Edward L. Arsura

Neuroimaging as a Guide to Predict Outcomes for Patients with Coccidioidal Meningitis

Sixty-two patients with coccidioidal meningitis underwent neuroimaging. Magnetic resonance imaging detected neuroimaging abnormalities in 76% of patients, and computed tomography scanning detected neuroimaging abnormalities in 41.6%. The most common abnormal neuroimaging findings were hydrocephalus (51.6%), basilar meningitis (46.8%), and cerebral infarction (38.7%). Significantly elevated mortality rates were associated with hydrocephalus and hydrocephalus coexisting with infarction. Basilar meningitis did not influence outcome. Patients without neuroimaging abnormalities had a mortality rate of 7.7%.

Emphysematous cystitis: An unusual disease of the Genito-Urinary system suspected on imaging

Emphysematous cystitis is a rare disease entity caused by gas fermenting bacterial and fungal pathogens. Clinical symptoms are nonspecific and diagnostic clues often arise from the unanticipated imaging findings. We report a case of 52-year-old male who presented with fever, dysuria and gross hematuria who was found to have emphysematous cystitis.

Septic shock in coccidioidomycosis

OBJECTIVES To describe the clinical and laboratory parameters of patients with septic shock following infection with Coccidioides immitis, estimate the incidence of septic shock from coccidioidomycosis, and outline clues that may be helpful in early diagnosis of this syndrome. DESIGN Retrospective, descriptive case series. SETTING A 250-bed general public hospital in Kern County, CA. PATIENTS Eight patients diagnosed with septic shock from infection with C. immitis from September 1991 to December 1993. Five were Hispanic, two were Filipino, and one was African-American. The diagnosis of C. immitis was made by microscopic examination and culture of the organism from sputum or other sites. Septic shock was diagnosed using criteria formulated by the American College of Chest Physicians Consensus Conference/Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS No patient had traditional immunocompromising conditions. All patients had pulmonary symptoms and were symptomatic for a mean duration of 19.4 +/- 19.8 days before admission. One patient presented with septic shock and the remaining seven developed shock during their hospital course. Serology for coccidioidomycosis was positive in six patients. The mean cardiac index was 5.8 +/- 1.9 (SD) L/min/m2, the mean arterial pressure was 71.0 +/- 16.7 mm Hg, the mean pulmonary artery occlusion pressure was 16.9 +/- 3.5 mm Hg, and the mean systemic volume resistance index was 846.6 +/- 224.1 dyne-sec/cm5xm2. All patients developed acute respiratory distress syndrome. Coccidioidomycosis was recognized or considered in only five of eight patients before they developed septic shock. Despite therapy with amphotericin B, all patients died. One patient died of progressive pulmonary disease, two patients suffered an acute arrest, and five patients developed progressive multiple organ system failure and died with additional organ involvement. CONCLUSIONS Septic shock following infection with C. immitis is an ominous yet underrecognized condition. Hemodynamic parameters and cytokine concentrations were not significantly different from values seen in gram-negative septic shock. Clinical clues to the diagnosis include duration of illness and conspicuous pulmonary involvement. Patient outcome in this series was poor but may improve with increased recognition of septic shock in infections from C. immitis.

Hypercalcemia in patients with disseminated coccidioidomycosis

Objective: Granulomatous disorders may be associated with hypercalcemia. In sarcoidosis, the pathogenesis of hypercalcemia has been clarified, whereas in other granulomatous disorders, such as coccidioidomycosis, the mechanism is unclear. We present 13 patients with coccidioidomycosis and hypercalcemia to illustrate the clinical course and the mechanism of hypercalcemia. Methods: We retrospectively reviewed all patients admitted to Kern Medical Center, a 270‐bed public hospital, from 1990 through 1997 with coccidioidomycosis and a serum calcium level of greater than 10.5 mg/dL on at least 3 occasions. In addition, no other causes for hypercalcemia were identified. Results: The mean highest serum calcium level was 12.7 ± 1.8 mg/dL. All patients had disseminated disease. Six patients were nonambulatory and 4 had bone involvement. Of the 9 patients in whom parathyroid hormone was measured, it was normal in 6 and suppressed in 3. Of the 9 patients in whom 25‐hydroxyvitamin D was measured, it was normal in 6, suppressed in 2, and elevated in 1. Of the 7 patients in whom 1,25‐dihydroxyvitamin D was measured, it was normal in 3 and suppressed in 4. Urinary calcium was elevated in 2 patients, both of whom were ambulatory. Nonambulatory patients had significantly higher serum calcium levels (14.3 ± 1.0 mg/dL) than ambulatory patients (11.3 ± 0.46 mg/dL) (P < 0.001). Conclusions: The mechanism of hypercalcemia in coccidioidomycosis is unrelated to increased production of 1,25‐dihydroxyvitamin D. Nonambulatory status is associated with higher mean serum calcium.

Abdominal pain secondary to pylephlebitis: an uncommon disease of the portal venous system, treated with local thrombolytic therapy.

Pylephlebitis is a rare complication of intraabdominal inflammatory processes that carries an elevated mortality rate. Even in the modern era, diagnosis and treatment are difficult because of the nonspecific nature of clinical signs and symptoms and laboratory studies. We present a patient with pylephlebitis who had rapid resolution of symptoms after administration alteplase (tPA). The outcome of this uncommon entity can be improved with a high index of clinical suspicion, better imaging modalities, and interventional radiology techniques.

Hepatic portal and mesenteric vein gas as a late complication of percutaneous endoscopic gastrostomy tube placement in an elderly patient.

Hepatic portomesenteric venous gas (HPVG) most often represents an ominous clinical finding. The presentation is usually consistent with an acute abdomen but at times vague abdominal symptoms and nonspecific laboratory predominate. The occurrence of HPVG as a late complication from percutaneous endoscopic gastrostomy (PEG) tube placement is a previously unreported event. PEG is a frequently performed procedure and the clinician should be aware of the significance of HPVG in a patient with recent PEG.

Stiff Man Syndrome: A Diagnostic Dilemma in a Young Female with Diabetes Mellitus and Thyroiditis

Stiff Person Syndrome (SPS), is a very rare neuroimmunologic disorder characterized by progressive muscle pain, rigidity, stiffness, and spasms. It can be very debilitating if misdiagnosed or not recognized in time. Herein we discuss a case of a female in her 20s who presented with an unsteady gait, lower extremity weakness, persistent leg pain, and stiffness few weeks after uncomplicated childbirth. She has type 1 diabetes mellitus (DM) and was diagnosed with thyroiditis in the course of her illness. The triad of thyroiditis, DM, and stiffness with normal neuroimaging in a young female patient is an unusual occurrence.

Impact of the duration of antiplatelet therapy after vertebrobasilar artery stent placement

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Cognitive decline in an elderly hospitalized patient with primary leptomeningeal melanomatosis

Delirium is one of the most common disorders in hospitalized patients. The authors present the case of an elderly male patient with postoperative cognitive decline that did not resolve with the conventional treatment. The diagnosis was only established on autopsy. A 75-year-old man was evaluated after a fall. Initial evaluation revealed voluntary guarding in the right epigastric region, and free air was detected under the right hemidiaphragm on abdominal radiography. An exploratory laparotomy revealed a perforation that had apparently sealed off. After surgery, he had initial improvement toward baseline; however, after several days, his postoperative course was complicated by a progressive deterioration in mental status, recurrent seizures, and aspiration pneumonia. Computed tomographic scan of the brain showed communicating hydrocephalus. Examination of the cerebrospinal fluid revealed an elevated opening pressure and elevated protein. His mental status continued to deteriorate, and he died. Autopsy revealed the pathologic diagnosis of primary leptomeningeal melanomatosis.

A fatal case of congenital pulmonary airway malformation with aspergillosis in an adult.

Congenital cystic adenomatoid malformation, currently referred as congenital pulmonary airway malformation (CPAM), is one of the rare lung malformations seen in adults. We report a case of a 59-year-old male with a chronic cough and hemoptysis that was not amenable to bronchial embolization. Further work up revealed cystic changes with fungal ball and type 1 CPAM. Patients with this condition who survive to adulthood usually suffer from recurrent respiratory bacterial infections. Only three cases of fungal involvement have ever been described. We present a fatal case, as well as the oldest patient.