Deepa Panikkath

Idiopathic intracranial hypertension: ongoing clinical challenges and future prospects.

Idiopathic intracranial hypertension (IIH) is an uncommon disorder characterized by increased intracranial pressure without radiological or laboratory evidence of intracranial pathology except empty sella turcica, optic nerve sheath with filled out cerebrospinal fluid spaces, and smooth-walled nonflow-related venous sinus stenosis or collapse. This condition typically affects obese women. The incidence of IIH is increasing with the rising prevalence of obesity. Persistent headache is the most common symptom. Visual impairment is a serious complication that may not be recognized by the patients. This paper reviews clinical manifestations, diagnostic challenges, and current treatments of IIH in adults. Various imaging modalities have been studied on their validity for detection of IIH and papilledema. This review also includes new studies on medical, surgical, and interventional management of this condition. Acetazolamide and topiramate are the only two medications that have been studied in randomized controlled trials about their efficacy in treatment of IIH. In patients who have severe visual impairment or progressive visual deterioration despite medical management, surgical or interventional treatment may be considered. The efficacy and complications of cerebrospinal fluid diversion, optic nerve sheath fenestration, and endovascular venous stenting reported in the last 3 decades have been summarized in this review. Finally, the prospective aspects of biomarkers and treatments are proposed for future research.

The alien hand syndrome.

A 77-year-old woman presented with the complaint of observing her left hand moving without her knowledge while watching television. Her left hand stroked her face and hair as if somebody was controlling it. These movements lasted only half an hour but on recovery, she had left hemiparesis. Alien hand syndrome as the presentation of cardioembolic stroke is extremely rare but can be terrifying to patients.

A Review of Inflammatory Bowel Disease in Patients with Human Immunodeficiency Virus Infection

The coexistence of inflammatory bowel disease and human immunodeficiency virus infection is rare but does occur. Since immune mechanisms have an important role in the pathophysiology of both diseases, we might expect HIV infection to significantly alter the course of IBD. The pathophysiologic relationship between HIV and IBD is complex and controversial. Although many studies suggest spontaneous improvement in IBD symptoms and stable remissions after HIV infection, there are reports of relapse and new onset IBD with the decline in CD4 counts. Many of the opportunistic infections in HIV can mimic IBD and can lead to misdiagnosis and treatment as IBD. The treatment of IBD in HIV is associated with an increased risk of infections and lymphoma, and careful follow-up is essential.

Mach band sign: an optical illusion.

The chest radiograph of a 63-year-old woman who was found unresponsive was concerning for pneumopericardium, but lacked the other corroborative features suggestive of pneumopericardium. None of the follow-up chest radiographs showed evidence of air around the heart. The radiolucent shadow that mimicked pneumopericardium in this case was due to an artifact known as Mach band sign, an illusion created by lateral inhibition in the light receptors in the retina.

Kernohan's Notch: A Forgotten Cause of Hemiplegia—CT Scans Are Useful in This Diagnosis

Hemiparesis ipsilateral to a cerebral lesion can be a false localizing sign. This is due to midline shift of the midbrain resulting in compression of the contralateral pyramidal fibers on the tough dural reflection tentorium cerebelli. This may result in partial or complete damage to these fibers. Since these fibers are destined to cross in the medulla and innervate the opposite side of the body, this causes hemiparesis ipsilateral to the site of cerebral lesion. Computed tomography (CT) scans have not been used to support the diagnosis of this entity until now. We report a 68-year-old woman with a subdural hematoma who developed ipsilateral hemiparesis without any other explanation (Kernohans notch). The CT of the head showed evidence of compression of the midbrain contralateral to the hematoma and was useful in the diagnosis. The purpose of this report is to increase the awareness of this presentation and to emphasize the utility of CT scans to support the diagnosis.

An Uncommon Complication With Use of Topical Local Anesthetic Agents: Methemoglobinemia.

Although the use of topical local anesthetics is generally safe, several potentially fatal complications have been reported. Methemoglobinemia is a rare but potentially fatal complication. Methemoglobin is a naturally occurring oxidized metabolite of hemoglobin, and physiologic levels (<1%) are normal. Methemoglobinemia can be congenital or acquired. Several drugs including topical anesthetic agents like benzocaine can induce this condition. Sudden appearance of cyanosis, with a disproportionately better oxygen saturation of 85% after use of local anesthetics can be a helpful for diagnosis.

Fatal Clostridium septicum infection in a patient with a hematological malignancy.

A 49-year-old woman with acute myeloid transformation of myelodysplastic syndrome was admitted with mild erythema and pain in the right thigh and left forearm. She was doing well and had been discharged the previous day after consolidation chemotherapy. Examination showed only mild erythema and tenderness of the right thigh. She was started on broad-spectrum antibiotics. Discoloration progressed rapidly, and within hours the right femoral and left brachial pulses were not palpable. She was taken to the operating room for a suspicion of embolic arterial occlusion. Surgical incision, however, revealed extensive necrosis of the tissues with the presence of gas. Her relatives did not want her to undergo amputation. The patient developed refractory hypotension and died within 15 hours of presentation. Blood samples later tested positive for Clostridium septicum. This case is presented to create awareness about the subtle presentation and rapid progression of this infection, which can lead to death in less than 24 hours.

Streptococcus agalactiae pyomyositis in diabetes mellitus

Pyomyositis is an acute infectious disorder affecting the skeletal muscle. Although seen more commonly in the tropics, cases are being reported in temperate countries, including the United States. We report a case of nontropical pyomyositis in a 58-year-old diabetic man who presented with a vague chest wall swelling. His initial clinical presentation and imaging findings suggested an intramuscular hematoma. He later developed fever with increased swelling, and pyomyositis was diagnosed after an aspiration of the swelling yielded Streptococcus agalactiae. Aspiration of the abscess and the use of appropriate antibiotics led to complete resolution of the disease. We discuss possible factors in diabetics that might predispose them to pyomyositis.

Amphetamine-related ischemic colitis causing gastrointestinal bleeding.

A 43-year-old woman presented with acute lower intestinal bleeding requiring blood transfusion. Multiple initial investigations did not reveal the cause of the bleeding. Colonoscopy performed 2 days later showed features suggestive of ischemic colitis. On detailed history, the patient admitted to using amphetamines, and her urine drug screen was positive for them. She was managed conservatively and advised not to use amphetamines again. She did not have any recurrence on 2-year follow-up.

An Uncommon Association of Familial Partial Lipodystrophy, Dilated Cardiomyopathy, and Conduction System Disease

A 46-year-old African American woman presented with severe respiratory distress requiring intubation and was diagnosed with nonischemic cardiomyopathy. She had the typical phenotype of familial partial lipodystrophy 2 (FPLD2). Sequence analysis of LMNA gene showed a heterozygous missense mutation at exon 8 (c.1444C>T) causing amino acid change, p.R482W. She later developed severe coronary artery disease requiring multiple percutaneous coronary interventions and coronary artery bypass surgery. She was later diagnosed with diabetes, primary hyperparathyroidism, and euthyroid multinodular goiter. She had sinus nodal and atrioventricular nodal disease and had an implantable cardioverter defibrillator implantation due to persistent left ventricular dysfunction. The device eroded through the skin few months after implantation and needed a re-implant on the contralateral side. She had atrial flutter requiring ablation. This patient with FPLD2 had most of the reported cardiac complications of FPLD2. This case is presented to improve the awareness of the presentation of this disease among cardiologists and internists.