A Case Report of Spinal Arteriovenous Fistula: Vague Presentation and Successful Outcome.

Spinal arteriovenous fistula (spinal AVF) malformation is one of the rare spinal vascular diseases. Its presentation could be misleading as the patient presents with spinal cord dysfunction, including motor power loss.  Early detection is essential and requires a high suspicion by the providing physician so the patient can be rightfully directed to the proper team with vascular intervention resources. Efficient management leads to promising outcomes with patient recovery. We are presenting a case with progressing motor and sensory neurological deficits that had a vague clinical course. After a prompt diagnosis of spinal AVF, the patient was referred to the neuro-vascular specialist, who performed an embolization of the spinal AVF. The patient had an excellent outcome and was discharged to a rehabilitation facility.

Disseminated Legionella Associated With Myocarditis in an Otherwise Immunocompetent Host: A Case Report and Review of the Literature.

Legionnaires' disease caused by the bacteria Legionella pneumophila, is considered a type of atypical pneumonia. The disease usually presents with dyspnea, cough, fever, muscle aches, headache, nausea, and vomiting. A milder form of the disease (Pontiac fever) with flu-like illness also exists. In addition to lung infection, extrapulmonary manifestations might occur including sepsis, rhabdomyolysis, neurological impairment, kidney, and liver damage. Myocarditis can be seen as a rare complication in Legionnaires' disease. Here, we are presenting a case of Legionnaires' disease associated with myocarditis in a patient with no predisposing risk factors for severe illness.

Apical Hypertrophic Cardiomyopathy: A Fatal yet Underappreciated Variant of Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a group of diseases affecting the left ventricle heart muscle that share a common feature of left ventricular hypertrophy without associated cardiac or systemic disorder. It was found to have a genetic basis with autosomal dominant mutations in the sarcomeric protein genes. Apical HCM is a rare subtype and underappreciated variant of HCM that primarily affects the apex of the heart. Apical HCM is dissimilar to classic HCM, with more challenges in diagnosis and inconsistent clinical course than other types. We report a case of a 91-year-old female who presented with a syncopal episode. Workup revealed atypical nonclassic features. Her transthoracic echocardiogram revealed a "spade-like" configuration of the left ventricular cavity at end-diastole consistent with apical hypertrophic cardiomyopathy. The remaining of her workup was consistent with the apical hypertrophic cardiomyopathy as a reason for the syncopal episode on presentation. Apical HCM is a distinct form of HCM that requires more attention among clinicians. In our case, the patient ended up having an implantable cardioverter defibrillator (ICD) for secondary prevention and a prescription of a beta blocker with a good outcome in her case.

An Unusual Etiology: Subarachnoid Hemorrhage Resulting in Transient Apical Ballooning Syndrome.

Intracranial bleeds, such as subarachnoid hemorrhage, carry high morbidity and mortality rates. Often intracranial hemorrhages result in debilitating residual neurological symptoms but can be so extensive that cardiac complications can also be seen. We present a rare case of a patient who was found to have a subarachnoid hemorrhage that incited the development of Takotsubo cardiomyopathy, which subsequently progressed to an acute myocardial infarction. The aim of this case report is to explore the underlying pathophysiology of how cerebral hemorrhage can result in apical ballooning of the left ventricle through various mechanisms including sympathetic-induced surge in catecholamines and neurogenic damage to the myocardium. We also intend to highlight the importance for clinicians to consider brain bleeds in the differential diagnosis when a patient presents with an acute myocardial infarction as treatment with heparin is generally contraindicated.

Spontaneous bacterial empyema in a non cirrhotic end stage renal disease patient with immunosuppression.

Spontaneous Bacterial Empyema (SBEM) denotes infection of the pleural fluid in the absence of pneumonia. Almost all cases of SBEM in literature are described in a background of ascites secondary to cirrhosis. Contiguous spread of the infected ascitic fluid through defects in the diaphragm is the most likely mechanism of SBEM. Most of these cases are transudative in nature and are managed with antibiotics. Literature on SBEM in the absence of cirrhosis or ascites is very limited so far. We describe a 59 year old female with ESRD status post renal transplant, on chronic immunosuppression for renal allograft rejection who was admitted with pleuritic chest pain that turned to be secondary to right sided pleural effusion. Further evaluation revealed Escherichia coli in both the blood and pleural fluid. There was no clinical or imaging evidence of pneumonia as well as cirrhosis or ascites. She was managed as a case of SBEM requiring drainage by chest tube. Management of SBEM in non-cirrhotic individuals usually requires drainage with chest tube as against patients with liver cirrhosis with hepatic hydro-thorax in whom chest tube drainage is contraindicated for risk of massive protein and electrolyte depletion and dehydration.

Treatment of brodifacoum overdose with prothrombin complex concentrate.

PURPOSE: A case of brodifacoum overdose and its treatment with prothrombin complex concentrate (PCC) are reported. SUMMARY: A 44-year-old Caucasian woman weighing 62 kg arrived at the emergency department with a chief complaint of lower left leg pain for two days. A computed tomography (CT) scan of the abdomen revealed perihepatic fluid collection (likely a hematoma), a small-bowel intramural hematoma, and blood in the paracolic gutter. A CT scan of the patient's left foot showed soft tissue swelling without evidence of fracture or dislocation. The patient was diagnosed with left extremity compartment syndrome secondary to hematoma and trauma. The patient had a history of depression and anxiety and eventually admitted to ingesting large doses of brodifacoum the week prior with suicidal intentions. The patient was treated with phytonadione 20 mg i.v., 1 unit of fresh frozen plasma (FFP), and 1 unit of packed red blood cells. Laboratory test values measured in the intensive care unit revealed an International Normalized Ratio (INR) of 15, a prothrombin time of >120 seconds, and a partial prothromboplastin time of >180 seconds. After consulting with a local poison center, phytonadione 50 mg i.v., PCC 3100 units, and 4 units of FFP were immediately administered to reverse the patient's coagulopathy. The dose of oral phytonadione was lowered based on INR stability. Once the coagulopathy was stabilized, the patient was transferred to an inpatient psychiatric facility on phytonadione 10 mg daily orally to maintain a stable INR. CONCLUSION: A 44-year-old woman who intentionally ingested brodifacoum was successfully treated with phytonadione, PCC, and FFP.

Noncompaction Cardiomyopathy with Charcot-Marie-Tooth Disease.

We report a case of a 53-year-old female presenting with a new-onset heart failure that was contributed secondary to noncompaction cardiomyopathy. The diagnosis was made by echocardiogram and confirmed by cardiac MRI. Noncompaction cardiomyopathy (also known as ventricular hypertrabeculation) is a newly discovered disease. It is considered to be congenital (genetic) cardiomyopathy. It is usually associated with genetic disorders and that could explain the genetic pathogenesis of the non-compaction cardiomyopathy. Our case had a history of Charcot-Marie-Tooth disease. There is a high incidence of arrhythmia and embolic complications. The treatment usually consists of the medical management, defibrillator placement, and lifelong anticoagulation. Heart transplantation will be the last resort.

Complete heart block with diastolic heart failure and pulmonary edema secondary to enlarging previously diagnosed thrombosed aneurysm of sinus of valsalva in a patient with history of autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is associated with vascular aneurysms that can affect any part of the vascular tree, like ascending aorta or coronary arteries. Sinus of Valsalva is known as an anatomical dilation at the root of aorta above the aortic valve and very few cases show aneurysm at that site in patients with ADPKD. Sinus of Valsalva aneurysm (SVA) can present with rupture and acute heart failure and infective endocarditis or could be asymptomatic accidentally discovered during cardiac catheterization. We report a case of a 76-year-old male with a unique constellation of cardiovascular anomalies associated with ADPKD. Patient was previously diagnosed with aneurysms affecting ascending aorta, sinus of Valsalva, and coronary arteries. Several years later, he came with complete heart block which was discovered later to be secondary to enlargement of his previously diagnosed thrombosed SVA. His case was complicated with acute heart failure and pulmonary edema. Conclusion. Patients with ADPKD can present with extrarenal manifestations. In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block.

Exfoliative erythroderma as a paraneoplastic presentation of adenocarcinoma of the gallbladder.

We report a case of a 71-year-old Caucasian male presenting with an exfoliative skin rash all over his body. The patient was also found to have a huge gall bladder mass extending into the liver that turned out to be adenocarcinoma of the gall bladder on biopsy. Gall bladder cancer usually presents with abdominal pain, swelling or jaundice. We report only the second case in literature of a gall bladder adenocarcinoma presenting with exfoliative erythroderma as its paraneoplastic presentation.

Mediastinal B-cell lymphoma presenting with jugular-subclavian deep vein thrombosis as the first presentation.

Jugular venous thrombosis infrequently could be secondary to malignancy and has seldom been reported secondary to mediastinal large B-cell lymphomas. The postulated mechanisms are mechanical compression that leads to stagnation of blood in the venous system of the neck and/or an increase in the circulating thrombogenic elements that could cause venous thromboembolism as a paraneoplastic phenomenon. We report the case of a middle aged male presenting with right sided neck pain and arm swelling secondary to ipsilateral jugular-subclavian deep vein thrombosis. Investigations revealed it to be secondary to a mediastinal mass shown on CT scan of the chest.

Multi-organ failure secondary to a Clostridium perfringens gaseous liver abscess following a self-limited episode of acute gastroenteritis.

BACKGROUND: Clostridium perfringens is an unusual pathogen responsible for the development of a gas-forming pyogenic liver abscess. Progression to septicemia with this infection has amplified case fatality rates. CASE REPORT: We report a case of an 81-year-old lady with pyogenic liver abscess with gas formation that was preceded by an acute gastroenteritis. The most common precipitating factors are invasive procedures and immunosuppression. Clostridium perfringens was unexpectedly isolated in the drained abscess, as well as blood. It is a normal inhabitant of the human bowel and a common cause of food poisoning, notoriously leading to tissue necrosis and gas gangrene. CONCLUSIONS: We report a case of gas-forming pyogenic liver abscess and bacteremia progressing to fatal septic shock, caused by an uncommon Clostridium perfringens isolate.

Metastatic malignant melanoma of the inguinal lymph node with unknown primary lesion.

Background. Malignant melanoma could present with metastasis with unknown primary (MUP) and this happens in 2-3% according to the studies. Around 90% of melanomas have cutaneous origin, but still there are melanomas that could be found in visceral organs or lymph nodes with unknown primary site. Spontaneous regression of the primary site could be an explanation. Case Report. We report a 58-year-old Caucasian male who presented with a right sided swelling in the inguinal region. Surgery was performed and biopsy showed metastatic malignant melanoma. No cutaneous lesions were identified by history or physical examination. Work up could not detect the primary lesion and patient was started on radiotherapy and immunotherapy. Conclusion. We present a case of malignant melanoma of unknown primary presenting in an unusual place which is the inguinal lymph node. Theories try to explain the pathway of development of such tumors and one of the theories mentions that it could be a spontaneous regression of the primary cutaneous lesion. Another theory is that it could be from transformation of aberrant melanocyte within the lymph node. Prognosis is postulated to be better in this case than in melanoma with a known primary.

Syndrome of inappropriate anti-diuretic hormone secondary to non-cirrhotic primary hepatocellular carcinoma.

BACKGROUND: The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is usually seen in pulmonary malignancies, central nervous system disorders, and secondary to medications. SIADH has very rarely been encountered in primary hepatocellular carcinoma. Two cases were reported in Japan and 1 case in Spain after extensive investigation of the medical records. CASE REPORT: We report a case of a 71-year-old man who presented with confusion, cachexia, and abdominal symptoms in the form of vomiting and abdominal discomfort. On the initial work-up, SIADH diagnosis was made. After an extensive work-up, the reason for SIADH turned out to be a newly diagnosed hepatocellular carcinoma. The precipitating factor for the cancer was not identified by history or by work-up. No metastasis was identified. Liver functions were preserved but patient was severely malnourished. CONCLUSIONS: SIADH can occur as a para-malignant feature of the malignancy. In our case, it was related to the hepatocellular carcinoma, which is a malignancy very rare to cause SIADH.

Dieulafoy lesion in the ascending colon presenting with gastrointestinal bleeding and severe anemia complicated by a coexisting severe resistant chronic idiopathic thrombocytopenic purpura.

Background. GI (gastrointestinal) bleeding can be due to a variety of etiologies ranging from being common like bleeding peptic ulcer disease or esophageal varices. One of the rarely documented causes is the Dieulafoy lesion which is known as an abnormally large ectatic artery that penetrates the gut wall, occasionally eroding through the mucosa causing massive bleeding. In addition to that, we refer to the uncommon presentation of Dieulafoy lesion itself as it is well known to be found in the stomach, esophagus, duodenum, and jejunum but not the ascending colon as in our case. The patient had a coexisting ITP (idiopathic thrombocytopenic purpura) that was resistant to different therapies. Case Report. We report a case of a 48-year-old Egyptian female known for chronic ITP resistant to treatment. The patient presented with bright red bleeding per rectum and severe life threatening anemia. Endoscopic study showed a Dieulafoy lesion. Endoscopic clipping was successful in controlling the bleeding. Conclusion. Dieulafoy lesion is a rare reason for GI bleeding and can present in common or unexpected places. Also extreme caution should be used in patients with bleeding tendency due to different reasons, like ITP in our case.

Recurrent sinus pauses: an atypical presentation of temporal lobe epilepsy.

Autonomic dysfunction related to seizures may give rise to a broad spectrum of cardiovascular abnormalities. Among these, ictal bradycardia and conduction delays may be encountered. Failure to recognize these abnormalities may contribute to sudden, unexplained death in epilepsy patients. We report a case of a Haitian female with temporal lobe epilepsy associated with recurrent sinus pauses.

Acute renal infarction presenting with acute abdominal pain secondary to newly discovered atrial fibrillation: a case report and literature review.

We report an 85-year-old female with known history of recurrent diverticulitis presented with abdominal pain. It was believed that the patient again needed to be treated for another diverticulitis and was started on the routine treatment. The initial CT scan of abdomen showed renal infarcts bilaterally that were confirmed by a CT with and without intravenous contrast secondary to unknown cause. An ECG found accidentally that the patient was in atrial fibrillation, which was the attributed factor to the renal infarctions. Subsequently, the patient was started on the appropriate anticoagulation and discharged.