scholarly journals A woman with fever and confusion

2020 ◽  
pp. 102490792097607
Author(s):  
Hung-Lin Hsu ◽  
Wei-Jing Lee
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Clinical Improvement ◽  
Mural Nodule ◽  
Hiv Positive ◽  
Cerebral Toxoplasmosis ◽  
Positive Woman ◽  
Target Sign ◽  
Eccentric Target ◽  
Multiple Ring

A 37-year-old HIV-positive woman presented to the emergency department with fever, headache, confusion, and seizures for 3 days. Computed tomography of the head with contrast demonstrated multiple ring-enhancing masses. An eccentric mural nodule in ring-enhanced mass characterizes eccentric target sign, which is pathognomonic for cerebral toxoplasmosis. The patient received anti-toxoplasmic therapy and had marked clinical improvement.

Fulminant diffuse cerebral toxoplasmosis as the first manifestation of HIV infection

2021 ◽  
Vol 14 (1) ◽  
pp. e237120
Author(s):  
Louise Dunphy ◽  
Bret Palmer ◽  
Fabian Chen ◽  
Joanne Kitchen
Keyword(s):  
Emergency Department ◽  
Antiretroviral Therapy ◽  
Hiv Infection ◽  
Cd4 Count ◽  
Sub Saharan Africa ◽  
Cerebral Toxoplasmosis ◽  
Hiv Test ◽  
Ct Head ◽  
Tenofovir Alafenamide ◽  
Multiple Ring

Individuals with HIV may present to the emergency department with HIV-related or HIV-unrelated conditions, toxicity associated with antiretroviral therapy or primary HIV infection (seroconversion). In individuals with HIV infection, central nervous system toxoplasmosis occurs from reactivation of disease, especially when the CD4+ count is <100 cells/μL, whereas in those taking immunosuppressive therapy, this can be either due to newly acquired or reactivated latent infection. It is a rare occurrence in immune-competent patients. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate and is often asymptomatic until the second or third decade of life when ocular lesions develop. Toxoplasmosis is an infection caused by the intracellular protozoan parasite Toxoplasma gondii and causes zoonotic infection. It can cause focal or disseminated brain lesions leading to neurological deficit, coma and death. Typical radiological findings are multiple ring-enhancing lesions. Histopathological examination demonstrating tachyzoites of T. gondii and the presence of nucleic material in the spinal cerebrospinal fluid (CSF) confirms the diagnosis. The authors present the case of a 52-year-old male UK resident, born in sub-Saharan Africa, with a 3-week history of visual hallucinations. He attended the emergency department on three occasions. Laboratory investigations and a CT head were unremarkable. He was referred to psychological medicine for further evaluation. On his third presentation, 2 months later, a CT head showed widespread lesions suggestive of cerebral metastasis. Dexamethasone was initiated and he developed rigours. An MRI head showed multiple ring-enhancing lesions disseminated throughout his brain parenchyma. CSF analysis and serology confirmed the diagnosis of HIV and toxoplasmosis, respectively. His CD4 count was 10 and his viral load (VL) was 1 245 003. He was then initiated on Biktarvy 50 mg/200 mg/25 mg, one tablet daily, which contains 50 mg of bictegravir, 200 mg of emtricitabine and tenofovir alafenamide fumarate equivalent to 25 mg of tenofovir alafenamide. After 3 months of antiretroviral therapy, his HIV VL reduced to 42. However, his abbreviated mental test remained at 2/10. Despite presenting with neurocognitive impairment and being born in a HIV prevalent region, an HIV test was not offered. This case highlights missed opportunities to request HIV serology and raises awareness that cerebral toxoplasmosis can occur as the first manifestation of HIV. Prompt diagnosis and early initiation of antiretroviral therapy reduces morbidity and mortality in this patient cohort.

scholarly journals Eccentric target sign in cerebral toxoplasmosis: Neuropathological correlate to the imaging feature

2010 ◽  
Vol 31 (6) ◽  
pp. 1469-1472 ◽  
Author(s):  
G.G. Sharath Kumar ◽  
A. Mahadevan ◽  
A.S. Guruprasad ◽  
Jerry M.E. Kovoor ◽  
P. Satishchandra ◽  
...  
Keyword(s):  
Imaging Feature ◽  
Cerebral Toxoplasmosis ◽  
Target Sign ◽  
Eccentric Target

scholarly journals Concentric and Eccentric Target MRI Signs in a Case of HIV-Associated Cerebral Toxoplasmosis

2018 ◽  
Vol 2018 ◽  
pp. 1-3 ◽  
Author(s):  
Adam D. Roche ◽  
Dominic Rowley ◽  
Francesca M. Brett ◽  
Seamus Looby
Keyword(s):  
Recent Literature ◽  
Cerebral Toxoplasmosis ◽  
Target Sign ◽  
Clinical Challenge ◽  
Immunodeficiency Virus ◽  
Common Causes ◽  
The Brain ◽  
Prompt Diagnosis ◽  
Cns Lesions ◽  
Eccentric Target

Cerebral toxoplasmosis is one of the most common causes of focal brain lesions in immunocompromised patients, such as those with human immunodeficiency virus (HIV). Differentiating toxoplasmosis from other central nervous system (CNS) lesions provides a significant clinical challenge. Magnetic resonance (MR) imaging of the brain is key to prompt diagnosis and treatment of cerebral toxoplasmosis. Several specific signs on MRI of brain have been described in recent literature including the “concentric target sign” and “eccentric target sign.” We report a case of successfully treated HIV-associated cerebral toxoplasmosis in which both MRI signs were present simultaneously.

scholarly journals Eccentric target sign of cerebral toxoplasmosis

QJM ◽  
2016 ◽  
Vol 109 (8) ◽  
pp. 555-555 ◽  
Author(s):  
S. Bansal ◽  
M. Goyal ◽  
M. Modi ◽  
C. Ahuja ◽  
V. Lal
Keyword(s):  
Cerebral Toxoplasmosis ◽  
Target Sign ◽  
Eccentric Target

Acute Colonic Diverticulitis: Diagnostic Evidence, Demographic and Clinical Features in ree Practice Settings

2014 ◽  
Vol 23 (4) ◽  
pp. 379-386 ◽  
Author(s):  
Rajan Iyer ◽  
George F. Longstreth ◽  
Li-Hao Chu ◽  
Wansu Chen ◽  
Linnette Yen ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Clinical Features ◽  
Clinical Characteristics ◽  
Past History ◽  
Colonic Diverticulitis ◽  
Co Morbidity ◽  
Objective Evidence ◽  
Multiple Variables ◽  
Acute Colonic Diverticulitis

Background & Aims: Diverticulitis is often diagnosed in outpatients, yet little evidence exists on diagnostic evidence and demographic/clinical features in various practice settings. We assessed variation in clinical characteristics and diagnostic evidence in inpatients, outpatients, and emergency department cases and effects of demographic and clinical variables on presentation features.Methods: In a retrospective cohort study of 1749 patients in an integrated health care system, we compared presenting features and computed tomography findings by practice setting and assessed independent effects of demographic and clinical factors on presenting features.Results: Inpatients were older and more often underweight/normal weight and lacked a diverticulitis past history and had more comorbidities than other patients. Outpatients were most often Hispanic/Latino. The classical triad (abdominal pain, fever, leukocytosis) occurred in 78 (38.6%) inpatients, 29 (5.2%) outpatients and 34 (10.7%) emergency department cases. Computed tomography was performed on 196 (94.4%) inpatients, 110 (9.2%) outpatients and 296 (87.6%) emergency department cases and was diagnostic in 153 (78.6%) inpatients, 62 (56.4%) outpatients and 243 (82.1%) emergency department cases. Multiple variables affected presenting features. Notably, female sex had lower odds for the presence of the triad features (odds ratio [95% CI], 0.65 [0.45-0.94], P<0.05) and increased odds of vomiting (1.78 [1.26-2.53], P<0.01). Patients in age group 56 to 65 and 66 or older had decreased odds of fever (0.67 [0.46-0.98], P<0.05) and 0.46 [0.26-0.81], P<0.01), respectively, while ≥1 co-morbidity increased the odds of observing the triad (1.88 [1.26-2.81], P<0.01).Conclusion: There was little objective evidence for physician-diagnosed diverticulitis in most outpatients. Demographic and clinical characteristics vary among settings and independently affect presenting features.Abbreviations: AD: acute colonic diverticulitis; BMI: body mass index; CT: computed tomography; ED: emergency department; IBS: irritable bowel syndrome; ICD-9-CM: International Classification of Diseases, 9th Revision, Clinical Modification; IP: inpatient; KPSC: Kaiser Permanente Southern California; OP: outpatient.

scholarly journals Primary oral cryptococcosis in an HIV-positive woman with suppressed viral load and normal CD4 count: a rare case

2021 ◽  
Vol 14 (6) ◽  
pp. e242633
Author(s):  
Antonio Jose Reyes ◽  
Kanterpersad Ramcharan ◽  
Samuel Aboh ◽  
Stanley Lawrence Giddings
Keyword(s):  
Viral Load ◽  
Rare Case ◽  
Cd4 Count ◽  
Hiv Positive ◽  
Positive Woman

scholarly journals A141 SPONTANEOUS ESOPHAGEAL PERFORATION: AN UNREPORTED COMPLICATION OF LYMPHOCYTIC ESOPHAGITIS

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 128-129
Author(s):  
A LAGROTTERIA ◽  
A W Collins ◽  
A Someili ◽  
N Narula
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Case Report ◽  
Proton Pump Inhibitor ◽  
Proton Pump ◽  
Esophageal Perforation ◽  
Distal Esophagus ◽  
Chest Discomfort ◽  
History Of ◽  
Lymphocytic Esophagitis

Abstract Background Lymphocytic esophagitis is a new and rare clinicopathological entity. It is a histological pattern characterized by lymphocytic infiltrate without granulocytes. Its etiology and clinical significance remains unclear. The clinical manifestations are typically mild, with reflux and dysphagia the most commonly reported symptoms. Aims We describe a case report of spontaneous esophageal perforation associated with lymphocytic esophagitis. Methods Case report Results A previously well 31-year-old male presented to the emergency department with acute food impaction. His antecedent symptoms were acute chest discomfort and continuous odynophagia following his most recent meal, with persistent globus sensation. The patient had no reported history of allergies, atopy, rhinitis, or asthma. A previous history of non-progressive dysphagia was noted after resuscitation. Emergent endoscopy revealed no food bolus, but a deep 6 cm mucosal tear in the upper-mid esophagus extending 24 to 30 cm from the incisors. Chest computed tomography observed small volume pneumoperitoneum consistent with esophageal perforation. The patient’s recovery was uneventful; he was managed conservatively with broad-spectrum antibiotics, proton pump inhibitor therapy, and a soft-textured diet. Endoscopy was repeated 48 hours later and revealed considerable healing with only a residual 3-4cm linear laceration. Histology of biopsies taken from the mid and distal esophagus demonstrated marked infiltration of intraepithelial lymphocytes. There were no eosinophils or neutrophils identified, consistent with a diagnosis of lymphocytic esophagitis. Autoimmune indices including anti-nuclear antibodies and immunoglobulins were normal, ruling out a contributory autoimmune or connective tissue process. The patient was maintained on a proton pump inhibitor (pantoprazole 40 mg once daily) following discharge. Nearly six months following his presentation, the patient had a recurrence of symptoms prompting representation to the emergency department. He described acute onset chest discomfort while eating turkey. Computed tomography of the chest redemonstrated circumferential intramural gas in the distal esophagus and proximal stomach. Conclusions Esophageal perforation is a potentially life-threatening manifestation of what had been considered and described as a relatively benign condition. From isolated dysphagia to transmural perforation, this case significantly expands our current understanding of the clinical spectrum of lymphocytic esophagitis. Funding Agencies None

Chronic mesenteric ischaemia presenting as possible large bowl malignancy: an easily overlooked differential diagnosis

2021 ◽  
Vol 14 (3) ◽  
pp. e240202
Author(s):  
Benjamin McDonald
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Weight Loss ◽  
Differential Diagnosis ◽  
Damage Control ◽  
Damage Control Surgery ◽  
Mesenteric Ischaemia ◽  
Abdominal Symptoms ◽  
Chronic Mesenteric Ischaemia ◽  
Descending Colon

An 80-year-old woman presented to a regional emergency department with postprandial pain, weight loss and diarrhoea for 2 months and a Computed Tomography (CT) report suggestive of descending colon malignancy. Subsequent investigations revealed the patient to have chronic mesenteric ischaemia (CMI) with associated bowel changes. She developed an acute-on-chronic ischaemia that required emergency transfer, damage control surgery and revascularisation. While the patient survived, this case highlights the importance of considering CMI in elderly patients with vague abdominal symptoms and early intervention to avoid potentially catastrophic outcomes.

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