A Rare Complication of Herpes Zoster: Segmental Zoster Paresis.

Segmental zoster paresis (SZP) is a rare complication of herpes zoster (HZ) that results in focal weakness of the extremity in the myotome that corresponds to dermatomal involvement.We present a case of an 80-year-old female with a resolving HZ rash on her left leg and buttocks that presented with left leg weakness for two weeks. The patient's rash preceded the left leg weakness by two weeks. The exam revealed erythematous macular and crusting lesions in the left L3/L4 distribution. The left thigh was flaccid with 1/5 knee extension strength with an absent patellar reflex. Lumbar spine magnetic resonance imaging (MRI) revealed enhancement of the left L4 roots, suggestive of inflammation or neuropathy. The patient was discharged on gabapentin, amitriptyline, and a two-week prednisone taper. In this case study, we present SZP, a rare complication that occurs in approximately 3% of HZ patients. The majority of SZP cases occur on the face or upper extremity, whereas our patient had SZP of the lower extremity. This case emphasizes the importance of maintaining a comprehensive differential diagnosis and highlights that SZP should be considered in patients who present with acute weakness in an extremity.

Left Ventricular Thrombus Formation in a Young Female With a Severely Reduced Left Ventricular Ejection Fraction and a Recent Non-ST Segment Elevation-Acute Coronary Syndrome.

A 30-year-old female with a past medical history of heart failure with reduced ejection fraction (HFrEF of 20%), non-ST segment elevation-acute coronary syndrome (NSTE-ACS), and polysubstance abuse (heavy alcohol and methamphetamine use) was admitted for a heart failure exacerbation. Electrocardiogram and troponin levels were negative. Pro brain natriuretic peptide was elevated at 4,152 pg/mL. The patient was restarted on guideline-directed HFrEF therapy and continued to improve. Two days after presentation, the patient was transferred to the intensive care unit for severe alcohol withdrawal, requiring intravenous phenobarbital and dexmedetomidine. After her withdrawal symptoms resolved, she complained of right-sided weakness and stroke-like symptoms. Brain magnetic resonance imaging (MRI) and computed tomography (CT) were both negative. Echocardiography revealed an ejection fraction of 20% and a severely dilated left ventricle with a 2.1 x 1.2 cm apical density, suggestive of a thrombus, and the patient was started on apixaban. Echocardiography two months prior to this admission revealed an ejection fraction of 20%, but there was no evidence of a thrombus. Our patient had three major risk factors for left ventricular thrombus (LVT) formation: severely reduced left ventricular ejection fraction (LVEF), dilated cardiomyopathy (DCM), and a recent NSTE-ACS two months prior. This case highlights the importance of anticoagulation in patients at high risk for LVT formation and emphasizes the DCM may be seen in younger patients with heavy alcohol and amphetamine use.

Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma.

Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.

Initial Presentation of Renal Cell Carcinoma as Heart Failure Secondary to Tumor-Thrombus Extension to the Right Atrium.

Renal cell carcinoma (RCC) can invade locally through the renal vein and into the inferior vena cava (IVC) with tumor-thrombus formation reported in 5%-15% of patients. From the IVC, RCC can grow intravascularly and extend into the right atrium. We present a rare case with two uncommon findings: tumor-thrombus extension leading to a right atrial mass and initial presentation of RCC as heart failure. A 69-year-old woman presented with signs and symptoms of heart failure. Electrocardiogram was normal and the initial troponin level was mildly elevated to 0.09 ng/mL. Echocardiography revealed a dilated right atrium with a 6.9 cm x 3.8 cm echogenic mass consistent with a tumor impinging on the tricuspid valve leading to a functional stenosis. Computed tomography (CT) of the abdomen revealed a large right-sided renal mass with enlargement of the renal vein suggestive of tumor thrombus. Although the initial presentation of RCC with cardiac symptoms is surprising, this case highlights the importance of maintaining a comprehensive differential diagnosis. It also signifies the need for further imaging as not all atrial masses are cardiac tumors. Many other primary tumors - kidney, liver, lung, and thyroid - can directly invade or metastasize into the atrium by way of the vena cava.