Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder. It primarily involves cutaneous, neurological and skeletal systems, with vascular involvement being relatively uncommon. Among the reported vascular manifestations, stenoses, aneurysms, and arteriovenous fistulas (AVFs) are infrequent but potentially serious complications. Their manifestation with cerebral steal syndrome is of even lower prevalence. We report a case of a 52-year-old female with known NF1 who presented with progressive headache, transient episodes of right-sided weakness and speech problems. Total selective digital subtractive cerebral angiography revealed AVF of the left occipital region, primarily supplied by a large longitudinal defect in the V4 segment of the left vertebral artery, with additional feeders from the left occipital and ascending cervical arteries. A vertebrobasilar "steal" phenomenon was observed, with retrograde filling of the basilar circulation via the carotid system. Given the progressive symptoms and hemodynamic compromise, the patient underwent endovascular embolization using balloon catheters, detachable coils and Onyx 18 liquid embolic agent. The procedure was uneventful, with successful devascularization of the AVF and improved perfusion to the surrounding tissue. Post procedural recovery was favorable, with disappearing of existed symptoms. AVFs are rare in patients with NF1, and their pathogenesis is not fully understood. Steal syndrome occurs when high flow vascular malformations divert blood from surrounding brain parenchyma, leading to ischemic symptoms. Our case contributes to the limited literature on NF1-associated AVF and supports early neurovascular imaging in symptomatic individuals. Awareness of this rare vascular complication in NF1 is crucial for timely diagnosis and management.

Methemoglobinemia is a potentially life-threatening hematologic condition characterized by the oxidation of hemoglobin iron, which impairs oxygen delivery. While acquired methemoglobinemia in children is commonly associated with direct oxidizing agents, accidental ingestion of industrial solvents like nitroethane presents unique management challenges. Nitroethane, found in products such as paint hardeners, metabolizes into nitrites, causing potent oxidative stress. Unlike many other causes, nitroethane ingestion is specifically associated with "rebound" methemoglobinemia due to the toxin's continued metabolism and the relatively short half-life of the antidote, methylene blue. We report the case of a 6-year-old boy who presented with vomiting, abdominal pain, and progressive central cyanosis following the accidental ingestion of a mouthful of paint chemical hardener (AkzoNobel) that had been stored in a reused drinking water bottle. Upon arrival, he exhibited cyanosis refractory to high-flow oxygen, with oxygen saturation (SpO2) fluctuating between 88% and 93% on room air. Venous blood gas analysis confirmed severe methemoglobinemia with levels exceeding 30%. The patient was treated with intravenous methylene blue (1 mg/kg), resulting in a rapid reduction of methemoglobin to 9% within 1 hour. However, 8 hours post-treatment, he developed clinically significant rebound methemoglobinemia (16.6%) accompanied by desaturation, necessitating a second dose of methylene blue. He was monitored in the intensive care unit and general ward for delayed complications and was discharged well on day 8. This case illustrates the severe toxicity of small volume nitroethane ingestion and highlights the critical risk of rebound methemoglobinemia. Because the oxidative effects of nitroethane metabolites can outlast the therapeutic duration of methylene blue, a single dose of antidote is often insufficient. Clinicians must ensure prolonged observation and serial co-oximetry monitoring for these patients. Furthermore, this case underscores the vital public health need for keeping hazardous chemicals in original, child-resistant containers to prevent accidental pediatric poisonings.

Cutaneous mastocytosis (CM) is a rare disorder characterized by abnormal mast cell proliferation limited to the skin. Conventional treatments including antihistamines and corticosteroids often provide suboptimal symptom control, with less than 50% of patients responding adequately to H1-antihistamine therapy. Omalizumab, a humanized monoclonal antibody that inhibits immunoglobulin E (IgE) binding to mast cells, represents a promising therapeutic alternative for refractory cases. We report a 14-year-old Middle Eastern female with a 1-year history of intensely pruritic, hyperpigmented macules significantly impacting her quality of life. Physical examination revealed widespread excoriated erythematous and brown macules with positive Darier's sign. Histopathological examination showed CD117-positive mast cells, confirming CM diagnosis. Laboratory investigations were normal except for mildly elevated IgE (217 IU/mL). Conventional management with antihistamines, corticosteroids, and Montelukast provided minimal improvement, with persistent urticarial attacks requiring systemic steroid pulses. Omalizumab was initiated at 150 mg monthly subcutaneously and increased to 300 mg monthly due to relapses. Following dose optimization, the patient achieved complete symptom resolution and improved quality of life without adverse events. This represents the first documented pediatric CM case in Saudi Arabia successfully treated with omalizumab. The treatment demonstrated remarkable efficacy when conventional therapies failed, with excellent safety profile. Omalizumab may serve as a viable therapeutic alternative for pediatric patients with refractory CM. Further clinical trials are needed to establish optimal treatment protocols.

Fungal infection of the bronchial stump is rare, characterized by insidious clinical manifestations and often misdiagnosed as bacterial infection or tumor recurrence. Most reported cases involve Aspergillus fumigatus, with Aspergillus flavus encountered far less frequently. Importantly, fungal colonization of the bronchial stump by Cryptococcus species has not been previously documented, nor has a mixed infection involving Cryptococcus and other fungi at this site. These rare presentations highlight diagnostic blind spots in postoperative airway management and underscore the need for heightened clinical awareness. Case 1: A 53-year-old man underwent left upper lobectomy for adenocarcinoma four years prior. In 2024, he presented with hoarseness and chest tightness. Positron emission tomography-computed tomography (PET-CT) revealed a metabolically active soft-tissue nodule adjacent to the surgical suture line. Bronchoscopic biopsy combined with metagenomic next-generation sequencing (mNGS) confirmed the diagnosis of bronchial stump aspergillosis (BSA). The patient received posaconazole therapy for 7 months. Case 2: A 77-year-old woman underwent right lower lobectomy for adenocarcinoma six years earlier. In 2025, she developed cough with sputum production. CT demonstrated bilateral pneumonia with focal consolidation/atelectasis and bilateral pleural effusions. Bronchoscopy and mNGS identified a mixed infection with Candida albicans and Cryptococcus neoformans at the bronchial stump. Following treatment with caspofungin and fluconazole, her clinical symptoms improved, and follow-up CT imaging showed resolution of inflammatory changes. Although fungal infection of the bronchial stump is rare, it warrants early consideration when post-lobectomy patients develop persistent symptoms unresponsive to antibiotics. Early radiological clues-such as unexpected metabolic activity around suture granulomas or localized nodular thickening at the stump-should prompt further evaluation. When conventional cultures remain negative and clinical deterioration continues, early initiation of mNGS can facilitate timely pathogen identification and guide targeted antifungal therapy.

Fibrosing mediastinitis (FM) is a rare disease characterized by excessive fibrotic tissue proliferation in the mediastinum, often leading to compression of vital structures. Tuberculosis is a common cause in certain regions. Diagnosis is challenging due to non-specific symptoms. This report explores the integrated diagnostic value of advanced three-dimensional (3D) computed tomography (CT) reconstruction and bronchoscopy in tuberculous fibrosing mediastinitis (TFM). A 69-year-old female presented with a 2-year history of progressive exertional dyspnea. Chest contrast-enhanced CT revealed mediastinal soft tissue infiltration, calcified lymph nodes, and right middle lobe opacities. 3D reconstruction from the CT data precisely demonstrated occlusion of the right middle lobe medial segmental bronchus, severe stenosis of the lateral segmental and right lower lobe dorsal segmental bronchi, and an extrinsic "knife-cut" stenosis of the right main pulmonary artery. Bronchoscopy confirmed multiple distorted and occluded bronchi with anthracotic pigmentation. Mycobacterium tuberculosis complex nucleic acid was detected in bronchoalveolar lavage fluid. The patient was diagnosed with TFM and showed symptomatic improvement after initiating anti-tuberculosis therapy combined with corticosteroids. The integration of pulmonary contrast-enhanced CT 3D reconstruction with bronchoscopic evaluation provides a powerful, minimally invasive approach for diagnosing TFM. This multimodal strategy enhances the visualization of complex mediastinal involvement, aids in differential diagnosis, and can critically inform management decisions to avoid unnecessary high-risk procedures.

Pneumoconiosis is a chronic occupational lung disease characterized by progressive diffuse pulmonary fibrosis and irreversible impairment of pulmonary function. The coexistence of bilateral giant bullous emphysema (GBE), end-stage chronic obstructive pulmonary disease (COPD), chronic hypercapnia, and cor pulmonale in pneumoconiosis patients is exceedingly rare and poses extraordinary anesthetic challenges. We report the anesthetic management of a 67-year-old man with stage III pneumoconiosis complicated by bilateral GBE, stage IV COPD, chronic hypercapnia, and cor pulmonale. Preoperative pulmonary function testing revealed profoundly impaired lung function, with a predicted forced expiratory volume in one second (FEV1) was 19.22%. The patient underwent staged video-assisted thoracoscopic bullectomy. Anesthetic management included individualized one-lung ventilation (OLV) using pressure-controlled ventilation-volume guaranteed (PCV-VG) mode, acceptance of permissive hypercapnia, and a stepwise contingency strategy involving continuous positive airway pressure (CPAP) and pulmonary vein clamping for refractory hypoxemia. Both procedures were completed successfully without the need for extracorporeal membrane oxygenation (ECMO). Postoperatively, the patient demonstrated significant symptomatic improvement, and FEV1% increased to 28.62% at follow-up. This case demonstrates that a meticulously tailored anesthetic strategy, incorporating staged surgery, advanced OLV strategies with CPAP and pulmonary vein clamping, can enable the safe performance of bullectomy and yield meaningful functional improvement in this patient with pneumoconiosis and profoundly compromised pulmonary function.

Percutaneous radiofrequency ablation (RFA) is a widely accepted, minimally invasive treatment for hepatic tumors. However, it can rarely cause severe complications, including visceral and diaphragmatic perforation leading to acute empyema. Such complex scenarios, particularly in patients with underlying liver cirrhosis and malignancy, require a highly specialized management strategy. We report a successful treatment case utilizing a staged, multidisciplinary approach prioritizing source control. A 76-year-old man with Child-Pugh B cirrhosis, previously treated for descending colon cancer and liver metastases, presented with fever and malaise 90 days after his third RFA session. Imaging revealed a right subphrenic abscess contiguous with the transverse colon and right pleural space, suggesting a delayed iatrogenic perforation caused by thermal injury. We diagnosed acute empyema secondary to pleuro-colonic communication. Given the severe infection and extensive adhesions, we executed a three-stage therapeutic strategy. Stage 1 involved thoracic infection control via drainage and thoracoscopic debridement. Stage 2 addressed the abdominal source; a diverting ileostomy was created to mitigate contamination, followed later by a right hemicolectomy and diaphragmatic repair using a Gerota's fascia patch. Stage 3 managed the residual refractory empyema and persistent air leak through an open window thoracostomy, followed by bronchial occlusion using endobronchial Watanabe spigots. The patient fully recovered, was discharged on day 162, and remains recurrence-free at the 15-month follow-up. Delayed colonic and diaphragmatic perforation is a rare but life-threatening complication of hepatic RFA. A rigorous staged, multidisciplinary approach focused on definitive source control and management of chronic pleural complications is essential for a favorable outcome in such complex cases.

BackgroundManaging emerging infectious exposures in the context of urgent surgical intervention, where standard guidelines may not provide direct answer, can be challenging.Case DescriptionWe present a unique case involving a 69-year-old female patient undergoing video-assisted thoracic surgery (VATS) for biopsy-confirmed adenocarcinoma of the right lower lobe (RLL). During preoperative preparation, a live Ixodes tick was found embedded in the patient’s right flank, directly over the intended surgical site, accompanied by a large erythematous rash suggestive of erythema migrans. Despite the patient being asymptomatic of Lyme disease, this finding posed an important question of whether to delay a time-sensitive surgery or proceed through a potentially infected field. The tick was resected fully intact and sent to the path lab for analysis. In adherence with Centers for Disease Control and Prevention (CDC) and Infectious Diseases Society of America (IDSA) guidelines, and after infectious disease consultation, the surgical team proceeded with the surgery. The surgery and recovery proceeded uneventfully.ConclusionsThis case illustrates a rare intersection of vector-borne illness and thoracic oncologic surgery. It demonstrates that timely surgery can safely proceed, in the appropriate context, after complete tick excision. The case also underscores the importance of preoperative skin examination in endemic regions and the need for clinical guidelines when unexpected, rare infections occur at surgical sites.

BackgroundImmunoglobulin G4-related disease (IgG4-RD) is a rare autoimmune fibroinflammatory condition that can affect multiple organs. Sinonasal and orbital involvement is exceedingly uncommon and poses significant diagnostic challenges. These manifestations often mimic malignancy, chronic infection, or other inflammatory disorders, leading to delayed diagnosis and repeated investigations. This study aims to illustrate the diagnostic challenges and management of IgG4-RD and to increase awareness of this rare presentation among clinicians.Case DescriptionWe present a case of a 52-year-old male with a history of diabetes mellitus who developed a left-sided nasal mass extending into the orbit, resulting in nasal obstruction, epistaxis, proptosis, and diplopia. Imaging revealed a sinonasal mass with orbital extension through the lamina papyracea, raising suspicion for invasive or neoplastic pathology. Initial biopsies were inconclusive, demonstrating chronic inflammatory changes with no evidence of malignancy, granulomatous disease, or invasive fungal infection. Despite surgical debulking and close follow-up, symptoms persisted and recurred. Multiple subsequent biopsies were performed, which continued to show non-specific inflammatory findings. Further evaluation revealed elevated serum IgG4 levels, and repeat histopathological analysis demonstrated dense lymphoplasmacytic infiltration with an increased number of IgG4-positive plasma cells and an elevated IgG4/IgG ratio, consistent with IgG4-related disease. Correlation of clinical features, radiologic findings, laboratory results, and histopathology confirmed the diagnosis of IgG4-RD involving the sinonasal cavity and orbit.ConclusionsThis case emphasizes the importance of maintaining a high index of suspicion for IgG4-RD in patients presenting with sino-nasal-orbital masses, considering the disease’s rarity and non-specific initial symptoms. Early diagnosis through repeated tissue sampling and comprehensive evaluation is essential to avoid misdiagnosis and unnecessary interventions.

BackgroundIntradural dorsal arteriovenous fistula (AVF) is a rare spinal vascular malformation that primarily affects the blood-supplying arteries of the intradural dorsal. Its clinical manifestations are dominated by bilateral lower limb weakness and a lack of specificity in early symptoms, which can easily lead to underdiagnosis or misdiagnosis. Thus, the successful diagnosis of intradural dorsal AVF is difficult.Case DescriptionA 56-year-old woman presented with lower limb weakness for 3 months without significant sensory deficits. The patient has a history of hyperthyroidism, but the condition has been cured, and the patient is not currently taking any long-term medications. Upon admission, the patient reported no abnormal sensations related to urination or defecation. We performed muscle strength testing, which revealed a grade V-muscle strength in both lower limbs. Magnetic resonance imaging (MRI) of the lumbar spine showed abnormal vascular shadows in the lumbar spinal canal. Initially misdiagnosed as extradural AVF, right iliac artery angiography via digital subtraction angiography (DSA) revealed an AVF at the L3–4 segment, supplied by nerve root artery from sacral external arteries and drained through chondromalacia veins. Due to the tortuous and delicate nature of the vessels at the lesion site, the microcatheter cannot reach the affected area. Therefore, we opted for surgical treatment. During surgery, the fistula in intradural dorsal was found to be supplied by upward and downward radicular arteries, draining through a soft meningeal vein. The drainage veins were clipped using an aneurysm clip and subsequently resected by electrocoagulation. The operation was successful, with significant improvement in lower limb weakness to class V muscle strength. Postoperative MRI at 2 weeks showed disappearance of abnormal vascular shadow. During subsequent telephone follow-ups, the patient did not report any significant abnormalities.ConclusionsIntradural dorsal AVF treatment aims to block arteriovenous shunts through surgical or endovascular methods. Surgical resection is the primary treatment. In this case, the long, narrow feeder arteries favored direct surgery. However, surgery risks trauma, cerebrospinal fluid leakage, infection, and neurologic injury; therefore, treatment decisions should consider fistula characteristics, vascular anatomy, and patient health status.