BackgroundThere are hundreds of pathogens that cause lung infections. Compared to infections caused by a single pathogen, mixed infections account for a larger proportion of pulmonary infections and have a more severe clinical presentation, while treatment options differ between the two. We aimed to explore the advantages of metagenomic next-generation sequencing (mNGS) in the diagnosis and treatment of mixed infections.Case DescriptionTo investigate the specific pathogens in a 79-year-old male pneumonia patient who had recurrent cough with poor empirical treatment, we collected bronchoalveolar lavage fluid (BALF) from the patient and performed mNGS technology, along with Sanger sequencing and polymerase chain reaction (PCR) was carried out to confirm the authenticity of the pathogens detected by mNGS. The findings showed that rare pathogen Scedosporium boydii (S. boydii, reads: 18) and Mycobacterium avium complex (MAC, reads: 19) were detected, and the patient was subsequently transferred to another hospital for the same mNGS with the same results as the first detection. Therefore, combined treatment with voriconazole, ethambutol, azithromycin, and levofloxacin were given to the S. boydii and MAC for 1 week, and then patient’s condition improved and discharged.ConclusionsmNGS, a non-targeted sequencing technology, could improve the efficiency of clinical diagnosis for mixed infection of rare or atypical pathogens, bring new ideas for clinical pathogen diagnosis, and improve patient prognosis.

Systemic Epstein-Barr virus (EBV)-positive T-cell lymphoma of childhood (STCLC) is a rare disease with few clinical reports and high mortality. By exploring the clinical manifestations of a child with STCLC in our hospital auxiliary examination and diagnostic and therapeutic process, to deepen pediatricians' understanding of this disease. This paper describes a 5-year-old Chinese girl who presented with acute fever and epistaxis. After admission, relevant ancillary tests indicated the presence of hemophagocytic lymphohistiocytosis (HLH) and the combination of EBV infection in this patient. Pathology of the cervical lymph node biopsy and bone marrow flow cytology examination indicated STCLC, and a diagnosis of STCLC combined with HLH was clear. Although the girl was clearly diagnosed within a few days and treated with chemotherapy and symptomatic support, she eventually died on the 6th day after admission due to progressive worsening of her disease. STCLC is a rare T-cell lymphoproliferative disorder that occurs primarily in the setting of acute EBV infection, usually presenting as HLH. It is a rapidly progressive and fatal disease of children and young adults characterized by monoclonal expansions of EBV-positive T-cells with an activated cytotoxic phenotype and by malignant proliferation. The mortality rate is close to 100%.

Despite its life-threatening nature, serotonin syndrome (SS) often eludes initial recognition and remains an underreported condition that can occur with the administration of serotonergic drugs alone or in combination with other medications known to increase levels of serotonin. The diagnosis of SS relies on clinical assessment, as laboratory tests and imaging studies cannot definitively confirm the condition. The majority of reported cases of SS involve polypharmacy rather than single-drug overdose. Diagnosing SS can be challenging for physicians, particularly in the intensive care unit (ICU) settings where patients often present with multiple comorbidities. Nevertheless, SS should be considered in the differential diagnosis, mainly when the treatment regimen includes multiple serotonergic medications. We present a case of SS that developed in a patient following the administration of fentanyl. The patient had a medical history of opioid use disorder and was on buprenorphine, amitriptyline, and pregabalin. Symptoms indicative of SS appeared within four hours after fentanyl was administered and began to improve within six hours after cessation of the potential offending agents, with complete resolution occurring within 24 hours. Our case underscores the significance of conducting a thorough neurological examination and medication assessment for the prompt diagnosis of SS. Additionally, it examines the medications that could have potentially triggered the events described in this case.

Chylothorax is an uncommon condition defined by the escape of lymphatic fluid into the pleural space originating from the thoracic duct. Our case involves a male patient in his 60s who developed traumatic chylothorax after being involved in a bicycle collision. The total body computed tomography (CT) showed multiple fractures of the ribs and spine, including a fracture of the anterior column of the Th12 vertebra. The patient was placed under observation in the intensive care unit and because of the instability of the Th12 fracture operative stabilization was performed with a percutaneous dorsal pedicle screw-rod spondylodesis. One day postoperatively, the patient suffered from acute respiratory distress; vital signs and hemoglobin levels remained stable. CT angiography was performed showing a large amount of fluid in the right pleural cavity. A chest tube was placed and a total of 3 L of fluid was evacuated. The next day a chylous production of 2 to 3 L per 24 hours was observed. Initiation of nutritional management for the patient involved a medium-chain triglyceride (MCT) diet in conjunction with total parenteral nutrition (TPN) administration. Due to the ongoing chylous leakage, despite the MCT diet and TPN, the patient underwent video-assisted thoracic surgery (VATS); the thoracic duct was identified and clipped. In addition, a VATS chemical pleurodesis with talc was performed. The chylous drainage ceased and after a total of 8 weeks the MCT diet was stopped. This case report encompasses relevant diagnostic evaluations and the array of medical treatments applicable to a chylothorax resulting from trauma.

The medial collateral ligament (MCL) is crucial for ensuring implant stability after unicompartmental knee arthroplasty (UKA). Intraoperative MCL lesions can cause valgus instability, affecting function and implant longevity, and thereby negatively impacting the patient's outcome. Every surgeon who performs UKA may encounter this complication in their daily practice. In this context, this case report presents a rescue technique. The existing literature does not specify a protocol for managing this complication. This article presents the first instance of accidental midsubstance section of the MCL during medial UKA, managed through primary suture and augmentation repair with a fascia lata (FL) autograft. The procedure was subsequently replicated step by step on an anatomical specimen. A 54-year-old woman, previously successfully treated with right medial UKA, was referred to our clinic following an unsuccessful attempt at conservative treatment for osteoarthritis in the left knee. Scheduled for a left medial UKA, an inadvertent midsubstance transection of the deep part of the MCL was encountered during the procedure, resulting in valgus instability. The MCL was promptly repaired and reinforced using an ipsilateral FL augmentation autograft. Subsequent UKA surgery was successfully completed. Follow-up at one year revealed favorable post-operative outcomes, with symmetrical stability on stress radiographs and no indications of early loosening. To our knowledge, this article represents the first documentation of the direct management for this rare yet severe complication. This case report could therefore inspire any surgeon facing this complication. The technique, grounded in biomechanical principles, ensures direct medial stability whilst allowing uninterrupted continuation of the initial procedure. Characterized by simplicity and reproducibility, the approach demonstrates favorable short-term outcomes. Because the results should be interpreted considering the limited impact of a case report, further prospective studies are essential to substantiate and strengthen these findings.

Coronavirus disease 2019 (COVID-19) novel severe acute respiratory syndrome affected the world population with an infectious condition for which therapeutic forms are limited and vascular sequelae are major challenges. Pregnant women are physiologically immunocompromised and can be more affected by the pandemic than the general population. Extra precaution measures against COVID-19 during and after the outbreak are essential to ensure the safety of the newborn. The aim of the present study was to report the cesarean birth of a female child with Klippel-Trenaunay of a mother currently infected by COVID-19. A newborn of a 21-year-old mother with COVID-19 in the final stage of the disease was born through a cesarean section at full term. The physical examination at birth revealed substantial edema of the left lower limb associated with port-wine stains on the limb and left torso. The ultrasound revealed venous-lymphatic malformation affecting the entire left lower limb, suprapubic region and ipsilateral abdominal region. Two evaluations for COVID-19 were performed and both were negative. Infants of mothers with active COVID-19 infection during the birth period have a low probability of being positive for the disease, but precautions should be taken. The association with malformations, such as the rare Klippel-Trenaunay syndrome (KTS), constitutes another challenge regarding the diagnosis and proper conduct to be taken with these children.

Subungual exostosis is a type of heterotopic ossification, which often has unclear margins. Therefore, marginal resection may cause recurrence and wide resection is sometimes required to achieve a complete cure. However, wide resection may cause postoperative nail deformity and revision of this deformity is generally difficult. The primary treatment of subungual exostosis is surgical treatment, and there have been no comprehensive reports on the efficacy of adjunctive treatments. Although postoperative electron beam irradiation has been successfully used after heterotopic ossification excision to prevent recurrence, there are no reports on the use of this procedure following subungual exostosis resection. Herein, we report a case of refractory subungual exostosis that developed as a result of chronic irritation and inflammation caused by an ingrown nail and recurred after initial resection. We performed marginal resection of the lesion to preserve the nail matrix and nail bed as possible, a two-stage skin grafting procedure, and electron-beam irradiation to prevent recurrence. Excellent results were achieved both in terms of complete cure and cosmetic appearance, suggesting that electron-beam irradiation following refractory subungual exostosis excision may help prevent its recurrence. We expect a further study including many cases of subungual exostosis treated with postoperative electron-beam irradiation to be conducted.

Epithelioid angiomyolipoma (EAML), a subtype of angiomyolipoma, is distinct. It has a biologic behavior of borderline tumor, a malignant tendency, and a risk of metastasis and recurrence. Adrenal EAML is very rare. It is true that only six cases of adrenal EAML have been documented in the English-language literature. A 65-year-old man who underwent a laparoscopic left adrenalectomy in July 2022 has adrenal EAML and this is a case report about it. The mass was surrounded by abundant blood vessels and adherence with surround-tissue. Postoperative pathology of the tumor analysis revealed adrenal epithelioid vascular smooth muscle lipoma. The patient underwent left upper abdomen and lumbar pain in July 2022. The enhanced computed tomography (CT) scan of the abdomen showed markedly enhanced masses in and around the left adrenal gland. A second left laparoscopic adrenalectomy was performed under general anesthesia. Postoperative pathology showed two taupe nodules of left adrenal, maximum diameter 0.9 to 1.1 cm. The postoperative pathological diagnosis in combination with immunohistochemistry was EAML. The patient was discharged 10 days later with symptomatic treatment with low molecular heparin. Adrenal EAML has a biologic behavior of borderline tumor with malignant potential and a risk of distant metastasis and recurrence. Therefore, radical surgical resection should be considered as its necessary treatment. Long-term postoperative follow-up is an important part of the treatment.

Porphyria cutanea tarda (PCT) is usually caused by acquired defects in uroporphyrinogen decarboxylase (UROD) activity in the liver. This more common form of PCT is called type 1 PCT. Major known risk factors for PCT include iron overload, such as occurs due to mutations in HFE, associated with classical hereditary hemochromatosis, chronic hepatitis C infection, heavy alcohol use, tobacco use, and estrogen therapy. In addition, in about 25% of patients with PCT, namely, those with PCT type 2, an inherited partial defect in UROD activity is found. In such persons, this partial defect, which is found in all cells, including hepatocytes, red blood cells, and others, contributes to the development of biochemically and clinically active disease. Herein we describe salient features of a man in his eighth decade of life with onset of clinical PCT. Among risk factors were heavy alcohol and tobacco use. Genetic testing revealed a novel mutation in one of his alleles of the UROD gene, namely, c.224 G>C; p. Arg 75 Pro, and enzymatic testing revealed that red blood cell UROD activity was decreased by 50%. This mutation in the UROD gene is predicted to have a major effect on protein structure and function, confirmed by the 50% decrease in activity of the enzyme. The previously undescribed mutation in UROD, found in this man, namely, c.224 G>C; p. Arg 75 Pro is pathogenic.

Breast augmentation through the injection of polyacrylamide hydrogel (PAAG) was a popular procedure in the past, but it has since been prohibited due to various complications, including masses, migration, infection, inflammation, and even cancer. However, there were rare cases of granulomatous mastitis with pectoralis major muscle defect following PAAG injection for breast augmentation. A 40-year-old female patient presented with a swollen and suppurative mass in her left breast and was insensitive to antibiotics. She was admitted to our department for further treatment after 7 months with progressive local and general symptoms. Ultrasound imaging showed ill-defined heterogeneous echoes, and contrast-enhanced magnetic resonance imaging (MRI) revealed non-mass enhancement lesions in the multiregional distribution in Breast Imaging-Reporting and Data System 4A (BI-RADS 4A) with oedema in the retroglandular space and multiple enlarged lymph nodes in the ipsilateral axilla. Intraoperative observations revealed necrotic tissues, multiple abscesses, residual mucoid PAAG prosthesis diffused into the mammary glands and intramuscularly into the pectoralis muscle, and partial loss of pectoralis major muscle. Histopathological results revealed foreign-body granulomas accompanied by gel-like granular PAAG and proliferative inflammatory cells. She recovered after undergoing the characteristic surgical management in our center under general anesthesia and had no recurrence during the 2-year follow-up. This case revealed that PAAG injection for augmentation mammaplasty, even after the removal operation, could result in subsequent complications, including granulomatous mastitis and pectoralis major muscle damage. PAAG filler complications are difficult to treat, therefore, it is essential to establish appropriate and effective therapeutic procedures.