The crucial role of gadolinium-enhanced MRI in a case of amaurosis fugax - a case report and literature review.

Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital space, such as pain, disc edema, ophthalmoplegia, proptosis. However, not all patients present with such suggestive symptoms, requiring a thorough assessment. We report the case of a young male admitted to our hospital for recurrent episodes of monocular blindness. Amaurosis fugax is a well-known presentation of transient ischemic attacks (TIA) and it was ruled out. Gadolinium-enhanced MRI revealed a typical aspect of optic perineuritis. It was mandatory to consider all possible causes of secondary optic perineuritis as they all represent serious clinical conditions, even if the idiopathic form is more frequent. The clinical and paraclinical evaluation of the patient excluded an underlying disease and primary optic perineuritis was diagnosed. Corticosteroid therapy is usually curative and a course of methylprednisolone was initiated for our patient with good outcome. However, response to treatment is not diagnostic as both primary and secondary optic perineuritis are normally responsive, hence thorough differential diagnosis is necessary.

Risk factors for the outcome after thrombolysis in acute ischemic stroke - the prominent role of kidney dysfunction: A retrospective cohort observational study.

A complex interplay of factors reflecting the general biological, cardiovascular, neurological, renal, and metabolic status of patients influences the outcome of thrombolysis in stroke patients. This is a retrospective cohort observational study aimed to determine the importance of kidney dysfunction among these factors. Data (demographic, lifestyle, physical examination, laboratory, imaging, including metabolic and cardiovascular risk factors and comorbidities, neurological scores, and outcomes) of all stroke patients who underwent thrombolysis have been registered since January 1, 2016, in an online database. A total of 296 patients registered until December 31, 2020, were included in the study. The National Institutes of Health Stroke Scale, modified Rankin scale, Barthel index, percentage of hemorrhagic transformation, and in hospital death were used to evaluate the neurological status and outcomes of the patients. Regression analysis, Mann-Whitney test, Fisher exact test, logistic regression, and multivariate analysis were used for statistical analysis. Kidney dysfunction, as reflected by the estimated glomerular filtration rate, was associated with in hospital death and all but one of the neurological scores. Other risk factors most frequently associated with neurological scores were age, international normalized ratio, and cognitive decline. Multivariate analysis revealed estimated glomerular filtration rate (as determined by chronic kidney disease-EPI equation) as a determinant for all but one of these scores, and as the most important determinant for most of them, except for those reflecting the pre-intervention neurological status of the patient. Kidney dysfunction seems to be the most important determinant of the outcome of thrombolysed stroke patients, a result obtained by no other study.

Cardiovascular Calcifications Are Correlated with Inflammation in Hemodialysis Patients.

Background and Objectives: The main cause of morbidity and mortality in hemodialysis patients is cardiovascular disease, which is quite common. The main objective of our study was to investigate the relationship between oxidative stress, inflammation, and vascular and valvular calcifications in hemodialysis patients. Materials and Methods: This observational study had 54 hemodialysis patients, with an average age of 60.46 ± 13.18 years. Cardiovascular ultrasound was used to detect and/or measure aortic and mitral valve calcifications, carotid and femoral atheroma plaques, and common carotid intima-media thickness. The aortic calcification score was determined using a lateral abdomen plain radiograph. The inflammatory, oxidative, metabolic, and dietary statuses, as well as demographic characteristics, were identified. Results: There were significant correlations between the levels of IL-6 and carotid plaque number (p = 0.003), fibrinogen level and aortic valve calcifications (p = 0.05), intima-media thickness (p = 0.0007), carotid plaque number (p = 0.035), femoral plaque number (p = 0.00014), and aortic calcifications score (p = 0.0079). Aortic annulus calcifications (p = 0.03) and intima-media thickness (p = 0.038) were adversely linked with TNF-α. Nutrition parameters were negatively correlated with atherosclerosis markers: number of carotid plaques with albumin (p = 0.013), body mass index (p = 0.039), and triglycerides (p = 0.021); number of femoral plaques with phosphorus (0.013), aortic calcifications score with albumin (p = 0.051), intima-media thickness with LDL-cholesterol (p = 0.042). Age and the quantity of carotid plaques, femoral plaques, and aortic calcifications were linked with each other (p = 0.0022, 0.00011, and 0.036, respectively). Aortic annulus calcifications (p = 0.011), aortic valve calcifications (p = 0.023), and mitral valve calcifications (p = 0.018) were all associated with an increased risk of death. Conclusions: Imaging measures of atherosclerosis are adversely connected with dietary status and positively correlated with markers of inflammation and risk of mortality.

Critical Damage of Lung Parenchyma Complicated with Massive Pneumothorax in COVID-19 Pneumonia.

It is already known that Coronavirus disease 2019 (COVID-19) may lead to various degrees and forms of lung parenchyma damage, but some cases take a strikingly severe course that is difficult to manage. We report the case of a 62-year old male, non-obese, non-smoker, and non-diabetic, who presented with fever, chills, and shortness of breath. The infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was diagnosed by real-time Polymerase Chain Reaction. Although the patient had been vaccinated with 2 doses of Pfizer-BioNTech COVID-19 vaccine 7 months earlier and had no risk factors for a severe outcome, serial computed tomography (CT) scan revealed lung involvement progressively extending from an initial 30% to 40% to almost 100% 2.5 months later. The spectrum of lung lesions included at first only ground-glass opacities and some tiny emphysema bullae, but later also bronchiectasis, pulmonary fibrosis, and large emphysema bullae as post-COVID-19 pulmonary sequelae. For fear of severe evolution of superimposed bacterial infection (Clostridoides difficile enterocolits and possibly bacterial pneumonia) the administration of corticosteroids was intermittent. Massive right pneumothorax secondary to bulla rupture, possibly favored by the indispensable high flow oxygen therapy, led to respiratory failure compounded by hemodynamic instability, and ultimately to the patient's final demise. COVID-19 pneumonia may cause severe lung parenchyma damage which requires long-term supplemental oxygen therapy. Beneficial or even lifesaving as it might be, high flow oxygen therapy may nonetheless have deleterious effects too, including the development of bullae that may rupture engendering pneumothorax. Corticosteroid treatment should probably be pursued despite superimposed bacterial infection to limit the viral induced damage to lung parenchyma.

The cutoff value of presepsin for diagnosing sepsis increases with kidney dysfunction, a cross-sectional observational study.

As presepsin levels increase with kidney dysfunction (KD), our aim was to establish cutoff points for presepsin adapted to the level of KD in order to avoid bacterial infection overdiagnosis, antibiotic overprescription, and risk of bacterial resistance. This is a unicenter retrospective study, which included all patients admitted on an emergency basis to 2 departments of a teaching hospital during a 2-year interval to whom presepsin level was determined at the emergency department prior to admission. Serum creatinine (sCrt) was employed to estimate the severity of KD using 3 thresholds (1.5, 2, and 4 mg/dL) resulting in 4 degrees of severity: KD_1, KD_2, KD_3, KD_4. There is an ascending exponential relationship between presepsin and sCrt: presepsin = 600.03e0.212sCrt. Presepsin levels are significantly different between the patients with KD_1, KD_2, KD_3, and KD_4. In the receiver operating characteristic curves exploring the usefulness of presepsin in sepsis diagnosis, the area under the curve was satisfactory for KD_1 (0.78), KD_2 (0.78), and KD_3 (0.82), but unacceptably low for KD_4 (0.59), while the optimal cutoff points were (depending on the computational method) 700/ 982, 588/ 1125, 1065, and 2260 pg/mL for KD_1, KD_2, KD_3, and KD_4 respectively. The threshold for abnormal presepsin should be about 600, 1000, and 1300 pg/mL in patients with KD_1, KD_2, and KD_3, respectively. In patients with KD_4, presepsin has a poor discriminating power for sepsis diagnosis. If, notwithstanding, it is used for this purpose, the cutoff point should be at least at 2200.

Giant Renal Artery Aneurysm With Hydronephrosis and Severe Atrophy of the Renal Parenchyma: Case Report and Literature Review.

Background: It is known that renal artery aneurysms may lead to hydronephrosis, but utter shrinking of the renal parenchyma due to a giant renal artery aneurysm has not yet been reported. This report is of an 88-year-old woman with resistant hypertension, hydronephrosis, and renal atrophy due to a giant saccular aneurysm of the left renal artery. Case Report: The patient presented with 2 weeks of worsening low back pain on the left side and resistant hypertension. The discovery of a left flank mass on physical examination, lead to the ultrasound detection of a para-aortic mass and a cyst-like partially septate structure replacing the left kidney. Thereafter, a contrast-enhanced computed tomography scan revealed a giant saccular aneurysm of the left renal artery causing severe hydronephrosis with severe parenchymal thinning. The extreme parenchymal atrophy of the left kidney made it an unlikely culprit of resistant hypertension, therefore the interventional radiologist considered that an endovascular attempt to re-establish the patency of the left renal artery would have scarcely produced any benefit. Given the advanced age of the patient, the vascular surgeon considered that risk of a nephrectomy outweighed the benefit, in agreement with the patient's unwillingness to accept an invasive intervention. Therefore, she was discharged with blood pressure lowering and pain relief medication and was thereafter lost to follow-up. Conclusion: To our knowledge, this is the most severe kidney parenchymal shrinking in association with a renal artery aneurysm reported in the literature.

Pathophysiology of sepsis-induced cholestasis: A review.

Sepsis is a critical condition resulting from the excessive activation of the inflammatory/immune system in response to an infection, with high mortality if treatment is not administered promptly. One of the many possible complications of sepsis is liver dysfunction with consequent cholestasis. The aim of this paper is to review the main mechanisms involved in the development of cholestasis in sepsis. Cholestasis in a septic patient must raise the suspicion that it is the consequence of the septic condition and limit the laborious attempts of finding a hepatic or biliary disease. Prompt antibiotic administration when sepsis is suspected is essential and may improve liver enzymes. Cholestasis is a syndrome with a variety of etiologies, among which sepsis is frequently overlooked, despite a number of studies and case reports in the literature demonstrating not only the association between sepsis and cholestasis but also the role of cholestasis as a prognostic factor for sepsis-induced death.

Multiple cranial nerve palsies following COVID-19 vaccination-Case report.

BACKGROUND: The novel COVID-19 vaccines have side effects that require efficient and close monitoring. AIMS OF THE STUDY: To examine whether the Pfizer-BioNTech vaccine is associated with multiple cranial neuropathy. METHODS: We report the case of a 29-year-old male patient with no notable history who presented with left oculomotor, abducens, trigeminal and facial palsies 6 days after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine. RESULTS: Gadolinium-enhanced MRI of the brain revealed enhancement in the left facial, trigeminal and oculomotor nerves, which persisted upon repeated examination. The cerebrospinal fluid analysis showed no sign of inflammation, both initially and after 1 month from the start of the patient's symptoms. Other causes were excluded by laboratory tests. The patient received high doses of corticosteroids, with improvement of symptoms. CONCLUSIONS: In our case, the most probable etiology of the patient's multiple cranial neuropathy is the Pfizer-BioNTech vaccine, which highlights the need for prolonged surveillance of COVID-19 vaccine neurological complications.

Mechanisms of Herbal Nephroprotection in diabetes mellitus.

Diabetic nephropathy (DN) is a leading cause of kidney morbidity. Despite the multilayered complexity of the mechanisms involved in the pathogenesis of DN, the conventional treatment is limited to just a few drug classes fraught with the risk of adverse events, including the progression of renal dysfunction. Phytoceuticals offer a promising alternative as they act on the many-sidedness of DN pathophysiology, multitargeting its intricacies. This paper offers a review of the mechanisms underlying the protective action of these phytoagents, including boosting the antioxidant capabilities, suppression of inflammation, averting the proliferative and sclerosing/fibrosing events. The pathogenesis of DN is viewed as a continuum going from the original offense, high glucose, through the noxious products it generates (advanced glycation end-products, products of oxidative and nitrosative stress) and the signaling chains consequently brought into action, to the harmful mediators of inflammation, sclerosis, and proliferation that eventually lead to DN, despite the countervailing attempts of the protective mechanisms. Special attention was given to the various pathways involved, pointing out the ability of the phytoagents to hinder the deleterious ones (especially those leading to, driven by, or associated with TGF-ß activation, SREBP, Smad, MAPK, PKC, NF-κB, NLRP3 inflammasome, and caspase), to promote the protective ones (PPAR-α, PPAR-γ, EP4/Gs/AC/cAMP, Nrf2, AMPK, and SIRT1), and to favorably modulate those with potentially dual effect (PI3K/Akt). Many phytomedicines have emerged as potentially useful out of in vitro and in vivo studies, but the scarcity of human trials seriously undermines their usage in the current clinical practice-an issue that stringently needs to be addressed.

Aortic Dissection: An Easily Missed Diagnosis when Pain Doesn't Hold the Stage.

BACKGROUND Type A aortic dissection (AD) is a rare disease, with a high mortality rate. Its most common symptom is thoracic pain, which is nevertheless absent in about 6% of cases. Neurologic complications are extremely rare and include ischemic stroke and ischemic neuropathy (which are the most common as presenting symptoms), spinal cord ischemia, and hypoxic encephalopathy. These rare neurological presentations can often be missed at initial clinical examination. CASE REPORT We report 2 cases of patients presenting with seemingly mild neurological symptoms. However, diagnostic tests revealed acute type A AD, and further steps were taken. CONCLUSIONS Although it is a rare cause of transient stroke or peripheral nerve ischemia, AD should be quickly recognized as a potential cause of new-onset neurological manifestations.

Early ST-segment elevation acute myocardial infarction after thrombolytic therapy for acute ischemic stroke: A case report.

RATIONALE: Acute ST-segment elevation myocardial infarction (STEMI) is a rare complication of acute ischemic stroke (AIS) during thrombolytic therapy. We report a case of STEMI occurring 40 minutes after thrombolytic therapy for AIS and discuss the possible mechanisms and therapeutic approaches. PATIENT CONCERNS: A 87-year-old woman with a history of arterial hypertension was admitted for acute onset of right-sided limb weakness 2 hours before arrival at the emergency department. Forty minutes after intravenous recombinant tissue plasminogen activator (i.v. rtPA) administration for AIS, STEMI occurred (signaled by a third-degree atrioventricular block). DIAGNOSES: The diagnoses were AIS and STEMI. Coronary angiography confirmed right coronary artery occlusion. INTERVENTIONS: Four hours after the onset of STEMI, stenting was performed, normalizing the coronary blood flow. OUTCOMES: The patient died 2 days thereafter because of persistent cardiogenic shock. LESSONS: Our case is remarkable owing to the unusually early (<1 hour) occurrence of STEMI after i.v. rtPA administration. A third-degree atrioventricular block after thrombolysis for AIS could signal a STEMI onset. New and ongoing trials are assessing whether adjunct administration of direct thrombin inhibitors of rtPA in the first 24 hours after thrombolysis for AIS can prevent early recurrent ischemic events.

Multiple acute ischemic strokes as the onset manifestation of acute promyelocytic leukemia.

Acute promyelocytic leukemia often manifests with hemorrhagic diathesis, thrombotic events being much rarer. This is the case of a 59-year-old patient with thrombotic cerebro-vascular complications as the onset manifestation of acute promyelocytic leukemia.