Hyperglycemia-Induced Complete Left-Sided Hemiballismus Due to Uncontrolled Diabetes in a 70-Year-Old Female: A Case Report.

This report details the presentation of a 72-year-old female with left-sided continuous non-rhythmic involuntary movements persisting for two months. The movements affected the left side of her face, arm, and leg. The patient had a history of multiple hyperglycemic episodes and diabetic ketoacidosis. This report investigates the basal ganglia's involvement in hemiballismus, a movement disorder possibly linked to the patient's hyperglycemia. It discusses the complex management of hyperglycemia-induced hemiballismus and the need for more research to understand the underlying mechanism and optimal treatment strategies.

Spider Bite-Induced Facial Nerve Palsy.

Spider bites, while rarely confirmed beyond a doubt, should always be in the differential for any severe symptoms or infection out of proportion to presentation with the suspected presence of appropriate vectors. While most arthropod bites will only result in mild localized irritation, the potential to cause severe cutaneous and systemic effects should not be overlooked. We present one such case, in which a presumed brown recluse (Loxosceles reclusa) bite on the neck resulted in severe illness with systemic manifestations. The patient presented to the emergency room minimally responsive with left-sided facial nerve palsy and septic shock. While the admitting physician initially prioritized stabilizing the patient, he noted the left-sided cervical cellulitis. Thorough history taking revealed that the patient had been worsening since being bitten by a spider three days prior to admission. After a month-long hospital stay and multidisciplinary treatment, the patient was transferred to a larger center with facial paralysis still present.

Predictive models of prolonged mechanical ventilation yield moderate accuracy.

PURPOSE: To develop a model to predict prolonged mechanical ventilation within 48 hours of its initiation. MATERIALS AND METHODS: In 282 general intensive care unit patients, multiple variables from the first 2 days on mechanical ventilation and their total ventilation duration were prospectively collected. Three models accounting for early deaths were developed using different analyses: (a) multinomial logistic regression to predict duration > 7 days vs duration ≤ 7 days alive vs duration ≤ 7 days death; (b) binary logistic regression to predict duration > 7 days for the entire cohort and for survivors only, separately; and (c) Cox regression to predict time to being free of mechanical ventilation alive. RESULTS: Positive end-expiratory pressure, postoperative state (negatively), and Sequential Organ Failure Assessment score were independently associated with prolonged mechanical ventilation. The multinomial regression model yielded an accuracy (95% confidence interval) of 60% (53%-64%). The binary regression models yielded accuracies of 67% (61%-72%) and 69% (63%-75%) for the entire cohort and for survivors, respectively. The Cox regression model showed an equivalent to area under the curve of 0.67 (0.62-0.71). CONCLUSIONS: Different predictive models of prolonged mechanical ventilation in general intensive care unit patients achieve a moderate level of overall accuracy, likely insufficient to assist in clinical decisions.

Clinical profiles and outcomes of acute aortic dissection in a predominantly Hispanic population.

BACKGROUND: Acute aortic dissection (AAD) is a life-threatening cardiovascular condition with high morbidity and mortality. We sought to assess clinical profiles as well as outcomes of AAD in a predominantly Hispanic population and to explore the relationship between this condition and uncontrolled/untreated hypertension in this community. MATERIAL AND METHODS: This was a single-center, retrospective, cross-sectional study of patients admitted with AAD over a 10 years period. RESULTS: Fifty-nine cases of AAD were included in the analysis. The group of Hispanics with AAD had more females (48.3%, p=0.002), more dyslipidemia and coronary artery disease (p=0.006 and 0.05, respectively), and a tendency to be older and have more hypertension and diabetes compared to non-Hispanics. Although 70.2% of all patients had hypertension, only 52.5% of them were being treated; of those, only 66.7% achieved optimal blood pressure control prior to presentation. Only 47.4% received beta-blockers for blood pressure control in the acute setting. Longer length of in-hospital stay was associated with older age, higher troponin and creatine kinase levels, and presence of hypertension. In-hospital death occurred in 10 (17%) patients and mortality was significantly associated with higher serum creatinine (p=0.01). CONCLUSIONS: Hispanic patients with AAD were more likely to be female, of older age, and have more cardiovascular risk factors in comparison to non-Hispanics. In addition, significant under-treatment of hypertension in this population and underutilization of beta-blockers for blood pressure control in the acute settings was evident. Better prevention and timely treatment may improve outcomes for this condition in this population.

Chorea, Hyperglycemia, Basal Ganglia Syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation.

PATIENT: Female, 66 FINAL DIAGNOSIS: Chorea • hyperglycemia • Basal Ganglia Syndrome (C-H-BG) Symptoms: Hemibalism • hemichorea MEDICATION: - Clinical Procedure: - Specialty: Endocrinology and Metabolic. OBJECTIVE: Challenging differential diagnosis. BACKGROUND: Hemichorea-hemiballism (HCHB) is a spectrum of involuntary, continuous non-patterned movement involving 1 side of the body. Possible causes of HCHB include hemorrhagic or ischemic stroke, neoplasm, systemic lupus erythematosus, HHNK, Wilson's disease, and thyrotoxicosis. This case illustrates the need to be aware of hyperglycemia as a cause of hemiballism/hemichorea, which is now referred to in the medical literature as C-H-BG (chorea, hyperglycemia, basal ganglia) syndrome. CASE REPORT: A 66-year-old Hispanic woman presented to our care with hemiballism/hemichorea of the right arm and leg of 1 week duration. She had been admitted 3 months prior with toxic metabolic encephalopathy secondary to hyperosmolar hyperglycemic non-ketotic syndrome with a blood glucose level of 984 mg/dL. Her blood glucose level was normal but hemoglobin A1C was 12.2%. A brain MRI revealed an asymmetric T1 hyperintensity of the left putamen. This specific finding was compatible with hyperglycemia-induced hemichorea hemiballism syndrome. The hemiballism/hemichorea slowly improved over the course of the hospitalization with strict glycemic control. At the 3-month follow-up visit she had no involuntary movements of her extremities, and she had well controlled blood glucose levels and a hemoglobin A1C of 9.0. CONCLUSIONS: In a patient with normal glycemic levels but a history of uncontrolled diabetes, C-H-BG syndrome should be on the top of the differential list when the characteristic MRI findings of a hyperintensity in the basal ganglia are observed. This is a rare disease that deserves attention because it is reversible with correction of hyperglycemia. Thus, prompt recognition and treatment is essential to avoid adverse outcomes.

Hepatitis C- and HIV-induced porphyria cutanea tarda.

PATIENT: Male, 47 FINAL DIAGNOSIS: Porphyria cutanea tarda Symptoms: Chills • cough dry • thumb swelling MEDICATION: - Clinical Procedure: - Specialty: Metabolic Disorders and Diabetics. OBJECTIVE: Challenging differential diagnosis. BACKGROUND: Porphyria cutanea tarda (PCT) is the most common type of the porphyria. It occurs due to the deficiency of enzyme uroporphyrinogen decarboxylase (UROD), which is the fifth enzyme in the biosynthesis of heme and catalyzes the conversion of uroporphyrinogen to coproporphyrinogen. The risk factors for PCT include hereditary hemochromatosis, hepatitis C infection, ethanol abuse, estrogen use, HIV, smoking, chlorinated polycyclic aromatic hydrocarbons, and hemodialysis. CASE REPORT: A 47-year-old Hispanic man presented with right thumb swelling, redness, and pain for approximately 1 week. Past medical history included HIV/AIDS, hepatitis C infection, alcohol abuse, heroin abuse, and CMV retinitis. Skin examination revealed blistering and hypo/hyper pigmented lesions over the dorsal aspects of the hands and other sun-exposed areas. Serum porphyrins were discovered to be elevated. The quantitative urine porphyrins revealed elevation of uroporphyrins, heptacarboxyl-porphyrins, hexacarboxy-porphyrins, pentacarboxyl-porphyrins and coproporphyrin. Genetic mutation of UROD was not detected. Due to the classic cutaneous lesions, laboratory findings, and associated risk factors, we were able to confirm our suspicion of the sporadic (type 1) form of PCT. CONCLUSIONS: A strong correlation has been demonstrated between the sporadic (type 1) form of PCT and hepatitis C virus (HCV) infection in multiple studies. The mechanism through which HCV infection may cause or trigger PCT is unknown. PCT has been described for many years, but still eludes the differential diagnosis in a patient with cutaneous findings. The uniqueness of our case is the possibility that combined risk factors have an effect on PCT.

Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting.

PATIENT: Female, 82 FINAL DIAGNOSIS: Achalasia Symptoms: Nocturnal regurgtation • weight loss MEDICATION: - Clinical Procedure: Esophageal stenting Specialty: Gastroenterology • Hepatology Objective: Unusual or unexpected effect of treatment. BACKGROUND: Pneumatic dilatation is one of the most effective methods for treating achalasia. Esophageal perforation is the most serious complication after pneumatic dilatation and has been reported to occur in the range of 1 to 4.3%. The appropriate management of esophageal perforation can range from conservative medical treatment to surgical intervention. CASE REPORT: We report a case of an 82-year-old male who had an 8 month history of dysphagia for solid and liquids, a 10 lb weight loss and nocturnal regurgitation. The diagnosis of achalasia was established by endoscopic; barium and manometric criteria. He underwent a pneumatic dilation with a 30 mm Rigiflex balloon. A confined or limited esophageal perforation projecting into the mediastinum and located 1-2 cm above the diaphragm was confirmed by a gastrografin swallow study performed immediately after the procedure. There was some accompanying epigastric abdominal pain. PATIENT was treated later that day by placing a fully covered metallic esophageal stent in addition to antibiotics, proton pump inhibitor, and fasting. PATIENT was discharged home 3 days later able to eat liquid-soft foods. Follow up endoscopy 2 weeks later and a gastrografin swallow showed a completely healed perforation and the stent was removed. Symptomatically he has done well, with no dysphagia or heartburn at six and twelve months follow up. CONCLUSIONS: Early esophageal stenting for esophageal perforation after pneumatic dilation for achalasia is a treatment option which accelerates healing shortens recovery period, as well as decreasing hospital stay and costs.

Dural arteriovenous fistula discovered in patient presenting with recent head trauma.

UNLABELLED: Patient Male, 32 FINAL DIAGNOSIS: Dural arterio-venous fistula Symptoms: Eye redness • post-trauma headache • tinnitus MEDICATION: - Clinical Procedure: Fistula embolization Specialty: Neurology. OBJECTIVE: Mistake in diagnosis. BACKGROUND: A dural arteriovenous fistula (DAVF), is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus. The pathogenesis of DAVF still remains unclear. Sinus thrombosis, head trauma, chronic central nervous system, hypercoagulable state, surgery, and hormonal influence are the pre-disposing factors that initiate this disease. The symptoms experienced by the patient will depend on the location of the fistula. CASE REPORT: Thirty-two year old Hispanic male who presented one day after a rear ended motor vehicle collision (MVC) with a severe throbbing headache in the left parietal region, left eye redness but no retro-orbital pain and tinnitus in the left ear. He was initially misdiagnosed to have a carotid-cavernous fistula but upon cerebral angiogram was actually diagnosed with a dural arterio-venous fistula in the posterior fossa venous system followed by successful embolization of the fistula. CONCLUSIONS: A cerebral angiography is the gold standard for detection and characterization of a DAVF and will distinguish it from a CCF. Endovascular surgery involves a catheter-based technique for embolization of the lumen of arteries feeding the DAVF, or directly into the vein draining the DAVF. It is very important to recognize the typical findings of patients presenting with a DAVF then quickly proceeding with a cerebral angiogram to determine the exact location of the fistula and the appropriate treatment plan. By diagnosing and treating a DAVF as early as possible, the associated fatal complications can be averted.

Pneumococcal meningitis in a young adult female with common variable immunodeficiency.

PATIENT: Female, 22 FINAL DIAGNOSIS: Pneumococcal meningitis Symptoms: Fever • headache • neck stiffness • nuchal rigidity • photophobia MEDICATION: Ceftriaxone Clinical Procedure: - Specialty: Neurology. OBJECTIVE: Rare disease. BACKGROUND: Common variable immunodeficiency (CVID) is a primary immunodeficiency associated with hypogammaglobulinemia and other various clinical manifestations. It is a rare disease with a prevalence of CVID is approximately 1: 50,000-200,000. Clinical manifestations of CVID include recurrent bacterial infections, autoimmune, gastrointestinal, lymphoproliferative, granulomatous, and malignancy. CASE REPORT: Twenty-two year-old Hispanic female presented with a throbbing headache, nuchal rigidity, photophobia and a high grade fever. Lumbar puncture with CSF assessment revealed a turbid fluid with WBC of 6937 per uL, polymorphnuclear cells of 81%, protein 248 mg/dL, glucose <3 mg/Dl. CSF antigens were positive for Streptococcus pneumonia and CSF culture grew pansensitive Strepococcus pneumonia. Immunoglobin (Ig) levels of IgA, IgE, IgG and IgM were all decreased. Absolute cell counts of CD3, CD4 and CD8 were all low. Bone marrow biopsy was normocellular. Excisional lymph node biopsy revealed lymph nodes with reactive follicular hyperplasia. Common variable immunodeficiency disease (CVID) was diagnosed based on exclusion. IVIG therapy was given and patient received a two-week course of ceftriaxone. CONCLUSIONS: THE DIAGNOSIS OF CVID IS MADE BASED ON THE FOLLOWING CRITERIA: 1) Marked decrease of IgG and at least one of the IgM or IgA isotypes. 2) The onset of immunodeficiency at greater than 2 years old. 3) Absence of isohemagglutinins and/or poor response to vaccines 4) Exclusion of other defined causes of hypogammaglobulinemia. A definite diagnosis is often late because it is wrongly assumed that primary immunodeficiencies are extremely rare, hence many patients are already seriously ill at the time of presentation.

A case with unusual stroke and fulminant outcome in a Hispanic male.

PATIENT: Male, 42 FINAL DIAGNOSIS: Moyamoya disease (MMD) Symptoms: Aphasia • concentration difficulty • dysarthria • personality change MEDICATION: - Clinical Procedure: - Specialty: Radiology. OBJECTIVE: Rare disease. BACKGROUND: Moyamoya disease (MMD) was first described in 1957 as "hypoplasia of the bilateral internal carotid arteries." The characteristic appearance of the associated network of abnormally dilated collateral vessels on angiography was later likened to "something hazy, like a puff of cigarette smoke," which, in Japanese, is Moyamoya. This paper describes the fulminant course of the disease in a Hispanic male involving the corpus callosum. CASE REPORT: A 42-year-old Hispanic male with progressive aphasia, slow mentation, and sudden onset of sensorimotor symptoms with gait disturbance was found to have multiple intracranial supratentorial infarcts of variable stages of evolution involving, but not limited to, the anterior corpus callosum, followed by rapid development of further infarcts. Angiography demonstrated right ACA occlusion, left supraclinoid ICA occlusion with a Moyamoya pattern of collateralization, and diffuse arteriopathy. A fulminant course ensued and the patient did not survive the acute phase of ischemic disease. CONCLUSIONS: Moyamoya disease may rarely present in North American Hispanic males, with advanced atypical clinical and imaging features involving the anterior corpus callosum and having a fulminant course.