Abdominal Epilepsy Masked with Hiccups in a Patient with Intracranial Malignant Glioma.

Abdominal hiccups are often masked by abdominal epilepsy (AE) in clinical settings. Spontaneous arrhythmic muscular movements sometimes raise the suspicion for abdominal myoclonus as well. AE is an atypical and rare cause of seizure disorder. It is a manifestation of different transient abdominal complaints correlating with abnormal electroencephalogram (EEG) changes and adequate response to anti-epileptic drugs. We present a case of an 80-year-old female who presented with an episode of tonic-clonic seizure that lasted for almost 10 minutes. The patient was confused and had a facial droop. She had another episode of seizure with a perseverative speech followed by left facial drooping and left upper extremity weakness. She continued having fluctuating mental status and left-sided hemiparesis with intermittent abdominal twitching. She was getting more bradykinetic than bradyphrenic. The computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain showed a parietal lobe mass that was confirmed on biopsy as malignant glioma. The long-term video monitoring EEG report showed the occurrence of persistent right parietal spikes with background slowing. The brain mass was later treated with radiation therapy and surgery.

Marked Atrophic Changes of the Brain in a Patient with Subacute Sclerosing Panencephalitis.

Subacute Sclerosing Panencephalitis (SSPE) is a debilitating disorder associated with the measles infection in childhood. It is a very rare manifestation in children. It usually presents with measles before the age of two. We report a similar case of SSPE in a 14-year-old girl who developed this life-threatening condition in spite of receiving the measles vaccination. Despite the vaccination, the patient had suffered from measles before the age of two. This highlights the dilemma of ineffective vaccinations in developing countries. We also describe the radiologic features of SSPE in this patient, with marked atrophy seen in the occipital region following hyperintensities noticed at a relatively earlier stage.

Cardiovascular Dysfunction Presenting as Autonomic Dysreflexia in a Patient with Spinal Cord Injury.

Autonomic dysreflexia (AD) is a medical emergency that is characterized by hypertension as an autonomic response to noxious stimuli in patients with a history of spinal cord injury at the level of T6 or above. We present the case of a 31-year-old Caucasian male with a history of spinal cord injury at the level of C3-C4, with symptoms described as recurring episodes of hypertension with flushing and sweating above the level of the lesion for the past five to six years. His symptoms are triggered by bowel distention, excitement, a bumpy car ride, or a simple turning of the neck to the left. Physical examination and laboratory studies ruled out other possible differentials (e.g., migraines, pheochromocytoma). As a result, AD was diagnosed.

Breast Cancer Metastases to the Gastrointestinal Tract Presenting with Anemia and Intra-abdominal Bleed.

Signet ring adenocarcinoma of the breast with synchronous metastasis to the gastrointestinal (GI) tract is a rare occurrence, typically presenting with abdominal pain, dyspepsia, or GI bleed. We report a case of metastatic breast cancer presenting with a complaint of anemia. A further diagnostic evaluation revealed generalized lymphadenopathy, nodular thickening of the urinary bladder wall, bone lesions, and enlarged pancreas. Biopsies from the lymph nodes, pancreatic biopsy, and bladder nodule all revealed a signet cell carcinoma. An upper and lower GI endoscopy revealed multiple ulcerated gastric mucosal nodules and polypoid folds in the cecum and proximal ascending colon; the biopsies from these lesions were also positive for signet ring cell adenocarcinoma.

Combination Therapy for Multidrug-Resistant Klebsiella Pneumoniae Urinary Tract Infection.

Hospital-acquired multidrug-resistant (MDR) Klebsiella infection is posing a significant challenge to physicians all around the world. The spread of multiple antibiotic resistance among various members of bacteria continues to be a significant clinical threat. Antibiotic susceptibility testing is the initial step in optimizing the appropriate antibiotic therapy for infections with MDR Klebsiella. We report a case of MDR Klebsiella urinary tract infection (UTI) in a patient following a trimalleolar fracture, which was appropriately treated with a combination of amikacin and meropenem.

Extensive Pyoderma Gangrenosum: A Challenging Diagnosis and Literature Review of Management.

Pyoderma gangrenosum is a very rare, non-infectious leukocytic dermatosis, which is often associated with an underlying systemic disease. It is usually diagnosed based on the apparent clinical findings and by excluding other causes of ulcerative skin diseases. Treatment modality includes the use of systemic steroids and oral steroids. Immunosuppressive agents, such as cyclosporine and mycophenolate mofetil, can also be added if it fails to respond to steroids. We report a case of pyoderma gangrenosum in an 85-year-old female who presented in the inpatient facility with rapidly enlarging necrotic, ulcerative lesions with accompanying fever. She was managed with systemic steroids to which she responded well. This led to the arrest of the initially progressive lesions with some residual scarring.

Prevalence of Obesity in Carpal Tunnel Syndrome Patients: A Cross-Sectional Survey.

Carpal tunnel syndrome (CTS) is the most common compressive entrapment neuropathy caused by the compression of the median nerve at the wrist space known as the carpal tunnel. The epidemiologic factors related to CTS include genetic, medical, social, vocational, and demographic factors. The common symptoms experienced include pain, paresthesia, and numbness in the median nerve distribution. If left untreated, it can lead to irreversible median nerve damage, causing a loss of hand function. Body mass index (BMI) has been attributed as a risk factor for the development of CTS. We planned to determine the frequency of obesity among CTS patients in the neurophysiology department of a tertiary care center in Islamabad, Pakistan. The survey was designed as a cross-sectional descriptive study from March 2016 to August 2016 using a consecutive nonprobability sampling technique. A total of 112 patients with a mean age of 54 ± 5 years were included in the study. In the study population, 39 patients (35 percent) were males and 73 were females (65 percent). Based on BMI, 74 patients (66 percent) had a normal weight and 38 (34 percent) were obese. The frequency of obesity in our study was 34 percent, excluding the other comorbid conditions, which is quite high. Targeted therapy in those with CTS should also include weight reduction measures because obesity poses a cause-and-effect relationship for both the severity and the pathogenesis of CTS.

Anti-n-Methyl-d-Aspartate-Receptor (NMDAR) Encephalitis in Association with Ovarian Teratoma.

Anti-N-methyl-D-aspartate-Receptor (NMDAR) encephalitis is an autoimmune disorder with a multifaceted presentation that involves memory deficits, psychiatric symptoms, and autonomic instability. This case report describes the classic presentation of Anti-NMDAR encephalitis and highlights its association with ovarian teratomas. We present a 26 -year-old female who came in with new onset seizures and altered mentation who subsequently developed automatism. Electroencephalograms (EEG) showed left frontal spikes and right temporal delta activity. Magnetic resonance imaging (MRI) revealed right temporal hyper-intensity. The diagnosis was established with positive anti-NMDAR antibodies in the cerebrospinal fluid (CSF). The patient was initially treated with steroids and valproic acid, however, her condition progressively worsened. A five-day course of intravenous immunoglobulins (IVIG) was started followed by rituximab. The clinical course was complicated with the patient developing neutropenic fever and cerebrospinal fluid cultures (CSF) growing methicillin-sensitive Staphylococcus aureus (MSSA). She underwent pelvic imaging which showed a right ovarian teratoma. Evidence suggests that removal of ovarian tumor leads to better clinical and mortality outcomes in patients with Anti-NMDAR encephalitis. It is important for the internist to consider paraneoplastic syndromes in patients with Anti-NMDAR encephalitis.