Chorea Hyperglycemia Basal Ganglia Syndrome in a 63-Year-Old Male

Chorea hyperglycemia basal ganglia syndrome (CHBG) is a rare condition that manifests within the setting of uncontrolled nonketotic diabetes mellitus. The objective of this case report is to present a patient found to have CHBG and provide a timeline in terms of his workup and subsequent treatment. We also present a commentary on the current understanding of the pathophysiology and treatment and how this was applied to our patient. The case involves a 63-year-old poorly controlled diabetic male who presented with a one-week history of uncontrolled choreiform movements of his left upper extremity. His initial glucose level was 339 mg/dl. HbA1C was 9.9%. CT scan of the head demonstrated an abnormal increased intensity within the right lenticular nucleus and right caudate head most likely due to microcalcifications/mineralization. MRI of the brain demonstrated nonspecific T1 and T2 hyperintense abnormalities in the same area about the right basal ganglia. These findings were consistent with the movement pattern he was displaying and with a diagnosis of CHBG. Gradual control of his blood sugar levels over 48 hours led to resolution of his choreiform symptoms. After better medication adherence as an outpatient, endocrinology follow-up 6 months after discharge found his HbA1C drop to a level of 7.1%. There was no recurrence of his symptoms. CHBG is a rare manifestation of poorly controlled diabetes but is the one that clinicians should be aware of. Early recognition and gradual treatment of elevated blood glucose levels appear to lead to total resolution of choreiform symptoms.

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Successful endoscopic management of efferent loop syndrome after Billroth II distal gastrectomy

Description 

We present the case of a 60-year-old woman with gastric adenocarcinoma presenting for elective surgical resection. The patient underwent an uncomplicated distal gastrectomy with Billroth II reconstruction, and D2 lymphadenectomy.

On postoperative day 3, an upper gastrointestinal series showed interval progression of oral contrast into the colon. The patient was subsequently started on a liquid diet.

On postoperative days 4–6, the patient was unable to tolerate sufficient oral intake. A repeat upper gastrointestinal series was obtained (figure 1), with findings of obstruction of the efferent limb. The patient was taken for oesophagogastroduodenoscopy which demonstrated a stenosed Billroth II gastrojejunal anastomosis at the efferent limb site. The anastomosis was transversed, and a 2.3x10.5 cm WallFlex covered stent was placed under fluoroscopic guidance (figure 2).

Figure 1

Upper gastrointestinal series with findings suspicious for obstruction of the efferent limb. (A) Passage of contrast through...

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Repetitive transcranial magnetic stimulation (rTMS) as a treatment for chronic dizziness following mild traumatic brain injury

A 61-year-old man sustained a mild traumatic brain injury (mTBI) following a pedestrian versus vehicle traffic accident. Post injury, he began to experience symptoms including light-headedness, spatial disorientation, nausea, fatigue and prominent dizziness brought on by postural change, physical activity or eye movements. Symptoms of dizziness persisted for over 5 years, despite numerous extensive and rigorous vestibular and vision therapy regimens. All investigations suggested normal peripheral and central vestibular functioning. The patient underwent 10 sessions of repetitive transcranial magnetic stimulation (rTMS) treatment, with stimulation of the left dorsolateral prefrontal cortex at 70% of resting motor threshold and a frequency of 10 Hz. Dizziness symptom severity and frequency were reduced by greater than 50% at 3 months post treatment, with a clinically significant reduction of dizziness disability from 40 to 21 points on the Dizziness Handicap Inventory. We propose rTMS as a safe, effective and cost-effective treatment option for patients who experience persistent post-traumatic dizziness secondary to mTBI.

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Use of mineral trioxide aggregate for retreatment of a tooth with large periapical lesion, wide-open apices and vertical root fracture

Chronic periapical lesions in necrotic teeth with open apex are difficult to manage. The situation becomes more complex if the tooth has a fracture line. This case report describes the management of a traumatised tooth that had already undergone unsuccessful endodontic treatment with a large periapical lesion and open apex along with a fracture line in the root. An attempt was made to save the tooth by using mineral trioxide aggregate (MTA) cement for orthograde filling, retrograde filling and also for sealing of the fracture line. Moreover, the bone defect was filled with autogenous bone harvested from the external oblique ridge. MTA, a bioactive tricalcium silicate cement, has been used in treating complex endodontic cases as it shows promising potential by inducing the biological mechanisms necessary for repair of involved teeth. A 1-year follow-up showed progressive healing as evident by radiographs and lack of any clinical signs and symptoms.

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Recurrent complications of PAAG implants during lactation

A 35-year-old lactating woman with pre-existing polyacrylamide gel (PAAG) implants for 10 years presented on numerous occasions following both her pregnancies with bilateral recurrent breast infection, pain and finally massive breast enlargement with a ruptured galactocoele necessitating surgical intervention. As the safety of PAAG for the breastfeeding baby is not known, breastfeeding with PAAG implants is not recommended.

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A rare skin condition masquerading as a serious wound infection

Abstract

Pyoderma gangrenosum is a rare, serious and commonly missed condition that can effect post-operative surgical patients. The condition is commonly misdiagnosed as a wound infection, with subsequent inappropriate antibiotic therapy and wound debridement. We present the case of a 46-year-old patient who suffered this delayed diagnosis and multiple unnecessary interventions. We present this in an effort to raise awareness of the rare but serious condition, pyoderma gangrenosum.

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Pulmonary artery embolism by a metal fragment after a booby trap explosion in a combat patient injured in the armed conflict in East Ukraine: a case report and review of the literature

Pulmonary artery embolization due to projectile embolus is a rare complication in combat patients. Such embolization is rare for combat patients in the ongoing armed conflict, in East Ukraine since 2014.

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