Pyogenic Hepatic Abscess in an Immunocompetent Patient With Poor Oral Health and COVID-19 Infection.

Background: Pyogenic hepatic abscess (PHA) is a collection of pus in the liver caused by bacterial infection of the liver parenchyma. PHA is more common in immunosuppressed individuals and those with diabetes mellitus, cancer, and liver transplant. Case Presentation: We present a rare case of PHA with Fusobacterium nucleatum in an immunocompetent patient with poor oral health, history of diverticulitis, and recent COVID-19 infection whose only symptoms were chest pain and a 4-week history of fever and malaise. The source of infection in this patient was likely dental caries and periodontal disease, with COVID-19 infection playing a role as a red herring in this patient's disease progression, delaying diagnosis. Conclusions: Diagnosis and treatment of PHA must be prompt with drainage and empiric anaerobic coverage followed by a more tailored antibiotic regimen if indicated by culture and further drainage if indicated by computed tomography.

Rhabdomyolysis Occurring After Use of Cocaine Contaminated With Fentanyl Causing Bilateral Brachial Plexopathy.

Background: Rhabdomyolysis is caused by muscle overuse, trauma, prolonged immobilization, drugs, or toxins. As rhabdomyolysis progresses, swelling and edema can compress surrounding structures. Few cases of the phenomenon occurring as a sequela of substance use have been described. Case Presentation: We present a 68-year-old male patient with rhabdomyolysis following use of crack cocaine contaminated with fentanyl. The patient had 0/5 strength bilaterally and bilateral absent reflexes in the upper extremities. Sensation was markedly decreased, as he was unable to feel temperature, pinprick sensation, or general touch. Creatine phosphokinase level was elevated at 21,292 IU/L. On magnetic resonance imaging, there was abnormal signal in the lower neck bilaterally. It is presumed that muscular edema resulted in partial narrowing of the thoracic outlet bilaterally with corresponding mass effect on the traversing brachial plexus. Conclusions: This is the seventh case of brachial plexopathy secondary to rhabdomyolysis precipitated by opioid use that has been reported in the literature. Prospective studies should examine treatment for this condition.

Autonomic Dysfunction in the Setting of CADASIL Syndrome.

Background: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) syndrome is the most common monogenic inherited cause of stroke. Case Presentation: A female patient aged > 50 years with genetically proven CADASIL syndrome and an extensive stroke/transient ischemic attack (TIA) history experienced a bradycardic episode following hospitalization for new strokelike symptoms. The literature of cardiac involvement in CADASIL syndrome is limited, with no definitive recommendations for surveillance and screening. Conclusions: This case report postulates that cardiac surveillance and screening may be indicated for patients with CADASIL syndrome.

Clinical Presentation of Subacute Combined Degeneration in a Patient With Chronic B12 Deficiency.

Background: Subacute combined degeneration (SCD) is a rare complication of chronic vitamin B12 deficiency that presents with a variety of neurologic findings, including decreased sensation in the extremities, increased falls, and visual changes. Treatment of SCD involves prompt replacement of vitamin B12 and addressing the underlying conditions that cause the deficiency. Given the prevalence of B12 deficiency in the older adult population, clinicians should remain alert to its possibility in patients who present with progressive neuropathy. Case Presentation: This report presents a case of a patient with progressive SCD secondary to chronic B12 deficiency despite monthly intramuscular B12 injections. Conclusions: Appropriate B12 replacement is aggressive and involves intramuscular B12 1000 mcg every other day for 2 to 3 weeks, followed by additional IM administration every 2 months before transitioning to oral therapy. Failure to adequately replenish B12 can lead to progression or lack of resolution of SCD symptoms.

Orbital Varix Masquerading as an Intraorbital Lymphoma.

Clinical context was paramount to the diagnosis and management of a patient with periorbital pain and a history of systemic lymphoma.

Emphysematous Aortitis due to Klebsiella Pneumoniae in a Patient With Poorly Controlled Diabetes Mellitus.

Patients with poorly controlled diabetes mellitus and an infectious source can be predisposed to infectious aortitis.

Hemiballismus in Patients With Poorly Controlled Type 2 Diabetes Mellitus.

Swift identification of hemiballismus as a complication of poorly controlled type 2 diabetes mellitus may help facilitate optimal care through glycemic control and prevent debilitating loss of patients' function and autonomy, prolonged hospital stays, and overuse of resources.

Review of Radiologic Considerations in an Immunocompetent Patient With Primary Central Nervous System Lymphoma.

Primary central nervous system lymphoma is increasingly seen in immunocompetent patients and should be considered in any patient with multiple nervous system lesions.

Acute Encephalopathy Following Hyperbaric Oxygen Therapy in a Patient on Metronidazole.

This case describes a patient who presented to the emergency department for an acute onset of encephalopathy following hyperbaric oxygen treatment and antibiotic therapy for radiation-induced osteonecrosis of the jaw.

Cerebral Venous Thrombosis.

For a patient with nonspecific symptoms and no obvious signs on imaging, having a high index of suspicion for cerebral venous thrombosis can help shorten the time to diagnosis and treatment and prevent more serious complications.

Imaging in head and neck oncology.

Evaluation of head and neck cancer with imaging is a topic that is far more extensive than can be covered in this article. The main reason for head and neck imaging is to evaluate the true extent of disease to best determine surgical and therapeutic options. This process includes evaluation of the size, location, and extent of tumor infiltration into surrounding vascular and visceral structures. Important anatomic variants must be pointed out so the surgeon can avoid potential intraoperative complications. These variant scan be evaluated with the appropriate multiplanar and three-dimensional images to provide as much information as possible to the surgeon preoperatively. Second, nodal staging should be assessed in an effort to increase the number of abnormal nodes detected by physical examination and, more important, to precisely define their location by a standard classification system that can be understood and consistently applied by the radiologist, surgeon, radiation oncologist, and pathologist. Although secondary to the previously described tasks, imaging frequently enables a limitation of the diagnostic and histologic possibilities based on lesion location and signal-attenuation characteristics, which may lead the clinical investigation along a different path. saving the patient unnecessary risk and shortening the time to diagnosis and ultimate treatment. This article has attempted to detail the current state of the controversy between CT, MRI, and other modalities, and has emphasized the constant evolution of this controversy because of the evolving imaging technology. Although CT and MRI are both well suited to evaluation of the deep spaces and submucosal spaces of the head and neck, each has some limitations.MRI has the advantages of higher soft tissue contrast resolution, the lack of iodine-based contrast agents, and high sensitivity for perineural and intracranial disease. The disadvantages of MRI include lower patient tolerance, contraindications in pacemakers and certain other implanted metallic devices, and artifacts related to multiple causes, not the least of which is motion. CT is fast, well tolerated, and readily available but has lower contrast resolution and requires iodinated contrast and ionizing radiation. The current authors' practice is heavily centered on CT for initial evaluation, preoperative planning, biopsy targeting, and postoperative follow-up. They reserve MRI for tumors that are suspicious for perineural,cartilaginous, or bony invasion on CT, or for tumors such as adenoid cystic carcinoma that are highly likely to spread by way of these routes. For patients who have head and neck cancer, a radiologist who is educated in the treatment options, patterns of tumor growth, and important surgical landmarks, and who has a well-established pattern of communication with the head and neck clinical services, including surgery, radiation oncology,and pathology, is key in providing accurate and useful image interpretation.