Paracentral Bitemporal Hemianopsia and Acquired Supranuclear Ocular Motor Paresis Following Cardiac Surgery.

Acquired supranuclear ocular motor paresis (ASOMP) is a rare complication following cardiac surgery, characterized by limited voluntary eye motility. The exact cause and development of ASOMP after cardiac surgery remain unclear. We report a case of ASOMP with paracentral bitemporal hemianopsia with optic atrophy after cardiac surgery, which, to our knowledge, is novel. The patient demonstrated bilateral ophthalmoplegia, with gradual improvement in voluntary smooth pursuit but persistent impairment in saccadic eye movements. Interestingly, the patient showed improved proprioceptive-driven pursuit of their own hand compared to pursuit or saccades following an examiner's hand. The visual field examination revealed a bilateral paracentral temporal hemianopic field defect. The underlying mechanisms of ASOMP and potential chiasmal ischemia in this case remain unknown. Clinicians should be aware of the possibility of ASOMP following cardiac surgery, with potential slow improvement over time.

Intra-Peritoneal Pseudocyst as a Rare Complication After Peritoneal Dialysis: The Use of a Staged Surgical Approach in Management.

Despite its numerous benefits, peritoneal dialysis (PD) can rarely result in dangerous and even life-threatening complications, including peritonitis, hernias, encapsulating peritoneal sclerosis (EPS), and rarely peritoneal pseudocysts. Herein, we present a rare case of a giant intra-peritoneal pseudocyst that presented four months following the discontinuation of a 5-year course of complicated PD. Despite the initially successful drainages, the patient's symptoms continued to recur, and the imaging findings were concerning for underlying neoplastic processes. As such, a staged surgical approach was performed, starting with a diagnostic laparoscopy and was subsequently followed with cyst excision and marsupialization to the peritoneal cavity. While previous reports of such rare pseudocyst have been documented in the literature as a complication of PD, to our knowledge, this is the second case of pseudocyst formation to occur months after the discontinuation of PD therapy. This case emphasizes the importance of close follow-up in PD patients and showcases how a staged surgical approach can be utilized to accurately diagnose and manage such complicated cases.

Antibiotic Stewardship and Inpatient Clostridioides difficile Testing in Solid Organ Transplant Recipients: The Need for Multilevel Checks and Balances.

BACKGROUND: Diarrhea among recipients of solid organ transplants is a commonly encountered problem and is often multifactorial in etiology. Owing to the combination of perioperative antibiotic administration and the immunosuppressed status of transplant recipients, a high degree of suspicion for Clostridioides difficile (C. difficile) colitis is prudent. The purpose of this study is to demonstrate the association of an institutional integrated stewardship program with C. difficile testing practices after abdominal solid organ transplantation. METHODS: Starting in July 2017, a diagnostic stewardship was enacted in our institution requiring the ordering provider to answer a series of questions within the electronic medical record before ordering a C. difficile toxin test. The charts were reviewed for all solid organ transplant recipients on whom a test was ordered between January 2016 and September 2019. RESULTS: Orders for C. difficile toxin per quarter significantly decreased in the postintervention era (18 vs 8.5, P = .038). Median cost of inpatient treatment and days of therapy per thousand patient days was significantly lower in the postintervention era (median cost, $2,944.55 vs $416.92; P = .01) (days of therapy per thousand patient days, 521.9 vs 300.5; P < .01). Quarterly rates of negative tests were similar between the pre- and postintervention eras (65% vs 73%, P = .38). CONCLUSIONS: Although no orders were blocked based on the responses, this multilevel intervention was associated with a 47% decrease in C. difficile testing without effecting the rate of negative testing. These results suggest that we have achieved significant cost savings, in testing and isolation, without sacrificing critical aspects of clinical care.

Massager-Induced Anterior Subcapsular Cataracts and Keratoconus in a Patient With Multiple Epiphyseal Dysplasia.

Multiple epiphyseal dysplasia (MED) is a phenotypically heterogeneous disease associated with orthopedic abnormalities among other systemic manifestations. While the spectrum of ocular abnormalities in this disorder is yet to be fully reported, MED has been rarely associated in the literature with the development of cataracts and keratoconus. Here, we report a case of bilateral massager-induced anterior subcapsular cataracts and keratoconus in a 46-year-old female with MED. This case presentation aims to prevent similar occurrences of inappropriate massaging device use and highlight potential ocular findings in MED patients.

Magnetic Resonance Imaging Enhancement Two Years Post Lumpectomy: An Unusual Timing for Fat Necrosis.

Breast fat necrosis is a common benign inflammatory process in the post-surgical or post-traumatic breast. It is often clinically silent with a wide spectrum of imaging findings that range from the characteristically benign to the suspiciously malignant. These characteristics pose a significant challenge for clinical providers to identify this common entity and distinguish it from more ominous diagnoses, especially in patients with a prior history of breast malignancies. We present a challenging case of fat necrosis with suspicious imaging features and an unusual timeline, occurring in the second year following lumpectomy. Radiologists' awareness of this condition and its varying presentations is of critical importance to appropriately guide evaluation of suspicious magnetic resonance imaging enhancements.

Torsion of the Epididymal Appendage in a Child.

The epididymal appendage, or the appendix epididymis, is a developmental remnant of the mesonephric duct that sprouts from the head of the epididymis. Due to its pedunculated anatomical configuration, the epididymal appendage is prone to torsion and can become a rare cause of an acute scrotum. Given its often challenging and atypical presentation, high clinical suspicion and Doppler ultrasonography are needed to guide diagnosis. We report a challenging case of epididymal appendage torsion that required prompt surgical exploration to accurately diagnose. Awareness of this condition and its radiological findings can play an important role in reaching an accurate diagnosis and avoiding surgical intervention.

Challenging Biopsy of a Benign Breast Lesion With Malignancy Features: Cystic Apocrine Metaplasia.

Apocrine metaplasia is a benign epithelial change that primarily occurs in the terminal lobule, where the normal cuboidal epithelium is replaced by secretory apocrine cells with abundant eosinophilic cytoplasm. Even with the most recent advances in imaging modalities, radiographic findings can sometimes be equivocal in the characterization of breast lesions, leading to the necessity of tissue sampling. We report a challenging case of biopsy-proven cystic apocrine metaplasia that presented in the posterior depth with initially suspicious imaging findings concerning for malignancy. Understanding the histological basis of apocrine metaplasia and correlating it with recognized imaging features may increase diagnostic accuracy and reduce tissue resampling due to discordant histopathological results.