Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis

Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.</p

Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis

Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.</p

Chasing the dragon and stumbling upon an octopus: a case of heroin-induced leukoencephalopathy and reverse takotsubo cardiomyopathy

The practice of heating heroin and inhaling its vapors, commonly referred to as "chasing the dragon" has been around for decades, but only gained popularity in the United States in the 1990s. Since then, there have been many documented cases of heroin-induced leukoencephalopathy (HIL) and takotsubo cardiomyopathy (TTC). This case highlights a patient with a history of heroin inhalation who presented with multiple neurological features, including bilateral upper and lower extremity weakness, blurry vision and slurred speech. Symptoms progressively worsened over the course of multiple weeks and brain imaging was consistent with toxic leukoencephalopathy secondary to heroin inhalation. Medical course was complicated by a rare associated feature of HIL: reverse Takotsubo cardiomyopathy (rTTC). Transesophageal echocardiogram demonstrated a classic basal hypokinesis and ballooning characteristic of rTTC. The patient's symptoms were treated as currently there is no guideline directed therapy for HIL or rTTC. This case demonstrated a rare and significant complication of heroin inhalation: HIL and rTTC and described potential therapies currently being studied. </p

Chasing the dragon and stumbling upon an octopus: a case of heroin-induced leukoencephalopathy and reverse takotsubo cardiomyopathy

The practice of heating heroin and inhaling its vapors, commonly referred to as "chasing the dragon" has been around for decades, but only gained popularity in the United States in the 1990s. Since then, there have been many documented cases of heroin-induced leukoencephalopathy (HIL) and takotsubo cardiomyopathy (TTC). This case highlights a patient with a history of heroin inhalation who presented with multiple neurological features, including bilateral upper and lower extremity weakness, blurry vision and slurred speech. Symptoms progressively worsened over the course of multiple weeks and brain imaging was consistent with toxic leukoencephalopathy secondary to heroin inhalation. Medical course was complicated by a rare associated feature of HIL: reverse Takotsubo cardiomyopathy (rTTC). Transesophageal echocardiogram demonstrated a classic basal hypokinesis and ballooning characteristic of rTTC. The patient's symptoms were treated as currently there is no guideline directed therapy for HIL or rTTC. This case demonstrated a rare and significant complication of heroin inhalation: HIL and rTTC and described potential therapies currently being studied. </p

Extended spectrum beta lactamase producing Escherichia coli eustachian valve infective endocarditis

Endocarditis is an infection of the endocardium caused by a multitude of bacteria, including S. aureus, viridans streptococci, S. bovis, or S. epidermidis, among others. It can cause a variety of physical findings, including new onset murmur, Osler nodes, and Janeway lesions. Endocarditis is diagnosed with multiple positive blood cultures with transesophageal echocardiogram (TEE) showing valvular vegetations. In this article, we present a 47 year old female with a history of ESRD on dialysis who presented with a bleeding fistula found to be in septic shock. Diagnosis of eustachian valve endocarditis with E. Coli ESBL was made through positive blood cultures as well as using TEE. She was started on IV meropenem for seven days, to which the patient completed and eventually was discharged home with resolution of symptoms. </p

Extended spectrum beta lactamase producing Escherichia coli eustachian valve infective endocarditis

Endocarditis is an infection of the endocardium caused by a multitude of bacteria, including S. aureus, viridans streptococci, S. bovis, or S. epidermidis, among others. It can cause a variety of physical findings, including new onset murmur, Osler nodes, and Janeway lesions. Endocarditis is diagnosed with multiple positive blood cultures with transesophageal echocardiogram (TEE) showing valvular vegetations. In this article, we present a 47 year old female with a history of ESRD on dialysis who presented with a bleeding fistula found to be in septic shock. Diagnosis of eustachian valve endocarditis with E. Coli ESBL was made through positive blood cultures as well as using TEE. She was started on IV meropenem for seven days, to which the patient completed and eventually was discharged home with resolution of symptoms. </p

Chilaiditi syndrome: a structural displacement in a heart failure patient

Background: Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea. Case presentation: In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging. Conclusion: Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution. Learning objective: Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.</p

Chilaiditi syndrome: a structural displacement in a heart failure patient

Background: Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea. Case presentation: In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging. Conclusion: Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution. Learning objective: Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.</p

Close, but no cigar: an unfortunate case of primary angiitis of the central nervous system

Primary angiitis of the central nervous system (PACNS) is an uncommon and misunderstood disease, where little is known regarding its immunopathogenesis and appropriate treatment. Due to the constellation of nonspecific clinical features and imaging findings, PACNS is a diagnostic conundrum for clinicians and can be very difficult to treat. Case presentation: A 64-year-old male with a history of prostate cancer presented to the emergency department with expressive aphasia and severe headache. Previously, he was diagnosed with ischemic strokes at outside hospitals and was subsequently initiated on anticoagulation medication but was later readmitted with a new onset of nontraumatic subarachnoid hemorrhage and later was found to have ischemic changes in the right temporoparietal lobe. He was suspected to have hypercoagulability of malignancy, as he was unresponsive to a wide variety of anticoagulants and his symptoms continued to deteriorate. On presentation, the physical examination was significant for right homonymous hemianopia, with positive antinuclear antibodies and notable erythrocyte sedimentation rate. The results from the full serologic workup was negative. Subsequent imaging of the brain revealed multifocal stenoses in multiple arteries. On further examination, digital subtraction angiography was concerning for vasculopathy, and was initiated on corticosteroids and cyclophosphamide. Discussion: This is one of the first cases of PACNS in which recurrent strokes were the presenting symptom for PACNS. Vasculitis should be a considered differential in patients with recurrent ischemic strokes and failed anticoagulant therapy. It is important to rule out malignancy and infectious causes due to the wide spectrum of conditions that cause central nervous system vasculitis.</p

Close, but no cigar: an unfortunate case of primary angiitis of the central nervous system

Primary angiitis of the central nervous system (PACNS) is an uncommon and misunderstood disease, where little is known regarding its immunopathogenesis and appropriate treatment. Due to the constellation of nonspecific clinical features and imaging findings, PACNS is a diagnostic conundrum for clinicians and can be very difficult to treat. Case presentation: A 64-year-old male with a history of prostate cancer presented to the emergency department with expressive aphasia and severe headache. Previously, he was diagnosed with ischemic strokes at outside hospitals and was subsequently initiated on anticoagulation medication but was later readmitted with a new onset of nontraumatic subarachnoid hemorrhage and later was found to have ischemic changes in the right temporoparietal lobe. He was suspected to have hypercoagulability of malignancy, as he was unresponsive to a wide variety of anticoagulants and his symptoms continued to deteriorate. On presentation, the physical examination was significant for right homonymous hemianopia, with positive antinuclear antibodies and notable erythrocyte sedimentation rate. The results from the full serologic workup was negative. Subsequent imaging of the brain revealed multifocal stenoses in multiple arteries. On further examination, digital subtraction angiography was concerning for vasculopathy, and was initiated on corticosteroids and cyclophosphamide. Discussion: This is one of the first cases of PACNS in which recurrent strokes were the presenting symptom for PACNS. Vasculitis should be a considered differential in patients with recurrent ischemic strokes and failed anticoagulant therapy. It is important to rule out malignancy and infectious causes due to the wide spectrum of conditions that cause central nervous system vasculitis.</p