Chronic liver disease in infancy is uncommon, diagnostically demanding, and rarely reported from sub-Saharan Africa, where advanced hepatologic evaluation is seldom accessible. We describe a one-year-old boy from rural Somaliland who presented with a two-week history of progressive abdominal distension, followed by jaundice, hematemesis and bloody diarrhea. Examination showed wasting, deep scleral icterus, tense ascites, caput medusae and splenomegaly. Investigations demonstrated severe anemia (hemoglobin 3.8 g/dL), thrombocytopenia (130 × 10[9]/L), conjugated hyperbilirubinemia (total 2.45 mg/dL, direct 1.69 mg/dL), severe hypoalbuminemia (albumin 1.8 g/dL) and marked coagulopathy (INR 3.0). Grayscale ultrasonography showed an irregular hepatic surface, splenomegaly and large-volume ascites. Doppler ultrasonography, upper gastrointestinal endoscopy, liver biopsy, elastography, cytomegalovirus IgM and polymerase chain reaction testing, and metabolic and genetic studies were unavailable, and an isolated positive cytomegalovirus IgG was considered inconclusive. A clinical diagnosis of decompensated chronic liver disease with suspected portal hypertension was therefore made without an established etiology. Whole blood transfusion, intravenous albumin, vitamin K, sodium restriction and combined spironolactone and furosemide produced short-term improvement, with a 4 cm reduction in abdominal girth, a rise in hemoglobin to 8.3 g/dL and cessation of bleeding. This case shows that a defensible syndromic diagnosis and effective stabilization are achievable without advanced testing, and supports adoption of a defined minimum diagnostic dataset-fractionated bilirubin, gamma-glutamyl transferase, coagulation profile, albumin, hepatitis serology, diagnostic paracentesis and grayscale ultrasonography-for infants with suspected chronic liver disease in low-resource settings.

Coffee-ground emesis in a patient with cirrhosis frequently triggers an emergency pathway for suspected variceal upper gastrointestinal bleeding (UGIB) and urgent endoscopy. However, diagnostic anchoring may delay recognition of alternative life-threatening conditions. A 68-year-old man with decompensated liver cirrhosis (Child-Pugh B), large-volume ascites, COPD GOLD grade 3 with chronic global respiratory failure developed shock and recurrent vomiting of coffee-ground material and fresh blood on a gastroenterology ward. Variceal bleeding was initially suspected. After transfer to ICU, he deteriorated with severe hypoxaemia and progressive ventilatory compromise. A markedly tense, distended abdomen prompted point-of-care ultrasound (POCUS), which demonstrated extensive pneumoperitoneum. Emergency percutaneous decompression via a standard paracentesis needle evacuated free intraperitoneal air under tension with rapid respiratory improvement. Urgent oesophagogastroduodenoscopy showed no evidence of upper gastrointestinal perforation or variceal bleeding. Computed tomography confirmed diffuse pneumoperitoneum and suggested pathology at the ileocaecal transition; surgery revealed perforation of the ascending colon with localized peritonitis. This case highlights the importance of whole-patient reassessment before emergency endoscopy, early use of POCUS when abdominal findings are discordant, and interdisciplinary crisis management. Needle decompression can be lifesaving as a bridge to definitive surgery in tension pneumoperitoneum.

Generalized subcutaneous emphysema (GSE) is an uncommon clinical presentation in equids, typically associated with penetrating trauma and rarely compromising systemic health. This case report documents a 4-year-old working mule presenting with diffuse subcutaneous emphysema secondary to an axillary penetrating wound in the right forelimb. Clinical examination revealed pronounced crepitus without concurrent ataxia, dyspnea, dehydration, or gastrointestinal dysfunction. Diagnostic investigations, including ultrasonography, radiography, complete blood count, paracentesis, and bacterial culture, yielded unremarkable hematological findings and no microbial growth. The wound was managed via local debridement, with adjunct systemic therapy, including penicillin G and flunixin meglumine. Complete resolution occurred within five days under stall rest. This case underscores that generalized subcutaneous emphysema in mules may represent a benign, self-limiting condition when infectious etiologies are excluded. Conservative management, including compulsory rest and anti-inflammatory therapy, can facilitate spontaneous resolution while mitigating risks of pneumothorax or gas gangrene. The rarity of non-infectious generalized subcutaneous emphysema in equids warrants further etiopathological investigation to establish species-specific prognostic criteria.

Tenecteplase (TNK), a genetically modified fibrinolytic agent, is increasingly used for acute ischaemic stroke because of its single-bolus administration and fibrin specificity. Haemarthrosis is an uncommon manifestation of bleeding that may occur in the setting of systemic fibrinolysis. We describe a man in his 70s who developed sudden right knee pain and swelling consistent with haemarthrosis 4 hours after TNK administration without preceding trauma or coagulopathy. Arthrocentesis confirmed the diagnosis and provided relief from symptoms. This case describes a rare bleeding complication following TNK therapy and adds to the limited literature on atypical extracranial bleeding after thrombolysis. It emphasises the need to consider such presentations during post-thrombolysis monitoring.

This study describes a novel approach of corneal reverse endothelial scraping technique (REST) for the diagnosis and management of deep stromal and endothelial infectious plaques. This retrospective, interventional study included 16 patients with infectious deep stromal endothelial infiltrates that did not respond to conventional medical therapy. Briefly, under aseptic precautions, a reverse Sinskey hook was used to delicately debulk and scrape the endothelial plaque via a paracentesis incision, and the samples were sent for microbiological evaluation. Smears were prepared for Gram's stain, 10% KOH mount, and Giemsa stain as suspected. Cultures were inoculated on blood agar, chocolate agar, and Sabouraud's dextrose agar. Treatment was tailored according to the microbiological results. Preoperative data [age, gender, etiology of keratitis, best-corrected visual acuity (BCVA), and previous ocular surgery] and postoperative data (follow-up duration, response to treatment, BCVA, and other significant clinical ocular examination findings) were recorded and analyzed. Sixteen eyes of 16 patients with endothelial plaque underwent REST. The mean age was 41.8 ± 19.54 years, with a male predominance (75%). All cases were unilateral. Fungal etiology was the most common cause (62.5%), followed by bacterial infection (25%), while Pythium and Nocardia accounted for 6.25% each. REST enabled microbiological confirmation in all cases and guided targeted therapy. Ten patients (62.5%) responded to medical management alone, whereas four patients (25%) required therapeutic penetrating keratoplasty in addition to medical therapy; the remaining two patients (12.5%) required adjunctive surgical interventions. Resolution of infection with stabilization of the ocular surface was achieved in 93.75% of cases, while one patient (6.25%) progressed to a phthisical eye. At final follow-up, a corrected distant visual acuity of 6/18 or better was achieved in eight patients (50%). REST is a novel technique for debulking and scraping infectious endothelial plaque with facilitated targeted therapy. A tailored approach to managing these cases can help us avoid invasive procedures, such as therapeutic keratoplasty.

Recurrent hemorrhagic pleural effusion presents as a challenge for both the clinician and the patient, with common causes being tuberculosis, malignancy, and collagen vascular diseases. Among uncommon causes of recurrent hemorrhagic effusion is catamenial hemothorax, which is a part of thoracic endometriosis syndrome (TES). Endometriosis is the extrauterine growth of endometrial glands and stroma. It is relatively common among women of reproductive age-group, with reported incidence of around 11%. Although rare, the thorax is the most common extraabdominal site for endometriosis. Here we present a rare case of recurrent hemorrhagic pleural effusion due to thoracic endometriosis in a young female with infertility. A 33-year-old female housewife presented with dyspnea on exertion modified Medical Research Council (mMRC) grade 2 and dry cough occasionally for 6 months. She had a history of tubercular cervical lymphadenopathy for which she was on treatment. Therapeutic thoracocentesis was performed thrice in 4 months. Routine microscopy showed predominantly lymphocytes, mesothelial cells, and numerous foamy histiocytes, some pigment laden. There were no malignant cells or acid-fast bacilli (AFB) detected in the fluid. Pleural fluid amylase and lipase were normal. Contrast-enhanced computed tomography (CT) thorax showed moderate right-sided pleural effusion without any evident parenchymal lesions, pleural lesions, or mediastinal lymphadenopathy. Ultrasonography (USG) abdomen and pelvis showed mild ascites which was nontappable. As we had not reached a definitive diagnosis, medical thoracoscopy was performed. It showed moderate hemorrhagic pleural fluid in the pleural cavity and a small raised erythematous glandular tissue on the parietal pleural surface from which biopsy was taken. Histopathology showed an island of endometrial stroma with a single gland. Immunohistochemistry was performed on this section, which was PAX8 and CD10 positive, confirming the diagnosis of thoracic endometriosis. Pleurodesis with talc slurry was done to prevent further refilling of the effusion. Gynecology opinion was sought, and patient was started on monthly subcutaneous injections of gonadotropin-releasing hormone (GnRH) analogue for 3 months. Chest X-ray after 3 months showed no refilling of pleural effusion. Catamenial hemothorax is the second commonest manifestation of TES, occurring in approximately 14% of cases. It affects the right side in about 80% of the cases. Diagnosis is based on high degree of suspicion and is often delayed. Video-assisted thoracic surgery (VATS) remains the gold standard for diagnosis and management of TES. Medical thoracoscopy is a viable alternative in resource-poor settings or when diagnosis is not confirmed. On histology, diagnosis is confirmed by the presence of endometriotic glands or stroma, which may also show stromal arterioles, erythrocytes, and pigmented histiocytes. In difficult-to-diagnose cases, CD10 immunohistochemical staining can help in diagnosis of endometrial tissue. There are various treatment modalities considered in the management of catamenial hemothorax, like surgical resection, medical management along with pleurodesis, combination therapy, or in some cases, simple observation. Currently, VATS with GnRH analogue therapy is considered the gold standard of management.

Gastric neuroendocrine tumors (gNETs) are uncommon neoplasms arising from enterochromaffin-like (ECL) cells of the gastric mucosa and account for less than 2% of all gastric malignancies.Their clinical presentation varies widely, ranging from incidental indolent polyps to aggressive, disseminated disease. Presentation with portal hypertensive ascites closely mimicking decompensated chronic liver disease (CLD) is exceptionally rare. A 63-year-old postmenopausal woman presented with six months of progressive abdominal distension and was initially evaluated as having decompensated CLD based on a high serum-ascites albumin gradient (SAAG) in ascites. Upper gastrointestinal endoscopy demonstrated a proliferative polypoidal lesion along the lesser curvature of the stomach with high-grade oesophageal varices. Triphasic computed tomography (TPCT) revealed multiple arterially hyperenhancing gastric lesions, retroperitoneal lymphadenopathy, hepatic and splenic deposits, and spleno-portal axis thrombosis, highly suggestive of a gastric neuroendocrine tumor, subsequently confirmed on image-guided biopsy. The patient received therapeutic paracentesis, portal hypertension-directed therapy, nutritional rehabilitation, and geriatric-focused multidisciplinary care. Surgery was deferred in view of comorbidities and functional status; endoscopic surveillance was selected as the preferred management strategy. This case highlights the diagnostic challenge posed by gNETs masquerading as decompensated CLD and underscores the need to consider occult malignancy in elderly patients with unexplained high-SAAG ascites lacking established liver disease risk factors.

PurposeThe increased injection volume of aflibercept 8 mg (0.07 ml versus 0.05 ml) raises theoretical concerns regarding intraocular pressure (IOP) effects. This study evaluated acute IOP dynamics following aflibercept 8 mg compared to aflibercept 2 mg and identified predictive factors for pressure elevation.Methods140 eyes of 127 patients receiving aflibercept 8 mg (70 eyes) or 2 mg (70 eyes) between January-December 2025 were included. IOP was measured at baseline (T0), immediately post-injection (T1), and 30 min post-injection (T2). Linear mixed-effects models assessed the effects of time, treatment group, and time-by-treatment interactions. Multivariable mixed-effects logistic regression was used to identify predictors of IOP >21mmHg and IOP elevation >5mmHg at T2.ResultsBoth formulations produced significant IOP elevations from baseline at T1 and T2 (p < 0.001 within each group). Mean IOP increased from 14.0 mmHg to 39.3 mmHg (aflibercept 2 mg) and 14.5 mmHg to 39.3 mmHg (aflibercept 8 mg) immediately post-injection, with near-complete resolution by 30 min (16.9 vs 17.7 mmHg). No significant between-group differences were identified at any timepoint. Pre-existing glaucoma/OHT was the only consistent independent predictor of both IOP >21 mmHg (OR 3.00-3.31, p = 0.024-0.038) and IOP elevation >5 mmHg from baseline (OR 10.45-11.75, p < 0.001) at T2; aflibercept formulation was not associated with either outcome. No injection required paracentesis.ConclusionAflibercept 8 mg demonstrates comparable IOP dynamics to aflibercept 2 mg. Glaucoma/OHT represents the strongest predictor of early pressure elevation, warranting enhanced monitoring.