Janhavi Modak

Gerstmann Syndrome in a Patient With Aggressive Mucormycosis

A 60-year-old nondiabetic woman with atrial fibrillation presented with fever, night sweats, and right leg pain. Laboratory testing showed pancytopenia; venous duplex revealed a deep vein thrombosis of the right leg, prompting treatment with rivaroxaban. Bone marrow biopsy showed acute myeloid leukemia (AML). After starting induction chemotherapy with idarubicin and cytarabine, she developed left retro-orbital pain, otalgia, and diplopia. Clinical examination demonstrated left Horner syndrome, cranial nerve V1 and VI palsies, Gerstmann syndrome, and right upper extremity weakness. Head computed tomography showed opacification of the left sphenoid and posterior ethmoid sinuses (not visualized on computed tomography angiography images presented). Brain magnetic resonance imaging confirmed acute multifocal infarcts within the left interior carotid artery watershed territory (Figure 1A and B). Computed tomography angiogram of the head showed significant multifocal left cavernous internal carotid artery stenosis and extradural mycotic aneurysm formation (Figure 1C). Posterior sphenoid sinus biopsy showed Rhizomucor (Figure 2). Despite extensive surgical debridement and antifungal therapy, the patient deteriorated and comfort measures were pursued.

Differential MicroRibonucleic Acid Expression in Cardioembolic Stroke

BACKGROUND MicroRNAs (miRNA) are a class of small, endogenous (17-25 nucleotide) noncoding ribonucleic acids implicated in the transcriptional and post-transcriptional regulation of gene expression. This study examines stroke-specific miRNA expression in large vessel territory cardioembolic stroke. METHODS Peripheral blood was collected from controls and ischemic stroke patients 24 hours after stroke onset. Whole blood miRNA was isolated and analyzed for differential expression. A total of 16 patients with acute middle cerebral artery territory strokes of cardioembolic origin were included in this pilot study. MiRNA profiling was conducted by miRCURY LNA™ microRNA Array. RESULTS In patients with cardioembolic stroke, significant differential expression of 14 miRNAs was observed when compared to controls. Ten of these miRNA had not previously been associated with ischemic stroke (miR-664a-3p, -2116-5pp, -4531, -4765-5p, -647, -4709-3p, -4742-3p, -5584-3p, -4756-3p, and -5187-3p). Subanalysis of severe strokes (NIHSS > 10) identified an additional 5 differentially expressed miRNA. No significant effects of sex or tissue plasminogen activator treatment were seen on miRNA expression. CONCLUSIONS Ischemic stroke patients show a differential miRNA expression profile as compared to controls. These new associations between circulating miRNAs and ischemic stroke may help to refine stroke subtype diagnosis and identify novel therapeutic miRNA targets for the treatment of ischemic stroke.

Herpes simplex encephalitis in an immunocompromised adult with novel MRI and pathology findings

Punctate scattered hyperintense diffusion-weighted imaging (DWI) lesions in convexities of both hemispheres have not been described in children or adult patients with herpes simplex encephalitis (HSE). Because this finding suggests a hematogenous spread of herpes infections, it has a special clinical significance. We present a case of HSE in an immunocompromised adult where multiple small DWI hyperintense lesions were seen at the grey-white matter junction of both cerebral hemispheres. A follow-up magnetic resonance imaging (MRI) 3 weeks later showed typical herpetic involvement of the limbic system. Autopsy revealed that the multiple small MRI abnormalities represented punched out pauci-inflammatory areas of parenchymal necrosis.