United States

Background:
Ulnar neuropathy is the second most common upper extremity entrapment neuropathy, typically occurring at the cubital tunnel or Guyon’s canal. Simultaneous compression at both sites, referred to as “double crush syndrome” is not common; examples of double entrapment involving compression and cubital tunnel entrapment unrelated to trauma are rare. Reports of dual-site entrapment in otherwise healthy athletes, particularly from overuse, are exceedingly uncommon. We present a novel case of unilateral, double-site ulnar neuropathy in a hypermobile gymnast following repetitive handstands; an activity not previously associated with this condition.
Case Presentation:
A 30-year-old left-handed professional gymnast presented with acute paresthesia, weakness, and pain in the fourth and fifth digits of her left hand following a performance involving prolonged handstands. She repeated the routine the next night, after which symptoms intensified. Neurological examination showed decreased grip strength, weakness in finger abduction, and reduced sensation in the ulnar distribution. Tinel’s sign was positive at both the cubital tunnel and Guyon’s canal. Froment’s sign and the elbow flexion test were also positive. The patient reported frequent long-duration handstands several times per week and demonstrated hypermobility at the wrists and elbows. Radiographs were unremarkable; electromyography and nerve conduction studies was deferred due to improvement. At one-month follow-up, after pausing performances but continuing to coach, her symptoms largely resolved, consistent with overuse-related ulnar neuropathy exacerbated by joint laxity and load-bearing mechanics.
Discussion:
Hypermobility increases joint laxity and amplifies tensile and compressive forces on the ulnar nerve. Anatomical variations may further predispose to entrapment; close to 60% of patients had anatomical changes in the cubital tunnel that caused the ulnar nerve neuropathy, of which nearly 20% of patients had a subluxation of the ulnar nerve.
Hypermobile athletes may have unrecognized variants that tolerate extreme ranges but place neural structures at risk. During handstands, prolonged elbow extension and wrist hyperextension stress the ulnar nerve at multiple points. At the elbow, compression may occur at the retrocondylar groove, beneath Osborne’s ligament, between the flexor carpi unaris heads, or due to variants like the Arcade of Struthers or anconeus epitrochlearis. At the wrist, Guyon’s canal and pisohamate arch can entrap the motor branch, while trauma to the nearby ulnar artery may produce secondary compression (Hypothenar Hammer Syndrome). Unilateral symptoms may reflect dominance or asymmetric loading. Recognizing handstands as a potential biomechanical risk factor may guide early intervention and inform preventive strategies in similar athletic populations.

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A Balancing Act: Dual Ulnar Nerve Entrapment In AHypermobile Handstand Performer

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Background: Chimeric Antigen Receptor T-cell (CAR-T) therapy has transformed treatment for hematologic malignancies but is associated with immune effector cell-associated neurotoxicity syndrome (ICANS), a complication typically marked by cortical dysfunction such as encephalopathy, aphasia, and seizures. Current ICANS grading criteria uses the Immune Effector Cell-Associated Encephalopathy (ICE) score and relevant neurologic findings, with motor deficits falling under grade 4. However, spinal cord–predominant presentations are rare and not well represented in existing grading criteria.

Case Presentation: A 30-year-old female with refractory B-cell acute lymphoblastic leukemia and KMT2A rearrangement underwent CAR-T therapy with brexucabtagene autoleucel. After developing cytokine release syndrome (CRS), she experienced a progressive decline in mental status consistent with grade 2 ICANS. Despite aggressive immunosuppression with corticosteroids, tocilizumab, and anakinra, she developed sudden paraplegia and bowel/bladder dysfunction by day 8 post-infusion. MRI revealed diffuse T2 hyperintensities and cord expansion throughout the cervical and thoracic spinal cord, consistent with inflammatory myelitis. Intrathecal cytarabine and hydrocortisone were administered, followed by intravenous immunoglobulin (IVIG). While her cognitive status fully recovered, motor deficits persisted and only some sensory function recovered. At one-year follow-up, she remained paraplegic with persistent spinal cord atrophy and T2 intensities demonstrated on MRI.

Discussion: Spinal cord-predominant ICANS is a distinct clinical presentation that challenges current pathophysiologic models centered on cortical dysfunction. The decoupling of cognitive recovery from persistent motor deficits suggests a localized spinal cord injury, likely mediated by cytokine-induced blood–spinal cord barrier disruption. Spinal MRI was key to diagnosis, and earlier imaging may have facilitated more targeted intervention. Current ICANS grading systems, which rely heavily on ICE scores and encephalopathy, may overlook spinal presentations, delaying diagnosis and treatment. Revised grading criteria that account for spinal cord involvement, as well as research into optimal management strategies, are warranted to better identify and treat this rare but serious form of neurotoxicity.

A unique case of spinal-predominant ICANS with long-term motor deficits after CAR-T therapy

Background:
Keratoconus is a progressive, non-inflammatory corneal ectasia that often escapes diagnosis until complications arise. Acute corneal hydrops, a rare vision-threatening complication, results from a rupture in Descemet’s membrane, leading to sudden stromal edema. Long-term outcomes can depend on effective patient education, especially in individuals experiencing communication challenges or developmental delays. Early identification, appropriate management, and patient education are essential in reducing morbidity and preventing recurrence or progression.

Case Presentation:
A previously healthy young adult with developmental delay presented with a 24-hour history of severe left eye pain, corneal cloudiness, photophobia, and sudden vision loss. Visual acuity tested at count-fingers in the left eye (OS) and 20/40 in the right (OD); intraocular pressures were normal bilaterally. Slit lamp examination revealed marked corneal edema, bullae, and central thinning with a deep anterior chamber OS. The right eye showed subtle inferocentral thinning without edema. Optical Coherence Tomography demonstrated extreme corneal swelling (central corneal thickness 2295 μm) and irregular keratometric rings OS, with early inferior steepening OD, which confirmed bilateral keratoconus with acute corneal hydrops OS. The patient was initiated on sodium chloride drops and ointment in both eyes, Cyclopentolate daily OS for pain, and artificial tears. At follow-up, the patient’s mother revealed a long-standing history of chronic eye rubbing due to allergic itching, which the patient had previously been unable to communicate. Olopatadine drops was prescribed for allergy control and strict eye-rubbing precautions were discussed. At one-week follow-up, pain and edema began to resolve and vision improved to 20/50 OS. The patient was informed that a preemptive corneal cross-linking procedure may benefit progression of currently mild keratoconus OD.

Discussion:
This case illustrates the importance of recognizing acute hydrops as an initial manifestation of keratoconus, thorough history-taking, and patient advocacy. In individuals with communication challenges, risk factors for keratoconus such as chronic eye rubbing may be overlooked. In this case, caregiver insight was essential in identifying allergies and eye rubbing as the root cause of the patient’s presentation, and allowed for targeted intervention. By initiating allergy control and behavioral counseling, progression of keratoconus was prevented in both eyes. This case highlights the value of early patient education and caregiver engagement, especially in vulnerable populations, to modify the trajectory of keratoconus and better preserve vision.

Acute Corneal Hydrops as the Initial Presentation of Keratoconus in a Young Adult

Background: Infections of the foot and ankle require prompt recognition and aggressive treatment to prevent complications such as osteomyelitis, nonunion, and limb-threatening deformity. In rare cases, fungal infections such as Phaeoacremonium venezuelense can lead to chronic osteomyelitis, posing significant reconstructive challenges. When extensive bone loss and joint destruction occur, traditional surgical options may not suffice. Recent advancements in 3D-printed implants have enabled limb salvage procedures in complex foot and ankle cases by offering patient-specific structural solutions. We present the first known case of midfoot reconstruction with a custom 3D-printed titanium cage following chronic P. venezuelense infection.

Case Presentation: A 56-year-old man with psoriatic arthritis initially presented in 2019 with right anterior ankle pain and was diagnosed with anterior tibial tendon tenosynovitis and synovitis. He underwent tendon repair and tenosynovectomy. Nine months later, following palm thorn trauma to the medial foot, the patient developed worsening pain, numbness in the 2nd and 3rd toes, and localized swelling. Subsequent imaging revealed first tarsometatarsal joint arthropathy with reactive bone marrow edema in the medial cuneiform and first metatarsal. Arthrodesis was performed, and intraoperative cultures confirmed P. venezuelense infection. Despite Voriconazole therapy and multiple surgeries, he developed chronic osteomyelitis and nonunion at the arthrodesis site. Amputation was recommended, but declined. Over two years, he underwent numerous debridements, skin grafts, methylmethacrylate spacer placements, and targeted antifungal regimens, including voriconazole, mycamine, amphotericin B, and isavuconazonium. Progressive bone loss necessitated cuboid and lateral column excision, resulting in midfoot-hindfoot discontinuity. After infection eradication was confirmed, a custom 3D-printed titanium cage packed with autograft harvested from the right proximal tibia was implanted. He progressed from non-weight-bearing to full ambulation, remaining pain-free with no sensory impairment or medication use at one-year follow-up. 

Discussion: This case report demonstrates the successful use of a custom 3D-printed titanium implant for limb salvage in chronic fungal osteomyelitis of the midfoot. Given the rarity and complexity of persistent P. venezuelense infections, traditional treatment options may not be sufficient, especially in patients with substantial bone deformity. Custom implants enabled an anatomic reconstruction for this patient after extensive bone loss, providing pain relief and restored function. This case supports 3D-printing as a viable option for complex foot and ankle reconstructions when standard interventions for chronic osteomyelitis fail. 


Complex Midfoot Reconstruction With 3D-Printed Titanium Cage Following Phaeoacremonium venezuelense Osteomyelitis

Tarsal tunnel syndrome (TTS), or posterior tibial neuralgia, is a neuropathy associated with compressive entrapment of the tibial nerve as it travels deep to the flexor retinaculum, or within the tarsal tunnel. The clinical signs and symptoms of a patient with TTS include: 1) painful burning, tingling, or numbness (paresthesia) sensations in the ankle the may extend distally into the toes or proximally to the knee; 2) inflammation of the feet; 3) abnormal temperature sensations within the feet; 4) electrical shock sensations due to impingement of the tibial nerve; and/or 5) patient complaints of lack of padding within the feet.1-5 These symptoms are exacerbated during physical activity or when a physician taps upon, or applies pressure to, the compressed tibial nerve, which is called a positive Tinel sign. Surgical incision of the flexor retinaculum of the foot usually relieves these TTS signs/symptoms because it creates additional space within the fibro-osseous passage for the impinged tibial nerve. Moreover, the presence of a variant leg muscle, the flexor digitorum accessorius longus (FDAL) muscle, has been implicated in TTS in that it can compress the tibial nerve along its course within the distal leg or by acting as a space-occupying structure within the tarsal tunnel as this supernumerary muscle passes deep to the flexor retinaculum. This muscular variant, which is present in 2-12% in cadaveric and imaging studies, should be ruled out before surgical incision of the flexor retinaculum, or these TTS signs/symptoms may persist.1,6-7 In this study of the FDAL muscle, novel distal insertions of this variant leg muscle were identified. We also describe the FDAL muscle in detail, share its anatomical relationship within the distal leg, and explain how the presence of this supernumerary muscle may predispose a patient to tarsal tunnel syndrome.

Novel distal insertions of flexor digitorum accessorius longus (FDAL) muscle and their implications on tarsal tunnel syndrome

Background
Ludwig’s Angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal species are the most commonly isolated causes. It is treated with securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid. Sources of infection include dentition, oral procedures, alcoholism, vascular disease, and immunocompromised states. This is a case which was positive for Streptococcus Constellatus with systemic abscess spread and a 45-day ICU course. 

Methods
Case Report

Results
This is a 22-year old with diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder. She reported poor dentition with dysphagia, drooling, pain in ears and throat for one week before arrival. She was seen at an urgent care four days prior and was given amoxicillin. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration noted to the submandibular area with tenderness to palpation with erythema with right side worse than left, and limited neck range of motion. She was intubated, started on broad spectrum antibiotics, and taken to the OR for an I&D of submental and submandibular abscesses. On day 6, OMFS removed five teeth. Chest tubes were inserted into the pleura and mediastinum for fluid collection, and repeat I&D procedures for the neck were performed. Abscess drainage on the right mastoid and a tympanostomy on the left were done. Spread to the cerebellum led to initiation of high dose ceftriaxone. Fluid studies from chest tube drainage and other wounds were negative. Her condition improved and was sent to a long-term acute care hospital.




Conclusion
This patient’s case shows complications found in Streptococcus Constellatus if not early controlled or immunosuppressed. Her Cushing’s Syndrome, steroid hormone therapy, and metabolic syndrome likely led to immunosuppression. These factors helped propagate the spread of abscesses to the CNS, mediastinum, lungs, and persistence of abscesses in mouth, neck, oropharynx, and mastoids. Early Pan CT in cases of Streptococcus Constellatus should be considered for its propensity to cause abscesses at distant sites, with early surgical evaluation of the mouth and neck. This patient’s difficulty of maintaining trough levels of vancomycin and not being on an antibiotic that was “sensitive” to this organism until day 4 after cultures resulted played a large role. Antibiotics providing double coverage for this organism would benefit patients like this as resistance continues to develop. 


Ludwig's Angina and a Complicated Course of Streptococcus Constellatus Management

Background
Treatment-resistant schizophrenia is defined by persistent delusions or hallucinations following failed trials of two other antipsychotic medications. Clozapine, an atypical antipsychotic medication approved by the FDA, is often the medication of choice in such challenging cases due to its proven efficacy. Its use is, however, tempered by a myriad of side effects which range from sedation, agranulocytosis, seizures, metabolic syndrome, and neuroleptic malignant syndrome. Mahendran R et. al particularly talked about clozapine being involved in the emergence or worsening of obsessive-compulsive symptoms (OCS) in up to 38.2% of patients, which is a side effect due to antagonism of the serotonin receptors 5-HT2A and 5-HT2C. On the other hand, tic-like vocalizations associated with clozapine are extremely rare and perhaps underreported.

Case Presentation
We describe a 39-year-old man with treatment-resistant schizophrenia and psychogenic polydipsia and Wolfe-Parkinson-White Syndrome s/p ablation, who, following the initiation and gradual titration of clozapine treatment, developed tic-like vocalizations and compulsive behaviors (excessive washing of face resulting in abrasions on forehead). While Clozapine was initially helpful in reducing some symptoms, the patient progressively developed treatment-emergent obsessive-compulsive behaviors and repetitive vocalizations. To manage these new challenges, a second antipsychotic medication, aripiprazole, was introduced in his regimen alongside intensive behavioral monitoring. Despite this, the vocalizations continued. A comprehensive evaluation ruled out any organic cause. This case illustrates the complex and treatment-resistant nature of these symptoms.

Discussion
Although clozapine-induced vocalizations are uncommon, they are a significant neuropsychiatric side effect that should be recognized by clinicians. Czapliński et al. described that vocalizations are characterized by sudden, repetitive, and stereotyped sounds, most commonly occurring hand in hand with compulsive behaviors or other movement symptoms. David D. Kim et al. explained in a systematic review that the response to adjunct therapies such as aripiprazole and behavior therapy can be helpful, and individualized treatment strategies are crucial. This case brings to light the importance of early identification and individualized treatment plans for atypical but meaningful side effects like clozapine-induced vocalizations. While clozapine is the treatment standard for treatment-resistant schizophrenia, its potential to cause or reveal obsessive-compulsive behavior and unusual vocalizations must be monitored carefully and addressed individually to maximize benefit with minimal risk of adverse effect.

Clozapine and the Voice Within: A Case of New-Onset Vocalizations and Obsessive Compulsive Symptoms

Background
Digital clubbing is a bulbous enlargement of fingertips and toes, increasing nail dimensions. First described by Hippocrates 2,500 years ago, it's often called "Hippocratic finger." Initially linked to pulmonary conditions, it's now known to occur in various diseases or even without underlying illness. While mechanisms like inflammation, increased vascular permeability, and collagen deposition have been proposed, the precise cause remains unclear. This report highlights a rare case of clubbing associated with long-term laxative use, aiming to improve understanding of this unusual correlation.
Case Presentation
A 73-year-old female with GERD, Irritable bowel syndrome with constipation (IBS-C), and hypercholesterolemia, on daily lubiprostone for months, was referred for digital clubbing. She denied respiratory or constitutional symptoms, and had no smoking, alcohol, or chemical exposure history. Family history included a smoking uncle with COPD.
Her initial physical exam revealed only digital clubbing. Lab work, including Alpha-1 antitrypsin, was normal. Pulmonary function tests and repeat tests a year later were within normal limits. Chest CT showed mild hyperinflation and emphysema, with a small nodule that later resolved. Abdominal CT was unremarkable. Cardiology evaluation was unrevealing. A gastroenterologist confirmed IBS-C. Given the extensive negative cardiac and malignancy workup, the pulmonology service concluded her digital clubbing was likely secondary to IBS and chronic laxative use.
Discussion
Digital clubbing, a sign associated with numerous conditions including neoplastic, pulmonary, and cardiac diseases, is also part of hypertrophic osteoarthropathy. Rarely, it's linked to laxative abuse, most often with senna. One theory suggests
megakaryocytes bypass the lungs, releasing platelet-derived growth factors (PDGF) at fingertips, increasing vascular permeability and inflammation. However, histological studies mainly show collagen deposition, edema, and vascular changes, not significant inflammation.
Our case describes a 73-year-old with digital clubbing due to long-term lubiprostone use for IBS-C, with no other common causes. This adds to limited evidence linking certain medications, especially chronic laxatives, to clubbing. While the exact mechanism is unclear, this case emphasizes the need for a detailed medication history in diagnosing clubbing, potentially avoiding extensive, unnecessary tests. Further research is needed to understand this association and raise awareness among healthcare providers for more efficient patient care.

Digital Clubbing and Chronic Laxative Use: A Case Report

Abstract Title: Making Sense of Insensible Losses: A Case Study on Post-Operative Fluid Management 

Background: Fluid management in post-operative patients remains a critical yet complex aspect of care. Balancing volume overload with adequate resuscitation is a delicate practice, with shifts contributing to electrolyte abnormalities, delayed wound healing, and organ dysfunction. This case study examines a sentinel event involving fluid overload, performed to investigate systemic shortcomings and potential solutions for optimizing fluid monitoring in the ICU. 

Methods: We conducted a retrospective case analysis of a 53-year-old female who presented on postoperative day eight following a laparoscopic appendectomy, complicated by necrotizing fasciitis. Her clinical course was reviewed in detail including surgical and medical interventions, imaging findings, and sequence of ICU care. A root cause analysis was performed to identify factors contributing to the harm event. A process map was created to review current hospital fluid monitoring practices. A literature review was completed, and a revised process map was created to highlight targeted strategies for improvement. 

Results: Despite current fluid monitoring protocols, the patient developed progressive respiratory failure in the setting of net positive fluid balance to 91-liters and worsening pulmonary edema on imaging. A root cause analysis revealed notable contributing factors as unquantified insensible losses, non-protocolized measurement of wound losses, and communication gaps between teams. A literature review supported interventions for future implementation including insensible loss calculators, protocols for weighing wound dressings, automated output monitoring systems, daily POCUS rounds, and structured communication tools such as rounding checklists and EMR-integrated fluid alerts. 

Conclusion: This case exemplifies the complexities of fluid management in the ICU and the need for continuous assessment and revision of current protocols. Fluid overload is a preventable, iatrogenic cause of patient harm events. Through exploration of the various systems involved, preventable harm events can be reduced using strategies focusing on accurate fluid monitoring/documentation, knowledge of assessment methods, and open communication between treatment teams. 



Making Sense of Insensible Losses

Background At large academic centers, healthcare providers manage patients with multiple chief complaints and diagnoses. Clinical pathways are evidence-based tools that integrate scientific knowledge into practice, improving care quality, reducing costs, and enhancing workflow efficiency. These pathways help minimize clinical variation and promote cost-effective care. Ensuring providers use them effectively and seamlessly integrate them into their workflow is crucial. Our goal was to analyze provider usage rates and gather feedback to improve pathway usability. We aimed to determine which providers are using the pathways, collect feedback, and generate suggestions for improvement. This led us to implement an educational session for clinical-year medical students to enhance the practice of high-value care at MUSC.

Methods: We designed surveys to collect feedback for quality improvement and distributed them to 100 healthcare providers across various MUSC campuses. To increase participation, we introduced a small incentive program (gift card raffle). We collected responses over four weeks, analyzed the data, and proposed improvements based on the feedback.

Results: We received 41 survey responses, including 10 attending physicians, 24 residents, and 7 other healthcare providers (PA, NP, nurse). Among respondents, 90% of attending physicians, 100% of residents, and 26% of others reported using pathways regularly. 74.3% found pathways "easy" or "very easy" to use, 62.9% reported workflow improvement, and 68.6% agreed that pathways helped implement high-value care. Feedback for improvement included issues with specific pathways, tracking progress, prolonged usage times, ease of access, linked resources, and a need for better medical education on pathway use and benefits.
Conclusion: Clinical pathways in EPIC are effective tools for streamlining the management of common diagnoses and are widely used among those surveyed. Improvements will focus on enhancing access and usability. Future efforts include incorporating pathway education into the third-year medical student curriculum to foster early adoption and further refine the tool.

Utilization and Benefits of Clinical Pathways in the Electronic Medical Record

Title: New diagnosis HIV linkage to care evaluation in Southeastern United States: A retrospective cohort study 

Background: The HIV epidemic has disproportionally impacted the southern US states, specifically, South Carolina with its estimated 20,000 residents living with HIV/AIDs. To combat this epidemic, the Ending the HIV Epidemic in the US initiative was published with 4 main pillars: diagnose HIV as early as possible, treat HIV rapidly to reach viral load suppression (<200 copies/L) (VS), prevent new HIV transmissions, and respond quickly to HIV outbreaks. New guidelines recommend initiating rapid antiretroviral therapy (ART) within 7 days of HIV diagnosis compared to the traditional goal of 30 days. This study investigated time to patient notification of positive HIV result, linkage to care, ART initiation, and achievement of VS in the SC Midlands. 

Methods: We retrospectively analyzed new HIV diagnoses from Prisma Health Midlands locations from 2022-2023. Descriptive statistics were used to analyze time to notifying patient of result, to first evaluation by HIV provider, to ART initiation, and to VS in both the inpatient and outpatient setting. 

Results: Among 91 patients newly diagnosed with HIV, 82.4% (75/91) were notified of results within 7 days and 69.2% (63/91) within 72 hours. For the remaining 16 patients, 15 were unreachable by phone after an average 3.2 attempts per patient. Eventually, 96.7% (88/91) were made aware of their diagnosis. Of 71 patients that established care with Prisma Health Immunology Center (PHIC), 33 were first evaluated by an HIV provider while inpatient and 38 in the outpatient clinic. Only 63.6% (21/33) of the patients evaluated inpatient initiated ART within 7 days of diagnosis, predominantly due to provider’s choice to wait until outpatient follow-up. For those with initial evaluation at PHIC, 47.4% (18/38) were seen within 7 days of diagnosis and 94.7% (36/38) were seen within 30 days. All patients initially seen outpatient were started on ART during their first appointment. Overall, for patients that established with PHIC, 67.6% (48/71) saw an HIV provider and 53.5% (38/71) initiated ART within 7 days of diagnosis. Nearly all patients (94.3%, 67/71) saw an HIV provider and (91.5%, 65/71) initiated ART within 30 days. For patients established with PHIC, 85.9% (61/71) achieved VS, averaging 97.15 days from diagnosis to VS. Patient non-adherence was the most common reason for not achieving VS. 

Conclusion: While almost all patients with new HIV diagnosis were linked to care and started ART within 30 days of diagnosis, only about half were started within 7 days. This study highlights opportunities to reduce this timeline by prioritizing patient contact information collection during medical encounters, considering point-of-care testing when applicable, standardizing inpatient HIV medication initiation protocols, and evaluating barriers to timely clinic referrals. Future studies with larger sample sizes could assess for demographic risk factors and system-based barriers leading to these delays.

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