Thyroid storm obscured by acute asthma exacerbation and concurrent H1N1 influenza.

We present an uncommon case of H1N1 triggered thyroid storm in a patient with previously undiagnosed Grave's Disease. This case illustrates the challenges of diagnosing thyroid storm in the emergency department and the importance of including it in the differential when treating more common diagnoses that fail to respond to usual therapies. Thyroid storm is an endocrinologic emergency and requires prompt recognition and treatment. However, it remains a diagnostic challenge as there is no laboratory test specific to thyroid storm. Diagnosis relies on clinical suspicion in corroboration with patient presentation, laboratory findings and response to therapy.

Re-Validation of the COmprehensive Score for Financial Toxicity (COST): Assessing the Scale's Utility in Chronic Disease Populations.

OBJECTIVE: To report the psychometric properties of the COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure (PROM), an 11-item scale previously validated among patients diagnosed with cancer and receiving chemotherapy. METHODS: Data come from a cross-sectional survey (n = 2755 response rate of 87%) of participants in a remote digital health coaching intervention collected between January 2017 and February 2019. RESULTS: COST demonstrated very good internal consistency (Cronbach's alpha = .89) and good convergent validity. Lower financial toxicity was associated with improved physical and mental well-being HRQOL measures after controlling for covariates (b = 0.13, P < .0001; b = 0.28, P < .0001, respectively). Supplemental analyses indicated that the COST instrument loaded on 2 factors. CONCLUSIONS: The COST measure of financial toxicity has good internal consistency and predictive validity in a sample of patients with chronic conditions. However, contrary to previous research examining the psychometric properties of COST in a sample of individuals with cancer, which found COST to be unidimensional, our analyses indicated that the COST measure of financial toxicity is multidimensional in a sample of individuals with chronic conditions. In particular, the items that asked about "general financial wellbeing" loaded on the second factor while "illness-related financial wellbeing" loaded on the first.

Preliminary assessment of computed tomography and satellite teleradiology from Operation Desert Storm.

Computed tomography at military transportable hospitals was used for the first time during the recent Operation Desert Storm in the Saudi Arabian desert. Scan quality was excellent and the scans proved clinically important in patient management. A teleradiology link via satellite to the U.S. mainland was also successfully employed. The objectives of the teleradiology link were to validate the concept distant interpretation of images obtained on the battlefield and to provide specialty radiology consultation. This technology shows great promise for future applications, both for combat casualty care and for civilian disaster medical support operations.

The anatomy of the inferior petrosal sinus, glossopharyngeal nerve, vagus nerve, and accessory nerve in the jugular foramen.

PURPOSE: To define the variations of the courses of the cranial nerves and the inferior petrosal sinuses as they enter and traverse the jugular foramen. METHODS: Thirty-nine cadaveric specimens containing the jugular foramen were scanned with 1-mm contiguous axial and coronal CT sections. Each specimen was dissected to evaluate the position of the cranial nerves and inferior petrosal sinus as they entered the jugular foramen. RESULTS: The glossopharyngeal nerve entered the most superior, anterior, and medial aspect of the jugular foramen and descended in the anterior portion of the jugular foramen, often within a groove. The vagus and accessory nerves could not be separated by CT. They entered the jugular foramen most often anterior or anterior and inferior to the jugular spine of the temporal bone and descended in a position ranging from medial to anterior to the jugular vein. The inferior petrosal sinus most often coursed inferior to the horizontal portion of the glossopharyngeal nerve and entered the jugular system in the jugular foramen, at the exocranial opening or below the skull base. A pars nervosa and pars venosa could be identified only at the endocranial opening, where the jugular spine separated the pars nervosa containing the inferior petrosal sinus and three cranial nerves from the pars venosa containing the jugular vein. CONCLUSION: Our evaluation demonstrated anatomic variation in the area of the jugular foramen.

White matter changes in patients with breast cancer treated with high-dose chemotherapy and autologous bone marrow support.

PURPOSE: To study MR changes in the white matter of the brain in patients with breast cancer treated with a widely used protocol of high-dose chemotherapy and autologous bone marrow support. METHODS: Thirteen patients with high-risk stage II or stage IV breast cancer treated with high-dose cyclophosphamide, cisplatin, carmustine, and bone marrow support underwent posttransplant MR examination of the brain. Serial posttransplant MR examinations were performed in 5 of the 13 patients and single MR examinations in 8. The severity of the white matter change was evaluated by two neuroradiologists and rated mild, moderate, or severe. RESULTS: In 9 of the 13 patients, central and peripheral cerebral white matter changes were observed. Four patients had severe changes, extending from the ependyma of the lateral ventricles to the gyri. An additional 4 patients had moderate white matter change at the last observation. One had mild change, and 4 had no white matter change. In all patients, there was sparing of inferior frontal, posterior inferior occipital, and anterior temporal lobes, and of the centrosylvian brain. CONCLUSIONS: White matter change occurred in patients treated with a high-dose chemotherapy and bone marrow support protocol. Most of the changes, and the more severe ones, occurred 5 or more months after the transplants. There was no apparent relationship between these changes and central nervous system function. Because of the increased longevity with this treatment, it is important to appreciate these white matter changes, recognizing however that their expression may be subclinical.

Myelolipoma of the thoracic spine.

We describe a myelolipoma of the thoracic spine in a patient with gradual and progressive myelopathy. MR imaging showed this predominately fatty lesion to be extradural in location.

MR imaging of patients with carotidynia.

BACKGROUND AND PURPOSE: Carotidynia is an idiopathic neck pain syndrome associated with tenderness to palpation over the carotid bifurcation. Although well known in the otolaryngology and neurology literature, the validity of the entity has recently been questioned, in part because of the almost uniform absence of radiologic or pathologic findings. We report the MR findings in five patients with carotidynia. METHODS: During a period of 44 months, five patients with clinical signs and symptoms consistent with carotidynia were referred for imaging from the otolaryngology service. Each patient underwent MR imaging of the neck on a 1.5-T system. The studies included, as a minimum, pre- and postcontrast axial and postcontrast coronal T1-weighted images. Two patients also had axial T2-weighted imaging and another two patients underwent duplex sonography of the carotids. RESULTS: All five patients had abnormal enhancing tissue surrounding the symptomatic carotid artery centered at the level of the distal common carotid and carotid bifurcation. This tissue had intermediate signal intensity on T1-weighted images and showed marked enhancement. In all patients, the remaining visualized portions of the carotid artery were normal. Normal flow voids were present throughout the vessel, and the caliber of the vessels was always within normal limits. There was no evidence of intramural hematoma, cervical lymphadenopathy, or atherosclerotic disease of the vessel. In one patient, repeat imaging after resolution of symptoms showed an absence of the previous abnormality. CONCLUSION: The MR findings in these patients, along with the lack of any findings to suggest alternative diagnoses, support the existence of carotidynia as a distinct clinical entity.

MR screening for brain stem compression in hypertension.

PURPOSE: To determine the clinical usefulness of MR imaging to screen for vascular compression of the lateral medulla, considered by some to be responsible for neurogenic hypertension. METHODS: MR images and clinical records of 120 adults who had received brain MR imaging for any reason were divided into two groups: group 1 (n = 60) consisted of patients with essential hypertension and group 2 (n = 60) included patients who lacked a diagnosis of hypertension. No patient manifested symptomatic cranial neuralgias. The root entry zone of cranial nerves IX and X into the left lateral medulla was examined by MR imaging for proximity to the ipsilateral vertebral artery or its branches. Images lacking any contact between visible vascular structures and the root entry zone were recorded as normal. Vascular compression was graded according to the degree of proximity to the root entry zone. Lateral medullary contact only (grade I), contact and depression (grade II), or lower brain stem displacement or rotation (grade III) of the root entry zone were recorded in both hypertensive and normotensive patients. Among hypertensive patients, additional data were gathered from electrocardiographic, echocardiographic, and urinary protein reports. RESULTS: We found compression in 34 (57%) of the patients from group 1 and in 33 (55%) of the patients from group 2. Compressions in group 1 were grade I in 22 (37%) of the patients, grade II in 8 (45%), grade II in 4 (7%), and grade III in 2 (3%). There were no statistically significant differences in MR findings between the two groups. Among group 1 patients, MR grading did not predict end-organ changes in the heart (left axis deviation and left ventricular hypertrophy) or kidneys (proteinuria). CONCLUSION: Vascular compression of the root entry zone of cranial nerves IX and X into the left lateral medulla is not an adequate lesion to produce systemic hypertension. This finding is as common among normotensive patients as among hypertensive populations. Neither the presence nor the severity of changes in the root entry zone on MR images increases the occurrence of common end-organ responses in the heart or kidneys among hypertensive patients. MR screening is not warranted among hypertensive patients lacking symptomatic cranial neuralgias.

Transdural spinal cord herniation: imaging and clinical spectra.

PURPOSE: Transdural herniation of the spinal cord is a rarely reported clinical entity, and many of the existing reports were published before the advent of MR imaging. We describe five current cases and compare them with findings in 25 cases reported in the literature to delineate the clinical and imaging spectra of transdural spinal cord herniation. METHODS: MR imaging, CT myelography, and conventional myelography were performed in five patients with transdural herniation of the spinal cord. These studies, along with clinical findings, are described. Intraoperative photographs are included for one case. The salient features of both the current and previously reported cases are summarized in tabular form. RESULTS: In three cases, transdural spinal cord herniation occurred posttraumatically, in one case the cause was iatrogenic and in the others the herniation occurred spontaneously. Imaging features not previously reported include dorsally directed herniations at thoracolumbar levels (two patients), apparent (lacking surgical confirmation) syringomeyelia (one case), a vertebral body nuclear trail sign (one case), and intramedullary hyperintensities on MR images (two cases). Clinical features not previously reported include unilateral pyramidal-sensory deficits (one case) and isolated unilateral pyramidal signs (one case). Clinical findings similar to previous reports include progressive paraparesis (two cases) and progressive Brown-Séquard syndrome (one case). CONCLUSION: Our five cases illustrate certain clinical and imaging findings not previously reported, and, together with the established features of the 25 cases in the literature, delineate the spectra of transdural spinal cord herniation.

Radiographic evaluation of chest-wall lesions.

Multiple imaging modalities are available today for the evaluation of the wide variety of pathologic processes that affect the chest wall. However, the evaluation of nearly all abnormalities still begins with conventional radiographs. Careful analysis of these films, along with the judicious use of chest fluoroscopy and conventional tomography, frequently can lead to the correct diagnosis without resorting to the more expensive modalities. However, the precise anatomic location and characterization of many lesions requires the cross-sectional imaging capabilities of CT or MRI. In the appropriate clinical settings, these newer modalities often yield important information that leads to a specific diagnosis or demonstrates the full extent of a disease process. They may also be helpful in providing anatomic localization of lesions for percutaneous biopsy or surgical planning.