A document by Ping Zhou. Click on the document to view its contents.

IntroductionAcute Inflammatory Demyelinating Polyneuropathy (AIDP) is the most common variant of Guillain-Barre Syndrome (GBS) that is seen in North American and Europe. It is an autoimmune disorder, where the body’s immune system attacks myelin sheath of peripheral nerves, and leads to progress weakness, loss of reflexes, and sensory disturbances, often paresthesia.1 There are many potential triggers to AIDP with certain infections being the most known, particularly upper respiratory of gastrointestinal illnesses. Other known triggers include certain vaccines, such as the flu vaccine which have described one case of GBS developing per 1 million flu vaccines given.1Diagnosis of AIDP is based on a combination of clinical symptoms, CSF analysis, MRI of the brain and spinal cord, and possible nerve conduction studies. Serologic tests for recent infections and ganglioside (GM) and anti-ganglioside (GD) antibody panels of different GBS variants are also used as supportive data.AIDP is one subtype within the broader category of the GBS spectrum, and the current incidence of GBS is 1-2 per 100,000 people per year,2 with a slight male predominance. The disease is most thought to be sporadic, and there is limited number of case reports describing its occurrence within multiple members of the family. The exact incidence of GBS within families is unclear, though a study in 2017 documented there to be 42 patients known patients affected within 20 families.3This case report depicts 3 Caucasian siblings diagnosed with AIDP. Two females, age 9 and 10, were diagnosed with symptoms presenting in April 2025, and one 18-year-old half-brother was diagnosed one year earlier in March of 2024. Key symptoms, workup, findings and ultimate treatment will be discussed. Given the rare familial clustering and young age of the three siblings depicted in this report, there is a need for further investigation looking into potential genetic or shared environmental factors that could play a role in the pathogenesis of AIDP and GBS.

Parathyroid carcinoma and intrathyroidal parathyroid adenoma with secondary hyperparathyroidism: a case report and literature reviewShuxiong Li1,2,Zhanhui Chen2,Shengfei Yang1, Mengling Wei1,Dongwei Li1,2*1The First School of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China.2DongGuan Tungwah Hospital, DongGuan, Guangdong, 523110, China.Correspondence，Dongwei Li，1The First School of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China. 2DongGuan Tungwah Hospital, DongGuan, Guangdong, 523110, China. Tel.: +86 13925582681; E-mail: ldw00696@163.com.

The Arrow and the Atlas - A Narrow Escape in the Cervical Spine: A Case Report About Penetrating Injury With an Arrow Impacted in the NeckABSTRACTBackground: Penetrating neck injuries (PNI) are rare presentation of all trauma cases. A rational strategy and prompt patient assessment are necessary for management. Selective treatment has replaced mandatory exploration in the treatment of penetrating neck trauma.Case presentation: A 41 years old male patient was admitted to the emergency department with anarrow penetrating the neck, without signs of neurological deficit. He had an arrow impacted into the right posterolateral aspect of his neck just posterior to sternocleidomastoid muscle corresponding to axial level of C1-C2 vertebra. The arrow was dislodged after extending the entry wound and removed with gentle maneuver in the operating room with uneventful post-operative period and follow-ups.Conclusion: Even though PNIs are uncommon, a thorough understanding of the anatomy of this area is essential. Direct withdrawal may be an excellent option for penetrating cervical and posterior neck injuries by a foreign body, that are away from the neurovascular region, without neurological loss, and with a sound surgical approach.Keywords: arrow, neurovascular, penetrating neck injuryKey Clinical Message (KCM): Penetrating neck injuries necessitate meticulous evaluation and controlled intervention due to proximity of vital structures. This case illustrates that selective operative management with direct extraction of a posterior cervical arrow, distant from neurovascular and aerodigestive pathways, can achieve safe removal and favorable outcome.Introduction: Penetrating neck injuries (PNI) occur in 5–10% of trauma cases(1). PNI can be caused by a variety of objects, including knives, bullets, metallic rods, bamboo sticks, arrows, and more. Such injuries have the potential to endanger life by harming critical neck tissues such as the pharynx, esophagus, major arteries, and nerves. Prior to surgical intervention, management requires a rational strategy and prompt evaluation of the airway and circulation’s sufficiency as well as the potential existence of any skeletal or neurological injury(2). The approach to treating penetrating neck trauma has changed from requiring exploration to targeted management. For patients with PNI, doctors are now widely favoring selective operative management based on selective diagnostic investigations and physical examination. Based on physical examination and auxiliary examination, selective management is safe and practical for hemodynamically stable patients who show no evidence of major structural damage(3).Case presentation: A 41 years old male from Kathmandu presented to the emergency department at TUTH, IOM with a penetrated arrow lodged in his neck from an accidental shot during archery by his friend 2 hours prior with no other injury reported.(Insert Figure 1) Upon examination, his vital signs were stable, he was alert, focused, not pale or cyanosed, and there were no signs of neurological deficit, mouth or nose bleeding, hoarseness in speech, stridor, respiratory distress, or active bleeding from the puncture site. With carotid pulses perceptible and the right upper limb’s range of motion and strength intact, there was soreness around the damage site upon palpation, but no crepitus or emphysema was detected. The remaining systemic examinations were normal. He had an arrow impacted into the right postero-lateral aspect of his neck.(Insert Figure 2) The entry point was just posterior to sternocleidomastoid muscle corresponding to the axial plane of C1-C2 vertebra also confirmed by the xray.(Insert Figure 3)He was taken to the operating room and underwent neck exploration under intravenous anesthesia.The entry point was extended and the track of wound was traced, freed of the soft tissue meticulously and the arrow was dislodged and was removed with a gentle maneuver as the head of the arrow was smooth and compact. The tract of the wound was debrided, washed and sutured.(Insert Figure 4)(Insert Figure 5)Post operatively, he was placed on intravenous antibiotics, analgesics and close monitoring as per postoperative hospital protocols. On 1st postoperative day, he only complained of mild pain at incision site but could tolerated feeds, speak and talk without difficulty and on examination had stable vitals, a clean wound with no central neurological deficit nor impaired use of the right upper limb. He was observed for another 24 hours which was uneventful and was then discharged on oral analgesia, antibiotics and counselled on warning signs. Subsequent follow up visits to the outpatient clinic were uneventful with no complications and has resumed his normal daily life routine.Discussion: As the neck contains vital structures, all penetrating neck wounds have the potential to be serious and need immediate medical attention(4). Structures are more susceptible to damage from any penetration injury of the neck that could have major and fatal repercussions since they are concentrated in a limited volume. The vital structures are, however, sometimes covered by a hard, bony shields, as well as muscles whereas in other locations they are more superficial and may become exposed. This arrangement’s diversity forces the clinician to use a separate management approach for various neck locations(1). In a stable patient with no need for urgent surgery, a CT angiography has emerged as the preferred test for PNI triage and subsequent care, regardless of the area of injury(5). Additionally, it has been observed that physical examination results may rule out injury in more than 99% of patients and are good indicators of vascular injury in patients with penetrating neck wounds. Physical indicators of vascular injury, such as active bleeding, expanding hematoma, bruit, pulse deficit, central neurologic deficit, etc., could accurately detect vascular injury with a missed injury rate of 0.7%, which is comparable to arteriography in accuracy but less expensive and noninvasive, according to a recent study by Saharan et al. on 145 patients with zone II penetrating neck trauma(4). In this case, the injury was confined to the posterolateral aspect of neck without damaging major structure/major neurovascular structure as well as the aero digestive tract. So, further extensive imaging were not done in our case.Foreign bodies can occasionally tamponade significant vessel damage; consequently, removing things blindly could result in potentially fatal bleeding. It is always best to remove such foreign bodies through examination in a suitable controlled setup. Many surgeons believe that neck exploration is required, but others believe that a selective approach is more suitable given the morbidity and mortality linked to surgical investigation(4). In our case, although the chances of major vessel and organ injury was very less according to the site of penetration, we removed the foreign body in a controlled setup keeping in mind of the above mentioned consequence.Conclusion: Despite the rarity of penetrating neck injuries, it is essential for clinicians to be well-versed in the anatomy of this area and to know how to handle these cases at the outset. Prior to a surgical procedure, appropriate assessments and preparation should be carried out. Prioritizing the patient’s life and minimizing tissue damage during the procedure are the two main goals of a smart surgical approach. Direct extraction might be a useful option for cervical and posterior neck penetrating injuries without causing neurological impairment and are away from the neurovascular area.Acknowledgements- We would like to thank Dr. Sudip Mishra and Dr. Sugam Pradhan for their help in formulating the report as well as we are very grateful to our patient for his co-operation.Authors’ contributions- SL: conceptualization, data curation, resources, software, writing-original draft. SK: validation, writing, review and editing. AA: validation, writing, review and editing. SP: supervision, validation, writing, review and editing. DK: supervision, methodology, validation and review

A document by Haripriya Bansal. Click on the document to view its contents.

IntroductionBernard-Soulier syndrome (BSS), or hemorrhagiparous thrombocytic dystrophy, is a rare autosomal recessive bleeding disorder caused by genetic mutations affecting the platelet glycoprotein Ib-IX-V complex [1]. This defect impairs platelet adhesion to von Willebrand factor at sites of vascular injury, leading to a severe coagulopathy characterized by prolonged bleeding time, macrothrombocytopenia, and giant platelets on peripheral smear [1]. Clinical manifestations typically include epistaxis, gingival bleeding, and menorrhagia [1]. Due to the presence of thrombocytopenia, BSS is often misdiagnosed as immune thrombocytopenic purpura (ITP), but it is critically distinguished by its lack of response to corticosteroids and the presence of abnormally large platelets [2].While mucocutaneous bleeding is common, hemoptysis is a rare and alarming presentation in BSS, signaling severe underlying pathology [3]. The literature on pulmonary hemorrhage in BSS is sparse and points to two primary etiologies. The first is bleeding secondary to underlying structural lung disease; for instance, a 14-year-old female with BSS was reported to have hemoptysis in the setting of active pulmonary tuberculosis [4]. The second, rarer scenario is hemorrhage intrinsic to the coagulopathy itself, as described in a 46-year-old male who developed diffuse alveolar hemorrhage [3]. Therefore, in a BSS patient presenting with hemoptysis, it is critical to aggressively investigate for an underlying pulmonary trigger.Here, we report the complex case of a 19-year-old male with BSS who presented with life-threatening hemoptysis and a platelet count of 5.59 x 10⁹/L. His presentation was uniquely challenging due to a convergence of three pathologies: the severe intrinsic bleeding risk from BSS, a destructive pulmonary lesion from active tuberculosis for which he was undergoing treatment, and a subsequent fungal superinfection within a tuberculous cavity, confirmed by microbiologic and radiologic findings. The coexistence of this clinical triad—an inherited bleeding disorder complicated by concurrent mycobacterial and fungal infections—created a perfect storm for refractory hemorrhage and presented a profound management dilemma. This report details the successful multidisciplinary strategies used to secure hemostasis and highlights the diagnostic and therapeutic challenges of managing such a rare and complex clinical scenario.

Bilateral ballismus: an unusual clinical sign with an unexpected originAuthors: S. Reichert*, A. Knoflach*, I. Wiedl, K. Hoskin, C. Ganser, M. Wertli, T. CosmaDepartment of Internal Medicine, Cantonal Hospital Baden, Switzerland* Shared first authorshipCorresponding author: adrian.kn.@hotmail.comConflict of interest: The authors declare no conflict of interest.Patient Consent: Written informed consent was obtained from the patient prior to writing the manuscript.Funding:  The authors received no specific funding for this work.Keywords: Ballismus, Hypoglycemia, Insulinoma, Whipple’s triad

Title: “Unveiling Wilson’s Disease: The Case of Recurrent Seizures as an Initial Indicator”

Fibromyalgia with Persistent Symptoms and Epstein-Barr Virus Infection: A case report

Implantable cardioverter-defibrillator (ICD) implantation is a common medical procedure that carries many serious risks including lead perforation. The incidence of ICD lead perforation has been estimated at 0.6-5.2% previously[(1)](#ref-0001). Risk factors for lead perforation include older age, female sex, worsened New York Heart Association (NYHA) heart failure class and nonischaemic cardiomyopathy[(2)](#ref-0002).

A document by Ayman Azhary. Click on the document to view its contents.

A document by Duo Zhou. Click on the document to view its contents.

A document by guoqiang zhang. Click on the document to view its contents.

Title: Sclerosing Mesenteritis a Rare Cause of Acute Abdomen

AbstractMetachromatic Leukodystrophy (MLD) is a rare genetic disorder characterized by progressive neurological decline due to the accumulation of sulfatides in the nervous system. In low-resource settings, limited access to advanced diagnostic tools often leads to delays in identifying rare disorders like MLD, resulting in misdiagnosis and late intervention. We describe a 16-month-old boy who presented with lower limb weakness, irritability, feeding difficulties, and skin abnormalities during an acute respiratory infection. Initial work-up suggested conditions such as tuberculosis, lymphoma, or leukemia due to overlapping clinical and laboratory features. However, neuroimaging revealed findings consistent with leukodystrophy, and subsequent genetic testing confirmed a variant in the FBP2 gene associated with childhood-onset leukodystrophy. This case illustrates the diagnostic complexity of MLD in resource-limited environments, where overlapping presentations with more common infectious and hematological conditions often delay recognition. The patient demonstrated partial improvement with antibiotics and Cholecalciferol, underscoring the role of supportive interventions while awaiting definitive diagnosis. This report highlights the urgent need for earlier access to neuroimaging and genetic testing to facilitate timely diagnosis and intervention. Strengthening multidisciplinary collaboration among clinicians, researchers, and policymakers is essential to improve outcomes for patients with rare genetic disorders like MLD, particularly in under-resourced regions

Primary Aortic Angiosarcoma: A Rare and Elusive Diagnosis. A Case Report and Review of the Literature

Bilateral Medial Meniscus Allograft Transplantation and Concomitant Revision ACL Reconstruction: A Case Study

IntroductionCoronary artery fistulas (CAFs) are rare abnormal connections between coronary arteries and cardiac chambers or great vessels. These fistulas can be congenital or acquired through trauma, infection, or iatrogenic injury, with pathologic relevance determined by site and resistance1. These connections are usually solitary and are commonly incidentally detected during coronary angiography. To date, optimal management for multiple, small and clinically insignificant fistulas remains controversial and requires consideration of individual patient risk factors and potential complications1. The clinical significance and consequences of CAFs, in particular ones that are incidentally found, are still unclear, and management is often individualised to the patient. We present an interesting case of incidentally diagnosed pulmonary CAF in a patient with chest pain ultimately attributed to a non-cardiac etiology.