Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder.

Vertebral hemangiomas (VHs) are benign vascular tumors that develop from the endoderm of blood vessels, although their exact pathogenesis is poorly understood. Most hemangiomas are small, about a third are multiple in number, and a very small number of these hemangiomas cause symptoms. Even more rare are aggressive VHs, which comprise a small number of all VHs, and are associated with expansion and extraosseous extension into the paraspinal and epidural spaces. Management of aggressive VHs involve pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery. Aggressive VHs are most commonly seen in the thoracic region but may rarely involve a large number of vertebrae. Cutaneous hemangiomas, when seen along with VHs, are often metameric.  We present a rare and challenging case of compressive myelopathy and a large cutaneous hemangioma or a "purple shoulder", found during an exam in a young male. He was found to have an extensive VH extending through 13 vertebral levels (C7 to D12), non-metameric to the cutaneous lesion. A thorough physical examination and evaluation along with prompt surgical treatment were the cornerstone of treatment and prevention of permanent neurological deficits.

Unabridged Histoplasmosis Myositis: Unsolved Dissemination with Diagnostic Challenge.

Histoplasmosis occurs predominantly in immunocompromised hosts and typically presents with mild constitutional symptoms, weight loss, weakness, fatigability, hepatosplenomegaly, and lymphadenopathy. The diagnosis is generally delayed and is based upon isolating the organism in blood cultures or by identifying intracellular organisms in tissues. Disseminated Histoplasmosis is well described in HIV patients but Histoplasmosis myositis is a rare manifestation and has not been reported in seronegative patients till date. We here address a case of a pharmacologically immunosuppressed patient with extensive Histoplasmosis myositis invading almost all the skeletal muscles of body (including plantar foot muscles) with no evidence of dissemination to other organ-systems. Clinical examination and investigations co-related with infiltrative muscle disease and skeletal muscle biopsy revealed Histoplasma capsulatum. This patient illustrates a distinctive clinical presentation of fungal infection with subtle constitutional symptoms and isolated muscle weakness which added to the diagnostic challenge. Hence, differential diagnosis of fungal infection must always be considered as a cause of myopathy in any pharmacologically immunosuppressed patient.