Salmaniya Medical Complex

Pleural effusion is a common clinical condition with a wide differential diagnosis, ranging from benign inflammatory processes to advanced malignancy. In some patients, malignant pleural effusion may represent the first manifestation of an underlying lung cancer. Early recognition and systematic evaluation are therefore essential for timely diagnosis and management. We report the case of a fifty eight year old Saudi male who presented with progressive shortness of breath and right sided chest discomfort of three weeks duration. The patient had a long history of cigarette smoking but no previous diagnosis of malignancy. Physical examination revealed reduced chest expansion and markedly diminished breath sounds over the right lower lung zone. Initial chest radiography demonstrated a moderate right sided pleural effusion without a clearly visible lung mass. Further diagnostic evaluation included contrast enhanced computed tomography of the chest, which confirmed a large right sided pleural effusion with partial lung collapse, mild pleural thickening, and a small irregular lesion in the right upper lobe. Diagnostic thoracentesis yielded exudative pleural fluid according to Light criteria. Microbiological studies were negative for bacterial infection and tuberculosis. Cytological examination of the pleural fluid revealed atypical epithelial cells suspicious for malignancy, and repeat analysis supported the diagnosis of malignant pleural effusion. Subsequent CT guided biopsy of the right upper lobe lesion demonstrated histopathological features consistent with pulmonary adenocarcinoma. Management initially focused on symptomatic relief through pleural fluid drainage and supportive care. Following confirmation of the diagnosis, the patient was referred for oncologic evaluation and further staging. This case highlights the importance of considering malignancy in patients presenting with unexplained pleural effusion, particularly in individuals with significant smoking history, and emphasizes the role of pleural fluid analysis and tissue biopsy in establishing the diagnosis.

Sickle cell disease (SCD) is a common hereditary hemoglobinopathy in Bahrain and is associated with a broad spectrum of acute and chronic multisystem complications. Fat embolization syndrome (FES) is a rare but life-threatening complication of SCD that results from the systemic release of fat globules, typically originating from ischemic bone marrow, leading to pulmonary, neurological, and multiorgan dysfunction. Early diagnosis is often challenging due to its non-specific clinical presentation and overlap with other sickle cell complications.We report the case of a 22-year-old male with SCD who presented with a vaso-occlusive crisis (VOC) and subsequently developed acute chest syndrome and pulmonary embolism during hospitalization. The patient later experienced acute neurological deterioration, and brain magnetic resonance imaging (MRI) demonstrated the characteristic “starfield pattern,” supporting the diagnosis of cerebral fat embolization. His clinical course was further complicated by acute kidney injury, sepsis-induced cardiomyopathy, and tension pneumothorax, requiring prolonged intensive care management. Treatment included repeated red blood cell exchange transfusions alongside comprehensive supportive care. The patient demonstrated gradual neurological and cardiopulmonary recovery following an extended intensive care unit stay.This case highlights the diagnostic complexity of FES in SCD and emphasizes the importance of early clinical suspicion in patients presenting with respiratory failure or neurological deterioration following VOC. MRI, particularly the identification of the starfield pattern, serves as a key diagnostic tool. Prompt recognition and initiation of exchange transfusion remain critical in improving clinical outcomes and reducing mortality.

Neuromyelitis optica spectrum disorder (NMOSD) is a severe autoimmune disorder affecting the central nervous system, often misdiagnosed as multiple sclerosis. The identification of aquaporin-4-IgG (AQP4-IgG) has improved diagnostic precision and enabled targeted therapies. Given the unique regional challenges in healthcare delivery across the Middle East and North Africa (MENA) region, the Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS) convened an expert panel to develop evidence-based, region-specific consensus recommendations for diagnosis and management. These guidelines endorse the 2015 International Panel for NMO Diagnosis (IPND) criteria, emphasizing AQP4-IgG testing via cell-based assays. Differential diagnosis should consider multiple sclerosis, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and acute disseminated encephalomyelitis (ADEM). For acute treatment: initiate high-dose intravenous methylprednisolone promptly and use plasma exchange early for severe or steroid-refractory attacks. For long-term immunotherapy, monoclonal antibodies (rituximab, inebilizumab, eculizumab, ravulizumab, satralizumab, or tocilizumab) are recommended according to availability and patient factors; conventional immunosuppressants remain alternatives when biologics are inaccessible. Guidance is provided for pediatric patients and for pregnancy and breastfeeding, including planning after ≥ 12 months of disease stability and early postpartum treatment resumption. These MENACTRIMS guidelines aim to improve NMOSD outcomes across the region by promoting accurate diagnosis and timely, effective therapy.

Scapulothoracic bursitis is an uncommon condition characterized by inflammation of the bursa located between the scapula and the thoracic wall. This disorder is frequently associated with repetitive shoulder movements or systemic inflammatory diseases. This report describes a 56-year-old woman with rheumatoid arthritis who presented with painless swelling in the left upper back. Imaging studies identified a well-defined, fluid-filled lesion beneath the latissimus dorsi and serratus anterior muscles. Ultrasound demonstrated an anechoic lesion without vascularity, and magnetic resonance imaging (MRI) confirmed a T1 hypointense and T2 hyperintense lesion with fine septations. The lesion resolved spontaneously without surgical intervention, possibly facilitated by ongoing anti-inflammatory therapy. This case emphasizes the need to consider scapulothoracic bursitis in the differential diagnosis of posterior chest wall masses and demonstrates the critical role of imaging in preventing unnecessary invasive procedures.

Falciform ligament appendagitis is an exceedingly rare cause of acute abdominal pain resulting from inflammation and infarction of the falciform ligament’s fatty appendage. Its presentation often mimics more common causes of acute abdomen, making diagnosis challenging. We report the case of a 36-year-old Bangladeshi male with no prior medical history who presented with a four-day history of severe epigastric pain radiating to the right upper quadrant (RUQ). Clinical examination revealed localized tenderness and a palpable soft, well-circumscribed swelling, with laboratory investigations within normal limits except for mild leukocytosis and a slightly elevated alanine aminotransferase (ALT). Initial ultrasound suggested a rectus sheath hematoma; however, contrast-enhanced CT imaging demonstrated a fat-density lesion adjacent to the falciform ligament with surrounding inflammatory stranding, consistent with falciform ligament appendagitis. The patient was managed conservatively with analgesia, intravenous fluids, and supportive care, resulting in progressive improvement and complete resolution of symptoms by hospital day 4 without surgical intervention.

Pulmonary arterial hypertension (PAH) is a severe and potentially life-threatening manifestation of connective tissue diseases, often presenting insidiously and complicating timely diagnosis. We report the case of a 48-year-old Saudi woman with no prior chronic illness who presented with progressive exertional dyspnea and fatigue over six weeks. Examination revealed mild central cyanosis, elevated jugular venous pressure, and a prominent right ventricular heave. Laboratory evaluation showed elevated NT-proBNP and mild hypoxemia, while echocardiography demonstrated right ventricular dilation and an estimated pulmonary artery systolic pressure of 70 mmHg. Right heart catheterization confirmed pre-capillary pulmonary hypertension. Serologic workup revealed high-titer anti-U1 RNP antibodies, ANA positivity, and features consistent with mixed connective tissue disease (MCTD), with no evidence of left heart disease, thromboembolic disease, or significant interstitial lung involvement. Management included combination PAH-targeted therapy with an endothelin receptor antagonist and a phosphodiesterase-5 inhibitor, alongside low-dose corticosteroid immunosuppression. Supportive care comprised oxygen supplementation and close hemodynamic monitoring. Over three months, the patient’s functional status improved from WHO functional class III to II, with reduction in NT-proBNP and increased six-minute walk distance. This case underscores the diagnostic challenge of MCTD presenting primarily with PAH, emphasizing that subtle systemic features may precede cardiovascular compromise. Early recognition, prompt hemodynamic assessment, and a multidisciplinary management strategy are crucial to improve prognosis and prevent irreversible right ventricular dysfunction. Clinicians should maintain a high index of suspicion for PAH in patients with connective tissue disease, even in the absence of overt systemic manifestations.

BACKGROUND Haemophilus influenzae is a gram-negative bacterium that normally inhabits the mucosal surfaces of the upper-respiratory tract system of many healthy individuals. The capsular types of H. influenzae are found to be responsible of invasive infections such as meningitis, epiglottitis, orbital cellulitis, and bacteremia. H. influenzae is rarely described as a causative agent of periprosthetic joint infection (PJI). Here, we report a case of H. influenzae causing prosthetic knee joint infection 1 year after total knee arthroplasty. CASE REPORT A 59-year-old woman was admitted with a 1-day history of a painful right knee and inability to bear weight. She had undergone a unilateral total knee arthroplasty 1 year ago. She reported a history of recurrent upper-respiratory tract infections, with the most recent episode occurring 3 months prior to the current presentation. H. influenzae grew on 2 knee aspirate specimens and a peripheral blood culture. The isolated H. influenzae strain was beta-lactamase-negative and identified as a non-type B by the public health laboratory. The patient was successfully treated with intravenous ceftriaxone for a total of 30 days followed by oral cefuroxime for 14 days. She underwent a first-stage revision of the right total knee arthroplasty, debridement, irrigation, and spacer placement; subsequently, second-stage revision was performed. CONCLUSIONS The findings of this case report, coupled with a thorough review of the literature, demonstrate the pathogenic potential of H. influenzae in periprosthetic joint infection (PJI). The diagnosis of PJI can be difficult and the management needs a multidisciplinary team.

Objective: The objective of this paper is to assess the quality of life and fatigue among adult patients diagnosed with inflammatory bowel disease (IBD) compared to healthy controls. Methods: We conducted searches in Medline and Embase from January 2015 to April 2025. We included publications that examined adult patients with IBD without comorbidities, compared them to healthy controls, and assessed quality of life and fatigue. Two reviewers independently conducted study selection, data extraction, and quality assessment. We described results narratively due to high heterogeneity. Results: Ten studies with a pool of 10,661 participants were selected. Three studies showed significantly worsened mental and physical components for quality of life in IBD patients compared to healthy controls. Additionally, three studies reported that fatigue was more prevalent among patients with IBD than in healthy controls. Conclusions: Our review suggests that quality of life is significantly reduced, and fatigue is more prevalent in IBD patients compared to healthy controls. Further long-term follow-up studies are needed to provide a more comprehensive understanding of the global impact of IBD, particularly in non-Western populations.