Archives of The Medicine and Case Reports

Deep Neck Abscess with Concurrent Orbital and Subgaleal Extension Secondary to Odontogenic Infection: A Case Report

2025-04-25T03:24:09+00:00

Deep neck infections (DNIs) originating from odontogenic sources are common, but extensive spread involving concurrent orbital and subgaleal spaces is rare. DNIs can lead to life-threatening complications, particularly in patients with comorbidities like diabetes mellitus (DM) and chronic kidney disease (CKD), which impair immune function. This report details a complex case of DNI with unusual superior extension. A 44-year-old male with poorly controlled type 2 DM and CKD presented with a two-day history of rapidly progressing left facial, submandibular, parotid, and orbital swelling, associated with fever, trismus, and severe pain, originating from a carious mandibular molar. CT imaging confirmed an extensive abscess involving the left masticator, submandibular, sublingual, parotid, and parapharyngeal spaces, with contiguous spread to the left preseptal orbital space and the fronto-temporo-parietal subgaleal space. Multidisciplinary management involved urgent surgical drainage of the submandibular and subgaleal abscesses, odontectomy of the offending molar, broad-spectrum intravenous antibiotics (Citrobacter amalonaticus and Proteus hauseri identified on culture), intensive glycemic control, hemodialysis, and supportive care. In conclusion, this case highlights the potential for aggressive craniofacial spread of odontogenic DNIs, particularly in immunocompromised individuals. Concurrent orbital and subgaleal extension represents a rare and serious complication. Prompt diagnosis with imaging, aggressive multidisciplinary surgical and medical management, including addressing underlying comorbidities, were crucial for a successful outcome.

Non-Keratinizing Sinonasal Squamous Cell Carcinoma Extending to the Skull Base: Surgical Management with Total Maxillectomy - A Case Study

2025-04-28T08:07:02+00:00

Sinonasal squamous cell carcinoma (SNSCC) is an uncommon malignancy arising within the nasal cavity and paranasal sinuses, representing approximately 3% of head and neck cancers. The non-keratinizing subtype (NKSCC) presents unique diagnostic and therapeutic challenges, particularly when exhibiting locally advanced disease with extension towards critical structures like the skull base. Management typically involves a multimodal approach centered around surgical resection, often followed by adjuvant therapy. We present the case of a 51-year-old female, employed in the wood furniture industry, presenting with a progressively enlarging right nasal mass initially noted four years after removal of a right cheek lesion. Symptoms included unilateral nasal obstruction, epistaxis, anosmia, and loosening of maxillary teeth. Clinical examination revealed a large, friable mass obliterating the right nasal cavity and extending onto the palate. Computed tomography confirmed an extensive destructive mass involving the right nasal cavity, maxillary sinus, ethmoid sinus, extending to the nasopharynx, parapharyngeal space, masticator space, buccal space, frontal sinuses, and abutting the right internal carotid artery. Biopsy confirmed Non-Keratinizing Squamous Cell Carcinoma. The patient was staged as T4bN2cM0 according to the AJCC 8th edition criteria. Following neoadjuvant chemotherapy, the patient underwent total maxillectomy via a Weber-Ferguson approach with Lynch modification, including placement of a dental obturator. In conclusion, advanced NKSCC involving the skull base requires aggressive, multidisciplinary management. This case highlights the necessity of radical surgical resection, such as total maxillectomy via extended approaches like the Weber-Ferguson with Lynch modification, to achieve oncologic control in extensive T4b disease. Despite the challenges posed by proximity to vital structures, surgery remains the cornerstone of treatment, often requiring adjuvant therapy to optimize outcomes. Long-term follow-up is crucial due to the inherent risk of recurrence.

Reconstructive Challenges and Outcomes Following Radical Resection of Sinonasal Squamous Cell Carcinoma via Weber-Ferguson Approach: A Case Study

2025-05-09T08:39:07+00:00

Sinonasal squamous cell carcinoma (SCC) is an uncommon malignancy characterized by diagnostic delays and complex management. Advanced-stage disease often necessitates radical surgical resection, leading to significant anatomical defects and formidable reconstructive challenges. The Weber-Ferguson approach provides wide surgical exposure for extensive tumors but results in considerable midfacial defects requiring meticulous reconstruction to restore function and aesthetics. This case study details the reconstructive challenges and outcomes following total maxillectomy with this approach for an advanced sinonasal SCC. A 53-year-old male presented with a one-month history of right cheek pain and swelling, preceded by a year of right upper molar pain and progressive facial masses. Clinical and radiological evaluations revealed an extensive mass originating from the right maxillary sinus, destructing surrounding bony structures and involving regional lymph nodes. Biopsy confirmed poorly differentiated keratinizing squamous cell carcinoma. The patient underwent a right total maxillectomy via a Weber-Ferguson approach with Lynch modification, extended to involve the mandible, along with reconstruction. The final staging was T4aN3M0. Postoperatively, the patient experienced minor wound dehiscence, which was managed conservatively. He was planned for an obturator and adjuvant radiochemotherapy, but he declined further oncological treatment. Radical resection of advanced sinonasal SCC using the Weber-Ferguson approach, while oncologically necessary, presents substantial reconstructive dilemmas. Addressing these defects is crucial for functional rehabilitation, including speech, deglutition, and acceptable cosmesis. This case underscores the complexity of managing such extensive defects and the importance of a multidisciplinary approach, even when patients decline standard adjuvant therapies. The long-term prognosis in such cases remains guarded, particularly without adjuvant treatment.

Empowering Mothers: The Critical Role of Knowledge and Positive Attitudes in Shaping Prenatal Nutritional Choices

2025-05-19T03:54:16+00:00

Optimal prenatal nutrition is foundational for positive maternal and fetal health, significantly impacting lifelong well-being. A pregnant woman's nutritional knowledge and attitudes are pivotal, modifiable determinants influencing her dietary choices. Inadequate knowledge or negative attitudes can precipitate suboptimal nutritional intake, thereby elevating risks for adverse outcomes such as maternal morbidity, intrauterine growth restriction, and developmental issues in the child. This study aimed to comprehensively explore the nexus between pregnant women's nutritional knowledge, their attitudes concerning gestational nutritional needs, and the consequent influence on their prenatal dietary practices within a distinct rural Indonesian community. This descriptive analytical study adopted a cross-sectional design, conducted in Desa Bale Redelong, Kecamatan Bukit, Kabupaten Bener Meriah, Aceh, Indonesia. The entire population of 60 pregnant women accessing local midwifery antenatal services was included via total population sampling. A structured, pre-tested questionnaire was administered to collect data on socio-demographic characteristics, nutritional knowledge, attitudes towards nutritional needs (independent variables), and self-reported nutritional practices (dependent variable). Data analysis encompassed descriptive statistics, Chi-Square (χ²) tests for bivariate associations, and a multivariate logistic regression to identify key predictors of good nutritional practices, with statistical significance set at p < 0.05. Baseline data (n=60) depicted a cohort primarily aged 20-35 years (70.0%), with secondary education (55.0%). Nutritional knowledge was 'good' in 33.33%, 'sufficient' in 40.0%, and 'poor' in 26.67% of participants. Positive attitudes towards nutrition were held by 63.33%, while 36.67% exhibited negative attitudes. Bivariate analysis revealed significant positive associations between higher nutritional knowledge (χ²=10.833, p=0.001) and positive attitudes (χ²=6.136, p=0.013) with good nutritional practices. Multivariate logistic regression indicated that 'good' knowledge (Adjusted Odds Ratio [aOR] = 3.8; 95% CI: 1.5-9.6; p=0.005) and 'positive' attitudes (aOR = 2.9; 95% CI: 1.1-7.8; p=0.030) were significant independent predictors of good nutritional practices, after controlling for maternal age and education. In conclusion, this study underscores the critical and independent roles of both robust nutritional knowledge and positive attitudes in shaping the prenatal dietary choices of pregnant women in the investigated community. Even when accounting for socio-demographic variables, enhanced knowledge and favorable attitudes significantly predicted improved nutritional practices. These insights strongly advocate for multifaceted, culturally-sensitive public health interventions designed not only to impart factual information but also to cultivate empowering attitudes, thereby enabling pregnant women to make informed, health-promoting nutritional decisions for optimal maternal and child outcomes.

When Pain Relief Turns Perilous: A Case Report on Paracetamol Dependence, Polypharmacy, and Severe Drug-Induced Liver Injury

2025-05-20T01:31:00+00:00

Drug-induced liver injury (DILI) from long-term therapeutic paracetamol use, especially when complicated by psychological dependence, and concurrent atorvastatin therapy within a polypharmacy setting is an uncommon but serious clinical concern. This report details such a case, emphasizing the diagnostic challenges and management. A 58-year-old woman with a 20-year history of dependence on paracetamol (500-1500 mg daily) and 12 years of atorvastatin use (20 mg daily) amidst other chronic medications (levothyroxine, candesartan, clopidogrel), presented with bleeding gums, abdominal discomfort, nausea, and weakness. Laboratory investigations revealed markedly elevated liver enzymes (SGPT 3913 U/L, SGOT 5863 U/L), severe thrombocytopenia (17 x 10³/L), and elevated Gamma GT (449 U/L). Viral hepatitis markers were negative. Paracetamol and atorvastatin were discontinued. Significant clinical and biochemical improvement followed, with SGOT/SGPT levels decreasing to 184/283 U/L by day six. In conclusion, the Roussel Uclaf Causality Assessment Method (RUCAM) indicated paracetamol and atorvastatin as "probable" causes of DILI. This case underscores the potential for severe hepatotoxicity from long-term therapeutic use of common medications, especially in polypharmacy and when psychological factors influence drug consumption. Vigilant monitoring and causality assessment are crucial in such complex scenarios.

Esophageal Squamous Cell Carcinoma Masquerading as Achalasia: A Case Report on Diagnostic Pitfalls and Therapeutic Strategies

2025-05-20T07:03:33+00:00

Esophageal squamous cell carcinoma (SCC) is an aggressive malignancy often diagnosed at an advanced stage, leading to a poor prognosis. Its initial symptoms can be nonspecific, occasionally mimicking benign esophageal disorders such as achalasia, thereby posing significant diagnostic challenges. This report details such a case, emphasizing the diagnostic pitfalls and discussing therapeutic approaches. A 43-year-old male presented with a 5-month history of progressive dysphagia and odynophagia, initially suspected to be achalasia. Clinical findings, including significant weight loss and specific laboratory abnormalities, are detailed. Esophagogastroduodenoscopy revealed an obstructing tumor, confirmed as esophageal SCC by biopsy. Staging investigations, including Multi-Slice Computed Tomography (MSCT), characterized the disease as Stage IVA (T4N1M0). The patient underwent feeding gastrostomy for nutritional support and commenced systemic chemotherapy with docetaxel, carboplatin, and cetuximab. The treatment course and initial follow-up are described. In conclusion, this case underscores the critical importance of maintaining a high index of suspicion for malignancy in patients presenting with symptoms suggestive of achalasia, especially if accompanied by atypical features or risk factors. A meticulous and timely diagnostic evaluation, incorporating early endoscopy and biopsy, is paramount for accurate diagnosis and staging. Multidisciplinary management, including robust nutritional support and carefully selected systemic therapy, remains central to addressing advanced esophageal SCC.

Mapping the Meridians and Acupoints in Traditional Bhutanese Medicine: A Comparative Analysis with Classical Chinese Acupuncture

2025-05-21T03:51:44+00:00

Traditional Bhutanese Medicine (TBM), or gSo-ba Rig-pa (Sowa Rigpa), describes vital energy channels (rtsa) and therapeutic points (gsang mig). Classical Chinese Acupuncture (CCA) features a detailed system of meridians (jing luo) and acupoints (xue wei). While both traditions modulate vital energy, a detailed comparative cartography is lacking. This study aimed to map and compare selected TBM channels and acupoints with potential CCA counterparts. A comprehensive review of Sowa Rigpa texts and Bhutanese traditional medical literature was conducted to characterize principal TBM energy channels and therapeutic points, including those for Serkhap (Golden Needle) therapy. Data for five key TBM channels and twenty associated acupoints (pathways, locations, indications) were compiled. Analogous CCA meridians and acupoints were identified based on topography, anatomical landmarks, and traditional indications. A comparative analysis focused on anatomical correspondence, somatic landmarks, and traditional indications (rLung, mKhris-pa, Bad-kan in TBM vs. Qi, Blood, Zang-Fu in CCA). The mapping characterized distinct TBM channels with unique attributes. Comparative analysis (detailed in a table) revealed significant anatomical overlap for 60% (12 of 20) selected TBM acupoints with CCA acupoints, particularly along Bladder, Gallbladder, and Stomach meridians. Notable divergences occurred in channel trajectories and point energetics. Some TBM points, especially for Serkhap, had unique locations or indications rooted in TBM’s humoral theory. Approximately 30% showed partial overlap, and 10% appeared unique. In conclusion, this comparative mapping provides foundational insights into TBM and CCA channel/acupoint systems. Anatomical convergences suggest shared empirical observations, while Sowa Rigpa’s distinct theories offer a unique lens on somato-energetic relationships.

Unmasking Advanced HIV Infection: A Case of Refractory Thrombocytopenia Misdiagnosed as Immune Thrombocytopenic Purpura

2025-07-09T08:51:25+00:00

Thrombocytopenia is a frequent hematological abnormality in individuals with human immunodeficiency virus (HIV) infection and can be the initial presenting sign. Its clinical picture can closely mimic primary Immune Thrombocytopenic Purpura (ITP), leading to diagnostic delays and inappropriate management. This report highlights a case where an HIV diagnosis was revealed during the workup for refractory thrombocytopenia. A 39-year-old female presented with fatigue and gingival bleeding. She had a previous diagnosis of ITP and had been treated intermittently, but the thrombocytopenia repeatedly recurred. Physical examination was notable for oral candidiasis. Laboratory investigations confirmed severe thrombocytopenia with a platelet count of 4,000/µL. Subsequent serological testing was reactive for HIV, with a CD4 count of 136 cells/µL. The patient was managed for severe thrombocytopenia and opportunistic infection, with a plan to initiate antiretroviral therapy. In conclusion, this case underscores the critical importance of including HIV infection in the differential diagnosis for patients presenting with new-onset or refractory thrombocytopenia. Clinical clues, such as opportunistic infections, should prompt immediate HIV screening to ensure timely diagnosis and initiation of definitive therapy, thereby preventing misdiagnosis and improving patient outcomes.

Cerebral Malaria from a Plasmodium falciparum and Plasmodium malariae Co-Infection: A Case Report on a Diagnostic Challenge

2025-07-10T08:13:50+00:00

Severe malaria, primarily caused by Plasmodium falciparum, is a life-threatening medical emergency. Its diagnosis can be significantly complicated by mixed-species infections, where the presence of a less virulent Plasmodium species may mask the true etiological agent of the severe disease, leading to potential delays in appropriate therapy. This report details a case of cerebral malaria where such a diagnostic challenge occurred. An 18-year-old male with a recent travel history to a malaria-endemic area in Indonesia presented with a one-day history of decreased consciousness (Glasgow Coma Scale score of 9) following a week-long febrile illness. The clinical presentation met the World Health Organization's criteria for severe malaria, specifically cerebral malaria. Initial microscopic examination of a peripheral blood smear exclusively identified Plasmodium malariae. However, a concurrently performed rapid diagnostic test (RDT) was positive for both the pan-malarial antigen and the P. falciparum-specific histidine-rich protein 2 (HRP-2) antigen. This critical discordance prompted treatment for severe falciparum malaria with intravenous artesunate and triggered an expert re-evaluation of the blood smears. Subsequent analysis confirmed a co-infection with both P. falciparum and P. malariae. The patient showed significant clinical improvement within three days of initiating appropriate therapy. In conclusion, this case underscores the peril of diagnostic anchoring in severe malaria. Clinical severity must supersede laboratory findings that are incongruent with the patient's condition. The presence of a Plasmodium species other than falciparum on an initial smear does not rule it out as the cause of a severe syndrome. Discordant results between microscopy and RDTs are a critical red flag for mixed infections and mandate immediate, expert parasitological re-evaluation to ensure timely, life-saving treatment.

Efficacy of Nutritional and Psychosocial Interventions on Linear Growth and Neurodevelopment in Stunted Children in East Java, Indonesia: A Systematic Review and Meta-Analysis

2025-07-16T07:30:58+00:00

Stunting remains a critical public health challenge in East Java, Indonesia, with profound implications for long-term health and capital development. While various interventions have been implemented, their consolidated effect on both physical growth and neurodevelopment is not well-established. This study aimed to synthesize the highest-quality evidence on the effectiveness of these programs. Following PRISMA 2020 guidelines, we conducted a systematic review and meta-analysis of studies evaluating stunting interventions in children under five in East Java, published between January 2015 and June 2025. We searched PubMed, Scopus, Web of Science, and Garuda databases. Included studies were randomized controlled trials (RCTs) and high-quality quasi-experimental studies reporting changes in Height-for-Age Z-score (HAZ) and/or standardized developmental outcomes. A random-effects model was used to pool effect sizes, reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Of 1,824 articles identified, seven studies (n=2,985 children) met the stringent inclusion criteria. Interventions were categorized as nutrition-specific (n=2), nutrition-sensitive (n=2), and multi-component (n=3). Overall, interventions showed a significant positive effect on linear growth (SMD = 0.45; 95% CI [0.31, 0.59]; I²=68%). Subgroup analysis revealed that multi-component interventions combining nutritional support with psychosocial stimulation yielded a greater effect on HAZ (SMD = 0.61; 95% CI [0.42, 0.80]) than nutritional (SMD = 0.34; 95% CI [0.19, 0.49]) or psychosocial interventions alone. A significant, albeit smaller, effect was observed for developmental outcomes across four studies (SMD = 0.30; 95% CI [0.16, 0.44]). The pooled evidence from these core studies confirms that stunting interventions in East Java produce meaningful anthropometric improvements. The synergistic effect of combining nutrition with psychosocial support suggests that interventions must address not only nutrient deficits but also the behavioral and environmental factors that impair development. This dual approach likely mitigates the pathophysiological cycle of malnutrition, inflammation, and impaired cognitive development. In conclusion, multi-component stunting interventions appear to be most effective in East Java. Health policies should prioritize integrated programs that combine nutritional supplementation with responsive caregiving to maximize benefits for both physical growth and human potential.