Insights from neuroradiology in acute disseminated encephalomyelitis.

Acute disseminated encephalomyelitis (ADEM) is a rare immune-mediated demyelinating disorder primarily observed in children, typically triggered by recent vaccination or viral infection. Although uncommon, there have been reports of ADEM occurring in adults, with varying radiological findings compared to pediatric cases. Distinguishing ADEM from other demyelinating disorders, such as multiple sclerosis (MS) and neuromyelitis optica (NMO), can pose a diagnostic challenge. We present a case report of an 18-year-old male with a history of polysubstance use who was successfully treated with corticosteroids and highlight the neuroradiological presentation of ADEM, emphasizing the importance of accurate diagnosis and management in both pediatric and adult populations.

Unveiling a rare radiological discovery: Interlobar pneumothorax in a young female patient.

Pneumothorax is a medical condition characterized by air in the space between the visceral and parietal pleural surfaces, with spontaneous and traumatic classifications. Spontaneous pneumothorax is further divided into primary and secondary groups based on the presence or absence of clinically apparent underlying lung disease. Here we present a case of a 23-year-old female with no past medical history who presented with chest pain and shortness of breath, ultimately diagnosed with primary spontaneous interlobar pneumothorax. Despite advancements in medical diagnosis techniques, spontaneous interlobar pneumothorax remains a rare presentation of pneumothoraces. Treatment strategies for clinically stable patients with a first episode of primary spontaneous pneumothorax include observation with or without supplemental oxygen, with further intervention only if the pneumothorax fails to improve or worsens.

Vancomycin-Resistant Enterococcus Endocarditis Complicated by Splenic Infarction and Embolic Stroke.

Infective endocarditis (IE) is a serious condition associated with high morbidity and mortality rates. The risk factors for IE include underlying heart disease, intravenous drug use, cardiac surgery, and interventional procedures. Enterococci are a common cause of IE, and vancomycin-resistant enterococci (VRE) infections are becoming increasingly prevalent. In this report, we present the case of an 88-year-old female patient with multiple cardiac comorbidities who developed VRE endocarditis with splenic infarction and embolic stroke. The patient was successfully treated with a combination of antibiotics and anticoagulation therapy. This report highlights the importance of recognizing the potential complications of VRE endocarditis and the need for appropriate management to prevent adverse outcomes. To the best of our knowledge, only one other case of VRE endocarditis with multiple systemic complications has been documented so far.

Hemiazygos vein dilation as a radiological finding and multifactorial cause of dysphagia.

Dysphagia is a common issue observed among the elderly, which can arise from various etiologies such as motility disorders and chronic neurologic conditions. Radiologists play a crucial role in diagnosing the cause of dysphagia, as they can identify anatomical abnormalities that may lead to the condition. One such anomaly is the hemiazygos vein, which is the left side equivalent of the azygos vein and can cause dysphagia if it crosses over the esophagus. To our knowledge, there are only 2 other recorded cases of azygos aneurysm/dilation causing esophageal dysphagia. In this context, we present a case report of a 73-year-old female with a 1-month history of weight loss and dysphagia due to a prominent hemiazygos vein. The case highlights the importance of thorough radiological evaluation in identifying the underlying cause of dysphagia and ensuring timely and appropriate treatment.

Echocardiographic Evaluation of Pulmonary Embolism: A Review.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.

Delayed-Onset Losartan-Induced Pancreatitis Secondary to an Overdose: A Case Report.

Acute pancreatitis is defined as inflammation of the pancreas and is most commonly caused by gallstones and alcohol use. Less commonly, acute pancreatitis can be drug induced from medications that are divided into 5 subgroups (classes Ia-V). The subgroups are determined based on the cases reported, reaction with rechallenge and a consistent period of latency. We describe a case of a 34-year-old female who overdosed on losartan pills in a suicide attempt but developed symptoms of drug-induced acute pancreatitis nearly a week later without gallstones, alcohol involvement, or other drug toxicity.

Two for the Price of One: A Case of Methicillin-Resistant Staphylococcus aureus (MRSA) Brain Abscess With Atypical Lymphoplasmacytic Infiltrate With Underlying Clonal Lymphoproliferative Process in a Patient Infected With HIV.

Multiple etiologies can coexist and trigger CNS symptoms in individuals infected with HIV. This article reviews a case of a cerebellar mass in an HIV patient who, on biopsy, grew methicillin-resistant Staphylococcus aureus (MRSA) and by pathology, showed an atypical lymphoplasmacytic infiltrate concerning a clonal lymphoproliferative process, which may be a precursor of CNS lymphoma. The patient, a 36-year-old male with multiple comorbidities including HIV Infection, presented to the hospital for evaluation of a one-week course of headache and photophobia. Remarkable physical examination findings included dilated pupils and anisocoria. Initial CT brain imaging revealed vasogenic edema seen throughout the left cerebellar hemisphere provoking mass effect on the fourth ventricle and pontocerebellar cistern resulting in mild hydrocephalus, new findings compared to prior. MRI brain displayed a T1 isointense, T2 hypointense ring-enhancing lesion in the left cerebellar hemisphere, with restricted diffusion, and surrounding vasogenic edema resulting in mass effect over the fourth ventricle, left cerebellar peduncle, and pontocerebellar cistern causing mild hydrocephalus. The patient underwent left suboccipital craniotomy with evacuation of the cerebellar lesion by neurosurgery. Tissue cultures grew MRSA. Pathology was sent to New York-Presbyterian Columbia University Irving Medical Center due to the presence of atypical lymphoplasmacytic infiltrates. The final diagnosis was polyclonal B-cell population in the sample; however, prominent peaks were also seen above the polyclonal background, possibly representing a clonal proliferation. Therefore, the lymphoplasmacytic infiltrates remained atypical and the possibility of the underlying clonal lymphoproliferative process could not be entirely ruled out.

Outcomes with use of extra-corporeal membrane oxygenation in high-risk pulmonary embolism: a national database perspective.

High-risk pulmonary embolism (PE) patients can be managed with systemic lysis, catheter-based therapies, or surgical embolectomy. Despite the advent of newer therapies, patients with high-risk PE remain with a 50-60% short-term mortality risk. In such patients, extracorporeal membrane oxygenation (ECMO) is increasingly utilized for hemodynamic support. To evaluate the outcomes of the use of ECMO in patients with high-risk PE. Using the National Inpatient Sample (NIS) database, we identified patients with high-risk PE using ICD 10 codes and compared in-hospital outcomes of patients with and without ECMO support. We identified 38,035 patients with high-risk PE, of whom 820 had undergone ECMO placement. Most patients who underwent ECMO were male (54%), white (65%), and with a mean age of 53.7 years. ECMO use was not associated with a meaningful difference in patient mortality when comparing treatment groups (OR, 1.32 ± 0.39; 0.74-2.35; p = 0.35). Rather, ECMO use was associated with a higher frequency of inpatient complications. ECMO use was not associated with a significant difference in patient mortality in patients with high-risk PE.

Clot In Transit in a Patient with Protein S Deficiency.

Clot in transit (CIT) is a rare condition in which a venous thromboembolism becomes lodged in the right heart. It is seen in up to 18% of patients with massive pulmonary embolism, and if left untreated, mortality rates are between 80% and 100%. The identification and management of CIT are crucial. However, there are no current guidelines for the treatment of CIT. We present the case of a 44-year-old woman who was found to have CIT that was ultimately treated with medical management. LEARNING POINTS: Clot in transit (CIT) is a dangerous entity that must be promptly managed.Risk factors for CIT include a history of heart failure, a pre-existing central venous catheter and recent hospitalization.New interventions are emerging for the treatment of CIT.

A Rare Case of Empagliflozin-Induced Euglycemic Diabetic Ketoacidosis Obscured by Alkalosis.

Empagliflozin-induced euglycemic diabetic ketoacidosis is a life-threatening metabolic complication of diabetes mellitus characterized by metabolic acidosis, ketonemia, and relatively normal serum glucose levels. We present a rare case of empagliflozin-induced diabetic ketoacidosis obscured by alkalosis. This case report aims to create awareness among clinicians about this entity and consider this diagnosis in their differential, especially in patients taking sodium-glucose co-transporter (SGLT-2) inhibitors who present to the hospital with unspecific symptoms that may not suggest DKA.

Hair Spray Induced Cardiomyopathy.

Inhalants are common drugs of abuse. Hydrocarbons, the active ingredient in most inhalants, exert depressant effects on the central nervous system, causing a 'high'. In the heart, hydrocarbon toxicity can predispose patients to arrhythmias and heart failure through increased sympathetic susceptibility. We present the case of a 28-year-old female who developed dilated cardiomyopathy in the setting of chronic inhalant abuse. LEARNING POINTS: Chronic inhalant abuse can lead to cardiac arrhythmia and heart failure.Chronic inhalant abusers should be screened for signs of heart failure.Severe hydrocarbon toxicity can cause sudden sniffing death syndrome.

Primary Malignant Melanoma of the Esophagus in a 76-Year-Old Female.

Mucosal melanomas represent about 1% of all melanoma cases. Primary malignant melanoma of the esophagus (PMME) is a rare and deadly condition, with only about 339 cases reported in the literature. Esophageal melanoma usually presents with progressively worsening dysphagia, and patients often present late in the disease course. Esophageal melanoma can be treated with surgical resection, chemotherapy, targeted therapy, or immunotherapy depending on the stage and tumor mutations. However, due to the rarity of the disease, no trials have been performed to deliver a gold standard of treatment. We present the case of a 76-year-old female who was diagnosed with metastatic primary malignant melanoma of the esophagus and underwent treatment with nivolumab, a PD-1 receptor antagonist.

Gabapentin-Induced Priapism.

Priapism is defined as an erection that lasts longer than four hours, is unrelated to sexual interest or stimulation, and is unrelieved by orgasm. The ischemic subtype is a urologic emergency and is often caused by medication side effects, most notably selective serotonin reuptake inhibitors and trazodone. We present the case of ischemic priapism thought to be caused by the recent initiation of gabapentin.

Adult-Onset Still's Disease in a 28-Year-Old Man From Ghana.

Adult-onset Still's disease is a rare, autoinflammatory disease characterized by spiking fevers, arthritis, salmon-colored skin rash, and leukocytosis. It has been compared to systemic juvenile idiopathic arthritis because of its similar features but is much rarer than its pediatric counterpart. It is usually treated with corticosteroids and disease-modifying anti-rheumatic drugs. However, those with refractory disease are candidates for one of many biological therapies. We present the case of a 28-year-old man who was successfully managed with first-line steroid therapy.

Bullous Erythema Multiforme Secondary to Trimethoprim-Sulfamethoxazole Use, Treated With Cyclosporine in a 91-Year-Old Male.

Erythema multiforme is an acute, immune-mediated, mucocutaneous condition in which 90% of cases are triggered by infection. The second most common cause is drug-induced. It classically presents with itchy, burning targetoid lesions on the skin and mucous membranes. The lesions may be mistaken for other conditions, and thus, rapid and correct diagnosis is crucial. It is most often treated with corticosteroids, though non-responders or those with weakened immune systems may require immunomodulatory therapy. We present the case of a 91-year-old male who developed bullous erythema multiforme after treatment with trimethoprim-sulfamethoxazole who was successfully treated with cyclosporine.

Post-Embolization Syndrome Complicated by Hypertensive Emergency and Severely Elevated Transaminases.

Transarterial chemoembolization (TACE) is a procedure reserved for the treatment of hepatocellular cancer that is unresectable through surgery. It combines both embolization and chemotherapy by injecting chemotherapy via a catheter directed at the tumor and then blocking the artery to prevent blood flow to the tumor. We present the case of a 69-year-old man who experienced post-embolization syndrome (PES) with a hypertensive emergency and elevated liver transaminases following his TACE procedure. Imaging combined with clinical assessment was necessary to determine whether the patient was experiencing a ruptured hepatic abscess or PES, as both are potential complications of TACE. The patient was ultimately managed with supportive care and discharged after several days.

Lion in Sheep's Clothing: Glioblastoma Mimicking Intracranial Hemorrhage.

Intracranial hemorrhage (ICH) as a unique image finding, is a rare presentation of glioblastoma (GBM), and can pose a diagnostic challenge. Hypertensive vascular changes are responsible for the majority of the ICH cases, where hemorrhage from brain tumors account only for 5.1% to 7.2% of cases and, the etiology seems to be multifactorial. We present a clinical case of a 70-year-old male who came to the emergency department after a syncopal episode at the workplace, associated with nausea and vomiting. Computed tomography scan and magnetic resonance imaging showed intracranial subdural hematoma, subarachnoidal and interventricular hemorrhage without any underlying lesion. Follow-up imaging in one month showed a new ICH with a thick peripheral mass concerning an underlying neoplasm. The patient underwent tumor resection and immunohistochemical staining confirmed glioblastoma. Despite a multiapproach treatment, including, chemotherapy, radiotherapy, and follow-up surgery, the outcome was poor. GBM is a great mimicker and may initially present with unassuming intracranial hemorrhage with a much more sinister hidden diagnosis. A high index of suspicion on initial imaging based on the patient's demographics with early tissue diagnosis is crucial in arriving at the correct diagnosis. This case reinforces the importance of close interval follow-up in patients with spontaneous ICH, maintaining a high suspicion for brain tumors. To date, GBM remains a poor prognosis despite combined surgery, chemotherapy, and radiotherapy treatment.

Molar Pregnancy Complicated by Impending Thyroid Storm.

Gestational trophoblastic diseases, which include molar pregnancy, have an increased risk of complications associated with the thyroid gland. This condition is mainly caused by elevated levels of beta-human chorionic gonadotropin produced during pregnancy, which is exaggerated in molar pregnancy and can lead to thyrotoxicosis. Hence, it is important to recognize the signs and symptoms of hyperthyroidism among women of childbearing age to prevent complications such as thyroid storm. Medical management of thyroid storm before surgery is critical to prevent adverse maternal outcomes. Here, we report a rare case of impending thyroid storm induced by molar pregnancy.

Osmotic Demyelination Syndrome Despite Appropriate Hyponatremia Correction.

Acute demyelination of the pons or extrapontine areas results in an osmotic demyelination syndrome (ODS), previously referred to as central pontine myelinolysis (CPM) or extra pontine myelinolysis (EPM). It is caused by osmotic dysregulation in the brain. Multiple risk factors have been known to contribute to these osmotic disturbances. Among them, osmotic stress caused by rapid correction of hyponatremia is the most common cause. Other risk factors include liver failure, alcohol dependence, malnutrition, and malignancy. Symptoms can vary depending on the location of the demyelination. It has a high rate of morbidity and mortality. We present a case of ODS in a malnourished patient who was found to have alcoholic hepatitis and invasive colon cancer. The initial presentation was sepsis secondary to pneumonia. The patient was found to be severely hyponatremic at the time of admission, and the hyponatremia was corrected as per the recommendations. The initial non-contrast head computed tomography (CT) scan was unremarkable. However, the hospital course was complicated by a deteriorating neurological exam with encephalopathy despite not overcorrecting the sodium. A short-term follow-up brain magnetic resonance imaging (MRI) eventually revealed ODS. Initially, the findings of ODS were masked due to symptoms of alcohol withdrawal. However, the patient had a quick recovery with the improvement of all the neurological findings.

Austrian Syndrome in an Immunocompromised Patient-A Case Report.

Austrian syndrome consists of a triad of endocarditis, meningitis, and pneumonia caused by Streptococcus pneumoniae. With the arrival of many antibiotic therapies, the disease remains rare, however, it can be overlooked due to the lack of awareness. We present a case of Austrian syndrome in an immunocompromised patient complicated by multiorgan failure.