Social media posts have become an integral part of the health system, and various hospitals utilize them to celebrate their milestones and achievements. A few days ago, I came across two photos in my feed that I wanted to share with you and your readers, along with some thoughts that might interest policymakers in Iran and around the world. As a neurosurgeon who trained in Iran and moved to the UK to top up my training, comparing two health systems in general and techniques and approaches of  eurosurgery specifically has been a passion since my first days when I started my journey at Royal Preston Hospital.

The deficiency of isovaleryl-CoA dehydrogenase leads to an inborn recessive error of leucine metabolism named isovaleric acidemia (IVA). Its presentation may be either in the neonatal period as an acute episode of metabolic acidosis or later as a “chronic intermittent form”. Normal development is promoted by early diagnosis and treatment with a protein restricted diet and supplementation with carnitine and glycine. The present case was a 35-day-old boy admitted with seizure whose initial screening test was in favor of organic acidemia of the isovaric acidemia (Ammonia: 200 µmol/L). As the venous blood gas (VBG) analysis revealed no acidosis, newborn metabolic screening was repeated. Typical laboratory findings and elevated levels of C5 and C5/C2 confirmed isovaleric acidemia again. As the above patient had no acidosis while the other tests including laboratory and genetic analysis were in favor of IVA, he considered to be a rare case.

Granulomatosis with polyangiitis is an ANCA-positive vasculitis primarily affecting small to medium-sized vessels, typically involving the lungs and kidneys. This article presents a remarkable case of a patient with an unusual pyoderma gangrenosum-like ulcer on the face and granulomatosis with polyangiitis.  A 28-year-old man, previously diagnosed with granulomatosis with polyangiitis presented at a dermatology clinic with a 6-month-old ulcer in the right preauricular region following a traumatic incident. A spindle biopsy revealed suppurative granulomatous dermatitis with secondary vascular damage, while cultures showed no signs of infection. The patient was subsequently treated with rituximab, leading to a positive clinical response. This case underscores the challenge of diagnosing this rare manifestation of granulomatosis with polyangiitis and suggests that rituximab could be a valuable treatment option.

We reported the case of a 25-year-old woman with antihistamine abuse who presented to our hospital with a GCS of 7 and no significant past medical, psychological, or allergic history. We couldn’t find any evidence of head trauma, seizures, suicide, or any other metabolic, infectious, intoxication, or electrolyte disturbances. During her 10-day admission, the patient developed non-specific manifestations such as fever, hyperthermia, agitation, hypotension, and sinus tachycardia. Physicians should always consider over-the-counter medicines such as antihistamines as a differential diagnosis for loss of consciousness in patients who do not have any footprints of intoxication in primary urine or blood tests.

Eagle Syndrome (ES) is a rare clinical condition presenting with anterolateral neck pain and potential serious complications. This case report details a head nurse in the emergency room (ER) with a severe throbbing headache, trismus, left-sided dysphagia, left otalgia, gum pain, and a very intense left-sided headache, associated with ipsilateral facial hypoesthesia. The patient met the International Classification of Headache Disorders (ICHD-3) criteria for headaches attributed to inflammation of the stylohyoid ligament, establishing
the diagnosis of Eagle syndrome. Chronic headaches associated with ES, as observed in this case, can impact concentration, comprehension, communication, and work performance, leading to economic loss. This prompts the question: Are individuals with ES capable of working under intense physical and psychological conditions? The paper proposes a management strategy for ES patients, emphasizing the need for further research on the impact of ES on occupational fitness, as no published studies currently address this concern.

Osteoma cutis (OC) is a rare condition characterized by the presence of bone particles within the skin. One subtype of osteoma cutis is miliary osteoma cutis (MOC), which primarily affects middle-aged women and commonly occurs on the face. Clinical features of MOC include papules and skin-colored hard nodules, similar to milia. In this case, we present a 60-year-old woman with facial skin lesions resulting from a plant injury. The diagnosis was miliary osteoma cutis, and successful surgical treatment was performed.

This case report describes a rare occurrence of tramadol misuse resulting in a manic episode in a patient without a history of psychiatric disorders. The patient had used tramadol off-label for premature ejaculation. Following discontinuation of tramadol and initiation of mood stabilizer treatment, the manic symptoms resolved. Tramadol, despite its potential antidepressant properties, also poses a risk of inducing psychiatric disturbances. Diagnosis can be challenging and necessitates a thorough examination.
Management involves immediate cessation of tramadol and administration of mood stabilizers. Clinicians should exercise caution and closely monitor patients when prescribing tramadol, particularly for off-label indications.

Small cell lung cancer usually presents as a progressive disease in over 70% of patients. Common organs of metastasis include the liver, adrenal glands, bones, and brain. However, metastasis to the parotid gland is uncommon, as it has been discussed only in case reports. Among all parotid tumors, small cell cancer is rare, seen in only 1.7%.A 60-year-old man presented with a slow-growing, painless tumor of the left parotid gland and peripheral facial paralysis. Neck ultrasound identified a solid mass in the left parotid gland with enlarged lymph nodes in the parotid gland and ipsilateral neck lymphadenopathies with pathologic features in levels 2 and 3. Chest computed tomography (CT) demonstrated subsegmental collapse in the lingula with peribronchial cuffing in this lobe and mild cylindrical bronchiectatic changes in the left lower lobe. CT also showed multiple
mediastinal lymphadenopa thies in prevascular, paraaortic, and paratracheal spaces. Core needle biopsy was done, and initial analysis revealed small cell carcinoma in the left parotid gland. Immunohistochemical analysis of the specimen demonstrated and confirmed the diagnosis. The patient was then referred to the radiation oncology unit for treatment. Chemotherapy was initiated with a combination of cisplatin and etoposide. No complications of the chemotherapy were observed after three cycles; treatment and follow-up are ongoing. No irradiation was performed after evaluation by the radiation oncology department. Due to the advanced stage of his disease, treatment is set for palliative purposes only. Small cell lung cancer diagnosed from solitary etastasis to the parotid gland is very rare. Physicians should keep pulmonary origin in mind when faced with a parotid tumor, as without careful examination, the primary focus may be overlooked, negatively impacting survival rates and the prognosis of the patient. Overall, this finding carries a poor prognosis, but the mainstay of treatment is palliation with systemic chemotherapy and possibly irradiation to control symptoms.

Distal renal tubular acidosis (RTA1) is a rare disease. It confirms the lab’s data and rules out other differential diagnoses. Late evaluation can interfere with healthy development. We explain a 38-year-old patient with a late and accidental RTA1 diagnosis. Correct treatment with alkali consumption and potassium citrate improves her general condition and eliminates further weakness attacks. Early diagnosis is crucial for patient development and morbidity avoidance with accurate treatments.

Breast cancer is highly prevalent amongs t older women but much less common in younger women, especially those under the age of 20 . Here we present a case of an 18-year-old woman with Neurofibromatosis 1 diagnosed
with breast cancer. Review of literature demons trates a five-fold increased risk of developing breast cancer before age 50 with a mutation in this tumor suppressor gene. Incorporation of earlier screening recommenda tions for
at-risk younger women is warranted in more guide lines.

Epidermal inclusion cysts (EIC) are common cutaneous cysts that can occur nearly anywhere in the body with common locations being the face, scalp, neck, back, and scrotum. Only a few cases of EIC to the breast have been reported in literature to date, with most occurring after trauma to the breast. Here we present the case of a
35-year-old woman that presented with a nontraumatic nipple lesion that was later biopsy proven to be an EIC. Although not a primary consideration, EIC should be on the differential for skin lesions of the nipple.