Rejected

Oral submucous fibrosis (OSMF) is a chronic insidious oral potentially malignant disorder characterized by increased collagen deposition and reduced collagen degradation causing burning sensation and difficulty in mouth opening.

Cancer patients accept surgeries as part of their treatment. They may not be aware of the possibility of surgical pain persisting long after the surgery. Understanding chronic postsurgical pain is essential for effective pain management.

Rosai-Dorfman disease (RDD) is a rare disorder of an unknown etiology, characterized by a benign histiocytic proliferation in the lymph nodes, as well as the extranodal sites. Painless bilateral lymphadenopathy is the classic presentation of RDD in the majority of patients. The exteranodal disease involves the skin, soft tissues, bones, the genitourinary system, the lower respiratory tract, and the central nervous system. A seven-year-old boy was referred to our hospital with left parietal swelling, headache, fever, imbalance, weight loss, and speech and walking impairments. In early examinations, he showed a hyposignal infiltrative lesion in the lateral ventricle and the choroid plexus, expanding to the subcortical white matter of the bilateral temporo-occipital areas. After surgery and sampling, he was diagnosed with cerebral RDD. According to his history, he had bilateral cervical lymphadenopathy at the age of two years, femoral soft tissue involvement at the age of three, and a skin disorder that improved with local treatments at the age of five. However, at the time of referral to the hospital, there were no other symptoms in other areas, except for brain symptoms. In the differential diagnosis of brain lesions with specific borders in high-contrast radiological views, the probability of RDD should be considered, similar to meningioma. The presence of painless and extensive bilateral cervical lymphadenopathy can improve the diagnosis of this disease. Isolated brain involvement in RDD is very rare, and it can be seen in less than 5% of cases. Nevertheless, by early diagnosis and intervention, the risk of complications is reduced, and the prognosis is improved.

Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been proposed as a safe and effective nonopioid analgesic when given in lower doses than those historically used for general anesthesia. Case reports have demonstrated efficacy using low-dose ketamine for pain management and opioid weaning in patients with chronic noncancer pain, but reports of successful use in patients with sickle cell pain are limited. A 35-year-old African American male with sickle cell disease presented to the emergency department with severe generalized body aches and left flank pain. Several days later, his pain became localized to the bilateral lower extremities. Escalating opioid doses provided no improvement. Workup was negative for infection, deep venous thrombosis, ischemia, and infarct. On hospital day 29, the Acute Pain Management Service was consulted and initiated a low-dose ketamine infusion for analgesia and to facilitate opioid weaning. Five days later, the patient was discharged pain-free. Ketamine is a potent nonopioid analgesic, and this report adds to the body of literature supporting the use of low-dose ketamine in patients with sickle cell disease to treat poorly controlled pain and opioid-induced hyperalgesia.

The co-occurrence of depression and chronic pain causes additive adverse effects on patients" outcomes, response to treatment, and poorer functioning. Despite this, there is a dearth of studies in developing countries. Therefore, this study aimed to provide a new insight into the understanding of the prevalence and associated factors between chronic pain and depression among patients with chronic pain in Jimma town public hospitals.

To describe the clinicopathological features of human coenurosis diagnosed at a single center in an academic Anatomical Pathology Laboratory, KwaZulu-Natal, South Africa.

Revision shoulder surgery can pose significant analgesic challenges as locoregional blocks are often avoided to enable early recognition of iatrogenic nerve injuries. Our case describes the utilisation of pre-operative and intra-operative low-frequency percutaneous peripheral nerve stimulation via a 'dry' interscalene catheter, inserted pre-operatively for a patient presenting for revision total shoulder arthroplasty who was experiencing significant shoulder joint pain despite a prior total shoulder arthroplasty. The clinical considerations and safety aspects are discussed further.

The outcomes of renal transplantation have improved significantly with the use of calcineurin inhibitors (CNI). However, this improvement comes at the price of side effects. CNI-induced pain syndrome (CIPS) is a benign but disabling painful syndrome. It particularly affects the lower limbs. We present the case of a young male renal transplant recipient. He presented with worsening bilateral lower limb pain four months after transplantation. Induction therapy was basiliximab. Tacrolimus, steroids, and mycophenolate mofetil constituted maintenance immunosuppressive therapy. Pain affected the ankles and toes bilaterally. It started gradually but progressed over four weeks. The relentless pain affected his mobility to an extent that he became wheel chair dependent. Pain was unresponsive to paracetamol and codeine. No formal psychiatry assessment was done but patient-reported depression symptoms related to his reduced mobility. On examination, he had bony tenderness over the affected areas with the good range of passive movements. Neurological and vascular examinations of lower limbs were unremarkable. Inflammatory and infective causes of joint pain were excluded. Magnetic resonance imaging (MRI) feet showed the features of bone marrow edema. He was diagnosed with CIPS. Immunosuppression was changed from tacrolimus to cyclosporine. Pregabalin was also introduced after the diagnosis. Symptoms improved gradually over a month. He started to walk with a stick initially and then without any aid. Renal transplant function remained stable throughout this period. MRI feet scan, five months after the symptoms showed resolution of the bone marrow edema. CIPS is an uncommon, benign but disabling complication of CNI. Recognizing it early could limit the burden of symptoms (both physical and psychological) and loss of productivity. The management of CIPS is not evidence based and further research is required in this therapeutic area.

To report a case of indirect carotid-cavernous fistula (CCF) in a patient who presented as a case of thyroid-associated orbitopathy (TAO). A 60-year-old female, known case of hypothyroidism, presented with left-sided headache associated with pain, protrusion and redness of left eye, the examination revealing vision of 20/ 80, proptosis, chemosis and severe ophthalmoplegia. All routine investigations were normal, including thyroid hormone levels. MRI brain & orbits showed increase in bulk of all extraocular muscles with tendon sparing. In view of suspicion of TAO, she was initially misdiagnosed and treated with parenteral and oral steroids, which resulted in further worsening of vision. Optical coherence tomography macula of the left eye revealed acute central serous chorioretinopathy that compelled the stoppage of steroids. While reviewing the patient again, dilated cork-screw tortuous episcleral vessels were found in the left eye. Thus, advised Digital subtraction angiography, confirmed as a case of low-flow left Indirect CCF, managed with endovascular embolization therapy improved her ocular symptoms completely in three days. CCF may mimic TAO due to overlapping features. In-view of different treatment protocols for both, it is critically important to look for atypical features in thyroid eye disease and keep CCF as one of the differential diagnoses for accurate management. CCF = carotid-cavernous fistula, ICA = internal carotid artery, ECA = external carotid artery, TAO = thyroid-associated ophthalmopathy, BCVA = best corrected visual acuity, MRI = magnetic resonance imaging, IVMP = intravenous methylprednisolone, OCT = Optical coherence tomography, CSCR = central serous chorioretinopathy, DSA = digital subtraction angiography, IOP = intraocular pressure, CT = computed tomography.

Petrous endostosis or prominent suprameatal tubercle is a rare entity which may prevent adequate microscopic exposure of the trigeminal nerve root entry zone during microvascular decompression (MVD) for trigeminal neuralgia. We present a rare case of trigeminal neuralgia (TN) with petrous endostosis, which was managed adequately by partial removal of the prominent suprameatal tubercle to improve the obscured site of neurovascular conflict and enabled complete MVD. Through this manuscript, we additionally discuss the nuances involved in this extension of the standard retrosigmoid approach in light of the published literature. Petrous endostosis encountered during MVD for TN can impose an operative challenge. Suprameatal extension of the standard retrosigmoid approach improves exposure at the site of neurovascular conflict but requires utmost care and attention to avoid complications. We emphasize recognizing this anatomical variation in the preoperative period to predict an operative difficulty, ensure appropriate patient counselling, and avoiding surgical complications.