Thromboembolic Central Nervous System Complications of COVID-19

Context: COVID-19 is well-known to increase the risk of developing thromboembolism; thus, patients may present with diverse neurovascular manifestations. Case report: A 56-year-old man presented with sudden onset of incoordination of his left arm and leg. He also had a history of recurrent episodes of transient left hemithoracic pain radiating to his left arm, along with right visual hemi-field positive phenomena. Additionally, he reported self-limited fever and anosmia three weeks earlier. Examination revealed left hemiataxia (NIHSS score: 2). Initial assessment with brain CT, intracranial and cervical CT angiography was normal. Shortly after admission, the patient developed acute weakness of his four limbs and urinary retention. Neurological exam showed left homonimous hemianopia, asymmetric tetraparesis and a superficial sensory level at C4. Neuraxis MRI was performed and diffusion-weighted imaging revealed acute ischemic lesions in the occiptal lobes, cerebellum and cervicalthoracic spine. A thorough diagnostic work-up was conducted. Laboratory tests were unremarkable, including inflammatory markers, viral hepatitis, HIV and syphilis serologies, as well as rheumatologic tests and a thrombophilia panel, except for SARS-COV-2 serology, with detection of IgM antibodies. RT-PCR nasopharyngeal swab was negative. Further investigation with CSF analysis, CT angiography of the aorta, transthoracic echocardiogram, 24-hour holter monitoring and transcranial Doppler didn’t show any abnormalities. Transesophageal echocardiogram revelead a minor patent foramen ovale. Conclusion: This is a case of acute cerebral, cerebellar and spinal embolic infarction, probably related to Covid-19, illustrating the infection’s associated coagulopathy¹.

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Longitudinally Extensive Transverse Myelitis (LETM) in COVID-19 Infection, A Case-Report

10.21203/rs.3.rs-978297/v1 ◽

2021 ◽

Author(s):

Jean-Christophe Van Cutsem ◽

Ann-Sophie Lamon ◽

Vincent Van Belleghem ◽

Evelien Vancaester

Keyword(s):

Spinal Cord ◽

Clinical Manifestations ◽

Transverse Myelitis ◽

Sudden Onset ◽

Nasopharyngeal Swab ◽

Sensory Level ◽

Longitudinally Extensive Transverse Myelitis ◽

Ataxic Gait ◽

Normal Glucose Level ◽

Extensive Transverse Myelitis

Abstract IntroductionSince the COVID-19 pandemic, a growing number of central nervous system (CNS) complications in patients with COVID-19 have been reported. Isolated, longitudinally extensive transverse myelitis (LETM), is a unique presentation of CNS involvement. The limited reports, its diverse clinical manifestations and the possible long-term consequences make the reporting crucial to further our understanding of those syndromes occurring in COVID-19 positive patients.Case PresentationA 63-year old male consulted the emergency department after a sudden onset of gait ataxia, a one-week history of paresthesia progressing from the feet to the midsternal area and urinary. He tested positive on a SARS-CoV-2 RNA RT-PCR nasopharyngeal swab two days prior to the onset of his symptoms. Neurological examination showed a sensory level at T7 with symmetrically reduced fine touch, vibration, proprioception and furthermore an ataxic gait was observed. Cerebrospinal fluid on day one of admission showed pleocytosis, predominantly neutrophils, elevated protein count and normal glucose level and IgG. MRI of the spinal cord revealed a diffusely increased signal intensity involving the near-complete spinal cord, from the brainstem to level T12, fitting the diagnosis of LETM. ConclusionThe few cases of transverse myelitis in association with COVID-infection are believed to have an immune-mediated postinfectious mechanism. In this case however, parainfectious direct viral invasion of the spinal cord is far more likely because of a neutrophilic predominance in CSF and a short timespan between infection and symptoms. It could provide more clues that the SARS-CoV-2 is acutally capable of causing direct neurotoxic effects.

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Acute Aortic Occlusion Presenting as Flaccid Paraplegia

Case Reports in Neurological Medicine ◽

10.1155/2015/713489 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Ayman Kilany ◽

Jasem Y. Al-Hashel ◽

Azza Rady

Keyword(s):

Back Pain ◽

Sudden Onset ◽

Aortic Occlusion ◽

Sensory Level ◽

Severe Stenosis ◽

Iliac Arteries ◽

Csf Analysis ◽

Severe Back Pain ◽

Compressive Myelopathy ◽

Acute Aortic Occlusion

A 67-year-old male known to be hypertensive and diabetic had a sudden onset of severe low back pain and flaccid paraplegia with no sensory level or bladder affection and the distal pulsations were felt. Acute compressive myelopathy was excluded by MRI of the dorsal and lumbar spines. The nerve conduction study and CSF analysis was suggestive of acute demyelinating polyneuropathy. The patient developed ischemic changes of the lower limb and CT angiography revealed severe stenosis of the abdominal aorta and both common iliac arteries. We emphasize the importance of including acute aortic occlusion in the differential diagnosis of acute flaccid paraplegia especially in the presence of severe back pain even if the distal pulsations were felt.

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Acute Limb Ischaemia Following Elective Left Upper Lobectomy for Early NSCLC: A Rare but Serious Complication Arising from the Pulmonary Vein Stump

10.31487/j.crss.2020.01.02 ◽

2020 ◽

pp. 1-2

Author(s):

James Elliott ◽

Anand Iyer ◽

James Elliott

Keyword(s):

Pulmonary Vein ◽

Ct Angiography ◽

Mediastinal Lymph Node ◽

Case Reports ◽

Common Femoral Artery ◽

Sudden Onset ◽

Leg Pain ◽

Limb Ischaemia ◽

Left Upper Lobectomy ◽

Acute Limb Ischaemia

Patients undergoing Left Upper Lobectomy (LUL) appear to be at risk of a unique post-operative complication that is not well-documented: Pulmonary Vein (PV) stump thrombosis +/- systemic arterial embolisation [1-3]. We describe the details of a rare case from our institution, present a review of this subject from the limited literature available, and suggest potential strategies to anticipate, detect and manage this entity. A 70 year old female patient underwent left upper lobectomy and mediastinal lymph node sampling via repeat left thoracotomy. The procedure was unremarkable apart from some adhesions. She progressed well post-operatively on the ward. On post-operative day 2 the patient developed sudden-onset left leg pain and paraesthesia and CT-Angiography confirmed the diagnosis of left common femoral artery embolus and left superior PV stump thrombosis. The patient returned to theatre for femoral embolectomy, continued systemic anticoagulation, and made an excellent recovery thereafter. The aetiology of this complication has been documented in some case reports, but it is not explored further in trials or thoracic surgery texts [2-3]. One cohort study involving CT-angiography after lobectomy surgeries found that left upper lobectomy was unique as a risk factor for PV stump thrombosis1. It may be related to the relatively longer LSPV stump and stasis of blood in the stump [4].

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COVID-19 lung injury as a primer for immune checkpoint inhibitors (ICIs)-related pneumonia in a patient affected by squamous head and neck carcinoma treated with PD-L1 blockade: a case report

Journal for ImmunoTherapy of Cancer ◽

10.1136/jitc-2020-001870 ◽

2021 ◽

Vol 9 (2) ◽

pp. e001870

Author(s):

Angelo Dipasquale ◽

Pasquale Persico ◽

Elena Lorenzi ◽

Daoud Rahal ◽

Armando Santoro ◽

...

Keyword(s):

Lung Injury ◽

Head And Neck ◽

Checkpoint Inhibitors ◽

Experimental Therapy ◽

Common Mechanism ◽

Nasopharyngeal Swab ◽

Immune Mediated ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

By the beginning of the global pandemic, SARS-CoV-2 infection has dramatically impacted on oncology daily practice. In the current oncological landscape, where immunotherapy has revolutionized the treatment of several malignancies, distinguishing between COVID-19 and immune-mediated pneumonitis can be hard because of shared clinical, radiological and pathological features. Indeed, their common mechanism of aberrant inflammation could lead to a mutual and amplifying interaction.We describe the case of a 65–year-old patient affected by metastatic squamous head and neck cancer and candidate to an experimental therapy including an anti-PD-L1 agent. COVID-19 ground-glass opacities under resolution were an incidental finding during screening procedures and worsened after starting immunotherapy. The diagnostic work-up was consistent with ICIs-related pneumonia and it is conceivable that lung injury by SARS-CoV-2 has acted as an inflammatory primer for the development of the immune-related adverse event.Patients recovered from COVID-19 starting ICIs could be at greater risk of recall immune-mediated pneumonitis. Nasopharyngeal swab and chest CT scan are recommended before starting immunotherapy. The awareness of the phenomenon could allow an easier interpretation of radiological changes under treatment and a faster diagnostic work-up to resume ICIs. In the presence of clinical benefit, for asymptomatic ICIs-related pneumonia a watchful-waiting approach and immunotherapy prosecution are suggested.

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Ambulatory (24-hour Holter monitoring, event recorders) and signal-averaged ECG for arrhythmia registration in the athlete’s heart

The ESC Textbook of Sports Cardiology ◽

10.1093/med/9780198779742.003.0012 ◽

2019 ◽

pp. 107-114

Author(s):

Mahdi Sareban ◽

Josef Niebauer

Keyword(s):

Clinical Importance ◽

Holter Monitoring ◽

Athlete’S Heart ◽

Grey Zone ◽

Diagnostic Uncertainty ◽

Diagnostic Work ◽

Work Up ◽

Opening Up ◽

Heart Arrhythmias ◽

Athlete's Heart

Systematic physical exercise leads to structural, functional, and electrical cardiovascular changes summarized in the term ‘athlete’s heart’. Arrhythmias that are common features in the resting ECG of otherwise healthy athletes may be an expression of the athlete’s heart, but on the other hand may be caused by underlying cardiac pathology, opening up a grey zone of diagnostic uncertainty. Differentiating adaptive changes from pathological cardiac conditions is of great clinical importance because some cardiomyopathies are leading causes of sudden cardiac death in athletes. In addition, there is increasing evidence that excessive endurance training may induce intermittent atrial arrhythmias, which can be hard to detect by resting ECG. Therefore this chapter will highlight 24-hour Holter monitoring, event recorders, and signal-averaged ECGs in the emerging field of ambulatory arrhythmia registration as part of the diagnostic work-up of athlete’s heart.

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Lyme aortitis

BMJ Case Reports ◽

10.1136/bcr-2019-231957 ◽

2020 ◽

Vol 13 (1) ◽

pp. e231957

Author(s):

Rita Reis Correia ◽

Fábia Cruz ◽

Sandra Martin ◽

Maria Eugenia André

Keyword(s):

Thoracic Aorta ◽

Sudden Onset ◽

Ascending Aorta ◽

Daily Activities ◽

Initial Assessment ◽

Descending Thoracic Aorta ◽

Type A Aortic Dissection ◽

Coronary Syndrome ◽

Prosthesis Replacement ◽

Cold Extremities

A 72-year-old man was admitted with complaints of sudden-onset oppressive precordial pain radiating to the back for 1 hour. He had hypotension, peripheral cyanosis and cold extremities. An initial assessment was done and acute coronary syndrome was excluded. After the patient was admitted, he developed fever and increased levels of inflammatory markers. Data obtained from CT angiography and transoesophageal echocardiogram revealed diffuse parietal thickening of the arch and the descending thoracic aorta, as well as dilatation of the aortic root and the proximal ascending aorta. In addition, the test for Borrelia burgdorferi was positive, and the patient was diagnosed with Lyme vasculitis of the thoracic aorta. He was treated with doxycycline for 3 weeks. Two months later, the patient exhibited a Stanford type A aortic dissection (clinically stable), which was treated by prosthesis replacement. The patient has remained asymptomatic for 1 year after the episode, performing his routine daily activities.

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Delayed diagnosis of long QT syndrome in a patient with seizures

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918754921 ◽

2019 ◽

Vol 26 (3) ◽

pp. 190-193

Author(s):

Seung Yong Shin ◽

Jun Young Hong ◽

Dong Hoon Lee

Keyword(s):

Emergency Department ◽

Long Qt Syndrome ◽

Delayed Diagnosis ◽

Clinical Manifestations ◽

Initial Assessment ◽

Long Qt ◽

Prolonged Qt Interval ◽

Qt Syndrome ◽

Seizure Episode ◽

Diagnostic Work

Introduction: Long QT syndrome accompanied by a seizure episode is often misdiagnosed as primary epilepsy. Although patients with Long QT syndrome who are misdiagnosed and improperly managed are likely to result in fatality, their first clinical manifestations are seizure episodes in many cases. Case presentation: A 17-year-old boy visited the emergency department with poorly controlled seizure during epilepsy treatment was found to have been misdiagnosed with epilepsy when he was 7 years old. His electrocardiography showed a prolonged QT interval. After careful re-evaluation, he was finally diagnosed with Long QT syndrome and recovered without any seizure episodes in the absence of anti-epileptic agents. Discussion and conclusion: Careful initial assessment including repetitive electrocardiography, when abnormal, is required for those who visit the emergency department with a seizure or who show no definite abnormalities in diagnostic work up process.

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A well-appearing infant with a sudden anisocoria

Archives of Disease in Childhood - Education and Practice ◽

10.1136/archdischild-2020-319993 ◽

2020 ◽

pp. edpract-2020-319993

Author(s):

Alessia Giuseppina Servidio ◽

Francesca Peri ◽

Andrew Tenore ◽

Laura Cesca ◽

Laura Diplotti ◽

...

Keyword(s):

Clinical Presentation ◽

Brain Mri ◽

Vital Signs ◽

Sudden Onset ◽

List Type ◽

Case Presentation ◽

Third Nerve Palsy ◽

Age Limits ◽

Unilateral Mydriasis ◽

A Minor

Case presentationA 10-month-old boy was admitted to the emergency department due to a sudden onset of left unilateral mydriasis (figure 1). His medical history was unremarkable. A minor head trauma 2 days before was reported, without alarming signs or symptoms. His mother was putting him to sleep, after coming back from work, when she noticed a different pupil size and promptly went to the ED with her husband. The parents denied any use of medications, including nebulised therapy or direct contact with plants. The child was well appearing and his vital signs were within the standard age limits. His extraocular motility was normal as well as the rest of his neurological and physical examination. Parents’ behaviour was somehow remarkable. Even though the child was not suffering, the mother seemed very worried while the father was nervous and aggressive, repeatedly asking for a discharge.Figure 1Left unilateral mydriasis.QuestionsWhat is the most likely diagnosis based on this clinical presentation?Local contact with a mydriatic substanceIntracerebral haemorrhageBrain tumourThird nerve palsyWhat would be the next step in the investigation to confirm this diagnosis?Brain CTBrain MRIFundus oculi examinationToxicological screening of urineHow is this condition managed, and what is the prognosis?Answers can be found on page XX

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Nocardial Osteomyelitis of the Spine with Epidural Spinal Cord Compression-a Case Report

Neurosurgery ◽

10.1227/00006123-198408000-00019 ◽

1984 ◽

Vol 15 (2) ◽

pp. 254-256 ◽

Cited By ~ 20

Author(s):

Issam Awad ◽

Janet W. Bay ◽

John M. Petersen

Keyword(s):

Vertebral Osteomyelitis ◽

Cord Compression ◽

Nocardia Asteroides ◽

Sensory Level ◽

Thoracic Myelopathy ◽

Underlying Malignancy ◽

Rare Manifestation ◽

Specimen Processing ◽

Epidural Compression ◽

Diagnostic Work

Abstract A 53-year-old man presented with complaints of back pain and weakness in his lower extremities. Physical examination demonstrated a thoracic myelopathy with a sensory level at T-4, The diagnostic work-up revealed vertebral osteomyelitis of the thoracic spine with epidural compression at T-2-T-4 causing a nearly complete block on myelography. A decompressive laminectomy and debridement were performed, followed by anterior spinal fusion. Nocardia asteroides was cultured from the epidural space. The patient was concurrently treated with sulfonamides. No underlying malignancy or immunosuppression could be demonstrated, but a primary pulmonary nocardial infection was suspected. A satisfactory recovery was accomplished. Only four other cases of nocardial osteomyelitis of the spine have been reported in the literature. These are discussed, and possible mechanisms are proposed for the pathophysiology of this rare manifestation. Current recommendations on the specimen processing, diagnosis, and therapy of nocardial infections are briefly reviewed.

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A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding

International Journal of Surgical Oncology ◽

10.1155/2016/3039261 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5

Author(s):

M. C. Breijer ◽

N. C. M. Visser ◽

N. van Hanegem ◽

A. A. van der Wurff ◽

B. C. Opmeer ◽

...

Keyword(s):

Retrospective Cohort ◽

Endometrial Hyperplasia ◽

Outcome Measure ◽

Endometrial Biopsy ◽

Initial Assessment ◽

Postmenopausal Bleeding ◽

Pathology Laboratory ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Objective.To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples.Design.Retrospective cohort study.Setting.Single hospital pathology laboratory.Population.Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up and assessed as insufficient for a reliable histological diagnosis.Methods.Endometrial biopsy samples were requested from the pathology laboratories. The retrieved samples were systematically reassessed by a single pathologist specialized in gynecology.Main Outcome Measure.Disagreement between initial assessment and conclusion after structured reassessment.Results.We retrieved 36 of 66 endometrial biopsy samples from six different pathology laboratories. Structured reassessment of the retrieved samples by a single pathologist specialized in gynecology did not change the conclusion in 35 of the 36 samples. The remaining sample contained a large amount of endometrial tissue and the diagnosis at reassessment was endometrial hyperplasia without atypia. All other samples contained insufficient material for a reliable diagnosis.Conclusion.A structured reassessment of endometrial biopsies samples, which were classified as inconclusive due to insufficient material, did not change the conclusion. Although it might be helpful for pathologists to have diagnostic criteria for adequacy and/or inadequacy of an endometrial biopsy sample, the gain in efficiency is likely to be small.

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