New Emirates Medical Journal - Volume 4, Issue 2, 2023

Psychiatric disorders are difficult to assess, diagnose, and treat in most cases. The present case describes an extremely rare psychological disorder in combination with metabolic and endocrine insufficiency.

The condition of a 7-year-old child with inherited psychopathology from his father was found to be aggravated by his mother's alcoholism. The child was delivered in emergency from a primigravida/primipara mother due to preeclampsia and premature membrane rupture. The examinations involved clinical signs and symptoms and instrumental and laboratory findings. All laboratory results were compared with the normal range of the local laboratory. The results of the examination showed pronounced impairment in learning and controlling behavior, and communication, as well as moderate impairment in orientation.

The future consequences and complications are poorly understood. Management guidelines for such complicated cases are underdeveloped.

The child was managed by diet correction, potassium iodide and hormone replacement therapy, calcium supplement, nootropics with 2 courses per year, examination by a urologist and pediatric endocrinologist 2 times a year, and hospitalization after 6 months of treatment.

Hepatotoxicity of amiodarone has long been described and consists mostly of mild and delayed onset elevation in liver function tests. Fulminant hepatitis, however, is much rarer and attributed to the parenteral administration of the drug. The mechanism of injury is yet to be understood, though multiple theories have been proposed. This case report aims at highlighting the importance of monitoring patients receiving intravenous amiodarone therapy to detect severe acute liver injury and showcase the appropriate management thereafter.

Our patient is a 79-year-old male who presented with epigastric pain that was crampy, intermittent, and aggravated upon exertion. His heart rate was 93 beats/min and cardiac auscultation revealed an irregular heart rhythm. His electrocardiogram revealed atrial fibrillation. He was given intravenous amiodarone with a total dose of 950 mg and developed acute liver failure with extremely elevated liver function tests 48 hours after initiating the drug. After discontinuation, liver function tests returned to baseline within 10 days and the patient was discharged home.

Physicians should be aware of the potentially life-threatening complications, including severe acute liver injury, by closely monitoring liver function tests following the administration of the drug and immediately discontinuing therapy if toxicity was detected.

Trichobezoar is a condition characterized by the accumulation of undigested hair and or other foreign bodies in the stomach. The reported occurrence is uncommon in the Middle East and usually affects female adolescents and young children. Rapunzel syndrome, which almost exclusively affects young women, is a rare form of trichobezoar in the stomach that spreads to the intestine and is associated with psychiatric disorders such as trichotillomania and trichophagia.

This report describes a rare case of giant trichobezoar complicated with acute pancreatitis in a young patient which was ultimately treated with the removal of trichobezoar by surgical gastrotomy.

Trichobezoar is an underdiagnosed and rare disease that should be addressed in adolescents with trichotillomania and trichophagia with delicate clinical symptoms, especially in females. Endoscopy can help with a definitive diagnosis and surgery remains the gold standard for the treatment of this condition.

The topic of COVID-19 (coronavirus disease)-associated complications during pregnancy is poorly postulated and remains an area that requires elucidation for the underlying pathophysiology mechanism in order to evaluate a new therapeutic strategy and optimize current therapies.

The study aimed to assess the proportion of associated complications with COVID-19 and the underlying pathophysiology in pregnant women.

The MedLine and Embase databases were searched for studies relevant to the study topic.

Preterm delivery and C-section have been found to be the most frequently reported complications. Approximately, 28.55% of pregnant women with symptomatic COVID-19 have been reported to require a C-section and 8.8% preterm delivery. In addition, anxiety and depression have also been frequently reported in 57% and 37% of pregnant women, respectively.

Symptomatic pregnant women with COVID-19 have a high risk of preterm labor, mortality and morbidity rates, and C-section requirements. The underlying pathophysiology of COVID-19-associated complications during pregnancy includes homeostatic disturbances of the immune system, pulmonary system, and hemostatic system. In addition to endothelial dysfunction, excessive immune response, coagulopathy, hypoxemia, and hypotension are involved in the pathogenesis that negatively affects neonates' health outcomes.

To estimate the recurrence of odontogenic keratocyst (OKCs) and increment of bone height upon an innovative treatment protocol of the OKC, i.e., enucleation along with the adjuvant therapy of Carnoy’s solution, followed by marsupialization.

Twenty cases of OKC treated at the Department of Oral and Maxillofacial Surgery from 2020-2021 were studied retrospectively. Clinical, radiological features and histologic features were reviewed. The patients diagnosed with OKCs were planned for enucleation with the use of Carnoy's solution and followed by marsupialization. Recurrence of the same and bone formation was analyzed concerning sites of involvement, based upon the gender and age group of patients, after undergoing the proposed treatment.

Mean age of the patients was 35.15 ± 13.02, ranging from 11 to 56 years. Most (85%) patients were symptomatic, and the remaining (15%) were asymptomatic and diagnosed on a routine check-up. Males (65%) were mostly affected than females (35%). Mandible (75%) was the most frequent site of occurrence. Most lesions were diagnosed histologically as OKC on incisional biopsy. All patients were followed for six months, an increment of 11.11 ± 1.68mm bone height was seen, and none reported recurrence.

The steady growth of bone without any cases of recurrence was reported. Hence, clinicians can consider enucleation along with adjuvant therapy using Carnoy's solution followed by marsupialization as the treatment of choice.

Microscopic colitis is an inflammatory GI condition whereby patients present predominantly with chronic watery diarrhea associated with other non-specific symptoms such as abdominal pain, urgency, fecal incontinence, weight loss, arthralgia, myalgia, anxiety, depression, and fatigue, which negatively impact their quality of life.

We present a case of a 44 -year old female with a history of hypothyroidism and celiac disease who presented to the GI clinic with a history of more than ten diarrhea episodes per day along with mild abdominal pain and bloating.

A colonoscopy was performed, and a random colon biopsy revealed collagenous/microscopic colitis.

Type 1 Diabetes mellitus (DM) is a chronic metabolic disorder in children and adolescents due to insulin deficiency. The disease is more common below 19 years of age with two peaks of incidence, one at 4-6 years and the other peak at early puberty (10-14 years). There is a gradual increase in the incidence of type 1 DM and a rise in incidence at 10,200 cases per year in the Middle East. Chronic type-1 diabetic patients develop microvascular and macrovascular complications.

The present retrospective cross-sectional study aims to describe the experience on the clinical profile, morbidity profile, and comorbidities of Type1 DM in children below 15 years of age admitted to the SAQR and Fujairah hospitals in the Northern part of United Arab Emirates (UAE) from 1^st January 2017 to 31^st December 2019. The study material was the digital medical records of children below 15 years who got admitted to emergency and pediatric wards with type 1 Diabetes mellitus (T1DM) in SAQR and Fujairah hospitals.

Total admissions during the study period were 98. At the time of diagnosis, 12.2% of children were below five years of age, whereas 87.75% were more than five years. All 98 children were UAE nationals, of which 52% were males and 48% were females. 50% of our study population has a strong family history of either type 1 or type 2 diabetes mellitus, of which 12.2% of siblings of the study population had T1DM. The first symptoms in 58% and 57% of children were polyuria and polydipsia. Among 90% of children under follow-up for three years, one child developed microalbuminuria, three developed systolic hypertension, and 8% were lost to follow-up.

The present study highlights the need for future prospective studies in the UAE to know the actual burden of the disease with an emphasis on early screening.

S100B, NSE, MMP-9, and Tau protein levels increase in cases causing hypoxic cell damage. The diagnosis of the severity of carbon monoxide (CO) poisoning in the early period of these parameters was studied.

COHb level measurement was made using a signal capture CO-pulse oximeter (Masimo's SET Rainbow, Masimo's Co, USA) at the first admission of the patients. Then, COHb levels were confirmed by arterial blood gas(ABG) analysis. The patients were divided into two groups as mild and moderate-severe, according to their Glasgow coma scores (GCS) [Mild (14–15); Moderate (9–13) or Severe (3–8)]. The control group was composed of 16 healthy and non-smoking volunteers.

The serum S100B protein and MMP-9 values at 0 hr of admission in the hospital and 3hr of treatment were not significantly different in the patient group as compared to the control group. Tau protein levels were significantly higher in the patient group at 0 and 3 hours (p> 0.05) as compared to healthy person.

There was no relationship between CO poisoning and MMP-9 and S100B protein levels. NSE and Tau protein were significantly higher in the patient group than the control group. Tau protein may be more useful marker as compared to neuron-specific enolase.

Caveolins are universal multifunctional physiologically active microparticles that collaborate in the caveolae formation to maintain the metabolic homeostatic balance of the cells. In fact, remarkable advances in the molecular biopathology of caveolae have been made in recent years by exploring the role of caveolae in norm and physiopathology.

The current literature data on the caveolae behavior in norm and pathology were revised.

Caveolae are expressed in various cell types, highly concentrated in endothelial cells, cardiomyocytes, and epithelial cells. Physiologically, caveolae contribute to maintaining a signaling balance between the various homeostatic processes, including pro-growth and pro-survival, such as endothelial nitric oxide synthase, glycogen synthase kinase-3β, p42/p44 mitogen-activated protein kinase, PKA, SFK, PKC, Akt through regulation of tyrosine kinases, G protein-coupled receptor, endothelial nitric oxide synthase, and MAPK pathways, and their signaling dysfunction is directly attributed to the pathogenesis of cardiovascular diseases, regeneration inhibition, neurodegenerative diseases, infection, osteoporosis, diabetes, and tumour induction and progression.

Regulation of the ratio and penetrance of caveolae activity/expression is a clinically significant potential therapeutic strategy to enhance the current therapies and eliminate the etiopathogenetic pathway of rising homeostatic disorders.

Priapism is one of the urological emergencies requiring prompt medical or surgical intervention. The clinical diagnosis is made with adjunct cavernosal blood gas analysis and colour doppler ultrasound to determine the underlying aetiology; ischaemic or non-ischaemic, and the majority are veno-occlusive in origin (ischaemic). The occurrence of warfarin-induced priapism complicated with penile necrosis is a rare occurrence, and many cases are related to protein C deficiency.

We report a case of warfarin therapy initiation following a thromboembolic event as a sequela of COVID-19 infection, subsequently developed veno-occlusive priapism complicated with penile gangrene despite being in an overwarfarinized state. The penis was non-salvageable following the gangrenous event, even with prior cavernosal blood aspiration. Thrombophilia panel screening, which includes Protein C activity was done where the protein C activity was low, measuring 23%. Unfortunately, he succumbed to death due to severe cardiorespiratory complications before this blood result was ready.

Prompt diagnosis and treatment of priapism is needed to prevent loss of penile function. Priapism as a sequela of anticoagulant therapy should be suspected in a patient with recent anticoagulant initiation. Thus, immediate treatment can be administered to correct the underlying coagulation disorder.

The development of veno-occlusive priapism and penile gangrene in a patient on warfarin therapy raises a concern about protein C deficiency.

Diseases of the gallbladder (GB) are a common occurrence, and gallstones are the most common biliary pathology. Lately, the incidence of gallstone disease has been on the rise in the United Arab Emirates (UAE).

We present a case report of a 52 years old female who presented with severe upper abdominal pain. The clinical examination and ultrasound imaging were consistent with the calculus of the gallbladder with acute cholecystitis without obstruction. Laparoscopic cholecystectomy (LC) was performed to remove a gallstone of 6.8 cm in size. This was performed uneventfully.

The prevalence of gallstones ranges from 0.1% to 50.5% worldwide. Gallstones more than 5 cm in diameter are not seen often. LC is quite challenging in such cases. This case report is being presented due to the limited availability of literature on the Laparoscopic removal of giant gallstones in the UAE.

Our aim here is to convey that LC can be considered the first choice vis-a-vis open method even in giant gallstone cases in the presence of trained personnel and equipped settings. The epigastric port can be extended for extracting the gallbladder specimen. Open cholecystectomy is a safe method if clear delineation of anatomy is not possible.

Right ventricular hemangioma is very rare. Corona Virus disease (COVID-19) and vaccination were documented to cause diverse thromboembolic phenomena.

We report a large right ventricular hemangioma presented as acute pulmonary embolism two weeks after COVID-19 vaccination associated with acute kidney injury and significantly elevated Interleukin-6 (IL-6). There was no thrombocytopenia; therefore, the diagnosis of vaccine-induced immune thrombotic thrombocytopenia (VIIT) was deemed unlikely. The patient underwent emergency cardiac surgery. The mass was excised through a right atriotomy, and tricuspid annuloplasty was done. IL-6 normalized after six days with resolution of acute kidney injury.

Pulmonary embolism is a rare presentation of the right ventricular hemangioma, and COVID-19 vaccination could play a role in this presentation. Cardiac hemangioma could be associated with high IL-6 that resolves with excision.

Implantable Cardioverter Defibrillator is a rare source of sternoclavicular joint (SCJ) infection. Management of SCJ infection is challenging because of the joint's proximity to major vascular structures.

We presented a case of SCJ infection two years post implantable cardioverter-defibrillator insertion in a 70-year-old gentleman. We managed the patient successfully with minimal surgical debridement, followed by negative pressure suction and antibiotic therapy for eight weeks.

Management of SCJ after implantable ICD is still challenging. Few cases reported the possibility of negative wound suction to manage this condition after wound debridement. Our case may support the conservative approach to managing SCJ infection.

SCJ infection can occur for a long time following ICD insertion. Wound debridement followed by negative wound therapy could be beneficial in the management of this condition

Volume replacement remains the cornerstone of resuscitation in critically ill patients. This study explored the ability of the subclavian vein collapsibility index to predict fluid responsiveness.

In this prospective observational study conducted in the Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, sonographic evaluation of inferior vena cava and the right subclavian vein was carried out at three time points for hypotensive patients admitted to the emergency department. The study population was divided into two groups: responders and non-responders, based on a ≥ 15% increase in stroke volume following fluid bolus.

Among 45 recruited patients, 33 patients were responders. The area under the ROC curve for SCV CI at baseline to predict fluid responsiveness was 0.745 (95% confidence interval: 0.549 – 0.941; p = 0.014). An SCV-CI of 46% predicted fluid responsiveness in a hypotensive patient in terms of change in stroke volume by 15% following fluid bolus with a sensitivity of 87.88% (95% confidence interval: 71.80% to 96.60%) and specificity of 66.67% (95% confidence interval: 34.89% to 90.08%). Spearman’s correlation coefficient between IVC CI and SCV CI was 0.59 (p < 0.001, n = 135).

The results of the study demonstrated that right subclavian vein respiratory variation has the ability to predict fluid responsiveness in a spontaneously breathing patient in circulatory shock and correlates with the inferior vena cava collapsibility index. The subclavian vein can be an alternative to the inferior vena cava in predicting fluid responsiveness in spontaneously breathing patients.

Wilms tumor, the second most common malignancy in childhood, is associated with hypertension in half the cases, but associated consanguinity rarely comes across, and no direct association between the incidence of nephroblastoma and consanguinity has been noted in current literature.

We present a rare case of Wilms tumor in a patient with consanguineous parents. The patient is a 4-year-old female that presented with colicky abdominal pain associated with an abdominal mass, fever over one month and hypertension. There were no congenital anomalies or urinary symptoms. Both parents are first-degree relatives. The patient underwent surgery, and histopathology confirmed a diagnosis of Wilms tumor. The postoperative course was uneventful, and chemotherapeutic treatment was initiated.

The findings in our case highlight a possible causal relationship between Wilms Tumor and consanguinity. There is little published about this, and Wilms's relative risk in consanguineous marriage is unknown. This relationship warrants further research.

Multisystemic inflammatory syndrome is a rare but severe complication in children and adolescents infected with SARS-CoV-2.

This report describes a four-year-old Arab descent female presenting with a history of high-grade fever of 7 days duration with erythematous rash and family history of COVID infection suggestive of atypical Kawasaki disease, which turned out to be multisystemic inflammatory syndrome (MIS-C) post COVID infection. Based on the available published evidence, the World Health Organization has provided a preliminary definition of MIS-C as “children and adolescents 0–19 years of age with fever > 3 days presenting with two of five clinical criteria, such as 1. skin rash or mucocutaneous inflammation or non-purulent conjunctivitis, 2. hypotensive shock, 3. signs of myocardial dysfunction, 4. coagulopathy, and 5. the acute gastrointestinal problem, elevated inflammatory markers, no evidence of other microbial infections, and evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19”.

Some criteria are similar, and others are different from Kawasaki disease and toxic shock syndrome, such as the presence of rash, conjunctivitis, mucocutaneous inflammation, and coronaries involvement are shared criteria between Kawasaki and MIS-C, whereas hypotensive shock and coagulopathy are shared criteria between MIS-C and toxic shock syndrome. The positive testing for COVID-19 in the absence of microbiological isolation confirms MIS-C.

Among the complications of COVID-19 infection, MIS-C is rare. Owing to the management differences among Kawasaki, toxic shock syndrome, and MIS-C, timely diagnosis of MIS-C saves the children from a poor outcome.