Seizure in the emergency department: Finding the zebra among the horses

Aortic dissection (AD) is a life-threatening emergency that mandates early and precise diagnosis. Seizure as an initial and exclusive manifestation of AD is extremely rare. The prevalence of this is sparsely available in the literature. We report the case of a 68-year-old male patient where the patient presented with seizures and discrepancy of blood pressures in the upper limbs. AD was suspected in this case with an atypical presentation

Clinics in diagnostic imaging (182). Acute descending aortic dissection with aortic root retrograde extension

A 77-year-old man presented with acute-onset severe chest pain radiating to the back and elevated blood pressure. Multiphasic computed tomography of the aorta revealed an intimal tear in the descending thoracic aorta which extended both retrograde to the aortic root and antegrade to the infra-renal abdominal aorta. The initial impression, that the images showed a Stanford type B aortic dissection, was because the portion of the false lumen that extended beyond the aortic arch remained unopacified even on delayed phases, making it challenging to assess the extent of the dissection flap. Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. This case highlights the need for early and accurate imaging assessment of acute aortic dissection, including accurate identification of the site of intimal tear and the extent of the dissection flap.

Nodular scleritis as a presenting feature of Takayasu’s arteritis.

Takayasu, a Japanese ophthalmologist, was the first to describe the disease in 1908.[1] Takayasu’s disease has an incidence of 2.6/million/year with a female to male ratio of 9:1.[2] Takayasu’s retinopathy (TR) is the most common ophthalmic manifestation. It reflects ocular hypoperfusion and is manifested by microaneuryms, arteriovenous anastomosis, and neovascular complications. Hypertensive retinopathy is less frequently encountered. Retinal arterial occlusion was recently reported as well.[3] Smith and Rosenbaum suggested a real association between Takayasu’s arteritis (TA) and scleritis because of the strong temporal relationship between the two conditions in their patient. Jain et al.[4] have published a report that describes a case of TA occurring in association with scleritis. Case Report A 44‑year‑old, (Indian) female was referred to our rheumatology clinic by an ophthalmologist with a history of fluctuating redness in both eyes with ocular pain. She was diagnosed as nodular scleritis and referred for systemic evaluation. On inquiry, she also gave a history of polyarthritis, lasting for 2–3 weeks, 10 years back, it had responded to symptomatic treatment. She also gave a history of intermittent claudication in the right arm, especially during activities such as washing clothes or utensils, for the past 10 years. She was a nonsmoker and had taken oral nonsteroidal anti‑inflammatory drugs for arm pain from her general practitioner (GP) without much relief. On inquiry, she also gave a history of recurrent headaches. She did not have any sinusitis, nasal discharge, hemoptysis, skin rash, and fever or weight loss. On ocular examination, her visual acuity was 20/20 oculus uterque and there was evidence of nonnecrotizing nodular scleritis in her right eye [Fig. 1] without any evidence of thinning bilaterally. There was no evidence of retinal vasculitis on dilated fundoscopy. On examination, her right radial pulse was absent without any subclavian bruit. The blood pressure in the right upper limb was not recordable, whereas in the left upper limb it was 140/80 mmHg, and both lower limbs 150/90 mmHg. Her investigations revealed hemoglobin 12 g/dl, white cells ‑ 5600/cu mm, erythrocyte sedimentation rate (ESR) of 90 mmHg, and C‑reactive protein (CRP) was 6.3 mg/l (normal <6). Rheumatoid factor, anti‑cyclic citrullinated peptide, antineutrophil cytoplasmic antibody (ANCA), and antinuclear antibody were negative, urine examination and biochemistry were normal. Serum venereal disease research laboratory was also negative. These reports add further evidence, in addition to the history and examination, to the lack of any other collagen vascular disease whatsoever. In view of the above findings, a working diagnosis of Takayasu’s disease was made, which was further confirmed on a computed tomography (CT) aortogram [Fig. 2]. It showed thickening of the right brachiocephalic artery, with complete occlusion of the right subclavian artery, origin of the right vertebral artery was not seen. The patient was started on oral prednisolone 1 mg/kg body weight along with injection methotrexate 25 mg/week, with folate supplements. Prednisolone was tapered by 5 mg/week after a month till 20 mg/day, then 2.5 mg/week till 7.5 mg daily, calcium supplements and alendronate 35 mg/week. Her attacks of recurrent scleritis subsided [Fig. 3], but right arm claudication persisted for which she underwent right subclavian artery stenting, with moderate symptomatic improvement. Discussion TA is a rare chronic obliterative vasculitis affecting the aorta and its major branches. It is more commonly seen in females of reproductive age and is more prevalent in Asian and Latin American countries. Although the pathogenesis has not been entirely elucidated, TA is considered to be a T‑cell‑mediated granulomatous vasculitis.[5]