Aims and Scope AME Case Reports (ACR, AME Case Rep, Online ISSN: 2523-1995) is an open access, peer-reviewed online journal publishing original and educationally valuable case reports in all medical disciplines. ACR has been indexed by PubMed/PubMed Central (PMC) and Web of Science [Emerging Sources Citation Index (ESCI)]. ACR received its latest impact factor of 0.6 for the year 2025. The journal aims to provide clinical information on common and rare cases for healthcare professionals, researchers and others. The high quality of its content is assured by a rigorous review process and supervised by a strong editorial board. All submissions are reviewed by the Editor-in-Chief, Associate Editors or Editorial board members, as well as invited referees. The entire submission is managed through OJS system, an electronic system to provide an efficient way and ensure a rapid turn around of papers submitted for publication. 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Example of statements in published articles: https://actr.amegroups.org/article/view/8875; https://med.amegroups.org/article/view/8358/html. Contact with Editorial Office Suki Tang, Corresponding Editor, AME Case Report Email: acr@amegroups.com Publisher Information ACR is published by AME Publishing Company. Address: Hong Kong branch office: Flat/RM C 16F, Kings Wing Plaza 1, NO. 3 on Kwan Street, Shatin, NT, Hong Kong, China. Updated on July 10, 2026
A case report of ocular infection caused by Aspergillus fumigatus
Background: Aspergillus fumigatus (A. fumigatus) can cause invasive infections in various sites of the body, including invasive pulmonary, hematogenous disseminated, and intracranial infections, posing substantial challenges for diagnosis and treatment. The methods of identification in this laboratory are worthy of study. Case Description: A 44-year-old male was admitted to our hospital with a 1.5-month history of bilateral scleral icterus accompanied by progressive visual deterioration. The patient was previously diagnosed with acute liver failure [hepatitis B e-antigen (HBeAg)-negative chronic hepatitis B] at another hospital. During hospitalization, his vision in the left eye decreased. Slit-lamp examination during ophthalmologic consultation suggested left endophthalmitis, with concurrent suspicion of retinal detachment. Examinations at admission confirmed the presence of hepatitis B virus (HBV) DNA, acute liver failure (Child-Pugh Class C), moderate anemia. The levels of the inflammatory markers were significantly elevated, including interleukin (IL-6, IL-8, IL-1β), and interferon-gamma (IFN-γ). After obtaining informed consent, emergency vitrectomy of the left eye was performed, retinal detachment repositioning and laser photocoagulation for retinal lesions, cryotherapy for retinal lesions, and vitreous silicone oil implantation in the left eye. The vitreous was cultured, then identified using next-generation metagenomic sequencing (mNGS) technology, enabling the detection of Aspergillus within a short period of time. This enabled a rapid diagnosis of Aspergillus endophthalmitis, guiding subsequent clinical management. After undergoing anti-infection and liver-protective treatment, the patient’s condition stabilized and he was discharged from the hospital. Conclusions: mNGS is a technology that can directly perform high-throughput sequencing of all the genetic material (DNA and/or RNA) of microorganisms in clinical samples (such as blood, bronchoalveolar lavage fluid, cerebrospinal fluid, etc.). The combination of mNGS and conventional detection methods effectively improves the detection rate of fungi.
Superior sulcus tumor with vertebral invasion following initial diagnosis of cavitary lung disease: a case report
Background: Superior sulcus tumors represent a rare and aggressive subset of non-small cell lung cancer characterized by early invasion of adjacent osseous, vascular, and neural structures. Diagnosis may be challenging when clinical and radiographic features overlap with infectious etiologies, particularly in the setting of cavitary lung disease. The increasing prevalence of nontuberculous mycobacterial pulmonary infection further complicates this distinction and may delay recognition of underlying malignancy. This report aims to highlight the diagnostic challenges posed by cavitary pulmonary lesions with confirmed infection and to describe the multidisciplinary management of a superior sulcus tumor with vertebral invasion. Case Description: A 48-year-old woman with a history of tobacco use initially presented with a cavitary right upper lobe lesion and microbiologically confirmed nontuberculous mycobacterial infection. Initial management focused on antimicrobial therapy, with partial radiographic improvement. Persistent symptoms and evolving imaging findings prompted further evaluation. Robotic navigational bronchoscopy revealed a locally advanced superior sulcus adenocarcinoma with invasion of the T3 and T4 vertebral bodies and neural foramina. Invasive mediastinal staging by endobronchial ultrasound confirmed absence of nodal involvement. The patient staged as cT4N0 disease and underwent induction chemoradiotherapy with carboplatin, pemetrexed, and 60 Gy of radiation, achieving a significant metabolic and radiographic response. She subsequently underwent multidisciplinary en bloc resection, including right upper lobectomy, mediastinal lymphadenectomy, and partial T3 corpectomy with T2 to T4 spinal stabilization. The postoperative course was uneventful. Final pathology demonstrated a complete pathologic response with negative margins and no nodal involvement (ypT0N0). Conclusions: This case highlights the diagnostic pitfalls associated with cavitary pulmonary lesions in high-risk patients and emphasizes the importance of maintaining suspicion for malignancy despite microbiologic confirmation of infection. It also underscores the role of multidisciplinary reassessment and induction therapy in facilitating successful resection of selected locally advanced superior sulcus tumors.
Idiopathic granulomatous mastitis a mimicking disease: a case report
Background: Idiopathic granulomatous mastitis (IGM) is a rare, benign, chronic inflammatory breast disease that frequently mimics infection or malignancy, resulting in diagnostic and therapeutic challenges. Although erythema nodosum is a recognized extramammary manifestation, it occurs in approximately 10% of cases and may further obscure timely diagnosis. Our objective is to present a rare case of granulomatous mastitis and highlight the challenges associated with its diagnosis and management. Case Description: We report the case of a 25-year-old Hispanic female who presented with persistent right breast inflammation unresponsive to multiple courses of antibiotic therapy. Diagnostic evaluation with core needle biopsy confirmed IGM. The patient developed concurrent erythema nodosum, representing a rare clinical presentation. Initial management with high-dose systemic corticosteroids resulted in significant adverse effects and progressive disease. Given refractory symptoms and intolerance to medical therapy, the patient underwent a right total mastectomy. Final surgical pathology confirmed the diagnosis of IGM. Conclusions: This case underscores a rare association between IGM and erythema nodosum and highlights the importance of early tissue diagnosis to guide management. While systemic corticosteroids and immunosuppressive therapy remain the cornerstone of treatment, surgical intervention should be considered in patients with severe, refractory disease or those experiencing significant complications from medical therapy. An individualized, severity-based approach and multidisciplinary management are essential for optimizing outcomes in this uncommon condition.
Tislelizumab-induced bullous epidermal necrolysis: case reports and pathogenetic insights
Background: Tislelizumab, a humanized IgG4 monoclonal antibody targeting programmed cell death protein 1 (PD-1), has demonstrated efficacy in advanced malignancies such as non-small cell lung cancer, nasopharyngeal carcinoma, classical Hodgkin lymphoma, and esophageal squamous cell carcinoma. Bullous epidermal necrolysis (BEN) associated with single-agent PD-1 inhibitors is rare and remains poorly characterized. We report three cases to describe their clinical presentation, histopathologic findings, management, and possible pathogenesis. Case Description: Three men aged 56, 81, and 70 years developed rapidly progressive erythema, flaccid bullae, or sheet-like desquamation involving 25%, 40%, and 30% of the body surface area, respectively, within 2–3 days after tislelizumab infusions for retroperitoneal lymph node adenocarcinoma, stage IV lung cancer, and esophageal squamous cell carcinoma. Skin biopsy in Cases 1 and 2 showed full-thickness epidermal or keratinocyte necrosis with subepidermal clefting; direct immunofluorescence in Case 1 was negative. Tislelizumab was discontinued permanently. All patients received systemic methylprednisolone and intravenous immunoglobulin, together with supportive and topical care as appropriate. Re-epithelialization or marked clinical improvement occurred without rechallenge. Conclusions: Early recognition, immediate drug discontinuation, and immunosuppressive therapy were associated with favorable outcomes. Vigilant assessment and multidisciplinary collaboration are important during immune checkpoint inhibitor therapy. Further studies are needed to define susceptibility factors and optimal targeted interventions.
Conservative management leading to delivery of a twin pregnancy complicated by previable preterm premature rupture of membranes: a case report
Background: The threshold of neonatal viability is established at a gestational age of 22–23 weeks. Previable preterm premature rupture of membranes (pPPROM) occurring prior to this period is frequently associated with recommendations for pregnancy termination due to exceedingly high rates of neonatal mortality and maternal infectious morbidity. Case Description: This report describes the case of a 35-year-old multiparous woman. A twin gestation [dichorionic diamniotic (DCDA)] was achieved via in vitro fertilization and embryo transfer (IVF-ET) secondary to tubal factor infertility. At 18 weeks and 6 days of gestation, protrusion of the amniotic sac to the vaginal introitus occurred, resulting in pPPROM. A multidisciplinary team conducted a comprehensive assessment. After detailed counseling, an active conservative management strategy was implemented. This encompassed targeted antibiotic therapy, emergent cervical cerclage, planned administration of fetal lung maturation agents, and intensive maternal-fetal surveillance. The pregnancy was successfully prolonged for nearly 10 weeks, during which infection was controlled and normal fetal growth was maintained. At 28 weeks and 3 days of gestation, preterm labor necessitated cesarean delivery. Two live neonates were delivered; notably, Fetus B was delivered using the en caul cesarean delivery technique. Conclusions: This case illustrates that, with meticulous patient selection and individualized intervention, management of pPPROM occurring before the established limit of viability can yield favorable perinatal outcomes. These findings challenge the conventional paradigm of relying solely on gestational age criteria for decision-making.
Case report: retentive fibroid tumor of the ileocecal region during pregnancy
Background: Desmoid type fibromatosis (DTF) is a rare, non-metastasizing but locally invasive intermediate soft tissue tumor. With an annual incidence of 2–4 per million, it is particularly rare during pregnancy. The particularity of this case is that the patient is pregnant, 14 weeks gestation, placenta previa, and a large mass is found in the abdominal pelvic cavity. The patient requests to terminate the pregnancy and remove the abdominal pelvic cavity mass. The large mass originates from ileocecal area, which is extremely rare and can be an excellent supplement to the literature. Case Description: A 32-year-old woman found out she was pregnant 6 weeks after her last period and had no discomfort. At 14 weeks of pregnancy, ultrasound and magnetic resonance imaging (MRI) showed: there was a huge hypoechoic mass above the uterus, accompanied by connecting blood vessels. It was misdiagnosed as uterine fibroids. Through multidisciplinary team (MDT) assessment, formulated a surgical plan. The patient and her family signed the informed consent form and decided to undergo the surgery. Following termination of pregnancy, exploratory laparotomy uncovered a mass originating from the ileocecal region, with vascular connections to the uterine surface but no significant adhesions. The patient underwent successful tumor resection with ileocecal resection. Histopathological examination of the mass confirmed a diagnosis of DTF, characterized by spindle cells without significant atypia. Immunohistochemistry was pivotal, showing nuclear positivity for β-catenin and a Ki-67 index of <10%, while being negative for markers like CD117, effectively ruling out gastrointestinal stromal tumor (GIST). Through this case, we recognize that there is a vascular connection between the tumor and the uterus, and its origin is not necessarily the uterus; it could be of intestinal origin. The uniqueness of this case lies in: a huge mass was found in the pregnant woman’s abdominal and pelvic cavity, without intestinal obstruction, and there is a vascular connection with the uterus. Conclusions: This case underscores the diagnostic difficulty of DTF. A clear diagnosis depends on postoperative pathological examination and immunohistochemistry, and multidisciplinary collaboration is of vital importance.
Cardiogenic shock associated with stress-induced cardiomyopathy in the setting of diabetic ketoacidosis initially suspected to be septic shock: a case report
Background: Shock associated with diabetic ketoacidosis (DKA) is commonly hypovolemic or distributive in nature, reflecting its underlying pathophysiology and precipitating factors. However, in rare cases, DKA can precipitate stress-induced cardiomyopathy, which may lead to cardiogenic shock. In addition, DKA causes metabolic derangements, increasing the risk of additional cardiac complications. Case Description: A 30-year-old woman with no known past medical history presented with acute onset of fever and altered mental status. Laboratory evaluation demonstrated hyperglycemia, metabolic acidosis, elevated anion gap, increased beta-hydroxybutyrate, and elevated lactate. Diabetic ketoacidosis and hyperosmolar hyperglycemic state (DKA/HHS) overlap was diagnosed, and possible sepsis was also considered. Standard management was initiated. However, the patient continued to require high-dose vasopressors. Further evaluation revealed diffuse ST-segment elevations on electrocardiography and a reduced left ventricular ejection fraction (LVEF) with mid-distal anteroseptal and apical hypokinesis on transthoracic echocardiography. Right and left heart catheterization demonstrated low-output cardiogenic shock with biventricular failure, requiring intra-aortic balloon pump (IABP). With hemodynamic stabilization and treatment of DKA/HHS, IABP was successfully weaned off. Serial echocardiography demonstrated normalization of LVEF, which was consistent with stress-induced cardiomyopathy. Conclusions: Shock in the setting of DKA is not necessarily hypovolemic or distributive. In cases of persistent shock in DKA, clinicians should pursue early cardiac evaluation and consider mechanical circulatory support for possible cardiogenic shock due to stress-induced cardiomyopathy. Early hemodynamic stabilization alongside rigorous treatment of DKA is important for favorable outcomes.
Congenital knee deformity: rare case report and unexpected finding in the delivery room
Background: Congenital knee dislocation (CKD), or genu recurvatum, is an uncommon congenital deformity marked by knee hyperextension and restricted flexion. It may occur either as an isolated finding or in association with other conditions. CKD can be diagnosed prenatally or postnatally. Most of the cases are treated during infancy by manipulation and serial casting or splinting without surgical intervention. This case report aims to enhance the understanding of this condition and its associations, improving the process of early diagnosis and management to prevent long-term functional impairment. Case Description: We report a case of a full-term female newborn with bilateral passive fixed hyperextension of the knees, limited flexion, and a full range of motion. She was born via lower segment caesarean section (LSCS) to a 28-year-old G3P1A1 (gravida 3, para 1, abortus 1) Emirati patient. The pregnancy was complicated by iron deficiency anemia, frequent micturition, vulvovaginitis, and gestational diabetes mellitus. The patient underwent knee reduction-manipulation and received serial casting and repeated radiographic evaluation for improvement. After 1 year of physiotherapy and serial casting followed by splinting, the patient exhibited an excellent prognosis and is walking normally with no pain or progressive deformity; however, a small degree of hyperextension remains. Conclusions: Early recognition is crucial to enable prompt treatment and improve the likelihood of a favorable outcome. Management should be tailored to the condition of the joint and any associated abnormalities.
Isolated IgG4-related lung disease: a case report
Background: IgG4-related disease (IgG4-RD) represents a chronic, immune-driven fibroinflammatory condition capable of affecting diverse organ systems; within this spectrum, pulmonary involvement (IgG4-RLD) remains comparatively uncommon. This case report outlines the clinical, imaging and pathological features of a patient with IgG4-related lung disease. Case Description: We report a 60-year-old male patient with recurrent fever, chest pain, and cough with hemoptysis. Chest computed tomography (CT) initially showed right upper lobe lesions suggestive of pneumonia, but the patient failed to respond to multiple courses of antibiotics including levofloxacin, nemonoxacin malate, ceftizoxime, and amoxicillin. Further investigations revealed significantly elevated serum IgG4 level (266 mg/dL). Endobronchial ultrasound-guided transbronchial lung cryobiopsy (EBUS-GS-TBLC) confirmed dense lymphoplasmacytic infiltration in the lung tissue, with IgG4-positive plasma cells >50 per high powered field (HPF) and IgG4-positive/IgG-positive cell ratio >50%, consistent with the diagnosis of IgG4-related interstitial lung disease. The patient was treated with oral cyclosporine and mycophenolate mofetil, resulting in significant clinical and radiological improvement. Conclusions: IgG4-RLD should be considered in the differential diagnosis of patients with pulmonary lesions unresponsive to antibiotic therapy. Comprehensive evaluation including serum IgG4 measurement and targeted pathological biopsy is essential for accurate diagnosis. Early initiation of immunosuppressive therapy can effectively improve outcomes and prevent disease progression.
Surgical stabilization of rib fractures in patients with open flail chest results in improved clinical outcomes: a report of three cases
Background: Open flail chest is a rare but life-threatening condition characterized by severe chest wall instability and contaminated wounds, which increase the risk of postoperative hardware infection. Surgical stabilization of rib fractures (SSRF) has shown benefits in blunt thoracic trauma; however, its application in open flail chest remains controversial due to infection concerns. Evidence guiding the decision to perform SSRF in this setting is limited. Case Description: We retrospectively analyzed three patients with open flail chest who underwent SSRF. Clinical data were collected, including demographics, injury characteristics, surgical management, postoperative recovery, and long-term outcomes. All patients underwent timely debridement and internal fixation. Postoperatively, all patients showed favorable recovery with restoration of chest wall stability. No hardware-related infections or chest wall deformities were observed during follow-up periods of 19, 72, and 122 months. Conclusions: For selected patients with open flail chest, when the time from injury to surgery is no more than 8 hours, the open wound contamination is mild, and thorough debridement is performed, chest wall reconstruction and internal fixation surgery may be relatively safe. This approach can help save patients’ lives in the early stage and may lead to favorable long-term outcomes. However, caution should be exercised when considering primary surgery for patients with open contaminated wounds and an injury-to-surgery time exceeding 8 hours. Admittedly, our conclusions need to be validated with more cases.
Carina™ modular robotic-assisted left lower lobectomy after neoadjuvant chemoimmunotherapy for stage IIIA squamous cell lung cancer: a case report
Background: Neoadjuvant chemoimmunotherapy has become a standard approach for locally advanced non-small cell lung cancer (NSCLC), enhancing resectability. However, it also increases surgical complexity because of treatment-induced fibrosis—a challenge well addressed by robotic-assisted thoracic surgery (RATS). This report demonstrates the successful application of a modular robotic platform for post-neoadjuvant left lower lobectomy in a patient with stage IIIA squamous NSCLC, highlighting its precision and feasibility in complex oncologic resections. Case Description: A 51-year-old man was diagnosed with squamous cell carcinoma of the left lower lobe (cT2aN2M0) and achieved a partial response following pembrolizumab plus chemotherapy. After completing neoadjuvant chemoimmunotherapy, robot-assisted left lower lobectomy with systematic lymph node dissection was performed using the Carina™ Modular Robotic System (Ronovo Surgical, Shanghai, China) because of anticipated pleural adhesions and the complex anatomical location of enlarged lymph nodes. The robotic platform demonstrated excellent outcomes: 20 mL blood loss, 5-minute docking time, and 141-minute console time. Intraoperatively, severe pleural adhesions were encountered but successfully managed with robotic assistance, enabling complete dissection and safe tumor resection. The patient recovered rapidly, with chest tube removal by postoperative day 5 and discharge on day 7. Pathology revealed a major pathological response (MPR) with negative bronchial margins. Conclusions: This case demonstrates the technical feasibility of the Carina™ system for complex post-neoadjuvant lobectomy in a patient with stage IIIA squamous NSCLC. Acceptable short-term perioperative outcomes were observed despite pleural adhesions and nodal complexity. Further experience and larger studies are needed to evaluate the potential role of this platform in thoracic surgery.
Idiopathic portal hypertension with transfusion-associated hemolytic anemia: a case report
Background: Idiopathic portal hypertension (IPH) is a rare non-cirrhotic cause of non-cirrhotic portal hypertension, characterized by splenomegaly, hypersplenism, and recurrent variceal bleeding. Transfusion-associated hemolytic anemia with autoimmune features following red blood cell transfusion is an uncommon but serious complication, and its occurrence in IPH patients undergoing invasive procedures has rarely been reported. Case Description: A 20-year-old woman with a 3-year history of recurrent hematemesis and melena presented with acute upper gastrointestinal bleeding. She had chronic anemia (hemoglobin 56 g/L), severe splenomegaly crossing the anterior midline, and hypersplenism (white blood cell 1.53×109/L, platelets 35×109/L). Liver function and coagulation were preserved, and contrast-enhanced computed tomography (CT) showed portal hypertension without cirrhosis. Comprehensive workup excluded viral hepatitis, autoimmune liver disease, Budd-Chiari syndrome, and myeloproliferative neoplasms, leading to a diagnosis of IPH. She underwent covered stent transjugular intrahepatic portosystemic shunt (TIPS) placement, with portal pressure decreasing from 41 to 30 cmH2O. On postoperative day one, after transfusion of washed red blood cells, she developed acute jaundice, dark urine, and worsening anemia (hemoglobin 46 g/L). Laboratory findings revealed indirect hyperbilirubinemia (indirect bilirubin 72.0 µmol/L) and positive direct/indirect anti-human globulin tests, confirming transfusion-associated hemolytic anemia with autoimmune features. She was treated with methylprednisolone (40 mg/day) followed by oral prednisone tapered over 3 months, along with urinary alkalinization and choleretic agents. Hemolysis resolved within 3 days, and no recurrent bleeding occurred despite recent variceal hemorrhage. At 12-month follow-up, the TIPS remained patent, gastroscopy confirmed absence of esophageal varices, and hypersplenism parameters normalized without need for splenectomy. Conclusions: Covered stent TIPS may effectively control portal hypertension and improve hypersplenism in select IPH patients. However, transfusion-associated hemolytic anemia is a potential complication in alloimmunized patients receiving transfusions during TIPS, requiring prompt diagnosis and glucocorticoid therapy. Multidisciplinary collaboration among hepatologists, hematologists, and interventional radiologists is essential for optimal outcomes.
Successful resection of multi-focal lung nodules in a 53-year-old male following preoperative 5G-assisted remote robotic bronchoscopy dye marking: a case report
Background: Robotic-assisted bronchoscopy is an effective platform for transbronchial localization of pulmonary nodules before sublobar resection. However, access to this specialized technology and expertise is often limited to tertiary centers, creating geographic disparities in care. This case report describes the first clinical application of fifth-generation (5G)-assisted remote robotic bronchoscopy for preoperative dye marking, aiming to address this gap in surgical access and resource distribution. Case Description: A 53-year-old asymptomatic male with two persistent ground-glass nodules [14 mm in the right upper lobe (RUL) and 7 mm in the right lower lobe (RLL)] was scheduled for resection. His medical history was unremarkable. Preoperative localization was performed using an artificial intelligence-enhanced robotic bronchoscopy system (PolarisTM). The surgeon, operating from a remote console, successfully navigated to both lesions and injected indocyanine green at each site, with stable network latency of 21–24 milliseconds. Subsequent uniportal video-assisted thoracic surgery (VATS) wedge resection, guided by fluorescence imaging, was completed within 30 minutes with negligible estimated blood loss. Final pathology confirmed that the nodule in the RUL was atypical adenomatous hyperplasia (AAH), while that in the RLL was predominantly bronchiolar adenoma with a focal 2-mm non-mucinous adenocarcinoma in situ (AIS) component. The patient had an uneventful recovery and was discharged on postoperative day (POD) three. Conclusions: This initial case suggests the technical feasibility of 5G remote-controlled robotic bronchoscopy for preoperative localization. The ultra-low latency 5G network ensured real-time and precise control. This approach potentially expands access to specialized thoracic surgical expertise across geographical barriers. Its broader safety, efficacy, and clinical utility require validation in larger, prospective studies.
Artificial intelligence-assisted multidisciplinary therapy for a complex case of cholangitis with septic shock: a case report and simulated decision-making analysis
Background: Acute cholangitis secondary to choledocholithiasis can rapidly progress to septic shock, with multidisciplinary team (MDT) management serving as the cornerstone of its. The potential of artificial intelligence (AI) in simulating such complex clinical decision-making remains underexplored. This study aims to examine the central role of MDT in the management of complex biliary septic shock and to evaluate the feasibility and value of AI in simulating clinical decision-making processes. Case Description: A 52-year-old female patient was admitted with septic shock (blood pressure 91/45 mmHg, heart rate 156 bpm) secondary to choledocholithiasis. Concurrently with real-world MDT management, we employed two large language models (DeepSeek and ChatGPT-5) to simulate MDT decision-making using a standardized clinical prompt. Both AI models demonstrated high concordance with the human MDT on core principles (immediate decompression, broad-spectrum antibiotics) but diverged on specific strategies, favoring percutaneous transhepatic cholangial drainage (PTCD) over the human team’s choice of endoscopic intervention. Following a real-world MDT discussion, emergency endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic nasobiliary drainage (ENBD) was performed. Due to rising amylase (peak 486 U/L) suggesting possible ENBD-related pancreatic duct obstruction, the ENBD was exchanged for an endoscopic retrograde biliary drainage stent on day 6. Concurrently, antibiotic therapy was escalated to imipenem-cilastatin. With this comprehensive strategy, the patient stabilized. Conclusions: MDT is pivotal in complex biliary septic shock. AI demonstrates potential to replicate core diagnostic and therapeutic logic, but current models lack deep perception of “clinical reality feasibility”. AI is a promising decision support tool, particularly in resource-limited settings, but human contextual adaptation remains irreplaceable.
Novel endovascular retrieval of duodenal-penetrating inferior vena cava filters: a report of two cases and technical considerations
Background: Inferior vena cava (IVC) filters are widely used to prevent pulmonary embolism in patients with venous thromboembolism. However, failure to remove retrievable filters within the recommended time window leads to significant long-term complications, the incidence of which has been gradually increasing. While filter tilt, adhesion, and venous wall penetration are commonly encountered, rare complications such as duodenal perforation by a filter foot or recovery hook present unique clinical challenges. Conventionally, such cases have necessitated open surgical removal due to the high risk of massive hemorrhage or bowel injury associated with standard endovascular retrieval techniques. Conventional endovascular retrieval is contraindicated for permanent filters or when the recovery hook has penetrated the IVC wall. This case series demonstrates the successful application of a novel endovascular technique in these two extreme scenarios. Case Description: We describe two patients with IVC filters that had been implanted for 9 and 8 years, respectively, who presented with epigastric pain and were found on gastroscopy to have a filter foot penetrating the duodenal wall. In the first case, a permanent Simon Nitinol filter lacked a recovery hook; in the second, the recovery hook of a Günther Tulip filter had itself pierced the IVC wall, and the filter foot was located in close proximity to the abdominal aorta. Both patients were deemed poor candidates for conventional intervention or refused open surgery. A novel endovascular technique was employed utilizing a combination of balloon-assisted intimal peeling, customized LOOP technology applied to the filter body, and real-time intra-arterial roadmap guidance via a pigtail catheter in the aorta. Conclusions: This novel endovascular technique offers a minimally invasive alternative for complex cases involving permanent filters and IVC-penetrating recovery hooks, with potential applicability in experienced interventional centers, though further validation is required.
Primary pulmonary artery synovial sarcoma: a case report
Background: Primary pulmonary artery synovial sarcoma (PPASS) is an extremely rare cardiac malignancy, often misdiagnosed preoperatively due to its nonspecific clinical and imaging features. This case report aims to enhance diagnostic recognition of this rare entity. Case Description: A 35-year-old male presented with chest pain after activity for 1 month. Physical examination revealed stable vital signs and no significant cardiac murmurs. Laboratory tests showed negative immunofixation electrophoresis, unremarkable urinary light chains and coagulation function, and an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of 2,298 pg/mL. Transthoracic echocardiography (TTE) revealed an irregular solid mass (46 mm × 18 mm) at the pulmonary valve orifice, with a broad base and unclear border. Contrast-enhanced echocardiography showed mild perfusion within the mass. Cardiac magnetic resonance imaging and positron emission tomography/computed tomography (PET/CT) revealed atypical features [ill-defined borders and mild fluorodeoxyglucose (FDG) uptake], raising suspicion for malignancy. The patient underwent surgical resection of the cardiac tumor, pulmonary valvuloplasty, and tricuspid valvuloplasty. Intraoperatively, two distinct tumors were identified and resected. Postoperative pathology revealed a spindle cell tumor. Immunohistochemistry supported a diagnosis of biphasic synovial sarcoma, which was definitively confirmed by fluorescence in situ hybridization (FISH) demonstrating SS18 gene rearrangement. The Ki-67 index was 60%. Six months post-surgery, imaging revealed local recurrence and lung metastases, and the patient received two cycles of ifosfamide, pirarubicin, and mesna chemotherapy with good tolerance. Conclusions: This case highlights the diagnostic challenges of PPASS, which can mimic myxoma on echocardiography. A broad base, unclear border, and atypical contrast perfusion should raise suspicion for malignancy. Definitive diagnosis relies on histopathology and molecular detection of SS18 rearrangement.
Diagnostic and operative challenge of a giant non-pancreatic intra-abdominal pseudocyst: a rare case report
Background: Large, non-pancreatic pseudocysts are rare pathologies that present as lesions in the intra-abdominal wall or peritoneal cavity. These cases can be diagnostically difficult, particularly in situations where fine-needle aspiration yields nonspecific cytology and imaging is also often nonspecific and nondiagnostic. These lesions may mimic hematomas, seromas, cystic neoplasms, and other bowel-related pathologies, which may require surgical excision for definitive diagnosis and curative treatment. Case Description: We present a case of a 73-year-old male with a body mass index of 43 who presented to the emergency department for a ureteral stone and was found on computed tomography (CT) imaging incidentally to have a large left lower quadrant abdominal wall mass. The lesion was highly vascularized and intimately adherent to both the abdominal wall and colon. Two separate biopsy results showed nonspecific cytology and hemorrhagic debris. Operative excision required tedious removal from the bowel and abdominal wall and evacuation of 3 L of fluid. Pathology results showed a chronic pseudocyst lacking an epithelial lining. Conclusions: The case demonstrates the diagnostic limitations of fine-needle aspiration and imaging, along with the potential for abdominal pseudocysts to mimic multiple differentials. Additionally, it highlights the importance of complete surgical excision for diagnostic and curative treatment.
Severe hyponatremia masking cryptococcal meningitis in a fingolimod-treated patient: a case report
Background: Cryptococcal meningitis is a life-threatening fungal infection and diagnostic delays have been associated with increased mortality. In individuals without human immunodeficiency virus infection, immunosuppressive medications are important risk factors for this condition. As it typically affects immunocompromised patients, cryptococcal meningitis may present without classic meningeal signs. In addition, hyponatremia is associated with central nervous system infection and may contribute to encephalopathy, potentially making the diagnosis even more challenging. Case Description: A 77-year-old man with a history of multiple sclerosis receiving fingolimod for 15 years presented with a four-week history of progressive confusion. On presentation, he was afebrile. Physical examination revealed a lethargic appearance with disorientation to place, without meningeal signs or new focal neurologic deficits. Laboratory evaluation demonstrated severe hyponatremia and lymphopenia. Head computed tomography (CT) was unremarkable. Cerebrospinal fluid (CSF) analysis showed mild pleocytosis and mildly elevated protein levels, with a normal opening pressure. CSF smear demonstrated encapsulated round yeast-like organisms. Cryptococcal polymerase chain reaction of the CSF was positive, and both CSF and blood cultures grew Cryptococcus neoformans, consistent with disseminated cryptococcosis. Dual antifungal therapy with liposomal amphotericin B and flucytosine was initiated. The patient’s systemic symptoms and altered mentation subsequently resolved without sequelae. Conclusion: In patients receiving fingolimod who present with subacute altered mental status and severe hyponatremia, clinicians should maintain a high index of suspicion for cryptococcal meningitis and consider early cerebrospinal fluid evaluation, even in the absence of fever or meningeal signs.
ALK-rearranged lung adenocarcinoma transforming to mucoepidermoid carcinoma in a 45-year-old female: a case report
Background: Pulmonary mucoepidermoid carcinoma (PMEC) accounts for less than 1% of pulmonary malignancies and is predominantly primary, exhibiting distinct clinical manifestations and treatment responses compared to lung adenocarcinoma (LUAD). Although the incidence of histological transformation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) following tyrosine kinase inhibitor (TKI) therapy is approximately 3–14%, transformation from LUAD to PMEC is an extremely rare event. Currently, there is a lack of unified understanding and diagnostic/therapeutic guidelines concerning its mechanism, clinical features, treatment strategies, and prognosis. This article reports a case of HT from LUAD to PMEC following anaplastic lymphoma kinase (ALK)-TKI therapy, aiming to enhance clinicians’ awareness of this rare condition and provide preliminary reference for the diagnosis and management of similar cases. Case Description: This report describes a 45-year-old female patient who was admitted to the hospital with a chief complaint of “persistent cough, sputum production, and dyspnea for 2 years, accompanied by chest tightness for 1 week”. She was diagnosed with ALK exon 20 mutation-positive left LUAD (cT1N1M1, stage IV). After 28 months of first-line ALK-TKI alectinib therapy, the patient experienced disease progression. Repeated pathological biopsy confirmed a transition from LUAD to PMEC, with persistent ALK mutation. Subsequent treatment included lorlatinib and third-line chemotherapy (pemetrexed/carboplatin regimen for four cycles), achieving acceptable disease control. The progression-free survival (PFS1) prior to transformation was 8 months, and the patient is currently receiving palliative care. Conclusions: Tumors that undergo LUAD-to-PMEC transformation after ALK-TKI therapy exhibit persistently low levels of ALK fusion and characteristic immunohistochemical alterations [deletion of thyroid transcription factor-1 (TTF-1)/Napsin A, upregulated expression of CK5/6/P40], along with inherent resistance to ALK-TKIs. When heterogeneous resistance emerges during TKI therapy, prompt repeat biopsy with concurrent pathological and next-generation sequencing (NGS) testing is recommended. If confirmed, immediate transition to phenotype-specific therapy should be initiated. Although this is a single-case observation requiring validation in larger cohorts, these findings provide preliminary guidance for clinical identification and management of such rare transformations.
Robot-assisted vesical neck h-shaped flap plasty for vesicourethral anastomotic stenosis: a case report
Background: Vesicourethral anastomotic stenosis (VUAS) is a challenging complication, occurring in 2%–7% of patients following radical prostatectomy. Endoscopic treatment fails in some patients, severely impairing their quality of life. Open reconstructive surgery is technically demanding with a long learning curve. Thus, to address a complication known as vesicourethral anastomotic stenosis following radical prostatectomy, we propose a new robot-assisted vesical neck H-shaped plasty. Case Description: A 57-year-old patient with prostate cancer developed vesicourethral anastomotic stenosis (with a stenosis segment length of 2 cm) 4 months after laparoscopic radical prostatectomy. Following short-term recurrence of the condition after three transurethral incisions for VUAS, the patient received robot-assisted vesical neck H-shaped plasty for posterior urethral reconstruction. The surgical technique primarily involves constructing an H-shaped bladder flap, tubularizing it to reconstruct a funnel-shaped posterior urethra, performing a tension-free anastomosis between the vesical neck and the posterior urethra, and constructing a retrocurvature structure of the urethra. Treatment success was defined by both anatomical and functional criteria, unobstructed passage of a 17 Fr cystoscope or a urinary flow rate >15 mL/s. The patient in this study achieved adequate early urinary patency and no related complications. Conclusions: Based on short-term follow-up, robot-assisted vesical neck H-shaped flap plasty is feasible for vesicourethral anastomotic stenosis, but long-term follow-up is needed for verification.
Staged transition from veno-arterial extracorporeal membrane oxygenation to left ventricular assist device using Extra-VAD in acute myocardial infarction cardiogenic shock: a case report of individualized management
Background: Acute myocardial infarction (AMI) and cardiogenic shock (CS) in patients requiring veno-arterial extracorporeal membrane oxygenation (V-A ECMO) are life-threatening, with extremely high mortality and complication rates due to hemodynamic instability and multiple organ dysfunction. A durable left ventricular assist device (LVAD) is a viable therapeutic option for these patients with severely impaired cardiac function who have failed attempts to wean from V-A ECMO. However, accurate assessment of right heart function during V-A ECMO and the complication rates associated with prolonged V-A ECMO support limit its long-term use. The MoyoAssist® Extra-VAD enables preoperative assessment by simulating the hemodynamic profile of a permanent LVAD, thereby helping to avoid complications associated with prolonged V-A ECMO support, bridging therapy decision-making and mitigating the risk of postoperative right ventricular failure (RVF) after LVAD. Case Description: A 58-year-old male was diagnosed with AMI accompanied by CS requiring V-A ECMO and intra-aortic balloon pump (IABP) assistance. Due to low left ventricular ejection fraction (LVEF) and difficulty in weaning from V-A ECMO, the patient was transferred to our hospital via ambulance on day 14 after V-A ECMO assistance. Despite optimization of medical therapy for heart failure following admission, ventricular function remained poor. Moreover, the IABP was removed on day 18 because of abdominal pain and marked leukocytosis. Over time, the sequelae of extended V-A ECMO support became apparent, characterized by systemic inflammation, impaired multi-organ perfusion, and the emergence of typical device-related complications. In response to this deterioration, an interventional Extra-VAD was implanted on day 19. Following several days of Extra-VAD support, despite improvement in general condition and organ function, left ventricular function remained poor. Thus, on day 25, our team proceeded with definitive LVAD implantation and removal of the Extra-VAD. The patient was discharged with LVAD support on postoperative day 38 and transitioned to outpatient follow-up care. Conclusions: This case demonstrates a staged bridging strategy from V‑A ECMO and Extra‑VAD to definitive LVAD therapy for acute circulatory failure. This approach achieves hemodynamic stability and organ protection in critically ill patients with shock and multi‑organ injury, provides a crucial time window for subsequent treatment, and underscores the value of a staged, minimally invasive, and individualized mechanical circulatory support strategy.
Concurrent human epidermal growth factor receptor 2-positive breast cancer with axillary nodal metastasis in a patient with pituitary prolactinoma: a case report
Background: Managing high-risk human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) concurrent with a functioning pituitary adenoma is clinically challenging. Current oncological guidelines lack specific clinical consensus protocols regarding the simultaneous administration of intensive dual-HER2 targeted therapy, tyrosine kinase inhibitors (TKIs), and continuous dopamine agonists. Case Description: A 56-year-old postmenopausal woman with a 5-year history of pituitary prolactinoma presented with a painless left breast mass over a 2-year duration. Her serum prolactin (PRL) was strictly pharmacologically controlled within the normal physiological range (8–15 ng/mL). Diagnostic breast magnetic resonance imaging (MRI) revealed a suspicious 3 mm × 5 mm spiculated nodule [Breast Imaging Reporting and Data System (BI-RADS) 4a]. She initially underwent an excisional biopsy which confirmed invasive carcinoma. Due to intraoperative sentinel lymph node positivity, the tumor’s proximity to the nipple, and the patient’s explicit refusal of breast conservation, she underwent a left modified radical mastectomy. Definitive surgery demonstrated a pathologically paradoxical finding: a minute 0.8 cm (pT1b) invasive ductal carcinoma accompanied by early axillary lymph node metastasis (pN1a, 2/27 positive nodes). The tumor exhibited high proliferative potential (Ki-67 40%) and parallel HER2 amplification (3+) in both the invasive and the high-grade ductal carcinoma in situ (DCIS) components. Adhering to a multidisciplinary plan while maintaining her cabergoline regimen uninterrupted, she received adjuvant chemotherapy, dual anti-HER2 blockade (trastuzumab and pertuzumab), and radiotherapy. She declined extended adjuvant neratinib due to gastrointestinal toxicity concerns. She remains completely disease-free at 36 months post-surgery with stable pituitary function. Conclusions: This case underscores the ongoing safety, feasibility, and practical compatibility of integrating dopamine agonists with intensive BC therapies. Furthermore, the paradoxical early lymphatic dissemination of a sub-centimeter primary tumor under physiological PRL levels suggests profound local crosstalk between HER2 and PRL receptor (PRLR) signaling. This necessitates vigilant management of even small, highly proliferative lesions in patients with concurrent endocrine comorbidities.
High-volume mucinous ascites secondary to low-grade mucinous neoplasm arising in a mature cystic teratoma: a case report
Background: Low-grade mucinous neoplasms arising within mature ovarian cystic teratomas are rare and represent an uncommon ovarian source of pseudomyxoma peritonei (PMP). Because mucinous ascites and peritoneal disease are most often associated with appendiceal or other gastrointestinal primaries, ovarian-origin mucinous neoplasms may be underrecognized, contributing to diagnostic uncertainty and potential misclassification. Case Description: We report the case of a 30-year-old nulliparous woman who presented with progressively worsening abdominal pain, distension, and respiratory discomfort. Imaging revealed a large, complex abdominopelvic mass with extensive intraperitoneal fluid accumulation. Tumor markers were notable for markedly elevated carcinoembryonic antigen (CEA) with normal cancer antigen 125 (CA125). Aspiration yielded mucinous fluid, and endoscopic gastrointestinal evaluation was unremarkable. Surgical exploration demonstrated a markedly enlarged ovarian mass and a high volume of mucinous intraperitoneal fluid, with no gross appendiceal abnormalities. Approximately 22 L of mucinous material were evacuated. Surgical management included oophorectomy, appendectomy, omentectomy, and peritoneal biopsies. Pathologic evaluation revealed a low-grade mucinous neoplasm arising within a mature cystic teratoma, with immunohistochemical features consistent with gastrointestinal-type differentiation. The postoperative course was uncomplicated, and the patient is undergoing close surveillance with planned interval imaging. Conclusions: This case highlights a rare but clinically significant ovarian source of mucinous peritoneal disease that closely mimics appendiceal pathology. Increased clinical and pathologic awareness of mucinous neoplasms arising within mature cystic teratomas may be important to support accurate diagnosis, appropriate multidisciplinary evaluation, and informed management.
Complete bilateral spontaneous pneumothorax at moderate altitude revealing Marfan syndrome: a case report
Background: Primary spontaneous pneumothorax (PSP) commonly occurs in young adults. However, simultaneous complete bilateral pneumothorax is rare and potentially fatal. Changes in barometric pressure associated with altitude exposure may precipitate pneumothorax in predisposed individuals, particularly those with unrecognized connective tissue disorders. Case Description: We report a case of a 17-year-old previously healthy male who developed sudden severe dyspnea while recreational skiing at a moderate altitude of 2,200 meters. Emergency on-site management required immediate bilateral needle decompression, followed by urgent hospital transfer. Imaging confirmed a complete bilateral pneumothorax with bilateral apical subpleural blebs. Sequential bilateral chest tube placement was performed, followed by staged bilateral video-assisted thoracoscopic surgery (VATS) with apical wedge resection and mechanical pleurodesis. Postoperative recovery was uneventful, with no recurrence during follow-up. Etiological investigations showed normal alpha-1 antitrypsin levels. Transthoracic echocardiography revealed a bicuspid aortic valve associated with moderate aortic regurgitation (grade 2/4). The combination of clinical, radiological, and cardiac findings ultimately led to the diagnosis of previously unrecognized Marfan syndrome. Conclusions: This case highlights complete bilateral spontaneous pneumothorax as a dramatic sentinel event revealing Marfan syndrome, potentially precipitated by moderate altitude exposure. It underscores the importance of systematic etiological evaluation in young patients presenting with severe or atypical pneumothorax and emphasizes the role of early multidisciplinary management to prevent life-threatening complications.
Smooth muscle actin (SMA)-negative uninodular plexiform fibromyxoma: case report of a challenging atypical presentation of a rare gastric mesenchymal tumor in a 25-year-old female
Background: Plexiform fibromyxoma (PFM) is an uncommon, benign mesenchymal tumor typically arising in the gastric antrum and usually characterized by a multinodular, plexiform growth pattern of smooth muscle actin (SMA)-expressing myofibroblastic-like cells. Rare variants with uninodular architecture and absence of SMA expression pose significant diagnostic challenges, as they may mimic gastrointestinal stromal tumors (GISTs) and require comprehensive histopathologic, immunohistochemical, and molecular evaluation to avoid misdiagnosis and inappropriate therapy. Case Description: Here, we present a case of PFM with a rare uninodular architecture, complete absence of SMA expression and no detectable MALAT1-GLI1 translocation in a 25-year-old female with unremarkable laboratory work-up (hemoglobin 13.9 g/dL, normal blood count and biochemistry) presented with diffuse upper abdominal discomfort and a palpable epigastric mass noted on self-examination. Physical examination revealed a firm, non-tender mid-abdominal mass without peritonism. The tumor measured 13 cm and was discovered as a palpable mass on self-examination during diagnostic work-up for upper abdominal discomfort. Histologically, the lesion was composed of bland spindle cells embedded in a loose myxoid stroma, lacking the classic multinodular configuration. Immunohistochemistry was negative for SMA, DOG1, S100, CD34, desmin, and anaplastic lymphoma kinase (ALK). Molecular analysis revealed no pathogenic mutations in KIT or platelet-derived growth factor receptor alpha (PDGFRA) and no detectable gene fusions. The final diagnosis was most consistent with uninodular PFM as diagnosed by exclusion. Conclusions: This case highlights the importance of an early multimodal diagnostic work-up (including histology, immunohistochemistry, and next-generation sequencing) in atypical gastric mesenchymal tumors, e.g., PFMs, to avoid misdiagnosis as a GIST and inappropriate tyrosine kinase inhibitor therapy. Complete surgical resection with negative margins using stomach-preserving techniques is curative and associated with an excellent prognosis.
Severe radiodermatitis and implant loss associated with pembrolizumab and olaparib following pre-pectoral breast reconstruction in a 31-year-old female: a case report
Background: Endoscopic nipple-sparing mastectomy (E-NSM) with immediate implant reconstruction is increasingly adopted to preserve breast appearance and quality of life. Immune checkpoint inhibitors (ICIs) and poly (ADP-ribose) polymerase (PARP) inhibitors have substantially improved survival in BRCA-mutated triple-negative breast cancer (TNBC). However, the safety of sequential olaparib following concurrent pembrolizumab and radiotherapy in patients with pre-pectoral breast reconstruction remains poorly defined, and the risk of severe cutaneous toxicity and implant loss is underrecognized. Case Description: We herein report the case of a 31-year-old female who presented with a chief complaint of palpable masses in the left breast and ipsilateral axilla. Diagnostic core needle biopsies of the primary breast lesion and axillary lymph node were conducted, and histopathological examination confirmed invasive TNBC with ipsilateral axillary lymph node metastasis. Germline genetic testing further revealed a pathogenic BRCA1 mutation. After completion of multidisciplinary neoadjuvant systemic therapy, the patient underwent E-NSM with immediate pre-pectoral prosthetic breast reconstruction. Postoperatively, the patient received adjuvant pembrolizumab followed by locoregional radiotherapy. Although only grade 2 radiodermatitis (RD) was initially observed, the subsequent initiation of adjuvant olaparib triggered a rapid and catastrophic clinical deterioration. Within one week of commencing olaparib, the patient’s condition progressed to grade 4 severe RD, characterized by extensive full-thickness skin necrosis and eventual implant extrusion, necessitating surgical explantation. Conclusions: This case highlights catastrophic synergistic cutaneous toxicity and implant loss caused by the sequential combination of pembrolizumab, radiotherapy, and olaparib in patients with pre-pectoral breast reconstruction. Olaparib serves as the dominant pathogenic factor, delivering a lethal “second hit” by inhibiting DNA repair in radiation-sensitized, hypovascular skin flaps overlying the implant. Weekly skin toxicity monitoring is mandatory from the initiation of radiotherapy until at least 2 months after the completion of radiotherapy. Pembrolizumab and olaparib should be initiated only after a mandatory washout period of 2 months following the end of radiotherapy, with monitoring performed every 1 to 2 weeks throughout the treatment course. No additional systemic anti-tumor agents shall be administered concurrently with radiotherapy. Upon detection of early skin reactions, prompt intervention with topical corticosteroids and temporary olaparib interruption is indicated, tailored to toxicity severity.
One-lung ventilation with intentional closure of the nonventilated lumen in a patient with giant pulmonary bullae undergoing laparoscopic anterior resection: a case report
Background: Anesthetic management of patients with giant pulmonary bullae undergoing nonthoracic laparoscopic surgery is challenging because positive pressure ventilation (PPV) may further distend or rupture the bullous lung, whereas carbon dioxide (CO2) pneumoperitoneum and Trendelenburg positioning increase ventilatory demand. In conventional one-lung ventilation (OLV) with double-lumen tube (DLT), non-ventilated lumen is usually left open to ambient air. However, this may theoretically promote further bullous distension in closed-chest state. Reports of intentionally keeping the nonventilated lumen closed in this setting are limited. Case Description: An 86-year-old man with a giant pulmonary bulla in the right lung underwent laparoscopic anterior resection for sigmoid colon cancer. Preoperative computed tomography showed a 17.5-cm bulla occupying the right middle-to-lower lung fields, and pulmonary function testing showed moderate obstructive ventilatory impairment. After induction of general anesthesia, a left-sided DLT was placed. OLV was initiated with ventilation of the left lung only, and the lumen connected to the nonventilated right lung was intentionally clamped and kept closed to ambient air as an initial risk-reduction strategy to reduce both direct positive pressure transmission and possible ambient air entrainment. Low tidal-volume ventilation and low-pressure pneumoperitoneum were used. Oxygenation remained acceptable, but progressive hypercapnia and acidosis developed during prolonged CO2 pneumoperitoneum, requiring conversion to two-lung ventilation (TLV). The patient was extubated uneventfully without pneumothorax or evidence of bulla rupture. Conclusions: OLV using a DLT with intentional closure of the nonventilated lumen may be considered a reasonable initial risk-reduction strategy when further inflation of a bullous lung is a major concern. However, prolonged laparoscopic surgery may exceed the ventilatory limits of OLV even when this approach is used. Close monitoring of gas exchange and readiness to convert to TLV are essential.
Langerhans cell sarcoma of the right calf: a case report
Background: Langerhans cell sarcoma (LCS) is an extremely rare malignant tumor originating from the neoplastic proliferation of Langerhans cells. To report a rare case of LCS with a prolonged clinical course following surgical excision and chemotherapy, we present this case report. Case Description: We report the case of a 46-year-old female Han Chinese patient who presented with persistent right calf pain. Surgical excision was performed, and the diagnosis of LCS was confirmed histopathologically and by immunohistochemical evaluation. Postoperative positron emission tomography/computed tomography (PET/CT) performed 24 days after surgery revealed bilateral femoral and tibial lesions, which are consistent with LCS in conjunction with pathological findings. The patient received six cycles of anthracycline chemotherapy. Subsequently, abdominal contrast-enhanced computed tomography (CT) and PET/CT indicated liver dissemination, prompting a switch to six cycles of ifosfamide chemotherapy. Follow-up evaluations demonstrated stable disease. After a treatment-free interval of 23 months, repeat abdominal contrast-enhanced CT showed complete resolution of the liver dissemination. The patient remains in stable condition during regular follow-up, with overall disease duration exceeding 9 years. Conclusions: Given the rarity of LCS, there are no standardized recommendations for adjuvant therapy, including radiotherapy and chemotherapy regimens for both localized and systemic disease. This case suggests that surgical excision followed by chemotherapy may be effective in preventing and controlling recurrence and systemic progression. Further research is needed to establish evidence-based management guidelines for LCS.
Pediatric middle ear actinomycosis: report of two cases
Background: Middle ear actinomycosis is a rare condition, with approximately 50 reported cases in the literature. It typically occurs due to dissemination through the Eustachian tube from the nasopharynx to the middle ear and mastoid cavity and presents as chronic suppurative otitis media (CSOM), requiring long-term antibiotics and surgical debridement. Case Description: We present two pediatric patients with middle ear actinomycosis. The first is a 7-year-old boy with Joubert syndrome who presented with right-sided persistent otorrhea 6 months after ventilation tube (VT) insertion. Histopathological analysis after surgical exploration showed actinomycosis. The patient underwent another debridement for persistent infection, followed by 3 months course of antibiotics to resolve the infection. The second case was that of a 10-year-old girl with no significant medical history who presented with 4 months history of left-sided otorrhea resistant to multiple courses of oral and topical antibiotics. Histopathological examination of the surgically debrided tissue revealed actinomycosis. The infection resolved after surgical debridement and 3 months course of oral antibiotics. Conclusions: Middle ear actinomycosis is a rare cause of persistent otorrhea in the pediatric population and should be suspected in resistant infections to conventional treatment.
Large abdominal wall and intraperitoneal pseudocysts: a diagnosis of exclusion that still requires the scalpel
Response to “Multi-agent pleurodesis: a new horizon in management”
Bronchoscopic lavage for pulmonary aspiration: a case series
Background: Pulmonary aspiration of gastric contents is a life-threatening complication during anesthesia. Although immediate interventions are recommended, the role of bronchoscopic lavage remains controversial due to theoretical concerns about disseminating contaminants and limited clinical evidence. Case Description: We present four illustrative cases of high-risk patients who underwent bronchoscopic lavage following large-volume aspiration of gastric fluid, solid material, or bile. All patients showed immediate improvement in oxygenation and reduction in airway pressure after bronchoscopic lavage, with a total of 250–700 mL of normal saline instilled into the affected lobar bronchi. None developed severe complications such as aspiration pneumonia, severe acute respiratory distress syndrome (ARDS), or death. Notably, one patient with pre-existing lung injury due to necrotizing pancreatitis also recovered favorably. In the two patients with available follow-up imaging, there was no radiographic evidence of bronchoscopic lavage -induced consolidation or diffused contamination. Conclusions: Prompt bronchoscopic lavage may be beneficial following large-volume aspiration, potentially through reducing inflammatory mediators and mechanically clearing particulate matter. Despite limitations inherent to its retrospective design and small sample size, this case series supports the safety and clinical utility of bronchoscopic lavage in this setting. Further large-scale studies are warranted to confirm these findings and establish standardized treatment protocols.
Clinical outcomes following Impella escalation in cardiogenic shock: a single-centre case series highlighting the gap between haemodynamic improvement and survival
Background: The use of temporary mechanical circulatory support has increased in patients with cardiogenic shock, particularly those with acute myocardial infarction (AMI). Impella provides effective left ventricular unloading and haemodynamic stabilisation. Escalation of such systems to higher-flow devices (e.g., Impella 5.0/5.5) has been proposed for patients with inadequate responses to Impella CP; however, the clinical impact and optimal timing of this approach remain unclear. Case Description: We conducted a single-centre retrospective case series of patients who underwent Impella escalation between September 2020 and March 2026. Their clinical characteristics, haemodynamic responses, and outcomes were analysed. Among 130 patients treated with Impella CP, eight underwent upgrades. The underlying aetiology was AMI in six patients and myocarditis in two. Six patients required ECPELLA support. Following the upgrades, four patients were successfully weaned off extracorporeal membrane oxygenation (ECMO). Despite haemodynamic improvements, the overall outcomes were poor. Thirty-day survival was achieved in four patients; however, three experienced severe frailty (Clinical Frailty Scale scores of 7–8). Only one patient survived until hospital discharge. Infection-related complications, particularly sepsis, represented the leading causes of death. Device-related complications (e.g., access site infections) were observed in five patients, who required continuous negative-pressure wound therapy. Conclusions: Impella escalation may facilitate haemodynamic stabilisation and ECMO-weaning in selected patients; however, this may not necessarily translate into improved survival outcomes. Non-haemodynamic factors (e.g., infection and frailty) likely play critical roles in determining patient outcomes. These findings should not be interpreted as evidence against Impella escalation itself, but rather highlight the importance of careful patient selection, comprehensive clinical assessment beyond haemodynamic parameters, and further investigation into the optimal timing of escalation.