Spontaneous Papillary Muscle Rupture: An Uncommon Presentation in the Absence of Myocardial Infarction.

BACKGROUND Papillary muscle rupture (PMR) is a rare complication of myocardial infarction (MI); experiencing PMR without MI makes it even more uncommon, thereby complicating its diagnosis. Therefore, we report a case of spontaneous PMR to raise awareness of this entity. CASE REPORT A 48-year-old man with type 2 diabetes presented to the Emergency Department (ED) after experiencing sudden shortness of breath that began the day before. He had no history of chest trauma, fever, chills, or ischemic chest pain. His vital signs showed stable blood pressure and mild tachycardia. The patient had hypoxemia that did not respond to use of a non-rebreather mask (oxygen saturation 70%). Upon examination, he had increased respiratory rate, altered sensorium, no lower-limb edema, and his chest auscultation revealed bilateral crackles. Chest radiography showed pulmonary edema. Two electrocardiograms (ECG) showed no signs of ST elevation myocardial infarction (STEMI) or RV strain. The patient was intubated but remained hypoxic despite maximum ventilation settings. Transthoracic echocardiography (TTE) performed immediately thereafter revealed acute severe mitral regurgitation with evidence of PMR. A multidisciplinary team approach was adopted early in this case, which resulted in a positive outcome. Eventually, mitral valve replacement was performed, and the patient was discharged home after 17 days, with a favorable neurological outcome. CONCLUSIONS We report a very rare case of spontaneous PMR in a middle-aged man with no evidence of MI, infective endocarditis, or preceding chest trauma. It shows the importance of adopting an early multidisciplinary team approach and showcases the abilities of emergency medicine physicians in early recognition.

Utilizing Triage Data for Medical Imaging Studies in the Emergency Department.

The use of radiological images is widespread in the emergency department (ED) as physicians commonly rely on them during initial evaluations to confirm diagnoses, contributing to prolonged waiting times. This study aimed to determine the relationship between commonly gathered triage data and the need for radiological imaging. Data were collected from electronic charts that contained routinely collected hospital data at the time of triage in the King Abdulaziz Medical City (KAMC) in Riyadh ED. The binary logistic regression results demonstrated a statistically significant relationship between age and radiological imaging ordered in the ED. Each one-unit increase in age corresponded to a 0.983-fold increase in the likelihood of ordering radiological imaging (odds ratio: 0.983, 95% confidence interval: 0.972-0.995, p = 0.004). In contrast, hypertension, diabetes, and heart failure were independent predictors of the need for radiological imaging in the ED (p >0.05). Patient data that are immediately available during ED triage can be used to predict the need for radiological imaging during ED visits. Such models can identify patients who may require radiological imaging during ED visits and expedite patient disposition.

An Unusual Cause of Cauda Equina Syndrome: Lumbar Epidural Venous Engorgement.

BACKGROUND Epidural venous plexus (EVP) engorgement occurs due to many conditions, so it can be easily misdiagnosed. This becomes problematic when the diagnosis requires prompt treatment for a good outcome, especially when it results in cauda equina syndrome (CES). We report a case of extensive iliocaval thrombosis leading to epidural venous plexus and ascending lumbar vein engorgement as an outcome of deep venous thrombosis (DVT) due to probable adverse effects of oral combined contraceptive pills (OCCP). CASE REPORT A 42-year-old woman presented to a rural medical facility with bilateral lower-limb swelling and skin darkening for 2 days. She was transferred to a tertiary medical facility where her condition deteriorated to severe CES. A lower-limbs ultrasonography confirmed the presence of extensive DVT extending to the lower segment of the inferior vena cava. Spine magnetic resonance imaging showed abnormal enhancement of the conus medullaris with thick enhanced cauda equina nerve roots, consistent with a possible case of Guillain-Barré syndrome. However, there was engorgement of the EVP extending to the ascending lumbar, azygos, and hemiazygos veins, which was misdiagnosed. The patient was managed immediately with low-molecular-weight heparin and steroids. She died 4 weeks after admission due to hospital-acquired pneumonia and acute respiratory distress syndrome, probably due to the high dose of steroids. CONCLUSIONS Acute CES has a wide differential diagnosis. This report describes an unusual cause of CES and emphasizes the importance of early recognition to avoid misdiagnosis and management delay. Early identification of this clinical entity markedly decreases morbidity and mortality and thus improves the prognosis. Likewise, underlying causing factors such as venous congestion due to OCCP-related DVT should be considered in the diagnosis.

Nonaneurysmal Perimesencephalic Subarachnoid Hemorrhage as an Atypical Initial Presentation of Cerebral Venous Sinus Thrombosis: A Case Report.

BACKGROUND Subarachnoid hemorrhage is rarely the first presentation of cerebral venous sinus thrombosis. This case study emphasizes the presentation of perimesencephalic subarachnoid hemorrhage due to cerebral venous sinus thrombosis and the importance of neurovascular imaging for reliable diagnosis of nonaneurysmal perimesencephalic subarachnoid hemorrhage due to cerebral venous sinus thrombosis. CASE REPORT We describe a case of cerebral venous sinus thrombosis manifesting initially as subarachnoid hemorrhage. Non-contrast computed tomography showed evidence of subarachnoid hemorrhage involving the prepontine and suprasellar cisterns. Cerebral convexities were totally spared while parenchymal microbleeding was observed in the midbrain. The diagnosis was confirmed by magnetic resonance arteriography and venography. Treatment included low molecular weight heparin and warfarin therapy to restore the international normalization ratio of the patient to 2.5, followed by oral warfarin therapy for 3 months. CONCLUSIONS Cerebral venous sinus thrombosis manifesting initially as subarachnoid hemorrhage is rare. Subarachnoid hemorrhage caused by cerebral venous sinus thrombosis has been reported previously to be confined to the cerebral convexities, sparing the basal cistern. However, this is not always the case where the radiological confirmation suggests the occurrence of nonaneurysmal perimesencephalic subarachnoid hemorrhage.

Primary Occipital Ewing's Sarcoma with Subsequent Spinal Seeding.

Ewing's sarcoma is a primary bone cancer that mainly affects the long bones. This malignancy is particularly common in pediatric patients. Primary cranial involvement accounts for 1% of cases, with occipital involvement considered extremely rare. In this case study, primary occipital Ewing's sarcoma with a posterior fossa mass and subsequent relapse resulting in spinal seeding is reported. A 3-year-old patient presented with a 1-year history of left-sided headaches, localized over the occipital bone with progressive torticollis. Computed tomography (CT) imaging showed a mass in the left posterior fossa compressing the brainstem. The patient then underwent surgical excision followed by adjuvant chemoradiation therapy. Two years later, the patient presented with severe lower back pain and urinary incontinence. Whole-spine magnetic resonance imaging (MRI) showed cerebrospinal fluid (CSF) seeding from the L5 to the S4 vertebrae. Primary cranial Ewing's sarcoma is considered in the differential diagnosis of children with extra-axial posterior fossa mass associated with destructive permeative bone lesions. Although primary cranial Ewing's sarcoma typically has good prognosis, our patient developed metastasis in the lower spine. Therefore, with CNS Ewing's sarcoma, screening of the entire neural axis should be taken into consideration for early detection of CSF seeding metastasis in order to decrease the associated morbidity and mortality.

Homonymous Superior Quadrantanopia due to Erdheim-Chester Disease with Asymptomatic Pituitary Involvement.

Polyostotic sclerosing histiocytosis, also known as Erdheim-Chester disease (ECD), is a rare form of non-Langerhans histiocytosis. ECD has wide clinical spectrums which mainly affect skeletal, neurological, dermatological, retroperitoneal, cardiac, and pulmonary manifestations. Here we describe a case of ECD in a 45-year-old female who presented initially with bilateral knee pain and homonymous superior quadrantanopia progressed to ophthalmoplegia and complete visual loss of the left eye over a period of one year. Plain X-ray of both knees showed bilateral patchy sclerosis of the distal femur and upper parts of the tibiae. Initial brain magnetic resonance imaging (MRI) showed bilateral enhancing masses in the temporal lobes anterior to the temporal horns, thickening of the pituitary stalk, partially empty sella, and involvement of the left cavernous sinus one year later. Our case is a peculiar case of ECD initially presented with unilateral homonymous superior quadrantanopia due to involvement of the visual apparatus in the mesial temporal lobe which progressed to unilateral ophthalmoplegia and total visual loss secondary to involvement of the cavernous sinus. Thus, the diagnosis of ECD should be kept in mind in the presence of bilateral bone sclerotic lesions.

Prevalence of Dietary Supplements Use among Gymnasium Users.

Background. Several studies showed that regular gymnasium users use various dietary supplements without comprehension of their potential risks. Objective. To determine the prevalence and dietary supplement intake and assess the awareness of supplement use among regular gymnasium users in Riyadh, Saudi Arabia. Methods. A descriptive cross-sectional study was conducted among regular gymnasium users in Riyadh, Saudi Arabia, between April 2015 and June 2015. A validated structured questionnaire was used. Results. The study included 299 participants. Of these 113 (37.8%) were dietary supplements users and this was more common among males than females (44.7% versus 16.4%). Gender based analysis showed that males were exercising more frequently than females and the type of cardiovascular exercise was more among them. The most commonly used supplements were whey protein (22.1%), amino acids (16.8%), multivitamins (16.8%), creatine (11.5%), and omega 3 (11.5%). The reasons for taking dietary supplements were to improve body shape (47.7%), increase health (44.2%), and improve performance (41.5%). Conclusion. Most of the information about supplements was obtained from unreliable sources. More studies are needed to better understand supplements use and their impact on health in Saudi Arabia.