Rare Case of Cryptococcal Meningitis in Non-HIV Patient with Mantle Cell Lymphoma Associated with Acalabrutinib (Tyrosine Kinase Inhibitor)

Cryptococcus neoformans infections are more common among immunosuppressed individuals, causing the most widespread opportunistic CNS infection among HIV-positive patients [1]. Specifically, those with cellular immunosuppression, such as patients with HIV positive CD4 counts less than 100. When a patient presents with atypical symptoms, it can be difficult to diagnose due to its infrequent presentation in HIV negative patients. Due to the rarity of encounters in HIV-negative patients, when atypical symptoms are present, it poses a diagnostic challenge. Mantle cell lymphoma (MCL) is a rare subtype of non-Hodgkin B-cell lymphoma that is known to be associated with cellular immunosuppression [2]. This demonstrates the need for early diagnosis and recognition of cryptococcal infections and as a physician should be vigilant to diagnose cryptococcal who is on Acalabrutinib with MCL [3]. CLL patients receiving ibrutinib should be evaluated for cryptococcal infection, which is potentially life threatening if overlooked [4]. Meningitis caused by Cryptococcus mainly presents with fever and altered mental status but in this case, our patient 78-year-old male with mantle cell lymphoma, undergoing a regimen of Rituximab-Bendamustine (BR) in combination with acalabrutinib (TKI), presented with hypotension to ED in June 2021. Cryptococcal infection in patient receiving ibrutinib were mostly reported in patients with Chronic lymphocytic leukemia, who have poor immune reconstitution. Here we are reporting case of cryptococcal meningoencephalitis in patient with MCL on acalabrutinib which is never reported before.

Extra-Intestinal Manifestations of Celiac Disease: What Should We Know in 2022?

Celiac disease (CD) is a chronic, small-intestinal, immune-mediated enteropathy due to gluten exposition in genetically predisposed individuals. It occurs in about 1% of the population and often remains an underdiagnosed condition. This could be due to the fact that the adult population often lacks the classical signs and symptoms of CD, manifesting only atypical symptoms. In this review we analyzed the main extra-intestinal manifestations of CD which include cutaneous and endocrinological disorders, abnormal liver function tests, and neuropsychiatric features. When CD is not diagnosed and therefore is not treated with a gluten-free diet (GFD), it can predispose to severe complications, not only gastrointestinal. Thus, it is important for clinicians to quickly recognize the atypical manifestations of CD, considering that an early diagnosis can significantly impact on a patient’s prognosis.

Endovascular therapy for distal hilar renal artery aneurysm: a case report and literature review

Renal artery aneurysm (RAA), a type of visceral aneurysm with atypical symptoms, is difficult to detect and is usually discovered incidentally by imaging examination. Hilar RAA (HRAA) represents a relatively rare subgroup of RAA that is located in the distal part of the renal artery, close to the renal parenchyma. We reported a 55-year-old woman with an HRAA measuring 19 mm × 20 mm × 20 mm. She underwent endovascular therapy with bare-metal stent implantation with nested coil embolization. She was discharged without complications. The uniqueness of this case is the aneurysm location, which was at the distal right renal artery, making it difficult to preserve the blood supply to the right kidney. The novelty of the minimally invasive technique was that this endovascular treatment not only eliminated the aneurysm, but also preserved the blood supply to the ipsilateral kidney. Endovascular therapy is effective in the management of HRAA.

Spectrum of mycobacterial pathogens responsible for head and neck tuberculosis-like presentation

Tuberculosis (TB) of the head and neck can be contained in the lymph nodes, larynx, oropharynx, salivary glands, nose and paranasal sinuses, ear, skin and skull. Head and neck TB presentations are varied in nature and thus difficult to diagnose. The clinical features, radiological findings, microbiological diagnostic modalities, surgical and medical management and outcomes of nine cases of head and neck TB are discussed in detail here, together with a thorough review of the literature. Patients presented with atypical symptoms such as discharging sinus, ear lobule swelling, otitis media, vision loss and facial weakness, long refractory otorrhoea and granulation tissue in the ear canal. We diagnosed tubercular skull base osteomyelitis (one case) and laryngeal tuberculosis (two cases), mastoid tuberculosis (one case) and non-tubercular mycobacterial infection involving the temporal bone (two cases), sino-nasal region (one case), maxilla (one cases) and ear lobule (one case) over a period of 8 months. All patients were managed successfully with a combination of surgery and a well-planned treatment regimen for non-tuberculous mycobacteria (NTM) or anti-tubercular drugs for TB. All had successful outcomes except one patient with tubercular skull base osteomyelitis who expired before the initiation of anti-tubercular therapy (ATT). High clinical suspicion followed by thorough diagnostic work-up for both TB and NTM would enable early diagnosis and complete treatment.

Atypical symptom reporting after mild traumatic brain injury

Objective: Early reporting of atypical symptoms following a mild traumatic brain injury (mTBI) may be an early indicator of poor prognosis. This study aimed to determine the percentage of people reporting atypical symptoms 1-month post-mTBI and explore links to recovery 12 months later in a community-dwelling mTBI sample. Methods: Adult participants (>16 years) who had experienced a mTBI were identified from a longitudinal incidence study (BIONIC). At 1-month post-injury, 260 participants completed the Rivermead Post-Concussion Symptoms Questionnaire (typical symptoms) plus four atypical symptom items (hemiplegia, difficulty swallowing, digestion problems and difficulties with fine motor tasks). At 12 months post-injury, 73.9% (n = 193) rated their overall recovery on a 100-point scale. An ordinal regression explored the association between atypical symptoms at 1 month and recovery at 12 months post-injury (low = 0–80, moderate = 81–99 and complete recovery = 100), whilst controlling for age, sex, rehabilitation received, ethnicity, mental and physical comorbidities and additional injuries sustained at the time of injury. Results: At 1-month post-injury <1% of participants reported hemiplegia, 5.4% difficulty swallowing, 10% digestion problems and 15.4% difficulties with fine motor tasks. The ordinal regression model revealed atypical symptoms were not significant predictors of self-rated recovery at 12 months. Older age at injury and higher typical symptoms at 1 month were independently associated with poorer recovery at 12 months, p < 0.01. Conclusion: Atypical symptoms on initial presentation were not linked to global self-reported recovery at 12 months. Age at injury and typical symptoms are stronger early indicators of longer-term prognosis. Further research is needed to determine if atypical symptoms predict other outcomes following mTBI.

Characterisation of Disease Patterns of Dermatomyositis with Different Initial Manifestations

Objectives To study the characteristics and prognosis of dermatomyositis (DM) with different initial symptoms. Patients and methods: A retrospective analysis was performed on the patients who were first diagnosed with DM from 1 Jan. 2019 to 1 Jan. 2021. According to different initial symptoms, patients were divided into five groups, including rash, myasthenia, arthritis, respiratory symptom and atypical symptom group. Clinical and laboratory data were recorded. All patients were followed up until 31st May 2021. Results In total 136 patients, rash (40%) was the most common initial symptoms of DM, followed by respiratory symptoms (22%), arthritis (20%), muscle weakness (10%) and atypical symptoms (8%). Rash groups and atypical groups had a higher positive rate of anti-TIF1γ antibodies than arthritis groups and respiratory symptom groups (P < 0.05). Respiratory symptom and arthritis groups had a higher positive rate of anti-Ro52 antibodies than rash and myasthenia groups (P < 0.05). Respiratory groups had a higher incidence of ILD than rash and atypical groups. The FVC and DLCO in respiratory group were significantly lower than rash, arthritis and atypical groups (P < 0.05). The 3-year survival rate of rash groups was significantly higher than myasthenia groups and arthritis groups (P < 0.05). Conclusions DM patients with different initial manifestations had different pulmonary function tests, myositis antibodies and prognosis.

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome

Background Pill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage. Case presentation A 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later. Conclusion Medication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Atypical Presentation of Acute Myocardial Infarction

Introduction: Chest pain has been reported as the cardinal clinical feature of Acute Myocardial Infarction (AMI). However, a substantial number of patients may have atypical or no symptoms on initial evaluation. The absence of typical chest pain and the vagueness of symptoms might result in a delay in seeking medical care. In this study atypical presentations of AMI and in-hospital mortality and outcome were evaluated. Material and Methods: A hospital based cross sectional study was performed among 110 patients of AMI admitted in the CCU who fulfilled the inclusion criteria. The Study was done from July, 2013 to January, 2014 in Dhaka Medical College Hospital, Dhaka, and National Institute of Cardiovascular Diseases (NICVD), Dhaka. Results: Among the 110 patients with AMI, 22 (20%) patients presented with atypical presentation. The maximum incidence of AMI with atypical presentations was in the age group of 65-74 years (28.57%). Dyspnoea (36.36%) was the most among the atypical symptom followed by vomiting 22.72% and the least incident with vertigo 4.54%. Inferior MI being the highest 46% among atypical MI where as mortality rate was high among the antero-septal MI (22.86%). The in hospital mortality of myocardial infarction patients who presented with typical and atypical symptoms were 15% and 36.36 %. Conclusion: The patients without chest pain represent a substantial segment of the MI population. Older patients presented with more atypical symptoms with breathlessness being the commonest atypical symptoms. Mortality was high among the patients who presented with atypical symptoms, increasing age, and who presented lately. J MEDICINE 2021; 22: 88-94

Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.