Delayed Superior Orbital Fissure Syndrome Arising More than One Month after Herpes Zoster Ophthalmicus and Meningitis.

A 79-year-old woman developed herpes zoster ophthalmicus (HZO) with a vesicular rash on the nasal root, which developed soon after intravenous acyclovir therapy. Although varicella zoster virus DNA was undetectable in the cerebrospinal fluid, she presented with ophthalmoplegia without optic nerve dysfunction 32 days after the onset of HZO. We diagnosed the patient with superior orbital fissure syndrome and administered intravenous immunoglobulin and systemic corticosteroids. Ophthalmoplegia did not immediately respond to these therapies but resolved 4 months later. We should be aware that ophthalmoplegia can occur, even after HZO and meningitis are completely treated.

Unusual Presentation of Double-seronegative Myasthenia Gravis with Positive Anti-LRP4 Antibody: Diagnostic Utility of a Videofluoroscopic Swallowing Study.

An 86-year-old woman was admitted to our hospital with cryptogenic progressive dyspnea and dysphagia following a tracheostomy procedure 4 months prior to presentation. She exhibited fluctuating diplopia, bilateral vocal fold paralysis, normal nerve test results, negative findings for serum anti-acetylcholine receptor and anti-muscle-specific kinase antibodies, and positive findings for anti-LDL-receptor related protein 4 (LRP4). A videofluoroscopic swallowing study (VFSS) with edrophonium revealed an improvement in bulbar paralysis. Consequently, the patient was diagnosed with double-seronegative myasthenia gravis (DSN-MG) and began immunomodulatory therapy. This case emphasizes the diagnostic challenges of bulbar-type DSN-MG and underscores the value of a VFSS with edrophonium for diagnosing this condition.

Pembrolizumab-induced Myopathy with Anti-striated Muscle Antibodies Successfully Treated by Plasma Exchange.

A 70-year-old woman with advanced endometrial cancer developed right ptosis and muscle weakness in the right quadriceps after pembrolizumab administration. Serum creatine kinase (CK) levels were elevated, and anti-striated muscle antibodies were positive. On magnetic resonance imaging, the right vastus lateral muscle showed an abnormal signal. She was diagnosed with pembrolizumab-induced myopathy. We initiated plasma exchange (PE), and the ptosis immediately resolved. We then introduced oral corticosteroids, which improved her muscle weakness. We were able to rapidly diagnose her with ocular symptoms and serum CK level elevation. The early initiation of PE might prevent the exacerbation of pembrolizumab-induced myopathy.

Pulse-gated noncontrast thoracic magnetic resonance angiography for acute aortic dissection with transient ischemic attack: A case report.

Aortic dissection is a rare cause of an acute ischemic stroke or transient ischemic attack (TIA). Aortic dissection is particularly challenging in stroke patients who are eligible for thrombolysis secondary to the diagnostic difficulty within a narrow time window (4.5 h) and have a risk of developing life-threatening hemorrhagic complications following thrombolysis. Computed tomographic angiography (CTA) has been the mainstay of imaging when evaluating acute aortic syndrome. However, it cannot be routinely performed for pregnant patients and those with renal failure or iodine-contrast media allergy. We report a case of a 72-year-old woman who developed transient right-hand paralysis without any chest symptoms. Brain magnetic resonance imaging (MRI) showed no recent infarction; however, the brachiocephalic trunk was not well visualized on carotid magnetic resonance angiography (MRA). Subsequent thoracic pulse-gated noncontrast three-dimensional balanced steady-state free precession MRA (bSSFP-MRA) detected a Stanford type A acute aortic dissection (TAAAD). This was confirmed by CTA, leading to the diagnosis of TIA due to Stanford TAAAD. Pulse-gated noncontrast thoracic bSSFP-MRA was acquired a few minutes after a series of brain MRI scans. This imaging modality is expected to be used as a screening platform to rule out Stanford TAAAD during the hyperacute phase of stroke.

A case of anti-AQP4 antibody-positive neuromyelitis optica spectrum disorder with MRI-proven lesions in lumbar nerve roots.

Neuromyelitis optica spectrum disorder (NMOSD) affects the central nervous system but is rarely reported to cause peripheral nervous system damage. We report a case of a 57-year-old woman with numbness and muscle weakness of the left lower limb during the course of 12 years of anti-AQP4 antibody-positive NMOSD. Lumbar magnetic resonance imaging (MRI) showed a contrast effect on the left L4, L5, and S1 nerve roots, which is a highly unusual presentation. Although radiculopathy without myelopathy is unusual in AQP4-positive NMOSD, the MRI-confirmed nerve root lesions in our case indicate that it can occur.

Left Atrial Spinning Ball Thrombus in a Patient with Cardioembolic Stroke: A Case Report.

A left atrial movable ball thrombus is unusual and may cause fatal systemic emboli or left ventricular inflow obstruction. Among movable ball thrombi, a spinning ball thrombus is a rare and devastating occurrence that results in cardioembolic stroke. Here, we report the case of an 88-year-old woman with a large spherical thrombus spinning in the left atrium when a catastrophic cardioembolic stroke recurred. She had a history of atrial fibrillation but was unable to continue anticoagulation therapy due to hemorrhagic complications and developed an initial cerebral embolism with a large thrombus attached to the left atrium. Twelve days after the initiation of anticoagulation therapy, an extensive cerebral embolism throughout the bilateral frontal lobe recurred with disturbance of consciousness. Transthoracic echocardiography revealed a large detached spherical thrombus spinning in the left atrium. She did not recover consciousness and was moved to another hospital for palliative care three months later. Movable type left atrial thrombi are regarded as a high risk for thromboembolic events, but those with spinning movements may have a worse prognosis.

Paradoxical Cerebral Embolism as Initial Manifestation of Chronic Thromboembolic Pulmonary Hypertension: A Case Report.

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by chronic thrombi in the pulmonary arteries, causing pulmonary hypertension and right heart failure. Early and accurate diagnosis are essential for successful treatment but are often difficult because clinical signs and symptoms can be nonspecific and risk factors, such as history of venous thromboembolism, may not always be present. Here, we report a case involving a 76-year-old woman who demonstrated paradoxical cerebral embolism as the initial manifestation of CTEPH. She developed right hemiplegia without dyspnea or edema. Brain magnetic resonance imaging revealed multiple fresh infarctions, while transesophageal echocardiography revealed a patent foramen ovale. Based on these findings, she was diagnosed as having paradoxical cerebral embolism. During the search for the embolic source, right heart catheterization showed significant pulmonary hypertension and pulmonary angiography revealed chronic thrombi in the peripheral pulmonary arteries, consistent with a diagnosis of CTEPH. To our knowledge, this is the first case of CTEPH to be diagnosed with the onset of paradoxical cerebral embolism. Because CTEPH is the only potentially curable form of pulmonary hypertension, clinicians should consider paradoxical cerebral embolism as a possible initial manifestation of CTEPH.