Does That Go There? A Rare Occurrence of Spontaneous Sternocleidomastoid Abscess without Trauma in a Diabetic Individual.

BACKGROUND Spontaneous abscesses are generally typical in patients with significant risk factors and have been linked to numerous muscle groups. The sternocleidomastoid muscle, however, piqued our interest as an unusual location, especially in this patient who, other than diabetes mellitus, had no associated risk factors or signs of trauma. CASE REPORT A 61-year-old man appeared with neck pain, erythema, and swelling that had been present for 9 days and for which he had previously been examined in the Emergency Department. He was discharged on oral doxycycline after initial computed tomography (CT) of the neck revealed infiltration without collection. He returned with worsening symptoms and new-onset fever and chills. Vital signs were normal on assessment, with no evidence of trauma. Swelling was observed near the right sternocleidomastoid muscle insertion. A repeat CT scan of the neck revealed an abscess 2.5 cm in diameter. He was originally treated with empiric antibiotics before being moved to targeted medications. Incision and drainage were completed without complication. The patient was given a 6-week course of oral antibiotics. CONCLUSIONS Spontaneous intramuscular abscesses are uncommon in people who have had no previous trauma or other known risk factors, but could be encountered in diabetic patients with non-optimal blood glucose levels, due to bacteremia. As a result, these cases require a high level of suspicion to be recognized and treated early. The scarcity of literature on this illness makes determining the cause challenging. However, by highlighting this case, we intend to raise awareness and facilitate early diagnosis and treatment.

Group A Streptococcus Pneumonia in a Previously Healthy Individual: Is It Still a Thing?

Group A streptococcus (GAS) is known to cause many different kinds of infections, including invasive pneumonia in rare cases. When it is the causative agent, it is associated with a more severe disease course, but it can often be adequately treated if caught early enough. We hereby present the case of a 32-year-old male with no past medical history who presented with fever, hemoptysis, and tachycardia. Laboratory results showed leukocytosis, hyponatremia, mild transaminitis, and elevated creatine kinase. Initial imaging findings and clinical presentation were concerning for tuberculosis (TB) vs. community-acquired pneumonia (CAP), as it yielded a consolidation in the right upper lobe. The patient had no obvious risk factor except for imprisonment two years prior to symptoms onset. Empirical antibiotics and steroids were started. Quantiferon and acid-fast bacteria (AFB) were negative, but sputum and blood cultures were positive for Streptococcus pyogenes, ruling out TB. Antibiotic therapy was narrowed down. The patient responded well to therapy, with subsequent resolution of symptoms. The current body of knowledge regarding respiratory infections caused by GAS is limited by multiple factors, including its relative rarity and the diversity of how it can present, especially in a developed country. Its mimicry characteristics of other clinical entities, such as TB, can be deceiving, which can delay appropriate treatment if it occurs in settings where the diagnostic tools are not readily available. By sharing more cases and atypical presentations of this disease, the clinical presentations of this pathogen can be more fully understood, and it can be more rapidly identified and treated.

Diminutive Ureteral Stone Causing Caylyceal Rupture: Case Report and a Review of the Treatment Options.

Rupture of the renal collecting system is a rare event, usually occurring at the ureterovesical junction (UVJ). The most common cause is nephrolithiasis, usually directly correlated with the size of the stone. Other causes include bladder outlet obstruction, ureteropelvic junction obstruction, and extrinsic ureteral compression by a malignant pathology. The mechanism is increased pressure within the collecting system, and symptoms vary from vague mild abdominal pain to severe excruciating pain. We present a case of a 19-year-old female with obstructive uropathy and renal calyceal rupture caused by a 3 mm stone at the UVJ. Due to the small size of the stone and her hemodynamic stability, she was treated conservatively with tamsulosin and IV ceftriaxone. The following day she passed sediment in the urine and noted pain improvement. Calyceal rupture with small stones is exceedingly rare, may be missed on a CT without contrast, and should be suspected when perinephric edema or fluid is seen. This is the smallest recorded stone causing calyceal rupture to the best of our knowledge. CT with contrast is indicated for diagnosis when calyceal rupture is suspected and is suggested by extravasation of contrast. Early diagnosis and intervention, in collaboration with urologists, can help to avoid long-term complications such as acute kidney injury, urosepsis, and urinoma. Conservative management may still be considered after a calyceal rupture in patients with small, potentially passable stones. However, if there is associated obstructive uropathy, infection, or significant rupture, then stenting may be indicated. This case highlights the diagnosis of calyceal rupture in the setting of tiny stones and the efficacy of conservative therapy versus early stenting in the management of stable patients.

Nonbacterial Thrombotic Endocarditis of the Mitral Valve With Echocardiographic Appearances Mimicking a Papillary Fibroelastoma in a Middle-Aged Female Patient.

Papillary fibroelastoma (PFE) and nonbacterial thrombotic endocarditis (NBTE) account for <1% of all cardioembolic strokes. When there is no evidence of infection, and an exophytic valve lesion is seen on echocardiography, PFE may be an initial imaging diagnosis. NBTE, or Libman-Sacks endocarditis, is a rare entity and can present with varied imaging findings. This report presents a case of embolic stroke and NBTE mimicking a PFE. We discuss a 49-year-old female with a past medical history of diabetes mellitus who presented with headache and right-hand numbness. The initial CT head was negative and the MRI brain showed multiple infarcts in the watershed areas where anterior and posterior brain circulation meet and overlap. A transesophageal echocardiogram (TEE) showed a left ventricle (LV) mass initially diagnosed as PFE. The patient was started on aspirin only with no anticoagulation since we thought the stroke was related to an embolus from a tumor, not a thrombus. The patient underwent surgery but the pathology report revealed a diagnosis of organizing thrombus with abundant neutrophilic infiltration and no neoplastic proliferation. This case report highlights the importance of a comprehensive evaluation of valvular masses and the diagnostic approaches currently available to help clinicians differentiate between various causes of embolic stroke like PFE, bacterial endocarditis, and NBTE. Early differentiation is critical because it can affect the treatment and outcome. This report shows that echocardiography of endocardial and valvular lesions may provide a differential diagnosis, but a definitive diagnosis requires microbiology and histopathology. Advanced imaging techniques such as cardiac CT or cardiac MRI may assist in identifying select cases that are at lower risk for subsequent embolic events, in which surgical intervention may safely be avoided.

Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism.

Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.