Isolated Abducens Nerve Palsy in the Setting of Isolated Sphenoid Sinusitis: A Case Report.

The cranial nerves (CNs) are responsible for multiple functions, including extraocular mobility, facial sensation and movement, hearing, mastication, tongue movement and sensation, and swallowing. Beyond these vital roles, they can also demonstrate importance in their diagnostic value. Isolated or combined palsies provide insights into potential localizations and various underlying etiologies, including stroke, tumor, and infections that may guide further neurological evaluation. CN VI, the abducens nerve, singularly innervates the lateral rectus muscle, which is responsible for the abduction of the eyes. Despite its long anatomic trajectory, making it susceptible to intracranial injury, an isolated abducens nerve palsy is extremely rare. The most common clinical presentation includes headache, diplopia, and the inability to abduct the afflicted eye. This case report introduces a 71-year-old female with a medical history of malignancy and pancytopenia who presented to the emergency room with complaints of ear pain and swelling and subsequently developed diplopia secondary to unilateral CN VI palsy. Magnetic resonance imaging (MRI) revealed isolated sphenoid sinusitis for which she was clinically asymptomatic. She was treated with a regimen of ampicillin-sulbactam, an oral anti-inflammatory agent, and a tapered course of methylprednisolone with a rapid and complete resolution of the abducens nerve palsy and sinusitis. Acute isolated diplopia is an unusual neurologic condition prompting the need for rapid and thorough investigation. Although exceedingly rare and infrequently cited in the literature, isolated abducens nerve palsies secondary to sphenoid sinusitis should be entertained in the differential diagnosis of this presentation.

Immunosuppression and Opportunistic Infections: A Rare Case Report of Nocardia Osteomyelitis of the Pelvis.

Patients with a long-standing history of immunosuppression are at significantly increased risk of opportunistic infections. One such group of organisms that may cause these types of infections includes the Nocardia genus, a gram-positive, filamentous rod that demonstrates a branching pattern, is urease-producing and has acid-fast properties. The disease profile of Nocardia varies with manifestations ranging from cutaneous infection to severe pulmonary or central nervous system (CNS) infections, and rarely, osteomyelitis. In this case report, we present an 87-year-old female with persistent left gluteal and lumbar pain, generalized body aches, chills, and fevers diagnosed with Nocardia asiatica osteomyelitis of the pelvis, likely secondary to dissemination from pulmonary cavitary disease in an immunosuppressed host with chronic neutropenia. On magnetic resonance imaging (MRI), the patient was found to have heterogeneous enhancement, central necrosis, and loss of cortical margins of the left iliac wing, alongside a rim-enhancing soft tissue mass from the left iliac bone into the left gluteal soft tissues and left paraspinal musculature representing an abscess. She was promptly treated with surgical irrigation and drainage with surgical wound cultures growing Nocardia asiatica. She received treatment with trimethoprim-sulfamethoxazole antibiotics with symptom improvement and is following up with an infectious disease physician outpatient. Management of osteomyelitis, like in this case, involves long-term antibiotics with the potential need for surgical intervention. There are few reported cases of extrapulmonary Nocardia infections, particularly osteomyelitis, demonstrating the importance of their inclusion in the literature to better serve patients to allow for timely intervention for rare and life-threatening conditions. In immunocompromised hosts, the differential diagnosis should include opportunistic infections and less common pathogens, especially in those with atypical presentations, including gluteal and leg pain.

Dysphagia: A Case Report of an Atypical Presentation of Statin-Induced Necrotizing Myositis.

Statin medications act by inhibiting the enzyme hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (HMGCR), thus decreasing hepatic cholesterol synthesis. They are considered the mainstay treatment of hypercholesterolemia due to their tremendous efficacy and mortality benefit. Although generally well tolerated, statins may adversely affect skeletal muscle resulting in side effects ranging from mild myalgia to life-threatening necrotizing myositis. Statin-induced necrotizing autoimmune myositis is a rare yet devastating adverse effect that may occur shortly after initiation of therapy or after several years of use. Unfortunately, medication discontinuation has shown no impact on prevention or alleviation of symptoms. Though there is currently no definitive guidance for the treatment of this condition, corticosteroids are generally considered to be first line, via high-dose oral prednisone or intravenous methylprednisolone. In this case report, we discuss the case of a 72-year-old male with an unusual presentation of statin-induced necrotizing autoimmune myositis: dysphagia, weakness, and weight loss. His diagnosis was confirmed by muscle biopsy indicating necrotizing myositis and his serum was found to be strongly positive for anti-HMG-CoA reductase antibodies. This patient had a very brief history of statin use, but his primary care provider discontinued the medication a couple of months prior to symptom onset due to elevated liver function tests. He was treated with aggressive intravenous fluid hydration and intravenous corticosteroids during an extended inpatient hospital stay. He was discharged to a rehabilitation facility. This report demonstrates the importance of creating a wide differential for patients who present with fatigue, generalized weakness, and dysphagia. It is essential to always consider statin-induced necrotizing myositis if a patient has a history of statin use, even if the statin has been discontinued. Necrotizing myositis demands timely diagnosis and management to improve mortality.

A New Early Finding of Moyamoya-Like Phenomena.

Moyamoya disease (MMD) primarily causes constriction of internal carotid artery, but it is known to extend to the middle and anterior cerebral arteries. Some of the symptoms caused by MMD include transient ischemic attack (TIA) and seizures. The etiology of MMD from Graves' disease (GD) is mostly caused by thyrotoxicosis, but our finding of leukocytosis indicates a new finding that may help physicians prepare for the pending outcome of MMD from GD with leukocytosis. A 26-year-old Hispanic woman with a significant past medical history of GD and hypertension presented to the emergency department complaining of cough and shortness of breath for the past 5 days. During the patient's stay in the hospital, the patient suddenly developed numbness of the right arm with subsequent right arm weakness 10 minutes later. The head CT showed no acute intercranial hemorrhage, but MRA showed right intracranial internal carotid artery stenosis, with marked focal stenosis along the proximal supraclinoid segment, moderate stenosis along its distal supraclinoid segment with marked stenosis along the origin of the right A1 segment. It was therefore believed to be moyamoya-like phenomena. We discuss an atypical presentation that led to moyamoya-like phenomena which we believe has not been described before. We believe that presentation of idiopathic leukocytosis may have triggered the cerebral stenosis.

Multivessel spontaneous coronary artery dissection in an unlikely patient.

When approaching the symptom of acute onset chest pain in a previously healthy 26-year-old male, anchoring heuristic presents a challenge to healthcare workers. This diagnostic error is the healthcare professional's tendency to rely on a previous diagnosis, and, in situations where a set of symptoms might mask a rare and deadly condition, this error can prove fatal for the patient. One such condition, Spontaneous Coronary Artery Dissection (SCAD), is an uncommon and malefic presentation of coronary artery disease that can lead to myocardial infarction and sudden death. We present a case of SCAD in an otherwise healthy 26 year-old male who had been experiencing chest pain during and after sports activity. In the young, athletic male with SCAD, the danger of diagnostic error was a reality due to the broad symptomatology and the betraying demographics.

Enteric Fistulous Communication with an Aortobifemoral Graft Permitting for Eggerthella Lenta Colonization.

The presence of an aortoenteric fistula following aortobifemoral graft repair of an abdominal aortic aneurysm is associated with a high probability of infection leading to clinically significant bacteremia. We report a case of an aortoenteric fistula that developed two years after initial aortic grafting resulting in colonization with the anaerobe, Eggerthella lenta. This dangerous bacterium is difficult to culture, associated with high mortality and the patient may have mild symptoms on presentation.