A 29-year-old gravida V para IV (3 spontaneous vaginal deliveries, prior cesarean for failed induction 4 years earlier) presented for ANC at 32 weeks by LNMP. Maternal labs: VDRL, HBsAg, and urinalysis negative; CBC within normal limits; blood group A Rh-positive. Obstetric ultrasound revealed normal fetal anatomy except the heart. Fetal echocardiography showed normal situs; atria of comparable size; normally positioned atrioventricular and semilunar valves with normal motion; ventricles comparable in size and contractility; left ventricle forming the apex; no ventricular septal defect. Two circumscribed, round, echogenic masses were noted on the left ventricular papillary muscles, measuring 18.2 × 8.3 mm and 13.5 × 8.3 mm. LVOT and RVOT anatomy and function were normal on 2D and color flow. Impression: cardiac rhabdomyoma. Given the association with tuberous sclerosis complex (TSC), detailed neurosonography and systemic evaluation were performed and were unremarkable. She continued routine ANC without complications to 39 weeks. At 39 weeks + 1 day, a cesarean section (repeat on request at term) delivered a 3200 g female, Apgar 10 and 10 at 1 and 5 minutes. Postoperative courses for mother and neonate were uneventful; discharge occurred on postoperative day 3. The neonate was evaluated on days 1, 7, and 30: physical examinations were normal; no seizure activity or new cutaneous lesions; mass dimensions were similar to the antenatal findings. At 7 months, development was age-appropriate; pediatric echocardiography showed well-circumscribed hyperechoic masses on both left ventricular papillary muscles measuring 21.8 × 9.2 mm and 14.7 × 8.5 mm, without left ventricular inflow obstruction. At 12 months, anthropometric and neurobehavioral development remained normal. Echocardiography again demonstrated well-circumscribed hyperechoic masses on both left ventricular papillary muscles with no size increment and no left ventricular inflow obstruction. Up to one year of age, apart from the persistent intracardiac rhabdomyomas, the child met none of the clinical diagnostic criteria for TSC. Notably, while cardiac rhabdomyomas often regress spontaneously in infancy, these lesions were stable through 12 months.


A 19‑month‑old boy was admitted following a fall from a feeding highchair, landing on his gluteal region and striking the occiput. He had three episodes of vomiting, marked irritability, RR >60/min, HR >150/min, and SpO2 <80%. On exam, he was hydrated and conscious but irritable, with subcostal retractions and decreased breath sounds at the left base. Bag‑mask ventilation with supplemental oxygen and pulse oximetry monitoring were initiated; paradoxically, SpO2 fell below 70% with ongoing ventilation. Lung ultrasound demonstrated absent A‑lines and consolidation, visualizing the lung as solid parenchyma. Given the poor clinical condition, orotracheal intubation with a cuffed endotracheal tube was performed. Post‑stabilization chest CT revealed complete atelectasis of the left lung with interruption of the main left bronchus at 12 cm from the bronchial bifurcation. In the context of maternal history of an intensive coughing episode in the preceding days that resolved spontaneously within 24 h, foreign body aspiration was suspected. Rigid bronchoscopy identified and removed a 2‑cm almond lodged in the left main bronchus. The patient improved progressively, was extubated at 24 h, transferred from intensive care to the general pediatrics ward, and achieved full recovery of respiratory function. Based on the clinical course, the team hypothesized that severe respiratory compromise likely preceded the event, causing altered consciousness and subsequent head trauma.


A 25-year-old man came to the oral medicine clinic with painful canker sores on his lips that started in the mouth four days earlier and involved the lips two days later. On exam there were blood-tinged crusts on the lips that bled easily, and diffuse, painful red lesions on the inside of the upper and lower lips. He had reported a fever about a week before the sores appeared, a period of heavy workload and poor diet, and a habit of frequently licking his lips. Initial tests showed a positive anti-HSV-1 IgG (ratio 6.32), supporting herpes virus involvement, and the working diagnosis was HAEM. Exfoliative cheilitis was considered but less likely because it does not involve the herpes virus. Other findings included poor oral hygiene and several unrelated dental problems. Treatment combined topical and systemic care: topical steroid ointment (triamcinolone acetonide 0.1% in orabase), warm compresses with 0.9% saline, oral acyclovir tablets (200 mg, five times daily for one week), and a daily multivitamin. Patients were also advised on non-drug measures: brush teeth and tongue twice daily with a soft brush and non‑detergent toothpaste, drink more water, eat a balanced diet, avoid acidic, spicy or hard foods (and foods with MSG), and stop licking or peeling the lips. Two days after the first visit pain was reduced but lesions remained; after starting acyclovir there was marked healing by the next follow-up and complete clinical recovery after 7 days. Oral-health–related quality of life improved (OHIP-14 score from 35 to 4). The patient was referred for further dental care (periodontics, restorative, oral surgery, and prosthodontics) and gave consent for publication.


This is about a 13-year-old boy. He has had small growths in his throat since he was two years old. The growths were in his voice box and windpipe. They narrowed his breathing tube, so he had trouble breathing. It was like trying to breathe through a pinched straw. A chest scan showed several small cysts in his lungs. Doctors removed the throat growths. They also placed a breathing tube through a small hole in his neck to help him breathe. He got one dose of a medicine called bevacizumab (400 mg) through a vein. He also had breathing therapy. He got better. The problem has not come back during follow-up.


This report is about a 13-year-old boy. He came to the ER with sharp chest pain that hurt more when he took a deep breath. He did not feel sick otherwise. His oxygen level was normal at 98% on room air. The lower parts of his chest sounded quieter when the doctor listened. A chest X-ray looked like one he had 4 years earlier. A CT scan showed many hazy and crisscross areas in both lungs, covering more than half of the lungs. This pointed to a rare lung problem called PAP, where material builds up in the air sacs. Tests for viruses, including COVID-19, were negative. A gentle lung wash showed milky fluid, and a special lab stain was positive. Breathing tests showed his lungs held a little less air than expected and moved oxygen less well. A gene test did not find a known cause. A blood test found strong antibodies that mean the body’s own immune system is likely causing this problem. About 20 months later, he feels well, and his breathing tests are normal.


A 69-year-old man with prior coronary bypass surgery presented with two months of severe shortness of breath with mild activity (NYHA class III). He was diagnosed with heart failure due to ischemia after failure of a saphenous vein graft to the right coronary artery. This was supported by an abnormal ECG, elevated NT-proBNP, and a coronary angiogram; echocardiography also showed reduced pumping function. The team reopened a chronic total occlusion in the native right coronary artery using a retrograde approach through septal channels (septal surfing). To enable that route, they first re-opened the totally occluded left coronary artery. After the procedure, his dyspnea improved before discharge, and at 6 months he had no recurrence of shortness of breath.


A 5-year-old presented to the pediatric ED 13 hours after ingesting chlorpyrifos with abnormal jerks, severe dyspnea, tachypnea (RR 48/min with intermittent sighs), diaphoresis, salivation, polyuria, vomiting, and subsequent aspiration of a charcoal–palm oil mixture. On arrival: T 38.3°C, GCS 3/15, pinpoint pupils, generalized hypotonia, SpO2 88% with widespread crackles, HR 180/min, BP 120/80 mmHg, random blood glucose 14 mg/dl. Serum lactate and cholinesterase levels were unavailable. The working diagnoses were severe organophosphate poisoning (cholinergic crisis with type I paralysis), aspiration pneumonitis, respiratory failure, and impending shock. Because ICU care was unaffordable, NIV via bubble CPAP was initiated, improving SpO2 to 99–100%. Hypoglycemia was corrected with a dextrose bolus; 20 ml/kg normal saline was given for tachycardia. The patient received IV dexamethasone, mannitol, and atropine 0.02 mg/kg (discontinued after the first dose due to rapid tachycardia), plus empiric IV antibiotics for aspiration pneumonitis; pralidoxime was unavailable. Within 3 hours, a 500 mL fresh whole blood exchange transfusion (FWB-EBT) was performed, after which GCS improved to 9/15. Blood glucose fluctuated between 41–259 mg/dl during the first 15 hours and subsequently normalized. By hospital day 2, the patient developed thready pulses and hypotension; an additional NS bolus was administered and dopamine was started at 5 mcg/kg/min via a peripheral vein. Mannitol was discontinued. A second 500 mL FWB-EBT was performed. Over the first 30 hours, consciousness and respiratory distress improved, though rhonchi developed and were treated with nebulized salbutamol and budesonide; the patient was transitioned to oxygen via nasal prongs with SpO2 ~97%. A day-2 chest radiograph showed bilateral infiltrates consistent with pneumonia. Full consciousness returned by hour 39. Antioxidants (IV vitamins C and B; oral vitamin E and zinc) were started, and diet was advanced over 48 hours. The patient responded rapidly overall, did not develop intermediate syndrome, and was discharged on hospital day 10; follow-up was lost. Exchange transfusion was utilized as a detoxification strategy in the absence of oximes and may have contributed to clinical stabilization by reducing circulating toxin and replenishing cholinesterase activity, alongside atropinization, ventilatory support, fluids, and inotropic therapy.


A 27-year-old man presented to the emergency department with a fracture at the base of the neck of the right femur after a low-energy fall that involved axial loading and a twisting motion of the right hip. He had a known history of fibrous dysplasia in the right proximal femur and, 20 years earlier, underwent curettage, bone grafting, and prophylactic fixation; the hardware was removed one year later, and biopsy at that time confirmed fibrous dysplasia. Given the pattern and pathologic nature of the current fracture, the team proceeded with a definitive treatment: wide resection of the proximal femur and a total hip replacement using a modular prosthesis, along with cerclage to secure the construct. An excisional biopsy performed during surgery confirmed the same fibrous dysplasia that had been treated in childhood. He recovered well: imaging at four weeks showed the components in good position, and he progressed from partial weight-bearing to full weight-bearing with a walker around day 20. He returned to daily activities with a mild, intermittent limp related to the gluteus medius incision and was able to do low-impact activities such as walking, reporting high satisfaction with the outcome.


A young man from Morocco had strong liver pain for about a month. He also had mild signs that can come with TB infection. Scans of his belly showed small spots in his liver. Doctors used a small camera surgery to take a tiny piece from one of the spots. The test on that piece proved the spots were TB in the liver. He started TB medicines. He felt better, and his blood tests got better too.


Technique (TFD/PDT): The patient receives intravenous photosensitizer (Photogen, 1.5 mg/kg) 24 h pre‑procedure; peak absorption is 630 nm. Under general anesthesia, standard duodenoscopy (Olympus TJF‑180) is performed. After identification of the greater duodenal papilla and retrograde cannulation, a digital cholangioscope (SpyGlass DS, Boston Scientific) is introduced into the common bile duct. Cholangioscopy is used to identify the neoplastic stenosis. Under direct visualization, the illumination catheter (Medlight S.A., RD10‑323) is advanced through the cholangioscope. The catheter is a three‑way cannula: port 1 carries a 1‑cm cylindrical light diffuser with two black radiopaque markers denoting its limits; port 2 accommodates a 0.025‑inch guidewire; port 3 is an injection portal. Following cholangioscopic positioning, illumination is delivered at 90 J/cm² with power of 70 mW/cm², with 1‑cm stepwise repositioning to cover the entire stenosed segment. Completion cholangioscopy assesses immediate outcome and adverse events. Post‑procedure care: patients are fasted for 24 h; if no adverse events occur, oral intake is resumed. Discharge includes strict photoprotection instructions (avoidance of light exposure and use of sunglasses), especially during the first week after TFD. Results/Case: An 82‑year‑old man presented with a 2‑month history of obstructive jaundice and weight loss. EUS showed severe dilation of the common bile duct with choledocholithiasis; ERCP confirmed these findings but stone extraction was unsuccessful due to disproportionate ductal dilation, so a plastic biliary stent was placed. Cholestasis recurred 45 days later; two additional ERCPs failed to clear stones. During the third ERCP, a long irregular CHD stenosis was noted, prompting repeat EUS. Repeat EUS revealed a well‑circumscribed hypoechoic solid mass (1.8 × 2 cm) compressing the common hepatic duct, with apparent involvement of the common hepatic artery. Ultrasound‑guided needle biopsy confirmed moderately differentiated cholangiocarcinoma (Bismuth I). After staging, the lesion was deemed unresectable and the patient was referred for palliative therapy. Following multidisciplinary discussion, adjunctive PDT was performed to treat recurrent biliary obstruction. The procedure lasted 150 minutes without complications. A 10 Fr plastic stent was placed for biliary drainage (SEMS unavailable at that time). No photosensitivity occurred in the subsequent week. Early recurrence of cholestasis with cholangitis ensued; ERCP demonstrated stent occlusion by debris and biliary sludge secondary to tumor necrosis. A biliary scan and re‑drainage resolved the acute episode. He then remained asymptomatic for three months—the longest interval since symptom onset. At subsequent recurrence, a self‑expanding metal stent was placed. He continued systemic therapy and later required a duodenal stent for palliation of dysphagia. He died from complications of pulmonary metastases two years after symptom onset and 15 months after the TFD session. Mechanistic context: PDT activates the photosensitizer at 630 nm to generate reactive oxygen species, inducing localized tumor cytotoxicity and microvascular damage, which can debulk malignant biliary strictures and improve ductal patency.


A 29-year-old woman, Para 1, presented with one month of abnormal vaginal bleeding to a level 2 hospital. She was HIV positive, had been commenced on antiretroviral therapy (ART) after diagnosis approximately one year earlier, but defaulted ART for one month when she became ill with vaginal bleeding, resulting in virological and immunological failure (viral load 37,400 copies/mL; CD4 26 cells/μL). On exam, there was an 8 × 8 cm friable cervical mass extending to the parametrium and bilaterally to the pelvic sidewalls, with contact bleeding and foul-smelling discharge. Ultrasonography showed a bulky cervix and bilateral hydronephrosis. She was clinically staged as FIGO stage 3B cervical malignancy based on pelvic wall involvement and hydronephrosis. ART was re-initiated with a switch from TLD (Tenofovir–Lamivudine–Dolutegravir) to a renal-friendly regimen (Lamivudine–Abacavir–Dolutegravir). A punch cervical biopsy revealed extra-nodal BL (Burkitt lymphoma). Immunohistochemistry and in situ hybridization confirmed the diagnosis: CD20, CD75a, CD10, PAX5, and Bcl-6 positive; CD44 and c-Myc positive; EBER-ISH focally positive. Ki-67 showed an almost 100% proliferation index, and PAX5 moderately positive BCL6. Baseline labs included WBC 2.67 × 10^9/L, hemoglobin 5.7 g/dL, platelets 71 × 10^9/L; creatinine 187 mmol/L, urea 11.1 mmol/L, albumin 21 g/L, AST 41 U/L, ALP 100 U/L. After histologic confirmation and multidisciplinary review, the plan was chemoradiation. She then waited 43 days to start treatment at the oncology unit due to a long waiting list—exceeding the recommended ≤48-hour window for initiating BL therapy. During this interval, further CT/MRI imaging could not be performed due to equipment dysfunction. Supportive care included ART, blood transfusion, and analgesia. She died on day 43 post-diagnosis while awaiting treatment and received no chemoradiation. No histopathological postmortem was performed because BL and HIV were established. Given BL’s rapid progression and high mortality in people with HIV and high viral load, the attending physician certified BL as the most likely primary cause of death, with multiple organ failure (including renal and hematologic) as a secondary cause.


A 46-year-old man from Haiti now lives in Chile. He had wart-like bumps on the front of his shin for about a year. Tests showed a long-lasting skin fungus called chromoblastomycosis. The skin sample had special cells that prove this infection. The lab also grew dark-colored fungus from the sample. Under the microscope, the germ looked like a kind called Fonsecaea. He took antifungal pills and got freezing treatments on the spots. Treatment lasted six months. All the bumps went away.


This is about a 20-year-old woman. She had a kidney problem since age eight that made protein leak into her urine. The problem first showed up when a big blood clot blocked veins in her brain, and a clot also went to her lungs. She took blood thinners and steroid pills. Later she took a medicine that calms the immune system to help her use fewer steroids. Tests showed no inherited blood-clotting problem. She had several flare-ups of the kidney problem. Steroid pills controlled them until 2017. After that she had no relapses. Her doctors stopped the blood thinner and the immune-calming medicine. One year later she had sudden, very bad belly pain all over. She threw up after eating. Both legs were swollen. Tests showed the kidney problem was back. A special X-ray picture (CT scan) showed a new clot in the main artery that feeds the small intestine. It was like a plug in a pipe that stops water. Blood could not reach the intestines. In surgery, most of her small intestine was dead. Taking out that much bowel would not allow life. She died 48 hours later.


A 52-year-old man had a seizure and was sent to a big hospital. X-rays showed a bad break-and-dislocation in his right shoulder. The same X-rays also found that his left shoulder had popped out of the socket in the back, which had been missed before. A later CT scan showed both shoulders had a break-and-dislocation, and the left shoulder got worse while he was in the hospital. Surgeons fixed both shoulders in one operation and held the bones with metal plates. The left shoulder needed two more surgeries: one because the repair failed, and another to free a stiff joint. Two years later, he was doing well. His arm disability score was 5% on QuickDASH. His shoulder scores (Constant) were 72 on the left and 76 on the right.


A 19-year-old male with no significant history presented with an 8-month painful left scrotal mass unresponsive to antibiotics for presumed pyogenic infection, along with intermittent low-grade fever, night sweats, anorexia, and weight loss. Exam showed a large, painful, slightly warm left bursa and two firm, painful subcutaneous formations on the anterior thoracic wall (3–4 cm). CRP was 90 mg/dl; CBC, creatinine, glucose, and liver function tests were normal. Chest radiograph demonstrated bilateral reticulonodular infiltrates. Scrotal ultrasound suggested an epididymal tumor, and a left orchidectomy was performed. Histopathology revealed granulomatous epithelioid necrosis of the epididymis, consistent with active epididymal tuberculosis involving the body and tail and sparing the head and testis. The tuberculin skin test was positive. AFB studies of sputum and urine on 3 consecutive days were negative on direct smear and culture. HIV, HBV, HCV serologies and Wright's were negative. Thoraco-abdomino-pelvic CT identified miliary tuberculosis, coelo-mesenteric necrotic adenopathies, two thoracic parietal collections within the external oblique muscles (33 × 10 mm right, 45 × 10 mm left), and focal osteolysis of D11 and L5 suggestive of early spondylodiscitis; spinal MRI confirmed spondylodiscitis at D7, D11, L4, and L5. The diagnosis was disseminated tuberculosis with epididymal, pulmonary, parietal, ganglionary, and osteo-articular involvement. Treatment consisted of isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid plus rifampicin. At month 4 of therapy he developed generalized tonic-clonic seizures; brain MRI showed multiple supra- and infratentorial nodular lesions compatible with tuberculomas. An anticonvulsant was added and anti-tuberculous therapy was continued. Evolution was favorable with early weight gain and disappearance of thoracic parietal formations, adenopathies, and miliary lesions on CT; there was no recurrence of seizures. Because the tuberculomas regressed slowly, therapy was prolonged; he was ultimately declared cured without sequelae at the end of the 234th month of treatment (as reported) with 2-year follow-up. Context: Epididymal tuberculosis can mimic neoplasm and may occur with negative AFB studies; CNS tuberculomas emerging during therapy are a recognized phenomenon, typically managed by continuing anti-tuberculous treatment with seizure control.


A 57-year-old woman with a 14-year history of asthma and allergic rhinitis on salmeterol/fluticasone presented with two months of intermittent, dull abdominal pain, nausea, anorexia, malaise, and 5-kg weight loss. She was afebrile, hemodynamically stable, underweight (BMI 16.6 kg/m²) with sarcopenia, and had epigastric/umbilical tenderness without guarding. CBC showed leukocytosis with marked eosinophilia (WBC 26.8 G/L with 20.8 G/L eosinophils; 77.8%). Peripheral smear showed morphologically normal eosinophils. Bone marrow aspiration revealed 48% eosinophils without blasts or atypia. FISH for CHIC2 deletion (surrogate for FIP1L1-PDGFRA) was negative. Autoimmune/vasculitis screens (ANA, anti-dsDNA, p-ANCA, c-ANCA) were negative. Serum immunoglobulins demonstrated elevated IgG (2760 mg/dL) and IgG4 (1260 mg/dL), mildly elevated IgE (137.5 IU/mL), and high RF (144.4 IU/mL). Liver enzymes, BUN/creatinine, C3/C4, vitamin B12, cortisol, and NT-proBNP were within normal limits. ECG/echocardiogram were normal. Chest CT showed mild fibrosis and bronchiectasis. Bronchoscopy and AFB smears were negative; BAL cytology had 35% neutrophils and no eosinophils. Spirometry demonstrated severe obstruction with bronchodilator responsiveness; FeNO was 15 ppb. Stool leukocytes were present, but ova/parasite exams were negative. Serology was positive for Toxocara canis IgG (54.2 NovaTec-Units) and negative for other helminths and HIV. Empiric albendazole (400 mg twice daily for 5 days) was ineffective. Abdominal contrast-enhanced CT showed cholelithiasis without cholecystitis and no GI structural abnormality. Upper GI endoscopy was unremarkable. Colonoscopy demonstrated mucosal inflammation in the sigmoid, left, transverse, and right colon. Systematic colonic biopsies showed dense eosinophilic infiltration (>85 eosinophils/HPF in the left colon; >100 eosinophils/HPF in the transverse and right colon). Given the exclusion of hematologic neoplasms and secondary causes (including lack of response to anti-parasitic therapy and negative work-up for vasculitis/autoimmune disease), the findings were diagnostic of eosinophilic colitis. She was treated with oral methylprednisolone 16 mg and montelukast 5 mg. Symptoms resolved within two weeks with normalization of eosinophils to 0.3 G/L. Corticosteroids were tapered and discontinued, and montelukast was continued for three months with no symptom recurrence. This case illustrates eosinophilic colitis in an atopic patient with marked peripheral and tissue eosinophilia, elevated IgG4, negative myeloid neoplasm markers, and steroid-responsiveness, consistent with primary eosinophilic gastrointestinal disease after exclusion of secondary etiologies.


A 2-year-old girl had a bulging left eye. The eye was pushed inward and upward. An MRI scan showed a clear lump. It looked dark on one kind of picture and bright on another. Tests on the tissue, including special lab tests, proved it was a teratoma (a type of growth). Doctors removed the lump through the inside of the lower eyelid and made small cuts at the outer corner to make room. One month later, the eye looked sunken. The white part was red. The clear front of the eye was inflamed. Doctors did a second surgery. They put donated eye-white tissue into the eye socket to add space, smooth the hollow, and help the eye surface heal. After one year, the growth did not come back, and there were no other problems.


This is a single-case report of a female third-grade student with developmental dyslexia (DD) and high abilities/giftedness (AH/S), evaluated pre- and post-phonological remediation. Ethical approval: CEP 1.012.635; informed consent/assent obtained. The first evaluation (T1) occurred at 8y2m (2018) and the second (T2) at 9y6m (2019). History: term birth; typical neuropsychomotor and language development; early bilingual exposure (French first words; Brazilian Portuguese at home); school transitions including French and later Portuguese–English bilingual schooling; interdisciplinary diagnosis of DD and AH/S at age 8; referral to LEIA/UFRN. Protocol: four assessment sessions at each time point (T1, T2) and 20 weekly 60-minute phonological remediation sessions (2H2018); limited parental engagement due to work. Assessments targeted phonological processing (phonological awareness, phonological working memory, rapid naming), reading, and writing. Measures: CONFIAS for phonological awareness; Phonological Working Memory Test (nonword repetition; digit span direct/reverse); RAN at T1 and TENA at T2 for rapid automatic naming; LPI (isolated word/pseudoword reading) and an expository text protocol (accuracy, oral/silent modes, comprehension, words/minute) for reading; spontaneous text plus dictation of LPI target words with Zorzi & Ciasca orthographic analysis for writing.
Results—phonological awareness (CONFIAS): performance aligned with the writing hypothesis at each time point. T1 scores: syllabic = 35; phonemic = 14 (consistent with a syllabic–alphabetic writing hypothesis). T2 scores: syllabic = 37; phonemic = 20 (consistent with an alphabetic writing hypothesis). The 4-point gain at the phonemic level likely reflects the remediation focus on phonemic skills.
Phonological working memory: At T1, nonwords were below expected (66 vs ET1 69) and reverse digits were below expected (4 vs ET1 6); direct-order digits were within/above expected (20 vs ET1 13). At T2, age-appropriate performance was documented with gains across categories: nonwords 69; reverse digits 12. The improvement in reverse span implicates executive mechanisms supporting rapid storage/manipulation, consistent with a strength often observed in high-ability profiles.
Rapid naming: T1 RAN performance was below normal across all subtests. At T2 (TENA), digits (41 vs ET2 35), objects (59 vs ET2 50), and colors (56 vs ET2 53) remained below expected; letters were within expected (29 vs ET2 32). Naming speed improved for letters (37→29 s), objects (62→59 s), and colors (60→56 s), but worsened for digits (37→41 s). Reduced naming latencies indicate more efficient access to the phonological/visual lexicon, though residual RAN deficits persisted—typical in DD.
Reading: T1 showed an alphabetic level with reliance on sub-vocal decoding, confusions for visually/phonologically similar letters, and very slow rate (≈20 words/min), well below grade expectations. T2 advanced to an orthographic level with oral reading ≈94.4 words/min, adequate prosody, rhythm, global reading, interest, and comprehension; low speech intensity suggested residual task-related insecurity.
Writing: T1 reflected a transition from syllabic–alphabetic to alphabetic, with maladaptive pencil grip, imprecision, letter substitutions/omissions, hyper-/hyposegmentation, word repetition, and limited cohesion. T2 remained qualitatively imprecise with low intelligibility, visual letter confusions (e.g., b/d), and limited punctuation; however, the sample was consistent with an alphabetic phase, with a broader vocabulary repertoire (visual input lexicon). Overall, alphabetic writing consolidated but orthographic accuracy lagged.
Conclusion: After phonological remediation, the child demonstrated gains in phonological processing (awareness and working memory) and progressed from alphabetic to orthographic reading, while consolidating alphabetic writing. Nevertheless, characteristic dyslexic features persisted, particularly reduced efficiency in rapid access to the mental lexicon (RAN) and ongoing orthographic/spelling errors (confusions, omissions, hypersegmentation).


We describe a rare case of euthyroid, single-muscle thyroid eye disease (Graves’ orbitopathy) in a 50-year-old man who smoked and had dyslipidemia. He developed a very rapid and severe loss of upward movement in the right eye, producing constant, uncorrectable double vision and major quality-of-life impact. Thyroid function was normal, and TSH receptor antibodies were only slightly elevated. Imaging showed isolated enlargement of the right inferior rectus muscle; the other eye muscles were normal. Intravenous steroid pulses reduced inflammation but did not improve the diplopia or eye position. He ultimately required two orbital decompression surgeries. A biopsy of the right inferior rectus confirmed massive fibrosis with fat infiltration, consistent with single-muscle involvement.


One day before the treatment, you get a light‑activated medicine through a vein. During the visit, the doctor slides a flexible camera through your mouth into your gut. They find the small drain where bile comes out. They thread a tiny camera up into the main bile tube. They look for a tight spot caused by a tumor. They slide a thin light cable to that spot while watching on the screen. They turn on the light and move the cable a small step, about 1 centimeter, each time to cover the whole tight area. At the end, they look again to see how it went and to check for any problems. This treatment was used for an 82‑year‑old man who had yellow skin from blocked bile for two months. Tests showed the main bile tube was very wide and had stones. They also found a firm lump about 1.8 by 2 centimeters pressing on the liver’s main bile tube. Surgery could not fix it. He got this light treatment to ease the blockage. He felt well for three months. He died from complications 15 months after the light treatment.


A 51-year-old man presented with 3 days of sudden, painful vision loss in the left eye. Visual acuity was 20/20 in the right eye and hand motion in the left eye. Left fundus findings included optic nerve head swelling, choroidal bulging, multiple areas of subretinal fluid, and RPE corrugations. Orbital/brain MRI with gadolinium showed a retrobulbar nodular mass enhancing at the junction of the optic nerve and sclera. Oncology and rheumatology evaluations were unremarkable. The clinical diagnosis was nodular posterior scleritis, and oral prednisolone was started.


A 70-year-old man had a bad leak in his main heart valve. Doctors placed a new valve through a small opening near the tip of his heart. Four weeks later, his heart got worse again. Doctors added a heart pump to help move blood. About a year later, a heart scan showed the valve was leaking badly through the middle. The team put a second valve inside the first one, like stacking one cup inside another. They turned the heart pump down to its lowest setting during the procedure. They also made his heart beat fast at 140 beats per minute to keep the new valve steady. The result was excellent. One year later, he felt well and the valve leak was no longer a problem.


A 15-year-old boy had bad belly pain and was throwing up. A CT scan showed his small intestine was blocked because a loop slipped through a small opening deep in the upper belly. Doctors first tried surgery with a small camera. They could not see well. They changed to a bigger cut down the middle above his belly button. They moved the trapped intestine back where it belongs. The intestine looked healthy, so nothing had to be removed. They did not do an extra step to try to stop this from happening again. After surgery, he got a pocket of fluid in the lower belly. It was treated with antibiotics. He is going to follow-up visits in the children’s surgery clinic.


This newborn had a very serious genetic condition called neonatal Marfan syndrome. It badly affected his heart. His fingers and toes were very long like spider legs. Some fingers and toes were stuck in a bent position. His elbows and knees could not fully straighten. His face looked old for a baby. His eyes were deep set and tilted downward. His ears were soft and not well formed. His mouth sagged. His head was short and wide. The clear lenses in his eyes were out of place. A DNA test found a new change in the fibrillin-1 gene in a spot linked to the newborn form of this condition. Doctors tried medicines to lower the heart’s workload, kept him deeply sedated to reduce strain, and gave water pills to help him pee and move extra fluid. Even with this care, the heart valve leaks and high pressure in the lungs got worse, and the heart grew weaker. Surgery would have been needed to help him live longer. Because the disease was getting worse very fast, the family chose comfort care. A few months after birth, his heart failure worsened and he died.


You are 78 and take many medicines in a pre-packed pill system (SPD). For months, you felt very tired, weak, dizzy, and confused. We checked your medicines. We looked closely at pills that the kidneys help clear, using your kidney filter number (eGFR). We wrote a note to your family doctor. We asked to lower the dose of two blood pressure pills: losartan and manidipine, based on your eGFR. Your doctor lowered the doses. We kept an eye on you. Your symptoms went away.


A 56-year-old Italian woman with transfusion-dependent beta-thalassemia major (with prior splenectomy and cholecystectomy) underwent MRI to measure iron in the heart, liver, and pancreas. At the time of imaging, she had no significant endocrine, cardiac, or hepatic complications and was taking deferasirox, vitamin D, and luspatercept. The MRI incidentally revealed a lobulated mass in the prevascular mediastinum. PET showed only mild FDG uptake, and chest CT identified multiple thin-walled cysts throughout both lungs, a pattern consistent with lymphangioleiomyomatosis (LAM). After multidisciplinary review, she had thoracoscopic thymectomy and a lung wedge resection. Pathology confirmed type B2 thymoma and pulmonary LAM. Based on these findings, adjuvant radiation therapy was recommended for the thymoma, and sirolimus was advised for LAM.


A 5-year-old developed severe organophosphate poisoning after ingesting chlorpyrifos and then aspirated a charcoal–palm oil mixture. The illness progressed to respiratory failure, shock, coma, and acute (type I) paralysis. In the emergency department, the child received noninvasive ventilation, repeated exchange transfusions, intravenous atropine, and an inotrope infusion to support blood pressure, along with antibiotics and steroids. The child improved rapidly, did not develop intermediate syndrome (the delayed muscle weakness sometimes seen after organophosphate poisoning), and was discharged after a 10-day hospitalization. Additional context: the child arrived about 13 hours after ingestion with heavy secretions, pinpoint pupils, fast breathing, low oxygen, and crackles on chest exam. Pralidoxime was unavailable. Blood sugar was low at first and then fluctuated before stabilizing. A chest X-ray on day 2 showed pneumonia. Consciousness returned by about 39 hours, oxygen was weaned to nasal prongs, and recovery continued to discharge.


A 70-year-old man with severe aortic regurgitation was treated with a transcatheter aortic valve implantation (TAVI) through the tip of the heart (apical approach) because he was high risk for open surgery. Four weeks later, he developed recurrent heart failure, so a left ventricular assist device (LVAD) was implanted. He remained stable for about a year, but echocardiography then showed severe central leakage through the valve. The heart team chose a valve-in-valve TAVI to fix the problem. During the procedure, they reduced the LVAD flow to a minimum and used rapid pacing at 140 beats per minute to stabilize the new valve during placement. The outcome was excellent: at 12 months, he was doing well with no significant aortic valve leak.


A 45-year-old man was hospitalized with COVID-19 pneumonia and had no prior neurologic history. On hospital day 16, he suddenly developed reduced consciousness, his eyes deviated to the right, and he had jerking movements on the left side of his face and chest, followed by a generalized tonic–clonic seizure. After the seizure, he was left with persistent weakness on the left side (left hemiparesis). Brain CT was normal, and a spinal tap showed slightly elevated protein but no increase in white blood cells. Importantly, the cerebrospinal fluid tested positive for SARS-CoV-2 by RT-PCR, making viral involvement of the brain (encephalitis) likely and bacterial meningitis unlikely. An EEG did not show clear abnormalities, and later MRI was also unremarkable. He improved gradually, his condition stabilized, and his overall outcome was favorable.


A 56-year-old female with CTD-PAH secondary to Sjogren’s syndrome (diagnosed 2013) complicated by ILD initially presented with dyspnea. Early studies showed interstitial changes and cardiomegaly on chest X-ray; echocardiography demonstrated PASP 99 mmHg, RA/RV enlargement, D-shaped LV, and severe TR. Chest CNYCT showed no filling defects to suggest PE, with enlarged pulmonary trunk, RA, and RV, consistent with PH. Sjogren’s was confirmed by sicca symptoms with Schirmer’s <5 cm OU, positive minor salivary gland biopsy, impaired salivary gland function on nuclear medicine scan, and positive anti-Ro. She began Revatio (sildenafil) 20 mg TID in 2013; Tracleer (bosentan) was added in 2016. Right heart catheterization in 2017 showed mPAP 39 mmHg, PVR nearly 15 Woods, and wedge 4 mmHg, indicating pre-capillary, group I CTD-PAH; Opsumit (macitentan) 10 mg QD replaced bosentan. From 2017 to 2020 she required repeated steroid hospitalizations for Sjogren’s control. Her risk status was low-to-intermediate on dual therapy until October–November 2020, when she developed worsened dyspnea and signs of infection, then severe decompensation on November 10 with SpO2 70% requiring 100% O2 via face tent, lactate 5.2 mmol/L, and BNP >10,000 pg/mL, consistent with cardiogenic shock. She was intubated in the ICU, started on four PH agents, stabilized, and improved; heart–lung transplant evaluation began November 12, vasopressors were discontinued November 13, she was extubated November 14, and transferred to the ward November 21 on nasal cannula 2 L/min. Follow-up RHC showed persistently elevated PA pressures attributed to chronic PH with right heart strain. She was reclassified as high risk; Ventavis (iloprost) 10 mcg/ml 2 ml was added in 2020. In May 2023, molecular hydrogen was initiated as adjuvant therapy: 1 capsule/day (PURE HYDROGEN; HoHo Biotech, Taipei, Taiwan), each containing 170 mg of hydrogen-rich coral calcium with 1.7×1,021 molecules of hydrogen, equivalent to 24 cups of water at 1,200 ppb H2 or 0.6 mM H2 per 200 ml water. Flow cytometry and serology (standard fluorescent dye preparation; dried reagent kits, Beckman Coulter; immunophenotyping and gating per prior methods) before and after hydrogen therapy demonstrated increased CD127+ Treg populations and decreased B cell subsets; anti-Ro antibody levels declined. Clinically, signs and symptoms stabilized following the addition of hydrogen therapy, and no adverse reactions occurred. The case adheres to CARE reporting guidelines (2013 CARE Checklist).


A 45-year-old male (Pakistan-born, 7 years in Portugal) with grade 3 obesity and no neurologic history presented with 4 days of fever, dry cough, dyspnea, chest pain, dysgeusia, headache, and myalgia. Admission exam: no focal neurologic findings; tachypnea; bilateral rough vesicular murmur; otherwise unremarkable. Labs showed mildly elevated inflammatory markers; on room air (FiO2 21%) arterial gases were consistent with type 1 respiratory failure. Chest teleradiography: extensive bilateral, predominantly peripheral and basal opacities. Nasal/oropharyngeal RT-PCR for SARS-CoV-2 was positive; influenza A/B, Streptococcus pneumoniae, and Legionella pneumophila tests were negative, confirming COVID-19 pneumonia. Respiratory status worsened over 48 hours, escalating from supplemental O2 to noninvasive ventilation, then high-flow nasal cannula without response. He was transferred to a level III ICU for sedoanalgesia, orotracheal intubation, and invasive mechanical ventilation.
By ICU day 11, he was on remdesivir, dexamethasone, enoxaparin, and empirical amoxicillin/clavulanic acid plus azithromycin for suspected bacterial superinfection. He had sustained fever with poor antipyretic response; inflammatory markers improved by ICU day 3. A sepsis workup included line changes; blood, catheter tip, bronchial secretion, urine cultures; urinalysis; and transthoracic echocardiography. Only blood cultures were positive (Klebsiella pneumoniae), sensitive to amoxicillin/clavulanic acid already in use. Echocardiogram: no valvular vegetations; hypokinesia of the lateral wall and LV apex with poor biventricular function. Troponin was mildly elevated (1.8 ng/mL) with ST-segment depression in leads I and aVL, raising concern for ACS vs septic cardiomyopathy. Noninfectious fever causes (e.g., neuroleptics, thyroid dysfunction) were excluded. He required dobutamine during ventilatory weaning and needed noninvasive ventilatory support post-extubation; first extubation occurred on hospital day 15.
On hospital day 16 (day 19 of illness), he developed an acute alteration in consciousness with conjugate rightward gaze deviation and left facial and thoracic myoclonus, progressing to a generalized tonic–clonic seizure that terminated after midazolam. Hypoxic-ischemic seizure etiology was deemed unlikely: he remained normotensive, without peri-event hypoxemia, had normal serum lactate, and preserved diuresis. No ionic or glycemic disturbances were identified. Postictally: no eye opening, no verbal response, no localization to pain (GCS 7), and persistent left hemiparesis (3/5). For airway protection, he was resedated, reintubated, and started on anticonvulsant therapy. Head CT was unremarkable. Lumbar puncture yielded turbid CSF with mild proteinorrachia, no pleocytosis, and normal opening pressure. CSF studies included panels for neurotropic viruses, VDRL, acid–alcohol resistant bacteria, cultures, and RT-PCR for SARS-CoV-2. EEG performed 1 hour after propofol discontinuation (under fentanyl; single 13-minute recording) showed no significant abnormalities. CSF RT-PCR returned positive for SARS-CoV-2 RNA, and in the absence of CSF pleocytosis, bacterial (but not viral) meningitis was excluded; encephalitis was considered the leading diagnosis. Brain MRI on hospital day 17 was limited by motion artifacts. After withdrawal of sedoanalgesia, his mental status improved (GCS 14); left hemiparesis improved to 4/5; no recurrent involuntary movements; he was safely extubated within 24 hours. Given the favorable trajectory, brain biopsy was not pursued. He was transferred to the ward on day 21, remained afebrile with stable mentation, had no further seizures or myoclonus, and a repeat MRI on day 26 was normal. He was discharged home on day 31 without antiepileptic drugs, with internal medicine follow-up. This case highlights COVID-19–associated encephalitic presentation with a generalized seizure and persistent unilateral deficits, supported by detection of SARS-CoV-2 RNA in CSF despite absent pleocytosis, and a favorable clinical outcome with gradual recovery.


A 46-year-old Haitian man living in Chile developed wart-like plaques on the front of his right shin for about a year. Doctors diagnosed chromoblastomycosis after a skin biopsy showed the characteristic cells of this infection and a fungal culture grew dark (dematiaceous) colonies; direct microscopy suggested a Fonsecaea-type fungus. He was treated for six months with itraconazole taken twice daily and cryotherapy to the thickened areas. The lesions cleared completely. Additional context: The problem began as a small bump that slowly enlarged, later causing itch, pain, shallow ulcers, and yellowish drainage. Routine blood tests and screening for syphilis, HIV, and tuberculosis were negative. Local wound care was provided, including antibiotic ointment when signs of bacterial infection appeared. After therapy, there has been no relapse, with only mild lightening of the treated skin, which is expected after cryotherapy.


A 36-year-old man had a tender lump at the junction of the penis and scrotum for five years. Surgeons removed the mass. Under the microscope, it was a spindle cell tumor, and special staining supported a diagnosis consistent with synovial sarcoma. He then had a second, wider surgery. Despite these aggressive steps, the cancer spread to other parts of the body and kept progressing even after multiple chemotherapy treatments.


A 32-year-old male baker from Bamako presented on 27 April 2023 with a 1-month history of chronic productive cough, otalgia, and chronic right-sided purulent otorrhea. He had been treated elsewhere for confirmed malaria and acute otitis media with artesunate, paracetamol, and unspecified antibiotics without improvement. He is HIV-1 positive, started on TDF/3TC/DTG 7 months prior but was non-adherent due to denial of illness.
On exam: T 38.2 °C, altered general condition, right foul-smelling purulent otorrhea and otalgia, right basal pulmonary condensation syndrome; neurological exam normal with no cranial nerve involvement (VII, VIII intact). ENT: right EAC inflammation with purulent secretions and a single tympanic membrane perforation in the anterior-inferior quadrant; left ear normal. Rinne and Weber favored right conductive hearing loss.
Immunovirology: at HIV diagnosis CD4 118 cells/µl, VL 12,370 copies/ml; at 6 months on ART CD4 193 cells/µl, VL 9,460 copies/ml; at TB diagnosis (month 7) CD4 89 cells/µl, VL 10,230 copies/ml.
Microbiology: Ziehl–Neelsen bacilloscopy positive (one cross) in gastric washings at admission; due to persistent otorrhea, repeat testing 19 days later showed a positive smear on the right ear swab. Xpert MTB/RIF detected M. tuberculosis without rifampicin resistance. Chest radiograph: accentuated bronchovascular markings at the right lung base. Diagnosis: tuberculous otitis media (middle ear TB) with concomitant pulmonary involvement in the context of HIV-1–related immunosuppression.
Treatment: first-line anti-tuberculosis therapy for 6 months—intensive phase 2 months of isoniazid, rifampicin, pyrazinamide, ethambutol (2RHZE), then 4 months of isoniazid and rifampicin (4RH); fixed-dose combination, 3 tablets each morning fasting; pyridoxine (vitamin B6) 1 tablet daily. Two sessions of adherence reinforcement for ART. ART was restarted 4 May 2023 with tenofovir/lamivudine/dolutegravir 1 tablet daily plus supplemental dolutegravir 50 mg daily per protocol. Cotrimoxazole prophylaxis 960 mg daily. Local ear care included suctioning of the external auditory canal and ciprofloxacin ear drops, 2 drops three times daily for 14 days.
Outcome: by day 14 there was clinical improvement with resolution of cough and otorrhea, and smear conversion to negative in both the gastric aspirate and the right ear swab. End-of-treatment status: complete clinical healing with normal ENT and neurological exams. Serial bacilloscopies with Xpert MTB/RIF at the end of month 2 (intensive phase), during month 5, and at the end of month 6 were negative. HIV viral load after 3 months of resumed ART was 329 copies/ml.


She was 29 years old and had one child. She had HIV and a very weak immune system (CD4 count of 26). She had abnormal vaginal bleeding for one month. A tissue test from her cervix showed a blood cancer called Burkitt lymphoma in the cervix, outside the lymph nodes. Doctors also said the cervical cancer was stage 3B because it reached the pelvic wall and caused the kidneys to swell from blocked urine. A team of cancer doctors said she needed chemotherapy and radiation together. There was a long waiting list for this treatment. The start of care was delayed. She died 43 days after the diagnosis. She did not get the planned treatment.


A 2-year-old female with a 1-year history of painless, progressive left proptosis and no systemic disease or family history presented with light perception only in the left eye. Examination showed proptosis with inward and upward globe displacement; restricted extraocular movements in downward and outward gaze; a palpable, irregular, well-defined soft mass in the inferior orbit; left lower lid ectropion; a 4 mm mydriatic, nonreactive pupil; and otherwise unremarkable anterior segment (fundus view limited by age). Hertel exophthalmometry: OD 10.5 mm, OS 18 mm. MRI demonstrated a well-circumscribed mass, hypointense on T1WI and hyperintense on T2WI; contrast-enhanced imaging demonstrated no significant improvement. The lesion was excised via a transconjunctival approach through the inferior fornix with canthotomy and cantholysis. Intraoperatively, a grayish-white cystic mass with a distinct boundary was identified; posterior dissection revealed tight adhesion to the optic nerve. Due to lesion size and limited exposure, volume reduction was performed with aspiration of approximately 12.5 mL of fluid, followed by complete excision. Histopathology showed a fibrous capsule lined by squamous and glandular epithelium with visible brain tissue and cartilage-like matrix, consistent with orbital teratoma; immunohistochemical examination corroborated the diagnosis. One month postoperatively, the patient developed enophthalmos, conjunctival hyperemia, and keratitis, attributed to prior orbital cavity enlargement by the mass leading to postoperative volume deficit; corneal nonapposition to the lids created a gap and corneal inflammation. After guardian consent, a second operation implanted allogeneic sclera to augment orbital volume, alleviate fossa pitting, and normalize keratitis. At 1-year follow-up, there was no recurrence of the teratoma. Residual findings included minor enophthalmos and outer canthus abnormality; visual acuity remained at preoperative levels. Hertel measurements were OD 10.5 mm and OS 8 mm; the remaining anterior segment examination was unremarkable.


A 36-year-old man presented with a 5-year history of a tender left penoscrotal mass attached to the left side of the bulbar urethra at the penoscrotal junction; on exam it was a deep, smooth, tender, partially mobile cystic lesion (~20 × 20 mm) without skin tethering and not involving the spermatic cord. Doppler ultrasound showed a well-defined hypoechoic mass (2.7 × 3.1 × 2.0 cm) with marked vascularity. Pelvic MRI demonstrated a mass at the left inferolateral base of the penis with a clear fat plane, isointense to the testes on T1, T2, and diffusion-weighted sequences, connected to the vas deferens, without lymphadenopathy. Serum AFP and β-hCG were normal. The mass was excised for diagnosis and symptom control. Pathology revealed a cellular spindle cell tumor arranged in interlacing fascicles with spindle-to-oval vesicular nuclei, evenly dispersed chromatin, and inconspicuous nucleoli; mitotic activity reached up to 3/HPF. Immunohistochemistry was positive for TLE-1, CD99, and BCL2 with focal cytokeratin and focal EMA, supporting synovial sarcoma. FISH demonstrated SS18 gene rearrangement at 18q11.2, confirming the diagnosis. Margins were difficult to assess due to specimen fragmentation. Two weeks later, a wider re-resection was performed; the specimen (6.0 × 6.0 × 3.0 cm), resected deeply to the corpus spongiosum with shaving up to the urethra, showed no residual tumor. Staging PET/CT was notable only for an incidental left thyroid nodule (29 × 27 mm, SUV 4.9; TR3 on ultrasound). After 16 months of surveillance, metastatic disease developed in liver segment VI and the L1 vertebral body. Systemic ifosfamide/doxorubicin (6 cycles) produced no response in the liver lesion. He subsequently underwent hepatic resection of segments V and VI with cholecystectomy. New pulmonary lesions later emerged; therapy included pazopanib and stereotactic body radiation therapy, followed by gemcitabine/docetaxel (3 cycles), dacarbazine (2 cycles), and pembrolizumab (2 cycles), with continued progression. He was transitioned to palliative care and was lost to follow-up. Overall, this case represents a primary penoscrotal synovial sarcoma with SS18 rearrangement and an aggressive, treatment-refractory course despite two surgical resections and multiple systemic regimens.


A 28-year-old Moroccan active-duty military male, BCG-vaccinated and without alcohol or tobacco use or relevant comorbidities, presented after 5 weeks of progressive abdominal pain maximal in the epigastrium and right hypochondrium, accompanied by fever, chills, profuse sweats, anorexia, and weight loss. On admission, he had SIRS with T 39.1 °C, HR 124 bpm, RR 22/min, and right hypochondrial tenderness with hepatomegaly; pulmonary exam and superficial lymph node survey were unremarkable. Laboratory data showed neutrophil-predominant leukocytosis (17,800/mm3) and markedly elevated CRP (323 mg/L), with normal lipase (38 IU/L), troponin (4 ng/L), LFTs (ALT 22 IU/L, AST 17 IU/L, GGT 42 IU/L, ALP 115 IU/L, normal bilirubin), PT 78%, albumin 39 g/L, normal electrolytes and renal function, LDH 231 IU/L, and beta-2 microglobulin 2.28 mg/L. Procalcitonin was 4.1 ng/L. Infectious workup including blood and urine cultures during febrile peaks, HBV/HCV/HIV and syphilis serologies, Quantiferon, GeneXpert on biopsy material, and three consecutive morning sputum examinations for mycobacteria were negative. Chest radiograph and abdominal ultrasound were unrevealing.

Cross-sectional imaging demonstrated non-specific focal hepatic lesions. Thoraco-abdomino-pelvic CT showed hepatomegaly (liver long axis 17 cm) with multiple, well-circumscribed rounded hypodense lesions lacking post-contrast enhancement; largest lesions were in segment I (21 × 16 mm) and segment V (36 × 27 mm). No suspicious thoracic or pelvic lesions were identified. Initial echo-guided liver biopsies showed subacute fibro-inflammatory changes without specific histology or malignancy. Liver MRI revealed a dysmorphic liver containing lesions with heterogeneous T2 signal, a hyperintense T2 rim, and peripheral enhancement after contrast; the largest lesions were in segment I (20 × 22 mm) and segment V (33 × 31 mm). No deep lymphadenopathy was seen on CT or MRI. Diagnostic laparoscopy with targeted biopsies demonstrated epithelioid and multinucleated giant-cell granulomas of varying size with caseous necrosis, confirming focal hepatic tuberculosis.

Treatment followed a standard anti-tuberculosis regimen: Phase 1 with isoniazid, rifampicin, pyrazinamide, and ethambutol once daily fasting for 2 months, followed by Phase 2 with isoniazid and rifampicin once daily fasting for 4 months. Clinical and biological improvement occurred within days, with resolution of the inflammatory response. At 3 months, control CT showed a decrease in both number and size of the hepatic lesions. This case underscores that focal hepatic TB can present with non-specific hepatic nodules on imaging and often requires histopathologic confirmation when microbiological tests are negative.


An 18-year-old man came to the emergency department with new chest pain, fever, shortness of breath when lying flat (orthopnoea) and a dry cough for several days. Initial tests showed an elevated troponin, diffuse ST-segment elevations on ECG, and an enlarged heart on chest X-ray. Transthoracic echocardiogram (TTE) showed severe concentric thickening of both ventricles and a pericardial effusion; Coxsackie A and B antibody titres were also positive, so clinicians initially treated him for viral myopericarditis with anti-inflammatory medications. Despite treatment he acutely worsened on day four, becoming hypotensive and short of breath; repeat TTE showed impending cardiac tamponade and he underwent pericardiocentesis. The procedure was complicated by a pulseless electrical activity cardiac arrest, and he required intubation and venoarterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support. An endomyocardial biopsy did not show inflammation, and blood testing found a very high Epstein–Barr virus (EBV) PCR. A separate biopsy of a small painless mass on his right arm unexpectedly showed EBV-positive natural killer/T‑cell lymphoma. With a working diagnosis of lymphoma involving the heart and pericardium, he was started on systemic chemotherapy (initially an emergency regimen followed by modified lymphoma protocols). After treatment his heart function steadily improved: ejection fraction recovered to normal range, the pericardial effusion resolved, and the abnormal myocardial thickening decreased. He completed most planned chemotherapy cycles and continues follow-up with cardiology and oncology.


A 59-year-old man with type 1 diabetes came to the hospital with heart failure. A heart ultrasound showed big clumps of germs stuck to two heart valves, the mitral and the aortic valves. His blood test grew a germ called Staphylococcus warneri. This is a kind of staph that usually lives on the skin and is normally harmless. Doctors found he had an infection on his own heart valves (native valve endocarditis). He later had surgery to replace both the mitral and the aortic valves. Looking back, small lab changes and weight loss that began about four months earlier may have been early warning signs. He had not been on immune-weakening medicines and did not have any implanted medical devices.


A 52-year-old man was transferred to a tertiary center after a tonic-clonic seizure. Initial radiographs confirmed a serious right shoulder injury and also revealed a previously missed simple posterior dislocation of the left shoulder. Follow-up CT scans of both shoulders showed bilateral posterior fracture-dislocations, indicating that the left shoulder had worsened during the hospital stay. He underwent a single-stage open reduction and internal fixation of both shoulders using locked plates. The left shoulder later required two additional procedures: one to address failure of the initial fixation (osteosynthesis failure) and another arthroscopic procedure to release a stiff joint. At two years, his recovery was favorable: QuickDASH showed 5% disability, and Constant scores were 72 on the left and 76 on the right.


We report a rare case of euthyroid unilateral GO with early massive mono-muscular fibrosis in a 50-year-old male. Family history included cardiovascular disease, type 2 diabetes mellitus, and myasthenia gravis, with no family or personal history of thyroid autoimmune disease. He smoked 20 cigarettes/day since age 30 and had longstanding dyslipidemia. Beginning June 2020, he developed rapid, progressive right orbital soft-tissue swelling, pain on ocular movements, eyelid redness, and diplopia; visual acuity was initially normal OU. In October 2020, examination showed active right orbital inflammation (CAS 3/7) with moderate eyelid edema. Palpebral fissure height was 14 mm OD and 10 mm OS. Hertel exophthalmometry was 24 mm OD and 18 mm OS. There was severe limitation of elevation, persistent depression in primary position OD, and constant diplopia per the Gorman score. GO-QOL was reduced in both subscales, with a greater decrement in function (12.5) than appearance (50) on a 0–100 scale. Color vision by Ishihara was 16/17 OD and 17/17 OS. CT (contiguous 1.25 mm slices, 200 mA, 120 kV, pitch 0.5) demonstrated severe enlargement of the right inferior rectus to the tendon insertion; all other extraocular muscles were normal OU. The muscle–orbit area ratio OD was 0.25 AutoCAD units (vn ≤ 0.20 ± 0.03). Thyroid function was normal with slightly increased TSH-R-Ab at 1.75 mU/L (n.v. < 1.5 mU/L). Electrophysiology showed a slight reduction in p100 amplitude OD. Thyroid ultrasound displayed a thyroiditis pattern. Hematologic and systemic evaluations were negative. Routine labs were unremarkable aside from dyslipidemia (total cholesterol 220 mg/dl, triglycerides 297 mg/dl, HDL 38 mg/dl).

Treatment with intravenous corticosteroid pulse therapy (methylprednisolone; cumulative 4,500 mg over 12 weeks) resolved inflammatory signs and symptoms; however, GO-QOL, Hertel exophthalmometry, and diplopia remained unchanged, and both visual acuity and electrophysiology worsened. As second-line therapy, two-wall orbital surgical decompression plus parenteral glucocorticoids was performed. Intraoperative biopsy of the right inferior rectus revealed massive fibrosis with adipose tissue infiltration.

This case exemplifies euthyroid unilateral GO with isolated inferior rectus involvement and early fibrotic transformation despite only mildly elevated TSH-R-Ab, producing a profound motility deficit and constant diplopia that was refractory to IV steroids and required bony decompression.


You developed a month of productive cough, ear pain, and a long-lasting pus discharge from the right ear. Tests showed tuberculosis bacteria: the direct smear for acid-fast bacilli (AFB) was positive in a gastric aspirate (stomach fluid) and in a swab of the pus from the right ear. This supported TB affecting the middle ear, with likely lung involvement.
You were treated with standard anti-tuberculosis therapy for 6 months, along with supportive care. The treatment cleared the infection, and you made a complete recovery.


This story is about a 4‑month‑old baby girl from an Indigenous community in rural Panama. The nearest clinic was three hours away by canoe. She was not getting enough protein and calories. She suddenly had bad diarrhea. She got very dehydrated, like a plant without water. A probiotic medicine called Enterogermina was given at the start. She was moved to a large hospital. She arrived breathing hard. She was in shock, which means her blood was not carrying enough to her organs. A blood test found a hard‑to‑treat germ called MRSA. A stool test found a germ called C. difficile that can cause diarrhea. Later blood tests from her arm and from a central line found Bacillus clausii. Doctors tried many antibiotics, but the germs did not respond. Her organs began to fail. She died 12 days after she got to the hospital.


A 19-year-old man had a painful lump in his left scrotum for 8 months. Doctors removed the left testicle. Lab tests showed the lump was from TB in the small tube behind the testicle that carries sperm. Scans showed the TB germs had also spread to his lymph nodes, lungs, chest wall, and his bones and joints. He started TB medicines. After 4 months, he had seizures. A brain scan showed small TB lumps in his brain. The doctors kept the TB treatment and added seizure medicine. He got better, and his scans looked better too.


A 20-year-old Arabic male martial artist had 5 weeks of left hamstring pain after a sports injury and did not improve with medications or physiotherapy. Hamstring syndrome was ruled out, and he stopped all sports during recovery. Intervention: a modified slump mobilization (a seated nerve-gliding technique) was performed with four repetitions on 3 consecutive days, along with postural retraining. Outcomes: Pain on the numeric pain rating scale improved from 5/10 at rest and 7/10 with activity to 2/10 at rest and 4/10 with activity by day 3. The Knee Society Score also improved: pain from 22 to 61 and function from 30 to 80. At 2 months, he reported complete symptom resolution and returned to sports without limitation.


A 23-year-old man came to the emergency department with a sudden severe headache, nausea, vomiting, and chest heaviness. His initial vital signs showed high blood pressure and a fast breathing rate. An emergency ECG showed a heart attack pattern (STEMI), so he was urgently sent for percutaneous coronary intervention; the angiogram revealed normal coronary arteries. Further evaluation with a brain CT identified a cisternal subarachnoid hemorrhage (bleeding around the brain). Despite coordinated care by multiple teams, his condition rapidly worsened, leading to cardiac arrest and death.


A 19-year-old woman presented with acute palpitations. The initial ECG demonstrated ventricular tachycardia with right bundle branch block morphology associated with left posterior hemiblock, and T-wave inversion in the inferior and precordial leads. Biomarkers were elevated (troponin 27 ng/L, normal <14 ng/L; NT-proBNP 2225 pg/mL, normal <130 pg/mL). She was admitted to the coronary care unit. Five years earlier, she had presented with cardiogenic shock due to fascicular ventricular tachycardia; CMR and a transoesophageal electrophysiological study at that time were inconclusive. She was discharged with a diagnosis of tachycardiomyopathy on ACE inhibitors, a mineralocorticoid receptor antagonist, and beta blockers, with an uneventful interval thereafter.

During the current hospitalization, there were no further hyperkinetic arrhythmias. Basal 12-lead ECG was obtained. Echocardiography showed diffuse hypokinesia of both ventricles. CMR was again inconclusive, and an undiagnosed congenital cardiac anomaly was suspected. Cardiac computed tomography angiography (CCTA) was performed (GE Lightspeed, retrospective gating, 100 kVp, 696 mAs, gantry rotation 0.35 s, 0.625 mm slice thickness; 70 mL Iomeron 400 mgI/mL IV). The left main and left anterior descending (with a wide ramus intermedius and two diagonal branches) and a thin, non-dominant left circumflex showed no obstructive coronary artery disease. The right coronary artery ostium and proximal segment were absent (ostial atresia); the mid and distal RCA were supplied by a large collateral from the distal LAD that coursed around the lateral right ventricular wall, traversed the distal atrioventricular groove, and gave rise to thin posterior interventricular and posterolateral branches. A thin branch from the mid LAD to the sinoatrial node was also observed.

In the differential for cardiogenic shock in otherwise healthy adults, once acute myocardial infarction is ruled out on 12-lead ECG and cardiomyopathy is not demonstrated on CMR, CCTA is the modality of choice to evaluate for congenital coronary anomalies and other causes. In this case, an echo-stress test confirmed inducible ischemia in the inferior wall, concordant with the arrhythmic focus location. The patient was transferred to a specialist congenital heart disease center, where she underwent transcatheter radiofrequency ablation of sustained ventricular tachycardia arising from the posteromedial papillary muscle. She was discharged on acetylsalicylic acid and verapamil. At 6-month follow-up she remained asymptomatic, without recurrent arrhythmias.


A 36-year-old man had a painful lump where the penis meets the scrotum for five years. Doctors took the lump out with surgery. Lab tests on the tissue confirmed it was a tumor. He had a second surgery to remove more tissue. Even with these surgeries, the disease spread to other parts of his body. It kept getting worse even after trying different chemotherapy medicines.