A Rare Case of Moyamoya Disease in a Hispanic Woman: Unveiling Non-Asian Ethnicity and Atypical Risk Factors.

BACKGROUND Moyamoya disease is a rare and progressive cerebrovascular disorder caused by narrowed or blocked arteries supplying the brain. First described in Japan, the disease's incidence is higher in Asian countries and primarily affects children, although adults can also be afflicted. Following a literature review, very little was found regarding non-Asian ethnicities and the lack of typically associated risk factors that are known correlates of Moyamoya disease. CASE REPORT We present the case of a 41-year-old Hispanic woman with a history of type 1 diabetes mellitus and asthma who presented to the Emergency Department with concerns of recurrent transient episodes of left upper extremity weakness and paresthesia followed by confusion. The patient's blood pressure on arrival was 215/134 mmHg, and heart rate was 124 beats per min. Computed tomography of the head was unremarkable, but a computed tomography angiogram of the head demonstrated several areas of severe and bilateral stenosis with radiographic appearances, suggestive of Moyamoya disease. Magnetic resonance imaging of the brain would later illustrate two 6×2-mm ischemic infarcts in the right posterior centrum semiovale. CONCLUSIONS Moyamoya disease in the non-Asian population is rarely reported. We present a case of this condition in a patient of Hispanic ethnicity. Although it is generally considered a non-atherosclerotic disease, some literature suggests that atherosclerotic disease may also contribute to the development and possible acceleration of clinical features of Moyamoya disease. Given our patient's risk factors, we postulated that our patient's presentation was likely multifactorial, with both non-sclerotic and atherosclerotic disease.

Pneumocephalus secondary to epidural analgesia: a case report.

INTRODUCTION: Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space. CASE PRESENTATION: We present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued. CONCLUSIONS: Although a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.

Acquired Long QT Syndrome: Ventricular Fibrillation in an Otherwise Healthy Young Female.

Long QT syndrome (LQTS) occurs when there is an abnormality of myocardial repolarization characterized specifically by a prolonged QT interval on an electrocardiogram (ECG). This can be particularly dangerous as it is associated with an increased risk of polymorphic ventricular tachycardia and a life-threatening arrhythmia otherwise known as torsades de pointes (TdP). We present a case of a 40-year-old Indian female whose medical history was significant only for anemia and depression/anxiety that presented in a ventricular fibrillation cardiac arrest after becoming dyspneic and light-headed while dancing. Of relevance, she was taking sertraline 50mg once daily, a class of medications known to prolong the QT interval as well as having low serum calcium on presentation. Both her initial and subsequent electrocardiograms illuminated significantly prolonged QTc intervals. She subsequently sustained a ventricular tachycardia cardiac arrest, which degenerated into ventricular fibrillation in the cardiac intensive care unit two days later. Ultimately, the patient was pronounced brain-dead by the end of the week. We concluded this to be a case of LQTS predisposing to TdP, which then would degenerate into ventricular fibrillation. This case highlights multiple risk factors that are known to predispose to the aforementioned etiology. Further research is needed not only on common medications and their dose-dependent relationship on the QT interval across different ethnic groups but also on educating providers regarding multiple risk factors they may or may not have the power to control.

Correction: A Case of Vaccine-Induced Thrombocytopenic Thrombosis Manifesting as Cerebral Venous Thrombosis and Intracerebral Bleed.

[This corrects the article DOI: 10.7759/cureus.33318.].

A Complicated Clinical Course of Community-Acquired Staphylococcus aureus Infective Endocarditis.

Infective endocarditis (IE) is an infection of the heart's endocardial surface, heart valves, or implanted cardiac devices, with the most common causative organism being Staphylococcus aureus. The clinical presentation of IE can be variable, with some patients presenting with multisystemic complications, including renal, pulmonary, cutaneous, and neurologic complications. Cerebral infarction is the most common complication of IE. Here we present a case of a young male with S. aureus IE of a native cardiac valve who developed multiple complications during his clinical course.

A Case of Cannabinoid Hyperemesis Syndrome and Acute Kidney Injury: A Review of the Literature.

Cannabis is a commonly used illicit drug worldwide with many noted adverse effects and medical properties. It has been previously used in medicine for the management of chemotherapy-induced nausea and vomiting. The chronic use of cannabis is well-known to be associated with psychological and cognitive adverse effects, however, cannabinoid hyperemesis syndrome is a less commonly recognized complication of chronic long-term use of cannabis, though it does not occur in the majority of chronic cannabis users. Here we present the case of a 42-year-old male who presented with classical clinical features of cannabinoid hyperemesis syndrome.

A Case of Vaccine-Induced Thrombocytopenic Thrombosis Manifesting as Cerebral Venous Thrombosis and Intracerebral Bleed.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but detrimental syndrome that has been most commonly reported after the administration of vaccination for the prevention of viral infections. VITT often presents with thrombosis at unusual sites such as cerebral venous sinuses, portal, splanchnic or hepatic veins, in association with thrombocytopenia and elevated anti-platelet factor 4 (aPF-4) antibodies. We describe the case of a young male patient who developed thrombocytopenia, cerebral sinus venous thrombosis, and intracerebral bleed 12 days after receiving the Ad26.COV2.S (Janssen/Johnson&Johnson) COVID-19 vaccine.

Staged Versus Concomitant Carotid Endarterectomy and Aortic Valve Replacement: A Case Report and Literature Review.

Stroke is a common complication of cardiac surgery, and carotid artery stenosis is an established risk factor for stroke. Therefore, patients with carotid artery stenosis who are undergoing cardiac surgery require proper management of the former either simultaneously or before cardiac surgery. We present a challenging case of a 67-year-old male patient who presented with generalized weakness, severe aortic stenosis, and significant bilateral carotid artery stenosis. The coexistence of these findings sparked a debate about whether to perform a carotid endarterectomy first or an aortic valve replacement. Moreover, a past history of percutaneous coronary intervention and coronary artery bypass grafts made the decision more challenging. Multiple approaches have been employed for the management of coexisting carotid artery stenosis with cardiac surgery; however, no definitive guidelines exist, especially for surgeries other than coronary artery bypass grafts or where the carotid stenosis is bilateral and severe.

Pseudo-thrombotic Microangiopathy - An Unusual Presentation of Cobalamin Deficiency.

Vitamin B12 is a water-soluble vitamin cofactor for many enzymatic reactions in the body. It plays a vital role in the normal maturation of red blood cells and in producing proteins needed for normal neurological function. The most common presentations of vitamin B12 deficiency are hematological abnormalities and neurological manifestations. Pseudo-thrombotic microangiopathy, a syndrome of hemolysis and thrombocytopenia, may mimic the presentation of thrombotic microangiopathies such as thrombotic thrombocytopenic purpura, an uncommon presentation of vitamin B12 deficiency. We present the case of a 58-year-old male with no significant past medical history who presented with severe macrocytic anemia and thrombocytopenia with laboratory findings suggestive of hemolytic anemia. He was found to have vitamin B12 deficiency with positive serological markers suggesting pernicious anemia is the underlying cause. Our case demonstrates that vitamin B12 deficiency should be considered in cases of suspected thrombotic microangiopathy, especially in the setting of significantly elevated lactate dehydrogenase levels and low reticulocyte count to avoid the initiation of unnecessary and expensive treatment modalities such as plasmapheresis.

Rare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection.

BACKGROUND On rare occasions, viral infections are known to also depress immune cell lines, further worsening clinical outcomes. We describe a patient who presented 3 weeks after recovery from mild COVID-19 disease with clinical features of an atypical pneumonia and was found to have a low CD4+ T-cell count. CASE REPORT An 82-year-old man with a past medical history of coronary artery disease, rheumatoid arthritis, gout, hypertension, and atrial fibrillation presented with a 1-week history of progressively worsening shortness of breath and cough. He was noted to have recovered from mild SARS-CoV-2 infection 3 weeks prior to his current presentation and had been at his baseline level of health following infection. A T cell subset panel was obtained, which revealed an absolute CD3 count of 92 (reference range 840-3060), absolute CD4 count of 52 (reference range 500-1400), absolute CD8 count of 37 (reference range 180-1170), and a normal CD4: CD8 ratio. He was subsequently started on atovaquone for pneumocystis jiroveci pneumonia prophylaxis. CONCLUSIONS This case highlights the need for a high index of suspicion for lymphocyte depletion in older patients with multiple comorbidities who present during or after SARS-CoV-2 infection with atypical symptoms that are suggestive of immunosuppression. In such instances, there should be a low threshold to start prophylactic therapy for possible opportunistic infections.

Isolated Superior Mesenteric Artery Dissection: A Rare Etiology of Colic Ischemia.

Although isolated superior mesenteric artery dissection is a rare disease entity, it possesses high mortality. The pathophysiology remains a mystery. In this case, we report a 68-year-old male with compromised coronary circulation been evaluated for coronary artery bypass surgery (CABG) and who developed a sudden, localized, right-sided abdominal pain. It was diagnosed on a computer tomography arteriogram (CTA), revealing a short segmental dissection involving the superior mesenteric artery (SMA). Vascular surgery was consulted and the decision was made to conservatively manage this patient's condition with anticoagulation. He was seen subsequently in the outpatient setting with a resolution of abdominal pain and a repeat computer tomography scan of the abdomen revealed resolution of previously seen colitis changes. Abdominal discomfort is a common complaint for which patients are seen in a variety of therapeutic settings, it is critical to bring attention to this case in order to raise awareness of the possibility of isolated SMA dissection as one of the underlying causes.