A rare case of glial fibrillary acidic protein astrocytopathy that resolved spontaneously within a self-limited course.

Glial fibrillary acidic protein astrocytopathy is a form of autoimmune meningoencephalomyelitis. The presence of antibodies in spinal fluid against glial fibrillary acidic protein is necessary to diagnose the disease. There is no standard treatment and few cases of glial fibrillary acidic protein astrocytopathy have been reported. A 31-year-old healthy Japanese man presented to our emergency department with a 7-day history of fever and headache. He was in good general condition, without abnormalities on physical examination, and a general hematological examination revealed hyponatremia (130 mEq/L). Five days later, he was followed up and new subjective symptoms were noted: tremor in the right hand, constipation, sweating, and lightheadedness. Cerebrospinal fluid examination revealed a cell count of 57/µL (96 % mononuclear cells, 4 % multinuclear cells), elevated protein level (103 mg/dL), elevated adenosine deaminase level (15.0 U/L), negative polymerase chain reaction test results for herpes simplex virus and Mycobacterium tuberculosis, negative cerebrospinal fluid culture, and negative cerebrospinal fluid anti-acid bacteria culture, indicating aseptic meningitis. T1-weighted contrast-enhanced magnetic resonance imaging of the head showed a linear contrast effect perpendicular to the lateral ventricular wall and along the perivascular vessels spreading radially. Based on the presence of hyponatremia, history of movement disorder and autonomic symptoms, high adenosine deaminase level in cerebrospinal fluid, and findings on contrast-enhanced magnetic resonance imaging of the head, we suspected glial fibrillary acidic protein astrocytopathy and assessed anti-glial fibrillary acidic proteinαantibody in cerebrospinal fluid, which was positive, and diagnosed glial fibrillary acidic protein astrocytopathy. After careful follow-up with symptomatic treatment without immunosuppressive therapy, the fever, headache, tremor, and autonomic symptoms were improved over time. Contrast-enhanced magnetic resonance imaging of the head and findings of cerebrospinal fluid also showed improvement. glial fibrillary acidic protein astrocytopathy should be a differential diagnosis in patients with aseptic meningitis with movement disorders or autonomic symptoms and elevated cerebrospinal fluid adenosine deaminase. Careful follow-up without immunosuppressive treatment should be considered for patients with minimal neurologic symptoms as glial fibrillary acidic protein astrocytopathy may have a self-limiting course and resolve.

Belly dancer syndrome improved by withdrawal of droxidopa and amantadine.

A man hospitalized for cerebral infarction developed drug-induced belly dancer syndrome, which improved after withdrawal of droxidopa and amantadine. Drugs that modulate dopamine neurotransmission have been reported to be associated with this syndrome. When belly dancer syndrome is suspected, clinicians should consider drug-induced abdominal dyskinesia and medication withdrawal.

Two Cases of Perihepatitis With the Liver Capsule Irritation Sign: A New Physical Examination Technique.

Perihepatitis, including Fitz-Hugh-Curtis syndrome, is an uncommon, chronic manifestation of pelvic inflammatory disease usually affecting premenopausal women. It causes right upper quadrant pain due to inflammation of the liver capsule and adhesion of the peritoneum. Since delayed diagnosis of Fitz-Hugh-Curtis syndrome can lead to infertility and other complications, physical examination findings need to be investigated to predict perihepatitis in the early stages of the disease. Here, we hypothesized that perihepatitis is characterized by increased tenderness and spontaneous pain in the right upper abdomen when the patient is placed in the left lateral recumbent position (we termed this indication the "liver capsule irritation sign"). We examined the patients physically for the presence of this liver capsule irritation sign for an early diagnosis of perihepatitis. We report the first two cases of perihepatitis due to Fitz-Hugh-Curtis syndrome in which the liver capsule irritation sign observed during the physical examination was used for diagnosis. The liver capsule irritation sign is caused by two mechanisms: first, the liver falls gravitationally into the left lateral recumbent position, which makes the liver easier to palpate; and second, the peritoneum is stretched and thus stimulated. The second mechanism is that the transverse colon running around the right upper abdomen slumps gravitationally when the patient is in the left lateral recumbent position, allowing for direct palpation of the liver. The liver capsule irritation sign can be a useful physical finding, suggestive of perihepatitis due to Fitz-Hugh-Curtis syndrome. It may also be suitable in cases of perihepatitis caused by factors other than Fitz-Hugh-Curtis syndrome.

A Case Report on Abdominal Pain Treated With a New Technique of Ultrasound-Guided Transversus Abdominis Plane Hydrodissection Using a Low Concentration of Local Anesthetics.

Hydrodissection, a technique for performing morphological dissection between the target tissues via injection, has attracted attention in recent years. However, high-quality evidence is available only for a few entrapment neuropathies, such as carpal tunnel syndrome, and further case studies are needed for other diseases. This case report presents the first case of hydrodissection of the ventral ramus of the spinal nerve, which innervates the abdominal wall, to improve abdominal pain. A 59-year-old Japanese man with a history of cerebral infarction and dyslipidemia presented to the emergency department with the chief complaint of left upper abdominal pain that began two days earlier. The pain radiated to the left side of the back and left axilla. The abdomen was flat and soft with no tenderness on examination, and the pinch test was negative. However, Carnett's sign was observed in the left upper abdomen, and the location of the left upper abdominal pain and that of the radiating pain were consistent with the ninth thoracic vertebra (Th9) dermatome; thus, the cause of the left upper abdominal pain was determined to be the ventral ramus of the spinal nerve of Th9. Two weeks of physical therapy and lifestyle guidance were ineffective; therefore, hydrodissection of the transversus abdominis plane (TAP) between the myofascia of the internal oblique muscle and that of the transversus abdominis at the Th9 level using a 23G 60 mm needle under ultrasound guidance was planned. The abdominal pain immediately improved after hydrodissection, and the patient was able to work without pain. Thus, ultrasound-guided TAP hydrodissection with a low-concentration local anesthetic is effective in the treatment of abdominal pain caused by the entrapment of the ventral ramus of the spinal nerve due to adhesions between the myofascia of the internal oblique muscle and that of the transversus abdominis. This condition should be termed ventral ramus of spinal nerve entrapment syndrome (VERNES), and this concept and TAP hydrodissection must be made known to the public.

Errate: Effectiveness of Hydro-Dissection of the Piriformis Muscle Plus Low-Dose Local Anesthetic Injection for Piriformis Syndrome: A Report of 2 Cases.

The authors have discovered an error in their figures and have provided replacement figures which have been corrected. Specifically, the positions of "Lateral" and "Medial" were reversed, and the positions of "Ischium" and "Sacrum" were reversed. Additionally, the solid lines at the boundaries of each muscle and bone have been removed, and only the nerves have been marked with dotted lines, which is a common notation in ultrasound images. The authors would also like to add the following Acknowledgment: The authors are grateful to Tadashi Kobayashi and Yoshihiko Shiraishi for advising us on the accurate anatomy of ultrasound images. Reference: Mihiro Kaga, Takeshi Ueda. Effectiveness of Hydro-Dissection of the Piriformis Muscle Plus Low-Dose Local Anesthetic Injection for Piriformis Syndrome: A Report of 2 Cases. Am J Case Rep, 2022; 23: e935346. DOI: 10.12659/AJCR.935346.

First Case of Occipital Neuralgia Treated by Fascial Hydrodissection.

BACKGROUND The injection technique "hydrodissection" has been used to isolate the nerves from their surrounding structures, such as the fascia, to treat nerve entrapment. However, no study has reported the use of hydrodissection for the treatment of occipital neuralgia. This report presents the first case of occipital neuralgia treated by ultrasound-guided hydrodissection of the fascia. CASE REPORT An 81-year-old woman presented to the Emergency Department with severe, paroxysmal, stabbing pain headache lasting 4 days. Under a diagnosis of occipital neuralgia, we performed ultrasound-guided hydrodissection of the right semispinalis capitis, obliquus capitis inferior, and sternocleidomastoid muscles, wherein the trigger points were palpated using a low-dose anesthetic agent (9 mL saline and 1 mL 1% lidocaine). Her headache disappeared immediately after treatment. Subsequently, the headache would recur every few days; however, the pain intensity had decreased, and the patient could tolerate it. The same hydrodissection procedure was performed on days 2, 6, and 10 after the initial visit using 2000 mg acetaminophen and 120 mg loxoprofen per day, and the headache episodes disappeared. Treatment was discontinued 23 days after the initial visit; the patient was followed up for 4 weeks, and no headache recurrence was observed. CONCLUSIONS We found that fascial hydrodissection was an effective treatment option for occipital neuralgia attributed to myofascial pain syndrome. The risk of local anesthetic poisoning was very low. Fascial hydrodissection is recommended as a new treatment for occipital neuralgia. Treatment with hydrodissection may be applicable to other neuralgia types.

Effectiveness of Hydro-Dissection of the Piriformis Muscle Plus Low-Dose Local Anesthetic Injection for Piriformis Syndrome: A Report of 2 Cases.

BACKGROUND Piriformis syndrome causes severe buttock and low back pain and numbness of the lower limbs, leading to difficulty in walking. The lack of unified diagnostic criteria for piriformis syndrome until 2018 made it difficult to diagnose; therefore, it is often underestimated, and some patients do not receive appropriate treatment. Treatment methods include local anesthetic injection, steroid injection, and local botulinum toxin injection. However, the most effective drug for the treatment of severe piriformis syndrome has not been established. This report aimed to propose a new and more effective treatment for piriformis syndrome with a minimal risk of adverse effects. CASE REPORT We performed ultrasound-guided hydro-dissection of the superficial and deep surfaces of the piriformis muscle under local anesthesia (a mixture of 18 mL of saline and 2 mL of 1% lidocaine) in 2 flexion, adduction, and internal rotation test-positive patients with tenderness of the piriformis muscle. In both patients, symptoms improved quickly after injection. One required hospital treatment but gradually returned to previous activities of daily living (ADL) status 5 days after admission and was then discharged. The other patient received 2 injections weekly to improve ADL status with continued lifestyle guidance. CONCLUSIONS Hydro-dissection by ultrasound-guided injection of a very low concentration of local anesthetic is effective and has lower risk of adverse effects, thus making it more convenient for the treatment of piriformis syndrome than conventional treatments, such as local anesthetics, steroids, and botulinum toxin injection.

Ultrasound Detection of the Aquarium Sign at the Bedside.

OBJECTIVES: The aquarium sign is the name given to a large quantity of bubble-like echoes that suggests the presence of hepatic portal venous gas (HPVG). Few studies in the literature have addressed the relationship between the aquarium sign and HPVG. In some cases, HPVG can only be detected using ultrasonography. HPVG can be observed in a variety of conditions, including those that require emergency surgery, such as acute mesenteric ischaemia (AMI). Therefore, it is important to identify the presence of HPVG as soon as possible. MATERIALS AND METHODS: We report a case of the aquarium sign, where bubble-like echoes flowed from the right atrium towards the right ventricle, which was identified using bedside cardiac ultrasonography as part of a point-of-care ultrasound test. RESULTS: This aquarium sign finding led to the diagnosis of AMI, which was confirmed using contrast-enhanced computed tomography (CT). CONCLUSION: The aquarium sign is a useful finding suggestive of HPVG and mesenteric ischaemia, which can be rapidly and easily observed using bedside cardiac ultrasonography. However, there are very few reports on the aquarium sign. The inability of other more cumbersome diagnostic imaging modalities, such as CT and magnetic resonance imaging, to detect HPVG emphasizes the utility and convenience of detecting the aquarium sign using bedside ultrasonography. This technique can lead to early detection of life-threatening diseases as well as improve the prognosis for patients. The diagnostic implications of the aquarium sign for HPVG are still unclear and require further research. LEARNING POINTS: The aquarium sign is a characteristic of hepatic portal venous gas (HPVG), which is often observed in acute mesenteric ischaemia (AMI).Owing to the high mortality rate of AMI with HPVG, urgent laparotomy is recommended.Bedside ultrasonography can more rapidly and easily detect HPVG than CT imaging, and with a higher degree of sensitivity.

Standardization of the apparent diffusion coefficient value of bladder cancer across different centers: Applicability in predicting aggressive pathologic phenotypes.

PURPOSE: We investigated whether the standardized apparent diffusion coefficient (ADC) value reflects bladder cancer characteristics across different centers. METHODS: Ninety-eight bladder cancer patients underwent MRI at two institutions. Standardized tumor ADC (sT-ADC) was calculated by dividing absolute tumor ADC (aT-ADC) by that of gluteus maximus. We compared ADCs between MRI protocols according to grade and T-stage. RESULTS: The differences in aT-ADC between MRI protocols were negated by sT-ADC. The best sT-ADC cut-offs to predict cancer aggressiveness in the development cohort worked in the validation cohort compared to the development cohort. CONCLUSION: Standardized ADC overcomes the incompatibility between different MRI protocols.