The effect of ocrelizumab on Balo's tumefactive lesion: A case report.

Balo's concentric sclerosis (BCS) is a rare subtype of multiple sclerosis. Advanced MRI metrics, such as magnetization transfer ratio (MTR), fractional anisotropy (FA), mean diffusivity (MD), and the ratio of total N-acetylaspartate concentration/total creatine concentration (tNAA/tCr) using proton magnetic resonance spectroscopy (1H-MRS), are commonly used in research studies to investigate the effect of a disease modifying therapy (DMT). We report a patient diagnosed with BCS, receiving ocrelizumab, and provide a comparison of the lesion volume, T1-gadolinium lesion volume, MTR, FA, MD, and MRS metrics at baseline, 6- and 12-month follow-up. There was a reduction in Balo's lesion volume on fluid-attenuated inversion recovery (FLAIR) imaging observed in our patient from baseline (23.925 mL) to 12-month follow-up (2.391 mL), with the largest decrease from baseline to 6-month follow-up (3.650 mL). There was no T1-gadolinium enhancement seen at month 6 and 12. The MTR of the lesion did not change significantly (baseline = 50.9%, 6-month = 49.9%, 12-month =50.1%) but the FA increased from 0.188 (at baseline) to 0.304 (at 6 months), while the 12-month follow-up FA was 0.297. We also noted a reduction in MD from baseline (1.333 × 10-3 mm2/s) to 6-month follow-up (1.037 × 10-3 mm2/s), while the 12-month follow-up MD was 1.086 × 10-3 mm2/s. There was a 10.3% increase in tNAA/tCr from 1.583 (at month 0) to 1.747 (at month 12). Our results demonstrate for the first time a direct effect of ocrelizumab on BCS lesions. To validate our findings, more observations are needed in a larger group of BCS patients.

Angiosarcoma: A Rare Malignancy Linked to Chemical Exposures.

Angiosarcoma is an exceptionally rare malignancy that accounts for less than 1% of all sarcomas. This case describes a 90-year-old male veteran who presented with a hematoma from a traumatic head injury. This then progressed to an ulcerated bleeding lesion that measured 2.5 cm in diameter with pearly borders and granulation tissue. CT scan of the head and skin biopsy were consistent with the diagnosis of cutaneous angiosarcoma. The patient may have unique exposures from the military training site Camp Lejeune including tetrachloroethylene (PCE), trichloroethylene (TCE), trans-1,2-dichloroethylene, and vinyl chloride predisposing to angiosarcoma. The patient underwent palliative radiation without obvious complications. This case presents an opportunity for further evaluation and understanding of the effects of these exposures and the implications for the health of veterans and aging populations. Patient outcomes may be improved with earlier diagnosis and aggressive treatment.

Normal ESR, CRP and Platelet Count in Giant Cell Arteritis and Polymyalgia Rheumatica: A Diagnostic Conundrum.

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are both rheumatological diseases of the elderly with a strong association with each other and which rarely present with normal inflammatory markers. Here we present the case of a 61-year-old Caucasian woman who had typical symptoms of both diseases. At the time of presentation, her blood work showed normal inflammatory markers, but because of the high clinical suspicion for GCA, a temporal artery biopsy was done which was positive for giant cells and disruption of the internal elastic lamina. Our patient responded very well to treatment with oral steroids and steroid-sparing medication and was able to return to her normal life without experiencing any complications of the disease. By sharing our case, we aim to increase the awareness of medical personnel regarding the importance of focusing on the clinical presentation as well as the laboratory and pathological aspects of diagnosing GCA and PMR. LEARNING POINTS: Normal levels of inflammatory markers like C-reactive protein and the erythrocyte sedimentation rate do not rule out the diagnosis of giant cell arteritis (GCA).We aim to increase clinician recognition and awareness of other parameters, particularly the clinical presentation, that should be considered when diagnosing GCA or polymyalgia rheumatica.If the index of suspicion for the disease is high, it is crucial to start treatment as early as possible for better management and to avoid harmful complications.

Gout gone awry: The importance of proper diagnosis.

Gout is the best-known type of arthritis with a prevalence of 1%-3% in the western world (Therapeutic Advances in Musculoskeletal Disease, 6, 2014 and 131; Journal of Advanced Research, 8, 2017 and 495). Although it is well understood, there is growing evidence of the misdiagnosis of gout from other forms of arthritis. These errors lead to delay in accurate diagnosis (Journal of Advanced Research, 8, 2017 and 495).

Creutzfeldt-Jakob disease as a cause of dementia.

Creutzfeldt-Jakob disease (CJD) is a rapidly progressive, fatal neurodegenerative disorder belonging to the family of transmissible spongiform encephalopathies. The disease is believed to be caused by an abnormal isoform of a cellular glycoprotein known as the prion protein. Our patient is an 84-year-old Caucasian man who presented to the geriatric clinic for evaluation of short-term memory loss and decreased concentration which started 3 months prior to initial evaluation. Rapid progression of dementia demonstrated by severe impairment in tasks with a predominantly visual component, including visual scanning, perceptual reasoning and visual spatial processing. Diagnosis of CJD was determined by characteristic ribboning on brain MRI as well as notable real-time quaking-induced conversion on cerebrospinal fluid.