Cureus最新文献

Pulmonary embolism (PE) remains a leading cause of sudden hemodynamic deterioration and death in emergency department patients. Although diagnostic algorithms frequently incorporate D-dimer testing, in patients with high clinical probability or hemodynamic instability, definitive imaging should not be delayed. We report a case of a 74-year-old man presenting with syncope, hypoxemia, and hypotension, in whom immediate computed tomography pulmonary angiography (CTPA) was performed without prior D-dimer testing due to strong clinical suspicion of high-risk PE. Imaging revealed extensive bilateral pulmonary emboli with radiological signs of right ventricular strain, which were subsequently supported by point-of-care echocardiography. Due to recent head trauma, systemic thrombolysis was contraindicated, and the patient was referred for urgent mechanical thrombectomy. This case highlights the importance of clinical judgment and early imaging in high-risk PE and emphasizes that laboratory testing should not delay life-saving diagnostic and therapeutic decisions in unstable patients.

Chronic arterial ulcers are associated with impaired healing and a high risk of infectious complications and limb loss. Bullous cellulitis represents a severe soft-tissue infection phenotype that may progress to extensive tissue necrosis. We report an 83-year-old woman with advanced atherosclerotic disease and a prior contralateral transfemoral amputation who developed bullous cellulitis complicating a long-standing circumferential distal lower-leg arterial ulcer, resulting in complete circumferential loss of skin and subcutaneous tissue with exposure of deep structures. After infection stabilization, the wound was managed with staged mechanical and chemical debridement, negative pressure wound therapy (NPWT) for wound-bed optimization, and definitive split-thickness skin grafting under NPWT bolster. Complete graft take was achieved without early complications. Limb salvage preserved the patient's mobility and quality of life, avoiding the functional consequences of bilateral major limb loss. The key novelty of this case is that even circumferential ischemic-infective necrosis, often presumed to mandate amputation, can be rendered graftable and salvaged through a strictly staged, NPWT-centered reconstructive strategy.

We report the case of a 15-day-old neonate presenting with multifocal osteoarticular infection, initially manifesting as septic arthritis of the right wrist, which rapidly progressed to involve multiple sites, including the right deltoid and left hip. The etiological agent was identified as methicillin-sensitive Staphylococcus aureus (MSSA). This case is notable for its multifocality, the severity of the clinical course in the neonatal period, and the association with a prior history of neonatal admission for severe hypernatremic dehydration.

Background Volar locking plate fixation has become the preferred operative treatment for unstable distal radius fractures because it allows stable fixation and early mobilization. However, long-term clinical outcomes and early complications in Asian populations treated in routine practice remain less well documented. Methods This retrospective cohort study included 40 consecutive adult patients with unstable distal radius fractures treated with volar locking plates by a single hand and wrist surgeon at a university hospital between January 2012 and December 2021. Patients met predefined radiographic criteria for instability and were followed for at least two years. Radiographic parameters (radial inclination, palmar tilt, and ulnar variance) were assessed preoperatively, immediately after surgery, at three months, and at ≥2 years. Wrist range of motion, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Wrist Evaluation (PRWE), and pain visual analog scale (VAS) scores were recorded preoperatively, at two weeks, three months, and at ≥2 years. Early complications within three months (carpal tunnel syndrome, median nerve palmar branch injury, and extensor pollicis longus rupture) were retrieved from medical records. Paired t-tests were used to compare changes over time. Results A total of 40 patients were included (mean age, 55.4 years), of whom 26 (65.0%) were women. Radiographic alignment improved after fixation and was maintained at ≥2 years. Patient-reported outcomes (QuickDASH and PRWE), pain, range of motion, and grip strength improved progressively, with minimal disability and pain at long-term follow-up. Early symptoms consistent with carpal tunnel syndrome occurred in seven (17.5%) patients; no median nerve palmar branch injury, extensor pollicis longus rupture, or flexor pollicis longus rupture was identified. Conclusions In this single-surgeon retrospective cohort with a minimum two-year follow-up, volar locking plate fixation for unstable distal radius fractures achieved durable restoration of radiographic alignment and progressive improvement in wrist-related pain and function. Patient-reported outcomes, range of motion, and grip strength improved over time, and major complications were uncommon; early symptoms consistent with carpal tunnel syndrome occurred in seven (17.5%) patients, and no extensor pollicis longus or flexor pollicis longus rupture was identified. Overall, these findings support volar locking plate fixation as a reliable treatment option for unstable distal radius fractures in routine clinical practice.

The most influential timing of continuous renal replacement therapy (CRRT) in gravely ill patients with acutely severe, uncompensated renal dysfunction continues to be a subject of ongoing debate. Although earlier initiation has been hypothesized to limit metabolic disturbances and prevent downstream organ dysfunction, clinical trials have yielded inconsistent findings, in part because of variability in how "early" initiation is defined across studies. This meta-analysis, in conjunction with a systematic review, sought to examine the correlation between early versus delayed CRRT initiation and mortality, with analyses stratified according to initiation strategy, including clinical staging-based benchmark by Kidney Disease: Improving Global Outcomes (KDIGO) and biomarker-driven approaches using neutrophil gelatinase-associated lipocalin (NGAL). A literature search was conducted in PubMed, EMBASE, and the Cochrane Library to identify studies published between January 2015 and June 2025. Eligible studies included randomized controlled trials and observational investigations that compared early and delayed CRRT initiation among critically ill adults with acute kidney injury (AKI). The primary outcome of interest was all-cause mortality measured between 28 and 90 days or at the time of intensive care unit (ICU) discharge. Pooled relative risks (RR) and odds ratios (OR) were estimated using random-effects meta-analytic models, with subgroup analyses performed according to initiation criteria. Nine studies encompassing 2,349 patients were included (six randomized trials and three observational studies). Overall, early CRRT initiation was not associated with a statistically significant decrease in mortality compared with delayed initiation (risk ratio (RR) = 0.87; 95% confidence interval (CI), 0.69-1.10; p = 0.25; I² = 90.4%). Subgroup analysis demonstrated no significant mortality benefit with biomarker-guided (NGAL-based) early initiation (RR = 0.90; 95% CI, 0.41-2.01), whereas KDIGO-based initiation showed a borderline association favoring early therapy (RR = 0.75; 95% CI, 0.57-0.99), though heterogeneity remained substantial. No meaningful interaction was observed between initiation strategy and mortality.

Pulmonary nodules with increased metabolic activity on positron emission tomography (PET) are frequently presumed malignant; however, inflammatory and rare benign neoplastic processes may produce false-positive findings. A 61-year-old African American male with a history of calcified and non-calcified pulmonary nodules and severe emphysema was referred to our pulmonary nodule clinic from the emergency department after a newly discovered lung nodule was identified on computed tomography (CT) of the chest. Subsequent evaluation demonstrated metabolic activity on PET, raising concern for malignancy; however, tissue diagnosis revealed organizing pneumonia. This case highlights diagnostic pitfalls associated with commonly used imaging and biomarker modalities in the evaluation of pulmonary nodules and emphasizes the importance of clinical awareness of a rare tumor, granular cell tumor (GCT), among physicians who may be unfamiliar with or have never encountered this condition.

Rheumatoid vasculitis (RV) is an uncommon but potentially fatal extra-articular manifestation of rheumatoid arthritis (RA), characterized by severe systemic inflammation and high mortality despite advances in disease-modifying therapies. We describe a 52-year-old woman with long-standing seropositive RA and irregular use of methotrexate who presented with progressive digital ischemia and extensive necrotic cutaneous ulcers, in the absence of active synovitis. Histopathology revealed small-vessel vasculitis, accompanied by markedly elevated rheumatoid factor and anti-cyclic citrullinated peptide titers, hypocomplementemia, and negative antineutrophil cytoplasmic antibodies. Despite high-dose corticosteroids, vasodilator therapy, and broad-spectrum antibiotics, the disease rapidly evolved to multiorgan involvement, including respiratory failure requiring mechanical ventilation, rapidly progressive renal failure requiring hemodialysis, and ischemic central nervous system lesions, culminating in refractory multiorgan failure and death. This case illustrates a fulminant presentation of RV with aggressive cutaneous and visceral involvement, emphasizing that severe vasculitis may occur independently of articular disease activity and is associated with poor prognosis. RV should be suspected in patients with long-standing RA who develop unexplained ischemic or ulcerative lesions, even in the absence of active arthritis. Early recognition and timely, sustained immunosuppression are critical to prevent irreversible organ damage and fatal outcomes.

Varicella-zoster virus, colloquially known as chickenpox in the United States, complicating pregnancy has become a rare diagnosis following the introduction of the varicella-zoster vaccine. Despite a lower incidence of chickenpox than in the past, those providing prenatal care should keep a high index of suspicion for varicella-zoster among patients presenting with a vesicular rash and no history of having received the varicella-zoster vaccine. This report reviews the case of a 28-year-old gravida three at 35 weeks gestation who presented with concern for a full-body vesicular rash and pruritus. The evaluation, diagnosis, and medical management of varicella-zoster infection in pregnancy are discussed.

Acute aortic syndromes (AAS) encompass life-threatening conditions that require rapid diagnosis and specialized intervention. Among these, large-vessel vasculitides, such as Takayasu arteritis (TA), pose unique surgical and anesthetic challenges due to active vascular inflammation, tissue fragility, and possible multiorgan involvement. We report the perioperative management of a 34-year-old female, who was 20 weeks pregnant, with TA who presented with rapidly progressive aneurysmal dilation and dissection of the thoracic aorta, complicated by multiorgan failure. She underwent emergent hybrid repair of the aortic arch using a frozen elephant trunk (FET) prosthesis, followed by second-stage thoracic endovascular aortic repair (TEVAR) for a descending aortic aneurysm six months later. The initial perioperative period was complicated by hemodynamic instability, cardiac arrest, ventilatory challenges, renal failure, and fetal loss. Intraoperative management included transesophageal echocardiographic assessment, hemostatic optimization, and prioritization of cerebral and end-organ protection using moderate hypothermia and antegrade cerebral perfusion. The postoperative period was further complicated by severe myopathy, bilateral vocal cord paralysis, and limb ischemia secondary to vasopressor use. Despite the complexity of the surgical case and the subsequent complications, the patient achieved a favorable functional recovery and remains under follow-up with stable aortic imaging findings. This report highlights the multidisciplinary challenges of managing extensive aortic disease, particularly when surgery is required during an active inflammatory phase. Careful preoperative assessment, individualized surgical and anesthetic strategies, advanced intraoperative monitoring, and prolonged postoperative support are essential to maximize outcomes in this high-risk population.

Background and objective Breast lesions represent a wide clinicopathological spectrum, with breast cancer being the most common malignancy in Bangladeshi women. It often presents at a younger age and at an advanced stage, placing strain on the country's limited oncology services. This study aimed to observe the histopathological pattern of breast lesions in women attending a tertiary care center in Dhaka and to identify clinical predictors of pathologically confirmed malignant breast cancer. Methods A retrospective, hospital-based study was conducted in the Department of Pathology, Medical College for Women and Hospital, Dhaka, from June to November 2025, including 160 women with histologically confirmed breast lesions. Clinical data and histopathology reports were analyzed using descriptive statistics, chi-square/Fisher's exact tests, and multivariable logistic regression. Results The mean age was 31.79 ± 11.88 years, with most patients aged 30-39 years. The predominant diagnoses were fibroadenoma (52; 32.5%), granulomatous mastitis (24; 15.0%), invasive breast carcinoma (24; 15.0%), and fibrocystic change (13; 8.1%). Overall, 47.5% of lesions were benign, 35.6% inflammatory, and 16.9% malignant. Age ≥40 years (OR 2.582; 95% CI 1.754-3.802), bilateral involvement (OR 2.088; 95% CI 1.391-3.134), and a clinical impression of malignancy (OR 2.290; 95% CI 1.536-3.414) independently predicted malignancy. Histopathology-based classification demonstrated a sensitivity of 98.68%, a specificity of 74.07%, and an overall accuracy of 89.82% in differentiating benign from malignant lesions. Conclusions Benign and inflammatory lesions, particularly fibroadenoma and granulomatous mastitis, predominate among Bangladeshi women; however, a substantial malignant burden is evident, especially in older and bilaterally affected patients. Because the histopathology-based classification showed moderate specificity, further robust studies incorporating immunohistochemistry and molecular subtype analysis are warranted. Strengthening clinicopathological correlation and maintaining high-quality histopathology services are essential to support earlier diagnosis and targeted management in this setting.