Splenic cysts are classified on the basis of epithelial lining, either primary or secondary. Primary cysts are further divided as parasitic and nonparasitic. The secondary cysts are usually post traumatic or after a splenic extension of pancreatic pseudocyst. However, not all pseudocysts are associated with trauma. Mostly, they are asymptomatic (30%-60%) and usually grow in size to cause compressive symptoms. Splenic pseudocysts should be differentiated with other malignant and nonmalignant pathology, specifically hydatid cysts, in order to manage them correctly. The walls of pseudocysts may be degenerative or calcified, which may resemble hydatid cysts. Here, we present a case of a non-traumatic splenic cyst masquerading as a hydatid cyst preoperatively. The patient was taken up for surgery and intraoperatively noted to be a hemorrhagic cyst with a non-splenic cyst wall. We decided to preserve the spleen with marsupialisation of cyst and omentoplasty. On histopathology, the diagnosis of a pseudocyst of spleen was made in view of absent epithelial lining. We would like to report this case because of the diagnostic dilemma, its clinical rarity and, even more, in the absence of any history of trauma.

Background Variceal hemorrhage (VH) is a medical emergency. Prompt endoscopic variceal ligation (EVL) is therapeutic. Terlipressin is used in VH and continued for 2—5 days even after EVL. As hemostasis is primarily achieved by EVL, the benefit of continuing trelipressin after EVL is unknown. Objective To evaluate the efficacy of continuing terlipressin after EVL to prevent re-bleed and mortality. Methods In this pilot study, after EVL 74 patients of VH were randomized into two treatment groups TG2 & TG5, received terlipressin (1 mg IV bolus q 4 hourly) for 2 days and 5 days respectively and one control group (TG0), received 0.9% normal saline (10 mL IV bolus q 4 hourly) and followed up for 8 weeks. Results A total of 9 (12.6%) patients had re-bleed with maximum 4 (5.6%) patients in TG5 group followed by 3 (4.2%) in TG2 and 2 (2.8%) in TG0 groups (P=0.670). The overall mortality was 15 (21.1%) patients, 6 (8.5%) patients in TG0 group, followed by 5 (7.0%) in TG5 and 4 (5.6%) in TG2 group (P=0.691). Adverse drug reactions were significantly higher in treatment groups with maximum 18 (24.32%) patients in TG5, followed by 8 (10.8%) in TG2 and 2 (2.7%) in TG0 groups (P=0.00). Duration of hospital stay was also significantly higher in treatment group, 6.63 (±0.65) days in TG5 followed by 3.64 (±0.57) in TG2 and 2.40 (±0.50) days in TG0 groups (P=0.00). Conclusion The rational for continuing terlipressin after EVL is doubtful as it didn’t have any benefit for the prevention of re-bleed or mortality; rather it increased the risk of adverse drug reactions and duration of hospital stay. Further randomized clinical trials are encouraged to generate more evidence in support or against continuing terlipressin after EVL.

A 40-year-old man presented with history of fatigue, low back ache, and dragging sensation in both his lower limbs since 1 month. On examination, there was continuous undulatory twitching of muscles (myokymia) over his right upper back (Video S1). He had normal muscle power and brisk deep tendon reflexes. MRI spine did not show any significant abnormality except early cervical spondylotic changes. He was clinically suspected to have Isaacs syndrome. CASPR2 antibodies in blood were strongly positive and confirmed the diagnosis. 1 Workup for systemic autoimmune diseases and malignancies was unremarkable. He was given pulse of high dose intravenous methylprednisolone 1 g for 5 days and oral phenytoin at a dose of 5 mg/kg daily. His symptoms were significantly reduced, and myokymia disappeared on follow-up after 1 month. AUTHOR CONTRIBUTIONSAlex Rebello conceptualized, organized, and executed the study, prepared the manuscript, collected the data, and involved in review. Mohd. Asif, Bandi Haritha, Nangadda Narmada, and Kumbha Dhanusha prepared the manuscript and collected the data. Ram Chandra Poudel executed the study, and involved in review and critique. ACKNOWLEDGMENTWe acknowledge the constant support and motivation of Amith Kumar S, who also suggested the title of the article. CONFLICT OF INTERESTNone. DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available from the corresponding author upon reasonable request. CONSENTWritten informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

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