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This clinial vignette explores the critical issue of uterine hemorrhagic rupture in cornual ectopic pregnancies, a rare but life-threatening condition. Cornual ectopic pregnancies are challenging to diagnose due to their location and can result in severe hemorrhage and hypovolemic shock if not detected early. This case presentation highlights the urgent need for prevention and intervention in such cases. This case also emphasizes the importance of considering social determinants of health, such as insurance and access to prenatal care, in patient care and research, as they can impact the course and outcomes of such conditions.

AMA Research Challenge 2023

Uterine Hemorrhagic Rupture in Cornual Ectopic Pregnancy​

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Case Presentation
A 2 year old female, ex-34 week preterm with a relevant family history of a male sibling with TTD and birth history of a TTD diagnosis, presents to the emergency department with feeding intolerance and episodic vomiting. Serially performed MRIs at 4 weeks old (corrected age of term birth) and 2 years old demonstrates progression of the condition. T1-weighted imaging presents with enlarged ventricles and significant hypointensity in areas of expected myelination. T2-weighted imaging displays significant hyperintensity in those same areas, suggestive of dysmyelination. Simplified gyral patterns were also observed. One week after the MRI, the patient had an overnight coughing episode resulting in her death, despite resuscitation efforts.

Discussion
TTD is a rare condition with a poor prognosis in children under 10 years old––a 20-fold higher risk of mortality than the general population, especially succumbing to infection. MRI performed on neonates as early as full term exhibits signs of dysmyelination in key structures such as the posterior third of the posterior limb of the internal capsule, ventrolateral nucleus of the thalamus and the optic radiations. Until 2 years of age, analysis of myelination of key structures can help monitor proper brain development. When physicians observe cortical atrophy and diffuse dysmyelination on MRI along with significant birth history, TTD should be included in the differential diagnosis.

From a Radiological Perspective: Progression of Trichothiodystrophy
in a Pediatric Case

Background
Intracranial pseudoaneurysms (IPAs) are rare in of themselves, accounting for <1% of all intracranial aneurysms, but have been reported at a higher incidence in the pediatric and adolescent population. If left untreated, the mortality rate of these lesions can reach up to 50% due to rupture and catastrophic intracranial hemorrhage. Therefore, early recognition and treatment of this condition in the pediatric population is essential to prevent further morbidity and future mortality.
In contrast to adult IPAs, pediatric IPAs account for up to one-third of all pediatric intracranial aneurysms and have different clinical presentations, complications, and treatment outcomes. Children do not possess the typical risk factors associated with intracranial aneurysms of adults, which should prompt further investigation into a cause for vessel wall injury. Potential etiologies include underlying vasculopathies, indicated in one tenth of pediatric cases; infectious agents; and extrinsic insults, such as head trauma. Pediatric IPAs can present with intracranial hemorrhage, with associated symptoms of sudden onset headache, seizures, vomiting, or loss of consciousness.
In contrast to adults, pediatric patients have a higher frequency of complex-appearing, large (i.e. 15-25 mm in diameter) or giant (i.e. >25 mm in diameter) IPAs, overall contributing to greater involvement of surrounding intracranial structures. Local mass effect due to these lesions can lead to intracranial complications, such as acute infarction or hydrocephalus.

Case Presentation
A 13-year-old with a family history of intracranial neoplasm presented with persistent headaches for a few months. Noncontrast MRI brain showed a large, mass lesion involving the right basal ganglia. The subsequently performed MRA brain and postcontrast MR imaging further characterized this lesion as a giant right MCA pseudoaneurysm. Local mass effect from the lesion on the foramen of Monro resulted in lateral ventricular enlargement. Right frontal encephalomalacia was also seen, presumably reflecting additional sequelae of prior vascular injury. Surgical intervention was performed soon after patient presentation.

Discussion
According to the ACR Appropriateness Criteria for pediatric headaches, imaging is not routinely indicated for primary headaches. In contrast, CT or MR imaging is usually appropriate for secondary headaches in pediatrics. Differentiation of primary and secondary headaches in children is clinically challenging. Clinicians should maintain a high level of suspicion for concerning symptoms and risk factors in pediatric patients, which would warrant an imaging assessment. While rare, IPAs are an important differential consideration to remember as definitive treatment is available and can help reduce future patient morbidity and mortality.

Pediatric Intracranial Pseudoaneurysms

Background
Autoimmune tracheitis is a rare condition where the immune system attacks the lining of the trachea, causing inflammation and swelling. It can lead to symptoms such as chronic cough, hoarseness, difficulty breathing, and, in rare cases, hemoptysis. The exact cause of autoimmune tracheitis is unclear, but it is thought to involve genetic and environmental factors. Diagnosing the condition can be challenging due to its rarity and overlapping symptoms with other respiratory conditions. 

Case Presentation
We present the case of an 82-year-old female with a history of well-controlled rheumatoid arthritis on methotrexate and a chronic tracheostomy inserted in childhood for vocal cord paralysis . The patient presented to the emergency department with a 6-month history of hemoptysis, weight loss, and loss of appetite. Physical examination and chest X-ray did not reveal any notable findings. Chest CT scan showed circumferential thickening of the mid trachea, including diffuse involvement of the posterior tracheal membrane. This area was also avid on PET scan, suggestive of ongoing inflammation. Rigid bronchoscopy revealed tracheitis and diffuse thickening of tracheal mucosa, resulting in severe narrowing of the tracheal lumen.
Biopsy results from the procedure were negative for malignancy but demonstrated the presence of plasma cells, complement deposition, and immunoglobulins suggestive of an autoimmune etiology. There was no evidence of granulomas and Congo Red Stain for amyloidosis was also negative. Microbiology, including Acid Fast Bacilli cultures, were negative as well.
Extensive autoantibody testing was performed to identify possible autoimmune conditions, and other than elevated rheumatoid factor, testing was unrevealing. Therefore, clinical diagnosis of autoimmune tracheitis was established. Treatment was initiated with prednisone therapy, followed by infusion of Adalimumab. The prednisone dosage was gradually tapered over time, and repeat bronchoscopy showed significant reduction of inflammation. During a six month follow up period, the patient remains asymptomatic. .


Discussion
Autoimmune tracheitis presents a significant diagnostic and management challenge due to its rarity and lack of specific criteria. There is paucity of literature on this topic. Guttman et al described a patient with Crohn's disease who developed tracheal cartilage inflammation successfully treated with anti TNF therapy. To our knowledge this is the first case report of autoimmune tracheitis in a patient with rheumatoid arthritis. It is important to be aware of this condition in patients with autoimmune disorders presenting with respiratory complaints.

A Rare Case of Autoimmune Tracheitis In A Patient With Rheumatoid Arthritis Successfully Treated With TNF-a Inhibitor

Background
Antisynthetase syndrome is a rare idiopathic inflammatory myopathy characterized by myositis, interstitial lung disease (ILD), arthritis, Raynaud’s phenomenon, mechanic’s hands, and antibodies against aminoacyl-transfer RNA synthetase, most commonly anti-Jo1 antibody.

Case Presentation
A 36-year-old Hispanic female with no known past medical history presented to the emergency department for 1 week history of left calf pain. She was diagnosed with unprovoked left popliteal vein thrombosis and was discharged on rivaroxaban. She returned the following day for dyspnea and chest pain. She had stable vital signs with adequate oxygenation at room air. Lung auscultation revealed clear breath sounds. Bloodwork showed mild leukocytosis and elevated CK, AST, ALT, and LDH. CT pulmonary angiogram (CTPA) was negative for pulmonary embolism but revealed large infiltrates in bilateral lower lung fields with small bilateral pleural effusions. Ground-glass infiltrates on bilateral upper and lower lobes were seen on high resolution chest CT. Infectious workup for pneumonia was negative. Further questioning revealed a history of two first trimester miscarriages, eczematous skin lesions, and bilateral knee pain. Rheumatologic workup was pertinent for elevated ESR and CRP and positive anti-Ro antibody. ANA, anti-dsDNA, anti-Scl-70, anti-RNP, anti-Smith, anti-cardiolipin, B2-glycoprotein, and lupus anticoagulant were negative. She was started on warfarin for possible antiphospholipid syndrome and steroids for ILD. Four months later, she had worsening dyspnea along with fever and proximal muscle weakness in bilateral lower extremities requiring hospital readmission. CTPA showed progression of bilateral upper and lower lobe ground-glass infiltrates. EMG-NCV was normal. Lung biopsy showed interstitial fibrosis and muscle biopsy of the left vastus lateralis revealed necrotizing autoimmune myopathy. Further rheumatologic workup was significant for positive IgM anticardiolipin and anti-PL-7 antibody but negative anti-Jo1 antibody. Based on the finding of ILD, myositis, and positive anti-PL-7 antibody, a diagnosis of antisynthetase syndrome was made. She continued steroid therapy and started mycophenolate. She had either inadequate control or experienced side effects of the various immunosuppressants. She had tuberculosis while on mycophenolate, myositis flares while on azathioprine, and rhabdomyolysis while on tacrolimus. Her course was complicated by cardiac myositis, and she received intravenous immunoglobulin and rituximab. She was stable on discharge with plans for further infusion, but she died a few weeks later from respiratory failure.

Discussion
Diagnosis of antisynthetase syndrome is based on clinical features and presence of aminoacyl-transfer RNA synthetase antibody, and treatment consists of immunosuppressive therapy. This case illustrates the complexity of diagnosis, often requiring a multi-disciplinary approach, and the difficulty to control symptoms.

Anti-PL-7 Antibody Positive Antisynthetase Syndrome

Background
Systemic lupus erythematosus (SLE) is a chronic, multi-systemic autoimmune disorder that presents in a myriad of ways. However, lupus enteritis is a rare initial manifestation. 

Case Presentation
A 30-year-old female with PMH DM2 and obesity presented with periumbilical pain for one day associated with nausea, NBNB vomiting, and fatigue. She denied rashes, skin changes, fever, arthralgias, oral ulcers or hair loss. On examination, temperature 97.7°F, BP 138/69, HR 121, RR 22, and O2 saturation 99% on room air; bowel sounds were normal and there was diffuse abdominal tenderness and distension without rebound/guarding. Notable labs included creatinine 1.2 and a urinalysis showing protein 300, RBCs (6-10), and protein/creatinine ratio 2304. A CT abdomen revealed moderate ascites and an approximately 42 cm segment of moderate small bowel wall thickening, predominately of the proximal jejunum, concerning for infectious or inflammatory enteritis. Ascitic fluid studies revealed SAAG <1.1 g/dL. A subsequent MRI abdomen showed possible mid-small bowel obstruction and targetoid mucosal and serosal enhancement. The obstruction was managed conservatively with NGT placement; however, her abdominal pain persisted even though she had bowel movements and had no radiographic worsening of the obstruction. During the hospitalization, her renal function did not improve; an autoimmune work-up revealed positive ANA, dsDNA, anti-smith Ab, RNP Ab, chromatin Ab, ribo protein IgG, and SM RNP Ab; C3 and C4 complement levels and serum albumin were low. She was transferred to a tertiary care center and a kidney biopsy revealed Class III lupus nephritis. She was started on pulse-dose steroids and hydroxychloroquine. She improved clinically, her renal function improved and she was discharged home on azathioprine, hydroxychloroquine and prednisone.

Discussion
SLE can affect numerous systems but rarely involves the gastrointestinal system as an initial manifestation. Lupus enteritis is only present in about 0.2 – 5.8% of cases with SLE. It is thought to be related to immune complex deposition and complement activation leading to submucosal bowel wall edema and mostly affects the Jejunum and the Ileum. The clinical presentation is often nonspecific, however frequent complaints include abdominal pain, nausea, and vomiting. CT abdomen/pelvis is the diagnostic modality of choice as pathology is low yield. Common imaging features include Target sign, Combs sign, Mesenteric fat stranding and ascites. Due to its rarity, there are no established guidelines for management, however prior case reports have demonstrated a positive response to steroids.



Lupus Enteritis: An Uncommon Manifestation of Systemic Lupus Erythematosus that Coalesced with Cryptogenic Lupus Nephritis

Background
Carcinoid tumors are masses originating from neuroendocrine cells and are one of the rarest forms of endocrine cancer. Minimal literature exists regarding neuroendocrine tumors arising from the mediastinum, let alone the thymus. This is likely secondary to its rarity, with a reported incidence of 0.2 per million in the United States.
Case Presentation
When diagnosing a neuroendocrine tumor, it is crucial to distinguish the combined neuroendocrine and epithelial characteristics of the neoplasm, acknowledge its potential aggressiveness, and establish additional markers for prognosis and prediction. In the following review, we present a case of a 64-year-old male with an incidental finding of an atypical thymic neuroendocrine tumor. A radical robotic-assisted thymectomy was performed, and adjuvant radiotherapy was administered. 
Discussion
Atypical thymic neuroendocrine tumors remain a niche disease, presenting a unique challenge due to rarity, diverse characteristics, and aggressiveness. Though lacking consensus or best-practice guidelines, surgery is considered the most curative treatment modality. Proving the variability of this type of tumor, however, radiation therapy has had unclear and inconsistent effects on long-term survival, either enhancing clinical outcomes or failing to improve 5-year survival rates. Overall, survival rates for thymic neuroendocrine tumors are lower than those of the gastrointestinal tract, highlighting the need for better therapeutic strategies to maintain the highest level of care for such patients.

Thymic Atypical Carcinoid Tumors vs. Gastrointestinal Neuroendocrine Tumors - 
Are They Really the Same Disease?

Xp11 translocation renal cell carcinomas (RCC) are a category of RCCs
that involve translocations of the chromosome Xp11.2, which is
responsible for generating fusions of transcription factor E3 (TFE3).
These malignancies encompass the most prevalent type of RCC in the
pediatric population, while in adults, Xp11 RCCs account for merely 1-
4% of renal malignancies.
We detail the case of a 68-year-old male who presented to the
emergency department after a ground-level fall with a small forehead
laceration. As part of his work-up, a non-contrast CT abdomen/pelvis
was obtained, on which a 3.9 x 4.5cm left posterior mid-pole renal mass
was noted, suspicious for an RCC. Further workup confirmed an
enhancing posterior left renal mass with no evidence of metastatic
disease. Histopathological and genetic analysis of the extirpated mass
was notable for a Xp11 translocation RCC, pT1bNXMX Fuhrman Grade 2,
with negative margins. Considering the patient had no local invasion or
metastasis, he was discharged and scheduled for surveillance imaging.
Overall, Xp11.2 RCCs in the elderly population are uncommon. Genetic
and IHC analysis is essential in providing accurate and timely diagnoses
of RCCs of this subtype. Since prognosis of this neoplasm in adults is
worse than in pediatric patients, awareness of adequate interventions
and diagnostic tools is of the utmost importance in order to improve
patient outcomes.

68 Year-Old Male with Rare Xp11 Translocation Renal Cell Carcinoma


Background: Testicular infarction is a rare complication of epididymitis. We present a case of testicular infarction to highlight this complication and the role of ultrasound in aiding diagnosis to guide management.

Case Presentation: 26-year-old male, with recent admission for left epididymitis secondary to Multiple Drug Resistant Enterobacter, presented to the emergency department with a two-day history of progressively worsening left scrotal pain and swelling. Physical examination revealed left scrotal erythema and tenderness. Scrotal ultrasound demonstrated asymmetric enlargement and heterogeneous appearance of the left testicle consistent with left scrotal edema. The left testicle showed peripheral hypervascularity without intrinsic flow on color and spectral Doppler interrogation compatible with testicular infarction. In contrast, the right testicle was homogenous and with normal arterial and venous spectral Doppler flow. Management included intravenous antibiotic and urology consultation with subsequent partial orchiectomy. Patient’s hospital course was complicated by wound dehiscence and residual necrotic tissue requiring scrotal debridement and washout. After transition to oral antibiotics, he was discharged with outpatient follow-up with urology.

Discussion: Ultrasound with color flow Doppler is the primary method to diagnose testicular infarction secondary to epididymitis. Characteristics of testicular infarction include asymmetrically decreased or absent intrinsic testicular blood flow with or without increased peripheral flow. Although understanding of the pathophysiology of testicular infarction is evolving, arterial and venous insufficiency are suspected. Risk of global testicular infarction is low due to the testes receiving blood supply from the testicular, the deferential and cremasteric arteries. Persistent clinical symptoms and worsening imaging findings can warrant surgical intervention. In addition to spectral and color doppler, there is expanding utilization of contrast- enhanced sonography (CEUS) to increase sensitivity for testicular infarction. Testicular infarction is a rare but important diagnosis to consider in the setting of epididymitis that has management implications to prevent morbidity.

Treatment Failure of Epididymitis leads to Testicular Infarction

Background: Myasthenia gravis, the most common autoimmune disease affecting the neuromuscular junction, is characterized by generalized muscle weakness. Myasthenia is easily treated, yet social determinants of health can complicate a patient’s access to treatment, prolonging symptoms and increasing patient suffering. Further, residents of rural Maine struggle with healthcare access, as 40% of Mainers live in rural areas and 6% of Mainers are uninsured. 

Case Presentation: A 29-year-old female presented to our hospital’s emergency department from her neurologist’s office. She presented with four months of neck and limb weakness and dysphagia; these symptoms worsened throughout the day. She recently had left her job, as she could no longer perform her duties due to weakness. A resident of rural Maine without health insurance who did not qualify for Medicaid, this patient had not seen a primary care provider (PCP) in five years. She was previously evaluated in an urgent care for similar symptoms and was advised to consult a PCP for further work-up. It took two months for the patient to secure a PCP; she was referred to a neurologist who immediately sent her to the emergency department.

On examination, the patient’s strength was globally 3/5. She was hyporeflexive. She ambulated with a walker. A workup for a neuromuscular syndrome was started. A chest CT did not show a thymoma. The patient was admitted to the hospital, where she was seen by neurology and started on pyridostigmine; she demonstrated immediate improvement. She was discharged one day later with a diagnosis of myasthenia and inflammatory motor neuropathy.

On follow-up with her neurologist one month later, the patient reported mild improvement with pyridostigmine. IV immunoglobulin (IVIG) therapy was ordered to treat her motor neuropathy. However, the patient was still unable to secure insurance, and IVIG therapy was delayed two months. Three months post-discharge, the patient secured insurance and began treatment with IVIG infusions. 

Discussion: The most salient aspect of this case is the patient’s social determinants of health – specifically lack of health care access. This case highlights the disparities that exist for underinsured adults and the great need for PCPs, especially in rural areas. Further, myasthenia is easily treated, yet the patient’s delay in treatment played an enormous impact on her physical and social wellbeing. This case serves to underline the consequences of limited PCP availability and insurance access which prolongs physical and social suffering for conditions with clear treatment, such as the myasthenia demonstrated in this case. 


Myasthenia Gravis Complicated by Lack of Healthcare Access in Rural Maine

Background:
Amiodarone-induced thyrotoxicosis (AIT) is one of the many side effects of the antiarrhythmic amiodarone. It can manifest in two forms: type 1 and type 2. Type 1 AIT occurs in patients with preexisting thyroid disease and is caused by excess thyroid hormone synthesis due to amiodarone’s high iodine content. Type 2 AIT is a destructive thyroiditis resulting from amiodarone’s direct toxicity on the thyroid gland causing the release thyroid hormone. Differentiating between these two is challenging due to overlapping clinical features and laboratory findings. However, it may be advantageous to differentiate between type 1 and type 2 AIT as the treatment approaches vary. A collaborative approach involving endocrinology, cardiology and the primary team is essential for accurate diagnosis and timely management.

Case Presentation:
A 67-year-old male with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease status post coronary bypass, and plaque psoriasis presented to our ER complaining of chest pain during bowel movements. Home medications included apixaban, amiodarone, lisinopril, carvedilol, atorvastatin, and isosorbide mononitrate. He was accepted to the ICU due refractory atrial fibrillation with rapid ventricular rate (A-fib with RVR).

Discussion:
The diagnosis was AIT causing refractory Afib w/RVR, however uncertainty remains regarding the type of AIT and complicating management. We suspected type II AIT as the patient lacks Graves’ disease or nodular goiter. Unfortunately, guidelines providing a clear distinction between type I and type II are limited, contributing to the lack of standard treatment approaches.
Clinical criteria used to differentiate between type I and type II AIT include timing, onset, underlying thyroid disease, thyroid hormone levels, and thyroid scintigraphy. There is also color flow doppler sonography (CFDS) which is a real time technique that depicts intrathyroidal blood flow giving physician information on thyroid morphology and hyperfunction. While these tools provide insight it is important to note that these criteria may overlap, and atypical presentations make the differentiation challenging. One aspect of contention revolves around the continuation or discontinuation of amiodarone. Some clinicians argue that if the type of AIT remains uncertain, continuing amiodarone for rhythm and rate control in atrial fibrillation does not significantly prolong the patient’s hospital stay. Conversely, others advocate for discontinuing amiodarone unless there is a life-threatening ventricular arrhythmia. Establishing a consensus to differentiate the types of AIT would improve treatment approaches and reduce the need for more invasive measures like thyroidectomy.


Next from AMA Research Challenge 2023

From a Radiological Perspective: Progression of Trichothiodystrophy in a Pediatric Case