Neurocysticercosis Presenting as Migraine in the United States.

BACKGROUND Cysticercosis is a condition caused by infection with the larval form of Taenia solium, a pork tapeworm that uses pigs as an intermediate host. Humans become infected when they ingest water or food contaminated with tapeworm cysts. Cysticercosis is increasing in frequency in developed countries due to increased access to travel. Neurocysticercosis occurs when Taenia solium cysts embed within the nervous system. The clinical presentation of neurocysticercosis ranges from asymptomatic to life-threatening, largely depending on the brain parenchymal involvement. The diagnosis is typically made with a combination of clinical evaluation, serology, and neuroimaging. Treatment for parenchymal neurocysticercosis may involve anthelmintic agents, symptomatic agents, surgery, or a combination of methods. CASE REPORT A 52-year-old man with a medical history of migraine headaches, complicated type 2 diabetes mellitus, and obesity presented with a 4-month change in his migraines becoming severe, worse over his occiput bilaterally, and unresponsive to abortive therapy. His exposure history was unremarkable except for a habit of eating undercooked bacon, by which he would have developed neurocysticercosis via autoinfection. Neuroimaging and serology confirmed a diagnosis of neurocysticercosis and he was treated accordingly with antiparasitic and anti-inflammatory medications. CONCLUSIONS This presentation is nonspecific and can easily be overlooked, especially if there is an underlying known neurological condition such as migraine. This case illustrates that neurocysticercosis should be considered when an existing neuropathological condition displays a change in presentation or requires a change in therapeutic management, even without obvious risk factors.

A Rare Case of Severe Stevens-Johnson Syndrome Triggered by Topical Ofloxacin.

BACKGROUND Stevens-Johnson syndrome (SJS) is a rare dermatologic disorder that is characterized by nonspecific flu-like prodrome with fever, malaise, myalgia, cough, rhinitis, and sore eyes, followed by a characteristic rash and mucocutaneous manifestations. It is triggered by medications in up to 80% of cases in adults. In each of these cases, the medication is oral or parenteral. Severe and progressive SJS can result in life-threatening complications. Adult-onset medication-induced SJS presents within 8 weeks of exposure to the offending substance, lasting 8 to 12 days. Recovery of denuded skin generally is complete within a month. There is no consensus on treatment, but supportive care with corticosteroids is often the initial intervention. CASE REPORT A 36-year-old woman with a flare of allergic rhinitis and tearing resistant to over-the-counter options was treated with topical ophthalmic ofloxacin. She began experiencing a diffuse mucocutaneous rash, with oral desquamation, tongue swelling, vaginal desquamation, and rash of the palms and soles within 24 h, which suggested the possibility of SJS. A skin biopsy was obtained, and pathology confirmed this suspicion. She was treated with parenteral antibiotics, corticosteroids, and supportive care, and after 10 days was discharged from the hospital. She had a complete recovery in 30 days. CONCLUSIONS The clinical course of SJS induced by the ophthalmic application of medication can be just as severe as the oral or parenteral routes. This is, to the best of our knowledge, the first documented case of SJS being triggered by topical ofloxacin.

Unusual Case of Ludwig Angina Caused by Clostridium sporogenes in an Immunocompromised HIV-Positive Patient with Alcoholism and Dental Abscess.

BACKGROUND Ludwig angina is a cellulitis of the soft tissues of the neck and floor of the mouth. It is most commonly caused by Viridans streptococcal species, but other bacterial species have been shown to lead to this severe infection. Clostridium sporogenes is an anaerobic gram-positive, spore-producing bacillus found in soil and the human gastrointestinal tract. This report is of a case of a 49-year-old HIV-positive man with alcoholism and poor dental hygiene leading to a molar abscess who presented with Ludwig angina due to C. sporogenes. CASE REPORT A 49-year-old man presented with severe left molar pain, fever, and worsening neck swelling for 5 days. His medical history was significant for AIDS; he was not on antiretroviral therapy. Computed tomography of the neck was positive for extensive subcutaneous emphysema of the left sublingual space. Ludwig angina was diagnosed, and he was taken urgently for incision and drainage of the bilateral neck fascial space. On day 6 of hospitalization, 1 of 2 blood cultures grew C. sporogenes. He left the hospital on day 13 and was readmitted 6 days later with progression of the disease and alcohol withdrawal. CONCLUSIONS This case illustrates the need for rapid diagnosis and treatment of Ludwig angina and the importance of considering commonly pathogenic and rarely pathogenic bacteria when considering the underlying bacterial cause of an infection in an immunocompromised patient. To the best of our knowledge, this is the first case of Ludwig angina caused by C. sporogenes reported in the medical literature.

Ovarian Vein Thrombosis: An Unusual Cause of Abdominal Pain in Breast Cancer.

Ovarian vein thrombosis (OVT) is a rare but potentially life-threatening complication that is usually seen in the intrapartum or postpartum period but can also be seen in patients with risk factors for venous thromboembolism. When symptomatic, it usually presents with abdominal pain and other vague constitutional symptoms, hence it is important for healthcare professionals to be aware of this condition when evaluating patients with risk factors. We present a rare case of OVT in a patient with breast cancer. Due to a lack of clear guidelines regarding the treatment and duration of treatment in non-pregnancy-related OVT, we followed the guidelines for the treatment of venous thromboembolism and started the patient on rivaroxaban for a three-month duration with close outpatient follow-up.

A 24-Year-Old Man Presenting with Lung Metastases from a Primary Retroperitoneal Extragonadal Choriocarcinoma.

BACKGROUND Primary retroperitoneal choriocarcinoma is a rare form of extragonadal germ cell tumor that is highly aggressive and responds poorly to chemoradiation. Extragonadal choriocarcinomas are notoriously challenging to diagnose, and have often progressed to advanced disease by the time of diagnosis. The survival rate for extragonadal choriocarcinoma is approximately 30%, which is much lower than that of extragonadal non-seminomatous germ cell tumors (GCT) in general. CASE REPORT A 24-year-old man with no significant past medical history presented with left-sided, pleuritic chest pain and back pain radiating down his left leg, of 1-year duration. Computed tomography (CT) of the chest revealed multiple bilateral pulmonary nodules and a CT of the abdomen and pelvis showed a large heterogeneous soft tissue mass measuring 9.3×8×10.5 cm. A CT-guided core needle biopsy of a lung nodule was performed and the findings were consistent with the diagnosis of metastatic choriocarcinoma. Magnetic resonance imaging (MRI) of the brain was negative for metastatic disease. Tumor markers were significant for a markedly elevated beta human chorionic gonadotropin (B-hCG) of 104 712 mIU/mL. He was diagnosed with a stage IIIC germ cell tumor, further classified as a primary retroperitoneal choriocarcinoma with lung metastasis, and was started on urgent inpatient chemotherapy. CONCLUSIONS Due to the poor outcomes associated with extragonadal choriocarcinoma, it is important to promptly and correctly identify this malignancy in order to initiate treatment in a timely manner. The following case report explores the histopathologic characterization of this malignancy and describes the clinical course and outcomes from treatment for this patient.

Systemic Lupus Erythematous and Neuromyelitis Optica Causing Hypercapnic Respiratory Failure.

BACKGROUND Neuromyelitis optica (NMO) is a rare neurological disease characterized by attacks of transverse myelitis and optic neuritis, contiguous spinal cord lesions on more than 3 vertebral segments on magnetic resonance imaging (MRI), and seropositivity for AQP-4 Ab. The tissue destruction from NMO is immune mediated and results in demyelination and axonal damage. Optic and spinal nerve involvement can eventually lead to blindness, weakness, and altered consciousness, and bladder and bowel involvement in some cases. CASE REPORT A 54-year-old Black woman presented with chest pain, dysphagia, generalized weakness, diplopia, and paresthesias in her bilateral feet. A brain MRI revealed an area of hyperintensity in the cervical medullary junction. A diagnosis of NMO was made after the treatment response was poor for systemic lupus erythematous (SLE) myelitis. She eventually developed acute hypercapnic respiratory failure, became encephalopathic, and was emergently intubated. She was extubated but had poor recovery and was eventually discharged home. CONCLUSIONS NMO is a rare immune-mediated disease that is often delayed in diagnosis and treatment. Clinical suspicion is important since there is a tendency for the disease to overlap concomitant autoimmune diseases in 25% of cases. Progressive and permanent tissue damage can occur despite the use of high-dose steroids, long-term immunosuppressant agents, immunomodulators, exchange transfusions, and even autologous hematopoietic stem cell bone marrow transplantation.

Left Ventricular Pseudoaneurysm and Left Ventricular Thrombus in a Patient Presenting with an Acute ST-Elevation Myocardial Infarction.

BACKGROUND ST-elevation myocardial infarction (STEMI), when associated with acute left ventricular (LV) free-wall rupture, is often a lethal complication, and if not followed by sudden death, the rupture may be contained by the parietal pericardium and a local thrombus, leading to the formation of a left ventricular (LV) pseudoaneurysm. The incidence of LV pseudoaneurysm after STEMI is ~ 0.3%. CASE REPORT A 73-year-old man who presented with an acute syncopal episode and intermittent chest pain for 7 days was found to have an anterolateral myocardial infarction (MI) with lateral wall rupture and pseudoaneurysm formation. He had an LV thrombosis in the LV aneurysm. While this increased his risk of thromboembolic events, it likely stopped the evolution of the rupture and stabilized the pericardial effusion size. The patient underwent coronary artery bypass grafting (CABG), thrombectomy, and lateral wall repair. CONCLUSIONS Left ventricular pseudoaneurysm and left ventricular thrombus in a patient presenting with an acute ST-elevation myocardial infarction is a rare complication of myocardial infraction, with an incidence of <1%. It is often a lethal complication and requires stabilization and repair if not followed by sudden death.

A mobile-assisted voice condition analysis system for Parkinson's disease: assessment of usability conditions.

BACKGROUND AND OBJECTIVE: Automatic voice condition analysis systems to detect Parkinson's disease (PD) are generally based on speech data recorded under acoustically controlled conditions and professional supervision. The performance of these approaches in a free-living scenario is unknown. The aim of this research is to investigate the impact of uncontrolled conditions (realistic acoustic environment and lack of supervision) on the performance of automatic PD detection systems based on speech. METHODS: A mobile-assisted voice condition analysis system is proposed to aid in the detection of PD using speech. The system is based on a server-client architecture. In the server, feature extraction and machine learning algorithms are designed and implemented to discriminate subjects with PD from healthy ones. The Android app allows patients to submit phonations and physicians to check the complete record of every patient. Six different machine learning classifiers are applied to compare their performance on two different speech databases. One of them is an in-house database (UEX database), collected under professional supervision by using the same Android-based smartphone in the same room, whereas the other one is an age, sex and health-status balanced subset of mPower study for PD, which provides real-world data. By applying identical methodology, single-database experiments have been performed on each database, and also cross-database tests. Cross-validation has been applied to assess generalization performance and hypothesis tests have been used to report statistically significant differences. RESULTS: In the single-database experiments, a best accuracy rate of 0.92 (AUC = 0.98) has been obtained on UEX database, while a considerably lower best accuracy rate of 0.71 (AUC = 0.76) has been achieved using the mPower-based database. The cross-database tests provided very degraded accuracy metrics. CONCLUSION: The results clearly show the potential of the proposed system as an aid for general practitioners to conduct triage or an additional tool for neurologists to perform diagnosis. However, due to the performance degradation observed using data from mPower study, semi-controlled conditions are encouraged, i.e., voices recorded at home by the patients themselves following a strict recording protocol and control of the information about patients by the medical doctor at charge.

Replication-based regularization approaches to diagnose Reinke's edema by using voice recordings.

Reinke's edema is one of the most prevalent laryngeal pathologies. Its detection can be addressed by using computer-aided diagnosis systems based on features extracted from speech recordings. When extracting acoustic features from different voice recordings of a particular subject at a concrete moment, imperfections in technology and the very biological variability result in values that are close, but they are not identical. This suggests that the within-subject variability must be properly addressed in the statistical methodology. Regularization-based regression approaches can be used to reduce the classification errors by favoring the best predictors and penalizing the worst ones. Three replication-based regularization approaches for variable selection and classification have been specifically designed and implemented to take into account the underlying within-subject variability. In order to illustrate the applicability of these approaches, an experiment has been specifically conducted to discriminate Reinke's edema patients (30 subjects) from healthy people (30 subjects) in a hospital environment. The features have been extracted from four phonations of the sustained vowel /a/ recorded for each subject, leading to a database that has fed the proposed machine learning approaches. The proposed replication-based approaches have been proved to be reliable in terms of selected features and predictive ability, leading to a stable accuracy rate of 0.89 under a cross-validation framework. Also, a comparison with traditional independence-based regularization methods reports a great variability of the latter in terms of selected features and accuracy metrics. Therefore, the proposed approaches contribute to fill a gap in the scientific literature on statistical approaches considering within-subject variability and can be used to build a robust expert system.

A Large Intrathoracic Hiatal Hernia as a Cause of Complete Heart Block.

Hiatal hernia is a not uncommon anatomic disorder resulting in portions of the bowel occupying space in the thoracic cavity. There are a number of antecedent risk factors including obesity but not hiatal hernias resulting in symptoms. When symptoms do occur, they can include chest pain, nausea, abdominal pain, and gastroesophageal reflux. Cardiac arrhythmias have also been reported as associated conditions resulting from a hiatal hernia. To date, however, a complete heart block secondary to a hiatal hernia has not been reported. An 88-year-old female with a history of GERD (gastroesophageal reflux disease) was found to have a large hiatal hernia at endoscopy after she presented to the emergency department with nausea and abdominal pain. Prior to her scheduled surgical repair, she developed symptomatic third degree heart block which resolved with nasogastric tube deflation of the gastric contents. After surgical repair of the hiatal hernia, she developed episodes of atrial fibrillation with rapid ventricular response and was started on diltiazem. She eventually converted back to normal sinus rhythm and remained dysrhythmia free. In addition to other known arrhythmias associated with hiatal hernia, a complete heart block can also be seen. Acute management requires deflation of the chest occupying hernia. This appears to be the one of the first reported cases of complete heart block caused by hiatal hernia.

Acute Hepatitis E: A Rare Cause of Acute Liver Failure in a Patient With Acute Myeloid Leukemia.

Immunocompromised patients are particularly at risk to develop hepatitis E virus (HEV) infection and its related complications. We present a rare case of HEV infection in a 35-year-old Hispanic female with concomitant acute myeloid leukemia (AML). The patient presented with acute liver failure within a few weeks after receiving a blood transfusion. Our case likely represented an acute de novo HEV infection after chemotherapy in a patient with concurrent AML, evidenced by the presence of anti-HEV IgM antibodies as well as histological findings, and with a previous history of recent transfusions being one of the strongest risk factors for transmission. Liver failure from an acute de novo hepatitis E infection with concurrent AML can be catastrophic in the immunosuppressed patient. Our case is particularly unique due to the uncommon presentation of acute hepatitis E in a non-pregnant reproductive aged Hispanic female with recently diagnosed AML. Clinicians should maintain a low threshold to test serum HEV-RNA if a patient presents with signs and symptoms suggestive of acute hepatitis.

Portal vein aneurysm with acute portal vein thrombosis masquerading as a pancreatic mass.

Portal vein aneurysm (PVA) with portal vein thrombosis (PVT) is an exceedingly rare vascular phenomenon with a limited number of reported cases in the medical literature. We describe a case of a 25-year-old man found to have a congenital PVA with PVT initially believed to be a pancreatic mass. While there remains some incongruity amongst clinicians with such a limited number of reported cases, herein, we describe the general consensus of the diagnostic approach and management of this vascular malformation.

Vaping-Induced Lung Injury: A Case of Lipoid Pneumonia Associated with E-Cigarettes Containing Cannabis.

Electronic cigarette, or vaping product use-associated lung injury (EVALI), is a group of lung disorders associated with vaping and e-cigarette products that has previously been categorized as a diagnosis of exclusion and best described as an exogenous lipoid pneumonia or chemical pneumonitis. Here, we describe the onset of an exogenous cause of lipoid pneumonia in an otherwise healthy patient using cannabis-containing electronic cigarettes. We explore similarities in the clinical case, define a common clinical presentation with progression of disease, characteristic radiographic findings along with pathological diagnosis and management.

Epidural Steroid Injection-Induced Pancreatitis: A Case Report.

BACKGROUND Degenerative disc disease of the lumbar spine can be associated with spinal canal and neuroforaminal stenosis, resulting in severe pain. Conservative approaches to treatment are generally recommended initially, especially in the elderly. Epidural corticosteroid injections can provide significant but temporary pain relief and are a commonly performed procedure in pain management. Pancreatitis caused by corticosteroids is unusual and the prognosis typically is good. CASE REPORT A 73-year-old woman presented with severe intractable back pain 1 week after lumbar epidural steroid injection for symptomatic spinal stenosis. Imaging confirmed severe multi-level degenerative disc disease of the lumbar spine resulting in severe canal and bilateral neuroforaminal stenosis. Because of abdominal pain and nausea, an abdominal CT and labs were performed, revealing evidence of pancreatic inflammation. CONCLUSIONS Lumbar epidural steroid injection may be a risk factor for developing steroid-induced pancreatitis.

Thrombocytopenia and endocarditis in a patient with Whipple's disease: case report.

BACKGROUND: Whipple's disease (WD) is a rare multisystem infectious disorder that is caused by the actinomycete Tropheryma whipplei. It presents with joint pain followed by abdominal pain, diarrhea, malabsorption and finally failure to thrive. Diagnosis requires tissue sampling and histology with periodic acid-Schiff [PAS] staining. Thrombocytopenia associated with endocarditis associated with WD has been reported twice. CASE PRESENTATION: A 56 year old Caucasian male presented with years of steroid treated joint pain and recent onset diarrhea, weight loss and abdominal pain. Ultimately he was found to have a platelet count of 4000 with concomitant endocarditis and embolic stroke. Small bowel biopsy confirmed the diagnosis of WD approximately 1 year after his first visit. His platelets improved with antibiotic treatment but he eventually expired 16 months after his initial consult and 5 months after his definitive diagnosis. CONCLUSION: WD can remain undiagnosed and untreated until late in the course of the illness. A high index of suspicion is recognized as necessary for early diagnosis to begin treatment. Critical thrombocytopenia associated with endocarditis is a rare and potentially poor prognostic sign in late stage Whipple's disease.

Successful Treatment of Hypokalemic Rhabdomyolysis Caused by a Pancreatic VIPoma: A Case Report.

BACKGROUND VIPomas are rare neuroendocrine tumors typically located in the pancreas. The majority of cases autonomously secret vasoactive intestinal polypeptide (VIP), which can result in profuse, refractory, watery diarrhea. The fluid and electrolyte imbalance can progress to dehydration and profound hypokalemia, resulting in the watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome. One previous case of a pancreatic VIPoma progressing to hypokalemic rhabdomyolysis has been described. CASE REPORT A 33-year-old woman presented with 3 months of progressive, refractory diarrhea and weakness. Her serum VIP level was elevated and imaging discovered a mass in the region of the pancreatic tail. Laparoscopic partial pancreatic resection was performed and a 3.7-cm diameter, solitary stage T2 N0 M0, well-differentiated carcinoma was removed. CONCLUSIONS A high index of suspicion is important when diagnosing chronic diarrhea. Minimally invasive surgery is an option in the surgical treatment of pancreatic VIPoma.

Lymphatic Malformation of the Nasopharynx in a Young Pregnant Female: A Case Report.

BACKGROUND Lymphangiomas represent the focal proliferation of benign, well-differentiated lymphatic tissue. They are most likely congenital, thus more commonly diagnosed at birth and before the age of 2 years. When they are found in adults, they favor the head, neck and axillary region. Rarely do they involve the nasopharynx region or occur in a pregnant patient. CASE REPORT A 21-year-old primagravida in the third trimester of pregnancy developed difficulty swallowing that progressed into difficulty breathing over a 1-month period. Imaging and examination suggested a benign mass in the nasopharynx and the patient underwent surgical removal of the stalk with bipolar cautery. The pathology report revealed a simple 4.5×1.5×0.8 cm lymphangioma. She had no fetal compromise during anesthesia. CONCLUSIONS Surgical removal of a nasopharyngeal lymphangioma during the third trimester of pregnancy is indicated if respiratory obstruction may be a complication.

Epithelioid Hemangioendothelioma: A Rare Case of an Aggressive Vascular Malignancy.

BACKGROUND Epithelioid hemangioendothelioma (EHE) is a rare vascular malignancy that occurs in multiple organs and tissues with a predilection for the extremities, bone, liver, and lung. It is often characterized by a clinically indolent course, delayed diagnosis, and unestablished standardized treatment options. CASE REPORT A 46-year-old female presented with a 2-month history of right shoulder and arm pain. Imaging revealed involvement of the humerus, lung, liver; and brain and biopsies of both the lung and humerus were performed. A diagnosis of epithelioid hemangioendothelioma was confirmed and the patient received radiation therapy to the right humerus and brain stereotactic radiosurgery. She was scheduled to begin palliative chemotherapy with doxorubicin but developed complications and never received chemotherapeutic agents. She died 5.5 months from her first admission with widespread metastasis. CONCLUSIONS Epithelioid hemangioendothelioma (EHE) is typically a low-to-intermediate grade vascular malignancy, but, as seen in this case, can be aggressive. In the future, diagnosis, prognosis, and treatment may improve using genetic or immune therapy considering a structural chromosomal translocation has been identified.

Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram.

BACKGROUND: Hyperosmolar hyperglycemic state is a life-threatening endocrine disorder that most commonly affects adults with type 2 diabetes mellitus. The condition results from an osmotic diuresis-induced loss of water exceeding that of sodium. Altered mental status, hypernatremia and hyperglycemia are characteristic features at presentation. Abnormal electroencephalogram findings have been reported. Successful therapy requires judicious fluid replacement and close monitoring. CASE: A 78-year-old Hispanic female with a significant past medical history of type 2 diabetes mellitus was admitted with altered mental status, severe hypernatremia and hyperglycemia. She was diagnosed with hyperosmolar hyperglycemic state, and fluid therapy was started. A continuous electroencephalogram revealed left frontocentral and temporal periodic lateralized epileptiform discharges that resolved as her hypernatremia and dehydration were treated. She survived and was discharged after 1 week of treatment. CONCLUSION: Abnormal electroencephalogram findings consistent with nonconvulsive seizure activity may be temporary and reversible and do not suggest a poor prognosis in an elderly patient suffering from hyperosmolar hyperglycemic state and altered mental status.

Clear-Cell Carcinoma of the Ovary with Bilateral Breast Metastases.

Ovarian clear-cell carcinoma is an uncommon subtype of epithelial ovarian carcinoma. It carries a generally poor prognosis because of its resistance to standard treatment and metastatic spread to vital organs. Metastasis to the breast is rare and bilateral breast metastasis is unreported. A 61-year-old white female with a 5-year status poststandard therapy for stage IC clear-cell ovarian carcinoma presented with widespread metastasis. Tissue analysis revealed ovarian cancer metastasis to the breasts bilaterally. Clinical awareness of this metastatic potential is important when staging and developing a treatment plan for patients with ovarian clear-cell cancer.