Opioid Overdose-Induced Diffusion Restriction in the Bilateral Basal Ganglia Revealed on Brain Imaging.

Opioid misuse and addiction have led to an opioid epidemic in the United States, with widespread effects on the healthcare system. Opioid-induced cardiovascular morbidity and mortality effects have been extensively described in past literature; however, neurological effects have been described less frequently.  Here, we describe a case of a female patient who presented to our center after being found unresponsive with magnetic resonance imaging (MRI), revealing bilateral basal ganglia diffuse restriction hyperintensities secondary to a diagnosis of opioid overdose.  Opioid overdose-induced bilateral basal ganglia diffusion restriction has only been described infrequently in the literature. Recognizing the associated imaging findings as a potential consequence of opioid overdose is important to avoid unnecessary workups for ischemic stroke.

Idiopathic Intracranial Hypertension Secondary to Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common immune-mediated inflammatory polyneuropathy, defined as progressive or relapsing symptoms for over two months with pathological or electrophysiological evidence of peripheral nerve demyelination. Papilledema is optic nerve head edema secondary to increased intracranial pressure or infiltrative/infectious etiologies. Regardless of the cause, visual loss is one of the feared manifestations due to optic nerve damage. We present a 50-year-old female patient with CIDP who developed papilledema that was secondary to increased intracranial pressure from high protein content in the cerebrospinal fluid (CSF) and elevated body mass index (BMI) secondary to prednisone use. Treatment with acetazolamide completely resolved the papilledema and headaches, and the patient was later maintained on mycophenolate, intravenous immunoglobulin (IVIG), rituximab, and prednisone. To the best of our knowledge, this is the first case that describes successful medical management of increased intracranial pressure in the setting of CIDP.

Magnetic Resonance Imaging-Negative Varicella Zoster Virus Plexopathy in a Young Patient: A Case Report.

Varicella zoster virus (VZV)-associated plexopathy mainly occurs in patients over 60 years old. Postherpetic neuralgia is a well-known complication of herpes zoster (HZ); however, segmental zoster paresis secondary to HZ was reported in 1-20% of cases in the literature. Magnetic resonance imaging (MRI) findings may be positive in up to 70% of the patients. We describe a 43-year-old male patient with a history of grade two left frontal oligodendroglioma, which was treated with two partial resections, radiation treatment and procarbazine/lomustine, who presented with left upper extremity pain and developed a blistering rash in a dermatomal pattern in the left proximal upper extremity two weeks after the initial symptoms. He was diagnosed with shingles and treated with steroids and acyclovir with minimal improvement. Six weeks after the initial symptoms, a physical exam revealed left deltoid, supraspinatus and infraspinatus weakness with normal muscle stretch reflexes and decreased sensation on the C5 dermatome. Electromyography (EMG) revealed absent left lateral antebrachial cutaneous sensory nerve action potentials (SNAP) amplitude and a small left radial SNAP amplitude compared to the right side. Evidence of ongoing denervation with reinnervation was seen in the left upper trunk-supplied muscles. MRI of the brachial plexus was negative for any abnormalities. The patient was diagnosed with VZV-associated plexopathy, which improved with pregabalin and physical therapy. Our patient was significantly younger than expected in the HZ group. MRI usually shows T2 hyperintensities and thickening of the nerve roots in patients with VZV-associated plexopathy. However, the presentation, onset of symptoms, characteristics of the rash, and clinical course were diagnostic of HZ, and the weakness pattern, supported by the EMG findings, was diagnostic of VZV-associated plexopathy.

Vaginal Herpes Zoster While Under Treatment for Relapsing-Remitting Multiple Sclerosis With Diroximel Fumarate.

Multiple sclerosis (MS) is an autoimmune demyelinating disorder that disproportionately affects middle-aged women, and is capable of resulting in severe disability. However, the use of disease-modifying therapies has profoundly contributed to the improvement in the morbidity of the disorder. Diroximel fumarate (DRF) is a second-generation drug that has seen success in the treatment of relapsing-remitting MS (RRMS). While its relatively mild side effects of gastrointestinal discomfort are known, the less common complications are often missed in clinical settings. This includes a resulting susceptibility to opportunistic infections. In this case report, we describe a patient who experienced lymphopenia, recurrent yeast infections, and labial shingles while on the medication. This case highlights the side effects and the rare complications of the immunomodulator, DRF.