Tissue Plasminogen Activator in Acute Cardiac Arrest.

Tissue plasminogen activator (TPA) is indicated as an empiric therapy for refractory out-of-the-hospital cardiac arrest for suspected pulmonary embolism and myocardial infarction. Intracranial hemorrhage following TPA administration is a rare complication resulting in increased morbidity and mortality. A history of intracranial bleed, oral anticoagulant use prior to hospital admission, low body weight, and unstable hypertension with blood pressure above 180/110 mmHg at the time of presentation are associated with intracranial bleeding following tPA administration. Dedicated imaging including a Computed Tomography of the head without contrast, while feasible for patients presenting with acute stroke, is impractical in the setting of cardiac arrest. Here we report a case of 66 years old patient who presented in context of refractory cardiac arrest with recurrent PEAs with interval return of spontaneous circulation (ROSC) and was given tPA with eventual ROSC. He was subsequently found to have both a subarachnoid and intraventricular hemorrhage.

Pulmonary Clostridium perfringens: Seeding Beyond the Gastrointestinal Tract.

Clostridia perfringens infection outside the gastrointestinal system is rare. Here, we report on a 75-year-old man with history of end-stage renal disease presenting after a syncopal event with lactic acidosis, leukocytosis, and mild hyper-bilirubinemia. Chest imaging revealed a loculated, left-sided pleural effusion; diagnostic thoracentesis identified Clostridia perfringens, consistent with an empyema. Video-assisted thoracic left lung decortication was performed; tissue culture also speciated Clostridia perfringens. Further imaging revealed concomitant acute cholecystitis, suggesting hematogenous seeding or transdiaphragmatic extension of Clostridia perfringens to pleural space from an abdominal source. The patient was successfully managed with laparoscopic cholecystectomy and discharged on a one-month course of amoxicillin-sulbactam. This case highlights the potential for Clostridia perfringens to produce a pleuropulmonary infection, necessitating timely diagnosis and intervention, to improve patient outcomes.

XRayWizard: Reconstructing 3-D lung surfaces from a single 2-D chest x-ray image via Vision Transformer.

BACKGROUND: Chest x-ray is widely utilized for the evaluation of pulmonary conditions due to its technical simplicity, cost-effectiveness, and portability. However, as a two-dimensional (2-D) imaging modality, chest x-ray images depict limited anatomical details and are challenging to interpret. PURPOSE: To validate the feasibility of reconstructing three-dimensional (3-D) lungs from a single 2-D chest x-ray image via Vision Transformer (ViT). METHODS: We created a cohort of 2525 paired chest x-ray images (scout images) and computed tomography (CT) acquired on different subjects and we randomly partitioned them as follows: (1) 1800 - training set, (2) 200 - validation set, and (3) 525 - testing set. The 3-D lung volumes segmented from the chest CT scans were used as the ground truth for supervised learning. We developed a novel model termed XRayWizard that employed ViT blocks to encode the 2-D chest x-ray image. The aim is to capture global information and establish long-range relationships, thereby improving the performance of 3-D reconstruction. Additionally, a pooling layer at the end of each transformer block was introduced to extract feature information. To produce smoother and more realistic 3-D models, a set of patch discriminators was incorporated. We also devised a novel method to incorporate subject demographics as an auxiliary input to further improve the accuracy of 3-D lung reconstruction. Dice coefficient and mean volume error were used as performance metrics as the agreement between the computerized results and the ground truth. RESULTS: In the absence of subject demographics, the mean Dice coefficient for the generated 3-D lung volumes achieved a value of 0.738 ± 0.091. When subject demographics were included as an auxiliary input, the mean Dice coefficient significantly improved to 0.769 ± 0.089 (p < 0.001), and the volume prediction error was reduced from 23.5 ± 2.7%. to 15.7 ± 2.9%. CONCLUSION: Our experiment demonstrated the feasibility of reconstructing 3-D lung volumes from 2-D chest x-ray images, and the inclusion of subject demographics as additional inputs can significantly improve the accuracy of 3-D lung volume reconstruction.

Acute inferior ST-elevation myocardial infarction mimicked by direct lightning strike: a case report.

Background: Direct lightning strikes are rare, and multiple organ systems can be involved. Prognosis is dependent on the severity of the injury. Severe myocardial injury associated with transient electrocardiogram changes, which have been previously described, is a hazardous complication. Case summary: A 35-year-old man with no known past medical history presented unresponsive following a direct lightning strike while sitting in a portable toilet. High-quality cardiopulmonary resuscitation was started in the field, with return of spontaneous circulation (ROSC) after 1 h. Following ROSC, he received volume resuscitation and was maintained on multiple vasopressors. Electrocardiogram showed significant ST-elevations in inferior leads with elevated troponin I, consistent with inferior ST-elevation myocardial infarction. Labs revealed lactic acidosis, hyperkalaemia, acute kidney, and liver injury. Due to concern for plaque rupture, coronary angiography was performed and revealed no obstructive coronary artery disease. Vasopressor support and volume resuscitation were continued for extensive burns covering greater than 30% body surface area. The patient became progressively hypotensive, eventually precipitating pulseless electrical activity arrest. Emergent labs were notable for severe acidaemia. Despite aggressive interventions, he expired due to severe multi-organ failure. Discussion: Direct lightning injuries are rare with serious potential complications. Myocardial damage, either from direct electrical insult or from induced coronary vasospasm, can lead to multi-organ system failure.

Dry Beriberi Post Roux-en-Y Gastric Bypass Surgery.

Bariatric surgery is an effective strategy for achieving substantial weight loss, prolonging survival, and improving the comorbidities associated with obesity. Nutritional deficiency is a commonly recognized post-procedural complication. Here, we present a case of a patient with paresthesia, lower extremity weakness, and altered mental status one year following Roux-en-Y gastric bypass, who was found to have multiple vitamin and micronutrient deficiencies and was diagnosed with beriberi in the setting of profound thiamine deficiency.

Topical Diclofenac-Induced Hepatotoxicity.

The hepatotoxic potential of diclofenac, a commonly used non-steroidal anti-inflammatory agent, is well established in literature. However, cases of diclofenac-induced liver disease have occurred almost exclusively with the oral formulation of this medication. We report the case of an elderly man with Paget's disease and osteoarthritis who developed acute hepatotoxicity, as evidenced by laboratory diagnostics, four months after use of topical diclofenac 1% gel. Once diclofenac gel was discontinued, repeat blood work three weeks after discharge demonstrated return of liver function tests to baseline. Given the temporal relationship between the initiation and escalation of topical diclofenac and the changes in liver function tests, the likelihood of diclofenac-induced liver injury was deemed possible using a well-recognized causality assessment tool. Further research on topically administered non-steroidal anti-inflammatory agents is needed to identify monitoring intervals for early detection and avoidance of adverse effects in patients using topical diclofenac.

Acute Pancreatitis Following Percutaneous Mechanical Thrombectomy of Left Common Iliac Vein.

While parental or oral anticoagulation remains a mainstay of therapy for thrombosis, in sporadic clinical situations, percutaneous mechanical thrombectomy is favored. Percutaneous mechanical thrombectomy is a well-tolerated subtype of catheter-directed intervention resulting in thrombus breakdown and removal. This procedure combines endovascular mechanical thrombectomy in combination with pharmacologic thrombolysis allowing for a significant reduction in procedure time. Similar to other catheter-based procedures, common complications include hemorrhage, dissection, pseudoaneurysm, and perforations. Acute pancreatitis, in contrast, is a rare complication of percutaneous mechanical thrombectomy with only limited cases reported and is hypothesized to occur secondary to release of heme byproducts. Here, we present a case of acute pancreatitis following outpatient percutaneous mechanical thrombectomy of the left common iliac vein that ultimately required hospitalization, intensive care unit (ICU) admission, and standard medical management for pancreatitis.

Type A Aortic Dissection and Non-Contrast Computed Tomography.

Non-contrast enhanced chest computed tomography (CT) carries a low sensitivity for acute aortic dissection; CT Angiography remains the gold standard. We highlight the potential utility of non-contrast CT for detection of aortic dissection in a case of a young, immunocompromised man presenting with acute abdominal pain and renal injury. Given elevated creatinine, an initial non-contrast chest CT demonstrated subtle findings suggestive of aortic dissection (aneurysmal dilation of the proximal ascending aorta as well as displaced calcified intimal flap/intraluminal high linear density in the thoracic descending and distal abdominal aorta). Subsequent CT angiography confirmed the presence of an extensive type A aortic dissection. He underwent emergent exploratory laparotomy and hemiarch repair. Displaced calcified intimal flaps, intraluminal high-densities, intramural hematoma, and aneurysmal aortic dilation are common non-contrast computed tomography imaging findings that suggest aortic dissection.

Peritoneal Amyloid as a Presenting Manifestation of AL Amyloid.

Amyloid is a systemic disease characterized by extracellular deposition of misfolded protein. Gastrointestinal and peritoneal deposition of light chain (AL) amyloid is an under-recognized manifestation of this systemic disease, usually as a late sequela. Here we present a case of recently diagnosed AL peritoneal amyloid that presented in the context of recurrent, acute onset abdominal discomfort and was found to have bowel obstruction complicated by perforation in the setting of AL-mediated gastrointestinal tract infiltration and dysmotility.

Coronary artery bypass grafting for triple vessel disease in cardiac amyloidosis.

Cardiac amyloidosis is a rare condition with an estimated incidence of 18-55 per 100 000 person-years. It is associated with either immunoglobulin light chain (AL) or transthyretin amyloid (ATTR), both of which result in a restrictive cardiomyopathy complicated initially by diastolic dysfunction and subsequently followed by biventricular systolic heart failure. Untreated cardiac amyloidosis carries an extremely poor prognosis with an estimated median survival time of less than 1 year in AL and 4 years in ATTR amyloidosis. This is the sixth described report of coronary artery bypass grafting in patients with underlying cardiac amyloidosis.

Erratum to "A large unruptured ectopic pregnancy" [Radiology Case Reports 16 (2021) 1204-1206].

[This corrects the article DOI: 10.1016/j.radcr.2021.02.048.].

Recurrent herpes simplex virus encephalitis with presumptive Human Herpesvirus 6 chromosomal integration.

Viral encephalitis can lead to encephalopathy, epileptic activity, focal neurological deficits, and death. Prompt recognition and a high index of clinical suspicion can lead to early initiation of appropriate management. We describe an interesting case of a 61-year-old presenting with fever and altered mental status, diagnosed with numerous episodes of viral encephalitis caused by divergent and recurrent viruses. On his initial presentation, lumbar puncture revealed lymphocytic pleocytosis and positivity for Human Herpesvirus 6 (HHV-6), and he was treated with ganciclovir. On subsequent admissions, he was diagnosed with recurrent HHV-6 encephalitis as well as Herpes Simplex Virus 1 encephalitis and treated with ganciclovir, foscarnet and acyclovir. Despite prolonged courses of treatment and resolution of symptoms, he continued to have persistently high plasma viral loads of HHV-6, consistent with probable chromosomal integration. In this report, we emphasize the clinical pearl of chromosomally integrated HHV-6 that can present in a patient with persistently high plasma viral loads of HHV-6, that are non-responsive to treatment. Individuals with chromosomally integrated HHV-6 may be more susceptible to other viral infections.

Light Chain Myeloma Precipitating Cryoglobulinemic Vasculitis.

Multiple Myeloma (MM) is characterized by monoclonal immunoglobulin production leading to widespread skeletal destruction and renal dysfunction. Light chain multiple myeloma (LCMM) affects 15% of individuals with MM and has an overall poor prognosis. Cutaneous manifestations are uncommon and it is rarely complicated by Type I Cryoglobulinemia (CG). Here we present an atypical case of κ-predominant LCMM complicated by Type I CG in an 80-year-old man who presented with a progressive non-blanching necrotic rash and ulcers involving his face, distal extremities, and oropharynx of two months duration prior to his admission at our facility. On admission to our facility, workup showed an overabundance of κ-light chains, elevated free κ/λ ratio, cryoglobulins, and an acute kidney injury. Marrow biopsy demonstrated 60% plasma cells with κ-light chain predominance. Cutaneous manifestations such as acral cyanosis and distal gangrene in LCMM indicate late stages of the disease, and such findings should raise suspicion for additional comorbid pathologies, including cryoglobulinemia, which could help direct earlier initiation of treatment.

Solid Pseudo-papillary Neoplasia: A Rare Malignancy of the Pancreas.

Solid pseudopapillary neoplasms (SPNs) are exceedingly rare type of exocrine pancreatic malignancy, representing only 0.9%-2.7% of all exocrine pancreatic malignancies. They predominantly affect young women and unlike other pancreatic malignancies, they have excellent prognoses with 5-year survival following surgical resection approaching 97%. Given the rarity of the disease, little is known about their histopathogenesis as they do not harbor similar genetic mutational abnormalities like other pancreatic tumors. We describe a rare case of SPN in a young female who was found to have the rare diagnosis during the work up for deranged liver function tests.

A mild, self-resolving case of Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a multisystem disease caused by an excessive activation of the immune system. In most instances, HLH can be fatal without treatment; a life-threatening syndrome driven by a dysregulated immune system and activation of macrophages resulting in cytokine release and consequent cellular damage. HLH can occur as a consequence of multiple genetic abnormalities or environmental triggers. We present an interesting case of mild, self-resolving, HLH due to Epstein-Barr Virus (EBV) infection in a young woman. The best-known diagnostic criteria are based on the HLH-2004 trial, incorporating either the presence of known mutations or five of eight clinical and laboratory findings. Prompt initiation of etoposide-containing therapy is associated with improved survival. Rituximab, an anti-CD20 antibody, can also remove EBV-harboring B-cells and improve outcomes. In a rare subset of patients, the disease can spontaneously resolve without any therapeutic interventions thus sparing the patients from toxic therapies.

Haemophagocytic lymphocytic histiocytosis/macrophage activation syndrome with acute inflammatory gastroenteritis.

Haemophagocytic lymphocytic histiocytosis (HLH) is a rare, life-threatening condition caused by abnormal activation of cytotoxic T lymphocytes, natural killer cells and macrophages resulting in hypercytokinaemia and immune-mediated injury of multiple organ systems. Secondary HLH occurs in the setting of a malignant, infectious or autoimmune stimulus. Macrophage activation syndrome (MAS) is the term used to describe HLH that develops secondary to rheumatological diseases such as lupus and juvenile idiopathic arthritis, among others. Commonly observed and documented symptoms include fever, organomegaly and lymphadenopathy. Given the potential for multiorgan failure in HLH/MAS, early identification, diagnosis and initiation of treatment is essential. We present a case of secondary HLH/MAS with acute inflammatory gastroenteritis in a middle-aged woman with a history of systemic lupus erythematosus.

A Case of Chest Jolts: Pulmonary Vein Thrombus Extending into the Left Atrium.

Pulmonary vein thrombosis (PVT) is a rare but life-threatening clinical condition, often found incidentally on imaging. In this report, we present an interesting case of PVT of the left inferior pulmonary vein with extension into the left atrium in a 78-year-old woman presenting with "jolts" in the chest. Initial imaging with plain chest film radiograph showed findings consistent with COPD and no acute intrathoracic process. A CT angiogram of the chest revealed a filling defect consistent with thrombus within the left inferior pulmonary vein extending into the left atrium. A transthoracic echocardiogram was remarkable for a severely enlarged right ventricular cavity with moderately reduced right ventricular systolic function and normal left ventricular size with preserved systolic function. She was not a candidate for any surgical interventions, and she was managed with systemic anticoagulation. Management of PVT mostly depends on the underlying cause as there are no well-defined treatment guidelines. The consensus recommends systemic anticoagulation until thrombus resolution. When anticoagulation is contraindicated, thrombectomy is indicated to restore blood flow. In patients with similar presentation and clinical history it is important to consider PVT, and to focus on prompt diagnosis and early initiation of appropriate treatment.

ST-Elevation Myocardial Infarction from Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening condition which occurs due to non-traumatic separation of the coronary artery wall. It is more common in women, with an unclear, non-atherosclerotic mechanism. We report a unique case of spontaneous coronary artery dissection presenting as ST-elevation myocardial infarction (STEMI). A 54-year-old woman presented with fever and recurrent abscess. On presentation, she was tachycardic, tachypneic and hypoxic, requiring nasal cannula. Physical exam was notable for healing a wound on the right lower back, status post incision and drainage, with no erythema, edema, ecchymosis or purulent drainage. Laboratory investigations were remarkable for anemia. EKG showed sinus tachycardia with no ST-segment changes. Her hospital course was complicated by septic shock, renal failure, and acute hypoxic respiratory failure requiring intubation. Following extubation, she complained of sudden-onset, severe chest pain. EKG showed ST-elevations in the lateral and inferior leads, with an elevated high-sensitivity troponin level. Cardiac catheterization revealed SCAD involving the mid to distal right posterior descending artery (RPDA) with TIMI-3 flow in the distal RPDA. Given vessel tortuosity and poor target for stenting, was medically managed with dual antiplatelet therapy, a beta-blocker and an eptifibatide infusion for 12 h post-procedure. Extensive rheumatological workup negative. She remained hemodynamically stable with no new ST changes on subsequent EKGs. This is an uncommon medical emergency requiring prompt recognition, appropriate management and early intervention to prevent unfavorable patient outcomes.

A case of superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome, also known as Cast syndrome, Wilkie's syndrome, or duodenal ileus, is a rare condition involving compression of the duodenum between the aorta and the SMA, primarily attributed to loss of the intervening mesenteric fat pad. Clinical symptoms include postprandial epigastric abdominal pain, nausea, emesis, and weight loss. At-risk individuals include those with rapid weight loss, debilitating illness, malignancy, malabsorption syndromes, trauma, neurologic injury, eating disorders, and substance abuse. Here, we present a case of SMA syndrome in a 24-year-old woman presenting with nausea, vomiting, and abdominal pain who improved with conservative management.

Migration of silicone oil for retinal detachment.

Here we describe two, separate, and unique radiological findings in two distinct patients, sequelae from prior silicone oil injection for management of retinal detachment. In both cases we present bilateral, frontal horn hyperdense "masses" without appreciable enhancement or surrounding vasogenic edema. Both cases serve as important reminders of the potential for silicone oil migration and its unique radiological presentation, which has the potential to be a radiologic mimic of intracerebral hemorrhage and significantly change medical management of individuals presenting with transient ischemic attack or cerebrovascular accident.