Great Mimicker Research Articles

Recurrent Bilateral Pleural and Pericardial Effusions due to Tuberculosis in a Child With Doose Syndrome: A Case Report

Tuberculosis (TB) is one of the 10 causes of death worldwide. According to the World Health Organization (WHO) in the 2020 Global Tuberculosis Report, 12% of all infected people correspond to children. Other reports have been published with collected data regarding extra pulmonary TB showing that it reaches 16% of incident cases in United States of America. Pleural TB is common among adolescents and is less frequent in children. Pericardial effusion due to TB is a rare manifestation of extra pulmonary TB, and the diagnosis can be hard to reach. In this paper, we describe the manifestations, diagnosis and management of children with extra pulmonary disease, specifically the simultaneous presence of two sites of TB and the approach in children with Doose syndrome. A 9-year-old male patient with an extensive medical record was admitted with unspecific lower respiratory infection symptoms. The diagnosis was reached with the GeneXpert test after 1 month of evaluation and readmission for massive pleural effusion. He required tube drainage twice and specific management with rifampicin, isoniazid, pyrazinamide and ethambutol. In this case, the symptoms were nonspecific which delayed the diagnosis. The purpose of this case is to emphasize the importance of suspicion and early diagnosis of extra pulmonary TB known as the “great mimicker”. Int J Clin Pediatr. 2022;11(1):14-19 doi: https://doi.org/10.14740/ijcp456

Abstract 95: Cushings: The tale of a great mimicker and its conundrums

Background: Cushing's syndrome is a rare endocrine disorder comprising of large group of signs and symptoms resulting from chronic exposure to state of endogenous hypercortisolemia or exogenous steroids. It is a gamut of clinical manifestations with varying presentation and indecisive diagnosis.Aim: We hereby present a case of 28-year-male with signs and symptoms of florid and rapid onset hypercortisolemia of 1 year duration.Objectives and Results/Case Details: Case was referred from psychiatry for weight gain. Clinical history and profound proteo-catabolic signs pointed towards rapid onset cushings. On evaluation hypercortisolism was non-suppressible by 1 mg dexamethasone (DST) and had high ACTH suggesting ectopic ACTH syndrome or pituitary origin. He had a history of watery diarrhea, recalcitrant hypokalemia, multiple hyper-pigmented acne, and striae with secondary superficial mycosis which compelled us to rule out ectopic, but CT chest & abdomen were inconclusive. MRI pituitary showed 4 mm adenoma, cortisol was suppressed following 8 mg DST. He underwent Trans-sphenoidal surgery (TSS), following which cortisol levels normalized within 1week with regression of symptoms.Conclusion: Throughout the course, several diagnoses were entertained like perceptive disorder due to depression and bizarre paresthesia (hypocalcemia), carcinoid syndrome secondary to diarrhea and dys-electrolytemia, ectopic ACTH source due to clinical profile, coincidental lung lesion, but ultimately proven as ACTH producing pituitary tumor out of the blue. Use of a more pragmatic approach makes this case a challenging one.

En plaque tuberculoma of the dura with extracranial extension in an adolescent mimicking an aggressive en plaque meningioma

Abstract Tuberculosis has been called the “great mimic.” We present an uncommon case of an en plaque dural tuberculoma in an adolescent that was both causing mass effect intracranially and eroding the skull and extending extracranially mimicking an aggressive meningioma and discuss the theories about the origin of dural tuberculomas, enumerate common radiological differential diagnosis and mention ways that may help to identify the disease without recourse to surgery.

Immature Squamous Metaplasia of Endocervix – A Great Mimicker of Invasive Squamous Cell Carcinoma of Cervix

Immature Squamous Metaplasia of Endocervix – A Great Mimicker of Invasive Squamous Cell Carcinoma of Cervix

Diffuse Intense Pleural FDG Uptake with Smooth Thickening: A MARKER of Tuberculosis in Isolated Pleural Effusion

Tuberculosis is a great mimicker of malignancy and both can present with isolated pleural effusion. Herein we present the characteristic PET/CT features of tuberculosis pleural effusion. Careful attention to these findings could direct the management towards tuberculosis in such scenarios, where demonstration of Acid Fast Bacilli and necrotizing granulomas would be difficult due to absence of nodal disease and/or technically challenging pleural biopsy

Correlation between radiographic and histopathological findings of conventional osteosarcoma subtypes: osteoblastic, chondroblastic, and fibroblastic

Background: Osteosarcoma is a connective tissue malignancy producing osteoid and some cartilaginous and fibrous matrix. It provides a challenging diagnostic approach since it is considered as a great mimicker in radiography and histopathology appearance. Triple diagnostic approach is mandatory, involving the clinical, radiologic and histopathologic aspect of all cases suspected. This study aimed to discover the correlation between radiographic and histopathological findings of fibroblastic, chondroblastic and osteoblastic subtypes of conventional osteosarcoma. Methods: This study implemented a cross-sectional study design. Components of radiographic findings of conventional osteosarcoma were bone destruction, transitional zone, periosteal reaction, matrix of calcification, skip lesion and soft tissue mass which were analyzed and correlated with its histopathological subtype. Statistical analysis was performed using the Spearman correlation test with p-value < 0.05.Results: Significant negative correlation was obtained between chondroid matrix calcification and histopathology description of conventional osteosarcoma with osteoblastic subtype (r = -0.383; p < 0.05) and negative correlation between osteoid matrix and histopathologic analysis of fibroblastic subtype (r = -0.435; p < 0.05). All of the radiographic components of the chondroblastic subtype did not show significant correlation with their histopathological findings.Conclusion: Chondroid matrix finding in radiography showed negative correlation with histopathologic evaluation of osteoblastic subtype while osteoid matrix description in radiography had negative correlation with histopathologic analysis of fibroblastic subtype.

Tuberculoma - a great mimicker: can diffusion tensor imaging and tractography help?

Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas. To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography. Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated. Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10-3 mm2/s and 1.157 ± 0.277 ×10-3 mm2/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors. Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors.

Melioidosis: A Neglected Infection in Bangladesh

Bangladesh is an example of a highly populous, agricultural country where melioidosis may be a significantly under diagnosed cause of infection and death. A recent regression model predicted 16,931 cases annually in Bangladesh with a mortality rate of 56%. However, we only manage to confirm (culture) around 80 cases in last 60 years. A lack of awareness among microbiologists and clinicians and a lack of diagnostic microbiology infrastructure are factors that are likely to lead to the underreporting of melioidosis. Melioidosis transmits through inoculation, inhalation and ingestion. Diabetes mellitus is the most common risk factor (12 times higher chance of getting the infection) predisposing individuals to melioidosis and is present in >50% of all patients. The clinical presentation is widely varied and can be mistaken for other diseases such as tuberculosis or more common forms of pneumonia giving rise to its nickname as the “great mimicker”. Disease manifestations vary from pneumonia or localized abscess to acute septicemias, or may present as a chronic infection. Culture is considered the current gold-standard for diagnosis and culture-confirmation should always be sought in patients where disease is suspected. It is strongly recommended that any non–Pseudomonas aeruginosa, oxidase-positive, Gram-negative bacillus isolated from any clinical specimen from a patient in an endemic area should be suspected to be Burkholderia pseudomallei (BP). In addition, based on antibiogram, any Gramnegative bacilli that are oxidase-positive, typically resistant to aminoglycosides (e.g., gentamicin), colistin, and polymyxin but sensitive to amoxicillin/clavulanic acid should be considered as BP. This bacteria is inherently resistant to penicillin, ampicillin, first generation and second-generation cephalosporins, gentamicin, tobramycin, streptomycin, and polymyxin. For intensive phase (10 to 14 days), ceftazidime or carbapenem is the drug of choice. For eradication phase (3 to 6 months), oral trimethoprim/ sulfamethoxazole is the drug of choice. Surgery (drainage of abscess) has an important role in the management of melioidosis. Preventive measures through protective gears could be useful particularly for the risk groups. J MEDICINE 2021; 22: 139-145

Ocular Manifestations and Full House Membranous Nephropathy as a Rare Presentation of Secondary Syphilis

Introduction: Syphilis is known as the great mimicker with symptoms that overlap many diseases. Here we present a patient with secondary syphilis which manifested as ocular symptoms, as well as membranous nephropathy with a full house staining pattern. Case Description: Our patient was a 54-year-old male who presented with a rash, joint pain, foamy urine and vision changes. Initial work up found a positive ANA and other autoimmune labs, and he was admitted for concern of lupus papillitis. Labs and CSF were positive for syphilis, and he was found to have nephrotic range proteinuria. Renal biopsy showed membranous nephropathy with full house staining, which is seen primarily in lupus nephritis with only one case report noting its presentation in syphilis (Jaunin E, Kissling S, Rotman S, Waeber G, Halfon M. Syphilis and parvovirus B19 co-infection imitating a lupus nephropathy: A case report. Medicine (Baltimore). 2019;98(36):e17040). He completed a course of penicillin and steroids with clinical improvement, and the diagnosis of secondary syphilis was made. Discussion: This case illustrates the importance of maintaining a broad differential diagnosis, and carefully examining all labs, imaging, pathology and symptoms in order to determine the definitive diagnosis. It also illustrates the importance of teamwork when faced with a challenge requiring input from multiple subspecialties to arrive at a final diagnosis.

EP.TH.697The great mimic of mesenteric cyst - an interesting case report of mucinous adenocarcinoma of the ovary

Abstract Aims A mesenteric cyst, rare intra-abdominal pathology, poses a clinical challenge due to lack of pathognomonic symptoms, variability in presentation and location. We present an interesting case with a significant diagnostic dilemma; a suspected benign ovarian cyst invading the mesentery on repeat imaging and laparoscopy is questioned for mesenteric in origin. Methods A 77-year-old female presented with a 6-year history of abdominal mass. She had multiple radiological scans which reported it as a simple cyst, but the origin could not be defined. She had repeated aspirations with benign cytology. They cyst developed septations, filled-up rapidly, became an abdominal cyst from the pelvis. A careful decision was taken for surgery. The procedure undertook with general surgeons and gynaecologists with a possibility of the mesenteric cyst. During laparotomy, the cyst was found extending from pelvis and base of mesentery up to the diaphragm densely adhered to sigmoid colon. The cyst was completely excised with hysterectomy and oophorectomy. Results The patient recovered well from surgery. Post-operatively, histopathology confirmed Figo IC2 Grade 2 mucinous adenocarcinoma of the ovary with an expansive growth pattern. She is awaiting further treatment with chemotherapy after discussion in the Gynaecology MDT. Conclusion This case emphasises the importance of having an insight into the question of established diagnosis in the face of a changing clinical picture. Also, it highlights the need for understanding the mesenteric cyst. Early exploration can prevent diagnostic delays and further treatment.

A DRAMATIC PRESENTATION OF A CARDIAC MYXOMA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac myxoma is the most frequent primary cardiac neoplasm, nonetheless, the cardiac tumor is very rare.1 The diagnosis of these tumors can be incidental or due to symptoms secondary to complications, like embolization, or valvular dysfunction.2 The management will depend on the size and characteristic of the mass. Embolic stroke is a dramatic and severe complication of cardiac myxoma.2,3 CASE PRESENTATION: A 31 year-old female with a PMHx of well controlled Crohn's disease, presented to our institution via helicopter for a higher level of care, after receiving TPA for an ischemic stroke. A mechanical thrombectomy was planned and her NIHSS was 9. After she arrived, a CT cerebral perfusion scan showed an acute ischemic infarction in the territory of the right MCA with right superior M2 occlusion. There was a mild mass effect on the right lateral ventricle without evidence of brain herniation. The patient was started on NS 3% and mannitol.On the 2nd day of hospitalization the patient suddenly desaturated requiring emergent intubation. A chest x-ray demonstrated flash pulmonary edema. The patient's mechanical ventilation was optimized for ARDS and she was turned prone. On the same day the patient was started on multiple pressors. On day 3 a copious amount of clear fluid was suctioned from the ET tube, analyzed as transudate with no signs of infection.The patient's cerebral edema also worsened and a right decompressive craniectomy was required. The patient began to go into multiorgan failure due to continued hypoperfusion. Her LFTs trended upwards as her kidney function declined. On day 4 an Echocardiogram showed a normal left ventricular size with decreased EF 25%-30%. A large mobile mass was attached to the interatrial septum obstructing the mitral valve with moderate mitral regurgitation and pulmonary hypertension. This mass was suggestive of an atrial myxoma. CT surgery was immediately consulted, intervention was scheduled for the following day. Unfortunately the patient coded the same day after she was turned from prone to supine. Multiple rounds of CPR were performed, however the patient expired. DISCUSSION: We suspect that the change in position caused increased outflow obstruction by the myxoma resulting in cardiac arrest. Due to the large size of the mass and the rapid progression of the patient's symptoms, it is unlikely an early diagnosis would have significantly changed her prognosis. CONCLUSIONS: The severe and dramatic presentation of this case, showed the relevance of this rare pathology and the devastating consequences of the natural course of this disease. In a retrospective analysis of the case, no personal history suggested this diagnosis. In the setting of a sudden ischemic stroke shortly followed or accompanied by flash pulmonary edema, should arouse clinical suspicions for some embolic pathology that may be causing outflow obstruction such as an atrial myxoma. REFERENCE #1: El Sabbagh, Abdallah et al. "Cardiac Myxoma: The Great Mimicker." JACC. Cardiovascular imaging 10.2 (2017): 203–206. Web. REFERENCE #2: Vontobel, Jan, Martin Huellner, and Paul Stolzmann. "Cerebral 'Metastasizing' Cardiac Myxoma." European heart journal 37.21 (2016): 1680–1680. Web. REFERENCE #3: Saddoughi, Sahar A., Joseph J. Maleszewski, and Hartzell V. Schaff. "Cardiac Myxoma: Simplifying a 'Complex' Case." The Journal of thoracic and cardiovascular surgery 152.5 (2016): 1439–1440. Web. DISCLOSURES: No relevant relationships by Javier Cabello Garza, source=Web Response No relevant relationships by Heriberto Cantu, source=Web Response No relevant relationships by Zachary Keatts, source=Web Response No relevant relationships by Ismael Polo Perez, source=Web Response

ACUTE PULMONARY HISTOPLASMOSIS: A DIAGNOSTIC DILEMMA DURING COVID-19 PANDEMIC

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute histoplasmosis is usually a concern in immunocompromised individuals. In immunocompetent patients, histoplasmosis is generally mild or asymptomatic unless there is inhalation of a large inoculum. Below, we present a case of severe acute pulmonary histoplasmosis in an otherwise healthy, immunocompetent person and discuss the diagnostic challenges it presented during the COVID-19 pandemic. CASE PRESENTATION: A 30-year-old non-smoking Caucasian man with hypertension presented to our hospital with 1 week duration of headache, dyspnea, productive cough and high fever. He was admitted with a provisional diagnosis of COVID-19 pneumonia and started on dexamethasone and empiric antibiotics. He had elevated inflammatory markers. Chest x-ray showed diffuse bilateral interstitial and alveolar opacities. CT chest demonstrated numerous clustered ground glass nodular opacities bilaterally with mediastinal and hilar adenopathy. Subsequently, RT-PCR for SARS-CoV2 returned negative. The patient continued to deteriorate clinically over the next few days. Repeat imaging showed diffuse micronodules with mediastinal adenopathy. Upon further questioning, the patient recalled demolishing a chimney at his parents' house in Michigan 2 weeks prior to admission. The differential diagnosis was broadened to include acute hypersensitivity pneumonitis and fungal infection. BAL, transbronchial biopsies and EBUS-TBNA was performed while escalating steroids. The lung biopsy confirmed Histoplasma. Urine Histoplasma antigen returned positive. The patient was treated with itraconazole with an overlap of steroids for 2 weeks upon discharge. He was readmitted within a week with worsening hypoxia and worsening infiltrates on lung imaging. He was then treated with liposomal amphotericin with gradual clinical improvement. Follow-up 1 month post discharge revealed complete clinical and radiologic resolution. DISCUSSION: Viral pneumonia and acute pulmonary histoplasmosis have overlapping clinical and radiologic features which can make diagnosis challenging. COVID-19 pneumonia typically presents with peripheral ground glass opacities with or without superimposed consolidations. Invasive fungal pneumonia can have a similar appearance on CT usually with additional findings of hilar and mediastinal adenopathy. CONCLUSIONS: This case highlights the challenges involved in diagnosing acute pulmonary histoplasmosis in an immunocompetent individual in the midst of the pandemic. Clinicians should always maintain a wide differential diagnosis to avoid diagnostic delay. REFERENCE #1: Staffolani, S., Buonfrate, D., Angheben, A., Gobbi, F., Giorli, G., Guerriero, M., Barchiesi, F. (2018). Acute histoplasmosis in immunocompetent travelers: A systematic review of literature. BMC Infectious Diseases, 18(1). doi:10.1186/s12879-018-3476-z REFERENCE #2: Duzgun, S. A., Durhan, G., Demirkazik, F. B., Akpinar, M. G., & Ariyurek, O. M. (2020). COVID-19 pneumonia: the great radiological mimicker. Insights into imaging, 11(1), 118. https://doi.org/10.1186/s13244-020-00933-z REFERENCE #3: Klein, M., Khan, M., Salinas, J. L., & Sanchez, R. (2019). Disseminated pulmonary histoplasmosis in immunocompetent patients: A common epidemiological exposure. BMJ Case Reports, 12(3). doi:10.1136/bcr-2018-227994 DISCLOSURES: No relevant relationships by Joseph Arguinchona, source=Web Response No relevant relationships by Michael Kaster, source=Web Response No relevant relationships by Muazzam Mirza, source=Web Response No relevant relationships by Anusha Pinjala, source=Web Response no disclosure on file for Venketraman Sahasranaman;

A case report on melioidosis: A rare mimicker of tuberculosis

Burkholderia pseudomallei is a saprophytic pathogen causing Whitmore's disease or Melioidosis. 1It can cause vertebral osteitis, abscess, pneumoniae, septicaemia, arthritis etc. It is a great mimicker of pulmonary as well as vertebral Tuberculosis. Southeast Asia and Australia report most of the cases. In India, the cases have been reported mostly from the coastal belt of southern states. We report the case of a 60-year-old agriculture worker with Type 2 diabetes, with lumbago and fever 1 month, initially misdiagnosed as spinal tuberculosis, presented with cold abscess. B. pseudomallei was isolated from the drained abscess. He recovered fully following treatment with Cotrimoxazole and Ceftazidime.

Occlusive retinal vasculitis in an immunocompetent woman: rare presentation of ocular melioidosis

Burkholderia pseudomallei is a known great mimicker responsible for melioidosis. Ocular involvement in melioidosis is unusual, with eyelid and orbital infection as the commonest presentation. We describe a 41-year-old, healthy woman who complained of reduced vision in her left eye. On examination, vision in the left eye was 6/9. There was evidence of occlusive retinal vasculitis on fundoscopy examination. Fundus fluorescein angiogram showed extensive capillary fallout. Diagnosis was established by a rise in the serum antibody titre for the bacterium and further supported by clinical improvement of vision after completion of treatment antibiotics. Sectoral panretinal photocoagulation at the capillary fallout area successfully arrested the sequelae of retinal ischaemia. Occlusive retinal vasculitis is a rare presentation of melioidosis. Early prompt diagnosis in an immunocompetent individual helps prevent visual-related morbidity. The ability of this bacteria to cause recurrent infection in an endemic area should not be underestimated.

A great mimicker of primary biliary cholangitis.

A 59 year-old man without past medical history was referred with biochemical features of cholestasis (aspartate aminotransferase (AST) 117 U/L, alanine aminotransferase (ALT) 83 U/L, gamma-glutamyl transferase (GGT) 1307 U/L, alkaline phosphatase (AP) 1803 U/L, total bilirubin 0,7 mg/dL), a strongly positive antimitochondrial M2 antibody (AMA-M2) titer (88 U), weight loss and abdominal pain since several months. He did not take any medications, nor there was a history of alcohol abuse or sexual risk behavior. Upon presentation, clinical examination showed a rather cachectic patient (body mass index 19 kg/m²), without further abnormalities. As primary biliary cholangitis (PBC) was suspected, treatment with ursodeoxycholic acid had been initiated but did not improve the cholestasis nor the pain. Additional investigations didn’t reveal any other irregularities, except for a mildly dilated aortic sinus root of 42 mm. The histopathological findings of a liver biopsy are shown below (Figure 1). This showed granulomas with cholangitis and increased presence of neutrophils, which raised suspicion for an infectious cause.

Poster Presentations

Background: The workload at rheumatology clinics have been growing relentlessly and an audit on new referrals helps to identify referral behavior of primary care doctors and improvement can be done by providing further training. Objective: To audit on new referral cases to rheumatology clinic during Covid-19 pandemic 2020 and to identify new cases with misdiagnosis for future training purpose. Methods: This was a retrospective study. The electronic medical records of all new referral to rheumatology clinic Hospital Sultan Ismail from 1 st January 2020 to 28 th February 2021 were reviewed. The variety of new cases, reason of referral and final diagnoses were identified and analyzed. Results: There were total of 462 new cases referred throughout the 14 months during Covid-19 pandemic. Majority of them are diagnosed to have rheumatoid arthritis (RA, 115/462) followed by systemic lupus erythematosus (SLE, 93/462), psoriatic arthritis (PSA,82/462), gout (26/462), osteoarthritis (23/462), soft tissue rheumatism (14/462), systemic sclerosis (SSc, 11/462), fibromyalgia (8/462), ankylosing spondylitis (AS, 8/462), sjogren syndrome (8/462), vasculitis (7/462), mixed connective tissue disease (MCTD, 7/462) and miscellaneous (23/462). 17 out of the new cases were diagnosed as unlikely rheumatic diseases. There were 20 pending cases awaiting final diagnosis. 96 of the referrals were identified as misdiagnosis with the highest as nodal osteoarthritis (18/96) followed by unlikely rheumatic disease (17/96), soft tissue rheumatism (14/96), RA (12/96), PSA (9/96), gout (4/96), sjogren syndrome (4/96), fibromyalgia (3/96), SLE (3/96), polymyositis (2/96), AS (2/96) and others (8/96 : DISH, hypermobility syndrome, RS3PE syndrome, degenerative disc disease, idiopathic uveitis, graft versus host disease, JIA, MCTD and traumatic arthritis). Conclusion: Nodal osteoarthritis and soft tissue rheumatism can be great mimicker for inflammatory arthritis and if wrongly diagnosed will induce unnessary anxiety or wrong treatment. More training are needed to improve clinical skills amongst primary care doctors.

Sleep-related hypermotor seizures of insulo-opercular origin: A review of 27 cases

Introduction . Insular epilepsy is known to be a “great mimicker” of various types of focal epilepsy, including sleep-related hypermotor epilepsy (SHE) in about 15% of cases. Because SHE tends to have a frontal origin, misdiagnosis can result in a poor surgical outcome when epilepsy surgery is considered. In this study, we reviewed the existing literature to identify electro-clinical features suggestive of an insulo-opercular (IO) origin in SHE. Methodology . We found 11 case series of SHE or insular epilepsy with sufficiently detailed patient data. We identified 27 patients with IO SHE from 6 studies. When available, the semiology patterns (SP), early nonmotor manifestations, alteration of consciousness (AOC), EEG and MRI features and histopathology were collected. Results . SP analysis of the 27 identified patients showed a wide variety of indiscriminate SP, including hyperkinetic and/or dystonic features. Early nonmotor manifestations were observed in 80%, most commonly somatosensory auras (44%). Laryngeal constriction, pain, oral and widespread paresthesia were observed in IO SHE but not in frontal SHE. AOC was uncommon (20%). EEG was rarely suggestive of an IO origin (17%) and MRI was diagnostic in 48%. Focal cortical dysplasia was the most common diagnosis (78%). Following surgery, 83% were seizure-free (follow-up: 12–60 months). Conclusions . Few electro-clinical features, except early non-motor manifestations, are suggestive of an IO onset in SHE. Therefore, in MRI-negative patients, a heightened vigilance for subtle subjective or behavioral signs is warranted to avoid misdiagnosis and poor surgical outcome.

A case of chronic cough due to sarcoidosis

Sarcoidosis is a multisystemic, chronic granulomatous disease of unknown aetiology that often affects the lungs. Diagnosis and treatment of sarcoidosis can be strenuous. Patients may be asymptomatic or experience cough, dyspnoea, fatigue, unintentional weight loss or night sweats. Computed tomography is valuable in the diagnosis of sarcoidosis. The typical histopathological lesion of sarcoidosis is granuloma without caseous necrosis in the involved organs. As tuberculosis is endemic in our region, clinicians should not forget this great mimicker. The cornerstone of treatment of sarcoidosis is corticosteroids but newer agents such as steroid-sparing agents and biological agents are available. We report a case of pulmonary sarcoidosis presenting with chronic cough.

Pheochromocytoma Multisystem Crisis: A Case Study

Known as the "great mimic," pheochromocytoma is rare and difficult to diagnose. When a pheochromocytoma begins to cause end-organ damage, it becomes pheochromocytoma multisystem crisis, an even more rare and deadly diagnosis. N.R., a 63-year old man, presented to the emergency department 1 day after receiving a cortisone injection for a nondisplaced wrist fracture. His chief concern was a "racing heart and chest pressure." N.R. was admitted to the telemetry unit after routine electrocardiography showed atrial fibrillation and elevated blood pressure. Symptoms quickly progressed, and N.R. was transferred to the intensive care unit where he received noninvasive positive pressure ventilation. A computed tomography scan revealed a 7-cm right intra-adrenal mass, and an echocardiogram showed a markedly reduced ejection fraction. N.R. received a preliminary diagnosis of pheochromocytoma multisystem crisis, although confirmatory laboratory test results were pending. N.R. became progressively more hemodynamically unstable and his respiratory status worsened, and by the end of hospital day 2 he had been intubated and was receiving multiple vasoactive medications intravenously. On hospital day 7, N.R. was transferred to a facility for definitive surgical intervention. This case represents the importance of timely interventions by nursing staff, clear communication between staff on different shifts, and real-time education by physicians to nursing staff. This collaborative milieu empowered nurses to use their experience and critical thinking to make clinical decisions in providing care.

The Great Gut Mimicker: A case report of MIS-C and appendicitis clinical presentation overlap in a teenage patient

BackgroundAbdominal pain and other gastrointestinal symptoms are common presenting features of multisystem inflammatory syndrome in children (MIS-C) and can overlap with infectious or inflammatory abdominal conditions, making accurate diagnosis challenging.Case PresentationWe describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment.ConclusionsWe note that MIS-C can mimic acute appendicitis. This case highlights MIS-C as a cause of abdominal imaging with features concerning for appendicitis, and MIS-C should be considered in the differential for a patient with appendicitis-like symptoms and a positive COVID-19 IgG. Lab criteria, specifically low-normal white blood cell count and thrombocytopenia, appears to be of high relevance in differing MIS-C from acute appendicitis, even when appendix radiologically is dilated.