BackgroundPercutaneous endoscopic gastrostomy (PEG) provides long-term enteral nutrition in patients who cannot maintain adequate oral intake. However, altered gastric anatomy after sleeve gastrectomy can make PEG technically challenging because the stomach becomes narrow and tubular, limiting its distensibility. Although several reports describe PEG placement in patients with reduced stomach size, there is very limited data available for patients with a history of sleeve gastrectomy. This makes such cases unique and important to report, as they add to the limited experience and help guide clinicians in managing similar situations in the future.Case DescriptionWe report a 64-year-old woman with a prior history of sleeve gastrectomy who was referred for PEG tube placement before starting radiotherapy for squamous cell carcinoma of the right buccal mucosa. The patient had previously undergone sleeve gastrectomy in 2010 without any adverse events and later had an incisional hernia repair. During the procedure, identification of the insertion site was initially difficult due to post-surgical changes and obesity. Using careful insufflation, transillumination, and the finger indentation method, a safe site was located and a 24-Fr PEG tube was placed using the pull (Ponsky-Gauderer) technique. The procedure was uneventful, and the patient remained stable post-procedure. She began PEG feeding 12 hours later and was followed up after 24 hours, 5 days, and 1 month, with no complications or tube-related issues.ConclusionsThis case highlights that PEG placement after sleeve gastrectomy is feasible when performed cautiously. With proper patient selection and technique, PEG can be safely achieved in surgically altered anatomy and can serve as an alternative to interventional radiology-guided methods.

BackgroundEctopic thyroid tissue (ETT) is primarily caused by embryonic dysplasia. It is commonly located laterally in the neck or in the thyroglossal duct, as well as in more remote locations like the mediastinum and the subdiaphragmatic organs. The incidence of ETT is relatively rare, and the risk of malignant transformation is extremely low. The clinical symptoms of ETT are typically linked to the site of ETT involvement, and histopathological or biopsy examination is typically used to confirm the diagnosis of ectopic thyroid cancer.Case DescriptionWe present a rare case of a 30-year-old woman with a mass in the neck, who was otherwise asymptomatic. Relevant examinations were performed before the surgery. However, a diagnosis of ectopic papillary thyroid carcinoma (PTC) with metastases in the lateral cervical lymph nodes was confirmed.ConclusionsAn excision of the anterior cervical mass and a lateral cervical lymphadenectomy were performed. Postoperative pathology revealed PTC in the anterior neck mass, with metastases to the lateral cervical lymph nodes. This case shows that thyroid cancer can originate from ectopic tissue, even when no thyroid lesions are present. Thus, early and accurate identification are essential to optimize the diagnosis and clinical treatment of ETT.

BackgroundChronic nonbacterial osteomyelitis (CNO) is a rare inflammatory disorder that commonly causes bone destruction in the metaphysis of long bones, pelvic and vertebral bones, the clavicle, and the mandible. CNO is often misdiagnosed and underreported. This presentation of debilitating back pain caused by CNO showcases diagnostic challenges and potential for novel therapeutic treatment.Case DescriptionA 14-year-old male with Crohn’s disease presented with acute, worsening lower back pain and two months of hematochezia after recently stopping infliximab. Physical examination showed sacral tenderness, diffuse erythematous lesions, normal strength and no focal neurological deficits. A T2 hyperintense mass at S4 on magnetic resonance imaging (MRI) was identified. Skeletal survey was negative; however, repeat MRI indicated phlegmon and epidural abscesses suggestive of osteomyelitis. Initial treatments with intravenous cefazolin and oral minocycline were ineffective, leading to interventional radiology (IR) guided S1 biopsy that revealed fibrous tissue without signs of infection. A left L5–S1 laminotomy and microdiscectomy were performed with surgical pathology of the L5–S1 disc showing focal acute inflammation with no evidence of microorganisms, leading to a diagnosis of CNO. Despite surgery, he experienced worsening pain and gait difficulties. After starting Ustekinumab for Crohn’s disease, his back pain and mobility significantly improved, and he returned to school. Follow-up MRI showed improvement in the epidural swelling, decreased enhancement of the lumbar and sacral canal extending from L4–S3, and significantly decreased osseous enhancement at S1.ConclusionsThis case illustrates an unusual manifestation of CNO with an S1 vertebral lesion. The initial MRI findings and failed treatment with antibiotics resulted in a diagnostic challenge leading to an invasive workup involving multiple biopsies to rule out infection and malignancy and a subsequent L5 laminotomy and microdiscectomy. The timing of symptom onset following cessation of infliximab suggests a Crohn’s flare likely triggered CNO. The soft tissue abnormalities noted on imaging were likely secondary inflammatory changes associated with the vertebral lesion. The resolution of back pain with ustekinumab is in line with other cases of successful resolution of CNO with biologic agents and supports the theory of shared pathophysiology in CNO and inflammatory bowel disease (IBD).

BackgroundChronic pulmonary aspergillosis (CPA) is often asymptomatic; however, respiratory symptoms may trigger detection of the disease. Some asymptomatic patients are diagnosed as having CPA after closer examination of abnormalities on chest computed tomography (CT). We report a rare case in which CPA was diagnosed after surgery for spontaneous pneumothorax.Case DescriptionAn 86-year-old man with old pulmonary tuberculosis and autoimmune hepatitis on oral prednisolone treatment developed a right-sided pneumothorax with persistent air leak and worsening subcutaneous emphysema. Despite thoracic drainage, his condition deteriorated. Chest CT showed numerous cysts and cavities with a small nodule in the right lung and interstitial changes bilaterally, although the precise site of the air leak was unclear. Thoracoscopy revealed adhesions, exudative pleural effusion, and a fibrinous exudate consistent with acute empyema. A 10-mm grayish necrotic mass was found to be adherent to the right upper lobe and to obstruct a 5-mm fistula. To avoid spillage, this material was removed en bloc, and thorough debridement and irrigation were performed. Suspecting fungal infection, we performed a wide wedge resection including the fistula site. Although intraoperative pleural fluid cultures were negative, Aspergillus fumigatus was grown from the resected necrotic material, based on which we initiated 3 months’ treatment with oral voriconazole. The patient recovered uneventfully without recurrence noted until the 2-year follow-ups. Histopathology revealed atelectasis-related sclerosis with nodular scarring and dry necrosis, while fungal growth was confirmed in the lung cavity wall, indicating localized pulmonary aspergillosis complicating a pneumothorax.ConclusionsIn pneumothorax patients with cystic changes in the lungs arising from old healed pulmonary tuberculosis, the potential presence of CPA should also be considered. Even with exposure of fungal colonies in the thoracic cavity during pneumothorax surgery, appropriate intraoperative and postoperative measures could allow even elderly steroid-treated patients to recover completely without recurrence of CPA.

BackgroundLeft ventricular free wall rupture (LVFWR) is a severe complication of acute myocardial infarction that frequently leads to cardiac tamponade and circulatory collapse. Prompt surgical repair and mechanical circulatory support are essential for patient survival. The Impella device provides left ventricular unloading and is increasingly used after cardiac surgeries. However, it carries the risks of bleeding and thromboembolism. Heparin-induced thrombocytopenia (HIT) may be an important contributor to thromboembolic risk. Diagnosing HIT in an acute postoperative setting using the Impella support is particularly challenging. Herein, we present a case of thromboembolism associated with HIT following Impella support after surgical repair of an LVFWR.Case DescriptionA 72-year-old man presented with chest pain. During preparation for percutaneous coronary intervention, the patient developed cardiac arrest and was resuscitated using extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography revealed left circumflex artery occlusion, and echocardiography revealed pericardial effusion. Surgical repair was performed using cardiopulmonary bypass. Intraoperative findings revealed left ventricular rupture in the circumflex artery area. Due to severe ventricular dysfunction, ECMO was continued, and IABP was initially chosen. On postoperative day (POD) 1, after stabilization of bleeding, the IABP was upgraded to Impella for ventricular unloading. ECMO was discontinued on POD 3, and Impella was maintained until POD 9. After Impella was removed, angiography revealed occlusion of both iliac arteries. Bilateral surgical thrombectomy was performed. A latex immunoturbidimetric assay confirmed HIT antibody positivity. Anticoagulation therapy was subsequently switched from heparin to argatroban.ConclusionsThis case illustrates the difficulty in diagnosing HIT in patients on Impella support in the acute postoperative period after cardiac surgery. Clinicians should be vigilant for Impella-associated thromboembolism and understand its possible mechanisms to ensure appropriate diagnosis and prevention.

Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis in infancy and the most frequent reason for hospitalization in the first months of life. While most infections follow a mild course, a proportion of infants develop severe disease requiring intensive care. Electrolyte disturbances, especially hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH), are a recognized complication and may trigger neurological symptoms. Severe hyponatremia with seizures is rarely documented in otherwise healthy term infants, which makes such cases clinically important. The aim of this report is to describe hyponatremia-induced seizures as a rare but clinically important complication of severe RSV bronchiolitis in a previously healthy infant. We report a 1-month-old previously healthy female infant who presented with cough, rhinorrhea, somnolence, and progressive respiratory distress. On admission, the infant developed generalized tonic seizures, and laboratory tests revealed profound hyponatremia with serum sodium of 113 mmol/L. RSV infection was confirmed by nasopharyngeal swab. The infant required transfer to the intensive care unit (ICU), where she was intubated and mechanically ventilated. Hyponatremia was managed with 3% hypertonic saline, and she received empiric antibiotics, later tailored to ceftazidime and amikacin, along with supportive therapy. Ventilatory support was required for 7 days. Neuropediatric assessment confirmed hyponatremia-related seizures, and no underlying neurological disorder was identified. After normalization of electrolytes and gradual clinical improvement, she was discharged after 20 days in good condition. This report highlights that RSV bronchiolitis can, in rare cases, present with profound hyponatremia and seizures even in previously healthy infants. Routine monitoring of serum sodium at admission, cautious use of intravenous fluids, and early recognition of neurological symptoms are essential to avoid serious outcomes. Awareness of this potential complication can help clinicians initiate timely management and prevent life-threatening consequences.

BackgroundCongenital anomalies of the kidneys and urinary tract (CAKUT) comprise a large spectrum of congenital malformations, and combined manifestations of CAKUT spectrum could coexist in the same person, which make the management more challenging. We present a rare clinical case of left incomplete duplex kidney with calculus and homolateral ureterovesical junction obstruction (UVJO) that occurred in a female adult, and report the combined surgical management of lithotripsy by flexible ureteroscopy with holmium laser, and refitting the ureter into the bladder after resection of the affected segment.Case DescriptionA 34-year-old female presented to our outpatient with the chief complaints of intermittent left flank pain for a week. The patient was diagnosed of renal calculus and hydronephrosis on the left side by abdominal color Doppler ultrasound, and intravenous pyelogram (IVP) revealed left incomplete duplex kidney, and UVJO, meanwhile, computerized tomography (CT) scan revealed the calculus located in the lower moiety of the incomplete duplex kidney, and the diameter of it was about 1.8 cm. The patient was diagnosed of left incomplete duplex kidney with calculus, hydroureteronephrosis and UVJO homolaterally. The flexible ureteroscopy with holmium laser was applied to remove the calculus, following a double-J ureteral stent insertion. The ureterovesical reimplantation was performed synchronously. The postoperative recovery and follow-up were uneventful.ConclusionsThis report documents a rare case of multiple renal anomalies that included left incomplete duplex kidney with calculus, hydronephrosis, and homolateral UVJO. Flexible ureteroscopy with holmium laser is a safe and feasible option to manage the calculus in the incomplete duplex kidney, and homolateral UVJO can be effectively treated by vesicoureteral reimplantation in one operation.

BackgroundCreutzfeldt-Jakob disease (CJD) is a universally fatal, rapidly progressive neurodegenerative disorder attributable to misfolded prion proteins. Emergency physicians should consider CJD in their differential in a patient presenting with altered mental status, especially those exhibiting rapidly progressive neurologic decline and cerebellar dysfunction on exam. Typical emergency department (ED) testing is non-diagnostic, but a lumbar puncture (LP) is a critical step to diagnosing this disease. Due to the infrequency of presentation, disposal of waste products for infection control can often be overlooked but does require special precautions. High suspicion and prompt detection through specialized cerebrospinal fluid (CSF) studies, in conjunction with neurology consultation, can play a pivotal role in the patient’s care and diagnosis of this rare but devastating disease.Case DescriptionWe describe a 75-year-old male presenting with rapid changes in mentation, functional ability, behavior and personality over a period of months. His neurologic exam demonstrated hyperreflexia, dysdiadochokinesia, and a “startle” response with pronounced myoclonus. More common CJD mimics were considered to exclude other reversible causes of infectious, metabolic, autoimmune, and endocrine etiologies without any findings. Due to the rapid onset of symptoms and abnormal neurologic exam findings, we proceeded with an emergent LP and prompt neurology consultation. Neurology recommended magnetic resonance imaging (MRI) and specialized CSF markers 14-3-3 protein, T-tau, real-time quaking-induced conversion (RT-QuIC) testing to be added on to the CSF with admission to their service. Approximately one week into his stay, the diagnosis was confirmed via the specialized CSF testing and MRI findings, providing his family with diagnostic answers for their loved one. Hospice was arranged and the patient passed away several weeks later surrounded by his family and friends.ConclusionsDespite its rarity, CJD is on the rise and ED providers should have a high suspicion in patients with rapid neurologic decline. Performing a LP, advocating for brain MRI and neurology consultation can play a pivotal role in the patient’s care. Understanding how this disease process spreads and how to properly dispose of waste products is essential for the hospital system and the ED provider.

BackgroundPatients with clonal cytopenia of undetermined significance (CCUS) who undergo hip replacement surgery are at risk of serious complications such as bleeding, infection, and anemia. There are certain difficulties in clinical treatment. Such cases have not been reported in international medical journals.Case DescriptionA 35-year-old man with CCUS for 4 years developed bilateral avascular necrosis of the femoral head 1 year after hormone therapy for the blood disorder. The patient required arthroplasty surgery due to hip pain and functional limitations. The patient’s persistent severe deficiency of platelets, red blood cells, and granulocytes limited the operation. Before surgery, the multidisciplinary team formulated the blood transfusion treatment plan for correcting blood system abnormalities, the treatment plan for basic internal medicine diseases, the minimally invasive manipulation anesthesia plan, the surgical plan, the postoperative refined care and the rapid recovery plan. We completed bilateral hip arthroplasty surgery for patients and had good recovery of hip joint function during the 6-month follow-up after surgery (Harris Hip Score =90 points).ConclusionsCCUS patients have a higher operation risk when perform the total hip arthroplasty. Under the collaborative treatment of the multidisciplinary team, we successfully completed the patient’s surgery and achieved a good surgical outcome.