A 60-year-old woman presented with intermittent chest discomfort for 1 month, which had worsened over the preceding week and was accompanied by progressive dyspnea. Her medical history was notable for hepatitis approximately 40 years earlier. On admission, physical examination revealed jugular venous distention, cardiomegaly, and bilateral pitting edema of the lower extremities. Laboratory testing showed an NT-proBNP level of 8,272 pg/mL and a D-dimer level of 7,948 ng/mL. Computed tomography pulmonary angiography(CTPA) revealed bilateral thrombi in the main pulmonary arteries. Transthoracic echocardiography showed marked biventricular enlargement (LVEF 20%), 2 mural thrombi in the left ventricle, and a mobile thrombus in the right atrium. Lower extremity venous ultrasonography demonstrated deep vein thrombosis. Genetic testing using a cardiomyopathy gene panel identified a likely pathogenic TTN truncating variant (c.6061C>T, p.Arg2021*), consistent with the patient's phenotype of dilated cardiomyopathy (DCM). In conclusion, this case highlights the complex management of acute pulmonary embolism(PE) complicated by severe heart failure, multisite thrombosis, and acute hepatic congestion, emphasizing the critical need for individualized anticoagulation bridging and early adjunctive mechanical interventions.

ObjectivesChronic refractory lower-extremity edema often remains undiagnosed despite standard evaluations that focus primarily on excluding deep vein thrombosis. We aimed to elucidate the underlying etiologies and assess the utility of a comprehensive, structured diagnostic protocol.MethodsWe retrospectively analyzed a prospectively enrolled, referral-based cohort of 58 patients with chronic refractory lower- extremity edema who underwent a structured multimodal diagnostic protocol after failure of standard noninvasive evaluation. Etiologies were classified as non-thrombotic iliac vein lesions, pulmonary hypertension, superficial venous insufficiency, or multifactorial.ResultsNon-thrombotic iliac vein lesions, pulmonary hypertension, and superficial venous insufficiency were identified in 55.2%, 48.3%, and 43.1% of patients, respectively. Single etiologies accounted for 51.7% of cases, 41.4% were multifactorial, and 6.9% remained unclassified. Among pulmonary hypertension cases, isolated postcapillary pulmonary hypertension associated with heart failure with preserved ejection fraction was the most common (13.8%). Superficial venous insufficiency was the sole cause in 12.1% of cases, while in others, it coexisted with non-thrombotic iliac vein lesions or pulmonary hypertension. Interventions included iliocaval endovascular therapy (n = 23) and saphenous vein ablation (n = 10), with the remainder receiving conservative therapy. Over a median follow-up of 2.98 years, 86.2% of patients achieved objective clinical improvement.ConclusionsThis protocol reduced the number of repeated low-yield ultrasound examinations and facilitated targeted treatment. A structured diagnostic protocol integrating duplex ultrasonography, invasive hemodynamic testing, and intravascular imaging enables accurate etiologic classification of chronic refractory lower extremity edema. This approach identifies treatable contributors, supports tailored interventions, and may improve outcomes while reducing unnecessary testing.

BACKGROUND Salmonella enterica commonly causes self-limited gastroenteritis but can occasionally lead to invasive disease in predisposed hosts. Soft-tissue involvement is an uncommon complication, and the combination of bacteremia, cellulitis, and gastroenteritis has rarely been described. Cellulitis without abscess formation appears to be exceptionally rare. CASE REPORT A 75-year-old man with diabetes, peripheral arterial disease, and cirrhosis presented with right lower-extremity cellulitis following several days of non-bloody diarrhea. On examination, he was afebrile and hemodynamically stable, with edema extending from the foot to the mid-shin and an ulcer on the posterolateral calf. Imaging showed diffuse subcutaneous edema without abscess. Blood cultures, wound cultures, and stool polymerase chain reaction (PCR) were positive for Salmonella enterica (pan-sensitive), confirming bacteremia, soft-tissue infection, and gastroenteritis. Cellulitis resolved with a 7-day course of intravenous ceftriaxone. Transthoracic echocardiography demonstrated no evidence of endocarditis, and repeat blood cultures obtained on hospital day 2 were negative. There was no recurrence at the 3-week and 3-month follow-ups. CONCLUSIONS Very few cases of Salmonella enterica infection with this triad of manifestations have been reported. The absence of abscess formation further distinguishes this presentation. Underlying vascular disease and skin disruption may have created a susceptible environment for infection through hematogenous seeding or direct inoculation. This case shows the importance of considering Salmonella species in atypical soft-tissue infections, particularly in patients with chronic vascular or metabolic disease and concurrent diarrheal illness, and emphasizes the need for early microbiologic diagnosis and targeted antimicrobial therapy to ensure a favorable outcome.

Congenital extrahepatic portosystemic shunts (CEPS) are rare congenital vascular malformations characterized by an abnormal communication between the hepatic portal venous system and the systemic venous system. Type Ⅱ CEPS preserves partial portal venous blood flow and can usually be treated with conventional surgery rather than solely relying on liver transplantation. To determine the optimal surgical methods and complication management strategies for type Ⅱ CEPS patients, we retrospectively analyzed 31 predominantly adult patients with type Ⅱ CEPS, documenting their surgical approaches and the occurrence of postoperative complications. Five surgical approaches were employed: 11 patients underwent shunt occlusion with 5 cases of complications; 5 patients underwent splenic vessels ligation with 2 cases of complications; 5 patients underwent shunt occlusion combined with splenic artery ligation with 4 cases of complications; 8 patients underwent shunt occlusion combined with distal splenorenal shunt with 3 cases of complications; and 2 patients with lower extremity edema underwent inferior vena cava shunt bypass surgery, with no significant complications observed. In conclusion, surgery centering on the shunt occlusion demonstrates promising therapeutic value and remains the mainstay in the treatment of type II CEPS. Meanwhile, postoperative complications remain a concern, necessitating long-term monitoring and management.

Fluorodeoxyglucose (FDG)-avid pericardial effusion is frequently associated with malignancy, but inflammation and reactive mesothelial proliferation may produce similar imaging and histologic findings, creating diagnostic uncertainty. This overlap may lead to unnecessary invasive procedures if metabolic imaging is overemphasized. A 76-year-old man presented with progressive bilateral lower extremity edema and was found to have a large pericardial effusion. Imaging demonstrated FDG-avid pericardial and pleural thickening with hypermetabolic lymphadenopathy on PET-CT. Serial cytology, bronchoscopic biopsies, and immunohistochemistry did not demonstrate malignancy. Cardiac MRI showed pericardial inflammation without myocardial involvement. The patient was treated with pericardial drainage and corticosteroids, resulting in clinical improvement and resolution of the effusion. This case is unique because FDG-avid pleuropericardial abnormalities, hypermetabolic lymphadenopathy, and reactive mesothelial proliferation closely simulated malignant disease but ultimately represented a non-malignant inflammatory process. FDG uptake in pericardial effusion is not synonymous with malignancy, and PET-CT findings alone are insufficient for diagnosis. Integrating metabolic imaging with pathology and dedicated cardiac imaging can prevent misdiagnosis and avoid unnecessary invasive interventions, particularly in older or frail patients.

Skin and soft tissue infections range from mild bacterial infections of the dermis and lymphatic system, such as erysipelas, to rapidly spreading necrotizing fasciitis. Mild infections are often caused by methicillin-sensitive Staphylococcus aureus and Streptococcus species, whereas more severe infections are often polymicrobial and involve anaerobic bacteria. Purulent skin infections are more likely to be caused by methicillin-resistant S aureus (MRSA). Nasal polymerase chain reaction testing for MRSA may be helpful for skin infections associated with a wound, but it cannot rule out MRSA as the cause of simple cellulitis or abscess. Before diagnosing cellulitis, clinicians should consider other possible causes such as venous stasis dermatitis and deep venous thrombosis. Bilateral cellulitis is rare. Cellulitis is a clinical diagnosis, but white blood cell count can indicate severity. Nonpurulent, mild cellulitis should be treated with penicillin or first-generation cephalosporins for 5 days. For nonpurulent, severe infections, antibiotic therapy that covers MRSA and anaerobic bacteria is warranted. Point-of-care ultrasonography can reliably differentiate cellulitis from abscess. Abscesses should be treated with incision and drainage, followed by antibiotics such as clindamycin or trimethoprim/sulfamethoxazole to reduce the risk of treatment failure. Recurrence of cellulitis is common, occurring in as many as 29% of cases. Risk factors for recurrence include lymphedema, dependent lower extremity edema, and malignancy.

Background and Clinical Significance: Kinesio tape (KT) has gained popularity as an adjunctive approach for treating edema during the rehabilitation phase, following traumatic events, as well as for managing edema in breast cancer patients. Its goal is to reduce swelling and improve mobility in the affected extremity; however, its use in critically ill patients remains limited. To our knowledge, this is the first report of its application in this population. Case presentation: This case series involved three patients in the Intensive Care Unit (ICU) who presented with lower extremity edema. One patient developed a cerebrovascular event secondary to moderate traumatic brain injury and two patients experienced sepsis. KT was applied, and extremity circumference, Godet sign, and Stemmer sign were assessed. The bandage was reapplied every 24 h over a 5-day period, with daily evaluations performed by the same nursing staff to ensure measurement consistency. All three patients exhibited a reduction in extremity circumference, along with improvement or resolution of the Godet and Stemmer signs. No adverse effects associated with KT were observed. Conclusions: Our results suggest that KT may be a beneficial adjunctive therapy for edema reduction in ICU patients. Larger-scale studies are needed to confirm its clinical value.

Patients with advanced HIV/AIDS are at high risk for Primary central nervous system lymphoma (PCNSL) due to impaired immune surveillance and HIV-driven B-cell proliferation. While intracranial lesions are well recognized, spinal involvement remains underrecognized due to the scarcity of well-documented reported cases in the current literature. In this report, we describe the case of a 35-year-old male with a new HIV diagnosis who experienced acute bilateral lower extremity weakness and urinary retention during hospitalization for fever, perianal abscess, and urinary tract infection. Initial CD4 count revealed profound immunosuppression, with a CD4 count of less than 20 cells/μL and a viral load of 178,000 copies/mL. Spinal MRI demonstrated an enhancing mass at T2-T3, with surrounding edema extending to C5-C6 and multiple vertebral lesions, while brain MRI was unremarkable. Liver biopsy confirmed Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL), establishing a diagnosis of AIDS-associated systemic lymphoma with secondary central nervous system (CNS) involvement presenting as cauda equina syndrome - a neurosurgical emergency with potential for irreversible paralysis. This case underscores the importance of early, comprehensive spinal imaging in HIV-positive patients with new-onset myelopathy or cauda equina symptoms.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment and are increasingly associated with cardiovascular toxicities, including myocarditis and accelerated atherosclerosis. While ICI myocarditis has received substantial attention, thrombotic complications remain underrecognized and may be difficult to distinguish from immune-mediated cardiac inflammation and cancer-related hypercoagulable state. We present a case of non-bacterial thrombotic endocarditis (NBTE) and myocardial microthrombi mimicking ICI myocarditis.

Ectopic adrenocorticotropic hormone syndrome is a distinct subtype of endogenous Cushing's syndrome characterized by excessive cortisol secretion, which increases susceptibility to opportunistic infections. Herein, we present the case of a male patient in his early 40s who was admitted with fatigue and bilateral lower-extremity edema. Laboratory tests revealed markedly elevated serum adrenocorticotropic hormone and cortisol levels. Ectopic adrenocorticotropic hormone syndrome was confirmed via dexamethasone suppression testing and somatostatin receptor-targeted positron emission tomography-computed tomography, which localized an ectopic adrenocorticotropic hormone-secreting right pulmonary carcinoid tumor (a neuroendocrine tumor). During hospitalization, the patient was diagnosed with concurrent Pneumocystis jirovecii pneumonia and pulmonary cryptococcosis, and he responded favorably to trimethoprim-sulfamethoxazole and fluconazole. This case, supported by a review of the relevant literature, highlights the importance of early infection diagnosis, prompt management, and appropriate prophylaxis in patients with ectopic adrenocorticotropic hormone syndrome to improve prognosis.