Left Upper Extremity Research Articles (Page 1)

Diabetic striatopathy is a rare, acute neurological complication of diabetes mellitus which presents with non-ketotic hyperglycemia and involuntary movements, specifically hemichorea or hemiballismus. Striatal abnormalities on neuroimaging have been reported in most, but not all cases. This case report aims to increase awareness that diabetic striatopathy can be a presenting symptom of diabetes mellitus.A 92-year-old Filipino female with no history of diabetes presented with acute onset of focal clonic flexion of the left upper extremity for a few hours, which progressed to right hemifacial spasm. She was diagnosed with a hyperosmolar hyperglycemic state and was treated accordingly. Cranial CT scan findings were unremarkable. There was an immediate resolution of her neurologic symptoms after the correction of hyperglycemia.The diagnosis of diabetic striatopathy highlights the importance of increasing awareness and understanding of this condition among clinicians to prevent delayed diagnosis and treatment. Screening for hyperglycemia is advisable for patients with involuntary movements. The prognosis for diabetic striatopathy is good with prompt glycemic control in most cases.

Simultaneous sub-massive pulmonary embolism (PE) and acute upper extremity ischemia from paradoxical embolism through a patent foramen ovale (PFO) is an exceedingly rare and life-threatening presentation that demands rapid, cross-disciplinary intervention. While paradoxical embolism accounts for <2% of systemic embolic events—and upper extremity involvement represents <5% of arterial emboli—coexistence with right ventricular (RV) strain significantly compounds diagnostic and therapeutic complexity. This case illustrates the need for integrated cardiovascular, vascular, and critical care collaboration in managing multisystem embolic crises. A 44-year-old male with a remote history of resected melanoma presented with acute-onset left upper extremity numbness and discoloration, progressing proximally. He also reported worsening dyspnea over one week. Physical exam revealed an absent left radial pulse and oxygen requirement of 6L via nasal cannula. CT angiography identified a left axillary artery thrombus with distal brachial artery reconstitution and bilateral pulmonary emboli. RV strain was confirmed by an RV/LV ratio of 1.2. Transthoracic echocardiogram demonstrated RV dilation and dysfunction, with a suspected PFO. Emergent open surgical thrombectomy of the left upper extremity was performed on arrival by vascular surgery. Due to persistent hypoxia and RV dysfunction, percutaneous mechanical thrombectomy of the pulmonary arteries was performed the next day by the same team. Post-operatively, the patient developed new-onset atrial fibrillation and was started on lifelong anticoagulation with apixaban. PFO closure was deferred due to the need for ongoing anticoagulation. Thrombophilia workup was negative; however, the patient had a family history of thrombotic events. This case underscores the importance of rapid, multidisciplinary coordination in managing complex embolic events. Our institutional Heart-Embolism-Lung Program (H.E.L.P.)—a collaborative team including cardiology, cardiovascular critical care, and vascular surgery—enabled timely, integrated management. While Pulmonary Embolism Response Teams (PERT) are well recognized, this case highlights the value of expanded, cross-specialty programs in addressing multi-system thromboembolic crises.

An 80-year-old male with a history of Parkinson's disease, dementia, and prostate cancer presented to the hospital with new onset right-sided weakness and aphasia. Emergency CT angiogram of the head and neck demonstrated occlusion of the M2 segment of the left middle cerebral artery (LMCA). The patient was out of the window for thrombolytics, and underwent mechanical thrombectomy. Brain MRI revealed acute multifocal infarcts in the LMCA territory and the left anterior cerebral artery (LACA) territory suggesting a thromboembolic etiology. A transthoracic echocardiogram (TTE) with agitated saline injected from the left upper extremity showed opacification of the left atria and ventricle but not the right-sided chambers, suggesting an extracardiac right-to-left shunt. A cardiac CT scan showed a persistent left levoatriocardinal vein(LACV) extending from the left brachiocephalic vein and draining into the left superior pulmonary vein. A left upper extremity venous ultrasound doppler showed a non-occlusive deep venous thrombus (DVT) in the left cephalic vein, which was the possible source of the embolic stroke. The patient was discharged on lifelong anticoagulation with Apixaban. At 3 months follow up, the patient developed no new strokes.

Essential thrombocytosis (ET) is one of the myeloproliferative neoplasms (MPNs) which increase the probability of thrombosis and bleeding. ET is usually discovered as an incidental finding on blood workup and in rare cases, will present as vascular events such as stroke. Our patient, a 77-year-old female, a case of acute cerebral infarct presented with numbness and severe weakness of left upper and lower extremity. Serial complete blood count showed an elevated platelet count. Bone marrow aspiration studies showed increased number of enlarged megakaryocytes. She was diagnosed as a case of ET and maintained on Aspirin 80 mg per tablet once a day and Hydroxyurea 500 mg per tablet once a day. Keywords: Essential thrombocytosis, Myeloproliferative neoplasms, Acute cerebral infarct, Aspirin, Hydroxyurea

Disclosure: M. Viana Padilha: None. M. Barnett: None. E. Messina: None. J. Carty: None. S. Ram Teja Sathi: None. S. Wajnsztajn: None. N. Shah: None. C. Anastasopoulou: None. J.V. Mayrin: None. Z. Azmaiparashvili: None.Introduction: Pheochromocytoma occurs in 0.1-5.7% of individuals with neurofibromatosis type 1. Although pheochromocytoma crisis is rare, it can cause severe hemodynamic instability and may be triggered by various factors. We present a case of steroid-induced pheochromocytoma crisis, an uncommon complication in clinical practice. Case Presentation: A 33-year-old female with neurofibromatosis type 1 was admitted for an elective laminectomy of the cervical vertebra and resection of a spinal neurofibroma. The procedure occurred without complications. On the fifth post-operative day, the patient developed worsening pain and weakness in the left upper extremity. Magnetic resonance imagining showed cervical cord edema extending from the third to seventh cervical vertebra. She was initiated on intravenous Dexamethasone, 6mg every 6 hours. On the sixth post-operative day, the patient was found to be tachycardic with heart rate of 188 beats per minute, with systolic blood pressure ranging from 180-200 mmHg. Upon review of patient's previous charts, she was found to have a known adrenal incidentaloma and increased metanephrines levels in the past that had been missed in the pre-operative workup. Laboratory analysis of the current event revelead free metanephrines levels of 8618 pg/ml (normal < 57 pg/ml) and normetanephrine levels of 3541 pg/ml (normal < 148 pg/ml), with urine metanephrines also elevated. Endocrinology was consulted and patient was managed for steroid-induced pheochromocytoma crisis. Steroids were discontinued. Two months later, she underwent adrenalectomy and pathological analysis confirmed the diagnosis of pheochromocytoma. Discussion Pheochromocytoma crisis can be precipitated by several factors, including surgical procedures, anesthesia, and medications. While these factors are well-documented, the role of steroids in precipitating pheochromocytoma crisis is less recognized, with only approximately twenty cases reported. Steroids are thought to trigger a crisis through interesting biochemical pathways. They increase the production of catecholamines by stimulating the activities of key enzymes in their biosynthetic pathway and enhance their effects on the peripheral vasculature, resulting in a hypertensive crisis. So, they can exacerbate the effects of the already elevated levels of catecholamines and lead to life-threatening complications. In this case, the patient did not develop a pheochromocytoma crisis immediately following surgery, despite a lack of standard preparations, such as preoperative alpha-blockage. However, after corticosteroid administration, the crisis developed. This suggests that the steroids precipitated the event. While this is not commonly reported, this case highlights the importance of cautious steroid use in patients with a known diagnosis of pheochromocytoma or in those with a high suspicion of the condition.Presentation: Saturday, July 12, 2025

Disclosure: J. Tatchou: None. B. Jesus: None. M. Hassan: None. B. Rebba: None.Introduction: Hemiballism is a rare movement disorder, most commonly associated with stroke. We describe a case of Diabetic Striatopathy presenting with a 1-week history of hemiballism movements in the setting of uncontrolled Type 2 Diabetes Mellitus. Case Presentation: A 77-year-old lady with hypertension, uncontrolled Type 2 Diabetes Mellitus on insulin therapy, HIV disease, and hyperlipidemia presented with a 1-week history of worsening painful, wild, involuntary muscle spasms of her left upper extremity. She endorsed a 1-day history of decreased appetite, abdominal pain, nausea, and vomiting. She denied fever, headache, focal weakness, or numbness. She did not report a recent change in medications. She is on aspirin 81 mg daily, atorvastatin 40 mg daily, carvedilol 25mg twice daily, chlorthalidone 50 mg daily, spironolactone 100 mg daily, losartan 50 mg daily and the combination of elvitegravir- cobicistat- emtricitabine-tenofovir alafenamide as 1 tablet daily.Physical exam showed dry mucous membranes, tachycardia, intermittent left upper extremity abduction and adduction movements, with no other motor or sensory deficits. CT brain ruled out intracranial hemorrhage. MRI of the brain showed no structural abnormalities.Serum creatinine was 1.75 mg/dl (n= 0.5-1.60mg/dl) (unknown baseline), BUN 37 mg/dl (n= 8-23 mg/dl), potassium 5.4 mmol/l(n=3.3-5.1mmol/l), glucose 84 mg/dl (n=82-115 mg/dl), and creatinine kinase 2388 iU/l (n=9-168 iU/l). HIV viral load was undetectable. She received IV fluids, and her kidney function improved to the normal range.During hospitalization, she was noted to have a fluctuating blood glucose level, ranging from 80 mg/dl to 370 mg/dl. Hemoglobin A1c was 14%. She was started on an adequate insulin regimen and clonazepam 0.25 mg three times daily. Hemiballism movements strikingly improved with control of glucose level and were concluded to be due to uncontrolled diabetes. At the time of discharge, she continued to show significant improvement in her involuntary movements. Conclusion: Diabetic striatopathy is a rare neurologic complication of uncontrolled hyperglycemia, characterized by abnormal movement (hemichorea/ hemiballism). The most common radiologic finding is hyperdensity in the contralateral putamen and/or caudate nucleus on CT scan. Management relies on the correction of hyperglycemia and the administration of antipsychotics (haloperidol, risperidone) or benzodiazepines(clonazepam).Presentation: Sunday, July 13, 2025

Abstract Disclosure: F. Noor: None. S. Siddalingaiah: None. S.R. MacLeod: None. Bleeding within the capsule of the adrenal gland is rare and most typically related to surgical trauma, sepsis, coagulopathy, underlying adrenal tumor, or as a postoperative complication. The incidence ranges from 0.8 to 2% with trauma, usually occurring within the first three weeks of illness or post-operative period (Zhu, 2011). Bilateral adrenal hemorrhage accounts for ∼10% of adrenal hemorrhages (Aloini, 2023). Primary adrenal insufficiency may develop in three-fourths of patients with bilateral adrenal hemorrhage (Dogra, 2023). Here, we present a case of adrenal hemorrhage leading to adrenal insufficiency.A 61-year-old male presented after a motor vehicle accident. He was hemodynamically unstable with tachycardia and hypotension. Work up showed anemia and bilateral lower extremity and the left upper extremity fracture. Massive transfusion protocol was initiated, and the patient underwent open reduction and internal fixation and a right hip total arthroplasty. One week later, the patient was improving and planned for discharge to a skilled nursing facility. However, he developed acute severe abdominal pain associated with nausea, vomiting, dizziness, fatigue and a macular, pruritic rash located on his back. He was febrile to 100.6°F and tachycardic with a heart rate of 107. Labs demonstrated leukocytosis. CT abdomen and pelvis with IV contrast revealed acute right adrenal hematoma; periadrenal edema and slight interval thickening of the left adrenal gland, concerning for left adrenal hemorrhage. Initially this was treated as sepsis with antibiotics, but infectious work-up was unrevealing. The patient then became hypotensive with hyponatremia and hyperkalemia. Random cortisol level was 7.5 ug/dL and cortisol stimulation test results were consistent with adrenal insufficiency. The patient was started on stress dose steroids and had significant clinical improvement. The hydrocortisone dose was reduced to physiological dose and fludrocortisone was started.The most likely etiology of this patient’s adrenal hematoma was trauma. There is high prevalence of adrenal insufficiency in bilateral adrenal hemorrhage. This may present as acute adrenal crisis, shock, and even death. Early recognition with imaging studies is thus an important prognostic factor, as is early initiation of treatment. While recovery of adrenal function is rare, it is important to follow-up outpatient to assess for the possibility. Repeat imaging may also be necessary to exclude an underlying adrenal tumor. On repeat imaging, adrenal hematoma may decrease in size and attenuation over time (Elhassan, 2023).In conclusion, bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency. This case demonstrates the importance of having a high index of suspicion for diagnosis, given that the clinical manifestations can be nonspecific and may be hard to differentiate from concurrent major illness. Presentation: Saturday, July 12, 2025

A fracture is a condition in which there is a partial or complete loss of bone or cartilage continuity caused by direct or indirect trauma. In the case of a fracture of the proximal one-third of the left radius, the injury generally occurs due to a strong impact or direct trauma to the left arm, often resulting from a traffic accident or a fall. Patients with this condition typically experience several problems, including pain at the fracture site, decreased muscle strength, limited range of motion (ROM), and functional activity disturbances such as difficulty in gripping, lifting, or writing. Physiotherapy management plays a crucial role in restoring upper limb function. The methods used include Infrared (IR) therapy and Exercise Therapy (ET). Infrared therapy helps improve blood circulation, reduce muscle spasms, and alleviate pain through the application of heat. Meanwhile, Exercise Therapy consists of Free Active Exercise, Passive Exercise, and Resisted Active Exercise, which aim to increase muscle strength, improve joint mobility, and gradually restore the patient’s functional abilities. The results of the physiotherapy intervention showed a significant reduction in pain, increased muscle strength, improved ROM, and enhanced functional activity of the left upper extremity, allowing the patient to return to daily activities more optimally and independently.

Proximal humerus fractures (PHFs) are increasingly prevalent, particularly in the geriatric population, where they represent a significant burden both individually and societally. Vascular injury, though rare, can have profound implications for management and outcomes. The presence of these concomitant injuries has been shown to be associated with an increased length of hospital stay, total cost, and patient mortality underscoring the critical need for accurate identification of both osseous and vascular injuries to provide appropriate, comprehensive care. Despite extensive research, controversy remains regarding the optimal management of these injuries. Nonoperative management is suitable for fractures meeting specific criteria, while operative options vary based on fracture characteristics, patient factors, and surgeon expertise. The rise in reverse total shoulder arthroplasty (RSA) as a treatment of complex fracture patterns reflects evolving trends in clinical practice. This report presents the case of a 76-year-old woman with a complex, 4-part PHF dislocation sustained secondary to a ground-level fall. On examination, she exhibited diminished radial nerve sensation with wrist extension weakness but was otherwise neurovascularly intact. Cross sectional imaging demonstrated significant medialization of an anterior fracture dislocation of the proximal humerus. Computed tomography angiography of the left upper extremity showed a markedly tortuous axillary artery with possible intimal injury, prompting a multidisciplinary approach. A shared decision-making model led to combination surgical case with vascular and orthopaedic surgery for subclavian artery exposure followed by RSA. Postoperatively, the patient recovered without complication, demonstrating the importance of an individualized, multidisciplinary strategy for managing complex PHF with associated vascular insult. This case highlights the critical role of recognition of potential neurovascular injuries due to traumatic events and coordinated management of osseous and vascular injuries in complex PHF. We also describe a combined surgical approach and interdisciplinary coordination for PHF dislocations with concern for vascular compromise. Glenohumeral fracture dislocations are high-risk injuries where RSA offers predictable outcomes for complex fracture patterns but demands careful consideration in the setting of possible vascular trauma.

The patient was a male in his 30s, under treatment for Crohn's disease of the small intestine since his 20s. He was admitted to the hospital due to worsening renal function. Two days after admission, he suddenly developed left upper and lower extremity paralysis followed by generalized convulsions and decreased level of consciousness. Head MRI showed multiple abnormal signal areas in the bilateral cerebral white matter and multiple microhemorrhages inside the lesions. CSF examination showed 11,136 cells/mm3 (98% polymorphonuclear cells, 2% mononuclear cells), 311 ‍mg/dl protein, 76 ‍mg/dl sugar, and MBP > 2,000 pg/ml. Chest X-ray showed infiltrate and multiple nodular shadows in both lung fields, and venous blood culture detected Staphylococcus epidermidis. Her general condition and neurological symptoms gradually improved after continuation of antimicrobial agents, methylprednisolone pulse therapy, and continuous hemodiafiltration. Acute hemorrhagic leukoencephalitis is a type of severe acute disseminated encephalomyelitis, and cases of marked improvement such as the present case are rare. We report this case with some discussion.

A 9-year-old girl presented with encephalopathy, left upper extremity rhythmic shaking, and fever, after 1 month of intermittent headaches and 1 week of upper respiratory symptoms. EEG confirmed focal seizures, and brain MRI revealed polyfocal T2/fluid-attenuated inversion recovery hyperintensities involving both the white and gray matter. CSF analysis showed lymphocytic pleocytosis, elevated protein, and elevated opening pressure. She was diagnosed with acute disseminated encephalomyelitis and treated with IV corticosteroids, plasmapheresis, IV immunoglobulins, and antiseizure medications with improvement in encephalopathy and seizures, but persistence of focal deficits. Six weeks after symptom onset, she again became critically ill with encephalopathy and a brain MRI demonstrated worsening of the previous lesions. Paraneoplastic and autoimmune encephalopathy antibody testing was negative, cultures and PCR testing did not identify infection, there was no evidence of rheumatologic conditions, and no malignant cells were found in the spinal fluid. Brain biopsy demonstrated an inflammatory infiltrate, primarily composed of macrophages, T cells, and a few B cells and neutrophils. A CD107a degranulation assay demonstrated a defect in natural and cytotoxic T-cell function, and ultimately, genetic testing revealed the diagnosis. This case highlights the diagnostic challenges faced in cases of CNS immune dysregulation, including differential diagnoses, interpretation of functional assays, and genetic considerations.

Background: Spontaneous Spinal Epidural Hematoma (SSEH) is a rare emergency in the general population. It is an even rarer entity in the pediatric population. Case Description: We report two cases: a 15-month-old boy with SSEH, who was presenting with irritability, acute pain, and a 3-year-old girl who presented with left-sided Horner’s syndrome and pain in the left upper extremity. Both patients were misdiagnosed upon admission. At 10 months and 2 months, respectively, after surgery, decompressive surgery was recommended as soon as possible, but this is normally carried out 12 to 24 hours after onset. Conclusion: The clinical presentation of SSEH is atypical and highly difficult to diagnose in children, especially in infants and toddlers. SSEH should always be included in the differential diagnosis when children present with acute back and neck pain, irritability, and uncontrolled crying.

The SHOX (short stature homeobox containing gene) haploinsufficiency can result in phenotypes ranging from idiopathic short stature to Leri-Weill dyschondrosteosis (LWD). It has been reported to have been detected in 5-17% of children diagnosed with idiopathic short stature, and in 60-90% of children with LWD. SHOX duplications, although typically associated with tall stature, can result in short stature and/or extremity anomalies in rare cases when partial or complete duplications involving the SHOX region occur. In this case report, two patients with extremity anomalies who were found to have SHOX region duplications with two different clinical features are presented. The first case was an eleven-month-old male, referred to the pediatric endocrinology clinic due to short stature, and skeletal deformities. On physical examination, the patient's weight was 8.6 kilograms (-1.19 standard deviation score; SDS), and his height was 68 cm (-2.57 SDS). The systemic examination was unremarkable, but examination of the extremities revealed the absence of the right thumb and left forearm bones. Radiographic images of the bones revealed possible rudimentary bone tissue of the radius and ulna in the left upper extremity. DNA extracted from the patient's peripheral blood was subjected to multiplex ligation-dependent probe amplification (MLPA) analysis, which revealed a duplication extending from the upstream regulatory regions of the SHOX gene on Xp22.3/Yp11.32 to the downstream CNE8 (conserved noncoding elements) region, including all of the gene's coding regions and upstream regulatory areas. The second case involved a fourteen-month-old male, who was referred after SHOX duplication was detected in a microarray analysis performed due to epilepsy. On physical examination, his weight was 10.3 kg (-0.3 SDS), and his height was 79 cm (-0.11 SDS). Systemic examination was normal, but Madelung deformities were observed in the extremity examination. DNA obtained from the patient's peripheral blood was analyzed using MLPA for deletions and duplications of the SHOX gene and the associated regulatory regions on Xp22.3/Yp11.32. This analysis revealed a heterozygous duplication which extended from the entire SHOX gene and upstream CNE regions to the CNE7/8 regions downstream. SHOX duplications can result in short, normal, or tall stature depending on the size, location, and transcriptional characteristics (such as containing non-coding elements) of the duplicated region. This case report emphasizes that, in the presence of idiopathic short stature and/or extremity anomalies, SHOX duplications should be considered in addition to the other common genetic causes.

The fifth and sixth (and sometimes the fourth) cervical spinal nerves merge to form the superior trunk, and the superior trunk and the anterior part of the median nerve merge to form the fasciculus lateralis. Fasciculus lateralis is divided into two branches as lateral cord and musculocutaneous nerve. The mus-culocutaneous nerve pierces the corocobrachialis muscle muscle and then travels between the brachia-lis muscle and the biceps brachii musculus. Variations in anatomical structures are common. However, nerve variations occur more rarely in these structures. These variations are anatomically and clinically important. This case report was detected during routine dissection of a male cadaver in the Depart-ment of Anatomy, Karabuk University Faculty of Medicine. For dissection, the fossa axillaris, arm and forearm of both upper extremities were dissected. During dissection, it was found that the musculocu-taneous nerve in the left upper extremity continued without piercing the corocobrachialis muscle and gave a connecting branch to the median nerve. There are limited case studies on this nerve variation and studies show that this variational condition is important for surgical operations in this region. The-refore, this study is important for both surgical and clinical sciences.

Aging is a natural process in the human life cycle. The increase in life expectancy has a positive impact on quality of life, but it also brings various consequences, one of which is the decline in physical and cognitive functions. As they age, the elderly become more susceptible to musculoskeletal disorders, which in turn increase the risk of falling. This community service activity aimed to enhance the understanding and awareness of the elderly regarding the importance of preventing falls and musculoskeletal disorders through ergonomic education and posture screening. The activity, themed "Ergonomics for Elderly Safety," was organized by the Physiotherapy Study Program, Faculty of Nursing, Hasanuddin University, on December 15, 2023, at the Tamalanrea Health Center, involving 30 elderly participants from the Prolanis program. The series of events included ergonomic counseling, demonstrations of ergonomic exercises, and posture screening using the Functional Reach Test and the Apley Scratch Test. The results of the Functional Reach Test showed an average reach of 26,88 cm, indicating a low risk of falling. Meanwhile, the Apley Scratch Test results revealed an average reach of 9,82 cm for the right arm and 16,95 cm for the left arm, reflecting the presence of musculoskeletal disorders, particularly in the left upper extremity. These findings highlight the importance of continuing ergonomic education and posture screening programs as part of preventive efforts to reduce the risk of falls and musculoskeletal disorders in the elderly.

Abstract Background: Breast cancer (BC) is a heterogenous disease with 3 major subtypes which can be further classified into different molecular subtypes with differing treatment responses. Patients may present with more than one of these subtypes simultaneously and executing a cohesive treatment plan to address the heterogenous nature of this disease is essential. Clinical Case: This is a case of a 40 year old female who presented with a large left breast fungating mass. She underwent a biopsy that revealed IDC, grade 3 with necrosis, Ki67 40%, estrogen receptor negative (ER- [&amp;lt;1%]), progesterone receptor negative (PR- [&amp;lt;1%]), HER2+ (immunohistochemistry [IHC] 3+). Imaging noted a 17cm x 8.8 cm left breast mass extending to inferior axilla, subpectoral region and skin surface with edema; left supraclavicular (SCV) nodes up to 2.9cm. Bone scan was negative. She was found to have a DVT in her left upper extremity due to disease burden causing lymphatic obstruction. Prior to start of chemotherapy, she developed dysarthria with right facial droop and right upper extremity drift. She received IV thrombolytic therapy due to CTA showing distal LM2 vs M3 occlusion with improvement of symptoms. MRI brain showed small left MCA territory strokes with an enhancing mass in the left cerebral peduncle consistent with metastasis. She completed gamma knife radiosurgery (GKRS) to a left brainstem lesion in 1/2023. She started 1st line therapy for HER2+ metastatic breast cancer (MBC) using Docetaxel, Trastuzumab and Pertuzumab in 1/2023. Repeat brain MRI in 5/2023 noted 5mm x 2mm left cerebral peduncle lesion, decreased from prior, with no new lesions. Chest CT reported progression in the left breast primary tumor. She received palliative RT to the left breast to 40.05Gy in 15 fractions. Her course was complicated by recurrent DVT and anticoagulant failure, now on a low molecular weight heparin. She was doing well until she presented to the ER in 7/2023 with fever and right axillary pain. Imaging revealed new right large SCV and right axillary lymphadenopathy. The known left breast/chest wall disease was improved. She underwent a right axillary biopsy which revealed IDC, grade 3, ER-(0%), PR- (0%), HER2- (IHC 1+), Ki-67 70%. Restaging scans remained free of distant disease. However, brain MRI showed development of numerous superficial enhancing lesions in addition to a lesion within the right basal ganglia and persistence of the lesion in the left cerebral peduncle. She was neurologically intact and subsequently underwent GKRS to 9 lesions. Given the diagnosis of right sided triple negative breast cancer (TNBC), treatment involved determination of therapeutic options that would simultaneously treat her TNBC and her HER2+ BC. Tumor genomic profile testing was performed which yielded no actionable targets. Treatment was switched to Trastuzumab Deruxtecan (T-DXd) in 9/2023. She has remained on this regimen to date with resolution of right SCV and right axillary disease, resolution of left breast fungating mass with significantly improved residual left axillary wound defect and continued disease control in the brain. Discussion: The decision to initiate T-DXd was made due to benefit of T-DXd in the treatment of both HER2+ and HER2 low MBC. In the DESTINY 02 clinical trial in HER2 + MBC, T-DXd showed a longer median overall survival (OS) of 39.2 months compared to 26.5 months with physician's choice therapy. In DESTINY 04 clinical trial in HER2 low MBC, T-DXd led to OS of 23.4 months compared to 16.8 months with physician’s choice therapy. In addition, the TUXEDO-I trial demonstrated that T-DXd showed efficacy in patients with active brain metastases, yielding intracranial responses in 73.3% of the population with median progression-free survival of 14 months. In conclusion, this unique case highlights the temporal heterogeneity of breast cancer and supports the use of T-DXd in the treatment of this patient with metachronous TNBC (HER2 low) and HER2+ MBC to the brain. Citation Format: Alexandra Noveihed, Milagros Cappa, Tal Kaplan, Nisha Ohri, Colleen Ciccosanti, Mridula George, Shridar Ganesan, Deborah Toppmeyer, Coral Omene. Metachronous triple negative breast cancer in a young patient with aggressive presentation of metastatic HER2 positive breast cancer: treatment considerations and management [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P1-10-25.

BackgroundAcute type A aortic dissection is a rapidly progressive and life-threatening condition. Without timely surgical intervention, the mortality rate can reach up to 50% within the first 48 h. Although surgery remains the primary effective treatment, it is associated with significant complexity and potential risks, particularly in managing the aortic root, where both intraoperative and postoperative bleeding complications are common. This study aims to evaluate the efficacy of the modified “sandwich” technique using a synthetic vascular patch for aortic root reconstruction in acute type A aortic dissection surgery.MethodsA retrospective analysis was conducted on the clinical data of 28 patients with acute type A aortic dissection who underwent aortic root reconstruction using the modified “sandwich” technique with synthetic vascular patches at the Department of Cardiovascular Surgery, the Third Hospital of Hebei Medical University, from October 2020 to November 2022. All patients underwent surgical treatment, during which the modified “sandwich” technique was applied for aortic root reconstruction. Statistical analysis was performed on operative time, cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, postoperative drainage volume, perioperative mortality, and complications.ResultsAll 28 patients underwent successful surgery with a cardiopulmonary bypass (CPB) time of 265.0 (210.0–322.5) min, an aortic cross-clamping (ACC) time of 151.0 (112.0–209.0) min, and a drainage flow rate of 237.5 (126.0–297.0) mL at 12 h postoperatively. There were 2 (7.1%) perioperative deaths caused by renal failure, ischemia in 1 case, and coronary artery causes in 1 case. Postoperative complications included reopening of the chest for hemostasis in 1 case (3.6%) for reasons unrelated to the vascular anastomosis, hemodialysis in 3 cases (10.7%), paraplegia in 1 case (3.6%), and cerebral infarction resulting in impaired mobility of the left upper extremity in 1 case (3.6%). Tracheotomy was performed in 1 case (3.6%), and the duration of mechanical ventilation was 89 (48.0–165) h. Among the 26 recovered patients reviewed with aortic enhancement CT before discharge, the artificial vascular anastomosis had smooth blood flow, though 1 case still had residual entrapment in the sinus of the aorta.ConclusionIn acute type A aortic dissection surgery, the “modified sandwich” technique using an artificial vascular sheet for aortic root shaping is simple, effective, and easy to master. This method can reduce anastomotic blood seepage and prevent anastomotic tear and bleeding, making it worth recommending for clinical application.

Transverse myelitis (TM) is a non-compressive myelopathy caused by spinal cord inflammation that can present with motor, sensory and autonomic deficits. Paraneoplastic TM represents a rare etiology of TM caused by autoantibodies targeting the spinal cord in the setting of malignancy, most frequently lung cancers and lymphoproliferative disorders. Anti-glutamic acid decarboxylase 65 (GAD65) is a rare antibody associated with paraneoplastic neurological sequelae. This case presents a GAD65 positive paraneoplastic TM in the setting of a pancreatic tail adenocarcinoma. A 51-year-old male with an 18.5 pack year smoking history presented for 4 months of progressively worsening left-sided weakness and back pain. He endorsed numbness, tremors and paresthesias of his left upper extremity, left lower extremity weakness with unsteady gait. Magnetic resonance imaging demonstrated C4-T1 demyelination consistent with TM. The serum paraneoplastic panel revealed a positive GAD65 prompting further workup for occult malignancy. Computed tomography chest abdomen and pelvis and magnetic resonance imaging with magnetic resonance cholangiopancreatography showed pancreatic body and tail enlargement. A pancreatic tail mass was confirmed on endoscopic ultrasound. Pathology was consistent with pancreatic ductal adenocarcinoma, confirming the diagnosis of a paraneoplastic TM. He received 5 days of methylprednisolone (1.0 g daily) and plasmapheresis for initial treatment of his TM and 5 days of methylprednisolone for his repeat episode. He was being treated for stage III T4N1 pancreatic cancer. He had completed 2 cycles of oxaliplatin, irinotecan, leucovorin, and 5-flurouracil (mFOLFIRINOX). The patient initially had improvement in his neurological symptoms following the first chemotherapy cycle but developed quadriparesis requiring readmission for subacute TM. He transitioned to hospice care given progression of malignancy. This case highlights the importance of GAD65 as a paraneoplastic antibody and promotes awareness of pancreatic tail adenocarcinoma as a rare cause of paraneoplastic TM.

Accidental intra-arterial injection of diazepam is an uncommon but potentially devastating complication. It could occur when parenteral diazepam is inadvertently given intra-arterial instead of intravenously. Cases have been reported globally, however, more are not reported especially when it occurred at under-resourced healthcare facilities. This case report detailed a case of Mr. K A, a 42-year-old plumber who was managed at a rural nursing home. He was accidentally given intra-arterial diazepam instead intravenous in the ante-cubital fossa of the left upper extremity. The patient presented with physical aggression during an episode of psychotic disorder. Two days after the injection, the patient complained about pain and swelling in the left hand and fingers, for which oral analgesic was administered and patient was reassured. Also, skin discolouration was observed after the 5th day. The condition deteriorated after about 6 weeks with skin becoming darker, absent of peripheral pulse in the left upper arm and gangrenous changes and falling off of two fingers. Relatives demanded for referrer to a psychiatric facility at this point because the patient was still psychotic. However, patient was immediately referred to a teaching hospital where there would be orthopedic and plastic and reconstructive surgeons as well as psychiatrists. The case highlights the importance of adequate training of health workers on injection technique and timely recognition of signs and symptoms suggestive of complications of intra-arterial injection.

Angiosarcomas are rare, aggressive tumors with a poor prognosis. Early detection is essential, as surgically removing localized tumors gives the best chance for a cure. While angiosarcomas predominantly occur in the head and neck region, they can arise from endothelial cells lining blood or lymphatic vessels throughout the body. This case study highlights a rare instance of angiosarcoma developing in a non-functioning arteriovenous fistula (AVF) many years post-renal transplantation. A 50-year-old male with a history of end-stage renal disease (ESRD), initially treated with hemodialysis through a left brachiocephalic AVF, underwent a deceased donor kidney transplant in 2016. In March 2023, patient developed pain and numbness in his left hand, revealing a thrombosed AVF and chronic arterial occlusions. Surgical interventions included a left brachial-brachial artery bypass and ulnar endarterectomy, but his condition deteriorated, leading to the identification of a 4.9 × 3.1 × 2.4 cm mass in the proximal ulnar shaft in January 2024. Biopsy results confirmed epithelioid angiosarcoma, which was subsequently treated with left upper extremity amputation and tumor resection. Metastatic disease was detected in the right lung, necessitating further surgical interventions. This case underscores the necessity for vigilance in monitoring AVFs in transplant patients. We further completed a comprehensive literature review, using PubMed, Cochrane, and Google Scholar, from 2000 to 2024, focused on angiosarcoma arising from AVFs to provide further insights into the rare association between AVFs and angiosarcoma.