Gradual Improvement Of Symptoms Research Articles

Lemierre Syndrome Associated with Streptococcus constellatus and Atypical Vascular Involvement: A Case Report and Review of the Literature

Background: Lemierre syndrome is a rare and life-threatening disease. It is characterized by septic thrombophlebitis of the internal jugular vein, historically associated with Fusobacterium necrophorum infection. However, atypical cases and associations with other organisms have been reported. Methods: Here, we describe a challenging case of Lemierre syndrome in a 71-year-old woman caused by Streptococcus constellatus and review the related literature. Case: The patient experienced multiple hospital admissions due to misdiagnoses and developed thrombosis involving the internal jugular vein and transverse sinus bilaterally, pulmonary complications including the formation of a pseudoaneurysm, and occipital abscess. She presented with headaches, neck pain, and blindness. Prolonged antibiotic therapy was administered, leading to gradual improvement of symptoms, with partial resolution of blindness. Prophylaxis with intramuscular penicillin was prescribed at discharge. Conclusions: Our case underscores the importance of considering Lemierre syndrome in patients who present with multiple thrombotic events affecting the intracranial circulation and/or jugular veins, particularly in those already receiving anticoagulation therapy or with no identifiable cause for thrombosis, even in the absence of sore throat or fever.

Locally brewed alcohol induced rhabdomyolysis: A case report

Background. This case report aims to present an occurrence of Rhabdomyolysis following locally brewed alcohol consumption. We describe the clinical features, diagnostic evaluation, treatment, and outcomes of a patient diagnosed with rhabdomyolysis and secondary to locally made alcohol consumption. Case report. The patient, a 31-year-old male, known alcoholic since 13 years, presented with sudden-onset bilateral lower limb weakness for 4 days, h/o inability to walk, h/o leg pain for 4 days, non-progressive, no aggravating and relieving factors following alcohol consumption. Investigations revealed critically high levels of CPK, deranged renal parameters and liver parameters. Prompt intervention and mechanical hemodialysis were initiated along with administration of supportive care. The patient demonstrated gradual improvement of symptoms and renal parameters. Conclusions. This case highlights the importance of recognizing the potential muscle injury with acute kidney and liver injury following locally brewed alcohol consumption. In many villages in India locally brewed alcohol is still being consumed. Early diagnosis and prompt management are crucial for good prognostic outcome.

Posterior scleritis following a single infusion of zoledronate for osteoporosis: A case report and literature review

Key Clinical MessageThe most frequently reported adverse reaction to zoledronic acid is an acute phase reaction resembling influenza. While rarer adverse events such as osteonecrosis of the jaw and atypical femoral fractures have gained significant recognition, the ocular adverse effects, particularly scleritis, are not yet fully comprehended. Here, we present the case of a 75‐year‐old female patient with osteoporosis who developed bilateral redness and intense eye pain 48 h after receiving a 5 mg intravenous dose of zoledronic acid. Clinical presentation suggested bilateral conjunctivitis, but treatment with levofloxacin eye drops and acyclovir ophthalmic gel exacerbated the symptoms over 2 days, predominantly affecting the left eye. Ocular ultrasonography revealed thickening of the left eyeball wall with a “T” sign, while an orbital CT scan showed increased thickness of the left sclera. Treatment with methylprednisolone 80 mg intravenous infusion twice daily led to gradual symptom improvement and eventual resolution of inflammation. This report, based on a review of relevant literature, investigates the treatment and outcomes of zoledronic acid‐induced scleritis, emphasizing the importance for clinicians to promptly identify and manage this rare and serious ocular adverse reaction.

Myocardial Infiltration in Primary Mediastinal B-Cell Lymphoma Detected by Cardiac Magnetic Resonance Imaging

Introduction: Cardiac involvement, particularly myocardial infiltration in primary mediastinal lymphoma, is a rare occurrence with an incidence of only 9% in known cases of primary malignancy. Neoplasm infiltration into the myocardium manifests through direct invasion, hematogenous spread, transvenous invasion through the great veins, or lymphangitic spreading in the mediastinal. Myocardial infiltration in lymphoma presents a grim prognosis and its treatment may be associated with specific risks, such as myocardial rupture. Various imaging modalities may detect cardiac involvement, with cardiac magnetic resonance (CMR) imaging considered the gold standard. CMR enables clear delineation of myocardial infiltration, making it valuable for local staging, pretreatment planning, and evaluating treatment response. Case Presentation: : A 37-year-old woman patient was diagnosed with primary mediastinal large B-cell lymphoma. Mild chest discomfort and shortness of breath were observed 3 months before hospital admission. A thorax CT scan showed a heterogeneous contrast-enhancing mass with a central necrotic area in the anterior mediastinum. Following thoracotomy and tumor debulking, the patient complained of severe crushing chest pain radiating to her back, accompanied by new T wave inversion on ECG and elevated cardiac troponin levels a week after surgery. Coronary angiogram results showed a normal coronary artery. Subsequent cardiac MRI showed tumor infiltration into the anterior pericardial space, as well as the myocardium of the left and right ventricles. Chemotherapy was promptly initiated, resulting in a gradual improvement of symptoms. Conclusions: In this study, we discuss the use of 3D-CRT in the re-irradiation of NPC with its limitation on obtaining optimum dose sculpture compared to more sophisticated and widely spread modalities like IMRT. However, with careful planning, we can still obtain optimum tumor dose, minimize OAR dose, and subsequently late toxicities that come after. We hope that this study can bring hope to centers with limited facilities, and we suggest further studies on reirradiation, especially in OAR dose tolerance guidelines.

P30 A STONE ON THE HEART

Abstract We report a case of a 71–year–old female patient presented to our observation with worsening episodes of chest pain associated with cold sweat and spontaneous regression. Seven months earlier, the patient had undergone mitral valve replacement surgery with bioprosthesis for severe insufficiency. Pre–operative coronary angiography had documented the absence of significant lesions of the coronary arteries. Four months after the operation, hospitalisation was necessary due to an infective endocarditis on the prosthetic valve, effectively treated with specific antibiotic therapy. The patient came to the Emergency Department reporting episodes of stress related angina, lasting for a few days. The ECG documented sinus rhythm and non–specific anomalies of the ventricular repolarization phase. The haematochemical tests showed a minimal increase in the HS troponine values. Ultrasound documented normal left ventricular dimensions, no regional kinetic abnormalities with normal global systolic function and good functioning of the mitral bioprosthesis. The patient was admitted in our department of cardiology for further investigations. The next day the patient complained of severe oppressive chest pain with ECG evidence of diffuse ST–T segment depression and elevation in aVR and V1. Blood pressure was 170/90 mmHg and ultrasound showed apex hypokinesia with severely reduced systolic function. Nitrate s.l was administered with gradual improvement of symptoms and normalisation of the ECG. The patient underwent coronary angiography but during the first injection of contrast test, an anomalous stagnation of the contrast was highlighted in the aorta. It was urgently decided to perform aortic CT scan. The examination showed the presence of a voluminous pseudoaneurysm starting from the aortic bulb, partially thrombosed, which compressed the left main and the origin of the circumflex artery. The patient was therefore subjected to cardiac surgery the following day, with a good follow–up result one month after discharge.

Under Pressure: Neurocysticercosis Manifests Itself as Intracranial Hypertension (P14-10.002)

<h3>Objective:</h3> N/A <h3>Background:</h3> Neurocysticercosis is the most common parasitic infection of the brain worldwide. Diagnosis can be challenging as cysticerca serologies take several days to result and tissue biopsy for definitive diagnosis can be invasive. Hence, having a high clinical suspicion based on epidemiological exposures, clinical presentation, and radiographic findings is crucial. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A twenty-year-old Guatemalan female presented to the hospital with two days of fever, emesis, and confusion. She experienced positional headaches, worse on bending forward, for one month that became severe one week prior to the presentation. She was a food handler and admits to consumption of uncooked pork. Neurological exam was positive for mild disorientation and grade 5 papilledema on fundoscopic exam. Brain imaging showed two peripherally-enhancing lesions in the frontal and temporal lobes with adjacent leptomeningeal enhancement. Lumbar puncture revealed an opening pressure of 55 cm H2O. CSF studies were notable for lymphocytic and eosinophilic pleocytosis. Given her recent immigration to the United States from an endemic area and history of suspected intestinal taeniasis associated with uncooked pork consumption, neurocysticercosis was highest on the differential. Serum and CSF cysticercosis IgG were positive, thus confirming the diagnosis of neurocysticercosis. As a result, brain biopsy was not pursued. High-dose steroids were initiated prior to Albendazole with gradual improvement in symptoms. Her workplace employees and family were screened to prevent further transmission. One month later, her neurological exam was normal except for mild papilledema. <h3>Conclusions:</h3> This case highlights the importance of having a high suspicion for this potentially preventable disease in the appropriate clinical context, especially with neurocysticercosis being increasingly prevalent in non-endemic countries. It also highlights the importance of recognizing intracranial hypertension in patients with neurocysticercosis as this may alter treatment, requiring steroid initiation prior to anti-parasitic agents to prevent further brain edema from killing the larval forms of the parasite. <b>Disclosure:</b> Ms. Hillhouse has nothing to disclose. Dr. Carr has nothing to disclose. Dr. Monk has nothing to disclose. Dr. Mannyam has nothing to disclose. Dr. Britt has nothing to disclose. Dr. Jhaveri has nothing to disclose. Dr. Gunturu has nothing to disclose.

Grave’s disease in a case of Goldenhar syndrome

Goldenhar syndrome (GS) is a malformation complex that involves structures arising from the first and second branchial arches. Graves’ disease is an autoimmune disorder resulting in the excessive production of thyroid hormones and is the most common cause of hyperthyroidism in children. We are reporting this case since the clinical association of Graves’ disease in GS has never been reported before and is a rare association of the syndrome. An 11-year-old developmentally normal child presented to us with swelling in front of her neck for the past 6 months associated with loss of weight, increased appetite, increased frequency of defecation, and palpitations. On examination, there was diffuse swelling in the thyroid region that moved with deglutition and did not move with protrusion of the tongue. The child also had an asymmetrical face with bilateral conjunctival dermoid and bilateral preauricular skin tag and pretragal sinus tract on the left side. Hence, a provisional diagnosis of goitre with features of hyperthyroidism in a child with first and second branchial arch syndrome was considered. Technetium 99 scan confirmed diagnosis of Graves’ disease. The child was started on carbimazole and propranolol and gradual improvement in symptoms noted. Propranolol was given for 3 months until symptoms such as palpitations and anxiety subsided and then stopped. Carbimazole was continued.

SHDB mutant functional metastatic paraganglioma: The efficacy of Lutetium-177 DOTATE

Abstract Introduction Therapeutic options for metastatic paraganglioma (PGL) are limited, especially in the presence of uncontrolled secondary hypertension (HTN). Early findings from Lutetium-177 (Lu-177) DOTATE show promise for efficacy, although data on HTN control and survival are uncertain. Herein, we presented the successful treatment of a patient with metastatic PGL and uncontrolled HTN with Lu-177 DOTATE. Clinical Case A 16-year-old woman was admitted to the emergency department with severe headache, nausea and vomiting. She also reported stomach and low back pain for three months. The patient's blood pressure was 220/140 mmHg and a sodium nitroprusside infusion was started to treat the hypertensive crisis. On physical examination she had abdominal tenderness. A computer tomography (CT) examination revealed 6 cm mass, multiple metastatic nodular lesions in the lung and liver, as well as lytic lesions in all bones, and metastatic lymph nodes in thorax and abdomen. She is referred to our department for further evaluation HTN. Laboratory examinations revealed that plasma norepinephrine 24926 ng/L (70–480), 24-hour urine norepinephrine 1335 µg/day (20–81), metanephrine 534 µg/day (52–341), 3-metoksitiramine 771 µg/day (0–451), normetanephrine 20456 µg/day (88–444). Other laboratory findings were normal range. MIBG I131 scan which showed pathological uptake of MIBG was demonstrated in the regions described on CT. Genetic panel by next-generation sequencing (NGS) identify germline mutation and she had heterozygous mutations in SHDB (c.725 G&amp;gt;A) and BUB1B (c.1378 C&amp;gt;T). Surgical treatment was performed, and pathological finding reported 6cm mass, Ki-67 labeling index: %2, chromogranin A diffuse positive and there was vascular invasion. It was confirmed to be malignant PGL. 131I-MIBG therapy couldn't be given because of drugs interaction that used by patient. She received 13 cycles chemotherapy (cyclophosphamide, vincristine, dacarbazine) and palliative radiotherapy to metastatic bone lesions. She continued, however, to suffer from low back pain and HTN. Rising plasma and urine catecholamine levels. Therefore, conventional chemotherapy had been discontinued and he was commenced on Lu-DOTATATE therapy. Up to now, she has received 2 cycles at intervals of three months. Her clinical response was excellent with gradual improvement of symptoms and quality of life. Blood pressure is now within normal values without medication. There was significant reduction in the size of overall metastatic disease on Ga-68 DOTATE scanning. Conclusion Lu-177 DOTATE has potential advantages (drug interaction, radiation-safety) compared with 131I-MIBG therapy and chemotherapy. Our case demonstrates significant clinical and biochemical success in patients with metastatic PGL in addition to excellent disease management with low toxicity from PRRT. Lu-177 DOTATATE therapy is an effective and safe modality of treatment for patients with metastatic PGL.

Persistent Generalized Cutis Marmorata Telangiectatica Congenita with Venectasia.

Persistent Generalized Cutis Marmorata Telangiectatica Congenita with Venectasia.

An Ayurvedic Management of Raktaja Abhishyanda – A Case Report

Introduction: Abhishyanda is one of the seventeen Sarvagata Rogas described under the heading of Netra Roga in Shalakya Tantra. According to Acharya Sushruta Abhishyanda is the main cause for all the Netrarogas. If we don’t treat it on time, it will cause Adhimantha. And Adhimantha will latter progresses in Asadhya Vyadhis like Hataadhimantha and leads to Drushtinasha. On the basis of Signs and symptoms Abhishyanda can be correlate with Conjunctivitis. Conjunctivitis is defined as an inflammation of the conjunctiva. Treatment of Raktaja Abhishyanda includes Shodhana, Raktamokshana, Aschyotana, Seka, Bidalaka etc. Materials and Methods: A 27 years old male patient came to the eye OPD, ITRA, Jamnagar with the complaints of Redness, Burning sensation, Excessive watering and mild itching in both the eyes since last 5 to 7 days. Majority of the symptoms are same as the Raktaja Abhishyanda mentioned in the classics. Hence it is diagnosed as Raktaja Abhishyanda. The Patient was intervened with Shadanga Paaniya, Avipattikara Churna, Shreeparniyadi Churna Aschyotana, Ushiradi Churna Bidalaka and Bruhatmanjishthadi Kwatha. Result: Patient showed gradual improvement in symptoms over a period of 2 weeks. Along with proper treatment and Pathya Sevana, complete relief in the symptoms has been achieved. Conclusion: It shows that the Ayurvedic treatment protocol described by the classics is a good choice of intervention for the management of Raktaja Abhishyanda.

Young patient with thunderclap headache, seizure activity, and fixed eye deviation.

A 39-year-old female with a history of iron deficiency anemia presented to the emergency department (ED) with a 3-hour history of severe headache followed by acute-onset projectile non-bilious, non-bloody vomiting, acute mental status change, and seizure-like activity. The onset of the headache was spontaneous and described as the worst headache of her life. Vomiting and seizure-like activity began several hours after the onset of headache, and emergency medical services (EMS) were called at that time. The patient was found to be unresponsive by EMS. Upon arrival to the ED, the physical examination was notable for fixed left eye deviation, intermittent withdrawal from noxious stimuli, and spells of sustained clonus in the lower extremities greater on the left than the right. The patient was given 2-mg intravenous lorazepam with minimal improvement in the tonic–clonic activity. The patient was hemodynamically stable and had an oxygen saturation of 98% on room air. Initial laboratory test results were significant for anemia (hemoglobin = 5.2 g/dL, hematocrit = 21%) and elevated platelets (426.5). Computed tomography (CT) of the head, CT angiogram of the head and neck, CT venogram of the head, and urgent neurology consult were obtained immediately after arrival to the ED. The patient continued to decline after CT and was intubated for airway protection. Imaging was suggestive of acute venous sinus thrombosis extending from the superior sagittal sinus to the right cranial jugular vein with no definite intracranial hemorrhage (Figures 1 and 2) and bilateral segmental and subsegmental pulmonary emboli (Figure 3). This case describes a typical presentation of cerebral venous sinus thrombosis (CVST). CVSTs are more commonly seen in women aged 30–50 years.1 Commonly, sinus thrombosis can lead to subarachnoid hemorrhage with a subsequent “thunderclap” headache that can lead to neurological symptoms.3 Neurology evaluated the patient in the ED, and the patient was taken to the operating room for an aspiration thrombectomy and started on a continuous heparin infusion. The patient had gradual improvement of symptoms after 1 week of inpatient care in the neurology intensive care unit. At discharge, she was started on indefinite anticoagulation and levetiracetam for seizure prophylaxis. Further workup showed no evidence of hypercoagulability, no recent trauma, and no oral contraceptive use. CVST is defined as occlusion of dural sinuses leading to decreased venous flow, an increase in intracranial pressure, decreased cerebral perfusion pressures, and dilation of the cerebral veins. Continued hypoperfusion can result in ischemic tissue damage, resulting in acute neurologic symptoms such as seizures, headaches, altered mental status, and increased intracranial pressure. Without treatment, the thrombus can damage vessel walls, increasing the chances of vessel rupture, leading to subarachnoid hemorrhages and decreased cerebrospinal fluid outflow.1 Common risk factors for CVSTs include recent trauma, malignancy, thrombophilia, infection, obesity, oral contraceptive use, and increased estrogen states such as pregnancy.2

PSAT316 Thyroid Storm Triggered by Coronavirus Disease-19 (COVID-19) In a Patient With Graves’ Disease

Abstract Background COVID-19 infection affects multiple organ systems including the endocrine system. Its effect on thyroid function has been reported in multiple studies and one of them observed overt thyrotoxicosis in 10.8% of COVID-19 hospitalized patients associated with higher mortality and longer hospital stays. There is paucity of data on the impact of COVID-19 in patients with pre-existing hyperthyroidism, with only few case reports highlighting the clinical course of such patients. We report a young woman diagnosed with Graves’ disease (GD) who was admitted 4 weeks later with thyroid storm precipitated by COVID-19. Case An 18 year old woman presented to the Emergency Room (ER) with fatigue, palpitations, diaphoresis, and diarrhea for 2 weeks. She had sinus tachycardia with heart rate (HR) of 118 beats per minute (bpm). She had diffuse thyromegaly and fine tremors on exam. TSH was &amp;lt; 0.01 uIU/mL and free Thyroxine (FT4) &amp;gt;8 ng/dL. Thyroid Stimulating Immunoglobulin (TSI) was elevated consistent with GD. She was admitted and treated with intravenous fluids (IV), propranolol and methimazole with significant improvement. She was discharged on methimazole and propranolol. FT4 improved to 3.31 ng/dL 3 weeks later with 100% medication compliance. A week later, patient visited ER due to sore throat, left earache, and dry cough. Influenza PCR and COVID-19 nasal antigen tests were negative, and patient was discharged on amoxicillin-clavulanate for suspected otitis media and acute pharyngitis. Her symptoms worsened over the next few days and she was admitted again with nausea, vomiting, anxiety, palpitations, dyspnea and diarrhea. She was febrile to 101F, HR 135 bpm with agitation and reduced concentration. Burch-Wartofsky score was 65, highly suggestive of thyroid storm. FT4 was elevated at 4.46 ng/dL. COVID-19 PCR was positive. She was treated with propylthiouracil, propranolol and IV hydrocortisone with gradual improvement in symptoms. She was discharged on methimazole, propranolol and prednisone 10 mg for 10 days. Due to worsening hyperthyroid symptoms and rise in FT4, 1 week after stopping prednisone, it was restarted, and an urgent out-patient surgical referral was placed. She was advised to repeat thyroid labs in 1 week. Conclusion Thyroid storm is a rare, life-threatening endocrine emergency with a mortality rate of 10-30% that demands prompt recognition and timely intervention. Our case highlights that there must be a high index of suspicion for COVID-19 with worsening hyperthyroidism in patients with GD who are compliant with anti-thyroid medication especially if they have upper or lower respiratory tract symptoms. Patients with GD should be closely monitored during COVID-19 infection for development of thyroid storm. Early initiation of steroids might be considered with worsening thyroid function despite normal respiratory status to counteract inflammatory thyroiditis. Further studies will be useful to see the effect of COVID-19 infection in patients with GD. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

S2420 A Case of Type II Achalasia Presenting With Markedly Elevated Troponins

Introduction: Achalasia is an esophageal motility disorder that most commonly presents with dysphagia to solids and liquids, regurgitation, and heartburn over several years. In rare instances, it can mimic the presentation of acute coronary syndrome resulting in delayed diagnosis and unnecessary interventions. We report a case of achalasia that presented with markedly elevated troponins, prompting extensive cardiac workup. Case Description/Methods: A 74-year-old female with a past history of hyperlipidemia presented with diffuse chest pain and shortness of breath for 1 day. Physical exam revealed tachypnea and diffuse chest tenderness. Chest X-ray showed a widened mediastinum. Laboratory studies revealed markedly elevated serial troponin values of 0.06 ng/ml, 0.09 ng/ml, and 1.14 ng/ml, respectively. This prompted an emergent cardiac evaluation with an electrocardiogram showing junctional ST depression, followed by a transthoracic echocardiogram that was unremarkable. CT angiogram of chest and abdomen revealed megaesophagus measuring 6 cm in diameter containing a large amount of debris extending to the cervical esophagus (Figure A). Barium esophagram showed a dilated esophagus with pooling at the distal esophagus (Figure B). Esophagogastroduodenoscopy revealed hypertonic lower esophageal sphincter (LES), severely dilated esophagus with large amounts of undigested food (Figure C). Botulinum toxin was injected at the LES followed by balloon dilation. Esophageal manometry confirmed the diagnosis of Type II Achalasia. The patient underwent an uncomplicated Heller myotomy with fundoplication with gradual improvement in symptoms. Discussion: Cardiac troponins (cTn) are sensitive biomarkers of myocardial ischemia (MI) and markedly elevated levels suggest acute thrombotic MI. Infrequently cTn elevation may be observed in gastrointestinal disorders such as achalasia that result in myocardial injury without ischemia. The likely mechanism is postulated to be significant myocardial compression secondary to the enlarged esophagus resulting in myocardial damage and troponin release. This case highlights the importance of forming a broad differential when evaluating patients presenting with elevated troponins and the importance of considering gastrointestinal causes to avoid misdiagnosis and delayed intervention once acute coronary syndrome has been ruled out.Figure 1.: A. Computed tomography angiogram of chest and abdomen showing megaesophagus in coronal view. B. Barium esophagram showing a dilated esophagus with pooling at the distal esophagus. C. Esophagogastroduodenoscopy showing severely dilated esophagus with large amounts of undigested food.

Microvascular Decompression for Hypoglossal Nerve Palsy Associated With Vertebral Artery: Case Report and Review of Literature

BACKGROUND AND IMPORTANCE: Hypoglossal nerve palsy is an infrequent condition that could be rarely caused by compression from nearing vasculature. Hypoglossal nerve palsy associated with vertebral artery (VA) is rarely reported. There are less than 15 cases of such conditions in the literature. CLINICAL PRESENTATION: We present a 17-year-old boy suffering from dysarthria, chewing disability, a tingling sensation, and deviation of the tongue to the right from 6 months ago. After a thorough examination, MRI was performed with clinical suspicion of hypoglossal nerve palsy, and the result showed an ectatic VA pressing against the right hypoglossal nerve. He underwent microvascular decompression surgery. On follow-up visits, he showed gradual improvement of symptoms. CONCLUSION: In cases of cranial nerve palsies, compression by adjacent vasculature should be considered as a differential diagnosis and microvascular compression should be considered as a safe definitive treatment.

Spinal Cord Injury Following Minimally Invasive Spinal Decompression

BACKGROUND: Minimally invasive lumbar decompression (MILD) is an interventional procedure for the treatment of patients with symptomatic lumbar spinal stenosis. Spinal cord injury after MILD has not yet been reported in literature. CASE REPORT: We describe a case of a 95-year-old woman who underwent the MILD procedure at the L1-L2 level for symptomatic lumbar spinal stenosis. Following the procedure, the patient noticed lower extremity weakness and numbness, suprapubic numbness, groin pain, and urinary retention. Emergent magnetic resonance imaging of the lumbar spine exhibited new cord signal change at T12-L1. She subsequently underwent emergent L1-S1 decompression with gradual improvement of symptoms. CONCLUSIONS: Direct trauma to the cord or increased pressure in a severely stenotic canal from injectate volume may have contributed to this patient’s injury. Consideration of the severity and location of stenosis is critical as these results may pose additional risk factors for injury with the MILD procedure. KEY WORDS: MILD, spinal stenosis, spinal cord injury, interventional procedure

Persistent headache in a young kidney transplant recipient caused by tacrolimus associated pseudotumor cerebri - A case report

Pseudotumor cerebri (PC) is characterized by chronic elevation of intracranial pressure with normal cerebrospinal fluid (CSF) examination and normal neuro-imaging. We report a case of a 22-year-old female with renal allograft and for the past 4 years on immunosuppressant including prednisolone, tacrolimus, and mycophenolate mofetil. The patient presented with persistent headache for 2 months along with nausea and vomiting. Fundoscopic examination revealed bilateral papilledema. Magnetic resonance imaging-brain with venogram was normal and cytochemical examination of CSF was also normal. Ocular coherence tomography revealed increased retinal nerve fiber layer thickness. A diagnosis of PC was made based on an elevated CSF pressure (35 cm H20). We reduced the dose of tacrolimus and added acetazolamide but the dose of prednisolone and mycophenolate mofetil was not modified. There was the gradual improvement of symptoms. On follow-up visits, papilledema disappeared and the patient is now asymptomatic with normal allograft function.

RELAPSE AND REMITTING COVID-19 INFECTIONS IN AN IMMUNOSUPPRESSED PATIENT ON CHRONIC RITUXIMAB INFUSIONS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The rapid spread of SARS-CoV-2 has resulted in an ongoing pandemic that continues to plague the world. In those exposed naturally to Covid-19, an antibody response is expected. However, we present a case of an immunocompromised patient who developed recurring COVID-19 infection due to an inadequate humoral response. CASE PRESENTATION: A 45-year-old female with hypothyroidism and Wegener's Granulomatosis on chronic prednisone, methotrexate, and bi-annual Rituximab was admitted with complaints of shortness of breath, fevers, and a positive PCR for SARS-Cov-2. Chest X-ray (CXR) demonstrated development of bilateral basilar airspace disease. Patient remained stable on room air, and was subsequently discharged.Over the next several weeks, she was admitted four more times for similar symptoms, a positive PCR, and a CXR with progressively worsening bilateral patchy alveolar/interstitial opacities. During the 2nd admission, patient received IV steroids and empiric IV antibiotics. She improved, and was discharged on PO antibiotics, steroids, and oxygen. However, patient was readmitted 3 days later. During this admission, patient was given IV immunoglobulin (IVIG) G due to concern for secondary humoral deficiency (IgG of 551 mg/dl, IgM of 15.8 mg/dl, & IgA of 56.3 mg/dl) from chronic rituximab. Patient improved and was discharged with a course of steroids.During her 4th admission she received her second dose of IVIG. On her 5th admission, she was hospitalized for 13 days and underwent extensive work-up and treatment. Other concomitant infections, obtained via serum, sputum, and bronchoscopy with bronchoalveolar lavage, were negative.SARS-CoV-2 total antibodies obtained from serum samples were non-reactive. Although IgA and IgM levels remained low, patient's IgG levels were elevated to 1959 mg/dl after two sessions of IVIG. Patient had gradual improvement of symptoms and was discharged home.She had no further admissions, but did require intermittent oxygen on exertion. She finally tested negative for SARS-CoV-2 seven months from her last admission, and was discontinued from Rituximab. DISCUSSION: Various studies have shown that Rituximab is associated with low IgG levels and severe COVID-19 infection. This unique case illustrates a relapsing COVID-19 infection in the setting of a patient on Rituximab. It demonstrates how patients diagnosed with COVID-19 on Rituximab likely need closer follow-up upon discharge. It also highlights potential efficacy of measuring Ig levels and utilizing IVIG as treatment in patients with an inadequate humoral response. CONCLUSIONS: Although one cannot draw definitive conclusions in regards to Rituximab based solely off this observation, this case demonstrates the necessity of continuing to study the long-lasting impact of rituximab in relation to COVID-19, as well as other viral illnesses, to better direct both inpatient and outpatient care. REFERENCE #1: Wu, J., Liang, B., Chen, C. et al. SARS-CoV-2 infection induces sustained humoral immune responses in convalescent patients following symptomatic COVID-19. Nat Commun 12, 1813 (2021). REFERENCE #2: Avouac J, Drumez E, Hachulla E, et al. COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases treated with rituximab: a cohort study [published online ahead of print, 2021 Mar 25]. Lancet Rheumatol. 2021 REFERENCE #3: Emilio. Low immunoglobulin levels increase the risk of severe hypogammaglobulinemia in granulomatosis with polyangiitis patients receiving rituximab. BMC musculoskeletal disorders vol. 17 6. 6 Jan. 2016 DISCLOSURES: No relevant relationships by Derrick Cleland, source=Web Response No relevant relationships by sahib grewal, source=Web Response No relevant relationships by Kanwaljeet Maken, source=Web Response

АДГЕЗИВНЫЙ КАПСУЛИТ ПЛЕЧЕВОГО СУСТАВА

The article presents a current view of the etiology and pathogenesis of, adhesive capsulitis of the shoulder joint and the basic principles of conservative and surgical treatmen. Idiopathic adhesive shoulder capsulitis is a self-limiting disease with gradual improvement in symptoms, sometimes demanding surgical treatment. Currently, the role of both inflammatory and fibrotizing processes in the pathogenesis of adhesive capsulitis is generally recognized, when the inflammatory process ultimately leads to fibrotic changes. The disease is associated with diabetes mellitus, thyroid disease, cerebrovascular disease, coronary heart disease, autoimmune diseases, and Dupuytren’s contracture. In theliterature there isno consensus on the unified treatment modality for adhesive capsulitis: conservative, operative, or combined. In a number of patients, improvement is achieved spontaneously, the recommended methods of treatment range from follow-up to invasive open capsulotomy. There is no universal treatment algorithm, so treatment should be individualized. By all accounts, conservative treatment is the first treatment of choice for adhesive capsulitis and includes physical therapy in combination with physiotherapy, anti-inflammatory drugs, corticosteroid injection, and hydrodilation. Surgical treatment of adhesive capsulitis is indicated for patients with persistent symptoms of the disease and ineffectiveness of conservative treatment. Surgical treatment includes manipulation under anesthesia and / or shoulder capsulotomy (arthroscopic or open). Treatment of adhesive shoulder capsulitis remains an unresolved clinical problem. The existing treatment regimens are not universal and further studies with long-term outcomes are needed to develop more effective treatment modality.

Pixel-CO2 laser for the treatment of stress urinary incontinence

The aim of this study was to assess the safety and efficacy of a minimally invasive pixel-CO2 laser procedure for the treatment of stress urinary incontinence (SUI). This was a prospective, open-label study with a cohort of 59 women. Patients were treated intravaginally with a fractional/pixel CO2 laser every 4–6 weeks for a total of three treatments and assessed at 3, 6, and 12 months. Evaluation tools included a Sandvik severity score based on a validated questionnaire, 1-h pad test, vaginal health index score (VHIS), validated female sexual function index (FSFI), patient’s impression of disease severity (PGI-S), global impression of improvement (PGI-I), and the short-term pelvic floor impact questionnaire (PFIQ-7) to assess improvements in quality of life. Reduction in SUI severity was noticed throughout the duration of the study, as compared to the baseline in which 2% of the patients were defined as “slight,” 73% “moderate,” and 25% “severe.” Gradual improvement of symptoms resulted in redistribution of severity score and the best outcome observed between 3 and 6 months. Sanitary pad weight declined from an average of 35.45 g per day at baseline to 12.47 g at the 3rd treatment, and increased to 23.06 g at 12 months. Vaginal acidity changes showed a similar pattern. No serious adverse events were reported. Pixel-CO2 laser is safe and effective for treating SUI. Additional maintenance treatments should be considered during the 6–12-month post-treatment period in order to maintain the beneficial effects.Brief summaryPixel-CO2 laser is a safe and effective treatment for SUI. Maintenance treatments should be considered at 6–12 months.

Efficacy of montelukast in preventing seasonal recurrence of vernal keratoconjunctivitis in children.

Vernal keratoconjunctivitis is a chronic, seasonally exacerbated, allergic inflammation of the eye. The study aims to evaluate the efficacy and safety of oral montelukast in treating vernal keratoconjunctivitis in pediatric patients. This is a 26-week, prospective, randomized, open-label study. Fifty-eight patients were randomly assigned to two groups-the treatment (montelukast) and control groups. At the beginning of the study, both the groups received topical loteprednol etabonate (0.1%) in tapering doses for a month, and topical olopatadine (0.1%) for the first 3 months. Symptoms and signs observed before and after treatment and assigned scores were studied. The primary efficacy endpoint was change in the mean score on the visual analog scale (VAS) for each subjective symptom. The secondary efficacy endpoint was change in the total score of objective signs. The montelukast group showed clinically relevant improvements in the signs and symptoms of vernal keratoconjunctivitis, compared to the control group. There was considerable improvement in clinical signs. Individual symptoms such as redness, itching, foreign body sensation, and tearing showed significant improvement at 6 months follow-up. The gradual improvement in symptoms until the last visit was statistically more significant within montelukast group. Mean VAS score showed statistically significant improvement in itching (p < 0.001) and redness (p < 0.008) in montelukast group even at 3 months. No adverse events were reported in either group. Montelukast was found to be safe and effective as a long-term therapy to prevent relapse in moderate to severe vernal keratoconjunctivitis.