Clinical Problem-Solving: A 19-Year-Old Woman With Progressive Neurological Decline and Multiple Intracranial Lesions.

The differential diagnosis for multiple intracranial lesions in a young adult is broad and includes demyelinating, neoplastic, and infectious etiologies. In this report, we describe the case of a 19-year-old immunocompetent woman presenting with progressive headaches and aphasia. MRI of the brain revealed multiple, large supratentorial lesions with concentric bands of alternating T2 signal intensities and peripheral contrast enhancement. Cerebrospinal fluid (CSF) analysis was overall bland with negative oligoclonal bands. Serum antibody testing for neuromyelitis optica (NMO) and myelin-oligodendrocyte associated disease (MOGAD) were negative. A broad infectious work-up was also unrevealing. A definitive diagnosis was ultimately obtained after brain biopsy and the patient was started on appropriate therapy. This case highlights a diagnostic framework in evaluating immunocompetent patients presenting with multiple intracranial lesions and progressive neurological decline. The main differential diagnoses for this constellation of radiological and clinical findings are discussed and a literature review is performed on the revealed diagnosis. Lastly, both acute and long-term therapeutic approaches are reviewed.

Therapeutic advances in neuroinfectious diseases.

There have been several major advances in therapeutic options for the treatment of neurological infections over the past two decades. These advances encompass both the development of new antimicrobial therapies and the repurposing of existing agents for new indications. In addition, advances in our understanding of the host immune response have allowed for the development of new immunomodulatory strategies in the treatment of neurological infections. This review focuses on the key advances in the treatment of neurological infections, including viral, bacterial, fungal, and prion diseases, with a particular focus on immunomodulatory treatment options. This review also highlights the process by which clinicians can request access to therapeutic agents on a compassionate or emergency basis when they may not be commercially available. While many therapeutic advances have been achieved in the past several years, there remains a pressing need for the continued development of additional therapeutic agents in the treatment of neurological infections.

Brachial Artery Vasospasm From Sequential Use of Intravenous Promethazine and Dihydroergotamine for Treatment of Status Migrainosus: A Case Report.

Promethazine, a common antiemetic, can cause severe tissue injury with intravenous (IV) injection. Dihydroergotamine (DHE), commonly used for the acute treatment of migraine, can cause arterial vasoconstriction. We report a rare complication of brachial artery vasospasm in a patient receiving IV promethazine and DHE sequentially through the same midline IV catheter. A 40-year-old woman with history of migraine headaches and Raynaud phenomenon was admitted for treatment of status migrainosus with scheduled IV DHE infusions. While receiving the DHE infusions, IV promethazine was added to the patient's regimen to treat nausea. During an infusion of DHE, the patient developed acute pain near the catheter insertion site due to active extravasation of IV DHE. An arterial Doppler ultrasound demonstrated stenosis in the right brachial artery near the region of infusion. The patient ultimately required balloon angioplasty and intra-arterial injection of nitroglycerin to restore adequate blood flow. We hypothesize that caustic injury to the right brachial vein from IV promethazine predisposed the patient to the extravasation of DHE, which, in turn, caused adjacent brachial artery vasospasm. This case suggests the need for careful consideration, if not strict avoidance, of the use of concurrent IV promethazine and DHE.