International Journal of Medical and Pharmaceutical Case Reports

Cerebral Venous Thrombosis Presenting as Optic Neuropathy: A Case Report

Rose Mary Joshy — 2026-06-05

Background: Cerebral Venous Thrombosis (CVT) is an uncommon cerebrovascular disorder with a highly variable clinical spectrum. While headache is the most prevalent symptom, acute and severe visual impairment as the dominant presenting feature is rare and constitutes a neuro-ophthalmic emergency.

Case Presentation: We report the case of a 63-year-old male with a chronic smoking history who presented with sudden-onset, progressive visual deterioration over three days, culminating in complete bilateral vision loss, accompanied by headache. An ophthalmology consultation revealed bilateral disc hyperemia. Neuroimaging, including Magnetic Resonance Imaging (MRI) and MR Venography, confirmed partial thrombosis involving the venous sinus confluence, posterior superior sagittal sinus, right transverse and sigmoid sinuses, and the right proximal internal jugular vein. The patient was managed with systemic anticoagulation and a course of high-dose corticosteroids for suspected compressive optic neuropathy. Clinical stabilization was achieved, and he was discharged on warfarin and a tapering dose of prednisolone.

Discussion: This case details an atypical manifestation of CVT. The pathophysiology of acute visual failure likely involves compressive optic neuropathy, corroborated by the ophthalmoscopic finding of bilateral disc hyperemia, and possible venous congestion of the optic nerves. Management necessitates a dual strategy: immediate anticoagulation to arrest thrombus propagation and corticosteroids to mitigate secondary optic nerve insult.

Conclusion: CVT should be considered in the differential diagnosis of acute, profound vision loss, particularly when accompanied by headache. Prompt diagnosis via MR Venography and expeditious, targeted intervention are critical to optimize neurological outcomes.

Evans Syndrome with Double-Positive Antiphospholipid Antibody Syndrome, NGS-Confirmed Cystic Fibrosis, Chronic Pancreatitis, Type-1 Diabetes Mellitus and Pulmonary Tuberculosis with Nocardiosis: A Rare Multi-System Overlap in a Young Adult Male

Marmik Patel — 2026-06-15

Evans syndrome is an uncommon autoimmune hematological disorder characterized by the coexistence or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia. Its occurrence with antiphospholipid antibody syndrome, cystic fibrosis, chronic pancreatitis, insulin-dependent diabetes mellitus, pulmonary tuberculosis, and nocardiosis creates a highly complex diagnostic and therapeutic situation. We report the case of a 33-year-old male with multiple established autoimmune, genetic, metabolic, and infectious comorbidities who presented with acute left lower limb pain and swelling for three days. Clinical examination showed erythema, tenderness, and swelling of the affected limb. Doppler ultrasonography confirmed deep vein thrombosis. Laboratory evaluation showed anemia, thrombocytopenia, and markedly raised D-dimer. The patient had a background of Evans syndrome, double-positive antiphospholipid antibody syndrome, next-generation sequencing-confirmed cystic fibrosis, chronic pancreatitis, insulin-dependent diabetes mellitus, pulmonary tuberculosis on anti-tubercular therapy, and nocardiosis. He had recently received eltrombopag for severe thrombocytopenia following a hemolytic episode. The thrombotic event was considered to be temporally associated with eltrombopag use in the presence of an underlying prothrombotic antiphospholipid antibody profile. Management included anticoagulation with enoxaparin, discontinuation of eltrombopag, continuation of anti-tubercular therapy, immunosuppressive therapy, insulin treatment, analgesia, and supportive care. During hospitalization, limb pain and swelling improved, and the platelet count increased to 0.60 lac/cu.mm by Day 10. This case highlights the importance of individualized risk assessment when using thrombopoietin receptor agonists in patients with prothrombotic autoimmune disease and emphasizes the need for coordinated multidisciplinary management in complex multisystem overlap presentations.

Maternal–fetal Safety During Electroconvulsive Therapy in Pregnancy: Anaesthetic Management of a High-risk Psychiatric Emergency

L. Pfokreni — 2026-06-22

Background: Severe depression during pregnancy with persistent suicidal ideation requires timely intervention, particularly when pharmacotherapy is ineffective. Electroconvulsive therapy (ECT) may provide rapid symptom control; however, uncertainty regarding periprocedural maternal-fetal safety and anaesthetic technique continues to influence its use. This case report describes the multidisciplinary anaesthetic management of modified ECT in a second-trimester high-risk psychiatric emergency.

Case Presentation: A 26-year-old primigravida at 27 weeks and 2 days of gestation presented with recurrent major depressive disorder, nutritional decline, treatment-refractory symptoms, and persistent suicidal ideation despite sequential pharmacotherapy. Following multidisciplinary planning by anaesthesia, psychiatry, obstetrics, and neonatology teams, six sessions of modified ECT were undertaken in an operating theatre with immediate obstetric and neonatal support available.

Anaesthetic Management: For each session, the patient was fasted, positioned with 15° left uterine displacement, and monitored using standard ASA monitoring. Aspiration prophylaxis was administered before treatment. After three minutes of preoxygenation, anaesthesia was induced with propofol 1 mg/kg, followed by succinylcholine 1 mg/kg. Low-pressure mask ventilation with 100% oxygen was used, and seizure adequacy was assessed clinically using the isolated arm technique. Fetal assessment comprised cardiotocography before and after the procedure, with intermittent fetal heart rate auscultation when feasible.

Outcomes: Mean motor seizure duration was 32.6 ± 5.4 seconds. Maternal oxygen saturation remained at or above 96%, and transient cardiovascular responses resolved spontaneously. No aspiration, airway event, arrhythmia, hypertensive crisis, prolonged seizure, uterine contraction, or fetal heart rate abnormality occurred. Suicidal ideation resolved after treatment. At 39 weeks and 3 days, the patient delivered a healthy female infant weighing 3,120 g with Apgar scores of 9 and 9 at one and five minutes.

Conclusion: Carefully planned modified ECT during pregnancy was feasible in this case when supported by multidisciplinary coordination, pregnancy-specific anaesthetic precautions, and structured obstetric surveillance.

Loeffler's endocarditis Complicating Crohn's Disease-Associated Hypereosinophilia: A Fatal Case of Eosinophil-Mediated Restrictive Cardiomyopathy

Samantha Aster Pinto — 2026-06-27

Background: Cardiac elastomyofibrosis represents the irreversible fibrotic end-stage of Loeffler's endocarditis, an uncommon restrictive cardiomyopathy driven by eosinophil-mediated endomyocardial injury. While most often associated with hypereosinophilic syndromes, its occurrence in the context of chronic inflammatory disorders such as inflammatory bowel disease (IBD) remains exceptionally rare. We report a fatal case of Loeffler's endocarditis progressing to elastomyofibrosis in a patient with Crohn's disease-associated hypereosinophilia.

Case Presentation: A 46-year-old man with hypertension and Crohn's disease on intermittent corticosteroid therapy presented with acute-onset dyspnea (NYHA Class III–IV), chronic fatigue, and intermittent fever. Examination revealed elevated jugular venous pressure and bilateral pleural effusions on chest radiography. Transthoracic echocardiography demonstrated reduced global longitudinal strain with apical sparing, multivalvular regurgitation, severe pulmonary hypertension, right ventricular dilatation, and a speckled left ventricular apex with an apical mass suggestive of restrictive cardiomyopathy. Cardiac magnetic resonance imaging confirmed a left ventricular mural thrombus with extensive subendocardial fibrosis, consistent with Loeffler's endocarditis. Laboratory evaluation revealed marked peripheral eosinophilia (21%). Hematologic workup excluded clonal leukemia and lymphoma. Autoimmune markers including ANA and c-ANCA were positive, consistent with the known IBD diagnosis. Despite supportive management, the patient deteriorated rapidly, culminating in multiorgan failure and death. The clinical, laboratory, and imaging findings collectively supported a diagnosis of Crohn's disease-associated hypereosinophilia leading to eosinophilic endomyocardial injury and elastomyofibrosis.

Discussion: This case highlights a rare cardiac manifestation of IBD-associated systemic inflammation. Eosinophil-mediated myocardial injury in Loeffler's endocarditis progresses sequentially from necrosis to thrombosis and irreversible fibrosis, resulting in restrictive physiology, valvular dysfunction, and pulmonary hypertension. Multimodality imaging — particularly transthoracic echocardiography and cardiac MRI — was essential for diagnosis in the absence of histopathological confirmation. Once advanced fibrosis is established, therapeutic options remain limited and prognosis is poor.

Conclusion: Loeffler's endocarditis culminating in cardiac elastomyofibrosis should be considered in patients with IBD presenting with unexplained heart failure and peripheral eosinophilia. Early recognition through multimodality imaging and multidisciplinary evaluation remains critical, as this case demonstrates that delayed diagnosis can permit progression to irreversible fibrosis with a fatal outcome.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Overlap Syndrome: A Case Report

B. B. Likhitha — 2026-06-29

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are uncommon, life-threatening acute mucocutaneous drug reactions characterised by keratinocyte apoptosis and epidermal separation occurring at the drug-host cell interface. SJS involves less than 10% of the total body surface area (TBSA), whereas TEN involves more than 30%. The intermediate spectrum, termed SJS/TEN overlap syndrome, involves 10-30% TBSA. Rapid identification, supportive care and early treatment are critically important because sepsis, multiorgan failure and mortality can develop rapidly.

Case Presentation: A 44-year-old man presented with high-grade fever, significant systemic symptoms and a rapidly advancing erythematous maculopapular rash that quickly progressed to widespread blistering and sloughing. Significant mucosal involvement was also present, including severe ocular inflammation (bilateral conjunctival injection with eyelid crusting), painful oral ulcerations and genital lesions. Total epidermal detachment was estimated at approximately 15-20% of TBSA, with a positive Nikolsky sign, leading to a final clinical diagnosis of SJS/TEN overlap.

The condition was attributed to the recent simultaneous administration, during the preceding two days, of newly introduced medications: betahistine, vitamin B12, etizolam, nandrolone decanoate, pregabalin/vitamin B12 combination capsules and cerebroprotein hydrolysate.

Although the exposure to several new drugs meant that a specific causative agent could not be definitively identified, pregabalin and etizolam were strongly suspected as triggering agents because of their chronological association with the development of the rash. Laboratory results indicated elevated systemic inflammatory parameters, mild transient derangement of renal function and profound hypoalbuminaemia, while the total white cell count was normal (7,600/mm). Using the SCORTEN scoring system, the score was 2, which predicted a baseline mortality risk of 12%.

Conclusion: Management consisted of immediate discontinuation of all newly introduced culprit medications and aggressive collaborative care, including intensive fluid therapy, close metabolic surveillance, intensive wound care, aggressive topical ophthalmic management and closely supervised systemic therapy with high-dose steroids (prednisolone 40 mg). The patient achieved complete and sustained epithelialisation, with no subsequent ocular or systemic sequelae. This case reinforces the value of rapid diagnosis, unequivocal withdrawal of precipitating agents and comprehensive multidisciplinary management in achieving favourable outcomes and reducing mortality in severe cutaneous adverse reactions.

Clinically Suspected Triple-hit Respiratory Failure in Kyphoscoliosis, COPD and Systemic Sclerosis: A Case Report

N. Meghashree — 2026-07-03

Background: Respiratory failure in patients with coexisting pulmonary and extrapulmonary disorders may be diagnostically challenging. Kyphoscoliosis can impair chest-wall mechanics and contribute to restrictive ventilatory dysfunction, chronic obstructive pulmonary disease (COPD) may add airflow limitation and ventilation-perfusion mismatch, and systemic sclerosis may further compromise respiratory status through pulmonary vascular or parenchymal involvement. Case presentation: A 55-year-old female with known kyphoscoliosis, COPD, and limited systemic sclerosis presented with progressive breathlessness, generalised weakness, abdominal pain, cough with thick whitish expectoration, and low-grade fever. She was somnolent but arousable, with oxygen saturation of 65% on room air, improving to 94% with oxygen at 4 L/min. Arterial blood gas analysis showed type II respiratory failure with respiratory acidosis (pH 7.31, pCO₂ 60 mmHg, and HCO₃⁻ 30.2 mmol/L). Laboratory evaluation showed leukocytosis and mild anaemia, while renal and hepatic parameters were within normal limits. Previous echocardiography showed right atrial and right ventricular dilatation, mild pulmonary hypertension, and preserved ejection fraction. Pulmonary function testing, previous spirometry, current echocardiography, right-heart catheterisation, and advanced thoracic imaging were unavailable. The patient was managed with controlled oxygen therapy, non-invasive ventilation using BiPAP, antibiotics, corticosteroids, bronchodilators, and supportive care. Her clinical condition improved, and she was discharged in a stable condition. Conclusion: This case highlights clinically suspected multifactorial acute-on-chronic type II respiratory failure in the setting of kyphoscoliosis, COPD, and limited systemic sclerosis.

Incidentally Detected Simple Bone Cyst, Similar to Other Lesions Radiographically: A Case Report

Monika Sharma — 2026-07-17

Background: Simple bone cyst (SBC) is a rare intraosseous pseudocyst of the jaws that lacks an epithelial lining. It is most commonly seen in children and adolescents and is usually detected incidentally because patients are often asymptomatic.

Aims: This study aims to present an incidental case of a simple bone cyst in a paediatric patient detected during radiographic evaluation of a retained primary maxillary incisor and to emphasise the importance of a multidisciplinary diagnostic approach for accurate diagnosis and management.

Case Report: A 12-year-old female patient presented with a retained primary maxillary left central incisor and delayed eruption of the permanent successor. Panoramic radiography revealed two mesiodens associated with the unerupted permanent maxillary left central incisor. An incidental radiolucent lesion was also observed in the mandibular left premolar region between teeth 34 and 35. Further evaluation using cone-beam computed tomography showed a well-defined radiolucent cavity with mild buccolingual expansion and intact cortical plates. Surgical exploration revealed an empty bone cavity and histopathological examination showed fibrovascular connective tissue with focal haemorrhage and haemosiderin deposition, supporting the diagnosis of SBC. One-year follow-up demonstrated satisfactory bone healing without recurrence.

Conclusion: This case highlights the importance of careful radiographic assessment in paediatric patients, as clinically silent lesions may be discovered during investigation of unrelated dental concerns. A combination of clinical, radiographic, and histopathological findings is essential for establishing an accurate diagnosis and appropriate management.

Multifocal Vasculitic Acute Ischemic Stroke Secondary to Tubercular Meningitis with Caseating Parietal Tuberculoma and Cavitary Pulmonary Tuberculosis Co-morbid with Alcohol Dependence: A Rare Clinical Intersection

Shashank N. Pastay — 2026-07-18

Background: Tubercular meningitis (TBM) is the most severe form of central nervous system tuberculosis, and its course is frequently complicated by vasculitis, tuberculomas, and ischaemic infarcts. When acute vasculitic cortical-subcortical infarcts occur alongside active cavitary pulmonary tuberculosis and chronic alcohol dependence, both diagnostic reasoning and day-to-day management become considerably more difficult.

Case Description: A 49-year-old man receiving anti-tubercular therapy (ATT) for pulmonary tuberculosis, with a 20-year history of heavy alcohol use, presented with sudden involuntary movements of all four limbs, generalised weakness, and slurred speech. He was drowsy but rousable, with severe dysarthria, left-sided hypertonia, and an extensor left plantar response. Contrast-enhanced brain MRI showed features of TBM, a well-defined ring-enhancing caseating tuberculoma with central liquefaction (~2.0 × 1.0 × 2.0 cm) in the left parietal lobe, and acute multifocal cortical-subcortical vasculitic infarcts in the left insular cortex and left temporo-parietal lobes. CSF analysis showed early neutrophil-predominant pleocytosis (52 cells/cumm; 85% neutrophils and 11% lymphocytes), raised protein (48.5 mg/dL), borderline glucose (45.0 mg/dL), and elevated adenosine deaminase (ADA) of 12.0 U/L. Chest imaging revealed cavitary consolidation with air-fluid levels in the right lung and bilateral consolidation. He was admitted to the ICU for airway protection and subsequently developed alcohol withdrawal delirium, which was controlled with haloperidol and quetiapine. Pulsed corticosteroids, a modified ATT regimen, mannitol, antiplatelet therapy, and thiamine repletion resulted in marked clinical improvement.

Conclusion: This case highlights how early neuroimaging and CSF biomarkers can identify uncommon vascular complications of neurotuberculosis when microbiological confirmation is elusive. Managing severe TBM alongside cavitary pulmonary disease and alcohol withdrawal delirium requires close multidisciplinary coordination and an adaptive management plan as complications arise.

Acute Urinary Retention and Hematometra Secondary to Imperforate Hymen in 14-Year-Old Girl: A Comprehensive Case Report

B. B. Likhitha — 2026-07-20

Imperforate hymen is a rare congenital obstructive anomaly of the female genital tract that is usually recognised after menarche, when retained menstrual blood causes haematocolpos and haematometra. Patients commonly present with cyclical lower abdominal pain, primary amenorrhoea or an abdominopelvic mass; urinary retention may occur when the distended vagina compresses the bladder neck and urethra. We report a 14-year-old girl with progressively worsening lower abdominal pain for 15 days and acute urinary retention for 2 days, requiring emergency transurethral bladder catheterisation. Examination revealed a firm, smooth abdominopelvic mass corresponding to a 22-week gravid uterus and a tense, bluish, bulging membrane at the vaginal introitus, consistent with an imperforate hymen. Transabdominal ultrasonography demonstrated marked distension of the vagina and cervix by a homogeneous, avascular fluid collection measuring 12 × 10 × 6 cm, with elevation of the normally sized uterine body. Emergency cruciate hymenotomy was performed under general anaesthesia, resulting in the drainage of approximately 550 mL of thick, dark, altered menstrual blood. The abdominal pain and urinary retention resolved after surgery, and the patient voided normally following catheter removal. She was discharged in a satisfactory condition with oral antibiotics, analgesia and follow-up advice. Imperforate hymen should be considered in adolescent girls presenting with primary amenorrhoea, cyclical abdominal pain, a pelvic mass or acute urinary retention, because timely diagnosis and surgical treatment can relieve obstruction and reduce the risk of delayed complications.

Isolated Lingual Dystonia: A Rare Tardive Manifestation of Amisulpride

Diya Fathima — 2026-07-21

Aims: To describe a rare case of isolated lingual tardive dyskinesia associated with prolonged low-dose amisulpride therapy and to emphasise the importance of early recognition and treatment.

Presentation of Case: A 72-year-old woman with bipolar I disorder developed progressive dysarthria, dysphagia, and involuntary choreiform tongue movements after approximately 13 months of amisulpride therapy, initiated at 50 mg/day and titrated to 150 mg/day. Neurological examination showed continuous lingual movements with intermittent dystonic posturing, without limb involvement or other focal neurological abnormalities. Brain magnetic resonance imaging demonstrated only mild age-related cerebral atrophy, and routine laboratory investigations were within normal limits. Alternative structural, metabolic, seizure-related, and neurodegenerative causes were considered and excluded clinically. The Naranjo score was 6, and the WHO-UMC assessment classified the reaction as probable/likely. Amisulpride was discontinued, and tetrabenazine was initiated at 12.5 mg each morning and 25 mg each night. After six weeks, tongue movements and speech improved markedly, permitting dose reduction to 12.5 mg twice daily. Psychiatric stability was maintained with clozapine and sodium valproate/valproic acid.

Discussion: The delayed onset, temporal relationship to prolonged dopamine receptor blockade, absence of an alternative cause, and improvement after withdrawal supported a tardive drug-induced movement disorder.

Conclusion: Isolated lingual dystonia may occur during long-term low-dose amisulpride therapy. Regular movement assessment and prompt treatment modification may reduce functional impairment.

Clinicopathological Spectrum of Buccal Mucosal Lipomas: A Report of Two-Case

Annu Gurjar — 2026-07-21

Background: Oral lipoma is an uncommon benign mesenchymal neoplasm composed of mature adipocytes. Its clinical appearance can overlap with other reactive and neoplastic oral soft-tissue lesions, making histopathological confirmation important.

Objective: To describe and compare the clinicopathological features of two conventional lipomas arising in the buccal mucosa.

Case Presentation: A 57-year-old woman presented with a painless, gradually enlarging yellowish swelling of the left posterior buccal mucosa for approximately one and a half months. A 71-year-old woman presented with a painless swelling near the left labial commissure that had enlarged over three months while retaining normal mucosal colour. Both lesions were well circumscribed and soft and were removed by complete surgical excision under local anaesthesia. The excised specimens measured approximately 0.6 × 0.5 cm and 0.5 × 0.5 cm, respectively. Histopathological examination showed lobules of mature adipocytes separated by delicate fibrous septa. The first lesion was well circumscribed but unencapsulated, whereas the second was enclosed by a thin fibrous capsule. No atypia, lipoblast formation, increased mitotic activity, or other evidence of malignancy was identified. Immediate postoperative healing was uneventful in both patients.

Conclusion: Conventional buccal mucosal lipomas may differ in mucosal colour and capsule status despite similar mature adipocytic morphology. Correlation of clinical findings with histopathological examination is essential for definitive diagnosis and appropriate management.

Bilateral Acute Suppurative Parotitis in a 9-Month-Old Infant Managed Conservatively: A Rare Case Report

Shashank N. Pastay — 2026-07-24

Background: Acute suppurative parotitis is uncommon in infants and is rarely observed beyond the neonatal period. When bilateral, its clinical presentation may resemble viral parotitis, cervical lymphadenitis, or deep-neck-space infection. Early high-resolution ultrasonography may help identify a potentially drainable collection or abscess.

Case Description: A 9-month-old, fully immunised girl presented with upper respiratory catarrh of 10 days' duration, low-grade fever for 2 days, and a painful, rapidly enlarging right parotid swelling for 1 day. Marked systemic inflammation was evident (CRP, 356.59 mg/L), and microcytic hypochromic anaemia was noted. High-resolution ultrasonography of the right parotid region showed a large, heterogeneous parotid gland with increased Doppler vascularity and reactive cervical lymphadenitis, without a drainable fluid collection. Intravenous cefotaxime and amikacin, together with empirical oral cloxacillin, were initiated. After 48 hours, the swelling had progressed to involve both parotid glands. Following paediatric surgical review, antimicrobial therapy was escalated to intravenous meropenem, vancomycin, and metronidazole to cover possible multidrug-resistant pathogens, including MRSA and anaerobes. Because of the parents' concerns regarding the child's condition, they declined planned surgical exploration and further invasive investigation; this refusal was formally documented in the medical record. The patient improved promptly with the intensified conservative regimen, became afebrile within 48 hours, and showed a marked reduction in CRP. She was discharged on oral linezolid and levofloxacin, recovered uneventfully, and had no recurrence at follow-up.

Conclusion: Early sonographic assessment and escalation of antimicrobial therapy to cover suspected MRSA and anaerobes may support conservative management when serial imaging shows no organised, drainable abscess.

Dapsone Induced Liver Injury, Hansen’s Disease, Multibacillaery-MDT: A Case Report

Niby Nebu — 2026-07-28

Dapsone is an important component of multidrug therapy for Hansen’s disease and is generally well tolerated; however, clinically significant adverse reactions may occur in susceptible patients. This case report describes a 54-year-old female patient with Hansen’s disease who developed systemic symptoms and biochemical evidence of liver injury while receiving dapsone-containing multidrug therapy. She presented with high-grade fever with chills, pruritic skin lesions over the upper limbs, breathlessness, body pain, epigastric pain and jaundice. Clinical examination revealed hypotension and tachycardia, while laboratory evaluation showed severe anaemia, leucopenia, hyperbilirubinaemia, raised hepatic transaminases, low total protein and hypoalbuminaemia. Peripheral smear examination demonstrated severe microcytic hypochromic anaemia with leucopenia. Based on the temporal relationship between drug exposure and symptom onset, clinical presentation, laboratory abnormalities and improvement after withdrawal of the suspected drug, dapsone-induced liver injury associated with a hypersensitivity reaction was considered. Dapsone was discontinued immediately, and supportive management was initiated with intravenous fluids, antiemetics, proton pump inhibitor therapy, nutritional supplementation, antibiotics and N-acetylcysteine. The patient was subsequently discharged on an alternative anti-leprosy regimen consisting of rifampicin, clofazimine and ofloxacin, along with supportive medications. Causality assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 7, indicating a probable adverse drug reaction. This case highlights the need for careful clinical observation and laboratory monitoring in patients receiving dapsone-containing therapy. Early recognition of fever, rash, jaundice or unexplained haematological abnormalities is essential to prevent further complications and ensure timely modification of treatment.

Prolonged Prednisolone Use Induced Iatrogenic Cushing Syndrome: A Case Report

G. R. Sahana — 2026-07-29

Introduction: Iatrogenic Cushing syndrome is a common endocrine disorder caused by prolonged exposure to exogenous glucocorticoids. Long-term corticosteroid therapy can result in characteristic clinical features such as moon facies, hypertension, oedema, metabolic disturbances and suppression of the hypothalamic-pituitary-adrenal axis. Prednisolone is a widely prescribed glucocorticoid and a well-recognised cause of steroid-induced Cushing syndrome when used for prolonged periods without adequate monitoring.

Case Presentation: A 72-year-old female with a history of chronic knee joint pain and hypertension presented with facial puffiness, bilateral lower-limb swelling and retrosternal chest pain radiating to the back. Detailed history revealed prolonged unsupervised use of prednisolone for knee pain. Physical examination showed facial puffiness, pedal oedema and elevated blood pressure (180/110 mmHg). Laboratory investigations demonstrated mild anaemia, hypoalbuminaemia and a serum cortisol level of 8.22 µg/dL. Imaging studies revealed bilateral knee osteoarthritis, concentric left ventricular hypertrophy with Grade I diastolic dysfunction and hyperinflated lung fields.

Methodology: Clinical evaluation, laboratory investigations, imaging studies, medication-history assessment and causality assessment using the Naranjo Adverse Drug Reaction Probability Scale were performed. Prednisolone was discontinued and supportive therapy was initiated.

Discussion: The temporal relationship between prolonged prednisolone exposure and the development of characteristic clinical manifestations supported the diagnosis of steroid-induced Cushing syndrome. Despite a near-normal serum cortisol level, the patient's history and clinical findings were strongly suggestive of exogenous glucocorticoid excess. Improvement following withdrawal of prednisolone further reinforced the diagnosis. The Naranjo causality assessment score of 8 indicated a probable association between prednisolone therapy and the adverse event.

Conclusion: Early recognition of steroid-induced Cushing syndrome and prompt discontinuation of the offending corticosteroid are essential to prevent serious complications. Careful prescribing practices, regular monitoring and patient education regarding long-term steroid use are crucial for minimising the risk of glucocorticoid-related adverse effects and improving clinical outcomes. These predictors, however, require further work to validate their reliability in patients.

Refractory Postoperative Chylothorax Following Adult Atrial Septal Defect Closure Managed with Multimodal Thoracoscopic Ligation and Chemical Pleurodesis: A Case Report

Akshata N Chavadi — 2026-07-31

Background: Postoperative chylothorax is uncommon after adult intracardiac surgery but may cause substantial nutritional, immunological, and respiratory consequences when drainage is persistent or high output.

Case Description: A 34-year-old woman developed a large right-sided pleural effusion following elective pericardial-patch closure of a large ostium secundum atrial septal defect. Thoracentesis yielded milky fluid with a triglyceride concentration of 2,402 mg/dL, confirming chylothorax. Initial management comprised intercostal tube drainage, bowel rest, total parenteral nutrition, dietary modification, and subcutaneous octreotide. Despite more than 2 weeks of conservative treatment, chylous drainage remained high at 500–1,500 mL/day. The patient subsequently underwent right thoracoscopic-assisted supradiaphragmatic mass ligation of the thoracic duct and surrounding fibrofatty tissue. Drainage decreased, but a low-output chylous leak persisted following a high-fat dietary challenge. Salvage chemical pleurodesis was therefore performed using 500 mg of intrapleural doxycycline. Drain output subsequently decreased to less than 20 mL/day, the fluid became non-chylous, and radiographic lung expansion improved. The patient was discharged in a stable condition with the drain in situ. It was removed 10 days later after three consecutive days without drainage. No clinical or radiographic recurrence was observed during 3 months of follow-up.

Conclusion: This case demonstrates the potential value of a staged multimodal approach comprising conservative therapy, thoracic duct ligation, and chemical pleurodesis for refractory postoperative chylothorax after adult atrial septal defect closure.

Hysterectomy In Complete Situs Inversus Totalis: A Rare Case Report

Likhitha B. B. — 2026-08-01

Situs inversus totalis (SIT) is an uncommon congenital autosomal recessive condition in which the thoracic and abdominal viscera are arranged as a mirror image of normal anatomy. Although SIT is generally an incidental and asymptomatic finding that does not affect life expectancy, it creates substantial anatomical and spatial challenges for safe surgical and anaesthetic management. We report the surgical management of a symptomatic enlarging intramural uterine fibroid with a concomitant left ovarian haemorrhagic cyst in a 36-year-old woman (gravida 3, para 3) with SIT, dextrocardia, and a right-sided aortic arch. The patient underwent total abdominal hysterectomy, bilateral salpingectomy, and left oophorectomy through a suprapubic transverse incision under combined spinal-epidural anaesthesia. The reversed pelvic anatomy required deliberate adjustment of the surgeon's right-left orientation and modification of the usual operative sequence. Intraoperatively, the surgical team carefully identified, exposed, skeletonised, divided, and ligated the pelvic vessels and uterine ligaments while preserving surrounding tissue integrity. Meticulous multidisciplinary preoperative assessment included two-dimensional echocardiography, which demonstrated concentric left ventricular hypertrophy, a left ventricular ejection fraction of 60%, and no regional wall-motion abnormality. The postoperative course was uneventful. Precise preoperative evaluation, careful documentation, multidisciplinary planning, and intraoperative spatial readjustment were central to the overall successful surgical outcome.

Acute Pulmonary Embolism in a 19-year-Old Male with Elevated Lipoprotein (a): A Rare Presentation in Early Adulthood

Sharon Sabu — 2026-08-04

Pulmonary embolism (PE) is uncommon in adolescents and young adults without recognised comorbidities or conventional thromboembolic risk factors. This report describes a 19-year-old male who presented with acute breathing difficulty and one episode of vomiting after recovering from a recent febrile illness. Electrocardiography showed sinus tachycardia and an S1Q3T3 pattern with right ventricular strain. Echocardiography demonstrated right ventricular dysfunction, reduced tricuspid annular plane systolic excursion, and pulmonary arterial hypertension, while computed tomography pulmonary angiography confirmed extensive bilateral emboli involving segmental and subsegmental branches, with significant right heart strain. Laboratory evaluation showed elevated D-dimer and brain natriuretic peptide levels, whereas troponin was normal. Lower-limb venous Doppler ultrasonography showed no evidence of deep vein thrombosis. The patient received systemic thrombolysis with tenecteplase, followed by enoxaparin and subsequent oral rivaroxaban, with favourable clinical recovery. Thrombophilia testing showed an elevated lipoprotein(a) concentration of 63.2 mg/dL, while homocysteine, free protein S antigen, protein C, antithrombin activity, and tested thrombophilic mutations were within normal limits or negative. This case demonstrates the diagnostic importance of considering PE in young patients with acute respiratory symptoms and signs of right heart strain. Elevated lipoprotein(a) may represent a contributing abnormality; however, its causal role in venous thromboembolism remains uncertain and requires cautious interpretation.

Epstein–Barr Virus-associated Lymphoma during Thiopurine and Anti-tumour Necrosis Factor Therapy: A Case Report

C. Elmajoudi — 2026-06-23

Epstein–Barr virus (EBV)-associated lymphoproliferative disorders are uncommon but clinically important complications that may occur during immunosuppressive treatment for inflammatory bowel disease. Such events pose diagnostic and therapeutic challenges in clinical practice. Combination therapy with thiopurines and anti-tumour necrosis factor agents can impair immune surveillance and may favour EBV reactivation and lymphoproliferation. We report the case of a 39-year-old man with stenosing ileocolic Crohn’s disease, classified as A2L2B2 according to the Montreal classification, who developed EBV-positive diffuse large B-cell lymphoma during treatment with azathioprine and infliximab. The patient initially presented with mucohaemorrhagic diarrhoea and was subsequently diagnosed with Crohn’s disease after clinical, endoscopic, radiological and histological assessment. Combination therapy with infliximab and azathioprine was started in June 2021, after negative screening for hepatitis B, hepatitis C, human immunodeficiency virus and tuberculosis, and serology consistent with previous EBV infection. In August 2022, he was admitted with septic shock secondary to ileal perforation and underwent ileocaecal resection. Histopathological examination of the surgical specimen showed EBV-positive diffuse large B-cell lymphoma with tumour-free margins. Immunohistochemistry demonstrated CD20 and LMP1 positivity, absence of CD5 expression and a Ki-67 proliferation index of approximately 90%. Postoperative staging did not identify distant disease. The patient received four cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, with complete metabolic response on follow-up positron emission tomography. Subsequent recurrence of Crohn’s disease was managed with ustekinumab after multidisciplinary discussion. This case emphasises the need for careful risk–benefit assessment, clinical vigilance and coordinated management when prolonged combination immunosuppression is used in patients with Crohn’s disease, especially when severe intestinal complications occur.

Non-Surgical Endodontic Management of Severe External Inflammatory Root Resorption in a Maxillary First Molar: A Case Report with 12-Month Follow-up

Serkan Uçmak — 2026-08-04

Aims: To describe the non-surgical endodontic management of a maxillary first molar with severe, symptomatic external inflammatory root resorption in an adolescent patient, and to report the 12-month outcome.

Presentation of Case: A 15-year-old boy presented with spontaneous pain and marked tenderness to percussion in the maxillary right first molar (tooth 16). A periapical radiograph showed advanced external resorption, most severe in the palatal and distobuccal roots, which had become considerably shortened. Root canal treatment was started without delay. Because the resorptive tissue was richly vascularised, controlling intracanal bleeding was difficult and time-consuming despite the short canals. After haemostasis was achieved, a dense calcium hydroxide dressing was placed in all canals. Three weeks later, the patient was almost free of symptoms, and the dressing was intact with no sign of infection. As the lesion was an external inflammatory resorption, each canal was then obturated along its full length with mineral trioxide aggregate (MTA).

Discussion: Early diagnosis, elimination of the microbial stimulus, and a calcium hydroxide dressing are central to arresting inflammatory resorption. Full-length MTA obturation was chosen to seal the resorptive communications and to provide a well-sealing, biocompatible barrier in the weakened roots.

Conclusion: Prompt endodontic intervention with calcium hydroxide followed by MTA obturation arrested the resorption and preserved the tooth, which remained asymptomatic and functional at the 12-month review.

Intravenous Neostigmine-atropine for Refractory Post-dural Puncture Headache in Obstetric Patients: A Case Series

L. Pfokreni — 2026-06-20

Post-dural puncture headache is an important complication of neuraxial anaesthesia and may be particularly disabling in obstetric patients during the early postpartum period. Although many cases respond to conservative measures, persistent symptoms may interfere with ambulation, breastfeeding, and maternal recovery and may require an epidural blood patch. This retrospective case series describes the clinical response to intravenous neostigmine–atropine in six obstetric patients with post-dural puncture headache that persisted despite 48–72 hours of conservative management. Post-dural puncture headache was diagnosed clinically on the basis of orthostatic headache occurring within five days of neuraxial anaesthesia, after exclusion of alternative causes where clinically indicated. All patients received intravenous neostigmine 20 μg/kg with atropine 10 μg/kg, diluted in 20 mL of normal saline and administered over five minutes under haemodynamic monitoring. Pain severity was assessed using a 10-point visual analogue scale. Outcomes included change in headache severity, need for repeat dosing, requirement for epidural blood patch, recurrence before discharge, and adverse effects. The six patients were aged 26–31 years. Four developed headache after spinal anaesthesia with a 25G Quincke needle, and two after accidental dural puncture during labour epidural placement with an 18G Tuohy needle. Baseline visual analogue scale scores were 7–8 after conservative therapy. Following treatment, final scores decreased to 1–2 within 10–16 hours. Five patients required a second dose at 8 hours. No patient required epidural blood patch during the hospital stay, and no clinically significant adverse effects were observed. Intravenous neostigmine–atropine was associated with improvement in headache severity in this small series of obstetric patients with persistent post-dural puncture headache. Larger controlled studies are required to confirm efficacy, safety, optimal dosing, and durability of response.