Doing More with Less: Complex Meningiomas Illustrative Case Series

Background: Miliary tuberculosis (TB) is a disseminated and potentially fatal form of TB characterized by the hematogenous spread of Mycobacterium tuberculosis, often complicated by anemia of chronic disease. The diagnosis and management of miliary TB, particularly in conjunction with anemia, can be challenging, especially in resource-limited settings. Case presentation: We report the case of a 20-year-old male from a remote region in Eastern Halmahera, Indonesia, who presented with progressive shortness of breath, productive cough, night sweats, unintentional weight loss, and generalized weakness. Clinical examination revealed signs of anemia and respiratory distress. Laboratory investigations confirmed microcytic hypochromic anemia and a positive GeneXpert MTB/RIF test. Chest radiography demonstrated diffuse miliary nodules, consolidation, and cavitation, establishing the diagnosis of miliary TB with concomitant anemia. The patient received a standard six-month anti-tuberculosis therapy regimen, along with supportive care and targeted treatment for anemia and associated symptoms. The patient demonstrated significant clinical and hematological improvement, leading to discharge after 11 days of hospitalization. Follow-up assessments confirmed continued progress and the absence of complications. Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for miliary TB in patients presenting with respiratory and constitutional symptoms, even in the absence of traditional risk factors. The presence of anemia can further complicate the clinical picture. Prompt diagnosis through a combination of clinical assessment, laboratory investigations, and imaging studies, followed by the immediate initiation of appropriate treatment, including the management of anemia, is paramount for achieving favorable outcomes in patients with miliary TB. The case also emphasizes the necessity for comprehensive care and follow-up to ensure sustained recovery and prevent relapse.

Catatonia in resource-limited settings: A case series and treatment protocol

Aims: Coronavirus disease 2019 (COVID-19) has very high mortality in severe forms of disease, where immunopathology plays an important role. Use of immunomodulating therapies including 6 to 12 mg of dexamethasone is well established. Higher doses of corticosteroids were used with reported success in some settings. This study aims to explore the role of pulse dose methylprednisolone therapy in very severe COVID-19 patients in preventing the need for ICU care and death in resource-limited setting. Study Design: Retrospective case series study. Place and Duration of Study: Oak-ta-chat-thal-ta-pwint COVID-19 treatment center in Yangon, Myanmar between September 2021 to December 2021. Methodology: This study included 13 confirmed COVID-19 patients with severe to critical illness, who were treated with pulse dose methylprednisolone therapy. We reviewed the patients’ demographics, comorbidities, and disease severity before starting pulse dose methylprednisolone therapy and changes in oxygen requirement, chest X-ray scores, inflammatory markers, development of significant clinical events, and 28 days mortality after therapy. Results: Before pulse dose methylprednisolone therapy, all 13 patients had very severe disease (mean SPO2/FiO2 = 173 mmHg, mean SPO2 = 88.54%, mean CRP = 115 mg/L, mean ferritin = 1,295.5 ng/mL and mean Brixia Score = 6.54). They received 3-7 days (mean = 5.5 days) of pulse dose methylprednisolone. Ten patients (76%) survived in a setting with limited ICU care. High ferritin was a significant predictor of mortality. Improvement in oxygen requirement was noticeable after 1-11 days (mean = 5.6 days). Hyperglycemia was common and confirmed bacterial infection was found in 3 patients, but all patients received empirical antibiotics therapy. Conclusion: Pulse-dose methylprednisolone therapy may be an effective salvage therapy in a carefully selected subset of very severe COVID-19 patients. It might be a feasible alternative to other more expensive immunomodulating agents and organ support treatments in a resource-limited setting.

Treatment outcomes in patients with papuloerythroderma of Ofuji: A systematic review

The most frequent cause of defect in the mandible is tumor-related surgery. Larger defects cause severe morbidity due to disturbances in function and esthetics. A fibular free flap is one way of filling a bony hole in either the upper or lower jaw. In this study, a new method combining preoperative planning and rapid prototyping for mandible fibula free flap reconstruction after preoperative planning was made based on Mimics software simulating surgery on a workstation. The preparatory work of surgery is divided into two parts: software simulation and model building. During software simulation the authors were able to choose the best site for the osteotomy regarding circulation and the model building can increase the precision and speed of treatment. A description of our surgical approach is presented and is supplemented by an illustrative case.

Airway management in patients with cervical masses poses significant challenges, particularly in resource-limited settings where advanced equipment may be unavailable. This case report describes a 45-year-old female with a large cervical lipoma (8 cm) causing restricted neck extension, admitted for surgical excision under general anesthesia. Due to the mass’s size and location, standard dorsal positioning was unfeasible. The patient was positioned semi-upright using a customized foam cushion, and awake fiberoptic intubation was performed following bilateral occipital nerve and superficial cervical plexus blocks with 0.5% lidocaine. Minor bleeding occurred during ventilation but was managed with tranexamic acid and compression, avoiding hemorrhagic shock. The procedure was successful, with complete mass excision, and the patient was extubated within 90 minutes, showing no residual lesions on postoperative ultrasound. This case highlights the efficacy of awake fiberoptic intubation and adaptive positioning in managing complex airways in resource-constrained environments, emphasizing the need for standardized guidelines to address such scenarios.

HF02-05 THE FIRST TEXTBOOKS ON PEDIATRIC UROLOGY

Objective: Surgical treatment of extracranial meningiomas is challenging. In this study, we present an illustrated case series to share our experience in the treatment of meningiomas with extracranial extension. Method: We retrospectively reviewed the data of 11 patients with meningiomas who underwent surgical treatment between 2008 and 2020. The intracranial and extracranial components were radiologically and intraoperatively confirmed for all patients. Results: The patients included seven men and four women with a mean age of 55.4 years. Most patients presented with facial disfigurement or asymmetrical skull growth. The most common symptom at presentation was headache. The most common location of the meningiomas was the frontal region and those of extracranial growth were the paranasal sinuses and parietal bone invasion. We recognized two distinct modalities of bone destruction: hyperostosis (n=3) and osteolysis (n=8). Pathological investigation revealed atypical features in six patients. Preoperative embolization was attempted in four patients but it proved to be difficult; proper embolization could be achieved only in one patient. The most commonly encountered challenges during surgery were large calvarial and cranial base defects due to bone erosion, dural defects, and managing the superior sagittal sinus with parietal tumors. Excessive blood loss was also of particular concern, which was managed using simple scalp clips, intraoperative transfusion, and other conservative approaches of tumor extensions into paranasal sinuses. No perioperative mortality occurred. Calvarial reconstruction was performed with polymethyl methacrylate cement where needed. Conclusion: Meningiomas with extracranial extension are surgically challenging but treatable. It contains fine neurosurgical trics in its treatment and follow-up.

Assessment of surgeon variability in preoperative planning of reverse total shoulder arthroplasty: a quantitative comparison of 49 cases planned by 9 surgeons

Brucellosis is a zoonotic disease with diverse and often misleading clinical presentations, including hepatobiliary and, less commonly, pulmonary involvement. In this case series, we discuss three patients presenting with complex hepatobiliary infections and pulmonary symptoms, initially misdiagnosed and treated as acute abdomen. Each patient exhibited a history of contact with cattle, abdominal pain, jaundice and systemic symptoms and required prolonged antibiotic courses due to persistent infection with diagnostic dilemma and slow clinical improvement. Diagnosis was a challenge due to negative conventional cultures and serology, necessitating empirical treatment based on clinical suspicion. In endemic regions like Sri Lanka, the lack of advanced diagnostics and the overlapping symptoms of brucellosis with other diseases mandate the need for increased clinical awareness and clinical pattern recognition, especially in resource-limited settings. These cases illustrate the importance of considering brucellosis in patients with prolonged fever, hepatobiliary symptoms and atypical pulmonary involvement. Early recognition of the clinical imprint of the disease can improve outcomes and potentially avoid unnecessary surgical interventions. Prevention measures are necessary to eliminate the spread.

In Indonesia, where lung cancer is often diagnosed at advanced stages, palliative care (PC) faces challenges like cultural and resource limitations. This study presents three cases of suspected lung cancer at Soehadi General Hospital. Despite the lack of specific lung cancer treatment services, a multidisciplinary approach, in line with the Ministry of Health guidelines, was initiated on the first day of hospitalization. Involving specialists, nurses, and spiritual support, the team addressed patients' physical and emotional needs. The cases highlight the importance of early palliative care, even in resource-limited settings, emphasizing its potential to enhance patient care and family support.

Background: Renal cell carcinoma (RCC) is one of the most prevalent kidney malignancies, with increasing incidence due to the widespread use of imaging techniques. It remains a significant healthcare challenge, particularly in resource-limited settings. Nephron-sparing surgery (NSS) is a preferred surgical approach for small and localized tumors, offering both oncological safety and renal function preservation. Methods: This case series analyzed 15 patients diagnosed with RCC who presented to our tertiary care hospital between 2018 and 2024 with a radiologically confirmed unilateral renal mass. Patients were evaluated through clinical assessment, imaging studies, histopathological examination, and laboratory investigations to confirm the diagnosis and guide treatment decisions. Surgical outcomes, postoperative recovery, renal function preservation, and imaging were assessed. Results: The case series included 15 patients (aged 34–75 years), with a male predominance (10/15), reflecting typical RCC demographics. Clear cell RCC (ccRCC) was the most common subtype. One case of right renal leiomyoma was identified, highlighting the need for differential diagnosis. Histopathological examination confirmed various tumor grades, with imaging (CT and MRI) effectively assessing tumor characteristics. Partial nephrectomy was successful in tumor removal, preserving renal function, especially for tumors between 4 and 7 cm. Postoperative follow-up showed no recurrence in most patients, emphasizing the safety and effectiveness of nephron-sparing surgery in localized RCC. Conclusion: Nephron-sparing surgery (NSS) was safe and effective for localized RCC, especially in tumors 4–7 cm. Most patients had no recurrence and preserved renal function, supporting NSS as the preferred option for achieving both oncological control and renal preservation.

Euglycemic diabetic ketoacidosis (EuDKA) is a rare but potentially life-threatening complication of sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy. It is characterized by high anion-gap metabolic acidosis and ketonemia despite near-normal blood glucose levels, which can delay recognition and treatment. Reports from low- and middle-income countries (LMICs) remain limited.This case series from an LMIC describes three patients with type 2 diabetes mellitus and multiple comorbidities, including hypertension, ischemic stroke, chronic kidney disease, and poliomyelitis developed EuDKA associated with SGLT2 inhibitor (SGLT2i) use. Despite blood glucose levels remaining below the typical diabetic ketoacidosis threshold, all patients presented with hallmark metabolic acidosis and ketonemia, posing diagnostic challenges exacerbated by overlapping acute illnesses and limited diagnostic resources. Diagnosis was based on clinical suspicion and laboratory confirmation through venous blood gas analysis, positive ketones, and high anion-gap metabolic acidosis. Management involved standard EuDKA protocols comprising intravenous fluids, insulin infusions, and electrolyte correction, which led to gradual resolution of acidosis and normalization of biochemical parameters. These cases emphasize the importance of maintaining vigilance and providing prompt treatment for EuDKA in complex clinical contexts, particularly within resource-constrained healthcare systems.All three patients developed EuDKA related to SGLT2i use during acute illness but recovered fully following prompt diagnosis and standard DKA management with fluids, insulin, and electrolyte correction. These cases emphasize that early recognition, appropriate management, and patient counseling on temporary drug cessation during intercurrent illness are vital to prevent recurrence, especially in resource-limited settings.

Any oral and maxillofacial surgery often requires reliable anesthesia to ensure analgesia, patient comfort, and surgical efficiency. While general anesthesia is the traditional choice, it carries risks of cardiopulmonary complications, prolonged recovery, and higher resource utilization. A superficial cervical plexus block has emerged as a potential alternative, offering simplicity, safety, and cost-effectiveness. This systematic review aimed to evaluate the efficacy and safety of the superficial cervical plexus block as an alternative to general anesthesia in mandibular and perimandibular, oral, and maxillofacial surgical procedures.Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive search of PubMed, Cochrane, Google Scholar, and Wiley (2000-2024) was conducted. Eligible studies included randomized controlled trials, clinical studies, case series, and case reports involving the superficial cervical plexus block in mandibular and perimandibular surgeries. The risk of bias was assessed using the RoB-2 tool and the Joanna Briggs Institute tools for specific types of included studies.Nine studies (n = 164 patients) were included where the superficial cervical plexus block alone or when combined with supplemental local blocks consistently provided effective intraoperative and postoperative analgesia. In comparative trials, superficial cervical plexus block groups demonstrated significantly lower postoperative analgesic requirements and pain scores compared to general anesthesia or local infiltration (p < 0.05). Case series and reports further supported the superficial cervical plexus block’s high success rate and patient satisfaction, with negligible complications and rare conversion to general anesthesia.The superficial cervical plexus block is a safe and effective alternative to general anesthesia in selected mandibular and perimandibular surgical procedures, particularly in high-risk or resource-limited settings. Despite heterogeneity and small sample sizes, current evidence supports its wider clinical adoption. Large multicenter randomized controlled trials and standardized protocols are recommended to strengthen the evidence base.

Combat-related liver injuries are among the most challenging abdominal traumas due to the high risk of massive hemorrhage, complex associated injuries, and limitations in battlefield medical resources. Rapid surgical intervention remains the cornerstone of management, particularly when non-operative management is not feasible. In this case series, two soldiers with liver injuries underwent emergency laparotomy with direct repair, both later complicated by biloma formation. These were successfully treated with ultrasound-guided pigtail drainage, avoiding reoperation and facilitating recovery. Both patients were discharged in stable condition following structured multidisciplinary care. The cases underscore the critical role of timely surgical intervention, vigilant imaging surveillance, and minimally invasive drainage techniques in reducing morbidity. The integration of damage control principles, early resuscitation, and vigilant postoperative care has significantly improved survival in recent years. A notable complication in liver injuries is the development of bilomas, which may prolong recovery and increase morbidity if not promptly addressed. Minimally invasive approaches, such as ultrasound-guided pigtail catheter drainage, have proven highly effective in managing these collections, avoiding the need for reoperation and reducing patient burden. The application of such adjunctive techniques, alongside critical care support and early mobilization, reflects the evolving standards of combat trauma management. Lessons drawn from these experiences emphasize the importance of multidisciplinary collaboration, adaptability in resource-limited settings, and the translation of combat trauma strategies to civilian practice. Article Details