An Unlikely Cause of Chest Pain: Recurrent Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy is described as transient, ventricular dysfunction. A relatively rare pathology accounting for 0.02% of hospitalizations, recurrent episodes are even less common, occurring at 1-6%. Here, we present a case of an elderly woman presenting with multiple, recurrent episodes of takotsubo cardiomyopathy. Similarities and differences between our case and others presented in literature are compared. Our case highlights the importance of maintaining a broad differential when presented with multiple episodes of recurrent, acute heart failure in the setting of chest pain and ST segment elevations.

Mycobacterium bovis: An unusual cause of aortic graft infection.

Mycobacterium has presented public health challenges since its inception, primarily affecting developing nations. Much less is known about M. bovis, a member of the mycobacterium family more frequently affecting zoonotic species. Infections postaortic aneurysm repair are rare, and few cases have reported infection secondary to the lesser-known mycobacterium member, M. bovis. Here, we present a case of aortic graft infection status-post aortic aneurysm repair secondary to M. bovis. We highlight the essential role multi-modal radiographic imaging played in establishing this diagnosis.

Integrating cardiovascular risk assessment into mobile low-dose CT lung screenings in rural Appalachia: A comprehensive analysis of the relationship between lung cancer risk, coronary artery calcium burden, and cardiovascular risk reduction strategies.

Objective: Mobile low-dose computed tomography (LDCT) lung screenings are part of an outreach program in rural Appalachia to detect early lung cancer. Coronary artery calcium (CAC) scoring on LDCT can identify calcium deposits in coronary arteries and can prompt consideration of risk modification for prevention of cardiovascular disease (CVD) events. It is not known if Lung CT Screening Reporting & Data System (Lung-RADS) scoring correlates with CAC scores. There is no clear guidance for patients undergoing LDCT screenings to receive follow-up regarding CAC or prevention of associated CVD risk. Methods: This was a retrospective review of mobile LDCT LCS in adults with no known history of CVD. CT images were obtained at 100 kVp with a slice thickness of 3 mm. Agatston CAC scoring was performed retroactively. Lung-RADS scores were categorized as: Negative (1), Benign (2), Probably Benign (3), and Suspicious (4). CAC scoring was grouped as 0, 1-100, 101-399, and ≥400. Descriptive statistics and chi-square analyses were utilized. Results: A total of 526 LDCT screenings were included. Over 54 % of patients had coronary calcification on LDCT LCS. 161 patients (30.6 %) had a CAC score of ≥100 and 75 patients (14.3 %) had a CAC score ≥400. Of patients with a CAC score ≥100, 7.5 % received referrals for follow-up after the LDCT screen and 9.3 % had additional cardiac testing. Of those with a CAC score ≥100 not already on a statin (45.3 %) and not already on aspirin (63.3 %), few were started within 3 months of LDCT for prevention (8.2 % and 5.9 % respectively). Among patients with a Lung-RADS score of 4, 17 % had a CAC score >400, whereas only 12 % with a Lung-RADS score of 1 fell into the same CAC category. Higher Lung-RADS scores correlated with fewer patients with CAC of 0. A significant correlation was observed between higher Lung-RADS scores and elevated CAC scores (p = 0.02). Conclusion: In patients with no CVD history, coronary artery calcification was frequently identified on mobile LDCT lung screenings in rural communities. Patients with higher probabilities of malignant lung nodules may also be at increased risk for significant coronary artery disease. Calcium scoring from LDCT screenings allowed for simultaneous assessment of lung cancer and CVD risk. Unfortunately, few referrals or CVD prevention medications were initiated. Awareness of CAC score utility, follow-up for identified coronary calcifications, and consideration of primary prevention medications when indicated, would be beneficial in patients undergoing LDCT lung screenings, especially in rural areas with limited healthcare access.

Ischaemic Colitis from an Unusual Cause: Oral Contraceptives.

Ischaemic colitis is responsible for more than half of the presentations of gastrointestinal ischaemia and develops due to an interruption of intestinal blood flow. Risk factors include increasing age and conditions associated with decreased perfusion. Infrequently, ischaemic colitis may develop in young females prescribed oral contraceptives. Here, we present a case of ischaemic colitis secondary to oral contraceptives that resolved with medication discontinuation. LEARNING POINTS: Ischaemic colitis is due to insufficiency of intestinal blood flow and is responsible for half of the cases of gastrointestinal ischaemia.Oral contraceptives have an increased odd of 1.05 predisposing development of ischaemic colitis.Symptoms typically resolve with removal of the oral contraceptive.

Cerebrospinal Fluid Leak Presenting as Headache: A Case Report.

Headache is a common chief complaint among patients. When presented with this chief complaint, clinicians often form a differential diagnosis of common etiologies, including dehydration, increased stressors, and medication side effects. However, a skillful clinician must always be vigilant of rare etiologies presenting with common chief complaints. Here, we present a rare case of a cerebrospinal fluid leak in a young female presenting with primary symptoms of headache, neck stiffness, and vision changes.

A Silent Cause of Shock: Autoimmune Polyglandular Syndromes.

Addison's disease is a rare, autoimmune condition leading to destruction of the adrenal gland. Autoimmune conditions are known to commonly co-occur. When Addison's disease presents in the setting of autoimmune thyroid disease and/or type 1 diabetes, this condition is termed autoimmune polyendocrine syndrome type II, a rare endocrinopathy found in roughly 1.4-4.5 per 100,000 individuals. Here, we describe a clinical case presenting with hypotension refractory to fluid resuscitation and electrolyte derangements later diagnosed as autoimmune polyendocrine syndrome type II. LEARNING POINTS: Primary adrenal insufficiency may present clinically as shock refractory to fluid resuscitation.Autoimmune polyglandular syndrome type 2 is a rare autoimmune condition occurring in 1.5-4.5 per 100,000 individuals.The presence of an underlying autoimmune condition should raise suspicion for multiple concurrent autoimmune conditions.

Case report: unravelling the puzzle of unicuspid aortic valve with multimodality imaging.

Background: Unicuspid aortic valve (UAV) represents a rare congenital anomaly characterized by two subtypes: acommissural unicuspid aortic valve and unicommissural unicuspid aortic valve. Acommissural UAV is often diagnosed and corrected during the neonatal period due to haemodynamic instability. Unicommissural UAV leads to aortic stenosis (AS) in early adulthood. The diagnostic challenge associated with UAV primarily stems from its eccentric orifice opening and valvular calcification, resulting in difficult visualization of the commissures and localization of the orifice plane. This case report aims to demonstrate the unique morphological features of UAV through a comprehensive analysis using multimodality imaging. Case summary: A 61-year-old woman presented to the emergency department for recurrent episodes of dyspnoea. Severe AS was diagnosed on transthoracic echocardiography (TTE) by Doppler haemodynamic measurement. However, follow-up transesophageal echocardiography (TEE) and CT transcatheter aortic valve replacement showed moderate AS by planimetry. Following this, patient was monitored closely, but her dyspnoea kept worsening. Cardiovascular magnetic resonance (CMR) was performed due to persistent dyspnoea, identifying UAV with eccentric loophole orifice with unicommissural attachment and opposite free leaflet edge. The patient was managed medically. Discussion: TTE is the test of choice for AS that defines valvular morphology by direct visualization and grades the severity by haemodynamic measurement. However, the accuracy of TTE can be limited by poor acoustic windows and heavy valvular calcification. TEE measures aortic valve area (AVA) by planimetry that requires accurate localization of the AV orifice plane. Similarly, it applies to multi-detector computed tomography (MDCT). While CMR is expensive and mainly available in tertiary centres, it can provide additional information when there is discordance.

Dogs Licks Are Not Benign: Pasturella Multocida Bacteremia From Household Dog.

Pasturella (P.) multocida is a gram-negative coccobacilli commonly colonized in the oral, nasopharyngeal, and upper respiratory tracts of animals. Infections due to P. multocida range in severity, and symptoms largely depend on underlying immune status and co-morbid conditions. Widely known, the transmission of P. multocida is commonly thought to occur through biting and skin breakage alone. However, multiple studies have highlighted instances of severe complications secondary to transmission through the passage of P. multocida through animal licking alone without skin disruption. Here, we present a case of a nonagenarian female presenting with septic shock secondary to P. multocida with the source of transmission found to be secondary to the patient's dog licking her chronic leg wounds. We also highlight other instances of similar transmission through a literature review, including common treatment courses. We aim to raise awareness of common transmissions of bacteria, specifically P. multocida, along with broadening differentials when one presents with skin and soft tissue infections.

CardioMEMS monitoring device migration: A rare complication.

We present a rare case of CardioMEMS device migration six years post-implantation. Much is still being learned about endothelization of pulmonary vasculature and this case highlights the importance of device surveillance and device-related complications.

Tipped Over the Edge: A Case of Diabetes Ketoacidosis Precipitated by High-Dose Steroids in the Setting of a Large Peritonsillar Abscess.

Peritonsillar abscess is an infection of tonsillar soft tissue which can spread into additional neck structures leading to symptoms of fever, sore throat, dysphagia, and airway compromise. We describe a case of diabetic ketoacidosis in a patient with a history of uncontrolled type II diabetes mellitus admitted for a peritonsillar abscess who received intravenous steroids for management of the abscess swelling. The patient was treated with an insulin drip, hydration, and electrolyte replacement with a resolution to his anion gap and metabolic acidosis. Diabetic ketoacidosis occurs during increased gluconeogenesis leading to ketosis and metabolic acidosis which can be a life-threatening condition if not quickly recognized and treated. This case highlights the importance of monitoring and treating elevated blood glucose in acutely ill patients receiving steroid therapy.

SARS-CoV-2 associated septic venous cavernous sinus thrombosis: A case report.

Cavernous sinus thrombosis (CST) is a life-threatening condition occurring due to an active infection, coagulation abnormalities, and trauma. Thromboembolic events are known complications secondary to novel coronavirus disease-19 (COVID-19) due to dysfunction in endothelial function and clotting factor dysfunction. We report a case of cavernous sinus thrombosis and delayed ophthalmic vein thrombosis associated with a preceding COVID-19 infection confirmed with a facial computed tomography (CT) scan. Clinicians should have a broad differential in patients with hypercoagulable states, as complications secondary to COVID-19 can be life-threatening.

Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes.

Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.

Myelin oligodendrocyte glycoprotein antibody-associated optic neuritis and myelitis in COVID-19: a case report and a review of the literature.

Background: Our case explored the spectrum of autoimmune and infectious neurological complications of Coronavirus Disease 2019. In addition, we also reviewed and discussed clinical features, neuroimaging, CSF findings, and outcomes in patients with COVID-19-associated Myelin Oligodendrocyte Glycoprotein Antibody Disorder (MOGAD) CNS inflammatory disorder. Case presentation: Here we presented a case of post-Coronavirus Disease 2019 infection Myelin Oligodendrocyte Glycoprotein Antibody Disorder in a 41-year-old male who presented with gait instability, urinary retention, and confusion. Workup done in hospital showed transverse myelitis in cervical spine region and left optic neuritis. Laboratory findings showed Myelin Oligodendrocyte Glycoprotein-IgG antibodies were positive in serum (1:100), suggestive of post-COVID Myelin Oligodendrocyte Glycoprotein Antibody Disorder. Conclusion: To our knowledge, this is the first comprehensive case report and the literature review that includes the clinical features, neuroimaging, CSF findings, and outcomes in COVID-19-associated Myelin Oligodendrocyte Glycoprotein Antibody Disorder.

Pediatric Traumatic Brain Injury: An Update on Preclinical Models, Clinical Biomarkers, and the Implications of Cerebrovascular Dysfunction.

Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality. Recent studies suggest that children and adolescents have worse post-TBI outcomes and take longer to recover than adults. However, the pathophysiology and progression of TBI in the pediatric population are studied to a far lesser extent compared to the adult population. Common causes of TBI in children are falls, sports/recreation-related injuries, non-accidental trauma, and motor vehicle-related injuries. A fundamental understanding of TBI pathophysiology is crucial in preventing long-term brain injury sequelae. Animal models of TBI have played an essential role in addressing the knowledge gaps relating to pTBI pathophysiology. Moreover, a better understanding of clinical biomarkers is crucial to diagnose pTBI and accurately predict long-term outcomes. This review examines the current preclinical models of pTBI, the implications of pTBI on the brain's vasculature, and clinical pTBI biomarkers. Finally, we conclude the review by speculating on the emerging role of the gut-brain axis in pTBI pathophysiology.

Acute transverse myelitis following SARS-CoV-2 vaccination: a case report and review of literature.

OBJECTIVE: To report a unique case and literature review of post COVID-19 vaccination associated transverse myelitis and with abnormal MRI findings. BACKGROUND: Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only a few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2). Here, we identify a post COVID-19 vaccination patient diagnosed with acute transverse myelitis. METHOD: A retrospective chart review of a patient diagnosed with post SARS-CoV-2 vaccination acute transverse myelitis, and a review of literature of all the reported cases of other post vaccination and transverse myelitis, from December 1st, 2010 till July 15th, 2021, was performed. CONCLUSION: To our knowledge, this is the one of early reported case of transverse myelitis and with post SARS-CoV-2 vaccination, who responded well to plasmapheresis. Further studies would be recommended to identify the underlying correlation between COVID-19 vaccination and transverse myelitis.

Spectrum of Neuroimaging Findings in Post-COVID-19 Vaccination: A Case Series and Review of Literature.

Background and Purpose: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first detected in Wuhan, China in December 2019. Symptoms range from mild flu-like symptoms to more severe presentations, including pneumonia, acute respiratory distress syndrome (ARDS), and even death. In response to the COVID-19 pandemic, the Emergency Use Authorization (EUA) approved the use of several vaccines. Because vaccines have been fast-tracked for emergency use, the short and long-term safety profile has been an area of concern. The aim of this paper is to extensively review published literature regarding post-COVID-19 vaccination neurological complications and characterize neuroimaging findings from three case presentations for early diagnosis and treatment. Methods: The analysis includes data from PubMed and Google Scholar. Articles included were retrieved from database inception beginning December 2020 with no language restrictions. Terms used include "SARS-CoV-2", "post Covid vaccination", "neurological complications", "Guillain-barre Syndrome", "Transverse-myelitis", "Cerebral Venous Sinus thrombosis", and "Cerebral hemorrhage". Results: The literature review yielded several neurological complications post vaccination, including cerebral sinus venous thrombosis, transverse myelitis, Guillain-Barré Syndrome and optic neuritis, to name a few. Patient case presentation findings were consistent with documented results in published literature. Conclusions: We present a case series with a thorough literature review documenting adverse neurological affects following COVID-19 vaccination. Our case presentations and literature review highlight the importance of neuroimaging when diagnosing post-COVID-19 vaccination adverse effects. MRI imaging study is an important tool to be considered in patients presenting with post-COVID-19 vaccination-related unexplained neurological symptoms for accurate diagnosis.

Mitochondrial Movement and Number Deficits in Embryonic Cortical Neurons from 3xTg-AD Mice.

Mitochondrial dysfunction is often found in Alzheimer's disease (AD) patients and animal models. Clinical severity of AD is linked to early deficiencies in cognitive function and brain metabolism, indicating that pathological changes may begin early in life. Previous studies showed decreased mitochondrial function in primary hippocampal neurons from triple-transgenic Alzheimer's disease (3xTg-AD) mice and mitochondrial movement and structure deficits in primary neurons exposed to amyloid-ß oligomers. The present study characterized mitochondrial movement, number, and structure in 3xTg-AD primary cortical neurons and non-transgenic (nonTg) controls. We found a significant reduction in mitochondrial number and movement in 3xTg-AD primary cortical neurons with modest structural changes. Additionally, application of the sigma-1 receptor agonist, (+)SKF-10,047, markedly increased mitochondrial movement in both 3xTg-AD and nonTg primary cortical cultures after one hour of treatment. (+)SKF-10,047 also led to a trend of increased mitochondrial number in 3xTg-AD cultures. Embryonic mitochondrial movement and number deficits could be among the key steps in the early pathogenesis of AD that compromise cognitive or metabolic reserve, and amelioration of these deficits could be a promising area for further preclinical and clinical study.