IntroductionAutoimmune inner ear disease (AIED) is a condition first described by McCabe in 1979 based on a diagnostic study on a cohort of patients[1] who presented with bilateral sensorineural hearing loss (SNHL) with a specific clinical pattern that did not fit with existing diagnoses and demonstrated audiometric improvement with corticosteroid and immunosuppressive therapy. The pathogenesis of AIED is not completely understood, though several mechanisms have been proposed, including uncontrolled humoral and cell-mediated reactions against inner ear antigens, [2] resulting in autoantibody development and T-cell responses. [3]AIED accounts for <1% of SNHL cases [2]but may be under-diagnosed due to a lack of standardised diagnostic criteria. [4] The main treatment has been corticosteroids; however, the overall reported response is 60-70%[2] and only 14% remain responsive after 34 months. [5] There is a risk of further decline in hearing in the absence of therapy. Alternative immunosuppressive treatments [3] were tried but these have yielded variable results. There is no standard treatment protocol for AIED following corticosteroids as randomised controlled trials are limited.[6] Here, we report a case of AIED in a patient that responded well to infliximab.

IntroductionSitus inversus totalis (SIT) is a rare congenital abnormality, where there is transposition of both the thoracic and the abdominal organs, thus forming a left-right asymmetrical picture of the normal anatomical placement of the organs.1 It is kept under an umbrella term, heterotaxia, which encompasses all congenital disorders associated with malposition about the left-right axis.2 An important distinction is from simply situs inversus, where only some of the major abdominal and thoracic organs are reversed from their normal anatomical positions.3 SIT is even more of a rare condition, with an incidence of 1:10,000, and males being affected more than females (1.5:1).1 Due to this anatomical asymmetry, it may pose difficulties during diagnostic and therapeutic procedures.1,3Situs inversus totalis appears to be familial and laterality is established early on in the developmental process, during gastrulation. A protein, namely “Sonic Hedgehog” (Shh) is deemed to be responsible for the expression of two growth factors, Nodal and Lefty. If these proteins are released on the right side, the rotation of the heart occurs to the left side. However, if they are released on the left side, rotation occurs to the right. A gene named PITX2 has been identified, which controls the secretion of Shh and Nodal.4 The exact mechanism behind this is yet unknown, however, it has been speculated that the mutation in the PITX2 and Nodal gene is responsible and is also associated with other conditions like primary ciliary dyskinesia (PCD) and Kartagener syndrome.1,3,4,5Due to the unique transposition of the anatomical structures in SIT, the usual causes of abdominal pain may be a misdiagnosis. Similarly, these patients with cholelithiasis may have a presentation, with left upper quadrant pain, instead of the usual right, likely posing a diagnostic dilemma.6,7 Operative management in SIT patients also presents with technical and ergonomic challenges, especially for right-handed surgeons.8 The mirror image of the anatomy causes difficulty in the dissection of the Calot’s triangle, thus requiring appropriate tweaks to the normal preoperative and intraoperative setting.8 This report describes a case of a SIT patient with symptomatic cholelithiasis, managed by laparoscopic cholecystectomy.

IntroductionAmeloblastic fibroma (AF) is a rare, benign odontogenic tumor, accounting for approximately 1.5% to 4.5% of all odontogenic tumors. It was first described by Krause in 1891, but it was later recognized as a distinct entity by Thoma and Goldman in 1946.1 It is more commonly seen in children and adolescents, especially within the first two decades of life. There is a slight predilection for males,2 and the posterior mandible is the most frequent site of involvement. It is often associated with impacted or unerupted teeth.3Clinically, AF typically presents as a slow-growing, painless swelling, which may remain undetected until incidental discovery during routine radiographic examination. Radiographically, it often appears as a well-defined, unilocular or multilocular radiolucent lesion often with sclerotic radiopaque borders.1 Although considered benign, AF has the potential for recurrence and, in rare instances, malignant transformation into ameloblastic fibrosarcoma, emphasizing the importance of early diagnosis and appropriate management.Histopathologically, ameloblastic fibroma consists of both epithelial and connective tissue components. The epithelial component shows proliferating islands, cords, and strands of odontogenic epithelium with a peripheral layer of cuboidal or columnar cells and a central area resembling the stellate reticulum. The connective tissue component, resembling dental papilla, contains spindle and angular cells within a myxomatous stroma of delicate collagen. 2,3 Treatment options typically involve enucleation and curettage, surgical excision, partial resection and reconstruction. This case report discusses a rare presentation of ameloblastic fibroma in an 8-year-old female child, who presented with a painless swelling in the right posterior region of the mandible, which was histologically characterized by dentinoid formation.

Manuscript Title: Basal cell carcinoma arising within a bacillus calmette-guérin vaccination scar with prolonged inflammatory response: case reportAuthors: Marwa3 Hallal, and Zeina1,2* Tannous1Department of Dermatology, Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon.2Department of Dermatology, Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.3School of Medicine, Lebanese American University, Byblos, Lebanon.Acknowledgements: Not applicable*Corresponding author : Prof. Zeina Tannous, Department of Dermatology Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University.P.O. Box 36, Byblos, Lebanon. Phone: (961) 01-200800, Ext. 6680.

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Key Clinical Message:Masson’s tumor is a rare condition that can mimic malignancy, particularly when located in atypical regions. This case emphasizes the importance of considering this diagnosis in unusual anatomical locations and highlights the critical role of histopathological evaluation in achieving an accurate diagnosis. Prompt identification and surgical management can lead to favorable outcomes, even in rare presentations.Introduction:Masson’s tumor, also known as intravascular papillary endothelial hyperplasia (IPEH), is a benign non-neoplastic lesion, first described in 1923 under the name of “vegetant intravascular hemangioendothelioma” [1]. Initially believed to be an atypical proliferation of papillary endothelial cells, it was reclassified as a reactive process in 1932 by Henschen. This tumor is rare, and accounts for 2% of benign and malignant vascular tumors of the skin and subcutaneous tissues [2].This case highlights a Masson tumor, a vascular tumor arising in the lower extremities, a region where such tumors are less commonly observed compared to their typical occurrence in the head and neck area.Case History/ExaminationA 49-year-old male hairdresser presented to an outpatient clinic in Beirut, Lebanon, with a chief complaint of a lesion on the right posterior lower extremity, which was present for the past 3 years. The lesion had grown recently, over the last 6 months and was not painful to touch. The patient’s occupation required prolonged periods of standing.On examination, a large, soft, well-demarcated subcutaneous nodule measuring approximately 4 x 4 cm in size was noted at the site (fig1). The lesion was non-tender to palpation. The patient had no significant past medical history, surgical history, or reported allergies. Family history included pilar cysts in the patient’s mother and brother.MethodsDifferential DiagnosisThe patient presented with a subcutaneous nodule with a benign clinical appearance, suggestive of a common soft tissue lesion such as a lipoma. No additional symptoms or concerning features, such as rapid growth, pain, or skin changes, were observed. Based on the clinical presentation, the differential diagnosis primarily included lipoma, epidermoid cyst, or a benign vascular lesion.InvestigationsDue to financial limitations, advanced imaging or biopsy was not performed prior to excision. The clinical evaluation supported the decision to proceed with direct surgical excision under the working assumption of a lipoma.Post-excision, the gross examination revealed a well-demarcated vascular nodule, located superficial to the subcutaneous tissue, comprising three lobules encapsulated within fibrous bands. Histologic examination of the excised tissue revealed a dilated vessel within the superficial subcutaneous tissue, showing intravascular proliferation of reactive endothelial cells. The endothelial cells formed numerous papillary structures lined by a single layer of plump endothelial cells. The lesion was enclosed within a fibrous pseudo capsule, supporting the diagnosis of a benign vascular tumor.TreatmentThe nodule was excised in its entirety during the initial surgical procedure. Complete surgical excision was achieved, as confirmed by histopathology, with no evidence of residual lesion or malignancy.Conclusion and results:Figures 2 and 3 show the histological results. The surgical approach and prognosis were explained to the patient. Informed consent was obtained for the use of his photos and clinical information in this case report.Following complete surgical excision, the patient experienced an uneventful recovery with no signs of recurrence at follow-up. Dermatologists and surgeons should maintain a high index of suspicion for IPEH when evaluating vascular tumors to optimize patient outcomes.Intravascular papillary endothelial hyperplasia (IPEH) is a rare but benign vascular lesion that poses diagnostic challenges, particularly in the clinical and pre-operative settings. Accurate diagnosis relies heavily on histopathological evaluation, as clinical presentations often mimic other soft tissue lesions. This case underscores the importance of considering IPEH in the differential diagnosis of vascular tumors to ensure timely and appropriate management.Discussion:This tumor has several names, including Masson’s hemangioma, Masson intravascular hemangio-endothelioma, intravascular papillary endothelial hyperplasia (IPEH), and reactive papillary endothelial hyperplasia [3].The precise etiopathogenesis remains unclear, though it is widely regarded as a reactive process believed to result from growth factors production, leading to excessive endothelial cell proliferation [4]. In fact, research employing northern blot and immunoblotting revealed a significant increase in the expression of fibroblast growth factor beta, suggesting its secretion by the endothelial cells through an autocrine mechanism. The condition is thought to arise from an aberrant resolution of a thrombosis, unfolding through several stages [5].It typically manifests as a firm or soft, reddish-blue color nodule over the head and neck and upper extremities [6]. Occurrences on the lower extremities, such as in our case, are rare. Generally, it is asymptomatic, slow-growing and is not associated with any pulsation. The sonographic features of subcutaneous IPEH are not specific; however, consideration of the diagnosis is warranted when encountering a soft tissue mass showing a vascular pattern. This entity has a slight predilection for adult females, and IPEH can also manifest in children [7].Diagnosis mainly relies on histology since imaging such as MRI or US cannot differentiate it from other vascular lesions. Histologically, it is characterized by the presence of papillary structures lined by a single layer of endothelial cells. There will be absence of pleomorphism, mitosis or necrosis. It has been classified into three main types. The first type is the pure form, where the endothelial proliferation occurs from veins and less commonly artery without any vascular abnormalities. The second type arises from a pre-existing vascular abnormalities such as an aneurysm [5], arteriovenous malformations, hemangiomas and pyogenic granulomatosis. The third and least common type arises from an extravascular hematoma.These tumors stain positive for CD31 and CD34 [8]. Staining positivity for factor VIII, type 4 collagen and SMA and MSA varies and is not as consistent.Clinically, IPEH can mimic a variety of conditions, both benign and malignant such as pyogenic granuloma and Kaposi’s sarcoma. Moreover, it should be distinguished from malignant angiosarcoma, a differentiation typically achieved through histology and immunohistochemical staining. The primary characteristic of IPEH is its intravascular development, in contrast to angiosarcoma, which rarely remains confined within the vascular lumen. Also, CD105 is a useful immunohistochemical stain, as angiosarcoma would stain positive while IPEH doesn’t [8].Since IPEH can be mistaken for angiosarcoma and other malignant tumors, surgical excision is the treatment of choice. Since these tumors rarely occur de novo within extravascular hematomas, meticulous surgical techniques should be utilized during resection to prevent any spillage of the aneurysm-associated thrombus, given the theoretical risk of extravascular recurrence. Other alternative options include observation or using sclerosing agents such as sodium tetradecyl sulfate [9]. Chemotherapy or radiotherapy may be considered for cases of recurrence following incomplete excision, as well as for multiple intracranial lesions or suspected lesions[10].Ethical Statement:the patient in this manuscript has given written informed consent for participation in the study and the use of their de-identified, anonymized, aggregated data and their case details (including photographs) for publication.Author ContributionMariana El Hawa (1st author): Conceptualization and study design, data analysis, manuscript drafting, and critical revision.Serena Saade: Critical review of histopathological findings and drafting specific sections of the manuscript.William Abou Shahla: literature review and drafting specific sections of the manuscript.Dana Saade: Critical review of the whole manuscript and contribution to the discussion section.References:1. Masson, P., Hemangioendotheliome vegetant intravasculaire. Bull.Soc.Anat.Paris, 1923. 93 : p. 517-523.2. Fasina, O., A. Adeoye, and E. Akang, Orbital intravascular papillary endothelial hyperplasia in a Nigerian child: a case report and review of the literature. J Med Case Rep, 2012. 6 : p. 300.3. Benantar, L., et al., Peri-orbital Masson’s tumor: a case report and literature review. Pan Afr Med J, 2022. 42 : p. 147.4. Sasso, S.E., et al., Masson’s tumor (intravascular papillary endothelial hyperplasia). An Bras Dermatol, 2019. 94 (5): p. 620-621.5. Chapman, S.C., et al., Masson tumor (intravascular papillary endothelial hyperplasia) arising in a superficial temporal artery aneurysm. J Vasc Surg Cases Innov Tech, 2019. 5 (3): p. 388-391.6. Kim, O.H., et al., Subcutaneous intravascular papillary endothelial hyperplasia: ultrasound features and pathological correlation. Skeletal Radiol, 2016. 45 (2): p. 227-33.7. Huang, W.P., et al., Intravascular papillary endothelial hyperplasia of the spleen in a child: a case report. BMC Med Imaging, 2022.22 (1): p. 207.8. Akdur, N.C., et al., Intravascular papillary endothelial hyperplasia: histomorphological and immunohistochemical features. Diagn Pathol, 2013. 8 : p. 167.9. De Maria, L., et al., Sclerotherapy for Venous Malformations of Head and Neck: Systematic Review and Meta-Analysis. Neurointervention, 2020. 15 (1): p. 4-17.10. Dryden, S.C., et al.,Intravascular Papillary Endothelial Hyperplasia of the Orbit: A Case of Masson’s Tumor. Cureus, 2019. 11 (12): p. e6266.

Title: “Choledochoduodenal fistula arising from pancreatic lymphoma: An exceedingly rare phenomenon”Authors (and institutional affiliations): Dr Shalvin Jassal (BiomedSci, MBBS, MSurg)1Dr Nathan Ip (5th year MBBS student)2Dr Adrian Fox (MBBS, FRACS)1Dr Melanie Crispin (MBBS (Hons), BMedSci, PGDipSurgA, PGDipSurgED, FRACS)11 Upper Gastrointestinal Surgery Unit, Eastern Health, Melbourne, Victoria, Australia2 Monash University, Faculty of Medicine, Nursing and Health Sciences, Clayton, Melbourne, Victoria, AustraliaThe listed authors declare they have no conflicts of interest to disclose. This manuscript has not been published or submitted elsewhere for consideration of publication. There are no further authors to list or acknowledge. Funding: No funding was acquired or sought for the production for this manuscript. Data accessibility statement: All data available has been presented within this manuscript.Keywords: Choledochoduodenal fistula, Biliary Obstruction, Pancreatic Lymphoma, Non-Hodgkin’s Lymphoma, Diffuse Large B-cell LymphomaCorresponding author: Dr Shalvin Jassal jassal.shalvin@gmail.com

IntroductionThe transgender and gender diverse population continues to rise as society shifts towards increased awareness and acceptance, with an estimated 2.6 million adults identifying as transgender in the United States [1]. Population growth and improved financial accessibility to healthcare has led to an increase in chest masculinization surgery, or gender-affirming mastectomy (GAM) [2]. GAM differs from risk-reduction, or prophylactic, mastectomy in that more breast tissue is left in-situ to create a natural-appearing chest contour. This is compared to prophylactic mastectomy which removes nearly all breast tissue for maximum oncologic risk reduction. This difference complicates breast cancer risk assessment in the post-GAM population [2]. Breast cancer risk in cisgender women is well-defined at 1 in 8 or 12.5% risk over a lifetime, however this is less clear in transgender patients due to confounding factors such as testosterone therapy or previous oophorectomy [3]. It has been theorized that after GAM transmale patients are at lower risk of breast cancer than cisgender women, yet higher risk than cisgender men [2-4]. No standardized preoperative screening guidelines prior to GAM currently exist, however strong family history and need for breast imaging should be assessed in this setting. Risk factors such as inherited genetic mutations have specific implications for this population as they are less likely to undergo cancer screening or participate in long-term follow up [4]. Approximately 5-10% of breast cancers are thought to be associated with inherited genetic mutations, BRCA being most common [5]. Risk reducing mastectomy is often offered to these patients, decreasing breast cancer risk by 90-95%[4,5]. Here we present a transgender male patient with the BRCA1 mutation. Rather than standard GAM, he underwent prophylactic bilateral mastectomy followed by chest masculinization with liposuction and free nipple grafts, as well as concurrent oophorectomy for gynecologic risk reduction. Here we highlight the nuanced problem that post-GAM patients have a higher, more variable risk of breast cancer compared to cisgender men and likely postmastectomy cisgender women. We demonstrate that appropriate risk reduction and desired cosmetic outcome can be achieved concurrently. The following case in presented accordance with the CARE reporting checklist.Case Presentation The patient is a 32-year-old transgender male who presented for surgical consultation regarding prophylactic mastectomy in the setting of a BRCA1 mutation. At the time of consultation, he had been on testosterone therapy for 7 years. Genetic testing was ordered by his endocrinologist due to a strong family history of breast, ovarian, and prostate cancers. He was referred to our high-risk screening program, breast surgical oncology, and gynecology to discuss risk reduction surgery. He had no previous breast imaging and was recommended to undergo breast MRI. This showed a 5.4 cm area of nonmass enhancement in the right breast for which biopsy was recommended, however at the time of biopsy the abnormality was no longer visualized and no tissue sample was obtained. After multidisciplinary discussion, he underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy followed by bilateral risk-reduction mastectomies. The plastic surgery team worked in conjunction with the oncological breast surgery team for markings. The double incision mastectomy approach was designed to place the scar slightly below the pectoralis major muscle. The nipples were thinned out as an oval full thickness skin graft placed on the closed chest. The nipple grafts were positioned along the lateral border of the pectoralis major muscle between the 4th and 5th ribs [6]. Suction assisted lipectomy was performed laterally and medially to optimize contour. Final pathology was without abnormality. Postoperatively he was satisfied with the aesthetic outcome (Figure 1) and plans to undergo annual chest wall exams by his primary care physician.Discussion Here we describe a transgender male patient found to have the BRCA1 mutation on preoperative evaluation for GAM. He was found to have a strong family history including breast, ovarian, and prostate cancers which prompted genetic testing. He was evaluated in a multidisciplinary setting, and ultimately underwent risk-reduction mastectomy and oophorectomy at the time of chest masculinization surgery. There has yet to be established guidelines for breast cancer screening in transgender men undergoing GAM. In general, transgender patients face many barriers in healthcare including stigmatization, psychosocial trauma associated with undergoing procedures that do not align with their gender identity, and lack of insurance coverage of procedures [7]. Disparity in healthcare for this population is especially prevalent in preventative care. When compared to cisgender individuals, transgender patients are less likely to be offered recommended cancer screening, which is reflected by suboptimal cancer outcomes in this population [1,7]. A recent single arm pilot trial published by C.S Cortina et. al highlights implications of patient education regarding individualized breast cancer risk in the preoperative setting can impact one’s decision to undergo risk reduction mastectomy as a part of gender-affirming top surgery [1]. Though rare, development of breast cancer after GAM has been described in multiple case series [7]. It is important to emphasize that GAM should not be considered equivalent to oncologic or prophylactic mastectomy due to the amount of breast tissue left behind, as the residual breast tissue imparts a theoretical future risk of breast cancer. In terms of long-term breast cancer screening, similar to postmastectomy cisgender females, physical exam is the recommended screening modality for post-GAM patients.Conclusion As the transgender population continues to grow, the role of breast cancer risk assessment prior to GAM is of particular importance. This case demonstrates the clinical utility for formalized, individualized preoperative screening to better identify patients who would benefit from oncologic risk-reduction at the time of gender-affirming chest masculinization. As exemplified here, formal guidelines for breast cancer risk assessment in patients pursuing GAM could mitigate lifetime risk of breast cancer development in the transgender and gender diverse population. A limitation of this case report includes discussion about a relatively small patient population, however with profound population growth the question of breast cancer risk in this group has become relevant in genetics, surgical oncology, and plastics. More work is needed to develop and implement formal guidelines to assess long term outcomes.Bailey N. Johnson:  Conceptualization; writing – original draft.Ivan Hadad:  Writing – review and editing.Aladdin H. Hassanein:  Conceptualization; writing – review and editing.Carla S. Fisher:  Conceptualization; writing – review and editing.

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Response to Accidental vs. Abusive Head Trauma in Infancy: Is Revival Shaking the Missing Link?We appreciate the opportunity to respond to the concerns raised regarding our recent case report 26 cm fall caught on video causing subdural hemorrhages and extensive retinal hemorrhages in an 8-month-old infant 11Brook C, Squier W, Mack J. 26 cm fall caught on video causing subdural hemorrhages and extensive retinal hemorrhages in an 8-month-old infant. Clin Case Rep. 2024 Jun 25;12(7):e9105.We agree with the author of the Letter that aging of retinal hemorrhages is not precise, which is why we did not use language that portrayed certainty regarding this issue. Instead, we stated that the evidence “indicates” the RHs occurred “around the time” of the fall and it is “reasonable to attribute” them to the incident. We did not mean to imply that the findings regarding the RHs can definitively attribute the RHs to the fall. However, we point out that there is no evidence of any other event prior to the infant becoming symptomatic that would plausibly explain the findings of retinal hemorrhage.The author of the Letter then asserts that “acuteness of RH onset would have been better supported by disappearance of most of them after 1 week, rather than the observed persistence.” We are not sure why the author makes this assertion. The longer the RH persisted, the more likely it is that they were acute at the time they were first found.The issue of whether the retinal folds are “typical of acute traumatic retinoschisis” is also raised. Is the author suggesting that there is a non traumatic cause of the retinal fold in this case? We do not believe there is sufficient evidence to accurately determine cause by reference to the “type” of retinal fold, and found no such evidence in the articles cited.The Letter then raises concerns about the period immediately following the recorded incident, noting that “the video ends abruptly”, and raises the possibility of revival shaking. We clarify that after the fall, a worker at the creche picked up and comforted the infant, and this was captured on video. The baby was not subjected to revival shaking. We also clarify that the mother arrived between 15 and 30 minutes after the fall, at which time the infant was lethargic and lacked focus in the eyes, presumably signs of concussion.The Letter suggests that video evidence should follow the infant from the time of the accident to the time of passing the infant to medical care. We wonder if the author applies the same evidentiary requirements for establishing that shaking can cause the findings commonly associated with abusive head trauma. We are not aware of any videotaped shaking event that has resulted in such findings (either violent or in revival attempts). Nor are we are of any independently witnessed shaking event that has led to such clinical findings in a healthy infant. If the evidentiary requirement for these cases was an extended videotape until delivered to medical care, then no case or case series would have ever been published in the field.The author of the Letter also discusses the historical narratives of shaking done by caregivers in order to revive or resuscitate the infant. We agree that such narratives are common, and are often dismissed or wrongfully intrerpreted as being confessions. However, with respect to shaking in revival attempts, we do not know how cerebral or ocular findings could be attributed to the act of revival shaking rather than to whatever caused the collapse in the first place.Finally, the author of the Letter questions whether our study helps clarify the pathogenesis of ocular or cerebral hemorrhage. Our case study should not be read in isolation, but as adding to the growing list of cases compiled over the past decades that, taken as a whole, provide strong evidence that short falls can result in both cerebral and extensive ocular hemorrhages.Chris BrookWaney SquierJulie Mack

IntroductionPorokeratosis (PK) is an epidermal disorder of keratinization caused by mevalonate pathway abnormalities. 1 Different clinical subtypes of PK are described. The common types include disseminated Superficial Actinic Porokeratosis, porokeratosis of Mibelli, and Linear porokeratosis. Disseminated superficial porokeratosis, eruptive disseminated porokeratosis, porokeratosis palmaris et plantaris disseminate, punctate porokeratosis, porokeratosis ptychotropica, penoscrotal porokeratosis, and Follicular porokeratosis (FPK) are the less common types of PK. 2 The clinical appearance, predilection site, and symptoms vary in various forms of PK.2 Cornoid lamella is the common histopathologic feature in all types of PK. 1, 2Follicular porokeratosis is a rare form of PK, characterized by the cornoid lamella filling the hair follicle infundibulum.3 Follicular porokeratosis may be concomitant with other PK forms 4 or occurs as pure FPK.5 Although most of the FPK cases are localized lesions3, 6-9, more diffuse distribution of lesions is reported in a few patients. 5, 10 The scalp is not a common site for FPK 3, 5, 11, and according to available sources, only one of the scalp FPK cases caused alopecia.5 Although diabetes mellitus type 2 accompanied some cases of porokeratosis 12, 13, we could not find any case of FPK associated with diabetes mellitus.Herein, we report a case of extensive FPK with spicules that caused alopecia of the scalp hair in a diabetic woman.

A case report of membranoproliferative glomerulonephritis (MPGN): infection-related or immune-related?Ayman Azhary *1, 2, \RLMohammed Taha3, Nooh Mohamed Hajhamed1, 2, Salahaldeen Ismail Mohammed1, Nouh Saad Mohamed2, Waleed Azhary Sir Alkhatim4 , Emmanuel Edwar Siddig5

1. INTRODUCTIONThe paranasal sinuses include the ethmoid, frontal, sphenoid, and maxillary sinuses. These air-filled spaces in the maxillofacial and skull area are lined with mucosa and communicate with the nasal cavity (1). The maxillary sinuses start developing in the third month of intrauterine life, making them the first paranasal sinuses to develop in the human fetus (2). They continue to grow until puberty. The maxillary sinus typically has an average volume of 6-8 cm³, making it the largest paranasal sinus, though its size varies with age (3).Maxillary sinus aplasia (MSA) is a condition characterized by the absence of sinus development. This rare condition is often asymptomatic but can sometimes present as facial pain or headaches. Typically diagnosed incidentally during radiological procedures for other purposes, such as dental implants, MSA shows no gender or geographical predilection and can occur worldwide (4). MSA may occur in isolation or be associated with broader craniofacial syndromes like cleft palate, Crouzon syndrome, or Apert syndrome. While many individuals with MSA are asymptomatic, those with symptoms may experience nasal obstruction, sinus infections, or facial pain (5). Symptomatic management focuses on addressing related nasal or sinus issues, and surgical intervention is rarely needed, reserved only for specific complications or associated craniofacial abnormalities (6). Hypoplasia of the inferior concha and the absence of the infundibulum and uncinate process are rare anatomical variations that can significantly impact clinical outcomes, particularly in cases of MSA or other sinus anomalies (7). Often discovered incidentally during imaging, these conditions can be asymptomatic but may sometimes present with sinonasal symptoms like nasal obstruction or chronic sinusitis. Case reports highlight the association of these anomalies with impaired sinus function and recurrent infections, necessitating careful evaluation and tailored management strategies (8).Maxillary sinus hypoplasia (MSH) refers to the underdevelopment of the maxillary sinuses, where the sinus is present but smaller than normal. This condition can affect individuals of any age and gender and is often discovered incidentally (9). Symptomatic individuals may experience chronic or recurrent sinus infections, nasal obstruction, or facial pain, particularly in the cheek area. MSH can also be associated with other craniofacial anomalies or developmental conditions like cleft palate and craniosynostosis syndromes (10). MSH is classified into three types according to Bolger’s classification: Type I (mild hypoplasia), Type II (significant hypoplasia with an absent uncinate process), and Type III (profound hypoplasia with an absent uncinate process). CT scans are the gold standard for diagnosing MSH and MSA, with MRI also being useful (11). Symptomatic cases are treated with medical management, including antibiotics, nasal decongestants, and corticosteroids (9). For chronic or recurrent sinusitis unresponsive to medical treatment, functional endoscopic sinus surgery (FESS) may be considered to improve sinus drainage and ventilation. Asymptomatic cases do not require treatment. An incidental finding of unilateral maxillary sinus aplasia was reported during a radiographic examination (8, 9). We report an incidental finding of unilateral aplasia of the maxillary sinus during a radiographic examination.

Unexpected Primaquine-Induced Hemolysis in a G6PD Normal Patient: A Case Report from NepalAarju Khadka1, Sachet Subedi2, Nisha Lama1, Indu Bhattarai1, Chandrashekhar Deuba1, Uttam Khatri1, Nisha Regmi11College of Medical Sciences Teaching Hospital2Tribhuvan University Institute of Medicine, Maharajgunj Medical Campus

Leaping to Diagnosis: The Frog Sign as a Key Clue in AVNRTAuthors: Andreas Müssigbrodt1, Maria Herrera Bethencourt1, Romain Vergier1, Marinela Blidar1, Alberto Alfie2

Abstract a. Background: Percutaneous closure of atrial septal defects (ASD) using atrial septal occluders (ASO) is an established treatment method. However, rare complications such as device migration can occur, especially in unusual locations like the systemic circulation. b. Case Presentation: A 23-year-old male underwent percutaneous closure of a secundum ASD five

Dyshidrosiform Bullous Pemphigoid with Dermatophyte infection: An association or coincidence? Diagnostic challenge of a case and review of literatureKeywords: Dyshidrosiform Bullous Pemphigoid; Heart disease; Dermatophyte infection

Primary Leiomyosarcoma of the Kidney: A Case ReportSrijana Khati1, Sagar Rana Magar2, Ankita Simkhada1, Ramesh Paudel1, Surendra Khanal2, Bishal Panthi1, Sadmarg Thakur2, Sujan Paudel2, Prajjwol Luitel21Department of Pathology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal2Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal