A Case of Epstein-Barr Virus Encephalitis and Orbital-Face Inflammation.

Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who presented with right pupil-involved complete ophthalmoplegia, orbital and masticatory muscle inflammation, trigeminal enhancement, and new corneal infiltrate highly suggestive of EBV. Labwork was negative except for positive EBV polymerase chain reaction (PCR) in serum. Magnetic resonance imaging (MRI) of his brain and orbits with contrast showed enhancement of the right ganglion of the trigeminal nerve, oculomotor nerve, all extraocular muscles in the right orbit, and right masticatory and temporalis muscles and a right subacute lacunar infarct. The patient was diagnosed with encephalitis and orbital-face inflammation secondary to EBV infection. The patient improved with systemic steroids.

Detection of Acute Brain Injury in Intensive Care Unit Patients on ECMO Support Using Ultra-Low-Field Portable MRI: A Retrospective Analysis Compared to Head CT.

Early detection of acute brain injury (ABI) is critical to intensive care unit (ICU) patient management and intervention to decrease major complications. Head CT (HCT) is the standard of care for the assessment of ABI in ICU patients; however, it has limited sensitivity compared to MRI. We retrospectively compared the ability of ultra-low-field portable MR (ULF-pMR) and head HCT, acquired within 24 h of each other, to detect ABI in ICU patients supported on extracorporeal membrane oxygenation (ECMO). A total of 17 adult patients (median age 55 years; 47% male) were included in the analysis. Of the 17 patients assessed, ABI was not observed on either ULF-pMR or HCT in eight patients (47%). ABI was observed in the remaining nine patients with a total of 10 events (8 ischemic, 2 hemorrhagic). Of the eight ischemic events, ULF-pMR observed all eight, while HCT only observed four events. Regarding hemorrhagic stroke, ULF-pMR observed only one of them, while HCT observed both. ULF-pMR outperformed HCT for the detection of ABI, especially ischemic injury, and may offer diagnostic advantages for ICU patients. The lack of sensitivity to hemorrhage may improve with modification of the imaging acquisition program.

Clinical Use of Bedside Portable Low-field Brain Magnetic Resonance Imaging in Patients on ECMO: The Results from Multicenter SAFE MRI ECMO Study.

Purpose: Early detection of acute brain injury (ABI) is critical for improving survival for patients with extracorporeal membrane oxygenation (ECMO) support. We aimed to evaluate the safety of ultra-low-field portable MRI (ULF-pMRI) and the frequency and types of ABI observed during ECMO support. Methods: We conducted a multicenter prospective observational study (NCT05469139) at two academic tertiary centers (August 2022-November 2023). Primary outcomes were safety and validation of ULF-pMRI in ECMO, defined as exam completion without adverse events (AEs); secondary outcomes were ABI frequency and type. Results: ULF-pMRI was performed in 50 patients with 34 (68%) on venoarterial (VA)-ECMO (11 central; 23 peripheral) and 16 (32%) with venovenous (VV)-ECMO (9 single lumen; 7 double lumen). All patients were imaged successfully with ULF-pMRI, demonstrating discernible intracranial pathologies with good quality. AEs occurred in 3 (6%) patients (2 minor; 1 serious) without causing significant clinical issues.ABI was observed in ULF-pMRI scans for 22 patients (44%): ischemic stroke (36%), intracranial hemorrhage (6%), and hypoxic-ischemic brain injury (4%). Of 18 patients with both ULF-pMRI and head CT (HCT) within 24 hours, ABI was observed in 9 patients with 10 events: 8 ischemic (8 observed on ULF-oMRI, 4 on HCT) and 2 hemorrhagic (1 observed on ULF-pMRI, 2 on HCT). Conclusions: ULF-pMRI was shown to be safe and valid in ECMO patients across different ECMO cannulation strategies. The incidence of ABI was high, and ULF-pMRI may more sensitive to ischemic ABI than HCT. ULF-pMRI may benefit both clinical care and future studies of ECMO-associated ABI.

Esophageal Pseudotumor Secondary to Treatment with a Potassium Binder Resin: A Case of Severe Esophagitis Mimicking a Malignancy.

Background. Sodium polystyrene sulfonate is a resin used to treat hyperkalemia. Colonic mucosal injury, intestinal ischemia, necrosis, and perforation have been widely reported in the literature, but few cases have reported upper gastrointestinal injury and identify the endoscopic features. Case Presentation. We describe a case of an 83-year-old male, with no prior esophageal symptoms, who developed dysphagia after being treated with sodium polystyrene sulfonate for hyperkalemia. Endoscopic features consistent with severe esophagitis and a mass in the lower esophagus mimicking a malignancy were found, and pathology confirmed resin-induced esophagitis. Discussion. The identification of basophilic crystals in the epithelium with surrounding inflammation is a hallmark of sodium polystyrene sulfonate-induced mucosal injury. Several direct and indirect mechanisms by which SPS may cause mucosal injury have been identified. Prolonged stasis of crystals in the lumen has the potential of developing erosions and ultimately necrosis. The internalization of these crystals to the underlying intestinal mucosa with the combination of the inflammatory response may give an appearance of a luminal mass that can mimic a malignancy. Recognizing the wide-ranging endoscopic findings of resin-induced mucosal injury in the esophagus is fundamental to consider a potential side effect of sodium polystyrene sulfonate. The use of this resin should be avoided in patients with suspected esophageal motility disorder.

Progressive Supranuclear Palsy: Improvement in Cognitive-Behavioral Disturbances and Motor-Function Disabilities Following Treatment With Antidepressants and Cholinesterase Inhibitors.

Progressive supranuclear palsy (PSP) is a neurodegenerative disease that usually develops after the sixth decade of life, and the diagnosis is purely clinical except in cases of pathologically confirmed autopsies. A multidisciplinary approach to meet the patients' complex needs is the current core treatment strategy for this devastating disorder. No medications can reverse the disease course. In this report, we present a case of PSP that developed after the sixth decade of life and where the diagnosis was supported by clinical and neuroimaging data. Despite the fact that PSP is a rapidly progressive neurodegenerative disorder and no effective treatments are currently available, our case illustrates the clinically significant improvement in cognition and function achieved in a patient with a treatment involving a combination of antidepressant medications and rivastigmine.

CLIPPERS associated with hypersensitivity pneumonitis: a case report.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare and poorly understood pathology. In this case report we present a 51-year-old male that presented with neurological deficits with recent hypersensitivity pneumonitis. Imaging studies showed multiple punctate enhancing lesions involving the brainstem. After initiation of corticosteroids his symptoms improved, with a decrease in size of his lesions 6-months after his initial presentation. Due to its misdiagnosis, we propose the use of diagnostic criteria, described on this case report, for prompt treatment to avoid neurological sequelae.

Aggressive blood pressure treatment of hypertensive intracerebral hemorrhage may lead to global cerebral hypoperfusion: Case report and imaging perspective.

Hypoperfusion injury related to blood pressure decrease in acute hypertensive intracerebral hemorrhage continues to be a controversial topic. Aggressive treatment is provided with the intent to stop the ongoing bleeding. However, there may be additional factors, including autoregulation and increased intracranial pressure, that may limit this approach. We present here a case of acute hypertensive intracerebral hemorrhage, in which aggressive blood pressure management to levels within the normal range led to global cerebral ischemia within multiple border zones. Global cerebral ischemia may be of concern in the management of hypertensive hemorrhage in the presence of premorbid poorly controlled blood pressure and increased intracranial pressure.

Sinonasal Fungal Infections and Complications: A Pictorial Review.

Fungal infections of the nose and paranasal sinuses can be categorized into invasive and non-invasive forms. The clinical presentation and course of the disease is primarily determined by the immune status of the host and can range from harmless or subtle presentations to life threatening complications. Invasive fungal infections are categorized into acute, chronic or chronic granulomatous entities. Immunocompromised patients with poorly controlled diabetes mellitus, HIV and patients receiving chemotherapy or chronic oral corticosteroids are mostly affected. Mycetoma and Allergic Fungal Rhinosinusitis are considered non-invasive forms. Computer tomography is the gold-standard in sinonasal imaging and is complimented by Magnetic resonance imaging (MRI) as it is superior in the evaluation of intraorbital and intracranial extensions. The knowledge and identification of the characteristic imaging patterns in invasive - and non- invasive fungal rhinosinusitis is crucial and the radiologist plays an important role in refining the diagnosis to prevent a possible fatal outcome.

Fungal Infections of the Central Nervous System: A Pictorial Review.

Fungal infections of the central nervous system (CNS) pose a threat to especially immunocompromised patients and their development is primarily determined by the immune status of the host. With an increasing number of organ transplants, chemotherapy, and human immunodeficiency virus infections, the number of immunocompromised patients as susceptible hosts is growing and fungal infections of the CNS are more frequently encountered. They may result in meningitis, cerebritis, abscess formation, cryptococcoma, and meningeal vasculitis with rapid disease progression and often overlapping symptoms. Although radiological characteristics are often nonspecific, unique imaging patterns can be identified through computer tomography as a first imaging modality and further refined by magnetic resonance imaging. A rapid diagnosis and the institution of the appropriate therapy are crucial in helping prevent an often fatal outcome.