Referral of a Patient With Ocular Symptoms to the Stroke Clinic: Not Always the Usual Suspect!

A 77-year-old male attended the stroke clinic as a delayed presentation of a stroke and was initially managed as an occipital stroke. He presented with a gradual decline in visual acuity with an initial suspicion of field deficit over a period of three to four months. He underwent extensive tests including imaging for a confirmatory diagnosis. He had a rapid deterioration of his vision, function, and cognition over a few weeks resulting eventually in death. The case highlights a rare variant of sporadic Creutzfeld-Jakob disease (sCJD), the Heidenhain Variant (HV-CJD). CJD is the commonest of human prion diseases. In HV-CJD, pathologic prions display demyelinating neurotropism for the occipital lobes resulting in visual changes and hallucinations.

Lesson of the month: Cytotoxic lesions of the corpus callosum (CLOCCs) in status epilepticus.

A 26-year-old man was diagnosed with epilepsy a few months previously and admitted with status epilepticus. Computed tomography (CT) of the brain and CT venography were unremarkable. Magnetic resonance imaging (MRI) of the brain showed evidence of possible acute focal infarction in the splenium of the corpus callosum that showed a true restricted diffusion. The patient had no vascular risk factors and no focal neurological deficit on examination to explain the occurrence of an acute infarction. MRI of the brain was repeated 1 month later to assess for progression of that lesion and showed resolution of it. This case highlights the association of cytotoxic lesions of the corpus callosum that show true restricted diffusion with status epilepticus. It also emphasises the importance of medical reasoning and not being solely dependent on diagnostic investigations without reasonably linking them to the history and examination.

JAK 2 positive myeloproliferative neoplasm presenting as stroke, recurrent TIA and isolated third nerve palsy.

A man in his early 40s with no significant vascular risk factors was managed within a period of 6 months for recurrent vascular events: ischaemic stroke, transient ischaemic attack and isolated third nerve palsy. He was extensively investigated throughout the course of illness. The only potential aetiological factor identified was a positive janus kinase 2 (JAK 2) mutation after screening on account of mildly elevated platelet count noted during his most recent admission. Bone marrow aspiration confirmed essential thrombocythaemia. He was started on hydroxycarbamide and has remained relatively symptom free since then.This case reiterates the known associations between thrombosis and JAK 2 mutation even without overt myeloproliferative neoplasms. It also highlights the need for specialists in stroke to consider screening for JAK 2 mutation in a young patient with cryptogenic stroke with or without polycythemia or thrombocytosis.

Posterior circulation stroke presenting as a new continuous cough: not always COVID-19.

A 19-year-old man was admitted with a 2-week history of continuous cough along with a day history of acute onset unsteadiness and hiccups. Given the current pandemic, he was initially suspected to have COVID-19, however he tested negative on two occasions. Subsequent brain magnetic resonance imaging (MRI)confirmed a small left acute and subacute lateral medullary infarction with chest X-ray suggesting aspiration pneumonia with right lower lobe collapse. This is a distinctive case of posterior circulation stroke presenting with a new continuous cough in this era of COVID-19 pandemic. We anticipate based on MRI findings that his persistent cough was likely due to silent aspiration from dysphagia because of the subacute medullary infarction. It is therefore imperative that healthcare workers evaluate people who present with new continuous cough thoroughly to exclude any other sinister pathology. We should also be familiar with the possible presentations of posterior circulation stroke in this pandemic era.

Capecitabine induced vasospastic angina.

Cardiotoxicity is a recognised side effect of intravenous 5-fluorouracils. In the two case reports described we demonstrate similar cardiotoxic side effects seen with the use of capecitabine. With the increasing use of oral adjuvant chemotherapeutic agents, capecitabine should be used with caution in those patients with existing coronary artery disease.