Complete Resolution Of Symptoms Research Articles

Treatment of Infectious Coryza in Canaries: Antibiotic Sensitivity and Clinical Outcomes

Introduction: Infectious coryza (IC) is a respiratory disease that affects poultry and other avian species. It is caused by Avibacterium paragallinarum. Common clinical signs of IC include rhinitis, facial swelling, anorexia, and retarded growth in young poultry. Case report: This report delves into a specific outbreak of IC among a herd of 120 ornamental canaries in Iran in February 2021, where 15 canaries succumbed to the disease. The canaries indicated symptoms, such as swollen heads, closed eyes, severe sinusitis, weight loss, loss of appetite, and reduced ovulation. After the necropsy, a clumpy discharge in the eyes and sinuses and minor bleeding were observed in the trachea. Samples from the sinuses of dead canaries were taken to the laboratory (Mashhad, Iran), and it was determined that the bacteria responsible for the deaths belonged to the genus Avibacterium. Avibacterium spp. are slow-growing and require a specific factor, Nicotinamide Adenine Dinucleotide (NAD), for growth. The antibacterial susceptibility of the bacteria was tested using 18 different antibiotics. Based on the results, fosfomycin and amikacin were selected for treatment. The birds were administered oral fosfomycin (160 milligrams per kilogram) and injection amikacin (10 milligrams per kilogram) for 7 consecutive days. However, a recurrence of symptoms was observed a week after the initial treatment (second outbreak), prompting a further 5 days of treatment. The isolate was completely sensitive to fosfomycin, trimethoprim-sulfamethoxazole, vancomycin, penicillin, amikacin, and furazolidone and the bacterium showed intermediate susceptibility to other antibiotics which tested. After 72 hours of treatment, casualties ceased, and clinical symptoms were reduced. Complete resolution of symptoms was observed within a week. In the second outbreak of the disease, no casualties occurred, and the symptoms vanished within 48 hours of initiating treatment. Conclusion: This case report underscored the infection of canaries flock by Avibacterium spp., which was sensitive to fosfomycin and amikacin in laboratory conditions, and and effectively facilitated the recovery of the infected birds in vivo. The antibiotic sensitivity test provided useful information for finding an effective treatment against bacterial infection, emphasizing the significance of collaborating with laboratories for optimal results. Furthermore, continuous monitoring of this isolate is imperative, as it may potentially play a role in upper respiratory disease outbreaks across diverse avian species.

Cervical Spinal Cord Herniation After Laminectomy

Following a recent cervical laminectomy, a 67-year-old female patient developed neck pain and torticollis after a coughing episode. On physical examination, manifestations of neck pain, stiffness, and 4/5 quadriparesis were noted. Magnetic resonance imaging findings indicated the presence of herniation of the cervical medulla, accompanied by cerebrospinal fluid leakage. Consequently, surgical intervention was performed to reposition the herniated cord within its original subarachnoid space, thereby averting potential recurrence. The patient experienced complete resolution of symptoms within a few days postoperatively. It is important to recognize that postoperative cervical spinal cord herniation following laminectomy is an infrequent complication that manifests with a delayed onset. Surgical repair serves as the main therapeutic modality.

Mid-Term Outcomes of "Complete Aortic Repair": Surgical or Endovascular Total Arch Replacement With Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair.

To describe a single-center experience of "complete aortic repair" consisting of surgical or endovascular total arch replacement/repair (TAR) followed by thoracoabdominal fenestrated-branched endovascular aortic repair (FB-EVAR). We reviewed 480 consecutive patients who underwent FB-EVAR with physician-modified endografts (PMEGs) or manufactured stent-grafts between 2013 and 2022. From those, we selected only patients treated with open or endovascular arch repair and distal FB-EVAR for aneurysms involving the ascending, arch and thoracoabdominal aortic segments (zones 0-9). Manufactured devices were used under an investigational device exemption protocol. Endpoints included early/in-hospital mortality, mid-term survival, freedom from secondary intervention, and target artery instability. There were 22 patients, 14 men and 8 women with a median age of 72±7 years. Thirteen postdissection and 9 degenerative aortic aneurysms were repaired with a mean maximum diameter of 67±11 mm. Time from index aortic procedure to aneurysm exclusion was 169 and 270 days in those undergoing 2- and 3-stage repair strategies, respectively. The ascending aorta and aortic arch were treated with 19 surgical and 3 endovascular TAR procedures. Three (16%) surgical arch procedures were performed elsewhere, and perioperative details were unavailable. Mean bypass, cross-clamp, and circulatory arrest times were 295±57, 216±63, and 46±11 minutes, respectively. There were 4 major adverse events (MAEs) in 2 patients: both required postoperative hemodialysis, 1 had postbypass cardiogenic shock necessitating extracorporeal membrane oxygenation, and the other required evacuation of an acute-on-chronic subdural hematoma. Thoracoabdominal aortic aneurysm repair was performed with 17 manufactured endografts and 5 PMEGs. There was no early mortality. Six (27%) patients experienced MAEs. There were 4 (18%) cases of spinal cord injury with 3 (75%) experiencing complete symptom resolution before discharge. Mean follow-up was 30±17 months in which there were 5 patient deaths-0 aortic related. Eight patients required ≥1 secondary intervention, and 6 target arteries demonstrated instability (3 IC, 1 IIIC endoleaks; 2 TA stenoses). Kaplan-Meier 3-year estimates of patient survival, freedom from secondary intervention, and target artery instability were 78±8%, 56±11%, and 68±11%, respectively. Complete aortic repair with staged surgical or endovascular TAR and distal FB-EVAR is safe and effective with satisfactory morbidity, mid-term survival, and target artery outcomes. The presented study demonstrates that repair of the entirety of the aorta - via total endovascular or hybrid means- is safe and effective with low rates of spinal cord ischemia. Cardiovascular specialists within comprehensive aortic teams at should feel confident that staged repair of the most complex degenerative and post-dissection thoracoabdominal aortic aneurysms can be safely performed in their patients with complication profile similar to that of less extensive repairs. Meticulous and intentional case planning is imperative for immediate and long-term success.

Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment.

Reversible segmental narrowing of the intracranial arteries has been described since several decades in numerous clinical settings, using variable nosology. Twenty-one years ago, we tentatively proposed the unifying concept that these entities, based on similar clinical-imaging features, represented a single cerebrovascular syndrome. This "reversible cerebral vasoconstriction syndrome" or RCVS has now come of age. A new International Classification of Diseases code, (ICD-10, I67.841) has been established, enabling larger-scale studies. The RCVS2 scoring system provides high accuracy in confirming RCVS diagnosis and excluding mimics such as primary angiitis of the central nervous system. Several groups have characterized its clinical-imaging features. RCVS predominantly affects women. Recurrent worst-ever (thunderclap) headaches are typical at onset. While initial brain imaging is often normal, approximately one-third to half develop complications such as convexity subarachnoid hemorrhages, lobar hemorrhages, ischemic strokes located in arterial "watershed" territories and reversible edema, alone or in combination. Vasoconstriction evolves over hours to days, first affecting distal and then the more proximal arteries. An overlap between RCVS and primary thunderclap headache, posterior reversible encephalopathy syndrome, Takotsubo cardiomyopathy, transient global amnesia, and other conditions has been recognized. The pathophysiology remains largely unknown. Management is mostly symptomatic: headache relief with analgesics and oral calcium-channel blockers, removal of vasoconstrictive factors, and avoidance of glucocorticoids that can significantly worsen outcome. Intra-arterial vasodilator infusions provide variable success. Overall, 90-95% of admitted patients achieve complete or major resolution of symptoms and clinical deficits within days to weeks. Recurrence is exceptional, although 5% can later develop isolated thunderclap headaches with or without mild cerebral vasoconstriction.

Clinical Symptoms, Laboratory Parameters and Long-Term Follow-up in a National DADA2 Cohort

Deficiency of adenosine deaminase-2 (DADA2) is an autosomal recessive autoinflammatory disease with an extremely variable disease presentation. This paper provides a comprehensive overview of the Dutch DADA2 cohort. We performed a retrospective cohort study in 29 ADA2-deficient patients from 23 families with a median age at inclusion of 26 years. All patients had biallelic pathogenic variants in the ADA2 gene. The most common clinical findings included cutaneous involvement (79.3%), (hepato)splenomegaly (70.8%) and recurrent infections (58.6%). Stroke was observed in 41.4% of the patients. The main laboratory abnormalities were hypogammaglobulinemia and various cytopenias. Patients presented most often with a mixed phenotype involving vasculopathy, immunodeficiency and hematologic manifestations (62.1%). In this cohort, malignancies were reported in eight patients (27.6%), of whom five presented with a hematologic malignancy and two with a basal cell carcinoma. Four patients developed hemophagocytic lymphohistiocytosis (HLH) or an HLH-like episode, of whom three passed away during or shortly after the occurrence of HLH. TNF-inhibitors (TNFi) were effective in treating vasculopathy-associated symptoms and preventing stroke, but were hardly effective in the treatment of hematologic manifestations. Three patients underwent hematopoietic cell transplantation and two of them are doing well with complete resolution of DADA2-related symptoms. The overall mortality in this cohort was 17.2%. In conclusion, this cohort describes the clinical, genetic and laboratory findings of 29 Dutch DADA2 patients. We describe the occurrence of HLH as a life-threatening disease complication and report a relatively high incidence of malignancies and mortality.

Pituitary Metastases From Differentiated Thyroid Cancers: A Systematic Review

Pituitary metastasis (PM) from differentiated thyroid cancer (DTC) is extremely rare and may adversely affect outcomes. We aimed to assess the characteristics and outcomes of patients with PM from DTC.We systematically reviewed the literature on publications on PM and the different DTC histologic types (papillary, follicular, and Hurthle cell cancers). Three databases (PubMed, Embase, and Scopus) were searched for articles published from 1967 to 2022. Survival time was estimated as the period from the first treatment of PM to the time of death or last follow-up.Twenty-five articles comprising 27 cases that met the eligibility criteria were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The median age of the patients was 60 years (23 - 86). A preponderance of females (66.7%) with PM most commonly reported papillary thyroid cancer (55.6%). This was followed by follicular thyroid cancer (37.0%) and Hurthle cell cancer (7.4%). The most common presentations were headache, nausea, and vomiting, with visual symptoms in 44.4%. Diabetes insipidus was an infrequent finding (7.4%). The median time from diagnosis or first treatment of DTC to the diagnosis of PM was 3 years (0 - 25). The most common endocrine abnormality was hyperprolactinemia (63.2%), while the most frequently deficient hormone was luteinizing hormone (50%). The most common treatment modality for PM was a combination of radiotherapy and surgery with or without radio-iodine. At the end of the follow-up, 30% of the patients died. Only 33.3% of the patients achieved complete resolution of symptoms. The overall median survival time was 12 months (3 - 108). There was a moderate inverse correlation between the age of patients and survival, which was, however, not statistically significant (rs = -0.45, P = 0.103).PM from DTC is extremely rare, and Hurtle cell cancer appears to be the least associated with PM. Diabetes insipidus is a rare initial manifestation of PM from DTC. Complete resolution of symptoms is less likely to be achieved in PM from DTC. Older age may confer an increased survival tendency, probably due to more intracranial space volume in older people compared to the younger population. Larger studies are needed to examine the relationship between age and survival in PM from DTC. Also, more observational data are required to determine the predictors of survival and compare the efficacy of the different treatment modalities in patients with PM from DTC.

Thalidomide for Recurrence of Symptoms following HIV-Associated Cryptococcal Meningitis.

Cryptococcal meningitis (CM) is a serious and fatal fungal infection that affects individuals infected with human immunodeficiency virus (HIV). Despite treatment, recurrence of symptoms is common and could lead to poor outcomes. Corticosteroids are not always useful in treating symptom recurrence following HIV/CM; thus, alternative therapy is needed. Thalidomide has been reported to be effective in treating symptom recurrence in several patients with HIV/CM. This retrospective study aimed to investigate the efficacy and safety of thalidomide in the treatment of symptom recurrence following HIV/CM. Patients who were treated with thalidomide for symptom recurrence following HIV/CM were retrospectively included. Clinical outcomes and adverse events were recorded and analyzed. Sixteen patients admitted between July 2018 and September 2020 were included in the analysis. During a median follow-up period of 295 (166, 419) days, all patients achieved clinical improvement in a median of 7 (4, 20) days. Among them, nine (56%) achieved complete resolution of symptoms at a median of 187 (131, 253) days, including 40% (2/5) of immune reconstitution inflammatory syndrome (IRIS), 50% (3/6) of patients with elevated ICP only, and 80% (4/5) of patients with symptoms only. Seven (43%) patients experienced nine episodes of adverse events, but no severe adverse event attributable to thalidomide was observed. None of the patients withdrew from thalidomide due to adverse events. Thalidomide appears to be effective and safe in treating different types of symptom recurrence in HIV/CM. This study provides preliminary evidence supporting future randomized clinical trials to further investigate the efficacy and safety of thalidomide in treating symptom recurrence in this population.

Are New Diagnostic Criteria Needed? Diffuse Idiopathic Skeletal Hyperostosis Concealed by Cervical Radiculopathy: A Case Report

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) involves widespread ossification of ligaments in the skeleton with associated nonspecific symptoms. Cervical DISH may result in dysphagia and orthopnea but can be missed with accompanying spinal pathology. CASE REPORT: A 52 year-old man with a history of coronary artery disease presented with worsening neck pain radiating to the bilateral upper extremities. Magnetic resonance imaging revealed ventral osteophytes at C3-C7 and moderate stenosis at C4-C5. The patient underwent cervical epidural steroid injections resulting in partial pain relief. However, axial neck pain persisted and he reported new-onset dysphagia and orthopnea. Subsequent imaging showed C2-C7 anterior osteophytes with tracheal displacement, confirming the DISH diagnosis. The patient underwent resection of the osteophytes and had subsequent complete symptom resolution. CONCLUSION: Although radicular symptoms improved with an injection, dysphagia not previously mentioned was concerning. DISH is routinely missed in the setting of spinal pathology, such as radiculopathy. The presence of anterior cervical spine osteophytes should prompt further respiratory or swallow evaluation. KEY WORDS: Pain medicine, spine, dysphagia, orthopnea, DISH, cervical spine

Lymphoma of the cerebellopontine angle mimicking metastasis lesion: A case report

Primary lymphoma of the cerebellopontine angle (CPA) is rare and uncommon in the central nervous system, accounting for approximately 0.2-2% of all brain tumors. To our knowledge, there have only been 32 cases reported worldwide so far. Here, we report a rare case of B-cell lymphoma in a 56-year-old woman who presented with seizure, dysphagia, and dizziness and showed a lesion involving the left CPA, right frontal horn and septum pellucidum on magnetic resonance imaging (MRI). The primary diagnosis was metastatic tumor; however, Stereotactic biopsy on left CPA lesion was done, and the histological features confirmed the diagnosis of B-cell malignant lymphoma. The patient was treated with chemotherapy, with complete resolution of symptoms after the first chemotherapy session.

1031 OSA management with RME device in pediatric patient with GBS on IVIg and non surgical candidate due to immunomodulated status

Abstract Introduction Adenotonsillectomy is considered the standard of care in pediatric populations diagnosed with OSA and adenotonsillar hypertrophy. For non-surgical and specific populations, Rapid maxillary expansion, a technique that consists in increasing the transverse diameter of the hard palate with the use of a fixed orthodontic appliance, has recently been used, with evidence of improvement of signs and symptoms of the disease, AHI normalization, and overall PSG parameters improvement. Report of case(s) Patient with a history of Chronic inflammatory demyelinating polyradiculoneuropathy and Guillain Barre syndrome, diagnosed at 8 years of age, posterior to gastrointestinal viral infection. MRI of the lumbosacral spine showed inflammatory changes at the cauda equina, conus and epiconus consistent with GBS. She also has CIDP, first diagnosed by Electromyography. The same year she had witnessed snoring and apneic episodes and underwent a PSG which showed an AHI of 2/hr. On Physical exam, she had tonsils 2+ and was referred to an ENT specialist for tonsillectomy. A repeat PSG at the age of 9 years revealed an AHI of 1.6/hour with no central apnea/hypopnea. At that time, due to clinical worsening of her neurologic symptoms, with ataxia and lower extremity weakness, she was started on a course of IVIg therapy. Due to IVIg treatment, she was not a candidate for tonsillectomy. In view of excessive daytime sleepiness, concentration difficulties at school and not being a candidate for tonsillectomy, she was referred for Rapid Maxillary Expansion. She has had maxillary expanders since the age of 9 and is now asymptomatic and her snoring has remarkably improved. She is now in the process of being fitted with braces and her lower extremity weakness has also improved with IVIg. Complete resolution of sleep apnea symptoms after rapid maxillary expansion without tonsillectomy. Conclusion Although tonsillectomy has been the gold standard for the treatment of OSA in the pediatric population, patients who are not surgical candidates for tonsillectomy can undergo orthodontic treatment and benefit from the outcomes. As reported in our unique case, the patient became completely symptom-free. Support (if any)

0992 Reversible Pediatric Central Sleep Apnea in Hyperhomocysteinemia and Cerebral Sinus Venous Thrombosis

Abstract Introduction Pediatric central sleep apnea (CSA) rarely initially presents in adolescent age groups, being more commonly diagnosed in infants. CSA may result from a multitude of neurological insults, such as stroke and brain masses. It may also less often present in metabolic and non-ischemic thrombotic disorders. Report of case(s) A 12-year-old female with history of global developmental delay of unclear etiology, chronic headaches, insulin resistance, and early morning tremors was referred for initial evaluation of possible narcolepsy. Severe daytime sleepiness had acutely worsened over the previous month. She was unable to stay awake during school, despite sleeping 13 hours per 24 hours. Central hypersomnia was suspected and polysomnogram with MSLT was scheduled. The patient presented to the Emergency Department 10 days later for worsening headaches and new oral aversion with 12-pound weight loss. Examination showed ataxic gait and dysarthria. Brain MRI revealed non-occlusive cerebral sinus venous thrombosis (CSVT) involving the superior sagittal sinus, right transverse sinus, right sigmoid sinus, right jugular bulb/vein, and cortical veins overlying both cerebral hemispheres with no stroke. Anticoagulation with enoxaparin was initiated and thrombophilia work-up commenced. Polysomnogram demonstrated a central AHI of 49.9/hr with significant periodic breathing and no obstructive sleep apnea. Oxygen titration sleep study failed to significantly improve CSA and BPAP was initiated. Thrombophilia work-up revealed severe hyperhomocysteinemia. Genetic analysis was consistent with autosomal recessive severe methylenetetrahydrofolate reductase (MTHFR) deficiency. The patient was begun on metabolic treatment with betaine, pyridoxine, hydroxocobalamin, and vitamin C, and transitioned to oral rivaroxaban. At 4 months, blood levels had normalized, and MRI demonstrated resolution of CSVT. Family endorsed BPAP compliance and complete resolution of all sleep symptoms. In addition, there was significant improvement in cognition, interpersonal skills, and abstract thought. Follow up polysomnogram 10 months after presentation demonstrated no CSA nor periodic breathing. Conclusion To our knowledge, this is the first report of MTHFR deficiency and CSVT resulting in severe CSA. While it is difficult to ascertain which entity ultimately caused the CSA, MTHFR deficiency can produce significant neurologic impairment through white matter disease and defective myelination, while CSVT can provoke venous hypertension, venous stasis, or hypoxia. Support (if any)

Parasacral transcutaneous electrical neural stimulation versusurotherapy in primary monosymptomatic enuresis: A prospective randomized clinical trial.

To evaluate the clinical response of parasacral transcutaneous electrical neural stimulation (parasacral TENS) associated with urotherapy in children with primary monosymptomatic nocturnal enuresis(PMNE) compared to urotherapy alone. This prospective controlled clinical trial enrolled 72 children over 5 years of age with PMNE. Children were randomly divided into twogroups, control group (CG), treated with urotherapy and scapular stimulation, and experimental group (EG), treated with urotherapy and parasacral TENS. In both groups, 20 sessions were performed, 3 times weekly, for 20 min each, with 10 Hz frequency, 700 μS pulse width and intesity determinated by the patient threshold. The percentages of dry nights were analyzed for 14 days before treatment (T0), after the 20th session (T1), 15 (T2), 30 (T3), 60 (T4), and 90 (T5) days after the end of the sessions. Patients of both groups were followed with intervals of 2 weeks in the first month and monthly for threeconsecutive months. Twenty-eight enuretic children, 14 girls (50%) with a mean age of 9.09 ± 2.23 years completed the study. There was no difference in mean age between groups. Mean percentage of dry nights in EG at T0 was 36%, at T1 49%, at T2 54%, at T3 54%, at T4 54%, and 57% at T5; while in CG, these percentages were 28%, 39%, 37%, 35%, 36%, and 36%, respectively. Parasacral TENS associated with urotherapy improves the percentage of dry nights in children with PMNE, although no patient had complete resolution of symptoms in this study.

Efficacy of allogeneic platelet growth factors in actinic cystitis: The resolution of trouble?

BackgroundActinic cystitis is a severe complication after radiotherapy for prostate cancer. It is a chronic inflammatory process that leads to an alteration of bladder mucosa with formation of petechiae and subsequently hematuria. Actinic cystitis responds poorly to medical treatment, with a heavy burden on patients’ quality of life. Patients with refractory hematuria may undergo cystectomy in the attempt to control bleeding. We conducted a prospective study to evaluate the effectiveness of the allogeneic platelet growth factors for actinic cystitis. Methods and MaterialNine patients with actinic cystitis were enrolled in this study. The primary outcome measures were the effects of the platelet growth factors on the injury of the bladder mucosa. The secondary outcome was the change in quality of life ResultsA total of 9 patients, mean age 68 (range 59–81) underwent a therapeutic program of bladder instillation with allogeneic platelets growth factors for 3 months. Of the 9 patients, all (100 %) had complete resolution of hematuria and urinary symptoms. After three months cystoscopy showed regeneration of the normal bladder mucosa. Biopsies allowed histological confirmation of the finding. DiscussionThe instillation of allogeneic platelet growth factors in actinic cystitis is a new treatment that in this setting of patients appears promising in promoting a resolution of urinary symptoms, hematuria and avoiding a disabling surgery such as cystectomy.

(432) Efficacy of Low-Intensity Shockwave Therapy on Hard Flaccid Syndrome: Initial Report of Three Cases

Abstract Introduction Hard flaccid syndrome (HFS) is characterized by chronic pain in the penis and perineum and firmness or rigidity of the penis even while not erect and may have a devastating impact on patient sexual quality of life. Although this syndrome has been discussed in myriad patient forums, there is no established evidence-based definition nor specific standard established treatment modalities in the literature. Current treatment options may include a combination of medical pain management, pelvic floor physical therapy, biofeedback, and stress reduction. In patients with other chronic pain conditions who fail traditional therapies, low-intensity shock wave therapy (LiSWT) has been increasingly utilized as management with positive response. We report a series of three patients with managed with LiSWT. Objective To report our initial experience of men with HFS managed with LiSWT. Methods Three patients, aged 36, 24, and 20 diagnosed with HFS were treated with LiSWT for a course of six sessions. In each session, LiSWT settings were: energy flux density of 0.13 mJ/mm2 and frequency of 3 Hz. While penis was held in stretched position, 600 shocks were delivered to each of the dorsum, left, ventral, and right aspects of penis along the shaft. The scrotum was then held up, and 600 shocks were delivered to each of the right and left crural areas, adding up to 3600 total number of shocks that were allocated evenly. All patients answered a questionnaire to assess improvement in symptoms after completion of the treatment sessions (Table 1). Results All patients reported initially alleviated symptoms after 3 treatment sessions, particularly with respect to penile rigidity in the flaccid state. Patient 1 elected for a combination of LiSWT and tadalafil. 5 months after treatment completion, Patient 1 has had complete resolution of HFS symptoms. Patient 2 had no response with tadalfil alone before he elected for LiSWT only, and patient 3 opted for LiSWT alone. After each LiSWT session, patient 2 reported relieved symptoms for 3-4 days, while patient 3 reported significant improvement lasting for 24 hours. Both patients 2 and 3 reported gradually returning to their pre-treatment baseline in 5 months’ follow-up. Conclusions While HFS is becoming increasingly recognized amongst sexual medicine clinicians, there are currently no established efficacious treatment options. LiSWT shows potential as a treatment modality and may have increased efficacy if used in combination with PDE5 inhibitors, as demonstrated in this pilot study. Nevertheless, a larger case series is necessary to establish LiSWT as a standardized treatment option and may require a more comprehensive approach to properly manage this condition. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

P304 ACUTE ST–ELEVATION MYOCARDIAL INFARCTION DUE TO AORTIC DISSECTION: HISTORY OF A LATE DIAGNOSIS AFTER PRIMARY ANGIOPLASTY

Abstract Introduction We report a case of aortic type A dissection, involving the right coronary ostium, presented as an inferior STEMI. The aortic dissection diagnosis was formulated only after the coronary angioplasty on the right coronary was successfully done, leading to chest pain resolution. Dual antiplatelet therapy was administered. We want to underline how sometimes, mostly in emergencies, can be difficult to do the right diagnosis at the right time, even if some angiographic findings could help us to avoid life–threatening mistakes. Case presentation: 60 years–old man with typical angina chest pain started after an effort. The electrocardiogram showed ST elevation in inferior leads, while the echocardiogram akinesia of the inferior wall, a preserved EF, a normal diameter of the aortic root, no dissection signs, no pericardial effusion. The coronary angiography showed ostial RCA occlusion, critical stenosis in mid–distal LAD. Angioplasty on the RCA ostium with one drug–eluting stent (DES 3.5 x 18 mm) achieving reperfusion with TIMI 3 flow, complete resolution of ECG alteration and symptoms. Then PCI of LAD with DES was performed. During hospitalization in ICU recurrence of mild chest pain without ECG alterations. Routine echocardiogram performed the following day showed signs of aortic root dissection and moderate aortic valve regurgitation; an angio–CT scan was immediately performed confirming the aortic dissection, and cardiac surgery was immediately performed with good result. Reanalysis of the angiographic images showed some signs that should have made us think right away of an aortic dissection: abnormal convexity of the right coronary sinus, extravascular stagnation of contrast medium, and ostial RCA stent create a communication between the real and the false lumen, visible at the final injection. Conclusion Aortic root dissection, involving coronary ostium, could be a sneaky diagnosis since signs and symptoms could be very similar to myocardial infarction ones. A correct diagnosis is very important, leading to the right surgery treatment, the PCI and the dual antiplatelet therapy could lead to worsening outcomes. It is mandatory to pay attention to the signs that could help us doing the right diagnosis when we are performing coronary angiography. Always check the patient accurately during the ICU stay in order not to lose signs that can let us change the wrong to the correct diagnosis.

The “Blast” Behind Jerky Eyes

AbstractOpsoclonus is defined as hyperkinetic, omnidirectional, spontaneous, and involuntary chaotic eye movements. Opsoclonus-myoclonus-ataxia syndrome is addressed by many names including “dancing eyes-dancing feet syndrome,” “Kinsbourne syndrome,” and “infantile polymyoclonia.” The early accounts of the clinical syndrome date back to 1962 when Marcel Kinsbourne described six cases of this phenotype. However, it was not until 1968 the association with occult neuroblastoma was first reported. We report the video of a 1-year-old boy who presented with this syndrome for a duration of 3 months. He was diagnosed to have an abdominal neuroblastoma and was treated with resection of the tumor and administration of intramuscular adrenocorticotropic hormone. He showed complete resolution of symptoms. The syndrome is difficult to recognize and might be confused with seizures, tremors, or chorea; hence, it is important that residents learnt to recognize this syndrome and look for an underlying tumor actively.

High-dose bevacizumab for radiation-induced brain necrosis: a case report.

Radiation-induced brain necrosis (RIBN) is a common adverse event from radiation therapy. We present a case of a 56-year-old man, diagnosed with non-small-cell lung cancer with brain metastases 2years prior, for which he had received whole brain radiotherapy and brain stereotactic radiosurgery, who presented to the oncology unit with headache, dizziness and abnormal gait. MRI of the brain revealed radiological worsening of a cerebellar mass, including edema and mass effect. After a multidisciplinary tumor board meeting, the patient was diagnosed with RIBN and received 4 cycles of high-dose bevacizumab, with complete symptom resolution and significant radiological response. We report the successful use of a high-dose, shorter-duration treatment protocol of bevacizumab for RIBN.

Solitary Extremity Schwannoma: A 20-Year Review of Outcomes.

Background: Reports on benign peripheral nerve sheath tumour extirpation over the last number of decades describe varying patient outcomes. We present our outcomes following excision of solitary extremity schwannoma over a 20-year period. Methods: A regional histopathology review was conducted for, "benign nerve sheath tumour" and schwannoma between 2000 and 2020. This search provided 131 histologically confirmed schwannomas that were excised from the extremities of 123 patients. Individual charts were reviewed retrospectively to establish presenting features and post-operative outcomes. Results: One hundred and twenty three patients underwent schwannoma excision, including 8 patients with synchronous tumours. The mean age at presentation was 49 years (range 11-92 years). The most common presenting symptoms were the following: palpable mass (88%), pain (70%), paraesthesia (21%), numbness (13%), and motor deficit (4%). Post-operative follow-up ranged from 1 to 168 months (mean 12.3 months) (N = 99). Fifty-eight cases reported complete resolution of symptoms by end of outpatient follow-up (59%). The remaining reported either residual or new numbness (21%), paraesthesia (11%), pain (10%), weakness (4%), hypertrophic or keloid scar (3%), or a combination. Thirty patients (30%) developed new symptoms post-operatively including numbness (13%), paraesthesia (10%), pain (2%), and weakness (2%). There was a trend towards higher risk of post-operative pain, numbness or paraesthesia in patients undergoing excision of schwannomas on larger mixed nerves than in patients undergoing excision on smaller sensory nerves (P = .0531). Conclusion: Surgical excision of benign schwannomas is a successful procedure, especially for pain management, however, complete symptom resolution cannot be guaranteed, and the risk of new or persisting numbness, paraesthesia, pain, and weakness should be highlighted to patients during the consent process.

Abstract #1406613: Recurrent Thyroiditis in a Patient with Multiple sclerosis on Natalizumab

Thyroiditis, or self-limiting inflammation of the thyroid gland consists of 3 phases: hyperthyroidism, from release of hormone from damaged cells; hypothyroidism, when thyroid stores are depleted and euthyroidism with restoration of thyroid function. Etiology can include infectious, drug-induced or autoimmune causes such as multiple sclerosis (MS). In fact, 20-25% of untreated MS patients have autoimmune thyroiditis [1]. Moreover, drugs used to treat MS such as alemtuzumab and interferon have been reported to cause thyroid disease [2]. A 42-year-old female with MS on natalizumab for 10 years presented with right sided neck pain radiating to her jaw for 3 months and difficulty swallowing. Family history was pertinent for hypothyroidism in her father, and MS in her brother. She was exposed to nuclear radiation at age 3 from the Chernobyl disaster. On presentation, vital signs and physical exam were unremarkable. Thyroid ultrasound noted an ill-defined 4.2X1.3X1.9 cm hypoechoic nodule in the right mid-pole. Fine needle aspiration of the nodule showed subacute granulomatous thyroiditis (SAH). Labs showed TSH 0.02mIU/L [0.4-4.5], FT4 1.5ng/dL [0.8-1.8] and elevated total T3 204ng/dL [76-181]. TSI< 89 [140%]. Naproxen was given for pain control. Repeat labs 1 month later showed TSH 0.83mIU/L, FT4 1.1 ng/dL and total T3 196ng/dL, consistent with resolution of thyroiditis and clinically correlated with resolution of her pain. However, a month later she presented with worsening left sided neck pain and left thyromegaly associated with speech difficulty, diaphoresis, and constipation. Repeat thyroid ultrasound showed decreased size of right thyroid nodule 1.1X1.1X0.9cm and findings consistent with thyroiditis. She was treated with prednisone with complete resolution of symptoms. Labs post treatment showed elevated TSH 6.01mIU/L, total T3 106ng/dL, and FT4 0.8ng/dL consistent with the recovery phase of thyroiditis. Anti-TPO antibody level was < 1 [< 9 IU/mL]. Labs 1 month later showed normal TSH and FT4 levels. Natalizumab, a humanized monoclonal antibody commonly used to treat MS, has rarely been associated with thyroid disease. Alterations in thyroid function are thought to be due to direct toxicity on the thyroid, its blood supply or indirectly mediated by the immune system [2]. Although MS can be associated with thyroiditis, our patient did not present with the typical pattern of thyroiditis. Instead, she reported symptoms consistent with inflammation of one lobe of thyroid followed by resolution, and thereafter developed inflammation and pain of the other lobe, raising suspicion of potential involvement of natalizumab due to her atypical presentation.

Abstract #1401671: Hashimoto’s Disease with Thyroid Eye Disease, Negative TRAB and Positive TPO Antibodies Treated with Teprotumumab

Thyroid Eye Disease (TED) is most commonly associated with hyperthyroidism secondary to Graves’ disease (GD). The disease activity of TED is positively correlated with the presence of thyrotropin receptor antibodies (TRAB). Some with TED are euthyroid at presentation but have positive TRAB. Less frequently, patients with Hashimoto’s disease have TED, the majority of which are TRAB positive. We present a unique case of euthyroid TED with negative TRAB but positive thyroid peroxidase antibodies (TPO Ab) treated with teprotumumab. A 65-year-old African-American male presented with a 9-day history of gradually worsening vision, ocular pain, and bilateral eye bulging. His best-corrected visual acuity at near was 20/200 right eye and 20/400 left eye with full peripheral vision by confrontation. Pupils were equal and reactive to light with normal intraocular pressure. There was bilateral upper eyelid retraction, diffuse conjunctival injection, proptosis, and diffuse external ophthalmoplegia. His clinical activity score was 7. The thyroid exam was normal. Computed Tomography (CT) scan of the orbits showed significant, tendon-sparing enlargement of all extraocular muscles along with bilateral orbital apex crowding. Bilateral compressive optic neuropathy from severe TED was suspected. TSH, free T4, and T3 were normal. TPO Ab was positive but TRAB was negative by both binding inhibitory and Thyroid Stimulating Immunoglobulin (TSI) assays. He was treated with high-dose intravenous methylprednisolone for 5 days followed by 2 weeks of oral prednisone. One month after presentation treatment was initiated with 8 infusions of teprotumumab with complete resolution of all ocular symptoms and restoration of normal vision. Six months after the last dose of teprotumumab he remains euthyroid with negative TRAB and positive TPO Ab. TED is uncommon in euthyroid individuals. Most have positive TRAB and many ultimately develop hyperthyroidism. Even less common are those with Hashimoto’s thyroiditis (HT) presenting with TED. Teprotumumab is the only Food and Drug Administration-approved medication to treat TED. Our patient with vision-threatening TED had a remarkable response to teprotumumab with the restoration of normal vision and resolution of TED. We could not identify any other reports of a patient with euthyroid HT with positive TPO Ab but negative TRAB treated with teprotumumab. Physicians should be mindful of this unusual presentation to detect cases early and institute appropriate treatment to prevent visual complications.