Bullous hemorrhagic dermatosis (BHD) is a rare cutaneous manifestation characterized by tense hemorrhagic bullae that appear at sites distant from low molecular weight heparin (LMWH) injections, typically within seven days of exposure. As of March 2022, only 94 cases have been reported. It most commonly affects elderly males with predisposing factors for thromboembolism, such as carcinoma, and usually involves the extremities.

This case highlights the importance of maintaining a high index of suspicion for bullous hemorrhagic dermatosis (BHD) in patients receiving low molecular weight heparin, even beyond the typical 7-day window and in demographics not commonly affected. Early recognition and prompt discontinuation of the offending agent, as demonstrated in this atypical presentation involving a Filipino elderly woman with multiple comorbidities and no malignancy, can lead to favorable outcomes. Clinicians should be aware of this rare but reversible complication to avoid misdiagnosis and ensure appropriate management.

Human ; Female ; Aged: 65-79 Yrs Old ; Affect ; Aged ; Blister ; Carcinoma ; Causality ; Demography ; Diagnostic Errors ; Enoxaparin ; Extremities ; Heparin ; Heparin, Low-molecular-weight ; Index ; Injections ; Lead ; Male ; Molecular Weight ; Neoplasms ; Patients ; Research Report ; Skin Diseases ; Thromboembolism ; Women

BACKGROUND

Myiasis is a parasitic infestation of humans caused by dipteran flies' larvae, which feed on the host's tissue. It affects various body parts, including the skin, eyes, ears, nose, mouth, and gastrointestinal tract. Cutaneous myiasis is the most common clinical form, while wound myiasis is the main manifestation. Myiasis can be caused by various fly families, including blowflies, flesh flies, and botflies, with different types depending on the site and infestation type. A rare occurrence rarely reported in medical literature, Sarcophaga species infestation within a tracheostomy tube in a patient with laryngeal carcinoma, is presented in this case. Given that the airway is protected and has built-in barriers against external contamination, the presence of flesh flies (Sarcophaga spp.) at a tracheostomy site is extremely uncommon. By showing how weakened respiratory structures, along with particular environmental and patient factors, may make people more susceptible to this uncommon parasitic complication, this report adds to our understanding of the condition. Recognizing such atypical infestations is crucial for clinicians in early diagnosis, prevention, and effective management of similar cases.

CASE PRESENTATION

The study details a rare instance of Sarcophaga species myiasis in a tracheostomy tube in a patient who Had laryngeal carcinoma after radiation therapy. The 71-year-old farmer patient first complained of pruritus, localized warmth, and tightness in his neck. Prior tracheostomy excision and cobalt therapy were part of his medical history. After being treated for pneumonia, the patient experienced severe bleeding at the tracheostomy site, which led to additional testing. Many larvae were seen emerging from necrotic tissues during clinical examination, which raised the possibility of myiasis. Sarcophaga spp., a rare discovery in respiratory structures, were confirmed to be present by species identification. More than 100 larvae were removed during the emergency surgical procedure, which also involved replacing the compromised tracheostomy tube and cutting and draining necrotic areas. Following surgery, there were no more bleeding or reinfestation episodes, and the patient showed signs of stable recovery.

CONCLUSION

The parasitic infestation known as myiasis, which is brought on by dipteran fly larvae, is usually linked to exposed wounds and weakened tissue. Flesh flies, or Sarcophaga species, are drawn to recently opened, exudative wounds, which makes them more likely to infest susceptible people. Although myiasis commonly occurs in cutaneous wounds, ocular, and nasopharyngeal sites, it is extremely uncommon to occur in tracheostomy incisions, especially in tropical areas like the Philippines. The need for increased clinical awareness of this uncommon complication is highlighted by this case, which shows an unusual manifestation of Sarcophaga species myiasis within a tracheostomy tube of a patient who had laryngeal carcinoma following radiation therapy. Prioritizing preventive measures, such as thorough wound hygiene, efficient fly control techniques, and ongoing postoperative monitoring, is necessary due to the grave consequences of tracheostomy-associated myiasis. Parasitic infestations are more likely to occur in patients recuperating from head and neck surgery, especially those who have had extended wound exposure. Patient outcomes can be improved and morbidity can be considerably decreased by teaching family members and caregivers about wound surveillance, early detection, and prompt intervention. To reduce the chance of infestation, preventive measures like appropriate wound dressing, environmental sanitation, and fly management must be strengthened. In order to develop more focused preventive measures, more research is necessary to identify the endemic distribution of rare myiasis-causing species and to characterize them. Clinicians can establish more efficient management procedures by identifying particular environmental factors and patient vulnerabilities that contribute to atypical myiasis cases. The knowledge gathered from this report adds to the body of knowledge on tracheostomy-associated myiasis and is a useful
guide for early detection and treatment of similar cases.

Human ; Animals ; Male ; Female ; Aged: 65-79 Yrs Old ; Research Report ; Patients ; Carcinoma ; Sarcophagidae ; Tracheostomy

Adenoid cystic carcinoma (ACC) is a rare subtype of invasive breast cancer, occurring in <0.1% of all malignant breast tumors. Though majority are triple-negative, ACC of the breast has good prognosis with a low incidence of regional and distant metastases.

A 45-year-old premenopausal female presented with a 5-month history of a gradually enlarging mass on her left breast. After core needle biopsy and subsequent metastatic work-up, she underwent total mastectomy with sentinel lymph node biopsy. Final histopathology showed adenoid cystic carcinoma, 2.1 cm in size and no lymph nodes positive for tumor. She has completed adjuvant radiotherapy of 50 Gy to the chestwall, and is currently well after 6 years of follow-up.

Surgery with either lumpectomy or mastectomy has been established as the mainstay of treatment of adenoid cystic carcinoma of the breast, but the use of adjuvant radiotherapy (RT) and chemotherapy has not been established. While adjuvant RT has been shown to improve cause-specific and overall survival following breast-conserving surgery, its indications after a mastectomy are not as well-defined. The decision to administer adjuvant RT was based on the current evidence indicating the advantages of adjuvant treatment for breast carcinomas, lack of survival difference between invasive ductal carcinomas and adenoid cystic carcinomas, indications for post-mastectomy RT in a retrospective Rare Cancer Network study, and reported incidences of local recurrences following mastectomy alone: 21.4% and 22.2%.

Our patient with adenoid cystic carcinoma of the breast, treated with surgery and adjuvant radiation therapy, showed favorable outcomes after 6 years.

Human ; Female ; Middle Aged: 45-64 Yrs Old ; Carcinoma, Adenoid Cystic ; Breast Neoplasms

Abstract Ectopic hepatocellular carcinoma (EHCC) is an extremely rare neoplasm, especially in the mediastinum, which shares morphologic characteristics with intrahepatic hepatocellular carcinoma (HCC). Its clinical features remain unclear, posing significant diagnostic and therapeutic challenges. The prognosis is also unclear due to its rarity and potential variability. This study reports the first case of EHCC in the mediastinum with subsequent brain metastasis. A 50-year-old man presented with shoulder and chest discomfort persisting for 5 months, accompanied by progressive weight loss and fatigue over the preceding 2 years. Imaging showed a mediastinal mass initially suspected to be lymphoma due to its malignant characteristics. However, histopathological examination identified the lesion as HCC, supported by characteristic immunohistochemical markers, despite normal abdominal imaging. Two months later, the tumor progressed despite intensive radiotherapy, and the patient experienced recurrent seizures. Subsequent brain imaging confirmed multiple intracranial metastases. Unfortunately, the patient died 6 months after diagnosis. The ectopic liver is more susceptible to hepatocarcinogenesis than the main liver; this is attributed to its incomplete functional structure. EHCC can be considered as differential diagnosis of mediastinal masses, even when no intrahepatic HCC is found. The rarity of EHCC in the mediastinum poses difficulties in developing treatment protocols. This case emphasizes the diagnostic challenges and aggressive nature of ectopic HCC and the need for comprehensive management strategies. There are currently no definite guidelines regarding the diagnosis, treatment, and prognosis of EHCC.
ectopic hepatocellular carcinoma ; mediastinum ; metastasis

BACKGROUND

Penile squamous cell carcinoma (SCC) is rare in high-income regions but remains a significant oncologic burden worldwide. Nodal involvement is the most important prognostic factor, and early identification is critical.

THE CASE

A 56-year-old circumcised male presented with a six-month history of a progressively enlarging, foul-smelling fungating penile mass and bilateral inguinal lymphadenopathy. Biopsy confirmed moderately differentiated SCC. Imaging showed large bilateral inguinal nodal disease without distant metastasis. Laboratory findings revealed leukocytosis, thrombocytosis, and mildly deranged coagulation parameters. The patient underwent total penectomy with perineali urethrostomy, followed by bilateral inguinal and pelvic lymph node dissection through single-curvilinear incisions. Frozen-section analysis confirmed extensive bilateral nodal metastasis. Postoperatively, a localized left inguinal surgical site infection was treated conservatively. He was discharged on postoperative day seven with drains in situ and was recommended adjuvant chemoradiotherapy in accordance with NCCN Guidelines.

CONCLUSION

This case highlights the challenges of managing advanced penile SCC with bulky bilateral inguinal metastasis and demonstrates the utility of single-curvilinear inguinal incisions for comprehensive lymphadenectomy. Early recognition, accurate staging, and guideline-based multimodal treatment remain essential for optimizing outcomes.

Human ; Male ; Middle Aged: 45-64 Yrs Old ; Carcinoma, Squamous Cell ; Lymph Node Excision

OBJECTIVE

To report a case of lacrimal gland adenoid cystic carcinoma in a 37-year-old female managed with globe-sparing surgery and adjuvant radiotherapy.

METHODS

This is a case report.

CASE PRESENTATION

This report details a 37-year-old Filipino female who presented with a 4-month history of right eye pain and non-axial proptosis. Computed tomography (CT) scan showed a right heterogenous extraconal mass with orbital roof remodeling. Lateral orbitotomy with excision biopsy was performed. Final histopathologic diagnosis of adenoid cystic carcinoma of the lacrimal gland was made based on the classic morphology and distinct arrangement of the neoplastic cells. Systemic surveillance revealed absence of metastases. Patient completed adjuvant radiotherapy four months post-operatively. Vision was preserved at 20/20 without signs of tumor recurrence five months post-operatively.

CONCLUSION

Adenoid cystic carcinoma is an aggressive lacrimal gland malignancy; hence, meticulous examination and high index of suspicion cannot be over-emphasized. Globe-sparing surgery with adjuvant radiotherapy could significantly preserve quality of life.

Human ; Female ; Adult: 25-44 Yrs Old ; Lacrimal Apparatus ; Lacrimal Gland ; Carcinoma, Adenoid Cystic ; Radiotherapy, Adjuvant ; Adenoids

OBJECTIVE

To present a case of chronic invasive infection rhinosinusitis (CIFRS) complicated by orbital apex syndrome, highlighting the significant diagnostic challenges and delays encountered before establishing the diagnosis.

METHODS

This is a case report.

CASE PRESENTATION

This patient is a 65-year-old diabetic female, status post-kidney transplantation with immunosuppressant use presented with headache and sudden painless vision loss and extraocular limitation of the right eye. Magnetic resonance imaging (MRI) revealed a right-sided ill-defined nasopharyngeal mass, with nasopharyngeal carcinoma as the radiologic consideration. Biopsy revealed bacterial and fungal elements. During admission, antibiotics, antifungals, and tumor debulking was done but symptoms persisted. Histopathology showed reactive inflammatory tissue; hence, a short course of intravenous high-dose steroids was given. Overall health declined and patient eventually expired.

CONCLUSION

This case highlights the importance of maintaining high clinical suspicion for fungal infection despite non-specific radiologic findings in immunocompromised patients with vague, localized symptoms. Prompt recognition and tissue diagnosis are critical for early intervention.

Human ; Female ; Aged: 65-79 Yrs Old ; Mycoses ; Fungal Infection ; Nasopharyngeal Carcinoma

Introduction: Adrenocortical carcinoma (ACC) is an aggressive malignancy with high rates of recurrence even after surgical resection. Surgery remains the mainstay of treatment, while adjuvant options are limited. Mitotane is the only approved systemic therapy. Current guidelines recommend stereotactic body radiotherapy (SBRT) alongside adjuvant mitotane therapy in Rx, R1, R2 resections and in locally advanced disease. Case: We present a case of a 40-year-old female who presented with abdominal pain and was found to have a large heterogeneous left adrenal mass measuring 8.2 × 8.5 × 9.5 cm (Hounsfield Unit 63) on computed tomography (CT) imaging. Clinically, she was obese with a body mass index of 33.7 kg/m². No discriminatory feature of Cushing’s was present. Hormonal evaluation demonstrated autonomous cortisol secretion with failure of suppression on both overnight and low-dose dexamethasone suppression tests at 301 nmol/L and 313.6 nmol/L, respectively. DHEA, testosterone, and urinary metanephrine were within range. Hemoglobin A1c was 6.6%. She underwent open left adrenalectomy. Intra-operatively, a 12 × 10 cm adrenal tumor was identified with multiple areas of tumor rupture and spillage during mobilization. HPE confirmed high-grade ACC with high Weiss score of 8, Ki-67 index 60–80%, and mitotic count 54/50 hpf (pT2Nx). Post-operative CT imaging demonstrated a residual soft tissue lesion in the left adrenal bed (largest diameter 3.8 cm) with fluorodeoxyglucose avidity. We commenced adjuvant mitotane therapy, titrated to 2 g TDS with supraphysiological hydrocortisone replacement. Mitotane level was within therapeutic range (16 mcg/mL). She was deemed unsuitable for repeat surgery due to the proximity of the residual mass to the adjacent vessel and was planned for SBRT therapy after a multidisciplinary team discussion. Conclusion High-risk ACC with suspected residual disease remains a therapeutic challenge. While mitotane remains the cornerstone of adjuvant therapy, SBRT may represent a promising adjunctive local treatment modality in carefully selected patients. Further studies are required to define its role in improving local control and outcomes in ACC.
Adrenocortical Carcinoma ; Mitotane

Introduction: Cushing’s syndrome is a multisystem disorder with significant cardiovascular morbidity, yet presentation as acute heart failure is uncommon. When driven by adrenocortical carcinoma (ACC), the clinical course is often aggressive and rapidly fatal, with particularly poor out-comes in resourcelimited settings where access to therapy is constrained. Case: A 39-year-old previously well female presented with acute decompensated heart failure, newly diagnosed hypertension, type 2 diabetes mellitus, and obesity, preceded by a 3-year history of secondary amenorrhea and progressive weight gain. On admission, she exhibited florid Cushingoid features. Biochemical evaluation confirmed severe adrenocorticotropic hormone (ACTH)-independent hypercortisolism: morning serum cortisol 1,950 nmol/L, failure of suppression on overnight dexamethasone suppression test (post-ODST cortisol 2022.9 nmol/L), and elevated 24-hour urinary free cortisol (2,069 nmol/24 hours, 2.56 × upper limit of normal). Androgen excess was evident, with elevated dehydroepiandrosterone sulfate (DHEAS more than 27 µmol/L) and testosterone (9.91 nmol/L). ACTH was suppressed, supporting an adrenal source, while aldosterone was normal. Contrast-enhanced computed tomography demonstrated a large left adrenal mass (12 cm) with tumor thrombus extending into the inferior vena cava and renal veins, with extensive hepatic and pulmonary metastases, consistent with advanced ACC. Management was limited by disease severity and resource constraints. Ketoconazole was contraindicated due to transaminitis, and alternative steroidogenesis inhibitors were unavailable, leaving metyrapone as the only feasible option. Oncological therapy was deferred due to sepsis and clinical instability. Her course was fulminant, complicated by recurrent heart failure, sepsis, and metabolic derangements, culminating in refractory cardiopulmonary failure. She died within 1 month of diagnosis, prior to definitive oncological intervention. Conclusion Fulminant cortisol-secreting ACC may present catastrophically as acute heart failure and progress rapidly. Early recognition and timely access to multimodal cortisollowering therapy are critical, particularly in resourcelimited settings. In fulminant hypercortisolism, the challenge is not diagnosis—but timing.
Adrenocortical Carcinoma ; Hydrocortisone ; Heart Failure

Introduction: Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with a predilection for metastasis to the liver, lungs, and lymph nodes. Bone involvement is less common and typically occurs alongside widespread disease. Isolated skeletal progression without visceral involvement is unusual and not well characterized. Case: A 60-year-old female underwent left adrenalectomy in 2019 for an incidentally detected adrenal mass, which was reported as a benign adrenal cortical adenoma (Ki67 <3%). In 2022, she presented with persistent low back pain. Imaging demonstrated fluorodeoxyglucoseavid lesions involving the T12 vertebra and right ilium, without evidence of local recurrence or visceral metastases. Histopathological evaluation of a bone biopsy initially suggested a neuroendocrine neoplasm based on synaptophysin positivity. Following multiple expert reviews and integration of clinical, radiological, and immunohistochemical findings, a consensus diagnosis of metastatic ACC was established. She received palliative radiotherapy to symptomatic skeletal sites and subsequently completed six cycles of etoposide, doxorubicin, and cisplatin chemotherapy in 2023, achieving disease stabilization. Surveillance imaging in May 2025 demonstrated progression confined to the axial and appendicular skeleton, with no involvement of the adrenal bed or visceral organs. Mitotane therapy was initiated in December 2025. Ongoing management focuses on systemic disease control, symptom palliation, and multidisciplinary supportive care. Conclusion This case illustrates an uncommon pattern of ACC progression characterized by bone-dominant metastases in the absence of visceral disease. It also highlights the importance of reconsidering the initial histopathological diagnosis when clinical behavior is discordant. Vigilance for atypical metastatic patterns is warranted, even years after resection of an adrenal lesion initially classified as benign.
Adrenocortical Carcinoma