Hypertrophic Pachymeningitis: An Unusual Cause of Headache.

Hypertrophic pachymeningitis (HP) is a rare condition characterized by inflammation and thickening of the dura mater. It can be idiopathic or secondary to various causes, including infections, tumors, or systemic inflammatory diseases. Diagnosis is challenging due to its rarity and the overlap of symptoms with other conditions. We present the case of a 42-year-old Hispanic woman with diabetes mellitus type 2 and end-stage kidney disease who presented with chest pain, dry cough, mild dyspnea, and chronic occipital headaches. Physical examination revealed cranial VI nerve palsy. Imaging showed pulmonary cavitary lesions and mediastinal lymphadenopathy. Elevated inflammatory markers and positive autoimmune tests, including rheumatoid factor and antineutrophil cytoplasmic antibody (ANCA), led to further investigation. Brain imaging revealed dural thickening, confirming HP. The patient's medical history revealed double ANCA positivity and a lung biopsy confirmed granulomatous pneumonitis. A diagnosis of ANCA-associated vasculitis (granulomatosis with polyangiitis (GPA)) was established, and treatment with rituximab and high-dose corticosteroids led to symptom improvement. GPA rarely involves meningeal inflammation, but severe and persistent headaches are common early symptoms. Inflammatory markers are often elevated, and around two-thirds of HP cases related to GPA have positive serum ANCA. MRI is the primary diagnostic tool, with characteristic findings of dural thickening and contrast enhancement. This case highlights HP as a rare cause of chronic headaches and the importance of a comprehensive medical history in diagnosis. Early recognition and treatment are crucial for improving outcomes in GPA-related HP.

Delayed Presentation of Osmotic Demyelination Syndrome Treated With Plasmapheresis.

We present a unique case of a 42-year-old gentleman with alcohol use disorder who developed osmotic demyelination syndrome (ODS) despite appropriate hyponatremia correction. This patient initially presented with severe hyponatremia (Na 97 mEq/L) due to beer potomania, which was corrected gradually over eight days, resulting in no observed neurological deficits upon discharge. However, he was readmitted with respiratory failure from aspiration pneumonia, leading to endotracheal intubation. Laboratory findings revealed a sodium level of 134 mEq/L and serum osmolality (293 mOsm/kg). The patient had neurological exam findings of spontaneous eye opening with left gaze preference and decreased power ⅕ in all extremities. Following extubation, he experienced a relapse with evolving subacute central pontine myelinolysis and bulbar weakness necessitating reintubation. Subsequently, five sessions of plasmapheresis were conducted, resulting in stable clinical findings. Despite remaining non-verbal, the patient demonstrated gradual neurological motor improvement, progressing from 1/5 power in all extremities to 4/5 on the right side and 3/5 on the left side. He was discharged with ventilator support, tracheostomy, and PEG tube placement to a long-term care facility. This case underscores the importance of vigilant monitoring in high-risk individuals following hyponatremia treatment because ODS presentation can be delayed.

Orbital Lymphoma Masquerading as Euthyroid Orbitopathy.

Thyroid eye disease (TED), also called Graves orbitopathy (GO), is the most common diagnosis of orbital tissue inflammation. It is typically associated with the onset of hyperthyroidism, an autoimmune response to excess amounts of thyroid hormone. However, a visible and palpable lump, strictly unilateral or gross asymmetric eye involvement, non-axial (eccentric) proptosis, a lack of lid retraction or lid lag on downward gaze, or weakened muscle function (suggestive of tendon involvement) are the key features of non-TED mediated ocular involvement, as was found in the case we report here. Orbital lymphoma should always be suspected and excluded in all cases of orbital inflammation. Our patient was diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma at 27 years of age, two years after the diagnosis of euthyroid ophthalmopathy. This case highlights the need to include space-occupying lesions in the differential diagnosis of proptosis and gaze restrictions, even in younger patients.

Perception of Preparedness of Health Care Professionals in Case of a Nuclear, Chemical, Biological Attack/Emergency in a Tertiary Care Hospital.

Background With the growth of global terrorism and rapid advancements in the field of science, the threat of a nuclear, biological, and chemical (NBC) attack remains imminent. This study assesses perceptions of preparedness of health care professionals in case of an NBC attack/incident in a tertiary care hospital. Patients and methods We conducted a descriptive, cross-sectional study of 200 health care workers (including nurses and doctors) in a tertiary care hospital, from October 2018 through December 2018. Participants answered 17 yes/no questions and five 5-point Likert scale questions. We analyzed the data using chi-square tests and one-way analysis of variance. Results Most participants (73.6%) reported availability to an isolation facility, and a majority of participants (72%) reported they had access to ventilators. Approximately 60% of participants reported they had access to beds, and 44.6% reported access to a laundry facility. Most participants (65.3%) knew of an employee assistance program while 31.1% did not know about such a program at their institution. More than 50% of the respondents think they can deal with an emergency involving an NBC attack while 60% of the respondents did not think that their institution would be able to protect them in the event of an NBC attack/incident. Overall, the participants were not adequately prepared for a mass scale NBC incident. The level of preparation was linked to the number of courses and training programs completed by the participants, with postgraduate medical personnel having the maximum level of preparedness, followed by medical graduates and nursing personnel. Conclusion Given the inadequate level of preparedness for an NBC incident as indicated by our findings, drills and seminars on large-scale emergencies such as an NBC attack should be included in the curriculum of undergraduate medical and nursing students in order to impart them the necessary training and confidence in dealing with an NBC incident.