Israel Medical Association Journal

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors arising from pancreatic tissue, predominantly affecting young women and possessing low malignant potential. Extrapancreatic SPNs are exceedingly uncommon. According to data from the English literature, only 30 cases of extrapancreatic SPNs had been reported by 1990, accounting for less than 1% of all reported SPNs from 2004 to 2018. The testis, paratesticular region, and ovary are the more frequently documented sites of these tumors [1,2]. Notably, to the best of our knowledge, no cases of SPN originating in the diaphragm have been reported in the English literature to date. The prevailing theory suggests that SPNs behave similarly regardless of whether they originate in the pancreas or in extrapancreatic locations.

We present the case of a 79-year-old female with a history of lung and endometrial cancer, who was diagnosed with a liver lesion during a routine follow-up ¹⁸F-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT). During surgery, the lesion was resected from the diaphragm and was confirmed to be consistent with the pathological findings of SPN.

Immune thrombocytopenia (ITP), driven by autoantibodies targeting platelet antigens, is an acquired disorder posing considerable challenges, particularly in pregnancy, where its prevalence escalates to 1–3 per 10,000 women, a tenfold increase compared to the general population [1]. Predominantly characterized by a heightened risk of bleeding, particularly during pregnancy, the incidence of significant hemorrhagic events stands at approximately 18%, mostly non-severe [1]. Despite its rarity, thrombosis can manifest as a complication, especially when accompanied by antiphospholipid antibodies, which amplify the propensity for arterial and venous thrombotic events alongside obstetric complications and thrombocytopenia [2,3].

In this case report, we present the case of a young female with primary unexplained infertility, complicated by ITP and antiphospholipid syndrome (APS), predisposing her to increased bleeding and thrombotic risks. During a multidisciplinary consultation, the medical staff navigated the intricate landscape of fertility treatments and pregnancy options, carefully considering the delicate balance between risks and benefits to optimize patient outcomes.

Burn injuries pose a significant challenge in mass casualty scenarios. They require rapid and effective intervention to optimize patient outcomes. In this case report, we present the management of three severely burned patients following the October 7th terrorist attack in Israel. Our objective is to highlight the role of NexoBrid® (MediWound Ltd, Yavne, Israel) enzymatic debridement [1] as a primary intervention and discuss the challenges encountered in a mass casualty setting.

We report a case of true syncope with documented vasovagal syncope which occurred at the time of an alarm due to missile attack. This case shows a severe vasovagal reaction to emotional stress and fear.

The vasovagal response (neurocardiogenic response) involves an abnormal interplay of bradycardia and paradoxical vasodilation. This intense vagal stimulation can result in syncope, which may have dramatic consequences, especially in elderly patients. Such an event was triggered during a missile alarm in an 80-year-old man. To the best of our knowledge, no similar case has been previously reported [1,2]. A sinus pause is a temporary cessation of electrical impulses from the sinus node, resulting in a brief but complete halt of heart contraction. The excessive vagal input diminishes sinus node automaticity, potentially causing pauses that vary in duration from seconds to even longer periods, depending on individual susceptibility and the length and intensity of the vagal response.

Although typically transient, sinus pauses may also result in significant symptoms like lightheadedness or syncope. In severe cases, they can compromise cerebral perfusion, necessitating immediate intervention. Recognizing the risk of sinus pause in susceptible patients is essential for preventing potential complications, particularly during procedures that may provoke a strong vasovagal reaction.

Pheochromocytoma, a rare neuroendocrine tumor, classically manifests symptoms such as hypertension, palpitations, and sweating. In this report, we present an unusual case in which muscle complaints were the primary symptoms, accompanied by elevated interleukin-6 (IL-6) levels. Our findings underscore the importance of considering pheochromocytoma in the differential diagnosis of patients presenting with unexplained muscle weakness and aches, and suggests a potential link between pheochromocytoma, myositis-like symptoms, and IL-6 elevation.

Minocycline is a tetracycline antibiotic prescribed to treat various infections, acne vulgaris, and rosacea. In addition to its antibiotic activity, it possesses anti-inflammatory properties, including reducing the production of proinflammatory cytokines, suppressing neutrophil chemotaxis, activating superoxide dismutase, and inhibiting phagocytosis. Among its side effects are hypersensitivity syndrome reactions, drug-induced lupus, and polyarteritis nodosa (PAN) [1].

Anorexia nervosa (AN) is a common psychiatric disorder primarily affecting adolescents and young adults. It is characterized by extreme restriction of food intake, distorted body image, and weight-gain anxiety. We report a case with rapid progression and severe metabolic changes in a young restrictive-type AN patient, highlighting unique aspects of this presentation and discussing pathophysiology.

An 11-year-old girl presented with a significant 29% weight loss over 4 months, leading to a body mass index (BMI) of 11.7 (< 1st BMI percentile for her sex and age). She presented with severe bradycardia and metabolic abnormalities including hypoglycemia, hypercholesterolemia, and hypothyroidism. Following diagnosis with restrictive type AN based on the DSM-5 [1] criteria and stabilization at our department, she was transferred to a specialized unit. The hypercholesterolemia our patient presented with is more typical of binge-eating/purging subtype AN, yet it was markedly elevated in this restrictive-type case.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder of immune dysregulation characterized by an inadequate attenuation of the cytotoxic and innate immune system resulting in uncontrolled inflammation in multiple organ systems. Predominant clinical findings include fever, cytopenia, and hepatosplenomegaly [1].

Infectious diseases are a well-documented trigger of HLH, with viral infection being the most common cause. Less commonly, HLH has also been reported in the setting of bacterial infections, with rare cases described secondary to rickettsial diseases [1]. In this report, we present a case of HLH in the setting of bacterial infection with Rickettsia typhi, murine typhus.

IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition. Accumulated research and data since 2003 have increasingly affirmed its classification as a systemic disease. Although IgG4-RD generally presents with involvement of one or several organ systems, it can affect almost any organ. The disease manifests gradually with the development of tumor-like lesions.

Constitutional symptoms, such as systemic fever and elevated inflammatory markers, are generally absent in association with this pathological condition. However, it is common for patients to exhibit allergy characteristics in addition to a slight increase in peripheral blood eosinophilia. The clinical manifestations of the disease exhibit variability on the specific organ system affected. Specific involvement of organs can ultimately result in organ failure. For example, retroperitoneal fibrosis commonly leads to post-renal failure [1]. The 2020 Revised Comprehensive Diagnostic (RCD) criteria for IgG4-RD include three components for diagnosis: clinical and radiological components (1), serological diagnosis (2), and unique pathological diagnosis (3). When all three are present it is a definitive diagnosis. The presence of components 1 + 3 constitutes a probable diagnosis, while the presence of components 1 + 2 indicates possible diagnosis [2].

Testicular involvement of IgG4-RD has been described in a few case reports. However, the uniqueness of our case is the manifestation of a testicular mass as a different target organ of relapse in a patient in remission from retroperitoneal fibrosis.

Cardiac amyloidosis is a form of restrictive cardiomyopathy resulting from the accumulation of misfolded protein aggregates in the myocardial extracellular space. Cardiac amyloidosis stems primarily from the misfolding of monoclonal immunoglobulin light chains (AL) originating from abnormal clonal plasma cell proliferation or transthyretin amyloidosis (ATTR).

Diagnosis of amyloidosis demands a high index of suspicion and requires histological confirmation of pathognomonic green birefringence under polarized light when an infiltrated tissue specimen is stained with Congo-red staining [1,2].

Pleural involvement of systemic amyloidosis has rarely been reported and is considered a serious complication [3]. Pleural amyloidosis is diagnosed with the identification of amyloid deposits in pleural biopsy specimens. However, pleural biopsies are rarely performed for this indication.

We describe the case of a patient with AL cardiac amyloidosis presenting as intractable pleural effusion and diagnosed via pleural biopsy.

Reversible cerebral vasoconstriction syndrome (RCVS) comprises a group of conditions characterized by reversible vasoconstrictions of cerebral arteries. Clinical manifestations include sudden-onset severe headaches with or without additional neurologic signs and symptoms [1].

The incidence of RCVS is 2.7 cases per million adults. It predominantly affects women, and about 9% of all RCVS cases occur during the postpartum period [2,3]. Other possible precipitating factors, such as subarachnoid hemorrhage, ischemic stroke, intracranial hemorrhage, and exposure to vasoactive drugs, have also been reported in association with RCVS [2]. The exact pathophysiology of RCVS is not well understood, although hormonal influences have been suggested as possible contributing factors.

Alkalosis-induced cerebral vasoconstriction is described but not well understood. Hyperventilation is commonly used in neurologic patients to decrease intracranial pressure and cerebral blood flow. Hyperventilation causes cerebral vasoconstriction directly by hypocapnia and may indirectly affect through alkalosis.

We present a case of RCVS in a postpartum patient admitted to the intensive care unit (ICU) with severe metabolic alkalosis necessitating hemodialysis.

Higher potency bisphosphonates, typically intravenous formulations, are given at lower doses for postmenopausal women. The treatment has improved compliance compared to daily oral therapy. Since bisphosphonates are exclusively excreted via the kidneys, intravenous formulation has been associated with deterioration of renal function, specifically in the setting of preexisting renal disease or concomitant use of nephrotoxic agents [1].

In the acute settings of generalized myasthenia gravis (MG) treatment options include plasma exchange (PLEX), intravenous immunoglobulin (IVIG), and pyridostigmines. A thymoma is associated with the disease in up to 20% of cases [1,2].

In cases where a thymoma is detected, surgical treatment to remove the tumor is recommended in certain age groups. At present, there are no clear guidelines regarding the optimal time to perform thymectomy after diagnosis of acute crisis or from the last treatment to thymectomy. Treatment is at the clinician's discretion.

Adenoid surgery (adenoidectomy) is one of the most common pediatric surgical procedures. Complications of this surgery include anesthetic issues, bleeding, pain, dysphagia, and velopharyngeal insufficiency. The intraoperative complications are usually the most urgent and therefore require prompt identification and resolution. Tension pneumothorax (TPX) is a rare intraoperative. We present the first case in the English literature, to the best of our knowledge, of TPX during adenoid/tonsil surgery.

Acute or chronic aortic dissection is considered a rare emergency, with an estimated rate of 2.9 to 5 cases per 100,000 patients each year. This condition is most prevalent in males older than 65 years of age with a history of hypertension, atherosclerosis, and previous cardiac surgery [1,2]. To confirm the diagnosis, imaging is used, often by computed tomography angiography (CTA) of the chest. Although prompt treatment is required, patients often present with non-specific symptoms, such as abdominal pain or neurologic deficits, resulting in the early diagnosis of less than 20% and a high mortality rate [1].