Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 01 101 104 Elham Nazar Department of Pathology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Zohre Shabanzade Department of Pathology, Fajr Hospital, Marivan, Iran. Amir Ahmadi Department of Pathology, Fajr Hospital, Marivan, Iran. 2021 02 22 2021 05 10 Synovial sarcoma is a malignant mesenchymal neoplasm which com- monly arises in the extremities of adults, in close association with joint capsules. Only a few cases of synovial sarcoma occurring in the abdominal wall have been reported. We report an extremely rare case of monophasic synovial sarcoma of abdominal wall in a 58-year-old woman who had presented with painless left ante- rior abdominal wall mass. The patient underwent excisional surgery. Histological and immunohistochemistry examinations revealed monophasic synovial sarcoma. Base on the diagnosis, the patient received chemoradiation.Primary synovial sarcoma is rarely found in the anterior abdominal wall. But, it should be included in the differential diagnosis. https://crcp.tums.ac.ir/index.php/crcp/article/view/486

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 01 105 108 Narjes Mohammadzadeh Department of General surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Seyed Mohammad Mahdi Hashemi School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 2021 04 03 2022 01 30 In this case report, a man presenting with a rare symptom of appendix cancer is dis- cussed. Hematuria, which was the key diagnostic feature in this patient, has never been re- ported as a presenting feature of appendix cancer which may explain why this patient has been experiencing this symptom for months and yet have not get the proper di- agnosis. As we discussed in the case report, although appendiceal cancer is a potentially life-threatening issue, it is frequently missed in patients. Therefore, we believe report- ing this key symptom in this journal would help physicians to make a more accurate diagnosis in this matter.  https://crcp.tums.ac.ir/index.php/crcp/article/view/509

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 109 116 Nasir Hematian Department of Perinatology and Fetal Cardiology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran. Shirin Torabi Perinatologist, Fetal-Maternal Research Center, Tehran, Iran. Sedigheh Hantoushzadeh Department Perinatology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Maasoumeh Saleh Department Fetal-Maternal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Mahboubeh Saleh Fasa University of Medical Sciences, Fars, Iran. 2021 05 11 2021 08 09 CCTGA, also known as levo- or L-loop transposition (L-TGA), double discordance, or ventricular inversion, is a rare cardiovascular anomaly with inversion of the ventricles and great arteries. In this anomaly, the right atrium communicates with the morpho- logic left ventricle, which gives rise to the pulmonary artery, while the left atrium communicates with the morphologic right ventricle, which gives rise to the aorta. Thus, atrioventricular and ventriculoarterial discordance (double discordance) exist, and although the blood flows in the normal direction, it passes through the wrong ventricular chambers. It is a unique conotruncal anomaly, in which the four-chamber view is abnormal. It may be associated with other heart disorders. In most fetuses, TGA remains undiagnosed before birth. The diagnosis of TGA can be made by care- fully and appropriately evaluating the anatomic locations of cardiac chambers and the connections between the atria, ventricles, and great arteries with high-resolution ultrasound. Patients with isolated CTGA generally present later in life with signs and symptoms related to either arrhythmias or heart failure. TGA is rarely associated with chromosomal abnormality and amniocentesis is usually not undertaken. We report a case of CTGA detected at 18 week’s gestation on screening ultrasound.  https://crcp.tums.ac.ir/index.php/crcp/article/view/538

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 117 119 Hana Magrouni Department of Neurology, Iranian Center of Neurological Research, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Nina Javadian Department of Neurology, Iranian Center of Neurological Research, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Ghasem Farahmand Department of Neurology, Iranian Center of Neurological Research, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Sakine Ranji-Burachaloo Department of Neurology, Iranian Center of Neurological Research, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. 2021 05 31 2021 08 02 The presented case is an 81- year-old woman who had experienced episodes of facial twitching without loss of consciousness and flu like symptoms for a few weeks prior to her admission. examinations were unremarkable except for left 3rd nerve and right 6th nerve palsy, right peripheral facial palsy and right -side hemiparesis. FH was positive for sarcoidosis. neuroimaging were in favor of PCNSL. Sarcoidosis and malignancy maybe etiologically related in at least 25% of cases. Coexis- tence of sarcoidosis and lymphoma have been reported previously. Our patient had two daughters with sarcoidosis and her chest CT scan showed multiple lymph nodes in medias- tinum. Unfortunately, due to the location and the technical restriction, biopsy of mediasti- nal lymph nodes was not performed for our patient and we could not differentiate whether it was reactive, paraneoplastic or granulomatous. We present this case as concurrence of lymphoma and sarcoidosis in a family, which could guide a new concern for the patient with granulomatous infiltrative disease for early diagnosis and familial screening.  https://crcp.tums.ac.ir/index.php/crcp/article/view/550

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 120 127 Ali Fathi School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Milad Rashidbeygi Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. AND Brain and Spinal Cord Injury Research Center (BASIR), Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Maryamalsadat Mousavi School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Zahra Azizan School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Seyed Mousa Sadrehosseini Otolaryngology, Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Azin Tabari Otolaryngology, Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Mehdi Zeinalizadeh Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. AND Brain and Spinal Cord Injury Research Center (BASIR), Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. 2021 06 01 2021 10 30 Cavernous sinus hemangiomas (CSHs) are rare, benign, slow-growing neoplasms within the cavernous sinus. Laterally located to these lesions, the cranial nerves and carotid artery are subject to injury during removal of hemangiomas through a transcranial route. Therefore, for surgi- cal management of cavernous sinus hemangiomas a medial corridor granted through an endoscop- ic endonasal approach may be less traumatic to the neurovascular bundle. Case-1 describes a 23-year old male who presented with intermittent blurred vision and very mild ptosis on the right side for two years before admission. Fundoscopic exam, visual acuity and perimetry tests were normal. With intense enhancement after contrast administration, both brain MRI and CT scan demonstrated an extra-axial mass in the right cavernous sinus. Case-2 presents a 59-year-old male, a known case of renal oncocytoma who underwent nephrec- tomy a year before, with chief complain of moderate intermittent headaches. Imaging study of the brain by MRI revealed a sellar mass. Near-total resection for case-1 and gross total resection for case-2 were performed through the an extended endoscopic endonasal approach. We report two cases of near-total and gross total resection of CSHs via an extend- ed endoscopic endonasal approach substantiating advances in minimal access neurosurgery to the treatment of such grim lesions of an intricate vicinity of the skull base. At the same time, we focus to review extensively the growing yet heterogenous literature of the past twenty years on the broached topic. The evolution of extended endoscopic endonasal approach over the past two decades changes the dynamism of the surgical practices steeped in tradition and provides a safer alternate route for preserving cranial nerves of this anatomic region. https://crcp.tums.ac.ir/index.php/crcp/article/view/551

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 128 133 Aamir Raina Department of Surgery, Sher-e-kashmir Institute of Medical Sciences, (SKIMS) SOURA, J&K, India. Mohammad Khan Department of Surgery, Sher-e-kashmir Institute of Medical Sciences, (SKIMS) SOURA, J&K, India. Aamir Shahr Department of Surgery, Sher-e-kashmir Institute of Medical Sciences, (SKIMS) SOURA, J&K, India. 2021 06 21 2021 10 03 Double J stent or DJ stent, is a self-retaining ureteral stent mainly used to provide effective drainage of kidney into urinary baldder. However, because of widespread use, lack of patient education or due to lack of adherence to regular follow up, patients may end up with a forgotten DJ stent which can stay undiagnosed in the pelvi-ureteral system for years and cause a lot of complications before coming to attention. We present a unique case of repetitively neglected (forgotten) DJ stent in a 28-year-old male, who had the stent placed 11 years back as a part of Percutaneous Nephrolithotomy (PCNL) and now presented with encrusted DJ stent with large bladder calculus and calculus deposits along entire length of the stent. To our knowledge, this study reports the forgotten stent with the maximum stone burden available in literature. https://crcp.tums.ac.ir/index.php/crcp/article/view/563

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 134 137 Sohil Pothiawala Department of Emergency Medicine, Woodlands Health, Singapore. 2021 07 05 2021 10 03 Accessory navicular bone occurs due to failure of fusion of a secondary ossification center with the navicular. It is the second most common ossicle of the foot, with majority of them being identified incidentally on imaging studies. We report a case of 45-year-old female who presented with complaints of pain and localized redness over the medial aspect of the right foot which was aggravated on walking. This brief review aims to describe the pathophysiology, radiographic findings and management of Os naviculare syndrome. We also wish to highlight to the physicians that it must be suspected in patients with localized pain over the medial aspect of the midfoot without obvious trauma. The presence of accessory navicular should not be disregarded as an incidental radiological variant in a symptomatic patient. https://crcp.tums.ac.ir/index.php/crcp/article/view/567

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 138 143 EN Abbas Tafakhori Department of Neurology, School of Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Alireza Soltani Khaboushan Department of Neurology, School of Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. AND Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran. Aydin Taghilou Department of Neurology, School of Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Sajad Shafiee Department of Neurosurgery, Mazandaran University of Medical Sciences, Sari, Iran. 2021 07 07 2021 10 17 A 20-year-old woman presented with left eye ptosis without any headache and pupillary dysfunctions. After the radiological examination, the oculomotor nerve compression was detected in the interpeduncular space by the posterior communicating artery (PCoA) with normal size and shape. The patient underwent frontotemporal craniotomy, and during the surgery, the nerve was detached from the PCoA. Immediately after surgery, all symptoms disappeared. Although oculomotor nerve palsy (ONP) owing to internal carotid-PCoA aneurysm is common, vascular compression due to a non- aneurysmal PCoA is very rare. To the extent of our knowledge, this is the first case in which a slightly displaced, otherwise normal, PCoA causes ONP without any pupillary involvement. After ruling out an aneurysmal artery, this should be considered as one of the possible causes of the ONP. https://crcp.tums.ac.ir/index.php/crcp/article/view/569

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 144 147 Pourya Farhangi Medical School, Tehran University of Medical Sciences, Tehran, Iran. Minoo Hajmiri Department of Endoscrinology, Vali-Asr Hospital, Endocrinology and Metabolism Research Center (EMRC), Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran. Nooshin Shirzad Department of Endoscrinology, Vali-Asr Hospital, Endocrinology and Metabolism Research Center (EMRC), Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran. AND Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. Mahboobeh Hemmatabadi Department of Endoscrinology, Vali-Asr Hospital, Endocrinology and Metabolism Research Center (EMRC), Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2021 07 13 2021 10 03 Hereditary hemochromatosis (HH) is a rare genetic disorder, causing systemic iron overload. High amounts of iron in the bloodstream gradually oversaturate the trans- ferrin which can cause sedimentation of iron in the pancreas, liver, heart, pituitary and joints, though it can establish multiorgan involvements. We present a case of TFR2 (type 3) HH who had minor α-thalassemia and uncontrolled diabetes mellitus, and discuss the clinical presentation and patient management. A 33-year-old man with type 3 HH and alpha-thalassemia trait, presented with uncon- trolled diabetes mellitus, skin hyperpigmentation and hypogonadism. The patient had high blood glucose ,despite the administration of 80 units of Glargine and 80 units of Aspart insulins per day, but after changing them into human insulins, his diabetes mellitus was surprisingly controlled with only 32 units of NPH and 18 units of Regular insulins. Furthermore, he was treated with testosterone (due to hypogonadism) and Deferasirox (due to iron overload). https://crcp.tums.ac.ir/index.php/crcp/article/view/574

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 148 157 Yu Peng Tan Department of Medicine, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah,Selangor Darul Ehsan, Malaysia. Vivek Vijayan Department of Medicine, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah,Selangor Darul Ehsan, Malaysia. Koon Ket Sia Department of Medicine, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah,Selangor Darul Ehsan, Malaysia. 2021 07 23 2022 01 16 Spontaneous pneumomediastinum has been reported in association with COVID-19. Pneumomediastinum could remain elusive until computed tomogra- phy is performed. Hence, we need to be vigilant even though it generally has a benign clinical course. We presented four confirmed COVID-19 cases with typical ground glass opacity on chest radiograph. All four had the computed tomography that re- vealed pneumomediastinum, pneumothorax and subcutaneous emphysema. Only one patient had pneumomediastinum after intubation. Pneumomediastinum is a devastating finding which should be picked up as early as possible and must be excluded in COVID patients whom deteriorate quickly, as adequate time may pass before any viable intervention can be done to expedite the patients’ recovery. https://crcp.tums.ac.ir/index.php/crcp/article/view/576

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 158 162 Swaroopa Deme Department of General Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telanagana state,India. Bhaskar Kakarla Department of Pulmonary Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telanagana state, India. Rajani Thakur Department of Radiodiagnosis,Nizams Institute of Medical Sciences, Hyderabad,Telanagana state, India. Purushotham Ramreddigari Department of General Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telanagana state,India. Nageswara Rao Modugu Department of General Medicine, Nizams Institute of Medical Sciences, Hyderabad, Telanagana state,India. 2021 07 31 2021 08 09 Tuberculosis, a preventable and curable disease caused by Mycobacterium tuberculosis, is the leading infectious cause of mortality worldwide. Organs commonly affected are lungs and extrapulmonary organs like lymph nodes, meninges, bones, genitourinary and gastrointestinal tract. Ileocaecal tuberculosis is the commonest form of the gastrointestinal tract. Disseminated infection can involve almost all organs in the body but isolated pancreatic tuberculosis is rarely reported in the literature. Hereby, we report a case of a young female presenting with abdominal pain and further evaluation with imaging revealed pancreatic mass raising suspicion of malignancy. Endoscopic ultrasound (EUS) guided FNAC of pancreatic mass surprisingly revealed necrotizing granulomatous lesions favoring tuberculosis. This was further supported by the complete resolution of the mass with Antituberculous Therapy (ATT). What is important: All pancreatic masses are not malignant. Infectious causes like tuberculosis should be considered in the differential diagnosis which is curable by medication. With a high index of suspicion and adequate workup, unnecessary invasive procedures can be avoided. https://crcp.tums.ac.ir/index.php/crcp/article/view/580

Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 7 3 2022 11 02 163 166 Durgesh Kumar Department of Pediatrics, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, India. Dinesh Kumar Department of Pediatrics, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Rajesh Yadav Department Department of Pediatrics, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, India. 2021 09 15 2021 10 30 A 13-year-old girl presented with fever, nausea and projectile vomiting and altered sensorium. On physical examination, the meningeal signs were presented without focal neurological deficits and Grade Ⅱ papilledema was presented on fundus examination. The patient was found to be positive for Japanese encephalitis virus in cerebrospinal fluid. Focal neurological deficit in the form of right hemiparesis was noticed at day 6 of hospitalisation. Multiple lesions with minimal enhancement with perilesional edema were observed in cerebral cortex in contrast with enhanced magnetic resonance imaging of the brain, giving rise to starry sky appearance. No tests for neurotuberculosis were found positive. Serum IgG enzyme-linked immunosorbent assay test was negative for Cysticercosis, but magnetic resonance spectroscopy was suggestive of cysticercal meningitis. During treatment, she had intermittent episodes of nausea and vomiting with waxing and waning sensorium. Subsequently, it was planned to start Albendazole after steroids coverage and anticonvulsants but the patient did not improve and succumbed to her illness.  https://crcp.tums.ac.ir/index.php/crcp/article/view/597