Fixed, Dilated, and Conversing—Unreactive Pupil With Preserved Consciousness Indicating Acutely Rising Intracranial Pressure due to Traumatic Intraparenchymal Contusions: Case Report and Review of the Literature

2021 ◽  
pp. 194187442110566
Author(s):  
Malia McAvoy ◽  
Gina Lee ◽  
Scott Boop ◽  
Madeline E. Greil ◽  
Kayla A. Durler ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Exceptional Case ◽  
Diabetes Mellitus Type Ii ◽  
Decompressive Hemicraniectomy ◽  
Tactile Stimuli ◽  
History Of ◽  
The Right ◽  
Work Up ◽  
Head Computed Tomography ◽  
Pupillary Change

Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). He described complete loss of vision and could not identify objects or count fingers. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. Corneal reflexes were intact bilaterally. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. His pupil became reactive 5 hours after surgery. While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.

scholarly journals Non-uremic Calciphylaxis: A Rare and Late Adverse Reaction of Warfarin

2019 ◽  
Vol 14 (3) ◽  
pp. 246-248 ◽  
Author(s):  
Dhruvkumar M. Patel ◽  
Mukundkumar V. Patel ◽  
Akash D. Patel ◽  
Jignesh C. Kaklotar ◽  
Greshaben R. Patel ◽  
...  
Keyword(s):  
Adverse Reaction ◽  
Inflammatory Markers ◽  
Metabolic Profile ◽  
Connective Tissue Diseases ◽  
Skin Ulcer ◽  
Wound Treatment ◽  
History Of ◽  
The Right ◽  
Work Up ◽  
Late Adverse Reaction

Background:Calciphylaxis is a complex dermatological lesion of micro vascular calcification that is typically presented as panniculitis with gangrenous painful lesions having uremic and non-uremic causes.Case Report:We present a case of a 48-year old male with a history of paroxysmal atrial fibrillation and hypertension taking amlodipine 5 mg and warfarin 5 mg daily for the last 26 months. The patient had a 6- months history of painful swelling followed by necrotic skin ulcer over the right leg. His remarkable examination findings were right leg tender ulcer with surrounding erythema and secondary sepsis. His hemogram, metabolic profile and connective tissue diseases work up were unremarkable except leucocytosis and raised inflammatory markers. His local part radiological and skin biopsy findings were suggestive of calciphylaxis.Results and Conclusion:In our case, warfarin and amlodipine were culprit drugs for the lesion, but Naranjo score (warfarin 7and amlodipine 1) speculate warfarin as a probable adverse reaction of warfarin. The lesion was cured with local wound treatment after discontinuation of warfarin. The physician should be aware of this rare cutaneous disorder of systemic origin for proper management.

scholarly journals Lifelong Idiopathic Unilateral Diaphragmatic Paralysis With Recurrent Pneumonia: A Case Report

2020 ◽  
Vol 10 (1) ◽  
pp. 26743
Author(s):  
Khosrow Agin ◽  
Akram Sabkara ◽  
Farzaneh Sadat Mirsafai Rizi ‎ ◽  
Bita Dadpour ◽  
Maryam Vahabzadeh ◽  
...  
Keyword(s):  
Primary Diagnosis ◽  
Diaphragmatic Paralysis ◽  
Recurrent Pneumonia ◽  
Emergency Center ◽  
Diabetes Mellitus Type Ii ◽  
X Ray ◽  
Breath Sounds ◽  
History Of ◽  
Chest X Ray ◽  
The Right

A 50-year-old woman was admitted to the emergency center with dyspnea, cough, and fever symptoms. She had a medical history of diabetes mellitus type II, rheumatoid arthritis, as well as several admission records due to aspiration pneumonia. The primary diagnosis was diabetic ketoacidosis and pneumonia. Normal breath sounds were reduced on the lower posterior right side of the thorax. A standard chest x-ray and lung Computed Tomography (CT) scan revealed collapse consolidation in the Right Lower Lobes (RLL) and Right Middle Lobes (RML). We here presented a case of unilateral diaphragmatic paralysis with a history of recurrent pneumonia.

scholarly journals Simultaneous Hydatid Cysts of Both the Right Atrium and Right Ventricle

2007 ◽  
Vol 50 (3) ◽  
pp. 217-219
Author(s):  
Caner Arslan ◽  
Emir Cantürk ◽  
Egemen Duygu ◽  
Ahmet Kürsat Bozkurt
Keyword(s):  
Right Ventricular ◽  
Right Atrial ◽  
Hydatid Cysts ◽  
Hepatic Hydatid Cyst ◽  
History Of ◽  
Ischemic Attack ◽  
The Right ◽  
Work Up ◽  
Hepatic Hydatid ◽  
Fatal Complications

Hydatid disease in both chambers of the heart is very rare. Mobile right atrial and right ventricular hydatid cysts were diagnosed incidentally in the etiologic work up for a transient ischemic attack in a 77-year-old man with a history of a hepatic hydatid cyst operation. Transthoracic echocardiography was very successful in the diagnosis of both hydatid cysts. Transesophagial echocardiography and computed tomography confirmed the diagnosis. Both right atrial and right ventricular hydatid cysts were removed under cardiopulmonary bypass to prevent morbidities and potentially fatal complications.

scholarly journals Focal superior quadrant haemorrhages in post COVID-19 patient: A target for personalized medicine

2021 ◽  
pp. 112067212110212
Author(s):  
Maria Cristina Savastano ◽  
Carola Culiersi ◽  
Alfonso Savastano ◽  
Gloria Gambini ◽  
Tomaso Caporossi ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Medical Work ◽  
Anomalous Increase ◽  
Retinal Bleeding ◽  
History Of ◽  
Artery Disease ◽  
The Right ◽  
Work Up ◽  
D Dimer ◽  
Care Support

Purpose: To report a case of multiple superior quadrant intraretinal haemorrhages in post-COVID-19 patient. Case description: A 58-year-old male with a history of coronary artery disease and hypertension, presented with multiple superior quadrant intraretinal haemorrhages in the superonasal quadrant of the left eye 1 month after hospitalization for COVID-19. The right eye was normal. During his 10-day stay, he was treated with hydroxychloroquine, lopinavir + ritonavir, ceftriaxone, and his pre-existing antiplatelet therapy. During hospitalization, a complete medical work up showed an anomalous increase in D-dimer. He did not require intensive care support. Conclusions: In this report, we focused on the origin of retinal bleeding in a post COVID-19 patient, likely due to a focal occlusion of a vessel. Considering the nature of SARS-CoV-2 infection, we hypothesize that retinal haemorrhages were caused by a combination of factors including the patient’s antiplatelet therapy and the thrombotic microvascular injury caused by the virus.

scholarly journals SUN-486 Unusual Presentation of Metastatic Follicular Thyroid Cancer

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Nikoletta Proudan ◽  
Kersthine Andre
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Follicular Carcinoma ◽  
Cord Compression ◽  
Whole Body ◽  
Follicular Thyroid Cancer ◽  
Lower Extremity Weakness ◽  
History Of ◽  
The Right ◽  
Work Up

Abstract Distant metastasis of follicular thyroid cancer to the bone has been well documented. However, spinal cord compression as the initial presentation of metastatic follicular thyroid cancer without any thyroid symptoms is relatively rare. Here we discuss such a case. A 78-year-old female with history of HTN and melanoma presented to the ED with a 1-month history of middle back pain that progressed to lower extremity weakness, numbness, and inability to ambulate. MRI showed a T7 vertebral mass with cord compression and edema. Metastatic work up was unremarkable except for incidental bilateral thyroid nodules, the largest on the right lobe, at 1.6 cm, with peripheral calcifications. The patient underwent T6-T7 laminectomy with vertebral decompression, partial colpectomy, and T4-T10 fusion. Pathology of the thoracic vertebral mass was positive for CAM 5.2, cytokeran 7, TTF-1, and PAX8 consistent with either metastatic pulmonary adenocarcinoma or thyroid carcinoma. The patient denied shortness of breath, dysphagia, hoarseness, or neck tenderness. She had no personal history of hyperthyroidism or hypothyroidism, or radiation exposure. She also did not have any family history of thyroid cancer. Laboratory work up was significant for TSH of 3.71 mcU/mL (0.4-4.0 mcU/mL), Free T4 1.56 ng/dL (0.7-1.9 ng/dL), thyroglobulin (Tg) 6940 ng/mL (1.6-55.0 ng/mL), and thyroglobulin antibody (Tg Ab) 20 IU/mL (0-115 IU/mL). FNA of the right thyroid nodule showed follicular neoplasm with very similar morphological features to the epidural pathology, favoring a follicular carcinoma. She underwent total thyroidectomy. Pathology showed a 1.6 x 1.1 cm follicular carcinoma with capsular and angiolymphatic invasion, but with uninvolved margins of resection. TNM staging was pT1b, pNx, pM1. She was ablated with 109 mCi of I-131 after withdrawal therapy. Whole body scan after treatment revealed radioiodine avid metastatic disease at T7 and activity in the thyroid bed compatible with residual thyroid tissue. Patient completed 10 fractions of external beam radiotherapy to the spine for a total of 30 Gy. Three months follow up lab work showed Tg 580 ng/mL and negative Tg Ab with a suppressed TSH. Thyroid bed ultrasound did not show any residual tissue or abnormal lymph nodes. Ten-year survival rates in patients with bony metastatic differentiated thyroid cancer range from 13-21% (1). Metastatic thyroid carcinoma should be considered in the differential diagnosis of every patient with new onset bony metastasis and thyroglobulin should be considered as a tumor marker in the initial work up. Research shows increased survival with I-131 avidity and complete bone metastasis resection (1). 1. Ramadan, Sami et al. “Spinal metastasis in thyroid cancer.” Head & neck oncology vol. 4 39. 25 Jun. 2012, doi:10.1186/1758-3284-4-39

A cutaneous tuberculosis mimic presented with recurrent soft tissue infection: A case report

2021 ◽  
Vol 9 (1) ◽  
pp. 30-30
Author(s):  
Abu Mansor Matardiah Nor Hashimah ◽  
Lim Ai Lee ◽  
Azman Ali Raymond
Keyword(s):  
Risk Factors ◽  
Septic Shock ◽  
Skin Diseases ◽  
Cutaneous Tuberculosis ◽  
Small Nodule ◽  
Right Hand ◽  
History Of ◽  
The Right ◽  
Work Up ◽  
Immunocompetent Patients

Recurrent cellulitis is one of the cutaneous tuberculosis mimickers. As the skin lesion can mimic other skin diseases, the diagnosis can easily be missed especially in immunocompetent patients without any other risk factors. We present a case of a 62-year-old lady with history of right hand extensor tenosynovitis presented with right hand and forearm swelling and pain, associated with fever. Clinically, her right hand and forearm were erythematous with a small nodule at the right elbow. She was treated for recurrent right upper limb cellulitis and thrombophlebitis complicated by septic shock needing several courses of antibiotics. However, she did not show any significant response to the treatment. Multiple septics work up were carried out and all were negative, except aspiration of her right elbow nodule was positive for Mycobacterium tuberculosis. Anti-tuberculous treatment was started but unfortunately, she succumbed due to nosocomial infection.

scholarly journals Secondary cluster headache and numb chin syndrome as initial manifestation of high-grade B-lymphoma: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Joe Munoz-Cerón ◽  
Felipe Díaz-Forero ◽  
Adriana Buitrago ◽  
Sandra Chinchilla
Keyword(s):  
Cluster Headache ◽  
Vascular System ◽  
Clinical Manifestations ◽  
High Grade ◽  
Initial Manifestation ◽  
Numb Chin Syndrome ◽  
History Of ◽  
Loss Of Appetite ◽  
The Right ◽  
Work Up

Abstract Background Cluster headache is a primary condition characterized by severe headache accompanied by trigeminal autonomic signs. By definition, it is not attributed to underlying etiologies; however, under certain clinical characteristics, secondary etiologies must be ruled out. Case presentation We present the case of a 48-year-old Hispanic man with a history of episodic right orbital pain, lasting 30 minutes, associated with ipsilateral tearing, who prior to the onset of his symptoms reported loss of appetite, weight loss, and paresthesias in the right chin region. After work-up studies, high-grade lymphoma with infiltration to the right submental nerve was diagnosed, in which numb chin syndrome was the initial presentation. Despite initiation of treatment, the patient died 3 weeks after the diagnosis. Conclusions In the study of cluster headache, underlying etiologies must be considered when there are atypical clinical manifestations. Within these etiologies, metastases to pericranial nerves must be included, which, besides generating localized symptoms, can activate the trigeminal vascular system simulating headaches of primary etiology.

scholarly journals A Pediatric Case of Reversible Segmental Cerebral Vasoconstriction

2006 ◽  
Vol 33 (2) ◽  
pp. 250-253 ◽  
Author(s):  
Adam Kirton ◽  
John Diggle ◽  
William Hu ◽  
Elaine Wirrell
Keyword(s):  
Previous History ◽  
Sudden Onset ◽  
Thunderclap Headache ◽  
Deep Dive ◽  
Cerebral Vasoconstriction ◽  
History Of ◽  
Repeat Angiography ◽  
The Right ◽  
Work Up ◽  
The Brain

ABSTRACT:Background:Reversible segmental cerebral vasoconstriction (RSCV) is a recognizable clinical and radiographic syndrome consisting of thunderclap headache with or without focal neurological symptoms combined with reversible segmental vasoconstriction of proximal cerebral blood vessels.Methods:We report a case of reversible segmental cerebral vasoconstriction in a child.Results:A healthy 13-year-old boy experienced the sudden onset of a severe, diffuse headache upon surfacing from a deep dive in a swimming pool. Severity was maximal at the onset and improved over several hours. The same headache recurred three times over the next four days and a low baseline headache persisted throughout. Vomiting occurred once and mild photo/osmophobia were reported but throbbing, aura, or autonomic symptoms were absent. Focal neurological signs or symptoms were absent and he denied previous history of headaches, medications, drugs, or trauma. Two normal CT scans were performed within hours of separate headaches. Cerebrospinal fluid study on day 5 was bloody with no xanthochromia. MRI/MRA/MRV of the brain and vasculitic work-up were normal. Cerebral angiography on day 6 demonstrated smooth narrowing of multiple proximal cerebral vessels including supraclinoid internal carotid artery (ICA), M1, and A1 on the right and M1 on the left. By ten days, the patient's headaches had resolved and repeat angiography was normal.Conclusion:RSCV should be considered in a child with thunderclap headache.

Massive cerebral involvement in fat embolism syndrome and intracranial pressure management

2013 ◽  
Vol 119 (5) ◽  
pp. 1263-1270 ◽  
Author(s):  
Robert G. Kellogg ◽  
Ricardo B. V. Fontes ◽  
Demetrius K. Lopes
Keyword(s):  
Intracranial Pressure ◽  
Mental Status ◽  
Right Hemisphere ◽  
Altered Mental Status ◽  
Fat Embolism ◽  
Decompressive Hemicraniectomy ◽  
Fat Embolism Syndrome ◽  
Embolism Syndrome ◽  
Seizure Episode ◽  
The Right

Fat embolism syndrome (FES) is a common clinical entity that can occasionally have significant neurological sequelae. The authors report a case of cerebral fat embolism and FES that required surgical management of intracranial pressure (ICP). They also discuss the literature as well as the potential need for neurosurgical management of this disease entity in select patients. A 58-year-old woman presented with a seizure episode and altered mental status after suffering a right femur fracture. Head CT studies demonstrated hypointense areas consistent with fat globules at the gray-white matter junction predominantly in the right hemisphere. This CT finding is unique in the literature, as other reports have not included imaging performed early enough to capture this finding. Brain MR images obtained 3 days later revealed T2-hyperintense areas with restricted diffusion within the same hemisphere, along with midline shift and subfalcine herniation. These findings steered the patient to the operating room for decompressive hemicraniectomy. A review of the literature from 1980 to 2012 disclosed 54 cases in 38 reports concerning cerebral fat embolism and FES. Analysis of all the cases revealed that 98% of the patients presented with mental status changes, whereas only 22% had focal signs and/or seizures. A good outcome was seen in 57.6% of patients with coma and/or abnormal posturing on presentation and in 90.5% of patients presenting with mild mental status changes, focal deficits, or seizure. In the majority of cases ICP was managed conservatively with no surgical intervention. One case featured the use of an ICP monitor, while none featured the use of hemicraniectomy.

scholarly journals Foix-Chavany-Marie Syndrome as a Manifestation of Unilateral Opercular Stroke

2021 ◽  
Author(s):  
Roberto Abel Toledo-Trevino ◽  
Diana Manrique-Otero ◽  
Enrique Castellanos- Pedroza ◽  
Vanessa Cano-Nigenda ◽  
Alonso Alvarado-Bolanos ◽  
...  
Keyword(s):  
Stroke Prevention ◽  
Masticatory Muscles ◽  
Pseudobulbar Palsy ◽  
Secondary Stroke Prevention ◽  
Endoscopic Gastrostomy ◽  
Excellent Functional Outcome ◽  
History Of ◽  
The Right ◽  
Work Up

Introduction: Foix-Chavany-Marie syndrome (FCMS) is a type of pseudobulbar palsy that affects facio-pharyngo-glosso-masticatory muscles. Materials and Methods: A 62-year-old man was admitted to the emergency department after 9 hours of acute dysarthria and dysphagia. MRI showed restricted diffusion in the right operculum on diffusion-weighted imaging (DWI). No thrombolytic therapy was given. The patient had a history of mechanical aortic valve replacement under anticoagulation with a vitamin K antagonist. Work-up demonstrated suboptimal levels of INR. Due to severe dysphagia during hospitalization, a percutaneous endoscopic gastrostomy (PEG) was performed. Results: The patient was discharged 5 days later, with a modified Rankin scale (mRs) score of 3, and secondary stroke prevention. He had achieved an excellent functional outcome (mRs 1) at 6-month follow-up. Conclusion: Our patient had a satisfactory recovery due to prompt diagnosis, secondary stroke prevention, and compliance with treatment.

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