Deposition of hydroxyapatite crystals in the para-articular soft tissues is a well-known condition. However, this condition has been rarely described in acromioclavicular joint . We report a case of 55 year gentleman, presented with acute onset of shoulder pain , who was diagnosed with calcific periarthritis of acromioclavicular joint.

Heart Failure due to Peripartum Cardiomyopathy Presenting in the First Week of Puerperium - A Case Series from NepalAbstract: Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure associated with pregnancy without any other known cause. Most of the clinical presentation is similar to symptoms of advanced pregnancy making the diagnosis difficult. Reported are three patients who developed dyspnea, orthopnea, and dry cough during the first week of puerperium. On examination, bilateral lower limb edema and bilateral basal lung crepitation were present in all patients. Chest radiograph showed pulmonary edema in cases two and three, and pleural effusion in case one. All patients had reduced left ventricular ejection fraction and raised N-terminal pro-b-type natriuretic peptide (NT-proBNP) levels. Case two developed PPCM in the background of left pyelonephritis. Case three was complicated by acute kidney injury. All patients were managed with bromocriptine, diuretics, beta-blockers, ACE inhibitors, and fluid restriction. Hence, PPCM though rare should be considered as a differential in women presenting with features of heart failure in later months of pregnancy or within five months of delivery.Keywords: heart failure, bromocriptine, peripartum dilated cardiomyopathy, pregnancy, peripartum cardiomyopathy.Introduction-Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure affecting women in the later months of pregnancy or within five months of delivery. PPCM often presents when peak volume load, reached just before delivery is greatly reduced after delivery.1,2PPCM affects women from all ethnicities globally with wide variation in incidence from 1:20,000 live births in Japan to 1:100 in Zaria, Nigeria.3,4 With a prognosis that can vary from the complete recovery of left ventricular function to maternal mortality as well as recurrence with subsequent pregnancies, the study of PPCM has been done sparsely in Nepal.2,5 This case series attempts to increase awareness of disease, diagnosis, and treatment in Nepal.CASE PRESENTATIONCase 1A 33-years lady, G2A1 at 38+6 weeks of gestation, with no significant medical history underwent emergency LSCS for non-progression of labor secondary to arrest of descent. On the 4th day of puerperium, she developed dyspnea on exertion, orthopnea, bilateral lower limb edema, and dry cough. On examination, she had increased blood pressure (160/110 mmHg) and bilateral lower limb pitting edema with bilateral basal crepitation on chest auscultation. Chest radiograph showed bilateral minimal pleural effusion. Transthoracic echocardiography (TTE) showed severe left ventricular systolic dysfunction, dilated left atrium (LA), moderate to severe mitral regurgitation (MR), severe tricuspid regurgitation (TR), moderate pulmonary artery hypertension (PAH) and reduced ejection fraction i.e< 25%. ECG showed T wave inversion in leads V1-V4 and aVL (figure 1). Serum N-terminal pro-b-type natriuretic peptide (NT-proBNP) was 10897 pg/ml (Normal <300). With the diagnosis of PPCM, she was managed with fluid restriction, diuretics, beta blockers, angiotensin receptor blockers (ARB), bromocriptine, and antibiotics. Repeat TTE done on the 12th day of puerperium showed EF of 30%. However, she had 3 episodes of syncopal attack on the 19th puerperal day which was probably due to orthostatic hypotension. She was discharged on the 22nd puerperal day with oral ARB and bromocriptine and with close follow-up with cardiology and obstetrics and gynecology clinic.

Perforated marginal ulcer following Whipple procedure: A case reportAbstractMarginal ulcers are rare complications of pancreatoduodenectomy. Patient can present with varying symptoms such as epigastric discomfort, pain, dysphagia, or can land in emergency with complications like bleeding and perforation.IntroductionWhipple procedures are performed for variety of benign and malignant lesions affecting the pancreatic head, duodenum, and distal bile duct.1 Marginal ulcer, one of the rare long term complications of pancreatoduodenectomy, are ulcerations that occur at or around the gastrointestinal anastomosis.2 Their associated morbidity and mortality have been infrequently described in literature.3 Here we present a case of a gentleman with a 6 year old history of Whipple procedure who presented in emergency department with acute onset abdominal pain and was later diagnosed with perforated marginal ulcer.Case presentationA 64-year-old retired soldier who underwent the Whipple procedure six years ago for carcinoma head of pancreas, adenocarcinoma (well-differentiated adenocarcinoma) presented to emergency department with complaints of severe abdominal pain for a one day on the day of presentation. The pain was acute in onset, continuous, non-radiating, and increasing in severity, which used to be aggravated after ingestion of food and movement. He had three episodes of vomiting since morning on the day of presentation. On his past history, he underwent the Whipple procedure six years ago and has received complete six cycles of chemotherapy after surgery. He was under irregular follow-ups for past two years. The patient had no other comorbid illnesses.On his arrival to the emergency department, his pulse rate was 130beats per minute, regular; oxygen saturation 85 % on room air; blood pressure 110/70 mm Hg, body temperature 38.7 ◦C, and respiratory rate(RR) 22 breaths/min. On his physical examination, his abdomen was distended with diffuse tenderness. There was diffuse guarding and rigidity all over the abdomen. Bowel sounds were absent. Digital rectal examination revealed a normal sphincter tone with a collapsed rectum and absent fecal stain on the gloved finger. He was immediately administered crystalloids and supplemental oxygen at 4 L/min. Nasogastric tube decompression and Foley catheterization were done. His laboratory parameters showed leukocytosis with raised amylase. Liver function test revealed total bilirubin 1.80 mg/dL, conjugated bilirubin 0.8 mg/dL and alkaline phosphatase 712U/L. On radiological examination, supine abdominal X-ray showed prominent dilated small bowel loops and free gas under right hemi diaphragm pointing towards hollow viscous perforation (Fig. 1). Ultrasonography of the abdomen and pelvis was unremarkable with minimal free fluid in the pelvis.After an initial fluid resuscitation, an emergency laparotomy was done. Intraoperatively, The findings were 300 ml of bilious fluid in the peritoneal cavity and dense adhesion between the small bowel loops and previous surgical scar. Adhesions were meticulously released and gastrojejunostomy site perforation was there, which was around 1 cm Fig.1. A thorough peritoneal lavage was done and the gastrojejunostomy site perforation was closed with a well-vascularized omental patch after a biopsy from the ulcer edge. He received Meropenem IV 1 g and Vancomycin IV 500 mg twice daily along with low molecular weight Heparin 60 mg twice daily the following day. His condition gradually improved and was discharged on 10th post operative day.

Urethral duplication is uncommon with few cases reported in the literature. We report a case in which a patient presented with discharge from proximal part of penis since childhood and recent history of infection. The diagnosis of pre-pubic sinus was made and complete excision of the sinus tract was done.