Gastric pneumatosis in immunocompromised patients: A report of 2 cases and comprehensive literature review

Gastric pneumatosis (GP) is a rare finding. It can be seen with both gastric emphysema (GE) and emphysematous gastritis (EG); however, both conditions present similarly and differentiating between the 2 is difficult radiographically. Moreover, the treatment is vastly different for both conditions, in which treatment for GE is focused on supportive care while treatment for EG may even involve gastrectomy. Making the distinction between GE and EG is crucial because GE has a benign clinical course, while EG carries significant mortality. Early endoscopy may be a useful tool in differentiating between the 2 conditions and to guide further management. Herein, we present a case series of 2 immunocompromised patients who presented with symptoms and radiographic evidence consistent with gastric pneumatosis. We found that early endoscopy assisted in risk stratification and helped guide our management strategy. We recommend consideration of endoscopic evaluation as part of ritualized evaluation of patients presenting with gastric pneumatosis.

Pott's paraplegia and role of neuroimaging in resource limited setting: A case report and brief review of the literatures

BACKGROUND

Tuberculosis (TB) is the leading cause of morbidity and mortality in low and middle income countries (LMIC). Approximately 50% of cases of skeletal TB involve the spine. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. The clinical and radiologic features of Pott's disease may mimic other spine diseases such as, metastatic lesions and other infectious etiologies, this is especially imperative in older patients.

CASE REPORT

We report a 60-year-old right handed male patient presented with back pain, paraparesis, and sensory symptoms 2 weeks duration. He has history of dry cough, fatigue, and reduced appetite, but no history of weight loss, fever, night sweat, and bowel/bladder incontinence. No contact history with TB patients. He has a borderline hypertension and diabetes mellitus. Serology for HIV was negative. Thoraco-lumbar magnetic resonance image (MRI) showed destruction of L2 and L3 vertebral body and the inter-vertebral disc; with T2 hyper and T1 hypointensity of the affected vertebral bodies. Probable tuberculous spondylitis with paraparesis was considered and the patient was initiated on antituberculous regimen and short course steroid therapy. After five months treatment, the patient showed significant clinical and radiological improvement.

CONCLUSION

In summary, the present case describes, a patient with Pott's paraplegia due to probable spine tuberculosis and showed significant clinical and radiological improvement following initiation of antituberculous drugs and short course of steroid; indicating the crucial role of imaging in the diagnosis of TB, especially in resource limited settings.

Pathologic fracture and hardware failure in Streptococcus anginosus femoral osteomyelitis: Case report

Introduction

Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has rarely been described. With limited evidence for treating S. anginosus osteomyelitis, the orthopaedic surgeon is presented with a difficult treatment decision at index presentation. Presented here is a case of failed conservative management, diagnostic dilemma, failed hardware stabilization, and definitive surgical treatment resulting in good clinical outcome.

Case presentation

A 69-year-old male experienced acute right thigh pain, edema, and erythema after dental treatment 17 days prior. He was diagnosed with right femoral diaphyseal osteomyelitis and Brodie's abscess. Blood cultures grew S. anginosus, but all site-specific tissue cultures resulted negative. Initial management consisted of intravenous antibiotic therapy and percutaneous abscess drainage. Months later, the patient sustained a displaced pathologic fracture of the diaphyseal femur and there was concern for neoplasm, but biopsies were negative. Stabilization was attempted with a lateral plate and screws. This hardware catastrophically failed in the setting of an oligotrophic femoral nonunion. Ultimately, the patient was successfully treated with an intramedullary nail coated with antibiotic-impregnated cement. Twelve months later, the patient achieved clinical and radiographic healing with no evidence of relapse of his osteomyelitis.

Clinical discussion

Conservative management of S. anginosus femoral osteomyelitis was inadequate and corroborates the existing literature. S. anginosus osteomyelitis and pyomyositis may be most optimally treated aggressively with early surgical intervention.

Conclusion

Early surgical debridement and stabilization of the compromised bone with an antibiotic coated intramedullary nail following medullary reaming may prevent pathologic fracture, eradicate infection, and achieve predictable outcomes.

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S. anginosus femoral osteomyelitis is rare and difficult to diagnose and treat.

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Conservative measures failed, and pathologic fracture later ensued.

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Although sparse, existing reports suggest early surgical management is indicated.

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This report provides more evidence for early and aggressive surgical management.

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Good outcome was achieved with antibiotic coated intramedullary nailing.

Lhermitte-Duclos disease: A case report with radiologic-pathologic correlation

Background: Lhermitte-Duclos disease (LDD) stems from the development of a rare benign lesion of uncertain pathogenesis that distorts the normal cerebellar laminar cytoarchitecture. We explored the lesion's appearance on conventional magnetic resonance imaging (MRI) combined with susceptibility-weighted imaging, diffusion-weighted imaging, perfusion imaging, or arterial spin labeling. Although many cases of LDD have been previously reported in the literature, the radiologic-pathologic correlation has been described in only a few of these cases. To the best of our knowledge, this is the first case report to provide detailed information about the radiologic-pathologic correlation of LDD. Case Report: A 48-year-old woman presented with left facial tics, occipital headache, and dizziness for 1 month. MRI revealed a left cerebellar lesion with hypointensity on T1-weighted images. On T2-weighted images, the mass was hyperintense with tigroid appearance due to alternating high and normal signal intensities. High signal intensity was noted on fluid-attenuated inversion recovery images. Magnetic resonance spectroscopy indicated decreased level of choline (Cho), N-acetyl aspartate, and myoinositol with elevated level of lactate on the affected side. The lesion showed a bright signal on diffusion-weighted images, whereas apparent diffusion coefficient mapping revealed no disturbance of diffusion. The pathology of the excised lesion was consistent with LDD. Conclusion: MRI with advanced techniques can provide not only preoperative diagnosis but also better pathologic correlation.

Effect of Corticosteroids on RVNA production of a patient with acute disseminated encephalomyelitis following rabies vaccination as well as administration of HRIG

It has not been reported that administration of combining rabies vaccines and immunoglobulin resulted in acute disseminated encephalomyelitis (ADEM) yet. This report described that an old man acquired ADEM after being administrated with purified Vero cell rabies vaccine (PVRV) and Human Rabies Immunoglobulin (HRIG). Then he was given intravenous and oral glucocorticoids. Simultaneously, rabies vaccination was continued with purified Chick embryo cell vaccines (PCECV) instead of PVRV. Furthermore, we analyzed the rabies virus neutralizing antibodies (RVNA) levels in the patient's blood at different time points after rabies vaccination. Collectively, we observed that PCECV vaccination did not affect the prognosis of ADEM, and glucocorticoid was crucial and effective, which had no significant influence on efficacy of PCECV.

Thalamic-hippocampal-prefrontal disruption in relapsing-remitting multiple sclerosis

Background

Cortical, thalamic and hippocampal gray matter atrophy in relapsing–remitting MS (RRMS) is associated cognitive deficits. However, the role of interconnecting white matter pathways including the fornix, cingulum, and uncinate fasciculus (UF) is less well studied.

Objective

To assess MS damage to a hippocampal–thalamic–prefrontal network and the relative contributions of its components to specific cognitive domains.

Methods

We calculated diffusion tensor fractional anisotropy (FA) in the fornix, cingulum and UF as well as thalamic and hippocampal volumes in 27 RRMS patients and 20 healthy controls. A neuropsychological battery was administered and 4 core tests known to be sensitive to MS changes were used to assess cognitive impairment. To determine the relationships between structure and cognition, all tests were grouped into 4 domains: attention/executive function, processing speed, verbal memory, and spatial memory. Univariate correlations with structural measures and depressive symptoms identified potential contributors to cognitive performance and subsequent linear regression determined their relative effects on performance in each domain. For significant predictors, we also explored the effects of laterality and axial versus radial diffusivity.

Results

RRMS patients had worse performance on the Symbol Digit Modalities Test, but no significant impairment in the 4 cognitive domains. RRMS had reduced mean FA of all 3 pathways and reduced thalamic and hippocampal volumes compared to controls. In RRMS we found that thalamic volume and BDI predicted attention/executive function, UF FA predicted processing speed, thalamic volume predicted verbal memory, and UF FA and BDI predicted spatial memory.

Conclusions

Hippocampal–thalamic–prefrontal disruption affects cognitive performance in early RRMS with mild to minimal cognitive impairment, confirming both white and gray matter involvement in MS and demonstrating utility in assessing functional networks to monitor cognition.

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We detect limbic white matter and gray matter insult in early RRMS patients with mild to minimal cognitive impairment.

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Thalamic atrophy and uncinate fasciculus microstructural changes are associated with cognitive performance in early RRMS.

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Depressive symptomatology also independently predicts cognitive performance