Carcinoid heart disease (CHD) is a complication of carcinoid syndrome that results from chronic exposure of the endocardium to circulating vasoactive substances, particularly serotonin. It leads to progressive right-sided valvular dysfunction and right heart failure. Presentation as cardiogenic shock is uncommon and may delay recognition of the underlying disease. We present the case of a 44-year-old woman with no prior medical history who developed progressive dyspnea, ascites, and lower extremity edema over four months and was admitted with cardiogenic shock. Transthoracic echocardiography revealed massive tricuspid regurgitation and moderate-to severe pulmonary regurgitation with marked right ventricular dilation with preserved conventional systolic indices. Abdominal imaging demonstrated hepatomegaly with multiple hypervascular hepatic lesions, and liver biopsy confirmed metastatic neuroendocrine tumor. Urinary 5-hydroxyindoleacetic acid was markedly elevated at 305 mg/24 hours with pro-B-type natriuretic peptide (pro-BNP) at 2,450 pg/mL, supporting the diagnosis of carcinoid syndrome with cardiac involvement. Lanreotide was initiated for biochemical and symptomatic control of the underlying carcinoid syndrome. Despite intensive hemodynamic support with inotropic and vasopressor therapy, the patient developed refractory cardiogenic shock and died from progressive right-sided heart failure. This case highlights an unusual and aggressive presentation of carcinoid disease manifesting as cardiogenic shock. Clinicians should maintain a high index of suspicion for CHD in patients with unexplained right-sided valvular dysfunction and systemic congestion, as early recognition may allow timely therapeutic intervention.

Chronic wounds remain a significant clinical challenge despite advances in dressings, biologics, and adjunctive therapies. Patients referred to advanced wound centers following unsuccessful treatment often demonstrate recurring and potentially correctable factors that contribute to delayed healing. Drawing upon observations from a quaternary referral wound center, this article focuses on recurring and potentially correctable factors encountered during evaluation of wounds that have failed to progress despite prior care. Although these patterns are neither novel nor unexpected, they continue to recur despite well-established wound care principles and treatment guidelines. This article highlights common pitfalls identified in patients referred for advanced wound care evaluation. Commonly encountered issues include inadequate implementation of compression therapy and lower extremity elevation, ineffective offloading in diabetic foot ulcers, limited attention to patient adherence and behavioral factors, and incomplete evaluation of underlying contributors to wound chronicity. Additional patterns include continued use of outdated or nonevidence-based topical agents, misapplication of debridement principles (particularly removal of stable eschar), and incomplete evaluation of underlying pathophysiology such as vascular insufficiency. Patients are frequently referred after undergoing advanced interventions, including hyperbaric oxygen therapy and grafting procedures, before optimization of fundamental wound care principles. In these settings, suboptimal patient selection and sequencing of therapy, particularly in the presence of uncontrolled edema or inadequate offloading, may contribute to prolonged treatment without clinical benefit. These observations highlight recurring gaps between recommended care and real-world execution. Recognition of these recurring pitfalls may improve wound healing outcomes, promote more effective use of advanced therapies, and reduce the need for escalation of care.

We report a 35-year-old man with chronic hepatitis B infection and decompensated liver cirrhosis who presented with an 8-month history of progressive fatigue, exertional limb weakness, anorexia, and dark urine, which partially improved following hepatoprotective and anti-cholestatic therapy. One day before admission, his condition deteriorated abruptly, with fever, chills, diarrhea, profound fatigue, and rapidly progressive bilateral lower-extremity oedema. Laboratory evaluation revealed severe systemic inflammation and coagulopathy, including a white blood cell count of 8.4 × 10[9]/L with neutrophil predominance (absolute neutrophil count, 7.6 × 10[9]/L; neutrophil percentage, 90.7%), severe thrombocytopenia (23 × 10[9]/L), markedly elevated inflammatory markers (C-reactive protein, 68.7 mg/L; procalcitonin, 5.81 ng/mL; interleukin-6, >5000 pg/mL), hypoalbuminemia, and prolonged prothrombin time. Empirical antimicrobial therapy was initiated immediately. Blood cultures obtained on admission became positive within 24 hours and were subsequently identified as Vibrio vulnificus. Antimicrobial therapy was adjusted according to susceptibility testing, and surgical incision, drainage, and debridement were performed for progressive lower-extremity soft tissue infection. The patient gradually improved after pathogen-directed antimicrobial therapy and surgical source control and was discharged after clinical stabilization. This case highlights the importance of early recognition, appropriate antimicrobial therapy, and timely surgical intervention in severe V. vulnificus infection, particularly among patients with underlying liver disease.

Identification of causes for venous outflow obstruction often requires multimodal evaluation. Anchoring bias can challenge recognition of rare pathophysiology, even when common imaging findings are found in uncommon locations. In this review, we present a case of a female patient with several months of right lower extremity edema. Initial misinterpretation of ultrasonography led to the diagnosis of deep vein thrombus as the instigating factor for which the patient was unsuccessfully treated with oral anticoagulation. Cross-sectional imaging and venography were employed showing external compression of the common femoral vein by a cystic structure. Subsequent percutaneous aspiration led to immediate improvement in venous flow by venography. Advanced MR imaging and arthrography were employed showing a labral tear with recurrence of a prominent paralabral cyst compressing the common femoral vein. The patient was managed with definitive arthroscopic cyst decompression and labral repair leading to complete resolution of the patient's presenting symptoms. This case underscores the American College of Radiology (ACR) appropriateness criteria recommending cross-sectional imaging when patients present with inconclusive vascular ultrasound or suspected iliofemoral thrombus. It also adds to well established data that high recurrence rates of paralabral cysts are noted after percutaneous aspiration while lower recurrence is noted with arthroscopic labral repair and cyst decompression.

A woman in her 50s was diagnosed with post-transplant lymphoproliferative disorder, diffuse large B-cell lymphoma, and germinal center B-cell-like type based on a lower gastrointestinal tract biopsy. The treatment course comprised R-CHOP chemotherapy. She had undergone a living-donor kidney transplantation 22 years ago. During the fifth cycle of R-CHOP, a pharmacist observed exertional dyspnea and edema of the left lower extremity. Transthoracic echocardiography revealed a decrease in global longitudinal strain; however, elevated D-dimer levels were noted. Additionally, the edema was unilateral, leading the pharmacist to suspect cancer-associated thrombosis as a possible cause of the lower extremity edema. The patient had been receiving daprodustat to treat renal anemia. However, because daprodustat is known to pose some risk to patients with thromboembolic disease, the pharmacist provided the attending physicians with information relevant to the discontinuation of daprodustat. Subsequently, the patient was diagnosed with left lower-extremity deep vein thrombosis, and daprodustat was discontinued.

Transcatheter tricuspid valve replacement (TTVR) is an option for selected patients with severe tricuspid regurgitation (TR) who are at high surgical risk, but experience remains limited in those with extreme right-heart anatomy, including a giant right atrium and a markedly enlarged elliptical tricuspid annulus.

This scoping review aimed to summarize the existing evidence regarding exercise interventions in individuals with lower limb lymphedema (LLL), focusing on intervention characteristics, outcome measures, and reported effects.MethodsA scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). This study was conducted using a scoping review design to examine the existing literature on the effects of exercise interventions in LLL between January 1, 2016, and March 1, 2026. Studies investigating any type of exercise intervention in adults with primary or secondary LLL were included. Data on study characteristics, participant demographics, exercise protocols, outcome measures, and key findings were extracted and synthesized descriptively.ResultsEighteen studies investigating exercise interventions for lower limb lymphedema were included. Most participants were women with secondary lymphedema following gynecological cancer treatment. Exercise, frequently combined with compression or complex decongestive therapy, was associated with reductions in limb volume and edema, as well as improvements in pain, functional capacity, walking performance, and quality of life. Preventive exercise programs also reduced the incidence or delayed the onset of lymphedema in several studies. Across all included studies, exercise was well tolerated, with no evidence of lymphedema exacerbation or serious adverse events. However, substantial heterogeneity was observed in exercise protocols, intervention duration, and outcome measures.ConclusionThe studies reviewed in this review demonstrate that exercise is a safe, feasible, and effective approach to managing lower-extremity lymphedema. Active exercise combined with compression therapy significantly reduces edema volume.

Cardiac lipoma is the second most common benign primary cardiac tumor. It can arise in any cardiac chamber and often presents with no or only nonspecific symptoms. Its variable morphology poses a diagnostic challenge.

Enlarged and tortuous veins along the dorsal aspect of the spinal cord are traditionally associated with a spinal dural arteriovenous fistula (dAVF). We present six cases demonstrating prominent dorsal perimedullary spinal veins in patients without a dAVF, but rather with a spinal CSF leak resulting in spontaneous intracranial hypotension (SIH). This imaging appearance can closely mimic the classic venous congestion with prominent dorsal perimedullary veins seen with dAVF, creating a potential diagnostic pitfall. The diagnostic workup of a spinal dAVF differs substantially from that of SIH, thus making accurate distinction between these two entities critical. Compared to patients with dAVF, patients with SIH more commonly present with orthostatic headache, absence of lower extremity weakness or paresthesia, brain sagging, and lack of spinal cord edema. Recognition of this pattern may help avoid unnecessary spinal angiography and prompt appropriate evaluation for an underlying spinal CSF leak.

Edema is defined as a palpable swelling on the body produced by expansion of the interstitial fluid volume. This accumulation of fluid in the interstitial space occurs as the capillary filtration exceeds the amount of fluid take out by lymphatic drainage. When Edema is massive and generalized, it is called anasarca. It is caused by a variety of clinical conditions like heart failure, renal failure, liver failure, or problems with the lymphatic system. Edema usually becomes clinically apparent as the interstitial volume exceeds 2.5 -3 liters.

Lymphedema is a chronic, progressive condition characterized by the accumulation of lymphatic fluid, followed by fat deposition and tissue fibrosis. It can also lead to local immune compromise and, in some cases, cutaneous malignancies. Here, we report a case of a patient with stage III combined perineal and lower limb lymphedema secondary to trauma. The patient was treated with lymphaticovenous anastomoses in the suprapubic region and both lower limbs, along with excision of excess skin and tissue in the perineal area. Optimal clinical improvement was achieved through this staged approach. This case emphasizes that although lymphaticovenous anastomosis effectively addresses extremity edema, radical excision remains essential for fibrotic genital elephantiasis. Comprehensive postoperative management is crucial for maintaining long-term results and minimizing recurrence.