Atypical Presentation of the Classical Form of Locked-In Syndrome in a Young Patient.

Locked-in syndrome (LIS) is an uncommon neurologic disorder that manifests in quadriplegia and anarthria with preserved cognition and self-awareness. Generally, patients with LIS may live for years with preserved quality of life and cognitive function, but with severe disability. There are 3 types of LIS: classic, partial, and total. The classical form is defined by total immobility, with preservation of the ability to perform vertical eye movements, blink, and maintain a normal level of consciousness. We present an unusual case of classical LIS in a 54-year-old man who presented initially with acute-onset left lower extremity weakness and dysarthria with radiographic evidence of extensive, acute right paramedian pontine infarction and high-grade vertebral artery stenosis. However, a week later, the patient developed sudden-onset aphonia, bilateral facial palsy, and quadriplegia with repeat magnetic resonance imaging of the brain showing expansion of right paramedian pontine stroke to also involve the left paramedian pons, without significant change to the vertebral stenosis and basilar artery patency.

The Continuing Emergence of Candida blankii as a Pathogenic Fungus: A New Case of Fungemia in a Patient Infected with SARS-CoV-2.

Candida blankii is a recently recognized human pathogen, with most cases of the infection being reported in the immunocompromised. We here describe the case of a critically ill elderly woman with COVID-19 who developed a C. blankii bloodstream infection from a femoral central venous catheter. Aspergillus niger was also isolated from her respiratory secretions. The patient was started on voriconazole for empiric coverage of both A. niger, and at that time, unidentified yeast was found in the blood. Fevers persisted, and the patient expired six days after the yeast was first isolated. Almost one month after her death, C. blankii was identified as the cause of fungemia by sequencing of the internal transcribed spacer (ITS) region of the ribosomal gene and BLAST searching against two databases (performed by a reference laboratory). The isolate demonstrated high minimum inhibitory concentrations (MICs) to azoles and low MICs to amphotericin B, similar to previously described isolates. Timely identification of C. blankii would have prompted different empiric antifungal choices and possibly changed the final outcome. Clinicians should be aware of the pathological potential of C. blankii, the challenges of correctly identifying the organism, and its susceptibility patterns to common antifungals. There is an urgent need to improve assays for C. blankii identification, which will aid in accurate and timely pathogen identification, and appropriate therapeutic management.

Lumen-Apposing Metal Stent Used to Treat Malignant Esophageal Stricture.

Malignant esophageal strictures often require stent placement to alleviate dysphagia and improve quality of life. We present a novel application of a lumen-apposing metal stent to bypass a malignant esophageal stricture in the setting of altered gastric anatomy.

An Event-Related Potential study of letter spacing during visual word recognition.

Increasing spacing between letters in words (e.g., s p a c e vs. space) helps children and adults read more fluidly and with fewer errors. This effect has been demonstrated behaviorally, chiefly through lexical decision reaction time and total paragraph reading time. To date, however, no electrophysiological work has examined the letter spacing effect, resulting in little insight regarding how letter spacing impacts "hidden" levels of processing between apprehension of the word form and the final behavioral outcome. Here, we examined how varying levels of interletter spacing (crowded, standard, and increased) impact ERPs elicited by words and other item types (pseudowords, illegal strings, and a false font). Results indicate that letter spacing does not impact the ERP within the first second after viewing a wordform, but that it does have downstream effects as indicated by data collected using a priming design. Further, the facilitation of downstream processing afforded by increased spacing seems to be greater for more word-like stimuli (e.g., greater for words than for consonant strings, etc). Results are discussed as being somewhat inconsistent with prevalent views of the mechanism of the letter spacing effect (i.e., crowding).