Diagnostic Difficulties Research Articles

Evaluation of dyspepsia symptom severity in pediatric patients: association with endoscopic and pathological findings

Aims: There is diagnostic difficulty in distinguishing between organic and functional causes of dyspepsia, which is characterized by a variety of gastrointestinal symptoms. This study aimed to evaluate the correlation between dyspeptic complaints, clinical symptoms, endoscopic findings, and pathology results in pediatric patients. Methods: A total of 159 children aged 8-17 years with dyspeptic complaints underwent upper gastrointestinal endoscopy (UGE). The Dyspepsia Symptom Severity Index (DSSI), comprising three parts (dysmotility-like, reflux-like, and ulcer-like symptoms) and 19 questions, was used to assess symptom severity. Endoscopic procedures were performed under general anesthesia, and biopsy samples were obtained. Results: The study included 159 patients with a median age of 15 years (ranging from 8 to 17 years). Among them, 29.1% were male (38) and 76.9% were female (121). DSSI scores were calculated for each subgroup and the total score. When assessing the relationship between chronic diseases and DSSI scores, no significant association was found (p=0.48). However, smoking showed a significant correlation with DSSI scores (p=0.01 for dysmotility-like, p=0.02 for reflux-like, and p<0.01 for ulcer-like symptoms). Gender differences were observed in DSSI scores, with girls exhibiting significantly higher median scores for dysmotility-like findings compared to boys (p=0.02). Endoscopy findings also correlated with DSSI scores, with significantly higher scores in patients with ulcers (p<0.01). Pathological findings such as esophagitis were found to have significant associations with reflux-like symptoms (p=0.04), and crypt hyperplasia was associated with ulcer-like symptoms (p=0.04) in patients with DSSI subgroup scores. However, no significant differences were found between pathology findings and dyspepsia severity, significant associations were observed between UGE findings (such as ulcers, pangastritis, erosional areas, and fragility) and ulcer-like symptoms. Conclusion: The study found significant links between dyspepsia severity and endoscopic results, stressing the need for reliable symptom scales for pediatric patients. It also highlights smoking as a factor in dyspepsia severity in children. Further research is needed to evaluate endoscopy's effectiveness in distinguishing between organic and functional dyspepsia. The study points out the limited understanding and consensus on diagnosing and managing dyspepsia in children, calling for the development of validated symptom scales and further research into cost-effective management strategies.

Diagnostic Difficulty in a Girl With Anti–Signal Recognition Particle Myopathy With a Slow Progressive Course

Diagnostic Difficulty in a Girl With Anti–Signal Recognition Particle Myopathy With a Slow Progressive Course

Infective endocarditis in injection drug users: disease course, diagnostic and clinical aspects (clinical case analysis)

Aim. To present and clinically analyze a case of “injection drug users” infective endocarditis (IE) to increase awareness among general practitioners and cardiologists about this special variant of IE.Materials and methods. Clinical observation of a 39-year-old female patient with long-term heroin and methadone addiction, viral hepatitis C, who was diagnosed with acute primary IE caused by methicillin-sensitive Staphylococcus aureus localized on the tricuspid and mitral valves. Bilateral septic pulmonary embolism and respiratory failure, secondary anemia, thrombocytopenia, nephrotic syndrome due to secondary glomerulonephritis were observed. On the 21st day of treatment, the patient underwent tricuspid valve replacement surgery with a biological prosthesis and multicomponent reconstruction of the mitral valve, the postoperative period was complicated by the development of exudative pericarditis.Results. The clinical picture and the course of a complex case of “injection drug users” IE are discussed. The difficulties of early diagnostics of IE caused by the absence of pathognomonic clinical manifestations of the disease and the variability of the debuts of IE with the prevalence of extracardiac manifestations is highlighted. The principles of antibacterial therapy and indications for surgical treatment are reviewed.Conclusion. Clinical observation draws the attention to the high probability of diagnosing IE in cases of fever in intravenous drug users and demonstrates both the difficulties of treatment and the possibility of a favorable outcome of this serious disease with timely diagnosis, appropriate antibacterial therapy, and early cardiac surgery.

Challenges in the Cytodiagnosis of Intraparotid Schwannoma.

Clear cell tumors of parotid gland encompass a wide spectrum of neoplasms, including benign and malignant epithelial neoplasms. Additionally, tumors from adjacent structures such as paraganglioma, and metastatic neoplasms may also show clear cells. Overlapping cytological features may cause difficulty in diagnosis. This 50-year-old female presented with inability to close the right eye for 4 years, and with an infra-auricular swelling. Fine-needle aspiration cytology (FNAC) done outside was submitted for review with a diagnosis of neuroendocrine tumor. Smears showed clusters of tumor cells with abundant vacuolated cytoplasm and uniform round to ovoid nuclei. Features were those of salivary gland neoplasm of uncertain malignant potential, that is Milan category IVB: cellular neoplasm with clear cell features, with differential diagnoses of myoepithelial cell neoplasms, acinic cell carcinoma and paraganglioma. FNAC repeated for better characterization showed similar polygonal cells, accompanied by few spindle-shaped cells with ovoid nuclei, suggestive of paraganglioma. However, DOTANOC uptake was absent. Patient underwent radical parotidectomy; intraoperative frozen section showed a spindle cell tumor. Final histopathology revealed an intraparotid facial nerve schwannoma. The tumor was multi-nodular, with some nodules being composed almost entirely of polygonal cells with clear cytoplasm, that is, Antoni B areas, and others showing typical Antoni A areas admixed with Antoni B areas. Parotid FNAC has high accuracy for diagnosis of epithelial lesions; however, mesenchymal tumors often pose a diagnostic difficulty. Intraparotid schwannoma is not uncommon and may be diagnosed easily on FNAC when morphology is classical. However, intra-tumoral heterogeneity and less common histological subtypes may present a pitfall in cytodiagnosis.

Diffuse idiopathic skeletal hyperostosis was the specific risk factors of methicillin-susceptible Staphylococcus aureus spine infection: a retrospective study in a single center.

To investigate how risk factors and reduced spinal mobility contribute to spinal infections arising from methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, known for increased mortality and diagnostic difficulties, especially in patients with septic shock or coma. This retrospective study divided MSSA bacteremia patients into three groups: spinal infections (Group A, n=14), non-spinal/implant infections (Group B, n=24), and implant-related infections (Group C, n=21). Analyses focused on demographics, medical history, laboratory inflammatory markers at antibiotic initiation, and spinal pathologies detected by CT. All results of the statistical analyses were significant at P<0.05. We employed multinomial univariable logistic regression and contingency table analysis to assess risk factors across three groups. Subsequently, binomial multivariable logistic regression was used to compare Group A against Groups B and C, successfully identifying significant predictors of spinal infection. A lower incidence of diabetes (p=0.029), higher C-reactive protein (CRP) levels at onset (p=0.014), and the presence of diffuse idiopathic skeletal hyperostosis (diffuse idiopathic skeletal hyperostosis (DISH); p=0.022) were significantly associated with spinal infections in Group A. Furthermore, binomial analysis revealed DISH (Odds Ratio (OR) = 41.750; 95% Confidence Interval (CI) [1.86-939.0]; p=0.019), absence of diabetes (OR = 1.20, CI [1.01-1.43], p=0.038), elevated CRP (OR = 23.34, CI [1.13-483.4], p=0.042), and a lower day 3/day 1 white blood cell (WBC) ratio (OR = 0.964, CI [0.93-1.00], p=0.047) as risk factors when compared with other groups. Spinal infection patients with MSSA bacteremia are less likely to have diabetes and more likely to have higher initial CRP levels and DISH. Notably, DISH might be emerging as a distinctive risk factor for spinal infection, underscoring its potential as a marker for clinical awareness.

Radiological features of the carpometacarpal joint in hamate body fracture on anteroposterior hand X-ray image

BackgroundHamate body fractures are rare and can be overlooked due to the diagnostic difficulty on X-ray. We focused on the carpometacarpal joint space width (CMC-JSW) and examined the features of this fracture on versatile anteroposterior hand X-ray images, initially taken for hand trauma cases. MethodsTen patients (nine males and one female; mean age, 34 years) diagnosed with a hamate body fracture on CT in our facility between January 2013 and October 2023 were included in this study. The fracture types were dorsal type in six cases and shear type in four cases. The 4th and 5th CMC-JSWs were measured on anteroposterior hand radiography and CT sagittal sections. If the metacarpal and hamate bones appeared to overlap due to depression, the width was expressed as a negative value (overlap sign). CMC-JSWs were compared between the types or unaffected sides using the Mann–Whitney U test. The correlation with X-ray and CT measurements was analyzed using the Spearman test. ResultsThe average CMC-JSWs (IV: −0.52 mm, V: −1.33 mm) in hamate body fractures on X-ray were minus and these values were significantly lower than unaffected side (IV: 1.51 mm, V: 1.48 mm) (p < 0.05, p < 0.001). CMC-JSW (IV: −1.64 mm) and CMC-JSW (V: −2.70 mm) of dorsal type were significantly lower than shear type (IV: 1.17 mm, V: 0.72 mm) (p < 0.05). CMC-JSW values on X-ray were positively correlated with those on CT (IV: ρ = 0.796, V: ρ = 0927). ConclusionsDecreased CMC-JSW, correlated with CT sagittal sections, and “overlap sign” on anteroposterior hand X-ray were possible radiological characteristics of hamate body fracture. Care should be taken to avoid overlooking shear-type fractures because of subtle CMC-JSW decreases.

Exploring the Intricacies of Encephalocele Case in Pregnancy: Unraveling Risk Factors, Diagnostic Difficulty, and Implications for Maternal and Fetal Health

Introduction: Encephaloceles are a type of neural tube defect that carries a significant risk of death and health complications. Ultrasonography can be utilized for the early detection of encephaloceles starting from 11 weeks of gestation. This case report describes the diagnosis of an occipital encephalocele using ultrasonography during the third trimester of pregnancy and the subsequent monitoring of the condition until delivery. This report serves as a reminder of the potential implications and the importance of ongoing research in prenatal diagnosis of encephalocele to improve diagnostic and therapeutic strategies.Case Report: A 23-year-old woman, gravida 2, para 1 (G1P0A0), presented with lower abdominal pain without uterine contractions at 38 weeks of pregnancy, was consulted in the Department of Obstetrics and Gynecology of Slamet General District Hospital. She did nine antenatal visits; and three were performed through ultrasonography by a general practitioner. The occipital posterior defect was visualized with protruding mass consistent with an encephalocele during the third trimester when she was admitted to Slamet General Hospital Garut. A baby born by cesarean section with an encephalocele died three hours later.Discussion: Encephaloceles can be detected using two-dimensional (2D) and three-dimensional (3D) sonography as early as 11 weeks; however, most instances are typically diagnosed during the second trimester. Using advanced imaging technology and skilled sonographers, an encephalocele can be diagnosed at 14 weeks.Conclusion: Prenatal screening through ultrasonography and other advanced imaging techniques plays a significant role in identifying encephalocele prenatally. Understanding potential risk factors, including genetic predispositions and environmental influences, is important to better counsel patients on preventive strategies.Eksplorasi Kasus Kehamilan dengan Ensefalokel : Faktor Risiko, Kesulitan Diagnostik, dan Implikasi untuk Kesehatan Ibu dan JaninAbstrakPendahuluan: Ensefalokel adalah jenis cacat tabung saraf yang membawa risiko kematian dan komplikasi kesehatan yang signifikan. Ultrasonografi dapat digunakan untuk deteksi dini ensefalokel mulai dari usia kehamilan 11 minggu. Laporan kasus ini menjelaskan diagnosis ensefalokel oksipital menggunakan ultrasonografi selama trimester ketiga kehamilan, dan pemantauan kondisi selanjutnya hingga persalinan. Laporan ini menjadi pengingat pada implikasi potensial dan pentingnya penelitian yang sedang berlangsung dalam diagnosis ensefalokel prenatal untuk meningkatkan strategi diagnostik dan terapeutik.Laporan Kasus: Seorang wanita berusia 23 tahun, gravida 2, para 1 (G1P0A0), datang dengan keluhan nyeri perut bagian bawah tanpa kontraksi uterus pada usia kehamilan 38 minggu ke Departemen Obstetri dan Ginekologi di RSUD Slamet Garut. Pasien telah menjalani sembilan kali perawatan antenatal, tiga di antaranya dilakukan dengan ultrasonografi oleh dokter umum. Defek posterior oksipital divisualisasikan dengan massa yang menonjol konsisten dengan encephalocele pada trimester ketiga ketika admisi di RSUD Slamet Garut. Bayi lahir melalui operasi seksio sesarea dengan klinis encephalocele lalu meninggal tiga jam kemudian.Diskusi: Encephalocele dapat dideteksi dengan sonografi dua dimensi (2D) dan tiga dimensi (3D) sejak usia 11 minggu, namun sebagian besar kasus biasanya didiagnosis selama trimester kedua. Encephalocele dapat didiagnosis pada usia 14 minggu menggunakan teknologi ultrasonografi, tetapi deteksinya didasarkan oleh kemampuan operator. Kesimpulan: Skrining prenatal melalui ultrasonografi dan teknik pencitraan canggih lainnya memainkan peran penting dalam mengidentifikasi ensefalokel prenatal. Memahami faktor risiko potensial, termasuk faktor genetik dan lingkungan adalah penting untuk memberikan konseling yang lebih baik kepada pasien tentang strategi pencegahan.Kata kunci: Counseling, Diagnosis, Occipital Encephalocele, Risk Factors

Chronic Sarcoidosis: Diagnostic Difficulties and Search for New Criteria of Inflammatory Activity (A Case Report and Literature Review).

Sarcoidosis is a systemic inflammatory disease with an unknown etiology and a wide range of clinical manifestations. The incidence of sarcoidosis ranges from approximately 1 to 15 cases per 100,000 individuals per year worldwide. The significant variability in clinical presentations and target organs, as well as concomitant diseases, greatly complicates diagnosis. We analyzed articles in PubMed, Scopus, Cochrane Library, and Embase, where databases were searched using the keywords "chronic sarcoidosis", "diagnosis of sarcoidosis", "course of sarcoidosis", "pulmonary sarcoidosis", "cardiac sarcoidosis", "skin sarcoidosis", "neurosarcoidosis", "ocular sarcoidosis", and "autoimmune inflammation". Studies on the course and diagnosis of sarcoidosis with a deep search of ten years were included. In this review, we present an analysis of publications on the course and diagnosis of chronic sarcoidosis, as well as a clinical case. We have noted that the diagnosis of chronic sarcoidosis is particularly difficult due to the lack of specific biomarkers or their combination. The development and introduction of new diagnostic criteria for this disease will contribute to increasing the level of efficiency, not only of the diagnostic complex, but also the prognosis of the development and course of the pathological process. Conclusion: For the most accurate diagnosis and determination of prognosis, the existence of a single immunological or imaging marker with sufficient sensitivity and specificity is necessary.

Foreign body aspiration through the eyes of a pediatric pulmonologist: Is it possible to reduce the rate of negative rigid bronchoscopies?

Identifying a foreign body aspiration (FBA) still remains a diagnostic difficulty. Moreover, the indications for bronchoscopy in subjects of suspected foreign bodies are not clear. The aim of this study was to evaluate the effectiveness of pediatric pulmonologists in diagnosing FBA. This was a retrospective, single-center study on children who underwent rigid bronchoscopy for suspected FBA. Data on the patients were obtained from the medical records. Patients who had foreign bodies (FB) identified during rigid bronchoscopy were classified as FB positive, and those in whom rigid bronchoscopy did not detect FB were defined as FB negative. Demographic data as well as consultation status with a pediatric pulmonologist were compared between these two groups. Furthermore, the patients were categorized into three groups based on their clinical scores that assessed the likelihood of the presence of FB: low risk, moderate risk, and high risk. Out of 474 rigid bronchoscopies, 232 (48.9%) detected FB. Consultation by a pediatric pulmonologist was not requested in 388 (81.8%). Out of these 388 patients, 206 (53%) were negative for FB. In terms of FB detection success, there was no difference between individuals who sought pulmonology consultation and those who did not (58.1% vs. 53.1% respectively, p=0.059). However, when the children were categorized based on their risk levels, the incidence of detecting FB among children in low-risk group was 42% when they received consultation from the pulmonology department, whereas this incidence dropped to 5.6% when pulmonology consultation was not sought (p<0.001). Consulting a pediatric pulmonologist, particularly for low-risk individuals, might reduce the likelihood of performing unnecessary bronchoscopies. Given that rigid bronchoscopy is an intrusive technique, it is crucial to reduce the number of negative bronchoscopies in order to mitigate complications associated with it.

POSSIBLE ERRORS IN THE DIAGNOSIS OF INTRAOCULAR TUMORS

Rationale: The article discusses difficulties in the differential diagnosis of intraocular tumors (IOT), particularly in cases of small choroidal melanoma. Despite a substantial number of publications dedicated to the diagnosis of intraocular tumors, difficulties in interpreting imaging methods, such as optical coherence tomography (OCT), persist.Objective: to analyze the OCT patterns that have led to diagnostic errors.Methods: We analyzed the OCT results of 15 patients whose diagnosis of «choroidal hemangioma» was revised to «choroidal melanoma» in 11 cases or «progressive nevus» in 4 cases. The mean age at the time of IOT detection was 50.20±13.08 years (range: 35–79 years); the average tumor prominence was 2.22±0.82 mm (range: 1-3.6 mm), and the average diameter was 8.01±2.72 mm (range: 3.11–11.5 mm). A detailed analysis of the specific OCT patterns that led to diagnostic errors was conducted.Results and discussion: The characteristics of the identified OCT patterns that frequently caused diagnostic difficulties were thoroughly examined, such as cystic changes and the «subretinal cleft» phenomenon. Cases in which complex OCT patterns overlapped with both melanoma and hemangioma were also analyzed, reinforcing the need for a multimodal approach to the interpretation of imaging data. Conclusion: for accurate diagnosis and to avoid erroneous planning of treatment strategies, OCT should be evaluated within the context of the clinical picture and patient history.

RADT-23. MOLECULAR PROFILING OF GLIOMAS: INSIGHTS INTO RADIONECROSIS AND PSEUDOPROGRESSION THROUGH NEXT-GENERATION SEQUENCING

Abstract BACKGROUND Gliomas, the most common primary tumors of the CNS, presenting diagnostic and therapeutic challenges due to their heterogeneity. Next-generation sequencing (NGS) enhances diagnostic precision by identifying genetic alterations, guiding accurate diagnosis and personalized treatment strategies. Post-treatment complications such as radionecrosis and pseudoprogression present additional diagnostic difficulties, often mimicking tumor recurrence. This study aimed to evaluate the association between genetic alterations detected by NGS and treatment-related complications. METHODS This retrospective study analyzed data from electronic medical records at a Brazilian Radiation Therapy Department (2018-2023). The study included patients with gliomas who underwent surgical resection followed by adjuvant radiochemotherapy and subsequently developed complications such as radionecrosis and pseudoprogression. Genetic alterations detected by the HSL 500 (NGS) test were evaluated for their association with these complications using Fisher’s Exact Test. RESULTS Out of 192 patients treated for glioma, 46 (23.96%) experienced treatment-related complications, with 20 patients having available NGS test results. Among these, eight cases were identified as pseudoprogression, fifteen as radionecrosis, with three patients presenting both conditions. All 20 patients with NGS results were diagnosed with high-grade gliomas, eight of whom underwent reirradiation, resulting in two cases of radionecrosis post-reirradiation. Although no statistically significant association was found between genetic alterations and radionecrosis or pseudoprogression, specific mutations were prevalent in each group. In radionecrosis cases, the most common mutations were TERT promoter (c.1-124C&amp;gt;T) (n=9, p=0.613) and EGFR amplification (n=8, p=1.0). In pseudoprogression, frequent mutations included TERT promoter (c.1-124C&amp;gt;T) (n=6, p=0.642), EGFR (n=5, p=0.67), PTEN (n=4, p=1.0), NF1 (n=2, p=0.537), and P53 (n=2, p=0.197). CONCLUSION Molecular testing for glioma characterization is crucial for diagnosis and prognosis, aiding in understanding treatment-related complications. Strategies to avoid radionecrosis and pseudoprogression are vital to improve patient quality of life, especially in high-grade gliomas. Further studies are needed to confirm these trends and explore clinical relevance of mutations.

UTERINE SAROMAS Retrospective Studies on 7 Cases at the Hassan II University Hospital in Fez

Introduction: Uterine sarcomas are rare tumors, representing less than 3% of malignant tumors of the female genital tract and between 3 and 7% of malignant tumors of the uterine body. They are a heterogeneous group of tumors comprising different histological subtypes, but with a generally identical evolutionary profile. Unlike uterine epithelial tumors, and apart from low-grade endometrial stromal sarcomas, uterine sarcomas have a poor prognosis. They have a high rate of recurrence (between 50 and 70%), local and especially metastatic (in approximately 70% of cases). The objective of our work is to specify the epidemiological characteristics of uterine sarcomas, the diagnostic difficulties faced by practitioners at the clinical, radiological and anatomopathological stages, the modalities of management as well as the different determinants of the prognosis of these rare tumors. Patients And Methods: Seven cases of uterine sarcomas treated in the gynecology - obstetrics II department at the Hassan II University Hospital in Fez between 2019 and 2023 were analyzed retrospectively. Results: The average age of our patients varies between 50 and 75 years with an average of 62.2 years. Of the 7 patients, 90% are multiparous, 100% menopausal. 78% of our patients consulted for metrorrhagia. On the paraclinical level, we performed a pelvic ultrasound for all patients, 80% of the results of which were in favor of an enlarged uterus with a heterogeneous echogenic intracavitary image, hysteroscopy in 04 patients for exploration of postmenopausal metrorrhagia and magnetic resonance imaging in 06 patients. The diagnosis was made at the preoperative stage in five patients. 71% of our patients benefited from surgical treatment. The anatomopathological analysis of the surgical specimens showed that 05, 07 patients benefited from adjuvant radiotherapy, while a combined chemotherapy/radiotherapy postoperatively was indicated in 02 patients. One patient presented a recurrence having ...

Renal Epithelioid Angiomyolipoma: Diagnostic and Therapeutic Difficulty!

Renal Epithelioid Angiomyolipoma: Diagnostic and Therapeutic Difficulty!

Patchy Dermal Melanocytosis: Differential Diagnosis and Management.

Nevus of Ito and Mongolian spots are distinct clinical presentations of patchy dermal melanocytosis, characterized by similar dermatological manifestations that can pose diagnostic difficulties for clinicians. This review aims to consolidate current understanding and research advancements on these conditions to facilitate clinical diagnosis, differential diagnosis, and management. A comprehensive search of databases including PubMed and Google Scholar was conducted, along with an analysis of pertinent literature retrieved from reference lists spanning nearly four decades. Epidemiological, clinical, and pathological profiles exhibit nuanced differences between the two conditions, with unique expressions under electron microscopy and the regression possibility. It is noteworthy that most Mongolian spots naturally fade with advancing age, in contrast to nevus of Ito, which persist and may potentially evolve into malignant lesions. While picosecond laser treatment has shown greater efficacy than nanosecond lasers, the lower-energy approach holds particular promise in pediatric cases. The therapeutic landscape for patchy dermal melanocytosis is evolving, shifting from selective photothermal action to photomechanical or subcellular photothermal modalities. This review underscores the importance of meticulous clinical assessment and the potential of innovative therapeutic approaches in managing these conditions.

The incidence, providers involved, and patient factors associated with diagnosis of specific lumbar spine pathology subsequent an initial nonspecific low back pain diagnosis

Background ContextLow back pain (LBP) is an exceedingly common diagnosis with significant societal and healthcare burden. While nonspecific LBP diagnoses are frequently assigned and often resolve soon thereafter, some patients may subsequently be diagnosed with specific underlying lumbar spine pathology. PurposeTo characterize the incidence, providers involved, and factors associated with specific pathology LBP (SP-LBP) diagnosed subsequent an initial nonspecific LBP (NS-LBP) diagnosis. Study DesignRetrospective cohort study. Patient SampleAdult patients diagnosed with NS-LBP between 2010 – Q1 2022 were abstracted from a large national administrative database. Outcome MeasurementsIncidence of subsequent SP-LBP diagnoses, providers involved, and factors associated with SP-LBP diagnoses in the 12-months following initial NS-LBP diagnosis. MethodsAdult patients diagnosed with NS-LBP were identified based on International Classification of Disease (ICD) codes ICD-9-D-724.2 and ICD-10-D-M54.5. These patients diagnosed with new NS-LBP were reported based on incidence per 100,000 covered lives. Exclusion criteria included: patients less than 18 years old, those with any prior NS-LBP diagnosis, any prior SP-LBP diagnoses, and those with trauma, neoplasm, or infection diagnosed within 3-months prior to the initial NS-LBP diagnosis. Patients who subsequently received SP-LBP diagnoses within 12-months following initial NS-LBP were then identified. Patients were characterized based on age, sex, history of cancer, obesity, opioid use disorder, anxiety, and depression and then compared with patients receiving no additional LBP diagnosis by univariable and multivariable analysis. Provider specialties who initially diagnosed NS-LBP and those involved with subsequent SP-LBP diagnoses were identified. ResultsNS-LBP was identified for a robust cohort of 6,861,235 patients, yielding an incidence of 4,258 diagnoses per 100,000 covered lives. Subsequent SP-LBP diagnoses were identified for 562,982 (8.21%) within 12-months, of which 62.57% of these SP-LBP diagnoses occurred within 3-months. The most common of these subsequent diagnoses included radiculopathy (3.01% of the overall study population), disc degeneration (2.84%), and disc herniation (1.23%). Patients receiving a subsequent SP-LBP diagnosis were more likely older (per year increase, odds ratio [OR] 1.02), male (OR 1.10), had a history of cancer (OR 1.32), obesity (OR 1.30), opioid use disorder (OR 1.17), anxiety (OR 1.21), or depression (OR 1.17) (p<0.001 for all). NS-LBP was initially diagnosed predominantly by primary care providers (PCPs) in family medicine (44.09%) and internal medicine (27.49%). These PCP providers also contributed to the majority of SP-LBP diagnoses, while specialty providers contributed to a greater degree in SP-LBP diagnoses than NS-LBP. ConclusionNS-LBP is a common diagnosis that usually, 91.79% of the time, does not subsequently convert to a SP-LBP diagnosis within 12-months. This may reflect improvement of LBP symptoms and/or accurate initial triage, largely by PCPs. Of the minority of patients receiving a subsequent SP-LBP diagnosis, various patient factors were significantly associated, and a greater degree of specialty providers were involved, which highlights potential contributors to diagnostic difficulty of SP-LBP and the multidisciplinary nature of LBP management.

Sump syndrome: Diagnosis dilemmas and therapeutic approaches-A case series.

It is important to consider the diagnosis of Sump syndrome in patients with a history of open cholecystectomy, particularly in those who migrate from developing countries where alternative biliary interventions may be limited. The presentation may range from acute severe, mimicking acute ascending cholangitis, to chronic recurrent abdominal pain without evidence of inflammation. Management is a case-by-case decision, with principal management aims to decompress the biliary tract and address any underlying sepsis. Sump syndrome is a rare and often long-term complication of choledochoduodenostomy (CDD). The presentation and severity are variable, and management should be tailored to each patient based on several factors. Herein, we report three cases of sump syndrome, each demonstrating unique diagnostic dilemmas and therapeutic modalities. Case I describes a woman presenting with acute cholangitis, managed with percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). Case II illustrates a similar presentation complicated by myocardial infarction, necessitating urgent biliary decompression via PTC and subsequent unsuccessful endoscopic stenting. Case III highlights the diagnostic difficulty in a stable patient with inconclusive diagnostic imaging. This case series emphasizes the importance of considering sump syndrome diagnosis in patients with a history of CDD or open cholecystectomy, especially in elderly patients and those who come from regions where alternative biliary interventions may be limited.

Antepartum Wernicke’s Encephalopathy: Common, and Yet Rarely Diagnosed. Discussion on the Disease and Its Treatment

This review article presents a comprehensive discussion on antepartum Wernicke’s encephalopathy (WE), a serious neurological disorder. This disorder stems from thiamine (Vitamin B1) deficiency, which is critical for normal metabolism and neuronal integrity. During pregnancy, women are more susceptible to this condition due to increased nutritional requirement and metabolic changes. In WE, inadequate thiamine (Vitamin B1) causes disruption of metabolism in cells and impedes neurotransmitter synthesis in the brain, ultimately causing adverse neural consequences. Key risk factors contributing to antepartum WE include conditions that hinder thiamine absorption or increase metabolic demand, such as hyperemesis gravidarum (intense antepartum vomiting), malnutrition, alcoholism, and post-bariatric surgery states. WE's classic triad of symptoms, confusion, ataxia (loss of balance and coordination), and ophthalmoplegia (occlumotor incoordination), are not commonly seen in antepartum WE. Therefore, diagnosing the disorder in pregnancy is challenging and the condition is often misdiagnosed. Pregnancy symptoms like nausea, vomiting, and fatigue often overlap with WE's presentation, complicating diagnosis and confounding treatment. While magnetic resonance imaging (MRI) can reveal characteristic lesions in brain areas such as the thalamus and mammillary bodies, these may not always appear in early stages, adding further diagnostic difficulty. Effective management of antepartum WE relies on early recognition and timely administration of high-dose thiamine, particularly parenteral administration for affected pregnant women. Prompt treatment is critical to preventing irreversible sequalae, neurological and otherwise in both the woman and the child. Once acute symptoms are managed, transitioning to oral thiamine supplementation is the norm to prevent recurrence and maintain normal thiamine levels. Balanced diet of macro-nutrients and maintaining fluid and electrolyte balance, also plays an essential role in recovery. In severe or treatment-resistant cases, more intensive, prolonged thiamine therapy and regular monitoring of maternal and fetal health are necessary, usually managed by a multidisciplinary medical team. This coordinated care approach aims to prevent recurrence and minimize risks associated with WE. The article emphasizes following clinical guidelines, which recommend regular thiamine monitoring and preventive measures in high-risk pregnancies, to improve maternal and fetal outcomes. By adhering to established protocols, healthcare providers can reduce the likelihood of severe complications associated with WE, ensuring better care and recovery for affected pregnant women. Categories: Pregnancy, Neurology, Nutrition.

A case report of bilateral psoas abscess with co-existing gluteal abscess in Pott`s disease of the spine in a middle-aged woman in a Specialist Hospital

Psoas abscess (PA) is the buildup of suppurative fluid in the fascia surrounding the psoas/iliopsosas muscle, is a rare condition, with diagnostic difficulty. Pott`s disease also called spinal tuberculosis occurs due to extra pulmonary tuberculosis. Backpain, fever, weight loss, lump in the groin and limping are its main symptoms. Curable by administering antitubercular therapy and sensitive antimicrobials with analgesics for indicative relief. Surgical procedures can be carried out to eliminate the accrued fluid based on the inter individual degree of presentation. In this case report, we report a rare case of bilateral psoas abscess with co-existing gluteal abscess and Potts’s disease. A 48-year old female presented with complaints of backpain, limping, lump in the flank/buttock and fever of two weeks. Abdominopelvic computed tomography scan showed massive right iliopsoas muscle collection with extension into the ipsilateral gluteal region and subcutaneous tissue. Similar collection was seen in the left psoas muscle superiorly. The bone window of the lumbosacral spine showed the anterior wedged collapse of the vertebral bodies with gibbus deformity. The patient had spontaneous rupture of the gluteal collection and surgical drainage of the right iliopsoas and left psoas collection was done. Anti-Kochs therapy was commenced and patient is currently doing great. The introduction of computed tomography (CT) and magnetic resonance imaging (MRI) has greatly improved the diagnosis of psoas abscess with Pott`s disease or in its isolated forms.

Multicentric Castleman’s disease mimicking extrapulmonary tuberculosis

Castleman disease is a rare proliferative lymph node disease with distinct histopathological features that manifest without any obvious symptoms. In high HIV prevalent areas Castleman’s disease pose diagnostic difficulties due to resemblance with other etiologies of lymphadenopathy. We report a case of a 58-year-old man who presented with complain of generalized body malaise and easy fatigability. Examination findings revealed left posterior cervical and bilateral axillary lymphadenopathy with CT scan of the abdomen showing generalized lymphadenopathy. Excisional lymph node biopsy was done and histology findings confirmed multicentric Castleman’s disease. This case illustrates that Castleman’s disease though rare can easily be confused with mimics such as tuberculosis in HIV patients.

Evaluation of the common skin diseases in patients with malignancies and the cutaneous side effects of cancer treatments

Purpose The diversity of skin diseases in patients with malignancies leads to diagnostic difficulties and complicate cancer treatment. Furthermore, the increasing use of chemotherapy drugs and novel treatment regimens raises the risk of the development of various cutaneous side effects and the need for dermatologists during cancer management. We investigated the skin diseases in patients with malignancies and the cutaneous side effects of cancer treatments. Methods Medical records of cancer patients evaluated in the Dermatology clinic between July 2018 and April 2023 were retrospectively reviewed. Results This study included 872 cancer patients, 374 females and 498 males. Acute myeloid leukaemia was the most common malignancy, followed by multiple myeloma and invasive ductal breast carcinoma. Graft versus host disease was observed in 89 (10.2%) patients after stem cell transplantation and radiodermatitis developed in 16 (1.8%) patients. Maculopapular drug eruption and hand foot syndrome were the most common cutaneous side effects of chemotherapy drugs. Capecitabine was the most common etiologic agent in hand foot syndrome. Cellulitis was the most frequent bacterial infection in cancer patients, whereas herpes zoster was the most frequent viral infection. Among the chemotherapy drugs that caused acneiform drug eruption, cetuximab and cytarabine were notable. Facial erythema was associated with cytarabine use in 27.3% of patients. Conclusion Identifying the common skin diseases in cancer patients and cutaneous side effects due to chemotherapy drugs may help to take preventive measures, develop specific and effective treatments, determine the most appropriate cancer treatment options, and increase patients’ compliance with cancer treatment.