Is there a link between COVID-19 and Creutzfeldt-Jakob Disease? a Case Report

Creutzfeldt-Jakob Disease (CJD) is a rare rapidly progressive neurodegenerative disease. The diagnosis of CJD is based on magnetic resonance imaging (MRI) findings, electro-encephalography (EEG), or 14-3-3 protein detection. We report a case of a previously-healthy 72 years old woman, with evidence of coronavirus disease 2019 (COVID-19), who complained of behavioral changes and rapidly progressive dementia. While hospitalization, she didn't have orientation to time and place and repeated an irrelevant sentence in response to questions. Also, anomia and impaired comprehension was observed. Myoclonic jerks, abnormal signal intensity at bilateral parieto-occipital cortices in MRI, periodic sharp wave complexes in EEG, and increased lactate dehydrogenase in cerebrospinal fluid (CSF), highly recommended CJD for her. This is the second case of CJD after COVID-19 during this pandemic, which can be an alarm to clinicians about the silent impact of COVID-19 on the central nervous system.

Diagnostic performance of T2-weighted imaging and intravoxel incoherent motion diffusion-weighted MRI for predicting metastatic axillary lymph nodes in T1 and T2 stage breast cancer

Background Non-invasive modalities for assessing axillary lymph node (ALN) are needed in clinical practice. Purpose To investigate the suspicious ALN on unenhanced T2-weighted (T2W) imaging and intravoxel incoherent motion diffusion-weighted imaging (IVIM DWI) for predicting ALN metastases (ALNM) in patients with T1–T2 stage breast cancer and clinically negative ALN. Material and Methods Two radiologists identified the most suspicious ALN or the largest ALN in negative axilla by T2W imaging features, including short axis (Size-S), long axis (Size-L)/S ratio, fatty hilum, margin, and signal intensity on T2W imaging. The IVIM parameters of these selected ALNs were also obtained. The Mann–Whitney U test or t-test was used to compare the metastatic and non-metastatic ALN groups. Finally, logistic regression analysis with T2W imaging and IVIM features for predicting ALNM was conducted. Results This study included 49 patients with metastatic ALNs and 50 patients with non-metastatic ALNs. Using the above conventional features on T2W imaging, the sensitivity and specificity in predicting ALNM were not high. Compared with non-metastatic ALNs, metastatic ALNs had lower pseudo-diffusion coefficient (D*) ( P = 0.043). Logistic regression analysis showed that the most useful features for predicting ALNM were signal intensity and D*. The sensitivity and specificity predicting ALNM that satisfied abnormal signal intensity and lower D* were 73.5% and 84%, respectively. Conclusions The abnormal signal intensity on T2W imaging and one IVIM feature (D*) were significantly associated with ALNM, with sensitivity of 73.5% and specificity of 84%.

A Case of Musicogenic Epilepsy

Musicogenic epilepsy is a relatively rare form of epilepsy characterized by seizures triggered by specific music experiences, with an estimated prevalence of 1/10,000,000 population. We report a case of 12-year-old boy with a history of recent onset focal seizures associated with an aura of formed visual hallucinations, feeling of familiarity (déjà vu), and impending fear lasting for seconds to a minute followed by eye blinking, oral automatisms, and unresponsiveness for almost 15 minutes. These episodes, most often, were provoked by music. Video electroencephalogram (EEG) done in our institute was suggestive of reflex musicogenic epilepsy arising from the left anterior temporal lobe. Magnetic resonance imaging of the brain 3T with epilepsy protocol confirmed video EEG findings, with an abnormal signal intensity in the left hippocampal and mesial temporal lobe. Treatment included lifestyle modification and antiepileptic drugs.

Edema-like marrow signal intensity: a narrative review with a pictorial essay

The term edema-like marrow signal intensity (ELMSI) represents a general term describing an area of abnormal signal intensity at MRI. Its appearance includes absence of clear margins and the possibility of exceeding well-defined anatomical borders (for example, physeal scars). We can define “ELMSI with unknown cause” an entity where the characteristic MR appearance is associated with the absence of specific signs of an underlying condition. However, it is more often an important finding indicating the presence of an underlying disease, and we describe this case as “ELMSI with known cause.” It presents a dynamic behavior and its evolution can largely vary. It initially corresponds to an acute inflammatory response with edema, before being variably replaced by more permanent marrow remodeling changes such as fibrosis or myxomatous connective tissue that can occur over time. It is important to study ELMSI variations over time in order to evaluate the activity state and therapeutic response of an inflammatory chronic joint disease, the resolution of a trauma, and the severity of an osteoarthritis. We propose a narrative review of the literature dealing with various subjects about this challenging topic that is imaging, temporal evolution, etiology, differential diagnoses, and possible organization, together with a pictorial essay.

<i>Salmonella</i> osteomyelitis of the distal radius in a healthy pregnant woman

Although characteristic, Salmonella is a rare cause of osteomyelitis, especially in healthy individuals. A 25-year old primigravida at 29 weeks' gestation noticed pain and swelling in her right wrist. Her leukocyte count was normal, but her C-reactive protein level was slightly elevated, at 1.1 mg dL−1 (normal range, <0.2 mg dL−1). Plain radiography showed an osteolytic lesion in the distal radius, and magnetic resonance imaging (MRI) showed an extraosseous fluid collection with bone edema in addition to the osseous lesion. After a needle biopsy was performed, the skin overlying the lesion became ulcerated at the site of the needle tract. We drained whitish pus from the site; both this pus and the original biopsy specimen grew Salmonella on culture. We diagnosed Salmonella osteomyelitis and began intravenous antibiotic therapy, avoiding oral quinolones to prevent fetotoxicity. Her symptoms resolved, as did the bone edema and fluid collection. Ossification occurred at the site of osteolysis, with localized abnormal signal intensity persisting on MRI. This rare case of Salmonella osteomyelitis was treated without surgery; the patient's pregnancy influenced the treatment course.

Intraoperative Arthroscopic Findings of Ulnar Impaction Syndrome

Purpose: The purpose of this study was to compare the preoperative magnetic resonance imaging (MRI) findings and intraoperative arthroscopic findings in ulnar impaction syndrome, and to assess the necessity of the arthroscopic evaluation in ulnar shortening osteotomy.Methods: We retrospectively reviewed 46 patients of idiopathic ulnar impaction syndrome, treated by ulnar shortening osteotomy and arthroscopic evaluation, from February 2012 to June 2018. In preoperative MRI and intraoperative arthroscopy, lunate, triquetrum, triangular fibrocartilage complex (TFCC) and lunotriquetral ligament were evaluated.Results: The chance to see the findings of chondromalacia of the lunate and triquetral cartilage in arthroscopy (58% and 2%) was less than the findings of abnormal signal intensity of the lunate and triquetrum in MRI (65% and 22%). The incidence of TFCC lesion in arthroscopy (89%) was almost equal with that of abnormal signal intensity of TFCC in MRI findings (87%). But there were 24 cases (52%) where the prediction of triangular fibrocartilage lesions in MRI was incorrect. In 19 cases (41%), arthroscopic findings were not appropriate with the disease stage of Palmer’s original classification. Conclusion: Although some recent reports say that arthroscopic surgery is not necessary in the treatment of ulnar impaction syndrome, we could confirm the value of arthroscopic evaluation for the identification of ulnocarpal pathologies. We would like to recommend the arthroscopic evaluation of ulnocarpal joint at the same time of the ulnar shortening procedure.

Myofascia-dominant involvement on whole-body MRI as a risk factor for rapidly progressive interstitial lung disease in dermatomyositis

Objective Rapidly progressive interstitial lung disease (RPILD) is a major cause of death in patients with DM. Although clinically amyopathic DM (CADM) represents risk for RPILD, the incidence rate of RPILD in patients with CADM varies widely. Whole-body (WB) MRI can reveal involvement of systemic muscle and myofascia. The objective of this study was to explore the risk factors for RPILD in patients with DM using WB-MRI. Methods This retrospective study comprised 41 patients with DM who underwent WB-MRI before the initiation of treatment in our hospital. Muscular and myofascial signals were scored on 42 muscular groups. The myofascia/muscle ratio was calculated and used to define the relevance of myofascia-dominant involvement. RPILD was defined as worsening of dyspnoea, hypoxaemia and radiographic ILD/fibrosis within 3 months from the onset of respiratory symptoms. Results Among the 41 patients, 17 had CADM and 30 had ILD, including 10 patients with RPILD. All patients including those with CADM showed abnormal signal intensity in both muscle and myofascia (median score: 15 and 23, respectively). Muscle signal scores positively correlated with the serum creatine kinase level (r = 0.714; P&lt; 0.001). Patients with RPILD showed a significantly higher myofascia/muscle ratio than those without RPILD (1.929 vs 1.200; P= 0.027). Logistic regression analysis identified higher myofascia/muscle ratio as independent risk factors for developing RPILD. Conclusion Myofascia-dominant involvement was defined and appreciated in patients with DM using WB-MRI. This may be one of the risk factors for RPILD.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

Background: Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear. Purpose: To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD. Study Design: Case series; Level of evidence, 4. Methods: Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group. Results: Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) ( P = .027). Conclusion: OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

PRES Associated with Eclampsia: A Case Report

The occurrence of posterior reversible encephalopathy syndrome (PRES) in patients with eclampsia is a rare condition. PRES is a reversible syndrome characterized by headache, seizure, altered mentation and loss of vision associated with white matter changes on imaging. The lesions in PRES are thought to be due to vasogenic oedema, predominantly in the posterior cerebral hemispheres. This study reports a 32-year-old pregnant woman who presented with headache, dimness of vision, right sided weakness and seizure. The MRI of her brain showed abnormal signal intensity in the white matter of the occipital and parietal lobes. She was treated successfully with pregnancy termination, anti-hypertensives, anticonvulsants, and supportive care. It is concluded that early diagnosis is important to prevent permanent neurologic damage and mortality. Bangladesh J Medicine July 2019; 30(2) : 104-107