Introduction and importance Synovial cell sarcoma (SS) is an extremely rare mesenchymal malignancy, representing nearly 10% of all soft-tissue sarcomas. These high-grade soft tissue sarcomas commonly arise in the para-articular regions of lower extremities. However, 15% of Synovial sarcomas has been described at Unusual locations, including head, neck, and trunk. Herein, we describe the twelfth case of primary synovial cell sarcoma of thyroid with a literature review. Case presentation A 43-year-old woman presented with complaint of a progressive neck mass for the last five-months. She developed with dysphagia and dyspnea nearly 2 months prior, without signs of hoarseness, and weight loss. Ultrasonography in which revealed a heterogeneous, hypervascularized thyroid mass. After total thyroidectomy immunohistochemistry was in favor of primary synovial cell sarcoma of thyroid. The diagnosis was confirmed via Molecular genetic analysis of the SYT-SSX fusion gene transcript using the RT- polymerase chain reaction method. Clinical Discussion: Primary thyroid SVS is an extremely rare malignancy with poor biological behavior. SVS has been known for its tendency to local and distal re-occurrence after a few years of treatment. SS can be classified into two subtypes of monophasic or biphasic based on the presence of mesenchymal and/or epithelial components. Accordingly, the most accurate diagnostic tool for SS is considered to be molecular genetic analysis for SYT/SSX fusion transcript. Conclusion Herein, we reported an extremely rare case of SVS of thyroid gland. These high-grade soft tissue sarcomas mainly present with an asymptomatic rapid growing neck mass. Unspecific clinical presentations and extreme rarity of this disorder, make the diagnosis of thyroid SVS very challenging. Due to paucity of data, there is not enough evidence to establish a reliable mortality rate. However, the prognosis of thyroid SVS seems unfavorable.

Background Bronchobiliary fistula is an extremely rare disease that involves abnormal communication between a hepatic segment and bronchial tree. It is mostly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma. Case presentation We experienced an extremely rare case of bronchobiliary fistula after motor vehicle accident. A 15-year-old Persian boy visited our clinic with chief complaints of persistent pleuritic chest pain, productive cough, weight loss, and fever for 2 months. Coronavirus disease 2019 reverse transcription polymerase chain reaction test was negative. Chest X-ray revealed hazy opacification of right lower lobe. Bronchoalveolar lavage for acid-fast bacillus came back negative. Thoracoabdominal computed tomography scan revealed a collection in segment VIII of the liver communicating with another 13 × 5 cm multiloculated collection in the lower lobe of the right lung, with air foci within the collection. Right posterolateral thoracotomy was performed with the impression of bronchobiliary fistula. Drainage of hepatic collection with debridement, diaphragmatic repair, and open decortication of lung followed by resection of the involved segment of the right lung was performed. Histopathologic evaluations revealed abscess formation in pulmonary tissue, and many multinucleated giant cells were seen that appear to be due to foreign body remnants after previous laparotomy surgery. The foreign body seemed to be the remnants of Surgicel absorbable hemostat. Conclusions Herein, we report an extremely rare case of a posttraumatic bronchobiliary fistula caused by remnants of Surgicel hemostatic agent. Bronchobiliary fistula is mainly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma. Migration and erosion of oxidized regenerated cellulose through the diaphragm seems to be the causative factor of bronchobiliary fistula in this patient.

Background and aims Asthma exacerbation is defined as an acute attack of shortness of breath with more than 25% decrease in morning peak flow compared to the baseline on 2 consecutive days, which requires immediate standard therapy. The majority of asthmatic patients are considered to be steroid-sensitive; however, corticosteroid-resistant asthma is a subset of asthma with poor response to corticosteroids and is responsible for frequent hospital admissions. In this study we aimed to compare the effects of two enhancing strategies, the nebulized ketamine and IV magnesium sulfate, in treatment of severe steroid resistant asthma. Materials and methods This double-blind randomized clinical trial was conducted on patients who presented to a referral clinic in Alborz, Iran. Using random allocation, patients were divided into two groups. The first group was treated with nebulized ketamine and the second group was treated with intravenous magnesium sulfate. Peak expiratory flow rates were assessed before the intervention, 30 and 60 min after the intervention and compared with the aid of SPSS software. Results The Peak expiratory flow rates before the intervention, 30 min and 60 min after the intervention was statistically significantly different in both ketamine and magnesium sulfate groups. Peak expiratory flow rates change between 0 and 60 min were 29.4 and 15.2% in the ketamine and magnesium sulfate group respectively. Although the ketamine group showed much higher increase in mean PEFR compared to the MgSO4 groups, there was no statistically significant difference across both groups. Conclusion Our study concluded that combined with standard therapy, both ketamine and IV magnesium sulfate are effective agents in the improvement of PEFR in patients with acute severe asthma that failed to respond to traditional therapies. However, there were no statistically significant difference between the two groups.

Thyroid follicular dendritic cell sarcoma (FDCS) is an extremely rare malignancy that originates from follicular dendritic cells of the thyroid germinal centers. To the best of our knowledge, there are only 4 reported cases of thyroid FDCS in the English literature. Herein, we present the fifth case of FDCS of the thyroid gland. A 63-year-old woman presented with a painless midline neck mass, enlarging for the last 4 months. Physical examination revealed a 6-cm nonmobile, firm, multinodular thyroid mass with palpable cervical lymphadenopathy. Due to high suspicion for thyroid malignancy, the patient underwent total thyroidectomy with bilateral modified radical neck dissection. Histologic evaluations revealed sheets of storiform eosinophilic tumoral cells with prominent nucleoli containing multinucleated giant cells, and subsequent immunohistochemistry showed immunoreactivity for CD4, CD21, CD35, CD45 (LCA), and CD68. The patient was started on 6 cycles of doxorubicin, ifosfamide, and radiotherapy. She has had monthly thyroid ultrasonography and contrast-enhanced thoracoabdominal CT scan every 3 months for detecting potential recurrence and/or metastasis screening. Fortunately, 8 months after the operation, the patient is alive without any signs of local or distant metastasis.

Background and objectiveTracheostomy in coronavirus disease 2019 patients can be performed in cases of prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomy among patients with severe COVID-19 infection. We also aimed to investigate the impact of various lab data and medications on patient outcomes. Materials and methodsWe included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas (ABG) analysis, laboratory workups, and medication history. We calculated the PaO 2 /FiO 2 ratio as an index to evaluate the severity of acute respiratory distress syndrome (ARDS). ResultsDuring the study period, 72 patients with severe COVID-19 underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%) patients passed away and only 18 (25.0%) survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). ConclusionBased on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO 3 , FiO 2 , PaCO 2 , and PaO 2 /FiO 2 ratio.