Acta Medica Indonesiana

From Biomarkers to Better Outcomes: Precision Medicine in Modern Internal Medicine

Laurentius Aswin Pramono — Mon, 28 Sep 2026 00:00:00 +0000

Internal medicine has traditionally focused on population-based approaches, utilizing diagnostic algorithms and treatment thresholds designed for the "average" patient. While beneficial, this one-size-fits-all model often leads to treatment failures. Precision medicine addresses this limitation by tailoring medical care to an individual's unique molecular, genetic, and clinical profile. Driven by advancements in multi-omics platforms, novel biomarkers, artificial intelligence (AI), and pharmacogenomics, precision medicine is transforming modern internal medicine from oncology into routine clinical practice. However, integrating these tools presents significant challenges, including high costs, lack of assay standardization, and the need for enhanced clinician literacy. Addressing these hurdles and ensuring equitable access are essential for translating biomarkers into better patient outcomes.

Scalp and Tongue Necrosis as Rare Manifestations of Giant Cell Arteritis Complicated with a Preauricular Abscess

Mon, 28 Sep 2026 00:00:00 +0000

Giant cell arteritis (GCA) is a systemic vasculitis that involves cranial arteries, the aorta, and its proximal branches, characterized by granulomatous infiltration of the arterial walls. GCA predominantly occurs in older adults, typically those over the age of 50. The etiology of GCA-associated vasculitis remains elusive; however, current evidence underscores the complex interplay of genetic and epigenetic drivers with immunological and non-immunological mechanisms in orchestrating the inflammatory response and vascular remodeling. Clinical manifestations of GCA are notably heterogeneous, significantly complicating the diagnosis. The predominant clinical manifestation of GCA is the onset of a new headache. Additional prevalent symptoms include jaw claudication, scalp tenderness, and weakness or malaise. We present a case of a 64-year-old woman who presented with jaw claudication and was subsequently admitted with scalp and tongue necrosis, further complicated by a preauricular abscess. Timely diagnosis and intervention for these rare manifestations can diminish the patient’s morbidity.

Metabolic Imprinting and Intergenerational Cardiometabolic Risk in Human Populations: Implications for Preconception and Maternal Health

Herry Herman, Davin Takaryanto — Mon, 28 Sep 2026 00:00:00 +0000

The global rise in obesity and type 2 diabetes has been too rapid to be explained by genetic change alone, which points to developmental and environmental contributions to cardiometabolic risk. Metabolic conditions during sensitive windows, particularly preconception, pregnancy, and early postnatal life, appear to shape long-term metabolic regulation and disease susceptibility. In this narrative review, we synthesise human cohort studies, natural experiments, and experimental models, and we translate the resulting evidence into clinical and public health practice. Across human cohorts, maternal metabolic disturbances such as gestational diabetes and obesity are consistently associated with higher offspring risk of obesity, insulin resistance, and impaired glucose regulation, with adjusted estimates commonly between 1.4- and 2.0-fold. Epigenome-wide studies report differential DNA methylation in insulin-signalling, adipogenic, and energy-homeostasis pathways, lending biological plausibility, and experimental models show that transient early perturbations can durably alter metabolic physiology even after diet is later normalised. We read these converging findings as metabolic imprinting: relatively stable but potentially modifiable regulatory states, rather than deterministic germline inheritance. Set against current guidance from the ADA, FIGO, WHO, USPSTF, and ACOG, the evidence supports concrete actions across the reproductive life course, including preconception screening and weight optimisation, gestational diabetes screening and glycaemic management, appropriate gestational weight gain, and postpartum and offspring follow-up. Preconception and maternal metabolic health therefore emerge as practical, high-value targets for reducing the long-term cardiometabolic burden.

Acute Respiratory Distress Syndrome and Corticosteroids: Reconciling Conflicting Evidence

Telila Mesfin Tadesse, Olifan Getachew Wakjira — Mon, 28 Sep 2026 00:00:00 +0000

Acute respiratory distress syndrome (ARDS) is a life-threatening form of acute inflammatory lung injury in which loss of alveolar-capillary membrane integrity produces protein-rich pulmonary edema, refractory hypoxemia, and reduced lung compliance, typically within 6–72 hours of a precipitating insult. The 2012 Berlin criteria defined ARDS by acute onset within one week of a known insult, bilateral opacities not fully explained by effusion, atelectasis, or cardiac failure, and a PaO₂/FiO₂ ratio of 300 mmHg or less with a minimum PEEP of 5 cmH₂O. The 2023 global definition expands this framework by accepting SpO₂/FiO₂ of 315 or less when SpO₂ is 97% or below, including patients supported with high-flow nasal oxygen at 30 L/min or more, permitting thoracic ultrasonography as an alternative imaging modality, and waiving the PEEP requirement in resource-limited settings. These revisions are particularly relevant to practice in low- and middle-income countries, where arterial blood gas analysis and mechanical ventilation may be unavailable. Management remains anchored in lung-protective ventilation, conservative fluid strategy, and prone positioning. Glucocorticoids remain the most contested pharmacological intervention: evidence from dexamethasone trials in ARDS and in COVID-19 suggests benefit in selected populations, yet questions persist regarding optimal agent, dose, timing relative to symptom onset, duration, the influence of ARDS subphenotypes, and the risk of secondary infection and neuromuscular weakness. This narrative review summarizes the pathophysiology, evolving diagnostic criteria, imaging findings, and current evidence on corticosteroid therapy, and considers how hyperinflammatory and hypoinflammatory subphenotypes may guide future trial design and individualized treatment.

Diagnostic Performance of Non-Invasive Tests in Assessing Liver Fibrosis Among Type 2 Diabetes Mellitus

Mon, 28 Sep 2026 00:00:00 +0000

Background: Noninvasive tools for assessing liver fibrosis are essential, especially in patients with Type 2 Diabetes Mellitus (T2DM) who are at high risk of developing metabolic dysfunction-associated fatty liver disease (MAFLD). This study aimed to evaluate the correlation between the diagnostic accuracy of the Fibrosis-4 Index (FIB-4), aminotransferase-to-platelet ratio index (APRI), and NAFLD fibrosis score (NFS) and the diagnostic accuracy of FibroScan® in Indonesian patients with T2DM. Methods: This cross-sectional study enrolled 80 outpatients with T2DM. Liver fibrosis was evaluated using FibroScan®. FIB-4, APRI, and NFS were calculated using routine clinical and laboratory parameters. Correlations between noninvasive scores and liver stiffness measurement (LSM) were analyzed. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic performance for significant fibrosis (≥F2) and cirrhosis (F3-F4). Results: MAFLD was present in 67.5% of subjects; significant fibrosis and cirrhosis were found in 25% and 7.5% of subjects, respectively. FIB-4 and NFS showed significant correlations with LSM (ρ = 0.291 and 0.296; p < 0.01), whereas APRI did not. FIB-4, APRI, and NFS demonstrated fair to good diagnostic performance for significant fibrosis (area under the curve (AUC) 0.693, 0.685, 0.693) and excellent performance for cirrhosis (AUC 0.825, 0.860, 0.870). Female sex and HOMA-IR were independent predictors of significant fibrosis; AST and platelet count were predictive of cirrhosis. Conclusion: FIB-4, APRI, and NFS are effective and affordable screening tools for initial fibrosis in patients with T2DM, particularly in low-resource settings. The combination of these measures may enhance the detection of at-risk individuals for referral and further management.

The Relationship Between Serum Interleukin-31 Levels and Chronic Kidney Disease-Associated Pruritus in Patients Undergoing Hemodialysis

Mon, 28 Sep 2026 00:00:00 +0000

Background: Chronic kidney disease-associated pruritus (CKD-aP) has been linked to immune dysregulation, including elevated interleukin-31 (IL-31) levels. However, the limited research on serum IL-31 levels in patients with CKD-aP has yielded inconsistent findings due to heterogeneous patient populations and varied assessment methods. This study elucidated the relationship between serum IL-31 levels, CKD-aP, and its severity in patients undergoing routine hemodialysis (HD). Methods: This cross-sectional observational study included patients undergoing HD at Dr. Cipto Mangunkusumo Hospital between April and May 2024. Pruritus was assessed using the visual analog scale (VAS) and 5-D itch scale. Serum IL-31 levels were measured using enzyme-linked immunosorbent assay. Bivariate and multivariate analyses were performed. Results: Among 70 participants (54.3% male; median age, 52.5 years; median HD vintage, 57 months), 35 experienced CKD-aP. The median VAS and 5-D itch scale scores were 5.3 and 13, respectively, indicating moderate itching severity. Patients with CKD-aP had significantly higher serum IL-31 levels than those without CKD-aP (p = 0.05). Receiver operating characteristic analysis showed modest discriminatory ability (area under the curve = 0.64), with a sensitivity of 51.4% and specificity of 74.3% at a cut-off of 173 pg/mL. A significant association was observed between serum IL-31 levels and CKD-aP (p = 0.03). However, no significant correlation was found between IL-31 levels and pruritus severity as measured by the VAS (p = 0.79) or 5-D itch scale (p = 0.44). Conclusion: Serum IL-31 levels were higher in patients with CKD-aP, suggesting its potential association with pruritus. However, its modest diagnostic performance and lack of correlation with itch severity indicate that IL-31 is unlikely to serve as a standalone clinical biomarker and may have a limited role as an adjunctive or exploratory marker.

Plasma Galectin-3 as a Predictor of Cardiac Dysfunction in Patients Undergoing Doxorubicin Chemotherapy: A Prospective Cohort Study

Mohammad Bhukkar Adil Sjam, Eka Ginanjar, Andhika Rachman, Kuntjoro Harimurti — Mon, 28 Sep 2026 00:00:00 +0000

Background: Doxorubicin is widely used in chemotherapy in oncology. However, it is associated with dose-dependent cardiotoxicity. Thus, early detection of cardiac dysfunction is crucial to preventing heart failure. This study aimed to evaluate plasma Galectin-3 levels, a biomarker of fibrosis and inflammation, as a predictive biomarker of cardiac dysfunction in cancer patients receiving doxorubicin chemotherapy. Methods: This observational prospective cohort study was conducted from June 2024 to February 2025 at the Integrated Cardiac Service of Cipto Mangunkusumo National General Hospital (RSCM) and Dharmais Cancer Hospital in Jakarta. Fifty-five patients completed plasma Galectin-3 and echocardiographic assessments at three time points: pre-chemotherapy, post-chemotherapy cycle 2, and post-cycle 4. Cardiac dysfunction was defined by a decrease in LVEF ≥ 10% or a GLS reduction ≥ 15%. Results: No cardiac dysfunction was observed pre-chemotherapy, but 34.5% and 50.9% of patients developed dysfunction after cycles 2 and 4, respectively. Galectin-3 levels increased significantly post-cycle 4 (mean: 46.89 ± 18.34 ng/mL; p < 0.05). Receiver operating characteristic analysis showed that post-cycle 4 Galectin-3 levels predicted cardiac dysfunction with an area under the curve of 0.767 (95% CI: 0.638–0.897; p = 0.001), 92.9% sensitivity, and 59.3% specificity at a cut-off of ≥ 37.28 ng/mL. Significant correlations were observed between Galectin-3 and GLS (r = 0.54; p = 0.00) but not LVEF. Conclusion: Plasma Galectin-3 levels, particularly after chemotherapy cycle 4, are sensitive biomarkers for detecting cardiac dysfunction in patients receiving doxorubicin. Integrating Galectin-3 with GLS may provide better detection of subclinical cardiotoxicity. Additionally, monitoring Galectin-3 levels may help identify high-risk patients requiring cardioprotective strategies

Novel Prognostic Model to Predict In-Hospital Mortality in Patients with Liver Cirrhosis

Hendra Raharja, Taufik Sungkar, Ilhamd Ilhamd — Mon, 28 Sep 2026 00:00:00 +0000

Background: Liver cirrhosis remains a major global health concern associated with high in-hospital mortality, especially in Southeast Asia. Existing prognostic scores, such as Child-Pugh and albumin-bilirubin scores, exhibit variable accuracy, necessitating simpler and more practical tools. This study aimed to identify independent predictors and to propose a novel prognostic model of in-hospital mortality in hospitalized cirrhosis patients. Methods: This retrospective cohort study included 190 patients with cirrhosis who were admitted to Adam Malik General Hospital, Medan, between 2022 and 2023. Demographic, clinical, and laboratory data were analyzed using univariate and multivariate logistic regression. A prognostic model was derived from significant variables and evaluated using the area under the receiver operating characteristic curve (AUROC) and Hosmer–Lemeshow test. Results: Of the 190 patients, 79 (41.6%) died during hospitalization. Independent predictors of in-hospital mortality were grade III–IV hepatic encephalopathy (odds ratio [OR] 30.12, 95% confidence interval [CI] 10.71–84.67, p<0.001), serum creatinine (ln-transformed; OR 3.23, 95% CI 1.80–5.79, p<0.001), and international normalized ratio (ln-transformed; OR 17.93, 95% CI 3.54–90.83, p<0.001). The model demonstrated excellent discrimination (AUROC 0.906) and good calibration (Hosmer–Lemeshow p = 0.587). Conclusion: Severe hepatic encephalopathy, renal dysfunction, and coagulopathy were the strongest predictors of in-hospital mortality among patients with cirrhosis. The model derived from these factors demonstrated reliable accuracy in this retrospective cohort and may support risk stratification in clinical practice. However, prospective multicenter studies are required to confirm the validity and clinical utility of this model before its routine application.

Risk Factors for Multi-Drug Resistance (MDR) Infections in COVID-19 Patients with Secondary Bacterial Infections

Mon, 28 Sep 2026 00:00:00 +0000

Background: The COVID-19 pandemic has significantly affected global health, contributing to an increase in secondary bacterial infections caused by multidrug-resistant (MDR) pathogens, thereby increasing morbidity and mortality. This study aims to evaluate the risk factors of MDR bacterial infections in affected COVID-19 patients. Methods: This retrospective cohort study analyzed medical records, as well as clinical and epidemiological data of COVID-19 patients with secondary bacterial infections hospitalized in Cipto Mangunkusumo General Hospital during 2020 – 2021. During the procedures, only patients with positive microbial culture results were included. Bivariate and multivariate analyses were carried out to evaluate risk factors of MDR bacterial infections. Results: A total of 3203 medical records of COVID-19 patients were assessed, and 192 subjects were enrolled. The results showed that the most common secondary infection and pathogen were pneumonia and Acinetobacter baumanii, respectively. In addition, the most common MDR pathogen was A.baumanii. In the multivariate log-binomial analysis, the risk factors associated with MDR bacterial infections in COVID-19 were female gender (RR 1,194;CI95% 1,024 – 1,393 p 0,020), comorbidity (RR 1,181;CI95% 1,006 – 1,385, p 0,041), prior antibiotic use (RR 1.718; CI95% 1,127 – 2,620 p 0,012), and history of invasive procedure (RR 1,979;CI95% 1,423 – 2.753 p <0,001). Conclusion: Comorbidities, female gender, prior antibiotic use, and a history of invasive procedures were risk factors for secondary bacterial infections with an MDR pathogen in hospitalized COVID-19 patients.

Thyroid Dysfunction and Its Association with Glycemic Control in Patients with Type 2 Diabetes Mellitus (T2DM): A Systematic Review and Meta-Analysis

Calvin Sasongko, Melvin Andrean, Afif Faizi Assaffah — Mon, 28 Sep 2026 00:00:00 +0000

Background: Diabetes mellitus (DM) is characterized by metabolic anomalies, such as hyperglycemia, resulting from pancreatic β-cell dysfunction. In this context, thyroid dysfunction is the second most prevalent endocrine disorder after DM, and the interaction with glycemic control in type 2 diabetes mellitus (T2DM) remains a topic of debate. Therefore, this meta-analysis aimed to evaluate the impact of thyroid dysfunction on glycemic control in T2DM patients. Methods: A systematic literature search was conducted using ScienceDirect, the Cochrane Library, and PubMed up to December 8, 2024, under PRISMA guidelines. Research evaluating the effect of thyroid dysfunction on glycemic control in T2DM was included, with Glycated hemoglobin (HbA1c) levels as the primary outcome measure. Furthermore, research lacking relevant outcome data, full-text availability, or appropriate design was excluded. Data extraction and quality assessment were performed collaboratively, using the STROBE checklist. Meta-analysis was conducted using Review Manager 5.4, with mean difference (MD) and 95% confidence intervals (CI) as the effect size. Random-effects models were used to account for anticipated clinical heterogeneity, assessed by Higgins' I-squared (I²) statistic. Results: The initial search identified 1,397 research studies, with only 3 papers meeting the inclusion criteria. A pooled analysis reported a significant increase in HbA1c levels in T2DM patients with thyroid dysfunction (MD: 1.94, 95% CI: 0.73 - 3.14; p < 0.000001) with high heterogeneity (I² = 98%). Conclusion: Thyroid dysfunction was prevalent in T2DM patients and was associated with poorer glycemic control. Routine thyroid function assessment could also be integrated into T2DM management to optimize metabolic outcomes.

TIMI Score Modification for Predicting 30-Day Mortality Following Primary Percutaneous Coronary Intervention among STEMI Patients at Cipto Mangunkusumo National Hospital

Mon, 28 Sep 2026 00:00:00 +0000

Background: This study to validate the TIMI (Thrombolysis in Myocardial Infarction) core and also assess the validity of a modified TIMI score that includes three additional variables from primary percutaneous coronary intervention (PPCI) findings: left ventricular ejection fraction based on echocardiography post-PPCI, TIMI flow, and the number of lesions in a population of STEMI (ST-elevation myocardial infarction) patients who underwent PPCI at Cipto Mangunkusumo National Hospital, with a focus on predicting 30-day mortality. This is the first study to validate the TIMI score among STEMI patients who underwent PPCI at Cipto Mangunkusumo National Hospital. This study aimed to develop a modified TIMI score with enhanced ability to predict 30-day mortality among STEMI patients at Cipto Mangunkusumo National Hospital following PPCI. Results: Among 230 study subjects, the 30-day mortality rate for the patients post-PPCI was 10%. There was no significant association between ejection fraction based on echocardiography after PPCI, TIMI flow, or the number of lesions and 30-day mortality post-PPCI in the STEMI patients. The discrimination performance of the TIMI score in predicting 30-day mortality post-PPCI was AUC (Area Under the Curve) 0.901, with good calibration. Conclusion: The performance of the TIMI score in terms of predicting 30-day mortality after PPCI in STEMI patients at Cipto Mangunkusumo National Hospital was excellent (AUC 0.901, 95% CI 0.849–0.952), with good calibration. TIMI score can predict the 30-day mortality rate among STEMI patients undergoing PPCI.

Cirrhotic Cardiomyopathy: Proportion and Correlation with Liver Fibrosis Severity

Mon, 28 Sep 2026 00:00:00 +0000

Background: Cirrhotic cardiomyopathy is characterized by an impaired systolic response to stress, diastolic dysfunction, and electrophysiological abnormalities, without underlying structural heart disease. Left ventricular diastolic dysfunction (LVDD) is the most common manifestation found in cirrhotic cardiomyopathy. Previous studies reported its correlation with a higher Child-Turcotte-Pugh (CTP) score in late-stage cirrhosis. To date, no studies have evaluated the correlation between liver fibrosis and LVDD parameters. This study aims to evaluate the correlation between liver fibrosis and LVDD parameters. Methods: We conducted a cross-sectional study on liver cirrhosis patients without a history of cardiac disease. Subjects were recruited consecutively from the Hepatobiliary Outpatient Clinic and Internal Medicine Inpatient Unit at Cipto Mangunkusumo National General Hospital. A total of 92 patients underwent 2-dimensional echocardiography with tissue Doppler imaging, transient elastography, and laboratory tests for routine hematology, ALT, and AST. Results: A total of 27.2% of subjects had diastolic dysfunction, and 37% had normal diastolic function with an increased left atrial volume index. APRI and FIB-4 showed a positive correlation with left atrial volume index (r = 0.302; p = 0.003 vs r = 0.401; p < 0.0001, respectively). FIB-4 demonstrated a fair performance in estimating increased left atrial volume index (AUC 0.746; 95% CI 0.646–0.846), with a cut-off point of 4.38. Conclusion: Diastolic dysfunction is the most common early manifestation found in cirrhotic cardiomyopathy. Liver fibrosis, assessed by APRI and FIB-4, was positively correlated with increased left atrial volume index.

Cost-Effectiveness Analysis of Multidisciplinary Care in Chronic Heart Failure: Insights from an Indonesian Tertiary Hospital

Lusiani Lusiani, Nurhayati Adnan Prihartono, Mardiati Nadjib, Idrus Alwi — Mon, 28 Sep 2026 00:00:00 +0000

Background: Chronic heart failure (CHF) is the leading cause of morbidity and healthcare expenditure in Indonesia, largely due to recurrent hospitalizations. Multidisciplinary Programs (MDSs) have been introduced to provide clinical and economic advantages by reducing hospitalizations. This study aimed to compare direct medical cost trajectories between patients managed under MDP and standard care (SC) at a tertiary referral hospital. Methods: The retrospective cohort study was conducted at Dr. Cipto Mangunkusumo National Hospital and included 189 patients with CHF who completed at least eight consecutive outpatient visits. Patient demographics, clinical data, and direct medical costs were obtained from medical records and hospital billing data. Results: Patients in the MDP group were younger (median age 55 vs 60 years) and had a more frequent ischemic etiology compared with SC. Outpatient costs were higher in MDP, mainly due to medications and consultation fees, while inpatient costs were substantially lower, particularly for procedures, consumables, and ward charges. The total direct medical cost per patient was significantly lower in MDP compared with SC (Rp 19.4 million vs Rp 31.3 million), reflecting a 38% reduction. Conclusion: Implementation of an MDP reduced overall direct medical costs by shifting expenditures toward outpatient management and lowering costly inpatient utilization. These findings support MDP as a feasible and cost-efficient strategy in resource-limited health systems.

Geriatric Assessment-Guided Care for Older Adults with Cancer: A Clinical Practice Review

Aulia Rizka, Czeresna Heriawan Soejono, Findy Prasetyawaty, Rahmat Cahyanur — Mon, 28 Sep 2026 00:00:00 +0000

Cancer is a growing global health burden among older adults, with incidence rising most rapidly in low- and middle-income countries. Chronological age alone poorly reflects physiological reserve, comorbidity, frailty, and functional status, which together determine how well an older patient tolerates cancer therapy. This clinical practice review summarizes contemporary geriatric oncology approaches based on international consensus guidelines and current literature. Comprehensive geriatric assessment (CGA), evaluating functional status, comorbidity, falls, cognition, mood, nutrition, polypharmacy, and social support, outperforms performance status alone in predicting chemotherapy toxicity, treatment completion, functional decline, and mortality. Beyond prognostication, randomized trials have shown that geriatric assessment-guided management reduces severe chemotherapy toxicity and improves communication about ageing-related concerns without compromising survival, which is the strongest argument for embedding assessment into routine oncology care. Validated brief screening tools such as the Geriatric-8 (G8) can identify patients who warrant full assessment, and chemotherapy toxicity calculators such as the Cancer and Aging Research Group and Chemotherapy Risk Assessment Scale for High-Age Patients scores improve risk estimation and support shared decision-making. Implementation remains the principal barrier in resource-limited settings, where geriatrician availability, clinic time, and reimbursement constrain routine use; pragmatic adaptations include nurse-led or self-administered assessment and stepwise screening pathways. Geriatric assessment-guided multidisciplinary care, adapted to local resources, should be regarded as the standard of care for older adults with cancer rather than an optional refinement, and deserves explicit incorporation into national cancer control planning.

Uncorrected Tetralogy of Fallot Complicated by Brain Abscess and Postoperative Intracranial Haemorrhage: A Case Report

Fanny Puspita Haryono, Agnes Lucia Panda, Ventje Ramond Kawengian — Mon, 28 Sep 2026 00:00:00 +0000

Cerebral abscess is a rare but potentially fatal complication of cyanotic congenital heart disease, in which chronic hypoxia, polycythaemia and right-to-left shunting allow bacteraemia to bypass pulmonary filtration. A woman in her 20s with uncorrected tetralogy of Fallot presented with severe headache, right-sided weakness and seizures. Examination showed hemiparesis, hypoaesthesia and hyperreflexia; blood tests revealed secondary polycythaemia and leucocytosis. No dental, sinus, otological or respiratory source was identified. Unenhanced computed tomography demonstrated a left parietal space-occupying lesion with midline shift, and echocardiography confirmed tetralogy of Fallot with pulmonary atresia. She received ceftriaxone, metronidazole and dexamethasone, followed by burr-hole drainage. Recovery was complicated by epidural haemorrhage requiring emergency craniotomy and a later subdural haematoma with focal seizures, both managed successfully. This case illustrates that new focal neurological signs in uncorrected cyanotic heart disease warrant urgent imaging for brain abscess, and that polycythaemia compounds perioperative haemorrhagic risk.

Progression of Secondary to Tertiary Hyperparathyroidism with a Coexisting Parathyroid Adenoma in Stage 3B Chronic Kidney Disease: A Case Report

Mon, 28 Sep 2026 00:00:00 +0000

Tertiary hyperparathyroidism arises when prolonged secondary hyperparathyroidism progresses to autonomous parathyroid hormone secretion with persistent hypercalcemia, most often in chronic kidney disease. Diffuse or nodular multiglandular hyperplasia is the expected pathology; a discrete parathyroid adenoma arising within hyperplastic tissue is uncommon and may be overlooked when imaging is negative early in the disease course.
A 60-year-old man with stage 3b chronic kidney disease and long-standing secondary hyperparathyroidism presented with recurrent hypercalcemia and severe vomiting. Laboratory evaluation confirmed elevated serum calcium and parathyroid hormone. Initial cervical ultrasonography showed no parathyroid enlargement, but repeat imaging demonstrated a progressively enlarging lesion adjacent to the left thyroid lobe. He underwent subtotal parathyroidectomy with bilateral cervical exploration. Histopathology showed multiglandular hyperplasia of the right parathyroid glands together with a distinct encapsulated adenoma arising within hyperplastic left parathyroid tissue. Serum calcium normalized postoperatively.

Airway Stenting for Benign and Malignant Central Airway Obstruction: A Case Series

Mon, 28 Sep 2026 00:00:00 +0000

Central airway obstruction (CAO) is a life-threatening condition caused by malignant or benign processes involving the trachea and main bronchi. Bronchoscopic airway stenting is an established intervention to restore airway patency, relieve symptoms, and stabilize patients, particularly in urgent or critical settings. However, its clinical role varies according to underlying etiology and disease context.
We report a single-center case series of seven adult patients with symptomatic CAO who underwent bronchoscopic airway stenting. Six cases were associated with malignant disease, and one involved benign obstruction due to endobronchial tuberculosis. Interventions included rigid and/or flexible bronchoscopy, with adjunctive techniques such as balloon dilatation, cryotherapy, and argon plasma coagulation. Stent selection was individualized based on anatomical and etiological considerations. Airway stenting led to immediate improvement in respiratory status in all cases. In benign obstruction, stenting achieved sustained airway patency without significant complications. In malignant CAO, stenting served primarily as a palliative or bridging intervention, providing temporary stabilization and enabling further oncologic or supportive therapy. In critically ill patients, including those with impending airway collapse or post-cardiac arrest, stenting functioned as a lifesaving or salvage procedure. Complications included tumor ingrowth, mucus retention, and infection; no fatal stent-related procedural events occurred.
Airway stenting is a versatile and effective modality for managing CAO. Its role differs by etiology, offering durable benefit in benign disease, palliative or stabilizing effects in malignancy, and potential life-saving intervention in selected critically ill patients. Individualized decision-making and multidisciplinary management remain essential to optimize outcomes.

Multiple Cavitary Lung Lesions in ANCA-Negative Small Vessel Vasculitis: A Case Report

Mon, 28 Sep 2026 00:00:00 +0000

Multiple cavitary lung lesions present a diagnostic challenge, with a broad differential diagnosis, including infectious, malignant, and autoimmune etiologies. ANCA-associated vasculitis (AAV), particularly in its seronegative form, is a rare yet important cause that is frequently overlooked, as pulmonary involvement is uncommon and its manifestations can closely mimic infection or malignancy. We report a case of a 30-year-old male who presented with a three-week history of dyspnea and hemoptysis, and a background of membranoproliferative glomerulonephritis confirmed by renal biopsy three months prior, consistent with pauci-immune glomerulonephritis. Chest radiography and contrast-enhanced CT revealed multiple bilateral cavitary lung lesions with air-fluid levels, micronodules, and centrilobular ground-glass opacities. Extensive infectious workup, including sputum and bronchoalveolar lavage cultures, acid-fast bacilli smear, GeneXpert, and fungal studies, was negative. Cytological examination excluded malignancy. Both p-ANCA and c-ANCA were negative. Based on the 2022 ACR/EULAR classification criteria, a diagnosis of ANCA-negative microscopic polyangiitis (MPA) was established, with a total score of +6 derived from imaging findings consistent with interstitial lung disease and histopathological evidence of pauci-immune glomerulonephritis in a prior renal biopsy. Immunosuppressive therapy with methylprednisolone and mycophenolate sodium was initiated, resulting in complete radiological resolution of all cavitary lesions within two months. This case highlights that cavitary lung lesions may represent a rare pulmonary manifestation of ANCA-negative MPA. A negative ANCA result should not exclude vasculitis when clinical suspicion is high, and tissue biopsy remains essential for definitive diagnosis in atypical presentations.