Background: Nephrostomy tubes are frequently used to relieve upper urinary tract obstruction but may become blocked by blood clots, especially in patients with hematuria. Urokinase, a plasminogen activator, is approved for treating catheter blockages but is rarely used in the urinary tract.Case Presentation: We report the case of a 78-year-old male with bilateral nephrostomies due to metastatic prostate cancer who developed right-sided nephrostomy blockage caused by clots. The patient also experienced acute kidney injury and severe anemia requiring transfusions. After conventional flushing failed, he was treated with intraluminal urokinase instillations (10,000 IU every 8 hours for 48 hours). This led to quick restoration of nephrostomy patency, resolution of hematuria, and clinical stabilization without the need for additional invasive procedures.Conclusion: This case shows that intranephrostomy urokinase instillation can be an effective, minimally invasive option for managing clot-related nephrostomy tube blockage, especially in palliative or fragile patients where procedural risks are high. Continue Reading

Background: Asthma is one of the most common pulmonary disease worldwide. Asthmatic patients are prone to frequent exacerbation of symptoms that range from cough to severe, disabling shortness of breath, leading to significant impairment of quality of life. Airway obstruction causes increased resistance to airflow and decreased expiratory flow rates. Revolizer is useful for inhaling dry medication powder orally for treating lung-related diseases.Objective: To determine the frequency and comparison of ease-of-use of Revolizer among asthmatic patients who were on metered-dose inhalers (MDI’s).Methods: Study Design: Quasi-experimental pre-post design. Setting: Medicine Department, PAEC General hospital Islamabad.Duration: Six months, i.e., 15-10-2024 to 15-4-2025. Data Collection: After meeting the inclusion criteria, 100 patients were enrolled. Then those patients who were using MDIs previously were assorted revolizers and taught about the proper method of using them by investigator. After that, patients were asked to repeat the performance of the inhalation technique in front of the... Continue Reading

Background Lateral medullary infarction (Wallenberg’s syndrome) is a classical posterior circulation stroke, typically presenting with dissociated sensory loss and lower cranial nerve involvement. Ocular motor abnormalities such as ipsipulsion and asymmetric saccadic gain are rarely reported but may provide important diagnostic clues.   Case Presentation We describe a 45-year-old Asian woman with diabetes, hypertension, and dyslipidemia who presented with acute-onset dysphagia, vomiting, and right-sided facial numbness, which progressed over 24 hours. Neurological examination revealed dissociated sensory loss, impaired gag reflex with uvular deviation, and nasal speech. Ocular motor findings included right-beating nystagmus, ipsilateral gaze deviation with ocular ipsipulsion, hypermetric saccades to the right, and hypometric saccades to the left. Magnetic resonance imaging confirmed an infarction of the right lateral medulla. CT angiography and echocardiography excluded arterial dissection and cardioembolism. She was treated with dual antiplatelet therapy, statins, and optimization of vascular risk factors.   Conclusion This case highlights three uncommon... Continue Reading

Learning Points of the Article• To increase physicians’ awareness of the postoperative risk of iatrogenic hypercalcemia in patients with prosthetic joint infections managed with calcium sulfate beads.• To highlight the importance of preoperative calcium level assessment in patients getting these calcium beads.• To demonstrate the role of regular serum calcium monitoring particularly preoperatively in the early detection and prevention of hypercalcemia. ABSTRACT Background:Calcium sulfate beads are frequently used in the management of periprosthetic joint infections (PJIs) because of their effectiveness in local antibiotic delivery and bone void filling. However, repeated use can lead to significant complications, including iatrogenic hypercalcemia. Despite reports of this complication in the literature, the cases in this paper demonstrate a relative lack of awareness among physicians. Cases:We report two cases of iatrogenic hypercalcemia secondary to repeated administration of calcium sulfate beads in the treatment of femoral PJIs, a cause that was initially unrecognized by the medical... Continue Reading

Background: Breast carcinoma is the most common malignancy in females, and while a few cases of second primary solid organ malignancies have been reported, the synchronous occurrence of breast cancer and chronic myeloid leukemia (CML) remains exceedingly rare, particularly in patients without prior cytotoxic treatment. CML, a rare myeloproliferative neoplasm, typically develops following exposure to ionizing radiation or chemotherapy. We present the first reported case from Pakistan of synchronous CML diagnosed during staging workup of breast carcinoma. Case Presentation: A 67-year-old female presented with a 10-month history of left breast itching and a palpable mass. The biopsy revealed invasive breast cancer with focal lobular growth pattern (grade 2), ER/ PR negative and HER2 3+.  Laboratory tests showed leukocytosis and thrombocytosis; peripheral smear indicated increased myeloid precursors. Bone marrow biopsy confirmed myeloid hyperplasia without metastasis, and molecular testing detected BCR-ABL fusion, confirming chronic myeloid leukemia. The patient was started on chemotherapy... Continue Reading

Background: Benign ovarian tumours affect around 10–20% of women during their lifetime, with mature ovarian cystic teratomas (MOCTs) comprising about 70% of cases in those younger than 40 years. MOCT fistulation into the bowel is a rare and poorly characterised complication. This systematic review aimed to summarise all reported cases of ovarian teratoma complicated by bowel fistulation, focusing on clinical presentation, diagnostic methods, management strategies, and outcomes. Method: A systematic search of PubMed®, SCOPUS, and EMBASE was conducted from inception to October 2025 in accordance with PRISMA guidelines. All case reports describing ovarian teratoma with bowel fistula were included. Data extracted included demographics, clinical features, imaging, management, histopathology, and outcomes. Results: Thirty-five cases published between 1965 and 2025 were identified. The mean patient age was 41.5 years (range 9–85 years). Abdominal pain (77.1%) and rectal bleeding (30.3%) were the most frequent presenting symptoms. Computed tomography (CT) was the predominant imaging... Continue Reading

Background: Diaphragmatic endometriosis (DE) is a rare and often underdiagnosed type of extrapelvic endometriosis. It usually presents with atypical cyclical symptoms of thoracic involvement. Case Presentations: We present three African women with pelvic endometriosis and thoracic symptoms. The first case involved a 32-year-old nulligravida who presented with dysmenorrhea, cyclical hemoptysis, pleural effusions, and subfertility. An MRI showed a right pleural effusion and associated diaphragmatic lesions. Laparoscopic excision provided a diagnosis of DE, and she improved with postoperative treatment of dienogest (Endogest: 2 mg). The second case was a 33-year-old woman with recurrent cyclical dyspnea and right chest pain with a history of pelvic endometriosis. She was urgently admitted and underwent VATS surgery and subsequent pleurodesis. She was treated successfully with a GnRH agonist (11.25mg) and stabilized on this treatment. The third case was a 29-year-old nullipara who presented with cyclical right chest pain. An MRI demonstrated a right diaphragmatic nodule... Continue Reading

Background: Post-emetic purpura is a benign condition characterized by the presence of non-blanchable petechiae or purpura (typically in the distribution of the superior vena cava), usually resulting from a sudden increase in intrathoracic pressure after episodes of vigorous vomiting. Despite its often alarming clinical appearance, which can simulate serious hematologic or infectious diseases, it is a self-limiting occurrence with no systemic implications.Case Presentation: We report the case of a 4-year-old female patient who presented with periorbital purpura after an episode of intense vomiting. Physical examination revealed an erythematous, non-bleachable and bilateral rash that was restricted to the region around the eyes, with no other relevant clinical changes. The condition evolved with spontaneous resolution, without the need for therapeutic interventions.Conclusion: Recognition of post-emetic purpura is essential to avoid additional investigations and reduce anxiety of family members, contributing to a safer and more efficient clinical approach. Continue Reading

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Background: Croup is a common pediatric respiratory illness characterized by a barking cough, inspiratory stridor, and hoarseness resulting from upper airway narrowing. While most cases are of viral etiology, spasmodic croup can be triggered by non-infectious factors such as allergy, gastroesophageal reflux disease, or psychological stress.Case Presentation: We describe a previously healthy with no significant past medical history 10-year-old girl, with multiple presentations to the emergency department with persistent hiccups accompanied by inspiratory stridor with the classic “steeple sign”. Her clinical course suggested overlapping mechanisms, including reflux-related and stress-related functional triggers, as her symptoms improved with proton-pump inhibition and corticosteroids. Conclusion: This case illustrates an unusual presentation of recurrent spasmodic croup with persistent hiccups, likely multifactorial in origin. Awareness of atypical features may help in early identification and improve patient outcomes. Continue Reading