Anti-N-methyl-D-aspartate receptor-associated encephalitis: A review of clinicopathologic hallmarks and multimodal imaging manifestations

Anti-N-methyl-D-aspartate receptor-associated encephalitis (NMDARE) is a rare immune-mediated neuroinflammatory condition characterized by the rapid onset of neuropsychiatric symptoms and autonomic dysfunction. The mechanism of pathogenesis remains incompletely understood, but is thought to be related to antibodies targeting the GluN1 subunit of the NMDA receptor with resultant downstream dysregulation of dopaminergic pathways. Young adults are most frequently affected; the median age at diagnosis is 21 years. There is a strong female predilection with a female sex predominance of 4:1. NMDARE often develops as a paraneoplastic process and is most commonly associated with ovarian teratoma. However, NMDARE has also been described in patients with small cell lung cancer, clear cell renal carcinoma, and other benign and malignant neoplasms. Diagnosis is based on correlation of the clinical presentation, electroencephalography, laboratory studies, and imaging. Computed tomography, positron emission tomography, and magnetic resonance imaging are essential to identify an underlying tumor, exclude clinicopathologic mimics, and predict the likelihood of long-term functional impairment. Nuclear imaging may be of value for prognostication and to assess the response to therapy. Treatment may involve high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange. Herein, we review the hallmark clinicopathologic features and imaging findings of this rare but potentially devastating condition and summarize diagnostic criteria, treatment regimens, and proposed pathogenetic mechanisms.

Association between Psychiatric Disorders and the Incidence of Heart Failure in Women

BACKGROUND

Depression and anxiety occur more frequently in women and are associated with an increased risk of cardiovascular disease.

OBJECTIVES

Data on the association between these psychiatric conditions and the incidence of acute heart failure (HF) and how they influence heart failure outcomes in women are lacking. We investigated this potential relationship using data from the National Inpatient Sample.

METHODS

We used ICD-10 codes to extract encounters for acute heart failure and/or the acute exacerbation of chronic heart failure, anxiety, and depression from the discharge data of the NIS from 2019 to 2020. We compared baseline characteristics and length of stay (LOS), cost of care (COC) and acute HF by depression/anxiety status for males and females and employed regression models to assess the influence of these psychiatric conditions on the outcomes.

RESULTS

There were 6,394,136 encounters involving females, which represented 56.6% of the sample. The prevalence of depression and anxiety were 15.7% and 16.8%, respectively. Among females, the occurrence of acute CHF did not differ by depression or anxiety status. However, Takostubo cardiomyopathy was more prevalent in those with depression (0.3% vs. 0.2%, p = 0.003) and anxiety (0.3% vs. 0.2%, p = 0.03) compared to those without these conditions. Among those with depression, LOS was significantly longer (3 days IQR: 2-6, vs. 3 days IQR:2-5 days, p < 0.001). The COC was USD 1481 more in patients with depression. On the contrary, LOS and COC were significantly lower in those without anxiety.

CONCLUSIONS

Depression was associated with an increased LOS among both men and women and an increased cost of care among women. Anxiety was associated with a decreased LOS and cost of care among women, which may be related to an increased rate of against medical advice (AMA) discharges among this population. Further research is necessary to identify optimal management strategies for depression and anxiety among patients hospitalized with HF.

Ameloblastic carcinoma with hepatic metastases: A case report and review of ameloblastomic carcinoma

Ameloblastic carcinoma is a locally aggressive odontogenic tumor that most commonly affects young and middle-aged adults. Metastatic disease may develop insidiously and manifest months or years after the initial diagnosis. Herein, we describe the clinical, imaging, and pathologic findings of a 31-year-old male who presented to the emergency department with headache and vision loss of 3 months duration and was subsequently found to have ameloblastic carcinoma with hepatic metastases. Initial computed tomography (CT) and magnetic resonance imaging revealed a multilocular cystic mass with avidly-enhancing nodular soft-tissue components associated with the right temporal fossa. Histologic examination of a tissue sample showed findings consistent with ameloblastic carcinoma. An initial staging CT scan showed several small hepatic cystic lesions. Follow-up surveillance imaging showed interval growth. A subsequent biopsy of a hepatic lesion showed findings compatible with metastatic ameloblastic carcinoma. The patient was started on systemic chemotherapy with evidence of disease progression at 1-year follow-up.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit

BACKGROUND

Timely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge. Currently available risk stratification scores are suboptimal. Recently, a new scoring system called the Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score has been shown to outperform the History, Electrocardiography, Age, Risk factors and Troponin (HEART) score, one of the most used risk scores in the United States.

AIM

To assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation.

METHODS

We retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1^st to April 17^th, 2019. To avoid potential biases, investigators assigned to calculate the SVEAT, and HEART scores were blinded to the results of 30-d combined endpoint of death, acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy [30-d major adverse cardiovascular event (MACE)]. An area under receiving-operator characteristic curve (AUC) for each score was then calculated. C-statistic and logistic model were used to compare predictive performance of the two scores.

RESULTS

A 30-d MACE was observed in 11 patients (3.33% of the subjects). The AUC of SVEAT score (0.8876, 95%CI: 0.82-0.96) was significantly higher than the AUC of HEART score (0.7962, 95%CI: 0.71-0.88), P = 0.03. Using logistic model, SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE (odd ratio 1.52, 95%CI: 1.19-1.95, P = 0.001) but not the HEART score (odd ratio 1.29, 95%CI: 0.78-2.14, P = 0.32).

CONCLUSION

The SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

PET/CT Ultrasound Fusion for Percutaneous Biopsy: A Retrospective Single-Center Study and Review of the Literature

PURPOSE

The aim of this study was to assess the diagnostic yield and complication rate of 18 F-FDG PET/CT ultrasound (US) fusion for percutaneous biopsy of FDG-avid lesions among patients with known or suspected malignancy.

PATIENTS AND METHODS

We describe the clinical, imaging, and histopathologic features of 36 patients who underwent percutaneous biopsy using real-time PET/CT US fusion. In addition, we review the literature on PET/CT US fusion. Using Medline, the following MeSH terms were searched and relevant citations assessed: "fusion imaging," "PET/CT fusion," "PET/CT-guided biopsy," "PET/US fusion," "ultrasound fusion," and "ultrasound fusion-guided biopsy."

RESULTS

A total of 36 patients (15 men, 21 women) with known or suspected malignancy and prior PET/CT imaging underwent percutaneous biopsy of FDG-avid lesions using PET/CT US fusion between October 2014 and July 2020. Coregistration was achieved using General Electric LOGIQ E9 software. Adequate tissue for analysis was obtained in all 36 patients. Histologic evaluation revealed malignancy in 14 patients (38.9%) and nonneoplastic tissue in 22 patients (61.1%). No intraprocedural or postprocedural complications were recorded.

CONCLUSIONS

Fusion of PET/CT and US for percutaneous biopsy of FDG-avid lesions can be used to achieve excellent diagnostic yield with a low risk of complications.

Endovascular thrombectomy in the setting of occult cerebral artery aneurysm: Reducing the risk of iatrogenic rupture

Cerebral artery aneurysms are present in up to 10% of ischemic stroke patients, often within or adjacent to the occluded vessel. In some cases, the approach to intervention may need to be modified based on the size and location of the aneurysm. We describe a 99-year-old female with a known history of cerebral aneurysm who underwent successfully mechanical thrombectomy of a right middle cerebral artery thrombus; an 8-mm aneurysm involving the right M1 bifurcation was identified only on post-procedural digital subtraction angiography. In addition, we discuss strategies to reduce the risk of iatrogenic aneurysm rupture in the setting of endovascular thrombectomy.

Multiple myeloma remission following COVID-19: an observation in search of a mechanism (a case report)

Coronavirus disease 2019 (COVID-19) represents a major challenge in the management of patients with hematologic malignancies. Individuals with plasma cell dyscrasias, including multiple myeloma, are at increased risk of developing severe disease. Furthermore, immunosuppressant agents, which represent an important component of multiple myeloma treatment, may increase the risk of serious infection; thus, treatment regimens may need to be modified in some patients. The pathogenesis of COVID-19 is incompletely understood and much remains to be established regarding cancer care in the setting of this new global health threat. We report a case of multiple myeloma remission that occurred after a single cycle of chemotherapy in a patient with COVID-19. In addition, we discuss possible mechanisms underlying this surprising observation. The findings warrant further investigation and may have important implications for the management of multiple myeloma and other plasma cell dyscrasias in the age of COVID-19.

ABC-type diffuse large B-cell lymphoma presenting as rotator cuff tendinopathy: A diagnostic dilemma and review of the literature

Diffuse large B-cell lymphoma often presents with extranodal manifestations involving the musculoskeletal system. Shoulder pain is particularly worrisome for malignancy. Individuals presenting with refractory upper extremity complaints should undergo a prompt and thorough evaluation for cancer, as a delay in diagnosis can result in an unfavorable outcome.

Sociodemographic characteristics as predictors of outcomes in hepatocellular carcinoma: A retrospective cohort study

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Background: It has been established that race, insurance status, and socioeconomic class play an important role in predicting health care outcomes. However, the impact of these factors has yet to be investigated in the setting of hepatocellular carcinoma (HCC). Methods: We designed a retrospective cohort study utilizing data from the SEER program (2007-2015) to identify patients with resectable HCC (N = 28518). Exposures of interest were race (Asian [AS], Black [BL], Native American/Alaska Native [NA/AN], or White [WH]), insurance status (Medicare/Private Insurance [ME/PI], Medicaid [MAID], or No Insurance [NI]), and median household income. Endpoints included: (1) likelihood of surgical recommendation and (2) overall survival. Multinomial logistic regression for relative risk ratio (RRR) and Cox models were used to identify pertinent associations. Results: Race, insurance status, and socioeconomic class had statistically significant effects on the likelihood of surgical recommendation and overall survival. AS were more likely to receive a recommendation for hepatic resection (RRR = 1.60; 95% CI: 1.42 – 1.80; Reference Race: BL) and exhibited prolonged overall survival (HR = 0.77; 95% CI: 0.73 – 0.82) as compared to members of other ethnic groups; there was no difference in these endpoints between BL, NA/AN, or WH individuals. Patients who had ME/PI were more likely than those with MAID or NI to receive a surgical recommendation. ME/PI was also associated with superior overall survival. Individuals with a household income in the highest quintile were less likely to receive a surgical recommendation than those in the lower quintiles, but nevertheless demonstrated prolonged survival. Conclusions: Race, insurance status, and socioeconomic class have measurable effects on HCC management and outcomes. The underlying causes of these disparities warrant further investigation.

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Localized cutaneous argyria: Report of two patients and literature review

BackgroundLocalized cutaneous argyria is a rare skin condition caused by direct contact with silver or silver particles. It presents as asymptomatic gray or blue-gray macules that appear similar to blue nevi. Histologic features include brown-colored or black-colored silver granules in the basement membrane and dermis, most commonly surrounding eccrine glands, elastic fibers, and collagen fibrils. The condition is most frequently observed in individuals who are regularly exposed to small silver particles, such as silversmiths and welders. However, localized cutaneous argyria has also been associated with acupuncture needles, silver earrings, and topical medications containing silver nitrate. Although the condition is benign, patients who are concerned about the cosmetic features of localized cutaneous argyria may benefit from laser therapy.PurposeWe describe the clinical and pathologic findings of two women who developed localized cutaneous argyria. We also review the characteristics of other patients with localized cutaneous argyria and summarize the differential diagnosis and treatment options for this condition.Materials and methodsThe features of two women with localized cutaneous argyria are presented. Using PubMed, the following terms were searched and relevant citations assessed: acquired localized argyria, acupuncture, argyria, argyrosis, colloidal silver, cutaneous argyria, and localized cutaneous argyria. In addition, the literature on localized cutaneous argyria is reviewed.ResultsTwo women presented with small, asymptomatic blue-gray macules appearing at sites directly adjacent to ear piercings. A punch biopsy was performed on one woman. Microscopic examination revealed a yellowish-brown colored granular material found adjacent to elastic fibers. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of localized cutaneous argyria was established. The second woman did not undergo a biopsy. However, the clinical presentation was highly suggestive of localized cutaneous argyria. Both women were reassured of the benign nature of the condition and agreed to return for clinical follow-up if they observed any changes in the appearance of the lesions.

Intravascular papillary endothelial hyperplasia of the vulva: report of a patient with Masson tumor of the vulva and literature review

BACKGROUND

Intravascular papillary endothelial hyperplasia -- also known as Masson tumor -- is a rare, benign vascular condition that manifests on the skin as a firm, blue-black colored nodule or papule. Lesions range in size from 0.25 to 5 centimeters in diameter and may be tender or painless. In some individuals, nodules appear red colored, mimicking hemangioma or pyogenic granuloma. Histologically, intravascular papillary endothelial hyperplasia is characterized by the presence of an organizing thrombus in the vascular lumen with accompanying hyperplastic endothelial cell proliferation. Common sites of presentation include the head, neck, and extremities. However, albeit rarely, lesions may also appear in the genital region.

PURPOSE

We describe the clinical and pathologic findings of a woman who developed intravascular papillary endothelial hyperplasia of the vulva. We also review the characteristics of other patients with intravascular papillary endothelial hyperplasia of the vulva and summarize the differential diagnosis and treatment options for this condition.

MATERIALS AND METHODS

The features of a woman with intravascular papillary endothelial hyperplasia of the vulva are presented. Using PubMed, the following terms were searched and relevant citations assessed: intravascular papillary endothelial hyperplasia, IPEH, labia majora, Masson hemangioma, Masson pseudoangiosarcoma, Masson tumor, and vulva. In addition, the literature on intravascular papillary endothelial hyperplasia is reviewed.

RESULTS

A 32-year-old woman presented with a 3 x 2 millimeter painless, black colored submucosal papule on her left labia majora. The lesion was removed by excisional biopsy. Microscopic examination revealed a re-canalizing thrombus and a proliferation of erythrocytes within a dilated vascular structure. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of intravascular papillary endothelial hyperplasia was established. The patient applied mupirocin 2% ointment to the biopsy site, which subsequently healed without complication or recurrence.

CONCLUSION

Intravascular papillary endothelial hyperplasia -- also known as Masson tumor -- is a rare, benign vascular eruption. Cutaneous lesions typically present as red colored or blue-black colored nodules ranging in size from 0.25 to 5 centimeters in diameter. The most common sites of presentation include the head, neck, and extremities. However, albeit rarely, lesions may also appear in the genital region. The histologic hallmark of intravascular papillary endothelial hyperplasia is an organizing thrombus in the vascular lumen with associated hyperplastic endothelial cell proliferation. Lesions often appears similar to other neoplastic and non-neoplastic cutaneous tumors, including hemangiomas, pyogenic granulomas, and cutaneous angiosarcomas. Therefore, pathologic examination is required to confirm the suspected diagnosis and exclude malignancy. The condition can usually be treated with simple local excision.

Molluscum contagiosum of the eyelid: case report in a man receiving methotrexate and literature review of molluscum contagiosum in patients who are immunosuppressed secondary to methotrexate or HIV infection

BACKGROUND

Molluscum contagiosum is a benign viral infection of the skin. Lesions typically present as dome-shaped, flesh-colored, umbilicated papules that range in size from 1 to 5 millimeters in diameter. They are usually asymptomatic, but can become tender or pruritic. Children and immunocompromised adults, including individuals being treated with immunosuppressive drugs, are most susceptible to infection. Single or multiple lesions most commonly appear on the extremities, face, genitals, and trunk. However, albeit rarely, molluscum contagiosum may also develop at other sites, including the eyelids.

PURPOSE

We describe the clinical and pathologic findings of a man who developed molluscum contagiosum of the eyelid while receiving methotrexate. We also review the characteristics of other patients with molluscum contagiosum acquired either during treatment with methotrexate or associated with human immunodeficiency virus (HIV) infection and summarize the unusual sites of presentation for the viral lesions in these individuals.

MATERIALS AND METHODS

The features of a man receiving methotrexate who developed molluscum contagiosum of the eyelid are presented. Using PubMed, the following terms were searched and relevant citations assessed: adalimumab, contagiosum, Enbrel, etanercept, Humira, infliximab, methotrexate, molluscum, Remicade, TNF alpha, and tumor necrosis factor alpha. In addition, the literature on methotrexate treatment and molluscum contagiosum is reviewed.

RESULTS

 Several small papules were observed on the eyelid of a 24-year-old man who had been receiving methotrexate and adalimumab (Humira) for the treatment of Crohn disease. The lesions were removed by shave biopsy. Microscopic examination revealed epidermal hyperplasia composed of keratinocytes filled with large eosinophilic intracytoplasmic inclusions. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of molluscum contagiosum was established. The patient applied mupirocin 2% ointment to the biopsy sites, which subsequently healed without complication or recurrence.

CONCLUSION

Molluscum contagiosum is a benign viral papular eruption that frequently affects children and immunocompromised adults. Patients treated with immunosuppressive agents, such as methotrexate, have a heightened risk of developing molluscum contagiosum lesions. It remains to be determined whether adjunct therapy with a tumor necrosis factor alpha inhibitor increasesthe risk of this viral infection. Diagnosis can usually be established by clinical presentation, although a biopsy is sometimesrequired to exclude other conditions. Molluscum contagiosum is generally self-limiting and often resolves spontaneously within18 months. However, topical (cantharidin) or locally destructive (curettage, cryotherapy, and/or laser) therapy may be indic tedfor patients who are concerned about persistent lesions and for children who are particularly susceptible to autoinoculation.

Cryotherapy-induced milia en plaque: case report and literature review

BACKGROUND

Cryotherapy-induced milia is a rarely described cutaneous reaction that may occur in patients who have received cryotherapy with liquid nitrogen. Cryotherapy-induced milia is characterized by 1-2 millimeter white dermal cysts that develop at the healed cryotherapy site. Milia en plaque, an erythematous plaque containing numerous milia, has not previously been described following treatment of a skin lesion with liquid nitrogen cryotherapy.

PURPOSE

We describe a man who developed cryotherapy-induced milia en plaque after receiving cryotherapy to his dorsal hand for the treatment of an actinic keratosis. We also summarize the potential complications of cryotherapy, the differential diagnosis of milia en plaque, and therapeutic interventions for this lesion.

MATERIALS AND METHODS

The features of a man with cryotherapy-induced milia en plaque are presented. Using PubMed, the following terms were searched and relevant citations assessed: cryosurgery, cryotherapy, hypothermia, milia, milia en plaque, and Wolf's isotopic response. In addition, the literature on cryotherapy-induced milia and cryotherapy-induced milia en plaque is reviewed.

RESULTS

Our patient developed cryotherapy-induced milia en plaque shortly after his cryotherapy site had healed. Some of the asymptomatic cystic dermal lesions had spontaneously resolved when a lesional biopsy was performed to confirm the diagnosis. The diagnosis, natural course, and potential treatments were discussed with the patient. Subsequent management was to observe the area; at follow-up examination, the remainder of the milia had also spontaneously resolved.

CONCLUSION

Cryotherapy-induced milia is a benign condition characterized by the development of small white dermal cystic lesions that develop at a healed liquid nitrogen cryotherapy site. The lesions may appear individually or as milia en plaque. While the mechanism of pathogenesis is unknown, we postulate that the condition is an example of Wolf's isotopic response, in which a new, unrelated skin disease develops at the site of a previously healed dermatosis - in this circumstance, following cryotherapy which created an immune compromised zone. The diagnosis of milia en plaque can usually be established by clinical presentation; if necessary, a biopsy can be performed to provide pathologic confirmation of the suspected diagnosis. Treatment options include manual extraction, topical retinoids, or observation. Similar to our patient, the milia may resolve spontaneously.