Lower Extremity Weakness Research Articles

Thromboembolism An unusual way of tissue diagnosis of Squamous Cell Carcinoma of Lungs

Lung carcinoma presents in multifarious ways from incidental imaging finding to respiratory or systemic symptoms secondary to local invasion or metastasis. We report an atypical presentation of lung cancer. A 69-year-old male presented with sudden onset bilateral lower extremity weakness. He had cold bilateral lower extremity with no palpable pulses or Doppler signals in the lower extremity. A computed tomographic angiographic (CTA) scan revealed large thrombus in the infra-renal aorta and bilateral common iliac arteries with total occlusion. Bilateral endovascular thrombectomy along with fasciotomy was done. Immuno-histochemical staining of thrombectomy mass showed metastatic squamous cell carcinoma. Positron emission tomography (PET) scan revealed hypermetabolic right pulmonary hilar foci with hypermetabolic mediastinal nodes. Diagnosis of non-small cell lung carcinoma was made and subsequently, chemotherapy was started. Atypical presentation and tissue diagnosis of lung cancer via histopathological examination from endovascular thrombectomy are quite unique. Our case highlights the importance of analysis of thrombectomy mass.

Acute Lower Extremity Weakness in a Pediatric Gymnast.

Acute Lower Extremity Weakness in a Pediatric Gymnast.

Biopsychosocial sequelae and recovery trajectories from whiplash injury following a motor vehicle collision

BACKGROUND CONTEXTFive out of 10 injured in a motor vehicle collision (MVC) will develop persistent pain and disability. It is unclear if prolonged symptoms are related to peritraumatic pain/disability, psychological distress, muscle fat, lower extremity weakness. PURPOSETo test if widespread muscle fat infiltration (MFI) was (1) unique to those with poor recovery, (2) present in the peritraumatic stage, (3) related to known risk factors. STUDY DESIGN/SETTINGA cohort study, single-center academic hospital. PATIENT SAMPLESA total of 97 men and women (age 18–65) presenting to an urban academic emergency medicine department following MVC, but not requiring inpatient hospitalization. PRIMARY OUTCOME MEASURENeck disability at 12-months. METHODSParticipants underwent magnetic resonance imaging (MRI) to quantify neck and lower extremity MFI, completed questionnaires on pain/disability and psychological distress (< 1-week, 2-weeks, 3-, and 12-months) and underwent maximum volitional torque testing of their lower extremities (2-weeks, 3-, and 12-months). Percentage score on the Neck Disability Index at 12-months was used for a model of (1) Recovered (0%–8%), (2) Mild (10%–28%), and (3) Moderate/Severe (≥ 30%). This model was adjusted for BMI and age. RESULTSSignificant differences for neck MFI were revealed, with the Recovered group having significantly lower neck MFI than the Mild and Moderate/Severe groups at all time points. The Mild group had significantly more leg MFI at 12-months (p=.02) than the Recovered group. There were no other significant differences at any other time point. Lower extremity torques revealed no group differences. The Traumatic Injury Distress Scale (TIDS) and MFI of the neck at 1-week postinjury significantly predicted NDI score at 12-months. CONCLUSIONSHigher neck MFI and distress may represent a risk factor though it is unclear whether this is a pre-existing phenotype or result of the trauma. Trial RegistrationClinicalTrials.gov Identifier: NCT02157038.

Mature B-cell lymphoma with acute myelitis as the first presentation: a case report and literature review

BackgroundLymphomas are malignant tumors of the immune system that arise in lymphoid organs and can impact the central nervous system. However, lymphomas with acute myelitis as the first manifestation are exceedingly rare, and most of them are symptoms of spinal cord damage due to the lack of specificity in their clinical manifestations. The rate of early misdiagnosis is exceedingly high, and the prognosis is dire. Here, we report a case of mature B-cell lymphoma with acute myelitis as the first presentation and review the related literature.Case presentationIn this study, We report a case of a 70-year-old male patient with bilateral lower extremity weakness, bowel and bladder dysfunction, and recurrent fever. A paraureteral mass was seen beneath the right kidney on imaging, and the final pathological biopsy revealed: CD20 ( +), mature B-cell tumor, The patient refused to undergo additional tests to ascertain the type of lymphoma and subsequent therapy and asked to be discharged. In mid-November 2020, the patient died.ConclusionsThis case report shows that patients with lymphoma can present with acute myelitis as the first symptom, especially if they have recurrent fever, that conventional treatment for myelitis is ineffective, and that tumors are considered after other causes of myelitis have been ruled out. Furthermore, a focused search for tumor-related evidence, as well as early identification and therapy, may help patients live longer lives.

Anti-Mi-2 antibody-positive lung cancer-associated polymyositis.

After a 75-year-old man was diagnosed with lung cancer, proximal weakness and myalgia in the bilateral lower extremities developed, and the creatinine kinase (CK) level was elevated. The anti-Mi-2 antibody test was positive, muscle T2-weighted/fat-suppressed magnetic resonance imaging showed high intensity, and there were no skin lesions. Therefore, he was diagnosed with lung cancer-associated polymyositis (PM). The lung tumour shrank after chemotherapy, accompanied by gradual improvement of his PM-derived symptoms and CK level. Although positive anti-Mi-2 antibody tests rarely indicate PM and cancer, examining myositis-specific autoantibodies, including anti-Mi-2, should be considered if the CK level increases after a cancer diagnosis.

Cerebral Nocardiosis: a diagnostic challenge

uncertain if this represented post-surgical change, residual neoplasm, radiation reaction, or infection. One-year after the brain mass resection, the patient presented to the hospital with new-onset expressive aphasia and focal weakness in the left lower extremity. Repeat MRI showed 3 new ring- enhancing lesions within the left cerebellum, left temporo-parietal junction, and left para-median superior parietal lobe (Figure 1). There was persistent irregular enhancement within the right cerebellum, now extending to the right middle cerebellar peduncle. Aspiration biopsy revealed a large amount of Nocardia farcinica, which was resistant to ceftriaxone, imipenem, clarithromycin, tobramycin, doxycycline, and minocycline. The patient was started on trimethoprim- sulfamethoxasole 400 mg three times/day, but despite continued antibiotic treatment, she became bacteremic. This was complicated by acute toxic

Dengue Fever Presenting with Severe Myositis-A Case Report

Dengue fever is one of the most common vector-borne diseases, which is a viral infection transmitted by female Aedes aegypti mosquitoes. It is most common in tropical countries like India. Dengue fever symptoms can range from a mild infection to severe flu-like sickness. Myalgia is a symptom of dengue infection. Dengue fever with myositis and/or high serum creatine phosphokinase (CPK) levels, on the other hand, is extremely uncommon. Dengue virus can cause myositis in many mechanisms. One of the most common mechanisms is by direct invasion of the myocytes by the dengue viruses. Myotoxins, Inflammatory cytokines have also been a part of the development of myositis. The clinical spectrum is broad, from the mild asymmetrical weakness of lower extremities to sudden progressive severe limb and trunk weakness, and even lung failure. This case study aims to show the rare neuromuscular complications of dengue fever, which can be managed well with a high index of suspicion. Our patient presented with fever and severe myalgia and was diagnosed with dengue. We started treating the patient with a provisional diagnosis of dengue-associated myositis. Significantly elevated CPK levels confirmed the myositis. Hereby, we are presenting a case of dengue fever with myositis with muscle weakness &amp; elevated creatine phosphokinase (CPK) levels who recovered completely with early suspicion of dengue-associated myositis and early management. Hence, Physicians should have a high index of suspicion and early management of dengue-associated neuromuscular complications.

Abstract Number ‐ 221: Lower Thoracic Spinal Dural Arteriovenous Fistula Presenting With Progressive Paraplegia: A Case Report

Introduction We present a 72‐year‐old male with osteoarthritis, lumbar stenosis, coronary artery disease with a 4‐vessel bypass graft in February 2020, hypertension, hyperlipidemia, and obesity who presented with subacute progressive lower extremity weakness. He began having lower back pain following his cardiac surgery in February 2020. He was evaluated by a rehabilitation doctor in September 2020 who diagnosed him with lumbar radiculopathy and treated him with one round of steroid injections that helped a bit. Six months later he returned for follow‐up with the aid of a wheelchair which he started using in the last two weeks due to progressive lower extremity weakness. He was sent to the ED for neurologic evaluation. He denied radicular pain, saddle anesthesia, and urinary or bowel incontinence. Methods On neurologic exam, he had 2/5 bilateral hip flexion strength, 4/5 bilateral distal lower extremity strength, intact sensation to all modalities, and diffuse bilateral hyporeflexia (1+) with flexor plantar responses. An MRI brain was unremarkable. An MRI cervical, thoracic and lumbar spine with contrast showed extensive confluent cord edema with enhancement from T9 to the conus medullaris. He was started on high‐dose IV methylprednisolone for concern of transverse myelitis. Serum metabolic, hematologic, autoimmune, and infectious workup were negative. Due to a lack of improvement, his spinal imaging was reviewed with neuroradiology who recognized previously unidentified posterior T2 flow voids in the subarachnoid space at T1. A spinal angiogram for suspicion of a spinal dural arteriovenous fistula (dAVF) was subsequently scheduled. Results Angiography confirmed a type I spinal dAVF which was treated with posterior laminectomy and surgical ligation. The patient’s lower extremity strength improved and he was discharged to acute rehab. At his 1‐month neurology follow‐up appointment, he was ambulating with minimal assistance from a cane with near full lower extremity strength. Conclusions With an initial presentation of subacute progressive lower extremity weakness and imaging findings concerning for longitudinally extensive transverse myelitis, our initial suspicion was highest for an underlying autoimmune or infectious disease. However, this case teaches us to not presume all transverse myelitis or enhancing spinal cord lesions must be from an inflammatory, neoplastic, or infectious condition. A wide differential for this presentation including spinal dAVF is necessary as this is one of the most commonly missed neurovascular diagnoses. T2 flow voids are highly suggestive of this condition, but a spinal angiogram is the gold standard for diagnosis.

Acute Occlusion of the Abdominal Aorta Associated with Left Ventricular Thrombus: A Case Report.

BACKGROUND Acute aortic occlusion (AAO) is a rare emergency with high mortality. The typical clinical presentation is the sudden appearance of pain, paralysis, sensory disturbances, and mottling of the lower extremities. The etiology of AAO can be broadly classified into 3 categories: in situ thrombosis, arterial embolism, and occlusion of grafts. AAO is a rare consequence of myocardial infarction in the era of anticoagulation therapy, as part of the management of acute coronary syndrome (ACS). CASE REPORT We report the case of a 65-year-old woman who presented with acute lower extremity pain and weakness after a myocardial infarction 2 weeks earlier. She was on standardized antiplatelet therapy, a high blood D-dimer level was found during a visit to the Emergency Department, a left ventricular mural thrombus was detected using bedside ultrasound, and computed tomography angiography revealed thrombotic occlusion of the abdominal aorta. AAO disease was diagnosed, but the patient refused further treatment and died after 7 days of follow-up. CONCLUSIONS In recent years, anticoagulation has become part of the standard of care for patients with myocardial infarction or atrial fibrillation, which has led to a lower incidence of arterial embolism leading to AAO than in situ thrombosis. Depending on the type of occlusion, there are also differences in the surgical approach. A computed tomography angiography of the abdomen should be performed on all patients in whom AAO cannot be ruled out. Timely diagnosis and prompt surgical intervention are essential to preventing mortality.

Carotid body paraganglioma metastatic to spine causing cord compression: a case report

BackgroundCarotid body tumors (CBTs) are rare neuroendocrine neoplasms arising near the carotid bifurcation with a reported incidence of 1 to 2 cases in 100,000 patients. Most CBTs are sporadic, benign, slow-growing, and non-secreting, but untreated CBTs can grow locally to compress the nearby blood vessels, esophagus, and airway. Regional metastases can occur in 5% to 10% of cases, but distant metastases are exceedingly rare, occurring in roughly 1–2% of cases. As such, the optimal treatment for metastatic CBTs is not well-defined. We report a rare case of a patient with CBT distant metastases causing spinal cord compression.Case presentationA 40-year-old African American female presented with a right neck mass, headaches, vertigo, tinnitus, hoarseness, and dysphagia. Imaging demonstrated a Shamblin II right neck mass; subsequent transcervical resection and pathology showed a carotid body paraganglioma. The patient recurred locally near the carotid bifurcation, so she underwent Stereotactic Body Radiation Therapy to the recurrent right neck disease. She later re-presented with new onset bilateral lower extremity weakness, dysmetria, and numbness. She was found to have metastatic disease to the thoracic spine causing spinal cord compression. She underwent laminectomy, tumor resection, and posterior fixation followed by adjuvant radiation therapy. She was started on systemic therapy with sunitinib. She eventually progressed with metastatic disease to the right iliac bone, which was treated with palliative radiotherapy. Second line systemic therapy with capecitabine and temozolomide was started. At last follow up, the patient was asymptomatic with stable persistent disease.ConclusionsParagangliomas often exhibit a prolonged interval to the development of progression; locoregional recurrences or rare distant metastases have been reported to occur as many as 20 years from diagnosis. The natural course of CBTs in other cases as well as the present case call into question the idea that CBTs are truly benign; instead CBTs may be indolent tumors with metastatic potential. Treatment choices for CBTs include surgical resection, radiation therapy, and systemic therapy, though the optimal treatment regimen for metastatic CBTs is not well-defined. A more advanced understanding of CBT pathophysiology, disease classification, risk stratification, and treatment options is needed to improve outcomes for patients.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Calcium pyrophosphate deposition disease mimicking spinal neuroarthropathy.

A 75-year-old male with degenerative joint disease status-post T12-L5 fusion five years ago presented with new-onset left lower extremity weakness. He denied any sensory abnormalities, saddle anaesthesia, or dysfunction of the bladder or bowels. Physical examination was notable for 2/5 left quadriceps and gastrocnemius strength, compared with 5/5 on the right side. CT scan shows erosion and sclerosis of the T10 and T11 end plates with gas within the disk space, consistent with Charcot spinal neuroarthropathy (Fig. 1A). Due to the persistent neurological deficits, the epidural mass was resected and a dural patch graft was placed. Histopathology revealed fibrocartilaginous tissue fragments with degenerative changes and deposition of positively birefringent crystals consistent with calcium pyrophosphate deposition disease (CPPD) (Fig. 1B). One month after resection, the patient’s lower extremity weakness had fully resolved. CPPD can mimic many joint pathologies, including gout and osteoarthritis, in atypical locations. In this case, the radiographic appearance of destruction, debris, distention, disorganization, and density changes resembled Charcot neuroarthropathy but in an unexpected location without the typical antecedent sensory neuropathy [1]. This case illustrates that, when radiographic evidence seems to contradict clinical signs and symptoms of joint disease, clinicians should reserve a high index of suspicion for CPPD [2]. Informed consent has been obtained.

Transverse myelitis following bivalent COVID‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Transverse myelitis following bivalent <scp>COVID</scp>‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Primary Lateral Sclerosis

A man in his mid-30s presented with gradually progressive upper and lower extremity weakness most prominent in his right leg. Clinical examination revealed an upper motor neuron pattern of weakness in the extremities, hyperreflexia, and sustained ankle clonus that had progressed over the preceding 2 years. Muscle bulk was normal with unremarkable sensory examination findings. Magnetic resonance imaging revealed marked atrophy of bilateral motor cortices and symmetric increased T2-weighted signal involving the corticospinal tracts (Figure).

Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?

BackgroundVitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. Case ReportA 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. Why Should an Emergency Physician Be Aware of This?Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.

Dual Primary Squamous Cell Carcinoma of the Lung and Adenocarcinoma Rectal

Introduction: Lung and colorectal carcinoma are commonly found in cancer and often cause mortality worldwide. Colorectal cancer (CRC) is the third most common cause of death. Although multiple primary cancers can exist, these two malignancies rarely happen simultaneously. This case report shows a patient diagnosed with squamous cell carcinoma of the lung and rectal adenocarcinoma with metastases to the liver, ocular, and cerebrum. Case: A 54-year-old woman came with chest pain accompanied by persistent and progressive breathing difficulty, cough, loss of appetite, and weight loss of almost 15 kg. The patient experienced sudden lower and upper extremities weakness two weeks after being hospitalized. The patient also experienced blurred vision and swelling of the eyes. At that time, the patient had an endoscopy procedure, and the biopsy showed colitis with severe dysplasia. Based on clinical and radiologic findings, the patient had lung and colon cancer. Conclusion: Dual primary carcinoma rarely happens, and metastases from different neoplasms are difficult. Warren and Gates’ criteria could be used to diagnose dual primary carcinoma, especially if diagnostic studies could not be performed. Signal that the hedgehog gene is still active when the neonate is born is suspected of causing these carcinomas.

A CASE REPORT OF HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES

Hereditary neuropathy with liability to pressure palsy is an autosomal dominant demyelinating disorder. In individuals with numerous compressive neuropathies, hereditary neuropathy with liability to pressure palsies (HNPP) should be taken into consideration.Here We present a case of 49-year-old man who exhibited right upper and lower extremity weakness with tingling and numbness of right upper limb and lower limb. Electrophysiological studies showed widespread, multifocal, motor &gt; sensory, chronic peripheral neuropathy affecting the upper and lower limbs.Type: demyelinating &gt;&gt; axonal.Genetic studies showed Heterozygous deletion of PMP22 gene (upstream, exons 1-5) along with anking regions encompassing TEKT3 and COX10 genes were detected.Treatment for this usually self-limiting illness is debatable, in this instance, patient was managed conservatively following which there is an improvement in patient condition

Preoperative Embolization of Metastatic Spinal Cord Compression with n-Butyl Cyanoacrylate: Safety and Effectiveness in Limiting Blood Loss

PurposeTo evaluate the safety and effectiveness of preoperative embolization with n-butyl cyanoacrylate (nBCA) performed for metastatic spinal cord compression (MSCC) in limiting blood loss (BL). Materials and MethodsIn this institutional review board–approved retrospective study, clinical records from 2017 to 2022 were reviewed. Twenty consecutive patients (11 men and 9 women; mean age, 65.8 years ± 10.0; range, 45–82 years) underwent 21 preoperative spine tumor embolizations with nBCA. Angiograms were used to calculate the percentage reduction in tumor vascularity, and relevant clinical data (levels studied and embolized, fluoroscopy time [FT], reference dose [RD], and Kerma area product [KAP]) and operative data (BL and operative time [OT]) were analyzed. Adverse events and outcomes were recorded. ResultsA median of 2 levels were embolized per procedure (range, 1–5) but 4.9 were studied (range, 1–10). After embolization, tumor blush was reduced by a median of 87.3% (range, 50%–90%). The mean FT was 41 minutes ± 15.4 (range, 16–67 minutes), the mean RD was 1,977.1 mGy ± 1,794.3 (range, 450.2–6,319 mGy), and the mean KAP was 180.5 Gy·cm2 ± 166.2 (range, 30.4–504 Gy·cm2). The adverse event rate was 1 (4.7%) of the 21 embolizations because a weakness of lower extremities related to swelling was observed. Surgery was performed at a mean of 1.4 days ± 1 (range, 1–5 days) after embolization. The mean surgical estimated BL was 432.5 mL ± 328.5 (range, 25–1,100 mL), and the mean OT was 210.1 minutes ± 97.4 (range, 57–489 minutes). ConclusionsPreoperative embolization of tumors resected for MSCC with nBCA is a safe procedure allowing for performance of surgery with acceptable BL.

Differential diagnosis of suddenly developed motor weakness in bilateral lower extremities of a 79-year-old male patient.

Differential diagnosis of suddenly developed motor weakness in bilateral lower extremities of a 79-year-old male patient.

Concomitant Thoracic Spinal Dural Arteriovenous Fistula and Spinal Cavernous Malformation

Both spinal dural arteriovenous fistula (SDAVF) and spinal cavernous malformation (SCM) are uncommon vascular malformations. To our knowledge, such a case of SDAVF concomitant with SCM has not been reported. We encountered a case of a 55-year-old man who had weakness and numbness in both lower extremities. Magnetic resonance imaging showed a round-shape lesion identified as a cavernous malformation in the middle segment of the thoracic spine, with spinal edema and obvious flow voids. Diagnostic angiography revealed an SDAVF fed by the right T7 radicular artery with venous drainage. The intramedullary venous hypertension due to fistula was suspected of inducing the formation of SCM. This case may provide new insight into the pathogenesis of SCM.