Patient: Female, 55Final Diagnosis: Left vagal nerve schwannomaSymptoms: DysphagiaMedication: —Clinical Procedure: SurgerySpecialty: Internal MedicineObjective:Rare diseaseBackground:Vagus nerve schwannoma is a benign neoplasm that usually presents as an asymptomatic slow growing mass, and its presentation as a neck mass is rare. The diagnosis can be difficult to make and complete surgical excision is challenging due to the proximity of the vagus nerve fibers from which it originates. The most common symptom associated with vagus nerve schwannoma arising in the neck is hoarseness due to vocal cord palsy.Case Report:We report a case of a 55-year-old woman who presented to the clinic complaining of throat irritation and feeling of something stuck in her throat for the past three months. On examination, a bulging left parapharyngeal mass was noted, displacing the left tonsil and uvula medially. A contrast-enhanced computed tomography (CT) scan of the neck showed a large, hypervascular soft tissue mass with splaying of the left internal carotid artery. Intraoperatively, the tumor was found to be arising from the vagus nerve. Macroscopic surgical pathology examination showed a tan-red, ovoid, and firm mass. Histopathology showed a benign spindle cell tumor with Antoni A areas with palisading cell nuclei and some degenerative change, confirming the diagnosis of vagus nerve schwannoma.Conclusions:Vagus nerve schwannomas should be distinguished from other tumors that arise in the neck before planning surgery, to minimize the risk of nerve injury. Physicians need to be aware of the differential diagnosis of a neck mass, investigations required, the surgical treatment and the potential postoperative complications.

Brown tumor of the bone or osteitis fibrosa cystica is a rare manifestation of hyperparathyroidism, most seen nowadays in association with secondary and tertiary hyperparathyroidism. Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are the major culprits of secondary hyperparathyroidism (sHPTH). CKD is known to cause phosphate retention and a decrease in 1,25-dihydroxyvitamin D and ionized calcium levels, which in turn trigger the PTH secretion. Brown tumor can affect the jawbones, femur, sternum, ribs, and rarely the spine. We present the case of a 60-year-old male with ESRD on hemodialysis who was found to have lytic bone lesions in the thoracic and lumbar spine. Initially, malignancy was suspected. Blood work revealed markedly elevated PTH at 3,563 pg/mL, hypocalcemia, and hyperphosphatemia. Biopsy of the L5-S1 lesion was consistent with reactive changes due to sHPTH. Once a diagnosis of the brown tumor was confirmed, the patient was started on cinacalcet and was referred for parathyroidectomy.

Hypothyroidism is frequently associated with myalgias, muscle stiffness, easy fatigability, and occasionally some degree of myopathy with mildly elevated muscle enzymes. Rarely, hypothyroidism may be complicated by rhabdomyolysis, the rapid destruction of skeletal muscle with myoglobin, creatine kinase, urate, and electrolytes release into the circulation. Recurrent cases of rhabdomyolysis are uncommon as most patients experience only one episode of rhabdomyolysis in their lifetime. Most common causes of such episodes are trauma, epileptic seizures, or medication. We describe a case of a 49-year-old male with a history of hypothyroidism, who repeatedly developed severe rhabdomyolysis precipitated by deep muscle injury, seizure, and poor medication compliance. Interestingly, he never developed any of the complications of rhabdomyolysis despite high levels of serum creatine kinase. The most common and feared complication of rhabdomyolysis is acute kidney injury which can occur in 15 to 50% of patients with rhabdomyolysis. Timely and appropriate fluid resuscitation is the mainstay therapy for acute kidney injury (AKI) prevention. Recurrent rhabdomyolysis in a patient should prompt further investigation if there is a family history of a neuromuscular disorder or exercise intolerance. In a case of refractory hypothyroidism, a patient should be counseled on proper regimen and medication compliance.