A Thorn in his Side

History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.

Rare case of post-COVID transverse myelitis

Case Report: Acute transverse myelitis (TM) is a rare inflammatory disease that typically presents asweakness, sensory alterations, and bowel or bladder dysfunction. Among the causes of TM are infections, paraneoplastic syndromes, or autoimmune conditions of CNS. Postinfectious TM can develop secondary to a viral or bacterial infection. SARS-CoV-2 is a recently discovered viral illness, and sequelae due to COVID-19 infection are still being studied. There is scarce literature relating the two conditions, and it is imperative to raise awareness. A 72-year-old man with hypertension and GERD, completely independent in ADL, was brought to the ED with sudden onset of bilateral lower extremity weakness. He reported symptoms started with difficulty climbing stairs that rapidly progressed to inability to ambulate independently and were associated with bilateral thigh soreness. Nine days prior, he developed fever and generalized malaise, and two days later, SARS-CoV-2 PCR and Ag tests were positive. He received azithromycin, Paxlovid, and dexamethasone as treatment. Upon evaluation, the patient was afebrile and hemodynamically stable. Neurological examination was remarkable for spasticity and hyperreflexia at bilateral lower limbs, clonus, preserved motor strength with adequate sensation to soft touch, and intact vibration and proprioception in all extremities. Cranial nerves were intact. These findings were consistent with an upper motor neuron lesion. On imaging, the Head CT scan was unremarkable. Thoracic/Lumbar Spine MRI was significant for distal thoracic and conus areas with central homogeneous brightness compatible with nonspecific myelitis. Laboratories showed leukocytosis without neutrophilia or bandemia, thrombocytosis, and elevated CRP. HIV and RPR tests were negative. A lumbar puncture for CSF analysiswas remarkable for mild monocytic pleocytosis (7 cell/muL), an increased level of total proteins (56 mg/dL), and normal glucose (57 mg/dL). CSF culture and gram stain were negative. CSF cytology yielded few lymphocytes and few monocytes and was negative for malignant cells. The meningoencephalitis panel was negative. Based on these findings, a clinical diagnosis of postinfectious myelitis secondary to COVID-19was made. The patient was treated with intravenous Methylprednisolone 1 g daily for five days. On follow-up, lower extremity weakness resolved completely, and he resumed his daily physical activities. Patients with COVID-19 infection can present with neurologic manifestations such as headache, myalgias, dizziness, dysgeusia, and anosmia. This case hopes to raise awareness of less commonly known neurological manifestations of SARS-CoV-2 infection and how the early recognition of symptoms can help expedite the diagnosis and treatment of the condition to avoid long-term sequelae. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

Left Ventricular Apical Thrombus after Covid-19 Infection Associated with Pediatric Stroke

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

A peculiar presentation of stroke in young patients

Introduction: Young patients presenting with stroke to the emergency department (ED) is more uncommon. Atypical presentations of stroke in young patients presenting to ED include loss of consciousness, headache, vomiting, and blurring of vision. Young patients may present with stroke of infective causes which include bacterial, viral, fungal, and parasitic origin. Case discussion: A 24-year-old male presented to the ED in semiconscious state with decreased responsiveness along with complaints of fever since 2days and giddiness since 2days, followed by two episodes of vomiting and loss of consciousness. His vital data are blood pressure of 90/60mm Hg, and on examination, Glasgow Coma Scale (GCS) was E3V2M2, pupils are 1mm sluggishly reacting to light and showing upbeat and downbeat nystagmus on both sides, horizontal gaze palsy was present on the right side, all four limbs are in paraplegia and hyperreflexive to deep tendon reflexes, and ankle clonus is present. In view of poor GCS, the patient was intubated in the ED. The patient had a history of right maxillary fungal sinusitis 7 years back for which Functional Endoscopic Sinus Surgery (FESS) was done. The patient denied COVID infection and immunization. Neuroimaging and magnetic resonance imaging (MRI) brain plain with contrast revealed right maxillary fungal sinusitis extending up to the base of the skull with bilateral pontine and cerebellar infarcts, and there was complete occlusion of basilar artery occlusion. The patient was shifted to the intensive care unit (ICU);on further evaluation, the patient's serum homocysteine, protein C, and protein S were normal. Carotid Doppler was normal. Infective workup was done for TB and herpes simplex virus (HSV), bacterial workup was done, and then fungal workup was done for KOH mount, and tissue fungal smear revealed Aspergillus which was managed with antifungals like liposomal amphotericin B and voriconazole;FESS was done during hospitalization. The patient improved clinically and was discharged to the rehabilitation center. Conclusion: In this case, the cause of stroke was an improperly treated fungal sinusitis which invaded the basilar artery. Being an emergency physician, we should have high index of suspicion in the case of young patients presenting with stroke to ED;we need to consider their past history which gives clue toward the diagnosis of infective causes besides routine workup.

Acute Disseminated Encephalomyelitis in a Puerto Rican patient with positive SARS-Cov-2: Casualty or Causality?

Objective: NA Background: Acute disseminated encephalomyelitis (ADEM) is an inflammatory disease of the central nervous system thought to be caused by environmental factors to genetic susceptible individuals, where there is autoimmunity towards myelin components. Given the wide variety of symptoms, etiology and mimickers, ADEM is a diagnosis of exclusion, making difficult a prompt diagnosis. The pathogenesis associated between COVID-19 and ADEM is unknown, however, it could be secondary to immune-mediated mechanisms or molecular mimicry, creating a neuro-inflammatory response. Design/Methods: A previously healthy 22-year-old Puerto Rican male presented to the ED with altered mental status, incoherent speech, imbalance, and dizziness of 2 months progression. Neurological examination was remarkable for slow mentation, positive right Hoffman, left leg weakness and bilateral sustained clonus. Brain MRI showed innumerable foci of increased T2/FLAIR signal intensity throughout supra and infratentorial gray and white matter, none showing contrast enhancement. CSF with evidence of high protein levels, WBC of 7 (100% mononuclear) and normal glucose levels. Extensive workup for evaluation of infectious, demyelinating, inflammatory and vascular etiologies came back negative. Patient with recent history of gastrointestinal symptoms, reason why COVID-19 IgG/IgM Rapid Test was performed with positive IgG results 2 months prior to our evaluation. Patient was treated with intravenous steroids and intravenous immunoglobulin, with marked clinical improvement. Results: NA Conclusions: Here we present a case of atypical coronavirus disease 2019 (COVID-19) manifestation of a Puerto Rican male patient that 2 weeks after detecting SARS-COV-2 on his blood neurological symptoms started to develop. This is the first case of a young Puerto Rican patient without any other comorbidities where an association of COVID-19 infection and ADEM was found. Since ADEM if a diagnosis exclusion, it is vital to being able to distinguish this syndrome when it comes to a patient with history of COVID-19 infection and vaccine for prompt management.

A rare case of an acute ascending longitudinally extensive necrotizing transverse myelitis in a young woman: a severe post-COVID-19 infection neurological complication

Objective: N/A Background: Neurological injuries from severe acute respiratory syndrome coronavirus 2 (COVID-19) are becoming recognized in the central and peripheral nervous systems. Pathophysiology processes include a hyperinflammatory immune response due to the affinity of COVID-19 to human ACE2 receptors and multi-organ failure. CASE REPORT: This report highlights a unique presentation of a rapidly progressive, hyperacute to chronic, necrotizing transverse myelitis with associated COVID-19 long haul syndrome in a 31-year-old Venezuelan obese woman without other vascular risk factors. There was a preceding symptomatic COVID-19 infection. Symptoms included headaches, dysgeusia, asymmetric ascending proximal more than distal paresis, lumbago with dysesthesias, autonomic dysautonomia, hyperreflexia with clonus, and severe functional mobility impairment. Results: Neuraxis imaging showed a longitudinally extensive transverse myelitis (LETM) with T7-T9 enhancement and expansion throughout the thoracic spine (T4-T11). CSF studies showed lymphocytic pleocytosis with elevated protein. Aggressive empiric treatment included 1G of IV methylprednisolone, plasmapheresis (PLEX), and high-dose cyclophosphamide given the life-threatening progression of clinical symptoms. Repeat imaging post-treatment showed expansion of lesions to the cervical cord with sparing of the brainstem, stabilizing after cyclophosphamide initiation. Clinically, there was partial recovery of upper extremity sensation and strength. A T5-T6 tissue biopsy showed evidence of necrotizing myelitis with extensive neutrophil and lymphocyte infiltration. Given clinical progression, a repeat round of immunosuppression, including a monoclonal complement antibody, was pursued. Post-rehabilitation, the patient's symptoms improved above the thoracic spine but not below it. Conclusions: To our knowledge, this is the most severe form of COVID-19 associated necrotizing myelitis ever reported. Future research may clarify the molecular pathways that trigger neurological injury in patients with severe COVID-19 infection-associated spinal cord complications and increase therapeutic options.

Risk of serotonin syndrome in critically ill COVID-19 patients receiving linezolid and opioids concomitantly: A retrospective cohort study

Introduction: Linezolid is an oxazolidinone antibiotic characterized by a reversible, non-selective monoamine oxidase inhibitory (MAOI) effect. Combining linezolid with MAOIs may increase serotonin syndrome (SS) risk. Secondary to its high lung tissue penetration, linezolid is recommended in patients with suspected or confirmed resistant gram-positive bacterial pneumonia, especially if vancomycin cannot be used. Opioids are required for sedation and analgesia in patients with respiratory failure requiring invasive mechanical ventilation. However, it remains unclear whether co-administration of linezolid with opioids should be avoided due to the risk of Serotonin syndrome. Research Question or Hypothesis: Whether combing linezolid with opioids will increase the incidence of SS in coronavirus disease 2019 (COVID-19) critically ill patients. Study Design: Retrospective observational study. Methods: All adult patients admitted to the intensive care units with COVID-19 pneumonia who received linezolid between March 2020 and September 2020 were included in the study. The primary outcome is the prevalence of SS defined by Hunter's criteria. SS was confirmed if the patient had spontaneous clonus;inducible clonus plus agitation or diaphoresis;ocular clonus plus agitation or diaphoresis;tremor plus hyperreflexia;or hypertonia plus fever plus ocular clonus or inducible clonus. Descriptive statistical analysis was done using SPSS version25. Results: We included 106 patients, most of the patients were males (91.5%). Approximately half of the patients had hypertension and diabetes (51.9%, and 44.3%, respectively). More than half of the cohort (56.6%) received a concomitant opioid agent. Morphine and fentanyl were the most commonly prescribed opioids (37.7% and 34%, respectively). Among patients who received opioids, only one incident of SS (1.6%) manifested as spontaneous clonus. However, this patient developed spontaneous clonus post cardiac arrest, which made the association with the linezolid-opioids combination doubtful. Conclusion: In this study, the incidence of SS was low in COVID-19 patients who received concomitant linezolid and opioids. However, larger prospective studies are required to confirm this finding.