Aspergillosis is defined as an opportunistic infection that may spread hematogenously. COVID-19 infection has not been reported as a direct cause or risk factor. Its treatment (e.g. corticosteroids) significantly increases the risk for invasive infections. The respiratory system remains the main target, and the Aspergillus fumigatus is the most responsible subtype. Other species like Aspergillus (A) flavus, A. niger, and A. nidulans follow in frequency. Other included sites are the skeletal muscular system and the entire spine leading to spondylodiscitis. Only a total of 118 cases of Aspergillus spondylodiscitis have been reported in the literature, and only 21 cases reporting spinal epidural abscess were identified. Case Presentation: The authors report a new rare case of invasive A. Niger spondylodiscitis with epidural and iliopsoas abscesses in a 63-year-old North African female patient with a history of coronavirus infection (COVID-19) treated with high doses of corticosteroids. The patient had favorable medical and radiological outcomes after 6 months of antibiotic and antifungal therapy. Clinical Discussion: Fungal spondylodiscitis is a rare pathology that may be lethal. Immunosuppression plays a determining role. Discovertebral contamination results from hematogenous dissemination, found in the majority of cases in adults. The main symptom is segmental spinal pain, with an inflammatory pattern most often predominating in the thoracolumbar spine. Clinical signs of spinal cord compression, such as paresthesias, radiculalgia, and paraplegia, can sometimes be associated. Diagnosis of such spondylodiscitis is based on cultures and/or histology, whereas in most cases, it was made by MRI. Epidural abscess remains a rare entity. The authors will explore the current literature in more detail to dissect and explain this rare entity. Conclusion: Aspergillus spondylodiscitis remains a rare and very demanding clinical entity. Early diagnosis and well-targeted medical treatment seem the ideal solution given that this type of infection has a poor prognosis.

Rare presentation of huge ectopic ureterocele in an adult female: a case report

Introduction and importance: Ectopic ureteroceles are primarily found in children, often detected incidentally during antenatal ultrasonography or due to urinary tract infection (UTI) symptoms. However, they are rare in adults, with limited published cases. Case presentation: This report details a case of a 24-year-old woman who experienced recurrent UTIs and sudden urinary retention, ultimately needing manual compression to urinate due to poor urine flow. Intravenous urography revealed a large right ectopic ureterocele that protruded through the urethra during urination. Cystoscopy confirmed extensive right-sided ureteroceles affecting the bladder and causing her urinary difficulties. Clinical discussion: Although ectopic ureteroceles in adults can present with a range of symptoms, including obstruction and recurrent infections, the management approach is often individualized based on the clinical presentation and imaging findings. In this case, endoscopic incision was chosen for its minimally invasive nature, leading to full recovery without complications. Despite the risks of recurrence and potential scarring, the patient showed no recurrence at follow-up and remains symptom-free. Conclusion: This case underscores the rarity of symptomatic giant ectopic ureteroceles in adult females and highlights the importance of considering this condition in women with recurrent UTIs.

A young female’s battle with toxic epidermal necrolysis induced by NSAIDs: a case report

Introduction: Stevens-Johnson Syndrome (SJS) is a rare but severe mucocutaneous reaction often triggered by medications or infections, characterized by extensive epidermal detachment and mucosal involvement. This condition poses a high risk of morbidity and mortality, requiring prompt recognition and treatment. Case presentation: An 18-year-old Asian female from eastern Nepal presented with nonitchy red spots, high fever, and significant discomfort following the administration of ibuprofen for minor sores. She developed extensive skin involvement covering 25% of her body surface area and severe mucosal lesions. Laboratory investigations revealed anemia, leukocytosis, and coagulopathy. She was admitted to the ICU, where she received broad-spectrum antibiotics, corticosteroids, and supportive care. The patient also developed acute kidney injury during treatment but eventually recovered and was discharged after a week. Clinical discussion: The rapid onset of SJS in this patient reveals the unpredictable nature of drug-induced reactions. Early intervention with a multidisciplinary approach involving dermatology, intensive care, and infectious disease specialists was crucial in managing her condition. Despite the controversy surrounding corticosteroid use in SJS, their administration likely contributed to the rapid improvement in inflammation and skin healing. The case highlights the importance of early recognition, prompt management, and careful monitoring for adverse drug reactions, especially when prescribing medications known to cause SJS. Conclusion: The successful outcome achieved through a multidisciplinary approach provides valuable insights into the effective strategies for handling severe drug reactions, emphasizing that early diagnosis and comprehensive management in patients with SJS is critical.

Neurobrucellosis complicated with cerebral venous sinus thrombosis in a young Syrian male: a case report

Introduction and importance Neurobrucellosis occurs when Brucella affects the nervous system and it has several presentations. One of its rarest complications is cerebral venous sinus thrombosis (CVST). Case presentation: A 16-year-old male patient complaining of a sudden onset of bilateral pulsatile headache accompanied by fever, dizziness, nausea, vomiting, and blurred vision. On neurological examination the patient had neck stiffness and a bilateral 2nd degree papilledema. Brain computed tomography did not reveal any space-occupying lesions. Lumbar puncture showed an elevated lymphocyte count in the CSF and the Brucella PCR was positive. MRI with contrast and magnetic resonance venography revealed a left transverse sinus thrombosis and a diagnosis of neurobrucellosis complicated with CVST was made. Discussion: CVST is a rare but serious complication of neurobrucellosis, it has been described in only a handful of cases. The diagnosis mainly consists of establishing the presence of neurobrucellosis using the CSF analysis and the Brucella PCR, and proving the existence of CVST using the brain MRI. Although, the management of this complication remains a controversy, the use of an antibiotic combination and anticoagulation therapy may improve the symptoms greatly. Conclusion: Although Brucella seldom affects the nervous system, with CVST being an extremely rare complication. Physicians should consider brucella as the cause of CVST, in endemic areas. Usually, it is treated with a combination of antibiotics. However, anticoagulation should be considered in some cases and future studies must be conducted to assess the role of anticoagulation treatment.

Extra-skeletal Ewing sarcoma of the diaphragm in a young female: a case report

Introduction and importance: Extra-skeletal Ewing sarcoma (EES) belongs to the family of primitive neuroectodermal tumors (PNET) and arises from soft tissue, with only 30 cases reported in the literature until now. Early diagnosis is crucial, and the management requires a multidisciplinary approach for better patient outcomes and survival. Case presentation: A 20-year-old female presented to the surgical outpatient department with complaints of shortness of breath and right lower chest pain. Upon physical examination, a lipomatous lesion was observed. Ultrasound and CT scan showed a heterogeneously enhancing soft tissue mass in the right lower hemithorax causing erosion and osteolysis of the right 9th rib, involving intercostal muscles, and exerting mass effect on the underlying hemidiaphragm. Later USG-guided Tru-cut biopsy was performed to confirm the diagnosis, which reported Ewing sarcoma with CD 99, FL-1, and NKX 2.2 positive. En-bloc tumor resection along with a portion of the diaphragm was performed, and a tube thoracostomy was carried out. Chest wall reconstruction was done with mesh and a local muscle rotation flap cover. Adjuvant chemotherapy was initiated. Clinical discussion: EES often presents with vague symptoms such as shortness of breath or abdominal or chest pain, thus making the diagnosis even more difficult. However, it has a relatively poor prognosis and thus is an important differential to rule out. Conclusion: Extra-skeletal Ewing Sarcoma is a highly aggressive tumor that requires prompt diagnosis and treatment, with surgical resection being the first line of treatment. Adjuvant chemotherapy has also shown better outcomes.

The interplay of immunity and growth: a case of combined variable immunodeficiency and growth hormone deficiency

Introduction: Common variable immunodeficiency (CVID) is one of the more common immunodeficiencies seen in clinical practice with a complex disease pathology; while growth hormone deficiency (GHD) is a disorder characterized by complete or relative absence of the human growth hormone. Case presentation: This case report presents a 13-year-old female patient with a long history of recurrent respiratory tract and ear infections, along with a notable failure to hit her developmental milestones early in the second decade of her life. The diagnosis was based on a thorough investigation of serum immunoglobulins for CVID and a GH stimulation test for GHD. For these, the patient was placed on a tailored regimen of IVIGs, somatropin therapy, and antibiotics for the recurrent infections. Case discussion: CVID patients characteristically present with recurrent respiratory and ear infections, showing a marked decrease in immunity. Often diagnosed in childhood, GHD typically presents as growth failure along with developmental delays in dentition. There has been a notable rise in the coexistence of immunodeficiency syndromes and endocrinopathies studied in the past few decades. The case highlights and discusses the complex underlying pathology at play that links the two conditions to each other, while also excluding the various differentials. Conclusion: The report highlights the various challenges faced by both clinicians and patients when dealing with dual health conditions that may have a relatively nonspecific presentation. Some of which include the diagnostic difficulties, financial strains on the patient leading to poor follow-up, and in the long-term, the development of various complications. This emphasizes the importance of early disease diagnosis and strict management protocols for the said disease, for the overall betterment of the patient’s quality of life.

Post-intubation tracheal rupture treated surgically using a muscle graft from the Latissimus Dorsi: a rare disorder and review of literature

Introduction: Post-intubation tracheal rupture (PiTR) is an extremely uncommon disorder. Pneumothorax, pneumomediastinum, hemorrhage, cutaneous emphysema, and sepsis are common clinical presentations that eventually result in organ failure and mediastinitis. Endoscopy and computed tomography (CT) are considered the gold standards for assessment and diagnosis. Case presentation: Here, the authors present a 96-year-old woman with asthma and ischemic heart disease presented to the Emergency Department with dyspnea following viral pneumonia. Despite initial treatment, her condition worsened, requiring tracheal intubation. Subsequent complications led to a diagnosis of tracheal rupture, requiring surgical repair. The procedure involved using a muscle graft from the Latissimus Dorsi muscle: which is a novel Surgical Technique as the authors have conducted a literature review. Discussion: Upon scrutinizing analogous cases delineated within the medical literature, it becomes evident that our patient manifests four distinct risk factors. These factors include gender, advanced age, asthma, and prolonged steroid use. While the clinical manifestation and diagnostic methods for tracheal rupture are frequently consistent throughout cases, there is a significant variation in the surgical treatments used to treat the condition. Conclusion: More research should be conducted to investigate the use of muscle grafts as a treatment technique for tracheal rupture in the future.

Tuberculous meningitis leading to stroke: a case report

Introduction: Tuberculosis is a major public health issue in developing countries. Vasculitis, resulting from tubercular meningitis, can lead to stroke. Case presentation: A 33-year-old male presented to the Emergency Department with relapsing-remitting fever with an evening rise in temperature for 1 month, personality changes (aggression and mutism) for 2 weeks, followed by difficulty in moving his lower limbs, and bowel and bladder incontinence. Neck rigidity, a positive Kernig’s sign, bilateral mute plantar responses, and 0/5 power in bilateral lower limbs were noted on examinations. MRI of the brain was suggestive of tubercular meningitis and showed an infarct with hemorrhagic transformation in the relatively uncommon, right basifrontal lobe. Gene Xpert test done on cerebrospinal fluid confirmed the diagnosis. Discussion: Tuberculous meningitis leading to infarct is a challenging diagnosis due to nonspecific symptoms and variable cerebrospinal fluid AFB staining results. Radiological imaging with MRI helps in suggesting the diagnosis and Gene Xpert confirms the diagnosis. Antitubercular therapy, steroids, physiotherapy, and supportive care are part of management. Conclusion: This case highlights the importance of considering tubercular meningitis-related cerebral infarction despite initial negative CSF AFB stain. Radiological investigation may help in guiding the clinician towards a diagnosis of tuberculous meningitis with vasculitis.

Erysipelothrix rhusiopathiae-associated bloodstream infection in a patient with systemic lupus erythematosus: a case report and literature review

Introduction. Systemic human infections caused by Erysipelothrix rhusiopathiae have been increasingly reported especially within immunocompromised hosts and those with significant occupational exposure to livestock and aquatic animals. We report a case of E. rhusiopathiae bacteraemia in a patient with systemic lupus erythematosus (SLE) and present a literature review on clinical outcomes and microbiologic diagnosis for this organism. Case presentation. A 43-year-old female patient was reporting a 1-month history of intermittent fevers. She recently increased her immunosuppression medication for her underlying SLE on the advice of her rheumatologist. The patient sustained a finger laceration from butchering cattle meat 2 weeks after the onset of her initial symptoms, with worsening index finger swelling and increased febrile episodes. Two weeks post-injury, multiple blood cultures were drawn, and each isolated Gram-positive bacilli. Given her recurrent intermittent fevers, there was a concern for ongoing infection, and therefore, intravenous vancomycin was started with prompt referral to an outpatient parenteral antibiotic therapy clinic. The Gram-positive bacillus was confirmed as E. rhusiopathiae via matrix-assisted laser desorption/ionization-time of flight analysis. Given intrinsic resistance to vancomycin, vancomycin was switched to intravenous ceftriaxone as targeted antimicrobial therapy for 2 weeks. Reassuringly, there was no echocardiographic evidence of infective endocarditis, warranting the prolonged treatment course. Post-treatment, she remained symptom-free with the resolution of joint symptoms and fevers. Conclusion. Our report illustrates a case of E. rhusiopathiae bacteraemia from an immunodeficient host, with prompt microbiologic diagnosis and intervention with appropriate antimicrobial coverage. Literature reflects the rarity of this infection, predilections to specific susceptible hosts and the importance of raising awareness of zoonotic infections.

Epidural anesthesia as a sole anesthetic for a parturient with cardiac disease and low ejection fraction – a case report in resource limited setup

Introduction and importance: The effective care of pregnant women with cardiac conditions relies on collaboration among the obstetrician, cardiologist, and anesthesiologist throughout the peripartum period. Limited research exists regarding the safety of specific anesthetic approaches for patients with congestive heart failure (CHF), particularly in the context of pregnancy. Case presentation: This was a 28-year-old woman who was pregnant with her third child (gravida III, para II) and has not had a menstrual period for the past 8 months. She had been receiving antenatal care at a local health center. Currently, she was experiencing symptoms including coughing, difficulty breathing, epigastric pain, and chest pain, which had been present for 1 week. Upon examination, she was diagnosed with New York Heart Association class IV CHF with pulmonary edema, and preeclampsia with severe features, and she was in the third trimester of pregnancy. Clinical discussion: Pre-existing medical conditions can adversely affect pregnancy outcomes for women and their offspring, especially in resource-poor settings in Africa. The goals of anesthetic management are avoidance of myocardial depression, maintaining normovolemia, avoiding an overdose of drugs during induction as the circulation time is slow, and avoiding sudden hypotension when regional anesthesia is the choice. Conclusion: We believe that successful management of anesthesia for this critical case depends on a thorough understanding of the pathophysiology of the disease condition, the selection of anesthetic techniques, and the decision-making of our team. We showed epidural anesthesia could be safely used to manage high-risk cardiac patients, however, further interventional study is needed to prove safety.

First bipolar episode following booster dose of COVID-19 vaccination

Introduction and importance: The interactions between the susceptibility of the host and some of the COVID-19 vaccine components happened. Viral infections, including COVID-19, are related to the pathogenesis of bipolar disorder (BD). These findings could trigger an initial bipolar episode. Case presentation: A 48-year-old Syrian married female, presented to the out-clinic of Modern Medical Centre Hospital, in July 2022 for episodes of sub-maniac/mania episodes, which began within 15 days after the booster dose of COVID-19 vaccination, preceded by depressive mood. Both family and personal past psychiatric and/or trauma history were negatives. Initiation of carbamazepine 600 mg/day showed significant improvement within 3 days; 3 months later, carbamazepine dose was decreased to 200 mg/day, as there were no clinical symptoms. Clinical discussion: mRNA vaccines of COVID-19 increase the levels of type I interferon (INF), an inflammatory cytokine that creates a signal leading to the expression of interleukins, INF, and tumor necrosis factor-alpha. The pathology of BD is also unclear. Genetic predisposition, immunological effects, and the classification of BD, itself, as an autoimmune disease play a role. Although rapid improvement following treatment, prolonged and maintenance treatment by essentially mood stabilizer should be considered in bipolar episodes initiated by COVID-19 vaccination. Rare data are available about maniac episodes after COVID-19 infection, but to our knowledge, we reported the first case of bipolar onset after the booster vaccination of COVID-19. Conclusion: Bipolar disease can present following a booster dose of COVID-19 vaccination in previously healthy people.

Acute renal failure requiring renal replacement therapy secondary to rhabdomyolysis due to rosuvastatin

Introduction and importance: Statins are the group of medicines that lower the level of low-density lipoprotein cholesterol. One of the life-threatening complications is rhabdomyolysis as the use of these drugs. Case presentation: Here, we report a case of a 69-year-old female who was diagnosed with non-ST elevation myocardial infarction one month and was on regular medication before presentation with generalized weakness and decreased urine output. Proximal muscle weakness was greater than distal muscle on the bilateral lower limb, and power at the hip, knee, and ankle was 3/5 in the bilateral area, with absent reflex at the knee and ankle bilateral area. Clinical discussion: A total of four hemodialysis sessions were performed; the first three sessions were performed at an interval of 24 h, then the last maintenance hemodialysis after 48 h of three sessions. The patient’s weakness in the bilateral lower limb returns to normal condition. Conclusion: Physicians need to be aware of the potential of developing severe rhabdomyolysis in patients taking rosuvastatin to prevent morbidity, extended hospital stay, and financial loss.

A comorbidity of ulcerative colitis, ankylosing spondylitis, Takayasu’s arteritis and silent thyroiditis: an extensive case-based review

Introduction and importance: Ulcerative colitis is a chronic condition characterized by continuous inflammation of the rectum and colon. Its clinical complications extend beyond the gastrointestinal tract to involve multiple systems, including musculoskeletal, hepatobiliary, cardiovascular, and ocular manifestations. Takayasu arteritis and ankylosing spondylitis are two autoimmune inflammatory disorders that have previously been reported as coexisting conditions associated with ulcerative colitis. is an autoimmune-mediated inflammation of the thyroid gland causing the release of thyroid hormones and is considered a variant form of chronic autoimmune thyroiditis (Hashimoto’s thyroiditis). Case presentation: The authors report a case of a 32-year-old Caucasian man with a 3-year history of ulcerative colitis who presented to our clinic in 2015, complaining of chronic lower back pain that alleviates with exercise but does not relieve with rest. Based on our physical exam findings and lab results, ankylosing spondylitis was diagnosed using Assessment of Spondylarthritis International Society and New York criteria. Computerized tomography angiography was performed and demonstrated stenosis in multiple arteries. These findings satisfied the American College of Rheumatology criteria for Takayasu’s disease. After the Infliximab was started, the patient had significant symptomatic improvement. Clinical discussion: The use of biological therapy plays a key role in the treatment of many autoimmune illnesses. The patient was considered resistant and nonresponsive to treatment; thus, biological therapy was indicated, and infliximab was administered, resulting in a significant clinical improvement and remission of all illnesses. Conclusion: The authors aim to report a rare coexistence of ulcerative colitis, ankylosing spondylitis, Takayasu’s arteritis and silent thyroiditis. And the authors believe this can aid in diagnosing and management of rare diseases.

Ascaris in infected pancreatic pancreatic necrosum: a case report of an intraoperative surprise

Introduction and importance: Ascariasis lumbricoides is a common gastrointestinal tract helminthic disease in developing countries and is also a cause of hepatobiliary and pancreatic disease in endemic areas of the world. Involvement of the pancreatic duct by worms and associated pancreatitis is less common than the hepatic and biliary involvement. Case presentation: A 38-year-old patient was admitted with a diagnosis of alcohol-induced acute pancreatitis and managed conservatively. However, the patient’s condition worsened after 2 weeks, and a CT scan revealed an acute necrotic collection with gas foci. After failed percutaneous pigtail catheter drainage, laparotomy was performed, revealing a necrotic collection in the right paracolic gutter, with the entire area frozen and a worm observed in the necrosum. The colon and small bowel were intact without perforation. The suspicion arose that the worm might have either migrated from a duodenal perforation, which had possibly sealed after the acute phase, or migrated from the major pancreatic duct. Debridement of easily accessible necrotic tissues was performed, and the patient was admitted to the intensive care unit (ICU). Unfortunately, the patient tested positive for COVID-19, and a few days later, blood was observed in the drain. Re-exploration revealed diffuse blood oozing, and the abdomen was closed with packing. Conclusion: The route of ascaris migration to necrosum or its association with severe acute pancreatitis needs to be ensured in endemic areas. Cautious use of antihelminthic therapy in endemic areas could prevent fatal pancreatobiliary complications and its associated mortality.

Recurrent Wheezing in a Child: Unraveling Atypical Presentations of Cystic Fibrosis and Polymorphisms: A Case Report

Background: Cystic Fibrosis (CF), is the most common, life-limiting, single-gene disease affecting the Caucasian population, with a reported incidence of1/3500 births. It is inherited in an autosomal recessive fashion and its diagnosis is notably challenging, since in several cases CF may not be detected by the newborn screening test and the sweat test, which are frequently reported negative of with doubtful results, especially in cases with atypical symptoms at onset or with uncommon mutations or polymorphisms. Case Presentation: In this case, we present a case of CF presented with recurrent wheezing, reporting multiple negative or borderline sweat tests. The genetic evaluation revealed delta F508 (CF- causing) and heterozygous poly T5 polymorphism TG11 (TG)11T5. Conclusion: The importance of this case lies in the recognition of wheezing as a symptom and not as a disease, thus many conditions such as CF have to be considered in its diagnostic process. Finally, it is of utmost importance to bear in mind that many mutations or polymorphisms might evade newborn screening and sweat tests.

A survival case of high-dose amlodipine intoxication with non-cardiogenic pulmonary edema: a case report

Introduction: Dihydropyridines calcium channel blockers at high dose can have conduction abnormalities, reduced inotropism, and non-cardiogenic pulmonary oedema (NCPE) which otherwise, at standard dosage have only vascular selectivity. They remain one of the commonly used anti-hypertensive exhibiting very lethal outcomes (50% mortality rates) in its overdose. Case presentation: The authors present a case of a 21-year-old male with amlodipine intoxication with 43 tabs of 10 mg (total of 430 mg) ingestion manifested by loss of consciousness, hypotension, tachycardia, and respiratory distress. Discussion: An amlodipine overdose causes refractory hypotension due to vasodilation and impaired cardiac metabolism and contractility. Further amlodipine toxicity can result in NCPE that manifests clinically as respiratory distress and low oxygen levels due to lung injury caused by inflammation and increased vascular permeability. Conclusion: This case report emphasizes the significance of early recognition and prompt treatment of amlodipine intoxication, which can result in serious complications like fluid overload and respiratory distress.

A case report of labyrinthine infarction: a ‘central’ cause of vertigo with ‘peripheral’ presentation

Introduction and Importance: The inner ear is considered an ‘end organ’ since its vascular supply comes from one terminal artery, making the labyrinth especially vulnerable to ischemia, causing loss of auditory and vestibular function with variable clinical patterns according to the different arterial distribution in the inner ear and which vascular branches are concerned by the embolism. Case Presentation: We report a misleading case of central vascular vertigo caused by a labyrinthine infarction resulting from an embolic vertebral artery, which manifested in a typical peripheral clinical presentation mimicking a vestibular neuritis. Clinical Discussion: Vertigo is the result of asymmetrical responses from the vestibules of both ears resulting from any disruption along the complex vestibular pathways, whether peripheral or central. The recognition of the origin of an acute isolated vertigo is fundamental since the therapeutic strategy and prognosis differ, but it can be challenging in the absence of neurological signs, especially when the clinical pattern involves only the vestibular part of the labyrinth. Conclusion: The diagnosis strategy should consider the patient vascular risk factors and the clinical bedside tests with diffusion-weighted magnetic resonance imaging (MRI). Then, the management of these patients requires pluridisciplinary cooperation with early vestibular rehabilitation.

Domestic single-port robot-assisted laparoscopic surgery for pyelotomy combined with shockwave lithotripsy: the first case report

Introduction and Importance: Kidney stones are a common condition treated in urology departments and rank first among hospitalized patients. Staghorn kidney stones are a particular type of kidney stone that fill or occupy most of the renal collecting system. They have a large stone load and are often associated with recurrent urinary tract infections and chronic renal insufficiency. Case presentation: The authors report a case of single-port robot-assisted laparoscopic pyelotomy combined with EMS (Electromagnetic Shockwave Lithotripsy) for surgical stone removal, and discuss and analyze it based on published literature. A 75-year-old woman visited our hospital in January 2024 due to right waist pain and hematuria. Computed Tomography (CT) indicated a stone ~6.1×5.8×3.5 cm in the right renal pelvis and calyces. Staghorn kidney stones are challenging to remove surgically, have a low stone clearance rate, and are prone to recurrence, making them one of the most difficult issues in urological surgery. Combined treatment effectively reduces the number of skin-renal passages, decreases the occurrence of injuries and complications, and improves the success rate of lithotripsy and the stone-free rate. Therefore, the patient underwent single-port robot-assisted laparoscopic pyelotomy combined with EMS surgical lithotomy and was discharged 7 days after the operation. There were no complications postoperation, and follow-up showed that the stones were completely cleared without any residue. Clinical discussion: The treatment of staghorn kidney stones requires a comprehensive approach to reduce the number of skin-renal passages and the occurrence of complications. Single-port robot-assisted pyelotomy combined with EMS lithotripsy can ensure the effectiveness of the surgery while reducing risks and enhancing patient recovery. Conclusion: For staghorn kidney stones, single-port robot-assisted pyelotomy combined with EMS stone removal is a safe and effective procedure with a beautiful incision, fewer complications, and excellent patient outcomes.

Management of recurrent end-stage achalasia with robotic-assisted esophagectomy: a case report and literature review

Introduction and Importance: Achalasia, an uncommon esophageal motility disorder, presents therapeutic challenges, especially in refractory cases with a history of multiple surgeries. Here, we present a complex case illustrating the dilemmas and multidisciplinary approach required in managing such patients. This case underscores the relevance of newer techniques like robotic-assisted esophagectomy in refractory achalasia management. Case Presentation: A 53-year-old male with recurrent achalasia endured persistent dysphagia, reflux, and esophageal spasms despite undergoing Heller myotomies, fundoplications, and hiatal hernia repairs. Imaging revealed severe esophageal dilation and anatomical alterations post-surgeries. Opting for a robotic-assisted thoracoabdominal esophagectomy due to relentless symptoms, the patient faced technical hurdles due to adhesions and a dilated esophagus. Post-surgery, complications like thoracic duct injury, milky pleural effusion, atrial fibrillation, and limb ischemia arose, necessitating multidisciplinary intervention. Clinical discussion: Managing refractory achalasia poses significant challenges, particularly in extensively operated patients. Despite aggressive surgeries, debilitating symptoms persisted, emphasizing the need for a multidisciplinary approach. Complications like thoracic duct injury and atrial fibrillation further complicate management, highlighting the intricacies of such cases. Careful consideration of surgical options and the potential of newer techniques like POEM are crucial in navigating such complexities. Conclusion: Managing refractory achalasia, especially in patients with extensive surgical histories, requires a multidisciplinary approach and careful consideration of treatment options. This case underscores the evolving landscape of achalasia management and emphasizes the potential benefits of newer techniques like POEM in select cases.

Integrated psychiatric and surgical care in managing self-inflicted abdominal trauma: a case report in a resource-limited setting

Introduction and importance: Self-inflicted abdominal stab wounds present rare yet critical challenges requiring urgent surgical intervention and comprehensive psychiatric evaluation. Such injuries often correlate with psychiatric disorders like schizophrenia and alcohol dependence, posing significant clinical and psychological management hurdles. Case presentation: A 36-year-old male with a history of chronic alcohol use and schizophrenia presented with a self-inflicted stab wound to the abdomen following auditory hallucinations. Upon admission, he was hemodynamically unstable, with eviscerated bowel loops and a lacerated greater omentum. Prompt surgical exploration revealed extensive abdominal trauma necessitating meticulous repair and intensive postoperative care. Clinical discussion: The case highlights the intricate interplay between severe psychiatric illness and self-harm, exacerbated by alcohol intoxication. Integrated psychiatric and surgical care proved pivotal in achieving stabilization and facilitating recovery. The challenges encountered in a resource-limited setting included a lack of advanced imaging modalities, limited access to specialized psychiatric care, and constraints in postoperative monitoring equipment, underscoring the importance of adaptive management strategies. Conclusion: This report emphasizes the critical need for a multidisciplinary approach in managing self-inflicted abdominal injuries. The successful outcome underscores the efficacy of timely surgical intervention and comprehensive psychiatric support. Integrated care models are essential for addressing the complex needs of patients with psychiatric comorbidities, ensuring holistic management, and reducing the risk of recurrence in similar cases.