Imaging in Rheumatic Immune-related Adverse Events.

Since their introduction, immune checkpoint inhibitors have revolutionized cancer treatment by harnessing the body's own immune system as a defense against tumor growth. The downside of activating the immune system is the development of immune-related adverse events (irAEs), which mimic autoimmune disease of various organ systems. The musculoskeletal system is an uncommon, but substantial one for patients and can lead to long-term pain and disability that affects their quality of life. This review summarizes recent literature on imaging forms utilized for diagnosis and assessing treatment response in rheumatic irAEs.

The Journey From Knee to Heart: A Case of Methicillin-Sensitive Staphylococcus aureus Infective Endocarditis Secondary to Septic Prepatellar Bursitis.

Staphylococcus aureus is a cause of life-threatening gram-positive bacteremia and the most common causative organism of septic bursitis. Although there are several case reports of infective endocarditis complicated with septic bursitis and other rheumatic complications, there are very few cases reports of septic bursitis leading to infective endocarditis (IE). We present a patient with a history of recurrent prepatellar bursitis requiring catheter drainage, who presented with sepsis and IE.

Arrhythmia With Lithium Toxicity Requiring Urgent Dialysis: A Case Report.

Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic side effects, primarily neurological are a concern. Cardiotoxic effects of lithium are rare, reported as non-specific T-wave flattening, prolonged QT interval, sinus node dysfunction, ventricular tachycardia, cardiomyopathy, and myocardial infarction. We report an interesting case of a young female patient with schizoaffective disorder on lithium who developed life-threatening cardiotoxicity secondary to lithium requiring urgent dialysis.

An Unusual Etiology of Aortic Insufficiency: A Case Report.

Identifying the etiology of aortic insufficiency (AI) is essential in the management of the patient with valvular heart disease. We report the case of a 34-year-old male who presented with New York Heart Association (NYHA) class IV symptoms. The physical exam was consistent with AI, which was confirmed on echocardiography. Interestingly, the trileaflet aortic valve (TAV) was comprised of three retracted cusps, a rarely cited anatomic abnormality yielding AI. The patient underwent an uncomplicated aortic valve replacement (AVR).

A 73-Year-Old Man with an Incidental Diagnosis of Deltoid Intramuscular Myxoma Following a History of Trauma.

BACKGROUND Intramuscular myxomas are rare and benign soft-tissue tumors of uncertain differentiation. Predisposing or precipitating factors have not yet been reported. Activating mutation in GNAS (exons 8 and 9) is detected in >90% of sporadic cases. The role of chronic myopathy, tendinopathy, or trauma to muscles in the etiology of these neoplasms is not known. We report an unusual case of a deltoid mass found following longstanding rotator cuff tendinopathy and a recent fall, later confirmed to be an intramuscular myxoma on biopsy. CASE REPORT A 73-year-old man with a 5-year history of left shoulder pain and rotator cuff tear presented with intractable pain in his left shoulder after a recent fall at home. Physical examination was suggestive of a rotator cuff injury and magnetic resonance imaging (MRI) of the left shoulder revealed a 2.7×2.5×3.7cm T1 hypo- and T2 hyperintense oblong mass-like signal abnormality with heterogeneous, predominantly peripheral enhancement within the deltoid muscle concerning for a malignant mass. Surgical resection was carried out along with left reverse total shoulder replacement, and histopathology revealed findings consistent with an intramuscular myxoma. CONCLUSIONS Intramuscular myxomas are rare, benign tumors. This case report presents one such myxoma incidentally found in a patient with longstanding rotator cuff tendinopathy and a recent fall. Although this co-occurrence is likely incidental, further research and case series review of similar presentations may influence postulations of the pathophysiology of myxomas.

Lambl's Excrescences Associated with Cardioembolic Stroke.

BACKGROUND Lambl's excrescences (LE) are threadlike fronds that occur along valve closure lines where minor endothelial damage occurs, resulting in thrombus formation. It is often asymptomatic but can result in cerebral embolism and coronary artery obstruction. The criterion standard for diagnosis is transesophageal echocardiography. CASE REPORT We report an interesting case of a 73-year-old right-handed man presenting with a visual disturbance. An MRI head demonstrated an acute-to-subacute infarct in the right posterior cerebral artery territory involving the posterior right temporal, right occipital lobes, and right thalamus, which was in keeping with embolic stroke. Investigation with transthoracic and transesophageal echocardiography showed echo density on the ventricle surface of the left coronary cusp, which was concerning for Lambl's excrescences, with no significant arrhythmia on his implantable loop recorder at 3-month follow-up. Therefore, we believe that his stroke was due to embolization from Lambl's excrescences. Since this was his first episode of stroke, monotherapy with aspirin was continued. CONCLUSIONS Although rare, Lambl's excrescences should be considered in the differential diagnosis of embolic stroke. However, there is no established guideline for its management. Patients with the first stroke episode can be treated conservatively with antiplatelet therapy. In patients with recurrent ischemic events, anticoagulation should be offered, along with discussion about surgical excision.

A Case of Osmotic Demyelination Syndrome in a Chronic Alcoholic With Moderate Hyponatremia.

Osmotic demyelination syndrome (ODS) is a clinical syndrome seen following aggressive correction of severe hyponatremia. Chronic alcohol use, malnutrition, and electrolyte derangement are additional risk factors promoting the demyelination in ODS. A 49-year-old female with a history of untreated mood disorder, hypertension, alcohol, and tobacco abuse presented to the emergency department (ED) with a three-month history of generalized body weakness. She also had a history of recurrent falls, difficulty walking, inadequate food and water intake, progressively worsening jaundice, and confusion which started about the same time. Her vital signs were normal; some of the significant physical examination findings were: sclera icterus, abdominal distension, bilateral pedal edema, hand tremors, rotary nystagmus, paraparesis, 1+ bilateral knee jerk, and absent bilateral ankle jerk. She had moderate hyponatremia, mild hypokalemia, deranged liver function test with a cholestatic pattern and transaminitis, hypoalbuminemia, elevated ammonia, lipase, in keeping with alcoholic liver disease and acute pancreatitis. In the ED, she received a normal saline infusion, and her serum sodium rose by just 6 mmol/L within the first 24 hours. She had drainage of her ascitic fluid and treatment with thiamine, folic acid, prednisone, lactulose, rifaximin, furosemide, spironolactone, and Ceftriaxone with improvement in clinical and laboratory abnormalities. Her lower extremity weakness persisted despite physical therapy, prompting neurologic evaluation. MRI of the lumbar spine showed an old compression fracture and lumbar spinal stenosis, while MRI brain findings were consistent with Osmotic demyelination. At the time of discharge to a rehabilitation facility, her serum sodium was 132 mmol/L, but her leg weakness persisted. Although rare, ODS can occur in the setting of moderate hyponatremia if there are additional risk factors that lower the threshold for demyelination.

Trends in hospitalizations for vertebral compression fracture in ankylosing spondylitis: data from the National Inpatient Sample 2000-2014.

Ankylosing spondylitis (AS) patients are at increased risk of vertebral compression fractures (VCF). Our objective was to examine the yearly trend of VCF hospitalizations in AS patients as compared to rheumatoid arthritis (RA) and the general population. National Inpatient Sample (NIS) database (2000-2014) was used to identify adult (≥ 18 years) hospitalizations, based on validated ICD-9 diagnosis codes. The rate of VCF hospitalizations, as a primary diagnosis, was assessed in three mutually exclusive groups: AS, RA, and the general population. The prevalence of VCF hospitalization was highest in AS (2.70%), compared to 0.77% in RA and 0.35% in the general population. Over the 15-year period, VCF hospitalization in AS was noted to have an increasing trend (Annual Percent Change (APC) = 4.73, p < 0.05) in contrast to the stable trend in the general population (APC = 0.34, p = NS) and a declining trend in RA (APC -3.61, p < 0.05). VCF related to AS was also associated with a longer hospital stay as compared to the general population (8.1 days vs. 5.1 days, p < 0.05) and higher inpatient mortality (3.4% vs. 1.0%, p < 0.05). A higher rate of VCF hospitalization along with an increasing trend was noted in AS as compared to RA and compared to the general population. Better screening approaches and treatment strategies for AS patients with VCF risk are urgently needed to reduce hospitalizations and related complications. Key Points • An increasing trend of VCF hospitalization was noted in AS, in contrast to a declining trend in RA and a stable trend in the general population. • VCF in AS was associated with longer hospital stay and higher inpatient mortality than in RA and the general population.

Bell's Palsy as a Late Neurologic Manifestation of COVID-19 Infection.

Bell's palsy is acute peripheral facial nerve palsy; its cause is often unknown but it can be triggered by acute viral infection. Coronavirus disease 2019 (COVID-19) infection commonly presents with respiratory symptoms, but neurologic complications have been reported. A few studies have reported the occurrence of facial nerve palsy during the COVID-19 pandemic. We present a case of Bell's palsy in a 36-year-old man with COVID-19 infection and a past medical history of nephrolithiasis. He presented to the emergency room with a day history of sudden right facial weakness and difficulty closing his right eye four weeks following a diagnosis of COVID-19 infection. Physical examination revealed right lower motor neuron facial nerve palsy (House-Brackmann grade IV). Serologic screen for Lyme disease, human immunodeficiency virus (HIV), and herpes simplex virus (HSV) 1 and 2 were negative for acute infection; however, neuroimaging with MRI confirmed Bell's palsy. He made remarkable improvement following treatment with a course of valacyclovir and methylprednisolone. This case adds to the growing body of literature on neurological complications that should be considered when managing patients with COVID-19 infection.

A Retrospective Study of Hospitalizations in the USA: Proportion of Hospitalizations With Non-Alcoholic Fatty Liver Disease in Non-Obese Population.

Background Non-alcoholic fatty liver disease (NAFLD), one of the leading causes of end-stage liver disease, is known to be associated with obesity. However, only a few studies in the United States (US) have described non-obese NAFLD, most of which were on the outpatient population. Aim We aimed to investigate the proportion of hospitalizations in the US with a diagnosis code that included NAFLD in the non-obese population. Methods We analyzed adult discharges from the Nationwide Inpatient Sample with a diagnosis of NAFLD from January 2010 to December 2014. We created two groups: obese (overweight or obese) and non-obese (normal or underweight) groups. Basic demographic and clinical characteristics were compared using the chi-square test and Student's t-test. Results A total of 194,787 hospitalizations with NAFLD were identified over the five-year period. It was observed that the prevalence of non-obese NAFLD hospitalizations increased yearly. Non-obese NAFLD hospitalizations had a higher mean age (57.5 vs 51.5 years, p < 0.0001) and a higher proportion of males (43.3% vs 36.1%, p < 0.0001) than obese NAFLD hospitalizations. With univariate analysis, non-obese NAFLD hospitalizations had lower odds of hypertension (OR 0.74, p < 0.0001), diabetes mellitus (OR 0.65, p < 0.0001). Non-obese hospitalizations had higher odds of cirrhosis (OR 1.30, p < 0.001) and decompensated cirrhosis (OR 1.30, p < 0.001) after adjusting for age, sex, race, diabetes mellitus, and dyslipidemia. Hospitalizations with non-obese NAFLD had higher odds of death (OR 1.49, p < 0.001) after adjusting for age, gender, race, co-morbidities, cirrhosis, and liver decompensation. Conclusion There is a continued rise in the proportion of non-obese NAFLD among hospitalizations in the US. Non-obese NAFLD hospitalizations were less likely to have hypertension and diabetes, but more likely to have decompensated liver disease. Further studies are needed to better characterize these patients to enable early detection, treatment, and reduction in complications of liver disease.

Rapidly Progressive Granulomatous Amoebic Encephalitis in a Diabetic Individual.

We present a case of rapidly progressive granulomatous amoebic encephalitis caused by Balamuthia mandrillaris in an individual with diabetes mellitus. Our patient presented with occipital headache, blurry vision, confusion, and gait imbalance of one week's duration. Brain imaging revealed numerous peripheral ring-enhancing lesions concerning malignancy. Brain biopsy was consistent with Balamuthia mandrillaris infection. He passed away 45 days after presentation despite being treated with a five-drug regimen. This case highlights the importance of considering amoebic brain infections, especially with ring-enhancing lesions on imaging. There are opportunities to design modalities for rapid diagnosis and better treatment.

Sustained Ventricular Tachycardia as a Harbinger of Cardiac Amyloidosis.

BACKGROUND Cardiac amyloidosis is an infiltrative cardiomyopathy caused by the extracellular deposition of insoluble precursor protein amyloid fibrils. These depositions of protein amyloid fibrils are found on the atria and ventricles and can cause a wide array of arrhythmias; however, sustained ventricular arrhythmias are quite uncommon. CASE REPORT A 71-year-old man with a history of hypertension developed a sudden onset of shortness of breath, profuse diaphoresis, lightheadedness, and presyncope. Upon emergency medical services' arrival, an initial electrocardiogram revealed wide complex tachycardia with a heart rate of 220 to 230 beats per min. He was subsequently given, in succession, magnesium, adenosine, and amiodarone with no change in heart rate or rhythm. Due to ongoing symptoms of diaphoresis and the development of dyspnea, he underwent direct current cardioversion and was converted from ventricular tachycardia to atrial fibrillation at controlled rates. A transthoracic echocardiogram and cardiac magnetic resonance imaging showed features suspicious for cardiac amyloidosis. A subsequent 99m technetium pyrophosphate single-photon emission computerized tomography scan revealed a grade 3 visual uptake and a heart-to-contralateral lung ratio of 1.92, consistent with transthyretin amyloidosis. The patient was treated with tafamidis and an implantable cardioverter-defibrillator for secondary prevention of ventricular arrhythmia. CONCLUSIONS This case highlights the need to consider cardiac amyloidosis in the differential diagnoses of patients with persistent ventricular arrhythmia and no prior history of heart disease.