World Journal of Clinical Cases最新文献

With fungal infections rising worldwide, the use of azoles, polyenes, and echinocandins, the mainstay of antifungal therapy has expanded markedly. With broader use, uncommon adverse effects are increasingly being identified. Azoles, the most widely prescribed class of antifungal agents, inhibit several cytochrome P450-dependent steps in human steroidogenesis, leading to disruption of endocrine pathways. Adrenal and gonadal dysfunctions with ketoconazole, and mineralocorticoid excess with posaconazole and itraconazole, are well-documented. Uncommon manifestations, such as voriconazole-induced syndrome of inappropriate antidiuretic hormone secretion or salt-losing nephropathy, and fluoride-related periostitis associated with voriconazole and itraconazole, have also been reported. The adverse reactions may be further influenced by drug interactions with enzyme inducers or inhibitors. Amphotericin B is known to cause electrolyte disturbances due to tubular damage. Echinocandins differ from azoles and polyenes in that they rarely affect endocrine pathways, making them a safer option when endocrine toxicity is a concern. Clinicians must remain vigilant to the endocrine adverse effects and pharmacological interactions of antifungal agents to enable timely recognition and management.

Disseminated herpes simplex virus infection in erythrodermic psoriasis remains exceedingly uncommon, yet it poses substantial diagnostic and therapeutic challenges in patients receiving biologic therapy. The recent case by Berjawi et al illustrates an atypical presentation of widespread herpes simplex virus-1 in a patient undergoing treatment with ixekizumab and topical corticosteroids, highlighting diagnostic uncertainty, cumulative immunosuppression, and therapeutic decision-making in severe psoriasis. This correspondence aims to emphasize the challenges of early herpes simplex virus recognition, discuss the potential but associative role of interleukin-17 inhibition in antiviral defence, and underscore the lack of clinical guidance regarding interruption and safe reintroduction of biologic therapy following viral clearance.

Background: Although hepatic adenomas (HA) account for less than 0.04% of all liver neoplasms, their occurrence in young women is rare but strongly associated with oral contraceptive use, particularly in the 20-40 years age group, with an annual incidence estimated at approximately 3 to 4 cases per 100000 population.

Case summary: We report the case of a previously healthy 30-year-old female patient, a regular user of combined oral contraceptives, who presented with acute hemorrhagic abdomen due to spontaneous rupture of a HA. The clinical presentation occurred after physical exertion and was with evidence of intra-abdominal bleeding. Initial management included selective hepatic arterial embolization as a conservative approach. Due to ongoing hemorrhage, an urgent left partial hepatectomy was indicated.

Conclusion: The operation was completed without adverse events, and postoperative recovery was favorable. This report emphasizes the significance of prompt diagnosis and immediate surgical intervention when hemodynamic compromise occurs due to HA rupture.

Background: Intraosseous lipomas are rare developmental anomalies that present with visual impairment. Due to their infrequency, they often pose diagnostic challenges, particularly in differentiating them from more common optic nerve pathologies. Magnetic resonance imaging (MRI) plays a crucial role in the early identification and management of these lesions.

Case summary: We present the case of a 41-year-old male with a history of dyslipidemia who developed sudden onset headaches and decreased vision in his left eye. MRI revealed a T1-hyperintense fat-containing lesion within the left anterior clinoid process of the sphenoid bone at the optic canal, causing extrinsic compression of the left optic nerve, initially interpreted as a lipoma. Intraoperatively, the previously thought lipoma lesion was actually shown to be adipose tumor of the bone and pathological examination confirmed the diagnosis. The left optic nerve was successfully decompressed, and the patient's vision improved significantly post-op. This case highlights that while MRI is essential in evaluating optic nerve compressive lesions, radiologic findings alone may be insufficient, and surgical and pathological correlation remains crucial for accurate diagnosis.

Conclusion: This case highlights the importance of considering intraosseous lipoma of the sphenoid bone as a rare cause of optic nerve compression and emphasizes the pivotal, but not definitive, role of MRI, which must be complemented by surgical and histopathological correlation to prevent irreversible visual loss.

Background: Erdheim-Chester disease (ECD) is an ultra-rare non-Langerhans cell histiocytosis driven by clonal proliferation of lipid-laden histiocytes. With fewer than a thousand documented cases globally, it remains largely unreported in South Asia.

Case summary: A 46-year-old male presented with chronic leg pain, polyuria, and visual disturbances. Radiologic findings revealed symmetric osteosclerosis of long bones and absent pituitary shadow with thickened stalk of pituitary gland. Histopathology showed foamy histiocytes positive for CD68 and CD163 but negative for CD1a and Langerin. Detection of BRAF V600E mutation confirmed the diagnosis. The patient was treated with corticosteroids and interferon-alpha, with significant symptomatic improvement at six months.

Conclusion: This case represents the first case of ECD reported from Pakistan. Awareness of its distinct imaging and histologic patterns can facilitate diagnosis even in resource-limited settings. National rare disease registries and access to molecular diagnostics are essential for improving outcomes.

Background: Scorpion envenomation in pregnancy is a rare but potentially fatal obstetric emergency, with limited evidence on optimal management and antivenom safety. Neurotoxic venom induces autonomic storms, threatening maternal cardiovascular stability and uteroplacental perfusion, which can lead to fetal distress or demise.

Case summary: A 31-year-old gravida 4, para 3 woman at 36 weeks' gestation presented 30 minutes after a confirmed Parabuthus maximus sting to her right foot. She manifested systemic envenomation, including agitation, profuse sweating, tachycardia (142 bpm), and hypertension (168/102 mmHg). Cardiotocography revealed fetal tachycardia (175-180 bpm). A multidisciplinary team initiated intravenous morphine, midazolam, and species-specific antivenom (South African Vaccine Producers Polyvalent Scorpion Antivenom), resulting in the resolution of maternal and fetal symptoms within 12 hours. Critically, antivenom was administered within 40 minutes of the sting, which likely contributed to the rapid reversal of the catecholamine surge. A key factor enabling this rapid and targeted response was the patient's action of capturing the scorpion, allowing for precise species identification. The pregnancy progressed uneventfully to term, culminating in an uncomplicated vaginal delivery of a healthy infant.

Conclusion: This case illustrates that scorpion envenomation in late pregnancy poses a dual threat to both maternal and fetal well-being. Prompt recognition, continuous fetal monitoring, and the very early administration of antivenom-buttressed by multidisciplinary care-can avert catastrophic outcomes. This case provides supporting evidence that antivenom can be safe and effective during the third trimester, even in resource-constrained environments. Public education on safe first aid, including bringing the scorpion for identification, is essential.

Therapy discontinuation in inflammatory bowel disease, particularly involving immunomodulators, biologics, and small molecules, remains a controversial and evolving topic. This letter reflects on developments following the publication by Meštrović et al, emphasizing the complex balance between risks of relapse, anti-drug antibody formation, and potential complications of long-term immunosuppression. Recent evidence underscores high relapse rates following withdrawal - especially of anti-tumor necrosis factor agents - and highlights the lack of robust data for newer biologics. Updated guidelines from European Crohn's and Colitis Organization, British Society of Gastroenterology, and American College of Gastroenterology all support cautious and individualized approaches, with strict criteria and close follow-up, particularly in Crohn's disease. For ulcerative colitis, therapeutic cycling remains insufficiently addressed. We proposed a flowchart to support clinical decision-making and stress the importance of shared decision-making in the era of personalized medicine since, despite new drug classes and evolving strategies, the therapeutic ceiling in inflammatory bowel disease has yet to be fully overcome.

Background: Due to the increasing rate of thyroid nodules diagnosis, and the desire to avoid the unsightly cervical scar, remote thyroidectomies were invented and are increasingly performed. Transoral endoscopic thyroidectomy vestibular approach and trans-areolar approaches (TAA) are the two most commonly used remote approaches. No previous meta-analysis has compared postoperative infections and swallowing difficulties among the two procedures.

Aim: To compared the same among patients undergoing lobectomy for unilateral thyroid carcinoma/benign thyroid nodule.

Methods: We searched PubMed MEDLINE, Google Scholar, and Cochrane Library from the date of the first published article up to August 2025. The term used were transoral thyroidectomy vestibular approach, trans areolar thyroidectomy, scarless thyroidectomy, remote thyroidectomy, infections, postoperative, inflammation, dysphagia, and swallowing difficulties. We identified 130 studies, of them, 30 full texts were screened and only six studies were included in the final meta-analysis.

Results: Postoperative infections were not different between the two approaches, odd ratio = 1.33, 95% confidence interval: 0.50-3.53, the χ ² was 1.92 and the P-value for overall effect of 0.57. Similarly, transient swallowing difficulty was not different between the two forms of surgery, with odd ratio = 0.91, 95% confidence interval: 0.35-2.40; the χ ² was 1.32, and the P-value for overall effect of 0.85.

Conclusion: No significant statistical differences were evident between trans-oral endoscopic thyroidectomy vestibular approach and trans-areolar approach regarding postoperative infection and transient swallowing difficulties. Further longer randomized trials are needed.

Background: Congenital hypothyroidism (CH) is a common condition in both preterm and term infants characterized by either thyroid gland absence or hypofunctionality. The clinical association of refractory lactic acidosis and heart failure has rarely been observed in cases of pediatric patients with CH pathology. Here, we explored the etiological relationship between CH, heart failure, and refractory lactic acidosis to reflect the importance of thyroid function screening in neonates with heart disease.

Case summary: A 33-day-old extremely premature female infant presented with tachypnea, respiratory distress, recurrent infections, and abdominal distension postnatal. On admission to our facility, she had cardiomegaly, hepatomegaly, and lactic acidosis (revealed on blood gas analysis), with lactate progressively rising to 25 mmol/L. Chest radiographs showed pulmonary congestion, while echocardiography revealed cardiac enlargement, left ventricular wall thickening, and pericardial effusion. Initial management aimed at correcting acidosis and treating heart failure proved ineffective. After reassessment, thyroid function tests showed significantly decreased triiodothyronine, free triiodothyronine, thyroxine, and free thyroxine levels, with a significantly increased thyroid-stimulating hormone level, confirming a CH diagnosis. Levothyroxine was administered, resulting in rapid correction of lactic acidosis and gradual improvement of thyroid function and systemic symptoms, culminating in full recovery and discharge. We also reviewed the relevant literature on thyroid and cardiac dysfunctions in order to explore their deeper association.

Conclusion: This case links CH-induced heart failure with refractory lactic acidosis, urging prompt thyroid screening in affected neonates to reduce mortality.

Background: Gallstones and gallbladder wall thickening (GBWT) are frequent findings in patients with cirrhosis, reflecting the critical interplay between hepatobiliary dysfunction and portal hypertension.

Aim: To assess the prevalence of gallstones and asymptomatic GBWT in patients with cirrhosis.

Methods: Hospitalized patients with cirrhosis who had undergone abdominal imaging studies during hospitalization were retrospectively analyzed.

Results: A total of 128 patients were included. The patients had a mean age of 64 ± 12.2 years, were predominantly male (73.4%), and most had decompensated liver cirrhosis (DeCi) (78.1%). Alcohol-associated liver disease (47.7%) and metabolic dysfunction-associated steatohepatitis (16.4%) are the leading causes of cirrhosis. Most patients were classified as Child-Pugh stage B (53.1%), followed by stage C (32%), and stage A (14.8%). A significant percentage of patients had cholelithiasis (39.8%), and DeCi patients were more likely to have gallstones (45%) than compensated patients (21.4%) (P = 0.024). Furthermore, a significant number of patients had asymptomatic GBWT (32.8%), and almost half (42.9%) did not have concurrent cholelithiasis. Patients with DeCi were significantly more likely to have GBWT (39%) than those with compensated disease (10.7%) (P = 0.005). There was no statistical correlation between cirrhosis etiology and cholelithiasis or GBWT.

Conclusion: This study underlines the high prevalence of radiologic gallbladder findings in patients with cirrhosis while simultaneously serving as a reminder to clinicians to refrain from accrediting these findings to a diagnosis of acute cholecystitis in the absence of symptoms.