Atypical hemolytic uremic syndrome (aHUS) represents a complement-mediated thrombotic microangiopathy (TMA) characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end-organ damage, most frequently affecting the kidneys. Although infection is a well-recognized precipitant, extensive skin involvement is uncommon. Here, we describe a 14-year-old boy who developed aHUS following Rhinovirus/Enterovirus infection. He was found to have anemia, thrombocytopenia, acute kidney injury, hematuria, and proteinuria, and peripheral smear examination demonstrated schistocytes. Complement evaluation showed reduced C3 and factor I concentrations, increased soluble C5b-9, and preserved ADAMTS13 activity. Investigations for Shiga toxin-producing Escherichia coli, systemic autoimmune disease, and alternative infectious etiologies were negative. Even with eculizumab, corticosteroids, therapeutic plasma exchange (TPE), and continuous renal replacement therapy (CRRT), his condition progressed to petechiae, ecchymoses, hemorrhagic bullae, and necrotic lesions of the axilla, neck, and back. Since the necrotic areas failed to heal and were accompanied by continued platelet consumption and a heightened risk of infection, surgical debridement and wound closure were undertaken after the platelet count reached 81 × 10^9/L. Histopathologic analysis of the excised tissue confirmed cutaneous thrombotic microangiopathy with microvascular thrombosis. Following the procedure, platelet count, hemoglobin, and complement C3 returned to normal, and the wound healed without complication. At subsequent follow-up, the scars were supple and level, with no sensory deficit or functional limitation. This report expands the range of infectious triggers associated with aHUS and demonstrates that persistent necrotic cutaneous thrombotic microangiopathy may necessitate prompt surgical management in addition to complement inhibition and supportive treatment.

We describe a fatal case of combined venlafaxine-mirtazapine poisoning in a 33-year-old man with schizoaffective disorder, who was found dead at home next to empty venlafaxine blister packs. Systematic toxicological screening (LC-MS/MS and full-scan GC-MS) identified venlafaxine, O-desmethylvenlafaxine, mirtazapine, N-desmethylmirtazapine, delorazepam and lorazepam; these analytes were subsequently quantified in central blood, peripheral blood, urine, brain and liver using a validated LC-MS/MS method, and intact venlafaxine tablets were also recovered from the gastric/duodenal content. In peripheral blood, venlafaxine measured 4.42 mg/L and mirtazapine 0.72 mg/L: both above therapeutic ranges yet below the lowest concentration reported in any published fatal case of either drug alone, pointing to an additive, likely synergistic, toxic interaction between the two compounds; delorazepam and lorazepam, by contrast, remained at therapeutic concentrations. The cause of death was attributed to acute combined venlafaxine-mirtazapine overdose, and the manner of death was classified as suicide. To the best of our knowledge, this represents the first reported fatal venlafaxine-mirtazapine co-ingestion with multi-matrix post mortem quantification, and only a handful of previous cases have documented venlafaxine concentrations in brain tissue after a fatal overdose.

Sildenafil is a commonly used medication for the treatment of erectile dysfunction and is generally well-tolerated. Cutaneous adverse drug reactions associated with sildenafil are uncommon and have been described in various clinical forms. We report a case of a 34-year-old man with no significant medical history who developed an asymptomatic, localized morbilliform eruption four days after taking a single 100 mg dose of sildenafil, representing his first reported exposure. The eruption consisted of erythematous macules and papules confined to the back, without mucosal involvement, facial edema, vesiculation, bullae formation, purpura, desquamation, or systemic symptoms. Complete blood count and serum biochemical investigations were unremarkable, with no eosinophilia or evidence of hepatic, renal, or hematologic abnormalities. No other medications, supplements, recent infectious illness, or other apparent triggers were identified. Based on the clinical presentation and temporal relationship, a sildenafil-associated morbilliform drug eruption was considered. The Naranjo Adverse Drug Reaction Probability Scale yielded a score of 6, indicating a probable adverse drug reaction. The patient was treated conservatively with antihistamines, and the eruption resolved spontaneously without corticosteroid therapy or other specific interventions. This case highlights an uncommon localized morbilliform eruption following sildenafil exposure and emphasizes the importance of recognizing this potential adverse reaction.

Necrotizing Sweet syndrome (NSS) is a rare and severe variant of Sweet syndrome characterized by erythematous and painful lesions accompanied by systemic inflammation. Because it closely mimics necrotizing soft tissue infections (NSTIs), NSS is frequently misdiagnosed, resulting in inappropriate treatment. This study reviewed published cases of NSS and characterized its demographic, clinical, and clinicopathologic features relevant to its differentiation from NSTI. For this narrative review, a literature search on PubMed (last updated June 30, 2024) identified 34 cases of NSS across 29 articles. Erythema was the most common feature (82.4%), followed by edematous plaques (41.2%). Necrosis (52.9%) and budllous lesions (38.2%), including hemorrhagic bullae, were also frequently observed, whereas pustular lesions were reported in 29.4% of cases. Multiple lesion morphologies often coexisted, highlighting the polymorphic presentation of NSS and its clinical overlap with NSTI. All patients underwent biopsy, 52.9% underwent surgical debridement, and 5.9% required amputation. Corticosteroids were the most frequently used treatment. NSS is a rare but important mimic of NSTI. Given its polymorphic presentation and overlapping cutaneous manifestations, including erythema, bullous change, and necrosis, differentiation cannot be based on clinical appearance alone and requires integration of microbiological and histopathological findings. Increased awareness of NSS is essential to avoid unnecessary surgical intervention and ensure timely, appropriate management.

This report presents a 44-year-old Mexican woman with hypothyroidism and atopic dermatitis who developed severe mixed-pattern hepatotoxicity after a 10-day course of an over-the-counter joint supplement (Ismerely FTX Plus) of incompletely disclosed composition. A public US Food and Drug Administration (FDA) Medication Health Fraud Notification confirmed the product was adulterated with undeclared dexamethasone phosphate and diclofenac. The clinical course was complicated by probable secondary hemophagocytic syndrome, with a peak ferritin of 19,114.9 ng/mL (93 times the upper reference limit), resolving spontaneously without immunosuppression after discontinuation of the causative agent. The rarity of this case lies in the convergence of an unconventional trigger, a hemophagocytic lymphohistiocytosis (HLH)-like response, and spontaneous resolution in a host with pre-existing autoimmune vulnerability. The patient presented with five days of intermittent fever up to 39.4°C and severe right upper quadrant pain, followed by fatigue, hair changes, and cutaneous lesions of the right upper extremity and face. Outpatient studies showed negative viral hepatitis serologies and splenomegaly. Hospital evaluation demonstrated severe mixed-pattern transaminasemia (alanine aminotransferase (ALT) 899 IU/L, aspartate aminotransferase (AST) 1,063 U/L, R factor 4.8), mild bilineage cytopenia (leukopenia 2.96 × 10[3]/µL, driven by lymphopenia rather than neutropenia, and mild thrombocytopenia 118 × 10[3]/µL, with normal hemoglobin), elevated inflammatory markers, and hypertriglyceridemia. Autoimmune testing showed a true-positive antinuclear antibody (ANA) titer of 1:80 (homogeneous/nuclear) and borderline anti-smooth muscle antibodies (1:100), with all other lupus-specific antibodies negative. Examination revealed periarticular papulosquamous lesions with mild edema on the right arm and elbow and bilateral malar erythema sparing the nasolabial folds. Skin biopsy showed spongiotic dermatitis with interface vacuolar degeneration and a subcorneal blister pattern, without vasculitis or tissue eosinophilia. Absent eosinophilia argued against drug reaction with eosinophilia and systemic symptoms (DRESS), while negative lupus-specific serologies and unmet classification criteria argued against subacute cutaneous lupus erythematosus (SCLE) or systemic lupus erythematosus (SLE). The most coherent interpretation was drug- or supplement-induced interface dermatitis with idiosyncratic hepatotoxicity, plausibly mediated by cytotoxic T-cell activity against keratinocytes and hepatocytes modified by undisclosed corticosteroid and nonsteroidal anti-inflammatory drug (NSAID) metabolites. Transaminases, ferritin, and cytopenias improved progressively: ALT and AST declined approximately 43% and 62% within five days, with ALT reaching a 70% decline by discharge (hospital day 9), and ferritin declining 93% to 1,309.7 ng/mL at last determination (outpatient follow-up, day 17), in parallel with resolution of cutaneous lesions after supplement discontinuation alone. This case underscores the importance of clinicopathologic correlation over isolated findings and highlights adulterated supplements as an underrecognized trigger of combined hepatic, hematologic, and cutaneous immune-mediated injury.

Informal waste pickers (IWPs) form an integral part of the waste management systems of cities around the world, playing a vital yet undervalued role in environmental sustainability and urban circularity. A well-known phenomenon in the Global South, informal waste picking is becoming more visible in Global North cities, but it is still under-researched, especially in quantitative terms. This study analyses and quantitatively estimates the role of IWPs in the waste management system in Barcelona, Spain. We study IWPs' role in material, environmental and monetary terms through a mixed method approach combining field observations, surveys, stakeholder interviews and secondary data analysis. Our findings show that between 1,640 and 1,940 IWPs operate in Barcelona in very precarious conditions, working almost 60 h a week for about €2 an hour (less than 25% of the Spanish minimum wage). They collect between 33% and 39% of the city's metal waste, saving at least 36-41,000 tonnes of CO2 emissions and 42-69,000 m[3] of water annually. We conclude that IWPs play an essential role in Barcelona's waste management system while operating under exploitative conditions, providing cheap labour and materials for the recycling sector and enhancing the circularity of the city's metabolism. The associated costs are largely borne by IWPs and public authorities, while the gains are private. Achieving just urban waste governance in Barcelona, as in other Global North cities, requires that IWPs' role and the value they create be acknowledged, both politically and economically, through policies that protect and dignify this activity and foster IWPs' socio-economic inclusion.

Contrast media extravasation (CME) is a recognized complication of intravenous iodinated contrast administration during computed tomography (CT) examinations, with a reported incidence rate ranging between 0.1% and 1.2%. Although most extravasation injuries are mild and self-limiting, a small proportion of them progress to skin blistering, tissue necrosis, or compartment syndrome. Blister formation, in particular, is an uncommon manifestation observed predominantly in moderate-to-severe extravasation. Herein, we report a case of iobitridol extravasation that occurred during lower-extremity CT angiography in a 68-year-old female patient with lower-extremity atherosclerotic occlusive disease. Approximately 5 h after the procedure, multiple fluid-filled skin blisters developed at the forearm injection site. A combined external regimen-topical Hirudoid (mucopolysaccharide polysulfate) cream, intermittent ice compresses, and Jinhuang San (Golden Yellow Powder) mixed with green-tea water as a wet poultice was applied immediately. The blisters were absorbed by the following day without skin breakdown, and complete resolution was achieved within 48 h. To our knowledge, this is the first report describing this specific three-component topical combination for iobitridol extravasation presenting with blistering. This case highlights the importance of early recognition and structured topical management of CME and suggests-at the hypothesis-generating level-that integrating a traditional Chinese medicine external therapy with conventional topical agents may be a useful option for such injuries. Prospective, controlled studies are required to confirm these observations.

Lung cancer associated with cystic airspaces (LCCA) is an increasingly recognised yet under-characterised presentation of non-small cell lung cancer, accounting for approximately 1-4% of cases. Despite growing awareness driven by thin-section computed tomography and lung cancer screening, LCCA remains absent from major international guidelines and classifications, including those of the National Institute for Health and Care Excellence, the International Association for the Study of Lung Cancer, and the World Health Organization. This narrative review synthesises the available evidence to define LCCA as a distinct clinico-radiological entity and to inform future guideline development. LCCA presents heterogeneously, with thin- or thick walled cysts, unilocular or multiloculated morphology, and variable solid components, frequently mimicking benign cysts, bullae, or emphysema. Such ambiguity contributes to diagnostic delay; in the NELSON screening trial, LCCA accounted for 22.7% of missed or delayed diagnoses. Several radiological classifications, notably that of Mascalchi, aid description and risk stratification. Conventional staging is problematic, as measurement of the solid component alone may underestimate true tumour extent, while fluorodeoxyglucose positron emission tomography carries a high false-negative rate. Tissue sampling is similarly complicated by low diagnostic yield and false negative results, underscoring the importance of multidisciplinary team discussion. The natural history follows a stepwise progression from thin-walled cyst to wall thickening, mural nodularity, and invasive disease, with prognosis determined principally by stage, although mural nodularity and increasing solid components confer higher recurrence risk. Treatment broadly mirrors that of solid lung tumours; current guidance advocates targeting the whole cystic lesion for radical therapy rather than the solid component alone, with systemic anticancer therapy appropriate in advanced or multifocal disease. Much current practice is extrapolated from part-solid tumours; consensus on Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation terminology, classification, and staging, supported by prospective registry data, is required to optimise outcomes.

Recreational substance abuse causes a broad spectrum of acute and chronic pulmonary injuries through inhalation and intravenous injection. Imaging findings often overlap with infection, pulmonary edema, and other inflammatory lung diseases, particularly when an exposure history is unavailable. This review discusses the mechanisms and characteristic CT imaging patterns of substance abuse-related lung injury (SARLI). Crack lung is an acute pulmonary toxicity syndrome occurring within 48 hours of crack cocaine inhalation and manifests as diffuse bilateral ground-glass opacities with patchy consolidations, or a crazy-paving pattern related to pulmonary edema, diffuse alveolar damage, or alveolar hemorrhage. Cannabis smoking is associated with upper-lobe-predominant paraseptal emphysema, apical bullae, and airway inflammation. E-cigarette or vaping product use-associated lung injury is a diagnosis of exclusion and requires vaping exposure within 90 days prior to abnormal pulmonary imaging for establishing the diagnosis. It most commonly demonstrates an organizing pneumonia pattern, although diffuse alveolar damage and alveolar hemorrhage may occur. Intravenous injection of crushed oral medications can cause excipient lung disease, which has three distinct imaging patterns: diffuse centrilobular micronodules, high-attenuation perihilar and upper lobe predominant fibrotic opacities, and lower-lobe-predominant panlobular emphysema (Ritalin lung). It is often accompanied by right ventricular strain and pulmonary hypertension and can lead to sudden death and long-term deterioration of lung function. Additional complications of drug abuse include aspiration, lobar or bronchopneumonia, septic pulmonary emboli, and barotrauma. Recognition of SARLI patterns within the appropriate clinical and temporal context can help radiologists suggest the correct diagnosis and facilitate timely management.

Intracranial blood blister-like aneurysms (BBAs) constitute a rare but clinically challenging subset of cerebrovascular lesions, distinguished by their fragile, thin-walled morphology and a tendency to arise at non-branching sites of intracranial arteries, most frequently in the supraclinoid segment of the internal carotid artery (ICA). Managing BBAs is particularly difficult due to their high propensity for rupture, rapid progression, and the challenges they pose in intraoperative identification and repair. Traditional surgical approaches, including direct clipping, wrapping, and bypass with trapping, have been employed; however, these techniques are often associated with high complication rates and technical limitations given the delicate structure of BBAs. In recent years, advances in endovascular therapy, such as stent-assisted coiling (SAC) and flow-diverter (FD) placement, have expanded the therapeutic options, offering less invasive alternatives with encouraging outcomes. Nevertheless, the optimal management strategy remains controversial, as both surgical and endovascular approaches carry distinct indications, technical challenges, and risks of recurrence or procedural complications. This narrative review systematically explores the epidemiology and pathophysiology of BBAs, delineates key diagnostic features, and critically examines both reconstructive and deconstructive treatment modalities within a stepwise, two-pathway (endovascular and surgical) algorithm, highlighting reported efficacy, complication profiles, and recommended treatment selection for distinct aneurysm subtypes. By contrasting the strengths and limitations of each approach, this article aims to provide clinicians with evidence-based guidance to support individualized management strategies for patients with BBAs.

Each year, migratory birds move thousands of kilometres across international borders to track optimal environmental conditions. How tightly annual-cycle events are linked and how much flexibility exists in migration schedules will determine how vulnerable migratory birds are to environmental change. Using a global tracking database, we reconstructed full annual-cycle schedules of 2,324 individuals from 83 species. We found strong temporal links during autumn and spring migrations: departure from the breeding grounds predicted arrival at the non-breeding grounds and vice versa. During both migration periods, late-departing individuals shortened migration duration, but still arrived later than early-departing individuals. By contrast, arrival at and departure from the non-breeding grounds were not correlated, suggesting a temporal reset that buffered earlier delays. Despite resetting during the non-breeding period, migratory schedules remain globally interconnected, such that disruptions in one season can propagate to subsequent stages of the annual cycle, with consequences for migratory species and the ecosystem functions they support.