Mohammad A. Hossain

A rare case of orthostatic headache due to spontaneous intracranial hypotension.

Headache is one of the most common clinical entities, and has a long list of differential diagnoses; however, one of the more uncommon causes of postural headache is spontaneous intracranial hypotension. It is important that clinicians be aware of this condition, as it is often overlooked, leading to invasive and unnecessary diagnostic testing. A good history and physical exam, paired with an MRI of the brain is sufficient to make the diagnosis of SIH, relieve the symptomology of the patient in a quick and efficient manner, and avoid costly invasive procedures.

Hyperhomocysteinemia Association With Transient Global Amnesia: A Rare Case Report.

Context: Transient global amnesia (TGA) is an intriguing condition that classically presents with an abrupt onset of temporary complete anterograde amnesia and partial retrograde amnesia. Most individuals who experience such a form of amnesia usually have only one attack but recurrent attacks are possible. Most attacks last for a few minutes or few hours and the ability to lay down new memories may also be affected but gradually improves, leaving only a dense amnestic gap for the duration of the episode. There has been some discussion about the etiology behind TGA; however, there has yet to be a consensus with regard to any significant association. Case Report: We report the case of a 65-year-old male presenting with a sudden onset of memory loss that is typical of TGA and who was found to have elevated homocysteine levels. There has only been one other case previously reported that discussed a possible correlation between hyperhomocysteinemia and TGA. It is yet to be determined if increased homocysteine level is a significant risk factor for attacks of TGA. Conclusion: Although it was first described more than half a century ago, it can still be misdiagnosed frequently as many physicians are not familiar with this condition. Furthermore, there are quite a few medical conditions that may cause sudden memory impairment, such as epilepsy and stroke, which make it difficult to distinguish them from this form of amnesia. The knowledge of these clinical identities is necessary for a high index of suspicion, which may lead to a meticulous medical evaluation as required for proper diagnosis.

A Simplified Approach to the Management of Hypercalcemia

Department of Internal Medicine, Jersey Shore University Medical Center, Neptune, New Jersey, USA Department of Endocrinology, Jersey Shore University Medical Center, Neptune, New Jersey, USA Division of Nephrology and Hypertension, Jersey Shore University Medical Center, Neptune, New Jersey, USA Division of Nephrology, Salisbury VA Health Care System, Salisbury, NC and Department of Nephrology, University of North Carolina, Chapel Hill, NC, USA

Recurrent optic neuritis as the only manifestation of chronic hepatitis B virus flare: a case report

BackgroundAutoimmune reactions have been associated with acute hepatitis B virus infection. Among these optic neuritis is a rare presentation with only a handful of cases reported in the literature thus far. The pathophysiologic mechanism governing this phenomenon includes high levels of circulating immune complexes, tissue deposit, and complement activation cascade.Case PresentationIn this report, we present the case of a 46-year-old African American man with a past medical history of untreated chronic hepatitis B virus, diagnosed 5xa0years ago, who presented to our facility on two occasions with the chief compliant of blurry vision. He was diagnosed with optic neuritis associated with acute on chronic hepatitis B virus infection, where the recurrent visual impairment was the main presenting symptom. Because hepatitis constituted a relative contraindication for steroid therapy, our patient was solely treated with antiviral medication. Antiviral therapy resulted in complete resolution of his symptoms and improvement in his liver function.ConclusionsFurther studies are necessary to conclusively establish whether antiviral therapy can be employed as the sole therapy in immune complex-mediated optic neuritis, in the setting of active recurrent hepatitis B infection.

Recognizing Obesity in Adult Hospitalized Patients: A Retrospective Cohort Study Assessing Rates of Documentation and Prevalence of Obesity

Background: While obesity is a chronic condition that predisposes patients to other more serious disorders, the prevalence and the documentation of obesity as diagnosis has not been extensively studied in hospitalized patients. We conducted a retrospective chart review to investigate the prevalence and documentation of obesity as a diagnosis among patients admitted to our medical center. Method: IRB approval was obtained for this retrospective study. Body mass index (BMI) as per CDC, admission and discharge diagnosis of obesity and common comorbidities (hypertension, diabetes, hyperlipidemia, coronary artery disease, congestive heart disease, chronic kidney disease and chronic obstructive pulmonary disease) were recorded. The length of stay in the hospital was also calculated. We also investigated whether counselling was provided to the obese patients for weight loss. Results: A total of 540 consecutive patients were reviewed with a mean age was 66 ± 6 years. Out of 540 patients only 182 (34%) had normal weight, 188 (35%) of the patients were overweight and 170 (31%) patients were obese. Of the obese group, 55% were female and 45% were male.100 (59%) had class I obesity, 43 (25%) had class II obesity and 27 (16%) class III obesity. Of the obese patients 40/170 (23.5%) patients had obesity documented on the admission problem list and only 21 (12%) had obesity documented as a discharge diagnosis. Only 3 (2%) patients were given appropriate counseling and referral for obesity management during the hospitalization. Comorbidities and their prevalence included, hypertension (68%), diabetes mellitus (35%), hyperlipidemia (36%), coronary artery disease (18%), chronic kidney disease (17%), congestive heart failure (18%) and COPD (24%). The average length of stay in normal weight, overweight and obese patients was similar for all three groups (4.5 ± 0.5 days). Conclusion: A significant number of hospitalized patients were overweight and obese. An overwhelming percentage never had weight status documented. Hospitalization offers health care providers a window of opportunity to identify obesity, communicate risks, and initiate weight management interventions.

Mesenteric Cyst Versus Lymphangioma: A Clinical Conundrum.

CASE PRESENTATION A 43-year-old Hispanic male presented to the emergency room complaining of abdominal pain and difficulty in breathing in recumbent position. Patient reported no significant medical, surgical or family history. Physical examination was unremarkable except for an abdomen that was firm and distended with no fluid thrill. Bowel sounds were present but diminished. All laboratory tests were normal except a mild normocytic normochromic anemia. Computed tomography (CT) scan of abdomen revealed a 16.5 3 25 3 23 cm rounded, well-circumscribed, hypodense lesion/mass within the peritoneal cavity (Figure 1). A further magnetic resonance imaging of abdomen and pelvis with and without contrast revealed a 25.3 3 16.7 large complex proteinaceous cyst in the midline of abdomen centered in the mesentery/peritoneum without any findings to suggest that it is originating from any adjacent structure. Radiological differential diagnosis included a mesenteric cyst or an intra-abdominal cystic lymphangioma. Laparotomy was performed and a 30-cm intra-abdominal cyst was removed. Histopathological examination revealed a hemorrhagic intra-abdominal cyst, which is a unilocular thin fibrous pseudocapsule containing fibrin debris and bloody fluid (Figure 2). Mesenteric cysts are quite rare intra-abdominal lesions. Mesenteric cysts size ranges between a few centimeters and 10 cm. Fortunately, they behave mostly as benign tumors, whereas malignancy accounts for 3% of the cases, arising gradually or de novo. This is in sharp contrast to intraabdominal cystic lymphangiomas that often present clinically and radiologically similar to mesenteric cysts. However, histologic and ultrastructural evidence suggests that they are pathologically different entities. Differentiation of these lesions is imperative because lymphangiomas may follow a proliferative and invasive course. In most of the cases, the cysts are located in the mesenterium of small intestine, but they can also be found in the descending colon and rectum. Their histopathological classification is designated by the cell type of the inner cyst wall layer, so mesenteric cysts can be of lymphatic, mesothelial, enteric, urogenital origin or nonpancreatic pseudocysts. Usually, they do not cause specific symptoms. Clinical presentations include common or intestinal obstruction causing acute and intense symptoms. Accurate pre-operative diagnosis is quite tough because of the rarity of the entity and the lack of specific symptoms and signs. Clinical imaging (ultrasound, CT scan or magnetic resonance imaging) may aid in the correct diagnosis. Careful interpretation of images is thus vital in making the correct diagnosis and formulating further management decisions. The treatment of choice is the complete surgical excision of the cyst. This can be performed either by laparotomy or laparoscopy. The choice regarding the surgical approach depends on the size of the cyst, its location in the abdominal cavity and also on surgeon’s expertise.

Multiple Myeloma and Atopic Eczema in an Adult

Multiple myeloma is the fourteenth cause of cancer-related death. The symptoms of myeloma are mostly nonspecific, and there is significant delay between the first symptoms and diagnosis of myeloma. Atopic eczema is a common chronic inflammatory skin disease associated with dysregulation of the immune system. It generally develops in early childhood but can also occur in adults. Eczema is associated with a variety of hematological and solid malignancies, and possibly multiple myeloma. We report a patient with eczema that developed 5 years before the diagnosis of multiple myeloma but was mistaken for psoriasis.

Guillain Barre Syndrome: A Rare Presentation Mimicking Acute Stroke

Guillain Barre Syndrome (GBS) is an acute neuromuscular weakness and paralysis associated with areflexia and often spontaneous recovery, but carries the potential risk of respiratory depression owing to muscle weakness. Worldwide, 1 to 3 cases/100,000 are reported. The syndrome is most commonly reported as symmetrical ascending weakness in arms and legs accompanied by hyporeflexia or areflexia. Sensory disturbances are not required for diagnosis, but may or may not be present. Acute inflammatory demyelinating poly-radiculoneuropathy (AIDP) is the most common variant, but acute motor and sensory axonal neuropathy (ASMAN) is more severe and usually leads to partial or slow recovery. We present a case of GBS presenting with asymmetric weakness and sensory disturbance in a patient with bloody diarrhea of unknown etiology. This patient had asymmetrical paralysis mimicking stroke, but the physical findings, laboratory studies, normal CT and MRI of the brain, Electromyogram (EMG) and the patient’s improvement with Intravenous Immunoglobulin (IVIG) support the diagnosis of GBS. People with inflammatory bowel disease are at increased risk of