Actinomyces europaeus Brain Abscess in a 69-Year-Old Female Causing Irreversible Neurologic Complications.

Actinomycosis is a chronic, indolent, granulomatous disease process caused by the Actinomyces genus of bacteria. More severe forms of actinomycosis include disseminated or central nervous system (CNS) infections. Actinomyces meyeri is the most common species of Actinomyces isolated from brain abscesses. A. europaeus species is commonly associated with skin and soft tissue abscesses. However, it rarely causes brain abscesses. We present an unusual case of A. europaeus brain abscess in a 69-year-old female who presented with acute encephalopathy and bilateral lower extremity weakness. She was diagnosed with left-sided mastoiditis with intracranial extension, left posterior fossa epidural abscess, and transverse sinus thrombosis. The patient's hospital course was complicated by hydrocephalus and declining neurological status. Empiric antimicrobial therapy was initiated, and the patient underwent mastoidectomy and external ventricular drain placement followed by decompression craniotomy and subarachnoid abscess aspiration. Given her poor and unchanged neurologic status, the patient was transitioned to comfort-oriented measures after shared decision-making with the family. It is crucial to identify Actinomyces as a causal agent of severe CNS infections like brain abscesses, meningoencephalitis, or subdural empyema, as untreated infections can lead to irreversible neurologic complications.

A case of spontaneous pneumothorax due to paragonimiasis in North America with literature review.

The species, Paragonimus kellicotti , causes human paragonimiasis in North America. As a foodborne disease, human infection with P. kellicotti occurs after eating raw or undercooked crayfish containing metacercariae. Many risk factors have been described in the literature, including young adult age, male, alcohol consumption, outdoor activities involving rivers within Missouri, and ingesting raw or partially cooked crayfish. Here, we report a case of a 41-year-old male with a 5-year history of cough who presented with acute shortness of breath. Further workup showed mild eosinophilia and spontaneous pneumothorax. A definitive diagnosis was made with a lung biopsy, which showed P. kellicotti eggs. Further questioning revealed that the patient took a hunting and river rafting trip on a river in Missouri 5 years ago, though the history was negative for any crayfish consumption. Paragonimiasis should be considered in those with associated clinical features, including cough and eosinophilia, with a history of a river raft float trip in Missouri, even if the history is negative for crayfish ingestion or travel.

Analysis of length of stay and treatment emergent complications in hospitalized myasthenia gravis patients with exacerbation.

INTRODUCTION: AIMS Myasthenia Gravis (MG) is an autoimmune neuromuscular disease in which patients suffer from recurrent exacerbation. There are insufficient data measuring the effects of the resources employed before and during acute exacerbation on subsequent disease outcomes. This study aims to identify factors which lead to lengthened hospital stay. METHODS: This is a retrospective chart review of acute MG exacerbations requiring hospitalization. Exacerbations were identified using ICD-9/ICD-10 codes and considered the following variables: age and Myasthenia Gravis Foundation of America (MGFA) class at initial MG diagnosis, age and MGFA class at exacerbation, sex, thymectomy, cause of exacerbation, treatment regimen at time of exacerbation, inpatient treatment regimen, length of hospital stay (LOS), intubation, use of noninvasive ventilation, complications, and disposition. RESULTS: Seventy patients with 141 hospitalizations were identified. Crisis management characterized by intubation and plasmapheresis positively correlated with LOS (both p < .001). Almost 1/5 hospitalizations required intubation. Previous thymectomy negatively correlated with LOS (p < .05). In contrast, male sex correlated with longer LOS (p < .05). One-third of hospital stays were followed by discharge to a post-acute care facility, 7% home with home health, and 1 hospitalization resulted in death. DISCUSSION: Plasmapheresis, intubation, and male sex were associated with increased LOS in acute MG exacerbation. Intubation appears to be the strongest predictor of LOS. Those with previous thymectomy had shorter hospital stays. The role of thymectomy in the acute setting merits further analysis.

Immunoglobulin A vasculitis induced by atypical pneumonia infection with Chlamydophila pneumonia.

Infections are a common trigger for IgA vasculitis. Among the bacteria that cause atypical pneumonia, Mycoplasma pneumoniae infection has strongly been associated with IgA vasculitis, with Chlamydophila pneumoniae reported with IgA vasculitis in only one case. Though IgA vasculitis is a self-limiting disease, patients with infection-related vasculitis have shown to benefit from early identification and treatment with antimicrobial therapy. Here, we report a case of IgA vasculitis due to C. pneumoniae infection in a 19-year-old male who presented with an acute onset of rash, that was later followed by symptoms of cough and fever.

Academic and Employment Status in Patients With Generalized Myasthenia Gravis Treated With Eculizumab: A Case Series.

OBJECTIVES: To evaluate the impact of treatment with eculizumab, a terminal complement inhibitor, on academic and employment status in patients with refractory generalized myasthenia gravis (MG). METHODS: Case review of 7 US patients. RESULTS: Six patients were aged ≤65 years; one was a full-time student and the remainder were in employment before MG diagnosis. After diagnosis, all patients gave up work (n = 3) or reduced their study/working hours (n = 4). In the 12 months after eculizumab initiation, patients who had stopped work resumed working in some capacity, whereas those who had changed their work/study hours returned to their original work/study pattern. Patients also experienced a reduction in the number of MG exacerbations, and a clinically significant improvement in MG-Activities of Daily Living scores, and were able to reduce other MG medications. CONCLUSIONS: These results suggest that treatment with eculizumab may help maintain education/employment activity in patients with refractory generalized MG.

Clinical features with anti fibroblast growth factor receptor 3 (FGFR3) antibody-related polyneuropathy: a retrospective study.

BACKGROUND: Despite its initial association with sensory neuropathies, anti-fibroblast growth factor receptor 3 (FGFR3) antibodies have been since reported with a broad range of neuropathies and clinical features. The aim of the study is to report the clinical and electro diagnostic findings in a cohort of patients with sensory or sensorimotor polyneuropathy and anti-FGFR3 antibodies. METHODS: We performed a retrospective chart review to assess the clinical characteristics of patients with sensory or sensorimotor neuropathy related to FGFR3 antibodies. Descriptive statistics were reported using frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables. RESULTS: This study included 14 patients (9 women) with a median age of 51.9 years (IQR 48-57). The most common presenting symptoms were painful paresthesia (100%), gait instability (42.9%), constitutional symptoms (42.9%), and autonomic symptoms (28.6%). Onset of symptoms was chronic (≥12 weeks) in eight patients (57.1%). Examination showed a distal loss of sensation to pin prick (100%), as well as impaired vibration sensation (78.6%) and proprioception (35.7%), in the distal extremities. We also observed mild weakness in the distal lower-extremities (42.9%). Three patients (21.4%) had trigeminal neuralgia, three patients (21.4%) had co-existing autoimmune disease, and one patient (7.1%) had a history of renal cell carcinoma. The mean titer of FGFR3 antibody was 14,285.71 (IQR 5000-16,750). All 14 patients produced normal results in the neuropathy workup. Nerve conduction study and electromyography showed sensory axonal neuropathy in four patients (28.6%), sensorimotor axonal neuropathy in seven patients (50%), and a normal result in three patients (21.4%). For those with a normal NCS/EMG, a skin biopsy showed a non-length-dependent small fiber neuropathy. CONCLUSIONS: Neuropathy related to FGFR3 antibodies can potentially involve small and large fibers, sensory and motor fibers, and even the trigeminal nerve, which contributes to a highly variable clinical presentation.

Anti-calcitonin gene-related peptide monoclonal antibodies for neuropathic pain in patients with migraine headache.

INTRODUCTION: There is increasing evidence that calcitonin gene-related peptide (CGRP) plays a role in the development of neuropathic pain, a common feature of peripheral neuropathy. Although clinical studies have shown that anti-CGRP monoclonal antibodies are highly efficacious for migraine headache prophylaxis, their effects on nonheadache chronic pain conditions, including neuropathic pain, in humans are unknown. Therefore, the aim of this study was to assess the effectiveness of anti-CGRP monoclonal antibodies for neuropathic pain in patients with coexisting chronic migraine. METHODS: A retrospective chart review was conducted of 14 patients with chronic migraine and peripheral neuropathy. All patients were treated with anti-CGRP monoclonal antibodies. We collected data on patient-reported scores on the Neuropathy Pain Scale (NPS) and the frequency of migraine headache days (MHDs) per month. Data were collected 3 and 0 months before and 3, 6, 9, and 12 months after treatment with anti-CGRP medications. RESULTS: With treatment of anti-CGRP monoclonal antibodies, patients reported a 41.7% decrease in NPS scores from 89.3 at baseline to 52.1 at 12 months posttreatment (P < .05). In addition, there was a 33.3% decrease in MHDs per month from 19.8 at baseline to 13.2 at 12 months posttreatment (P < .05). DISCUSSION: Administration of anti-CGRP medications significantly improved neuropathic pain in patients who also had chronic migraine. To confirm these promising outcomes, it would be worthwhile to conduct a blinded, randomized study with a larger population of patients.