Hassan Tahir

Extranodal Rosai-Dorfman Disease Involving the Left Atrium: Cardiac MRI, CT, and PET Scan Findings

Rosai-Dorfman disease (RDD) is a rare entity that usually involves the lymph nodes but extranodal involvements have been seen in numerous cases, although RDD with cardiovascular involvement is extremely rare. We describe a case of a young male who presented with intermittent palpitations and was found to have a left atrium mass. Our case not only emphasizes the rarity of the above lesion but also highlights the importance of modern-day imaging like computed tomography, Cardiac Magnetic Resonance Imaging (CMRI), and PET scan in characterizing such nonspecific lesions and directing appropriate line of treatment. RDD should be considered as one of the differentials even for isolated cardiac lesions.

Pseudoradial Nerve Palsy Caused by Acute Ischemic Stroke.

Pseudoperipheral palsy has been used to characterize isolated monoparesis secondary to stroke. Isolated hand nerve palsy is a rare presentation for acute cerebral stroke. Our patient presented with clinical features of typical peripheral radial nerve palsy and a normal computed tomography scan of the head, which, without a detailed history and neurological examination, could have been easily misdiagnosed as a peripheral nerve lesion deferring further investigation for a stroke. We stress the importance of including cerebral infarction as a critical differential diagnosis in patients presenting with sensory-motor deficit in an isolated peripheral nerve pattern. A good history and physical exam can differentiate stroke from peripheral neuropathy as the cause of radial nerve palsy.

Metabolic ketoacidosis with normal blood glucose: A rare complication of sodium-glucose cotransporter 2 inhibitors.

Ketoacidosis is a significant and often a life-threatening complication of diabetes mellitus seen mostly in type 1 diabetes mellitus as well as occasionally in type 2 diabetes mellitus. Diabetic ketoacidosis usually manifests with high blood glucose more than 250 mg/dL, but euglycemic diabetic ketoacidosis is defined as ketoacidosis associated with blood glucose level less than 250 mg/dL. Normal blood glucose in such patients results in significant delay in diagnosis and management of diabetic ketoacidosis, thus increasing mortality and morbidity. We present a case of euglycemic diabetic ketoacidosis secondary to canagliflozin in a type 2 diabetic patient.

Immune Thrombocytopenia (ITP) Secondary to Subclinical Hashimoto's Thyroiditis: Role of Levothyroxine in Improving the Clinical Outcome of ITP.

Immune thrombocytopenia (ITP) is the most common cause of isolated thrombocytopenia in healthy people. ITP may rarely coexist with autoimmune thyroid disorders, which may indicate more complex defect in immune system. Primary ITP usually responds well to steroids and intravenous immunoglobulins. However, ITP may be difficult to treat when associated with thyroid autoimmune disorders. In such cases, treating the underlying thyroid disorder may significantly improve platelet count and can either cause remission of disease or improve response to standard ITP therapy. We report a case of 47-year-old male who was diagnosed with ITP and was also found to have subclinical Hashimoto’s thyroiditis. Treatment of subclinical hypothyroidism with levothyroxine in our patient significantly improved the platelets, thus successfully bringing the disease in remission.

Phencyclidine Induced Oculogyric Crisis Responding Well to Conventional Treatment.

Background. Oculogyric crisis is a form of acute dystonic reaction characterized by involuntary upward deviation of eye ball. Its causes are broad with antipsychotics and antiemetics as the most common causes. Case Presentation. A 25-year-old man with the past medical history of marijuana use presented to ED with involuntary upward deviation of eye 1 day after using phencyclidine (PCP) for the first time. He did not have any other symptoms and was hemodynamically stable. All laboratory investigations were normal except urine drug screen which was positive for PCP. Patient was treated with IV diphenhydramine which improved his symptoms. Conclusion. Illicit drug abuse is a growing problem in our society with increasingly more patients presenting to ED with its complications. The differential diagnosis of acute dystonic reactions should be extended to include illicit drugs as the potential cause of reversible acute dystonias especially in high risk patients.

Raghib Syndrome Presenting as a Cryptogenic Stroke: Role of Cardiac MRI in Accurate Diagnosis

Raghib Syndrome is a rare developmental complex, which consists of persistence of the left superior vena cava (PLSVC) along with coronary sinus ostial atresia and atrial septal defect. This Raghib complex anomaly has also been associated with other congenital malformations including ventricular septal defects, enlargement of the tricuspid annulus, and pulmonary stenosis. Our case demonstrates an isolated PLSVC draining into the left atrium along with coronary sinus atresia in a young patient presenting with cryptogenic stroke without the atrial septal defect. Majority of the cases reported in the literature were found to have the lesion during the postmortem evaluation or were characterized at angiography and/or echocardiography. We stress the importance of modern day imaging like the computed tomography (CT) angiography and cardiac MRI in diagnosis and surgical management of such rare lesions leading to cryptogenic strokes.

Glomangiosarcoma Involving the Heart with an Unknown Primary Lesion

Glomus tumors are usually benign tumors of the glomus cells with the immunocytochemical and structural features of smooth muscle cells. The majority of the cases of glomus tumors are benign but, rarely, they demonstrate malignant features both clinically and histologically (also known as glomangiosarcomas). Although glomangiosarcoma involving extracutaneous sites is uncommon, a few cases have been reported. A glomangiosarcoma of the heart is extremely rare due to the rarity of glomus bodies in the myocardium. In this case report, we present the case of a 31-year-old female with glomangiosarcoma involving the heart with an unknown primary lesion.

A Case of Massive Recurrent Rheumatoid Effusion

Rheumatoid arthritis (RA) is a well-known auto-immune disease affecting the joints, its signature signs being bone erosions and joint deformity. Other than arthritis, RA can also affect other organs in the body, such as eyes, heart, lungs, etc. In our case we are going to discuss an elderly lady with RA, presenting with large pleural effusion as presenting complaint.

Staphylococcus aureus Endocarditis with Multivalvular Involvement Secondary to an Atrial Septal Defect

Infective endocarditis is usually diagnosed using modified Dukes criteria. Our patient had a subacute presentation and a low suspicion for endocarditis during admission, unfortunately leading to her death. Despite advances in diagnostic and therapeutic measures including antibiotic therapy and surgical techniques, morbidity and mortality with staphylococcal infective endocarditis remain high. Hence, we stress the significance of having a low threshold for TEE in patients with multisystem involvement due to Staphylococcus aureus that have evidence of persistent infection despite antibiotic treatment, even if the suspicion for endocarditis is low based on Dukes criteria. TEE substantially improves the sensitivity of diagnosis but may not be readily available in many medical centers. Presence of an ASD has been noted to have increased the risk of left sided endocarditis even with conditions that predispose to right sided endocarditis, particularly in patients with hemodialysis and diabetes as morbid risk factors.

Tachyarrhythmias in Microscopic Polyangitis Responding Well to Plasmapharesis Treatment

Microscopic polyangiitis (MPA) is a form of anti neutrophilic cytoplasmic antibody associated necrotizing vasculitis, which may present with a variety of clinical manifestations. Cardiac involvement in vaculitis is common and the manifestations usually include cardiomyopathy, pericarditis and arrhythmias. Our patient presented with dyspnea, hemoptysis and acute kidney injury. The patient developed frequent episodes of supraventricular tachycardia (SVT) and non-sustained ventricular tachycardia during the course of his stay, which subsequently resolved on treatment with plasmapheresis. Mortality rate is significantly high in patients with pulmonary hemorrhage and renal failure; plasmpheresis has proven to be beneficial in such acute case. Our case not only highlights the therapeutic effects of plasmapheresis on MPA but also stresses the importance of prompt plasmapheresis to mitigate MPA complications like SVT.