Stabbing Pain Research Articles

Severe Bilateral Glossopharyngeal Neuralgia Managed With Nerve Blocks Following Plasmodium falciparum Malaria Infection Treated With Mefloquine

BACKGROUND: The Internal Classification of Headache Disorders diagnosis for glossopharyngeal neuralgia (GN) includes recurrent paroxysmal severely painful attacks in the glossopharyngeal nerve distribution. Precipitating factors may be swallowing or talking, and diagnosis is made by exclusion. Conservative management includes medications, such as carbamazepine. For refractory cases, interventional nerve blocks may be required. CASE REPORT: A 38-year-old woman experienced severe bilateral GN and occipital neuralgia with atypical migraines after treatment with mefloquine for severe Plasmodium falciparum malaria. Symptoms included the inability to perform activities of daily living (ADLs) due to severe “electric sharp stabbing pain.” Following ineffective conservative management, she was successfully treated with a series of nerve blocks every 3 months. Over time, with repeated interventions, she acquired a significantly lower baseline of pain enabling her to participate in ADLs. CONCLUSIONS: This case report highlights nerve blocks as a viable treatment option for refractory bilateral GN following treatment with mefloquine. KEY WORDS: Glossopharyngeal neuralgia, malaria, plasmodium, falciparum, mefloquine, regional nerve blocks, stellate ganglion nerve block,glossopharyngeal nerve block

Wilson’s Disease- A Child with An Atypical Presentation

Wilson’s disease is a hereditary disorder of copper metabolism which leads to copper overload in different tissues of the body. Clinical presentation of Wilson disease can vary widely; therefore, diagnosis is not always straightforward. Here we report a 13-year-old girl presented with diffuse persistent stabbing pain in the abdomen, jaundice & dark urine. She had no history of unconsciousness, convulsion, deterioration of school performance, or alteration of sleep pattern. On examination, she was ill-looking, pale, and icteric. The liver was enlarged. Higher psychic Function was intact, with no neurological deficit. A slit-lamp examination by an ophthalmologist promptly revealed the presence of a “Kayser Fleischer Ring” in both eyes. On investigation, hemoglobin was 5.73g/dl, Total bilirubin-37.82mg/dl, ALT-50 IU, AST-95 IU, PT/INR-3.20, serum ceruloplasmin 21mg/dl. Twenty-four hours of urinary copper excretion after penicillamine challenge was 8784 μg/24 hours. We diagnosed the case as Wilson’s disease. This case report aims to share our experience regarding the clinical presentation and diagnosis of Wilson’s disease in a child where Kayser–Fleischer rings in eyes appeared before neurological manifestation occurs and normal serum ceruloplasmin which often creates a diagnostic dilemma.

Trigeminal Neuralgia Management with <i>Varmam</i> Therapy and <i>Siddha</i> Medicine – A Case Report

A 48 year old female staff nurse from Chennai consulted in the Varma Maruthuvam Outpatient Department of APH-NIS, Chennai presented with complaints of sudden and severe stabbing pain with burning sensation at the left half of the maxillary and mandibular region for one year. After her MRI scan was done, she was diagnosed with trigeminal neuralgia due to vascular compression. The patient had consulted an allopathic hospital and used carbamazepine for the long term. She experienced some temporary relief, but the episodes occurred for a short while, and she felt drowsy. For further improvement, she came for Varmam treatment. The present study is a case report of typical Trigeminal Neuralgia (TN) that was treated with Siddha Varmam therapy along with Amukkarachooranam, Arumugachenduram and Arakku thailam for two months. This case report showed a promising reduction in pain episodes and recurrence following treatment, as measured by the Visual Analogue Scale (VAS) score. This study sheds light on the fact that Varmam therapy with concomitant medicines has a promising effect in the management of trigeminal neuralgia.

Heightened presence of inflammatory mediators in the cerebrospinal fluid of patients with trigeminal neuralgia.

Trigeminal neuralgia (TN) is a chronic, debilitating facial pain disease causing stabbing pain attacks in the sensory distribution of the trigeminal nerve. The underlying pathophysiology of TN is incompletely understood, although microstructural abnormalities consistent with focal demyelination of the trigeminal nerve root have been shown in patients with TN. Studies of the cerebrospinal fluid (CSF) in patients with TN suggest an increased prevalence of inflammatory mediators, potentially implicating neuroinflammation in the pathophysiology of TN, as it has been implicated in other chronic pain conditions. This study aimed to further assess the inflammatory profile of CSF in TN. Cerebrospinal fluid was collected from 8 medically refractory patients with TN undergoing microvascular decompression surgery and 4 pain-free controls (2 with hemifacial spasm; 2 with normal pressure hydrocephalus). Cerebrospinal fluid was collected from the cerebellopontine angle cistern intraoperatively in the patients with TN. Inflammatory profiles of CSF samples were analyzed using a 71-plex cytokine and chemokine multiplex assay. Ten inflammatory markers were found to be significantly higher in TN CSF, and no analytes were significantly lower. Elevated factors can be classified into pro-inflammatory cytokines (IL-9, IL-18, and IL-33), chemokines (RANTES and ENA-78), the tumor necrosis factor superfamily (TRAIL and sCD40L), and growth factors (EGF, PDGF-AB/BB, and FGF-2). This study further supports the notion that neuroinflammation is present in TN, and that multiple molecular pathways are implicated.

Peningkatan Pengetahuan Remaja Putri tentang Hipnoterapi dengan Musik Instrumentalia Melayu Jambi dalam Mengatasi Dismenore

Dysmenorrhea or menstrual pain is a stabbing pain that is felt in the lower abdomen and thighs, this occurs due to an imbalance of the hormone progesterone in the blood, resulting in pain arising. Almost all women have felt interference during menstruation in the form of menstrual pain (dysmenorrhea) with various levels, ranging from just aches in the pelvis from the inside to extreme pain. The prevalence of dysmenorrhea in adolescent girls is 74.42%. The highest proportion of dysmenorrhea was found in adolescents aged 14 and 16 years, had no family history of dysmenorrhea, menarche age 11-12 years, menstruation for 7 days or more, normal nutritional status, and adolescent girls who rarely exercised. The most complained and felt impact due to dysmenorrhea is limited physical activity, poor concentration and absence in the teaching and learning process. Non-pharmacologically, pain can be treated, one of which is with distraction techniques. The technique of distraction or distracting someone is the most effective to reduce pain by listening to classical music (mozart) and also back exercises. The purpose of this community service is to increase the knowledge of young women about hypnotherapy with Jambi Malay instrumental music in overcoming dysmenorrhea. The method / approach taken is to assess the knowledge of young women before and after education about hypnotherapy with Jambi Malay instrumental music in overcoming dysmenorrhea. After participating in a series of activities in accordance with the implementation plan, the results were obtained before good knowledge education was carried out 5 (23.8%) young women and less good 16 (76.6%) young women, after good knowledge education 21 (100%).

Abstract 116: Reversal of Acute Ocular Ischemic Syndrome Following Rescue Carotid Revascularization: A Case Report

Introduction Ocular ischemic syndrome (OIS) is a rare, vision‐threatening condition resulting from severe carotid artery disease secondary to severe atherosclerosis or arteritis. Common clinical features include acute/subacute to gradual vision loss, ocular pain, amaurosis fugax, photophobia and diplopia. We are presenting a case of acute ocular ischemic syndrome secondary to acute re‐occlusion of the right internal carotid artery (RICA) post Carotid Endarterectomy (CEA), that reversed with carotid revascularization. Methods Case Summary: 59‐year‐old male with history of T2DM, hyperlipidemia, tobacco use presented to an outside hospital with complaints of dizziness, blurry vision, left upper extremity weakness and multiple falls with head trauma. Exam revealed left lower quadrantanopia, mild left arm weakness and left hemineglect. Computed Tomography (CT) Head showed scattered right middle cerebral artery (MCA) territory infarcts. CT Angiography (CTA) revealed ulcerated plaque with a small focus of thrombus intraluminally in the RICA. Subsequently, the patient was initiated on heparin infusion and underwent CEA. On postoperative day (POD) 2, the patient experienced severe stabbing right eye pain with reduced visual acuity and worsening of left arm weakness. Imaging revealed complete occlusion of the right common carotid artery (RCCA). Perfusion imaging did not reveal a core or a penumbra. Given acute loss of vision likely secondary to ocular ischemic syndrome, decision was taken to proceed with rescue stenting. Using a transfemoral approach, an 8‐French balloon guide catheter was advanced into the proximal RCCA. A primary suction thrombectomy was performed under proximal flow arrest. After achieving a complete recanalization in one pass, we started the patient on cangrelor 30 mcg/kg intravenous bolus followed by 4 mcg/kg/min infusion. Post bolus, we placed a tandem closed‐cell carotid stent measuring 8x36mm & 10x37mm. The patient reported immediate relief of ocular pain, vision and weakness following the procedure. He transitioned from cangrelor infusion to ticagrelor 90 mg twice daily and aspirin 81 mg daily. On post‐stenting day 7, the patient experienced acute onset headache, and imaging revealed re‐occlusion of the entire carotid artery sparing only the ophthalmic segment of the RICA which now filled retrograde via anterior communicating artery (AcoA) from the contralateral carotid artery. However, his visual acuity remained unchanged and reported no ocular pain. At one month follow‐up the patient remains symptom‐free. Results Discussion: Incidence of OIS is estimated to be 7.5 cases per million every year. Carotid artery atherosclerosis is the most common etiology. Majority of OIS (∼90%) present with gradual vision loss and approximately 40% present with ocular pain. Gradual vision loss is predominantly related to chronic ocular hypoperfusion and resultant iris neovascularization and glaucoma. In this case, patient suffered acute vision loss secondary to acute ICA occlusion following CEA. Emergent carotid revascularization resulted in restoration of vision and resolution of ocular pain. Conclusion Our main goal is to emphasize the importance of rescue stenting to address symptoms of aOIS. Immediately post‐stenting, there was remarkable improvement in ocular pain and visual acuity. Although, the carotid re‐occluded within seven days post‐stenting, we hypothesize that gradual re‐occlusion while on DAPT provided enough time recruit and preserve collaterals into the right ophthalmic artery via retrograde flow into the ophthalmic segment of RICA from the contralateral carotid artery via the AcoA which was subsequently confirmed on imaging.

Subungual Glomus Tumor of the Hallux A Report of 4 Cases.

This study reports the clinical outcomes and evolution of 4 patients with subungual glomus tumor (GT) of the hallux treated with tumor excision. Preoperatively, all patients had pain of intensity 9 or 10. Three were sensitive to cold and had stabbing pain, and one reported pulsatile pain. No patient presented nail alterations. There were no bone alterations on radiographic images and diagnostic suspicion of GT was supported by magnetic resonance images. Surgical treatment was indicated due to severe pain and functional limitation. The GT excision was performed by removing the nail through an L-shaped incision in the nail bed. After surgery, they all showed clinical improvement with return to previous activities and had no difficulty in wearing regular shoes. Three patients were pain-free and one had occasional stabbing pain of intensity 2. Half of them had nail changes. There has been no recurrence so far. Thus, we found that resection of subungual GT of the hallux was effective for the clinical improvement of patients.Level of Evidence: IV, case reports.

Real World Characterization of Chronic Pain, Success Rates and Implant Rates: Evidence from a Digital Health Platform of Patients Undergoing Spinal Cord Stimulation Evaluations

Spinal cord stimulation is an effective treatment for those experiencing chronic back and leg pain but requires a temporary evaluation period (SCSeval) before permanent implantation. We present real-world data from 7,000 patients who underwent SCSeval while utilizing a mobile digital health platform for education, feedback, and outcomes collection during their surgical journey. We analyzed preoperative patient demographics, characterized patient pain profiles using the patient-reported outcomes measurement information system-29 surveys, and calculated the rates of conversion from temporary to permanent spinal cord stimulation (SCS) implantation. Between August 1, 2021, and March 2, 2023, 7,000 patients (mean age 59.1, 59.6% female) underwent SCSeval procedures while utilizing a mobile application. Patients commonly experienced aching, sharp, stabbing, tingling, numb, and burning pain. Patients had tried multiple prior therapies and wanted to reduce their use of opioids and pain medications. Overall, 90.1% of the patients had a successful SCSeval, and 80.4% of those converted to permanent implant, with the highest rates among those who underwent SCSeval in a hospital setting. There was a significant improvement in all domains of pain as evaluated by pre and postoperative patient-reported outcomes measurement information system-29 surveys. This study supports the use of digital health technology as part of the SCS journey to improve the patient experience and allow for robust patient-reported outcomes collection. The overall rate of SCSeval to permanent SCS in our study of 72.4% was higher than national rates of 64%, suggesting that an app may allow clinicians to better quantify changes in chronic pain and provide more insight into choosing to implant SCS permanently. PerspectiveThis article presents real-world evidence from a digital health platform for therapy education and outcomes collection from patients undergoing spinal cord stimulation evaluation procedures. Such tools could allow for better pain characterization and allow for more nuanced tracking of patient outcomes among those with chronic pain.

FROM A SYNCOPE TO MYOCARDITIS - AN UNUSUAL MANIFESTATION OF MYOCARDITIS IN OBESE PATIENT WITH HYPERTENSION AND PARANOIDAL SCHIZOPHRENIA

Objective: The case report presents a 30-year-old obese patient with a history of paranoidal schizophrenia, sinus tachycardia and hypertension which was admitted to the Department of Internal Medicine and Hypertension after fainting the day before. In the admission the patient suffers from a chest pain, dizziness, and abdominal pain. The physical examination revealed: BP 161/104mmHg, HR 120/min, SatO2 94%, overdeveloped fatty tissue and pain in the left chest and abdominal area after a collapse. Laboratory tests showed increased inflammation and cardiac parameters as well as extremely high concentration of TCAs (Tricyclic antidepressants). The ECG and ECHO were carried out, the former showed ST elevations in ECG leads II, III, aVF, V4-V6, the latter reveled dilation of the right ventricle, left ventricular hypertrophy and lower ejection fraction, EF = 48%. Hypotensive treatment was implemented resulting lowering blood pressure. However, the patient's condition did not get better. Stabbing and burning chest pain persisted. Considering a clinical picture, contrast-MRI was performed showing LGE (late gadolinium enhancement) on the lateral-inferior part of the left ventricle wall characteristic for myocarditis (MC). The objective of this case report is to highlight a possibility of myocarditis when there are symptoms responding to other heart diseases, atypical for MC and the role of detailed diagnostic process and holistic perspective. Design and method: Case report presentation of the patient admitted to the hospital due to the collapse episode the day before. Symptoms and additional test analysis and making the final diagnosis. Results: Initial diagnostic tests were negative or inconclusive until heart contrast-MRI was performed revealing - LGE foci in the left ventricle wall corresponding to the area of inflammatory lesion of the lateral-inferior part of the left ventricle wall. Conclusions: Although, myocarditis is a rare finding, more frequent in younger population, it is associated with significant complications and mortality thus early diagnosis can prevent critical condition. In presented case, the difficulty in making a final diagnosis of myocarditis was affected by predominant cardiac attack symptoms. Moreover, MC could be caused by TCA which high concentration was found in the patient's blood.

ID: 215433 The History of Spinal Cord Stimulation to Treat Painful Diabetic Peripheral Neuropathy

Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18.

Can exostoses of the external occipital protuberance and superior nuchal lines cause headache? A report of two cases

Compression of the occipital nerves can cause occipital headache. Several potential compression points have been identified along their course. One of these points is the hitherto undescribed instance of exostoses of anatomic structures of the occipital bone. A 34-year-old man with a prominent external occipital tuberance and superior nuchal lines complained of headache in the area of distribution of the greater occipital nerve with tenderness near the bony protrusion on palpation. A 44-year old woman experienced stabbing pain in the lateral orbital region with pressure on the ossified insertion of the ipsilateral trapezius muscle near the external occipital protuberance. Local nerve block achieved temporary relief of pain. Exostosis of the external occipital protuberance and superior nuchal lines may impinge on the greater and third occipital nerves. The characteristics of the pain in our cases differ in some aspects from those of occipital neuralgia.

A comparative study to analyze the efficacy of platelet rich plasma versus corticosteroids in treatment of chronic plantar fasciitis

Plantar Fasciitis is responsible for 15% of all foot problems. Over ten percent of the population will be affected at some point in their lives. It is caused by inflammation of a broad band of tissue that links your heel bone to your toes and runs across the bottom of your foot (plantar fascia). Plantar fasciitis is a type of plantar fasciitis that causes stabbing pain when you take your first steps in the morning. The discomfort usually goes away as you get up and move around, but it may come back after long periods of standing or when you stand up after sitting. Runners are more likely to get plantar fasciitis. The plantar fascia is made up of of white-coloured fibers that run longitudinally from the calcaneum to the toes. The attachments include the following: Proximal- Affixed to the calcaneum's medial tubercle. The fascia fanning out into five slips against the metatarsophalangeal joints and attaches to the base of the appropriate toes' proximal phalanges. Chronic heel pain is a difficult condition to treat and takes a long time to resolve. This study outlines both PRP and steroid are effective and safe modalities in the treatment of plantar fasciitis. But statistical data suggest that steroid injection is effective for immediate pain relief. And PRP injection is better for long term pain relief in plantar fasciitis with no side effects.

Role of Physical Therapy in Trigeminal Neuralgia: A Case With 4-Year Follow-up

BACKGROUND: Trigeminal neuralgia presents with acute stabbing unilateral facial pain along the nerve distribution precipitated by innocuous sensory stimuli. Trigeminal neuralgia can be unrelenting and can lead to severe physical and emotional consequences. Medical and surgical intervention often has adverse effects, and reports of physical therapy treatment are uncommon. CASE PRESENTATION: The patient in this case presented for physical therapy with a history of head/neck surgery, migraines and headaches, joint pain, and depression, with severe sharp shock-like pain aggravated by innocuous oral activity in the trigeminal nerve distribution. Over 10 sessions, she received manual therapy for joint, myofascial, and nerve mobilization, and upper limb stretching and strengthening. OUTCOME AND FOLLOW-UP: Her pain level decreased substantially and interfered with only 1 oral activity at 4-year follow-up. DISCUSSION: Her presentation may inform the differential diagnosis of craniofacial pain. Her management integrating manual therapy with exercise and the positive clinical outcome suggest a new avenue for treatment of trigeminal neuralgia. JOSPT Cases 2023;3(2):119–126. Epub: 13 April 2023. doi:10.2519/josptcases.2023.11446

A case report: Diagnosis and treatment of idiopathic hypertrophic pachymeningitis

AbstractA 57‐year‐old man who suffered from a headache for 1 year, accompanied by blurred vision for 7 months and numbness in his left face for 1 week was admitted to the Affiliated Hospital of Zunyi Medical University on May 7, 2022. One year ago, the patient had no obvious precipitating factor of paroxysmal stabbing pain in the whole skull with dizziness, which could be relieved by oneself after lasting for 1–2 min each time, with about 20 episodes per day. The cranial magnetic resonance imaging revealed changes in bilateral frontal lobe ischemic foci, bilateral frontal, ethmoid, sphenoid and maxillary sinusitis, and retinal macular degeneration. After hormone shock treatment, the condition improved. He suffered from headaches again with blurred vision in the right eye 7 months ago and was initially diagnosed with multiple sclerosis. He then was discharged after improvement due to hormone shock therapy. Oral hormone therapy was continued outside the hospital, but he stopped it due to drug side effects (details remained unclear). After cutting off, he developed a headache and visited our hospital once more, the relevant tests were performed and the patient was diagnosed with idiopathic hypertrophic pachymeningitis (IHP). The symptoms were slightly abated after hormone therapy. We hope that through this case report, we can deepen the clinicians' understanding of IHP, and improve the diagnosis rate of the disease through relevant examinations in future clinical work, so that patients can receive timely treatment and the mental pressure and economic burden caused by the disease on patients are reduced.

WINGED SCAPULA CAUSED BY PARSONAGE-TURNER SYNDROME AFTER BNT162B2 MRNA COVID-19 VACCINATION.

Parsonage-Turner syndrome (PTS), also referred to as idiopathic brachial plexopathy or neuralgic amyotrophy, is characterized by acute onset of unilateral upper extremity pain.PTS often results in a winged scapula due to paralysis of the long thoracic nerve.PTS should be considered in patients with post-neuralgic motor paralysis of the unilateral upper extremity, which can occur after COVID-19 vaccination.

Diagnosis and treatment of occipital neuralgia: focus on greater occipital nerve entrapment syndrome

Background: Occipital neuralgia is defined as paroxysmal shooting, or stabbing pain in the posterior part of the scalp, in the distribution of the greater and lesser occipital nerves. Occipital neuralgia may present only as an intermittent stabbing pain, but different opinions exist on its cause and diagnostic criteria.Current Concepts: According to the latest version of headache classification, only paroxysmal stabbing pain is included in the diagnostic criteria, and persistent aching pain is excluded. Pain intensity was also limited to severe cases. It has therefore become difficult to classify existing occipital neuralgia, whose main symptom is persistent pain rather than paroxysmal stabbing pain. Occipital neuralgia is classified as either idiopathic or secondary. Secondary occipital neuralgia is caused by structural lesions innervating the trigeminocervical complex (TCC) in the upper spinal cord, the dorsal root of second cervical cord, and the greater occipital nerve (GON).Discussion and Conclusion: Although idiopathic occipital neuralgia has no cause, the entrapment of the GON in the tendinous aponeurotic attachment of the trapezius muscle at the superior nuchal line has recently been proposed as an etiology. Chronic, irritating afferent input of occipital neuralgia caused by entrapment of the GON seems to be associated with sensitization and hypersensitivity of the second-order neurons in the TCC receiving convergent input from trigeminal and occipital structures. TCC sensitization induces referred pain in the facial trigeminal area.

584 AN UNUSUAL CASE OF A STRESSED HEART

Abstract A 53-year-old woman was admitted to our emergency department complaining severe stabbing and oppressive retrosternal pain radiating posteriorly to left scapulae and left arm The onset was followed by general malaise, nausea, vomiting which she attributed to a period of intense emotional stress. She denied common cardiovascular risk factors, but in 2019 had a suspected acute coronary syndrome with subsequent finding of normal coronary artery at angiography in another institute. Her past medical history included severe asthma on multiple drug therapy with regular follow-up. Physical exam was normal. Electrocardiogram (ECG) showed subtle diphasic-negative T wave in anterior leads with mild ST depression in V4-V5, with patient still symptomatic. Lab examinations showed significantly increased troponins levels (hsTnI 664 ng/L, reference < 34 ng/L) with other lab values within normal range. A transthoracic echocardiogram at the bedside revealed mildly reduced systolic function with hypo-akinesis of the mid-apical anteroseptal and anterior left ventricular myocardial wall. Therefore, acute coronary syndrome was suspected and heparin and aspirin at a loading dose were administered. Still symptomatic, the patient was admitted in the ICU. In the same day a left heart catheterization revealed normal aspect of epicardial coronary arteries and ventriculography showed preserved basal and apical myocardial wall motion but hypo-akinesis of mid-cavitary walls, suggesting a possible mid-ventricular variant of Takotsubo syndrome (Figure 1). The patient was still symptomatic for stabbing chest pain after coronarography. To rule out the suspicion of acute aortic syndrome and pulmonary embolism, she also underwent a contrast-enhanced chest CT scan, that was fortunately normal. During her hospital stay, the patient had no arrhythmic and hemodynamic complications. Peak troponin level was 5027 ng/L. At serial ECGs, she developed diffuse deep T-wave inversion and a mild prolonged QT interval. Echocardiogram was repeated after 4 days showing complete normalization of left ventricular wall motion and restored ejection fraction also. From the traditional “apical ballooning” Takotsubo Syndrome with apical akinesia and basal hypercontractility, different variants have been described. The mid-ventricular variant, seen in our patient was found in only 14.6% of the cases in the International Takotsubo Registry, followed by basal “reverse” and focal variants (2.2% and 1.5%, respectively).

Electrophysiological and computational analysis of Cav3.2 channel variants associated with familial trigeminal neuralgia

Trigeminal neuralgia (TN) is a rare form of chronic neuropathic pain characterized by spontaneous or elicited paroxysms of electric shock-like or stabbing pain in a region of the face. While most cases occur in a sporadic manner and are accompanied by intracranial vascular compression of the trigeminal nerve root, alteration of ion channels has emerged as a potential exacerbating factor. Recently, whole exome sequencing analysis of familial TN patients identified 19 rare variants in the gene CACNA1H encoding for Cav3.2T-type calcium channels. An initial analysis of 4 of these variants pointed to a pathogenic role. In this study, we assessed the electrophysiological properties of 13 additional TN-associated Cav3.2 variants expressed in tsA-201 cells. Our data indicate that 6 out of the 13 variants analyzed display alteration of their gating properties as evidenced by a hyperpolarizing shift of their voltage dependence of activation and/or inactivation resulting in an enhanced window current supported by Cav3.2 channels. An additional variant enhanced the recovery from inactivation. Simulation of neuronal electrical membrane potential using a computational model of reticular thalamic neuron suggests that TN-associated Cav3.2 variants could enhance neuronal excitability. Altogether, the present study adds to the notion that ion channel polymorphisms could contribute to the etiology of some cases of TN and further support a role for Cav3.2 channels.

Abstract 12668: Coronary CTA Finding of Libman Sacks Endocarditis Presenting as Chest Pain

Case Presentation: A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren's contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months. Discussion: Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.

S3558 A Tale of Two Sisters: Two Pediatric Cases Within a Familial Cluster of Hereditary Diffuse Gastric Carcinoma

Introduction: We report a case of HDGC in two sisters, (10 and 15 years old) and their father (41 years old). Case Description/Methods: Our patient is a 15-year-old Caucasian female who initially presented to our clinic with a 4-month history of right lower quadrant tenderness and generalized abdominal pain, which she characterized as “stabbing pain.” Review of systems was significant for intermittent diarrhea and constipation. Family history was significant for a paternal great-aunt who reportedly died from gastric cancer at age 28. Abdominal ultrasound showed no significant abdominal pathology and no appreciable stomach wall thickening. EGD revealed diffuse mild inflammation of the stomach with normal appearing rugae without ulceration or masses and normal proximal duodenum. Biopsy results from the antrum revealed poorly differentiated signet ring cell carcinoma. The patient underwent a second EGD and imaging to confirm and stage the cancer. The patient subsequently underwent a laparoscopic roux-en-Y esophagojejunostomy, jejunojejunostomy with exploratory laparoscopy. Based upon the unusual occurrence of SRCC in a young female, the patient and her family underwent genetic testing. The patient was found to be positive for a CDH1/E-cadherin mutation. It was found that the patient’s father and her 10-year-old sister also carried this mutation. The 10-year-old sister and the father underwent screening EGD with greater than 40 biopsies taken throughout the stomach, esophagus, and duodenum in representative areas. Surprisingly, both patients were found also to have gastric SRCC. The father has since undergone chemotherapy, radiation, and a laparoscopic roux-en-Y esophagojejunostomy, jejunojejunostomy. The family is opting for conservative management at this time for the 10-year-old patient with plans to undergo the same surgery when she is older (Figure). Discussion: Gastric carcinoma in the pediatric population is exceedingly rare. HDGC should be considered when a patient presents with gastrointestinal symptoms and has a positive family history of gastric cancer among 1st and 2nd degree relatives, particularly if a relative was diagnosed before the age of 50. For carriers of the CDH1 mutation, prophylactic total gastrectomy is recommended with intraoperative confirmation of squamous epithelium in the esophagus at the proximal margin and duodenal mucosa at the distal margin. If gastrectomy is contraindicated, yearly endoscopic surveillance with random biopsies is recommended.Figure 1.: Biopsy from gastric antrum demonstrating poorly differentiated signet ring cell carcinoma present in the lamina propria.