Palestine Polytechnic University

Necrotizing fasciitis (NF) is a rare but life-threatening soft tissue infection that spreads rapidly along the fascial planes, causing extensive tissue necrosis and high mortality. Necrotizing fasciitis can be caused by various types of bacteria; the majority of cases are polymicrobial infections. However, necrotizing fasciitis caused by a monomicrobial infection, such as Escherichia coli, is rare. Necrotizing fasciitis can affect any part of the body, but the most common sites are the lower extremities, abdominal wall, and perineum. Necrotizing fasciitis secondary to a perirectal abscess is uncommon and poses a diagnostic and therapeutic challenge. We report a case of a 75-year-old male patient who developed type 3 necrotizing fasciitis of the left gluteal region and left thigh secondary to a perirectal abscess. The patient presented to our hospital with severe pain, swelling, erythema, induration, and fever. He was diagnosed with necrotizing fasciitis based on clinical and radiological findings. He showed gradual improvement and was discharged after 28 days of hospitalization.

Chronic osteomyelitis of the coracoid process is extremely rare with limited medical literature. This case reported a 17-year-old male who presented with persistent left shoulder pain and restricted range of motion for 2 months without a history of trauma. Imaging revealed an osteolytic lesion at the base of the coracoid process, confirmed by surgical biopsy. Initially, the patient underwent conservative management with non-steroidal anti-inflammatory drugs, but symptoms persisted, requiring surgical intervention involving decortication, biopsy, and fixation of the lesion using a screw. Histopathological analysis confirmed chronic osteomyelitis, and postoperative intravenous antibiotics for 3 weeks then symptom relief and restored shoulder function. This case highlights the diagnostic challenges for atypical presentation of chronic osteomyelitis in rare anatomical sites, emphasizing the importance of advanced imaging, prompt surgical intervention, and biopsy confirmation. Clinicians should consider osteomyelitis in the differential diagnosis of persistent shoulder pain, even in the absence of trauma or systemic signs of infection.

Introduction The distal tibiofibular syndesmosis is a key structure for the ankle joint’s stability and function, especially when the body is weight-bearing. Recent literature indicates that weight-bearing radiographs demonstrate superior diagnostic yield compared to non-weight-bearing radiographs. This study aimed to determine the diagnostic yield of the weight-bearing compared to the non-weight-bearing radiographs. Materials and Methods A total of thirty-six healthy adult individuals, with an age group ranging from 18 to 65 years, who had never experienced any trauma, were selected for this study. We performed radiographic imaging in three planes of view: anterior-posterior, lateral, and mortise, for both ankles under both weight-bearing and non-weight-bearing conditions. The tibiofibular clear space, tibiofibular overlap, medial clear space, tibiofibular distance-lateral, anteroposterior tibiofibular ratio, and Lateral Tibial (LT) width were measured. Results Tibiofibular clear space and anteroposterior tibiofibular ratio were higher in the weight-bearing position, while tibiofibular overlap, medial clear space, and lateral tibiofibular distance were higher in the non-weight-bearing position. There was a gender effect, as males had higher values for most of the parameters; however, no significant difference was seen in the anteroposterior tibiofibular ratio and tibiofibular distance lateral. The results of this study demonstrate that X-rays of the distal tibiofibular syndesmosis reveal very different outcomes when the person is bearing weight or not pulling weight. These clinically significant differences suggest that weight-bearing radiographs may enhance the identification and diagnosis of syndesmotic injuries. Further studies will be necessary to help with the refinement of the imaging protocols and to improve diagnostic accuracy based on various types of patient demographics. Conclusion WB radiographs provide a more functionally accurate assessment of syndesmotic integrity than NWB imaging. They should be incorporated into routine diagnostic protocols, especially for active individuals and those with higher BMI. These findings support the need for demographic-specific imaging strategies to improve diagnostic precision.

Neuroendocrine neoplasms of the lung include neuroendocrine carcinomas and neuroendocrine tumors (NETs). NETs are also known as carcinoid tumors (CaTs), which are categorized as typical carcinoid and atypical carcinoid (AC). Pulmonary CaTs often metastasize to various sites, including regional lymph nodes, lungs, liver, and bone; however, metastasis to the brain is relatively rare. It is even rarer for patients with CaTs to present with signs of brain metastasis initially. We report the case of a 50-year-old female patient who initially presented with neurological symptoms and magnetic resonance imaging findings suggestive of multiple sclerosis. Despite initial treatment for multiple sclerosis, further evaluation uncovered a rare case of bronchopulmonary AC tumor metastasis to the brain. This case highlights the importance of considering metastatic disease in patients presenting with atypical neurological symptoms, especially when initial management fails to yield expected outcomes. Our literature review revealed 7 cases of CaTs initially presenting with brain metastases, with our patient being the youngest among all published cases.

Appendiceal intussusception is an exceedingly rare condition where a segment of the appendix invaginates into itself or the cecum. We present a case of a 22-year-old female without significant medical history who presented to the emergency room with acute abdominal pain, nausea, vomiting, and fever for 7 hours. Clinical examination revealed diffuse abdominal tenderness and guarding, with stable vitals. Laboratory results showed leukocytosis and elevated C-reactive protein. Abdominal ultrasound and a limited non-contrast computed tomography scan, suggested ileocecal intussusception, but the appendix was not visualized, indicating it as the leading point. Intraoperatively, an inflamed appendix with mucocele and a Type IV intussusception, where the appendix telescoped into itself and the cecum, was found. Manual reduction, appendectomy, and partial cecectomy were performed. Histopathology confirmed severe appendiceal inflammation but no malignancy. This case highlights the diagnostic challenges and rarity of Type IV appendiceal intussusception, emphasizing the importance of surgical exploration in complex presentations.

Uterine rupture during pregnancy is a rare but life-threatening complication that poses severe risks to both mother and fetus. While it is typically associated with a history of uterine surgery, its silent presentation post-vaginal delivery remains exceptionally uncommon and diagnostically challenging. We present an extraordinary case of a 30-year-old multigravida at 33 + 2 weeks gestation, who developed a silent uterine rupture days after an uneventful vaginal delivery. The condition was masked by atypical symptoms, leading to delayed diagnosis, prolonged sepsis, and an intra-abdominal abscess. Despite the absence of classical warning signs, the rupture necessitated urgent surgical intervention, ultimately preserving maternal health and uterine integrity with loss of the fetus. This case underscores the critical need for heightened clinical suspicion and advanced imaging techniques in managing post-delivery complications, especially in patients with a scarred uterus.

Study Design Modified Delphi study. Objectives Telementoring, the practice of providing remote guidance and teaching from a distance using telecommunication technology, has demonstrated feasibility and value in assisting surgeons in remote locations. However, limited evidence exists regarding its effectiveness in improving surgeon performance. This study aimed to develop metrics to assess spine surgeon performance in scoliosis surgery, potentially within the context of a telementoring training program. Methods Ten expert spine surgeons participated in a four-round modified Delphi process including both online and in-person meetings. The resulting metrics were validated for objective assessment by eleven surgeons, who reviewed and rated a video recording using the established rubric. Results The final set of metrics, comprising 50 procedural steps and 28 error categories, was unanimously approved by the panel. Additionally, the panel agreed that utilizing cameras, smart lenses, and output from intraoperative imaging monitors would provide sufficient visibility for assessing both steps and errors. Conclusions A set of assessment metrics for adolescent idiopathic scoliosis surgery was successfully defined and validated by reviewing example videos. The longer-term research objective is to employ this rubric to assess surgeon’s performance throughout a telementoring program, thus assessing its educational impact. The rubric could also be used in other contexts, such as live surgical observation.

Introduction Wandering spleen (WS) is a rare circumstance characterized via exaggerated splenic mobility because of absent or lax suspensory ligaments. It predisposes the spleen to torsion, that could purpose infarction, rupture, or gangrene, requiring urgent intervention. Presentation of case We report a 10-year-old girl with a three-day history of acute abdominal pain, vomiting, and fever. Physical examination revealed diffuse tenderness, predominantly in the right lower quadrant (RLQ), mimicking appendicitis. Ultrasound and CT showed WS with torsion, showing the characteristic whirl sign. Emergency laparotomy revealed a 720-diploma splenic torsion with necrosis, necessitating splenectomy. The patient had an uneventful recovery and was discharged on postoperative day five. Discussion WS is an extraordinary entity (<0.2 % occurrence) with a bimodal age distribution, often affecting adolescents and girls. It can be congenital or acquired and presents variably, from asymptomatic cases to acute abdomen. Torsion leads to vascular compromise, requiring prompt surgical intervention. This case was very interesting to the surgical team for its atypical presentation and its resemblance to perforated appendicitis. Conclusion WS must be considered in cases of acute abdomen with an absent spleen on imaging. Early recognition and surgical intervention are essential to prevent complications in patients with acute abdomen. Ultrasound and CT are critical for early detection and differentiation from different abdomen emergencies.

Differentiation syndrome (DS) is a life-threatening condition caused by the use of differentiating agents, which are used for remission induction in acute promyelocytic leukemia (APL).This study aimed to investigate the current evidence on risk factors for DS. Related articles were searched from PubMed, Scopus, Cochrane Library, Web of Science, and China National Knowledge Infrastructure. RevMan 5.4 software was used for meta-analysis. A total of 22 studies were included in this study. Risk factors that had significant relation with DS were BMI 25 < Kg/m2 (OR: 3.87, 95% CI: 2.06 to 7.25, p > 0.0001), WBCs < 109/L (OR: 3.02, 95% CI: 1.85 to 4.92, p > 0.00001), and high risk APL (OR:2.16, 95% CI: 1.39 to 2.26, p = 0.0007). This study highlights important predictive factors for DS, with WBCs < 109/L, high-risk APL and BMI 25 < Kg/m2 as the most prominent factors.

Introduction and importance Gastroduodenal artery (GDA) pseudoaneurysm is a rare but potentially life-threatening vascular anomaly, typically associated with pancreatitis, trauma, or previous surgery. Due to its high risk of rupture, early diagnosis and intervention are crucial. This case report highlights a unique presentation of GDA pseudoaneurysm in a 38-year-old female without traditional risk factors, emphasizing the importance of vigilance in atypical cases. Case presentation A 38-year-old female with a history of cholecystectomy and chronic iron deficiency anemia presented with recurrent epigastric pain and anemia. Laboratory findings revealed significant microcytic hypochromic anemia. Initial imaging ruled out pancreatitis, but a contrast-enhanced computed tomography (CT) scan detected a GDA pseudoaneurysm with impending rupture. Given the high risk of hemorrhage, the patient underwent urgent endovascular embolization, successfully isolating the pseudoaneurysm. Post-procedural recovery was uneventful, with follow-up imaging confirming successful exclusion of the pseudoaneurysm. The patient's hemoglobin levels normalized, and she resumed daily activities without recurrence of symptoms, indicating a favorable long-term outcome. Clinical discussion GDA pseudoaneurysms are rare, accounting for only 1.5 % of visceral artery aneurysms, and typically occur in males over 50 years old with risk factors such as pancreatitis or alcohol abuse. This case is distinctive due to the patient’s younger age, female gender, and absence of common etiologies. The successful use of endovascular embolization highlights its efficacy as a minimally invasive alternative to open surgery in managing visceral artery pseudoaneurysms. Conclusion This case underscores the importance of considering GDA pseudoaneurysm in patients with unexplained epigastric pain and anemia, even in the absence of traditional risk factors. Early imaging, prompt intervention, and postoperative monitoring are key to preventing catastrophic complications.

Introduction and importance Neurologic disorders are among the most significant clinical symptoms of systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), primarily affecting the central nervous system. Both SLE and APS increase the risk of cerebrovascular events, and stroke is one of the most serious and late consequences that often occur years after diagnosis. Stroke as an initial symptom is uncommon in its early stages and frequently misinterpreted as ischemic cerebrovascular illness, posing diagnostic challenges. Case report A 15-year-old female patient presented to the emergency department with a history of right-sided body weakness, mouth deviation, and dysarthria. A brain MRI revealed a complete occlusion of the left MCA with multiple acute left periventricular ischemia. She was referred for urgent brain catheterization, where complete recanalization of the MCA was performed. Extensive investigations were performed, including serological laboratory studies, which led to a subsequent diagnosis of SLE and APS. Clinical discussion Ischemic stroke is a serious and late consequence of SLE and APS that often occurs years after diagnosis. Ischemic stroke as an initial symptom is uncommon in its early stages and frequently misinterpreted. Conclusion This case exemplifies a sudden and possibly fatal presentation of SLE and APS in pediatric patients, emphasizing the need of early recognition and tailored treatment in influencing the disease’s progression and outcomes.

Background Histoplasma capsulatum infective endocarditis (IE) is rare and often fatal, especially in prosthetic valve patients, due to delayed diagnosis and limited therapeutic options. This case demonstrates the utility of AngioVac for managing large fungal vegetations, underscores the importance of considering fungal IE in culture-negative cases, and highlights the role of a multidisciplinary approach in high-risk patients. Case summary We report a 76-year-old female with a bioprosthetic aortic valve who presented with persistent culture-negative fever, splenic infarcts, and large vegetations on her prosthetic valve. Extensive diagnostic workup confirmed fungal endocarditis after AngioVac-assisted debulking revealed H. capsulatum on tissue cultures. Despite prompt initiation of antifungal therapy and multidisciplinary management, her course was complicated by recurrent embolic events, septic shock, and eventual death. Conclusion This case underscores the importance of considering fungal IE in culture-negative cases, especially in high-risk patients such as those with prosthetic valves. It also highlights the role of advanced diagnostic techniques and minimally invasive interventions like AngioVac in managing complex cases, despite their limitations.

Introduction and importance Bone metastases as the sole manifestation of colorectal carcinoma (CRC) are extremely rare, and their coexistence with a second malignancy, such as melanoma, adds complexity to diagnosis and management. Method A comprehensive evaluation was conducted, including PET imaging, immunohistochemistry, and genetic testing, to determine the origin of bone lesions and identify concurrent malignancies. Case Presentation A 62-year-old male with stage III CRC developed isolated bone metastases and was simultaneously diagnosed with invasive melanoma. PET imaging and bone biopsy confirmed CRC as the source of metastases. Genetic testing identified a BRAF V600E mutation in CRC, but advanced targeted therapies were unavailable locally. Clinical Discussion This case highlights the rarity of isolated bone metastases in CRC, the utility of PET imaging, and the implications of BRAF mutations in dual malignancies. The synchronous diagnosis of melanoma emphasized the need for integrated diagnostic approaches. Conclusion Unusual metastasis patterns require heightened clinical vigilance and multidisciplinary care. Genetic insights can aid in understanding tumor behavior and optimizing management.

Background Although nutritionally beneficial, honey may harbor Clostridium botulinum spores, posing risks to infant botulism (IB). Infants under one year are vulnerable due to immature gut flora, with IB potentially causing severe symptoms, such as respiratory failure. Despite global awareness, cultural beliefs influenced caregivers’ practices in Palestine. This study evaluated Palestinian parents’ knowledge, beliefs, and feeding practices regarding honey to guide targeted interventions. Methods This cross-sectional study (August–September 2024) surveyed 469 Palestinian parents (aged ≥18 years) from 10 West Bank cities, excluding 88 ineligible responses. A validated questionnaire assessed their knowledge, attitudes, and practices. Data were analyzed using the R software (frequency, Chi-squared/Fisher’s tests; p < 0.05). Results Most participants were female (89%), under 30 years old (53%), and highly educated (77%). While 58% knew of honey-linked IB, only 32% identified C. botulinum as the causative agent. Notably, 15.8% fed honey to infants aged <12 months and 62.5% introduced complementary feeding at 6–12 months. Age and income-influenced practices, with many believing that honey aids digestion or supplements nutrition. Conclusions The findings reveal gaps in knowledge and widespread cultural beliefs about the benefits of honey, which contribute to unsafe feeding practices. Health interventions in Palestine should incorporate these insights to improve awareness and to prevent IB.

Objective Burn injuries are prevalent worldwide, especially in developing countries; and there are significant children burn injuries in Palestine. This study was performed to analyse the pattern, cause, of burn injuries in Palestine. Methods Prospective study, we undertook a prospective study of all patients under 6 years who admitted to burn unit 1 January 2022, and 31 December 2022. In‐person interviews with the children's parents determined the burns' genesis and environmental causes. Demographic and clinical data were obtained. Result The population being studied had a mean age of 3.1 years. The majority of the 91 patients who were burned did so because of scalds. Flame 10 sufferers represented 60% of the patients; 60% were residents of urban areas. Five people were living in residence. Most of the children (81 of the total) were with another person at the time of the burn injury, and the kitchen was the location of the burn in 41 cases. Conclusion The patients' crowded environment was a challenge. Even when an adult was close, the caretaker did not watch the child well. Burns are likely in the kitchen, where people cook and eat harmful foods. First, ensure the kitchen is safe, and then apply other safety procedures around the house to decrease the danger of burns to children.