Arachnoiditis is a rare clinical entity that usually presents with severe debilitating radiating pain that can pose a challenge in diagnosis especially in areas without appropriate imaging modalities. We present a 26-year-old male with progressive lower back pain with radiation to the lower extremities, aggravated by movement and touch. We diagnosed idiopathic arachnoiditis based on cerebrospinal fluid analysis and magnetic resonance imaging. He was managed with a 5-day course of methylprednisolone and analgesics with a good outcome. Severe back pain without a specific cause in a young patient should be investigated with proper imaging modalities and lumbar puncture if warranted to evaluate the cause.
Summary Acromegaly is a rare disease caused by hypersecretion of the growth hormone (GH). Most cases are caused by either pituitary microadenoma or macroadenoma. The GH producing tumors present with clinical manifestations of acromegaly due to excessive GH secretion or symptoms resulting from mass effects of the enlarging tumor. The physical changes are usually slow and, therefore, recognition of the disease is delayed. These adenomas are never malignant but can have significant morbidity and mortality. A subgroup of patients with acromegaly present with severe hyperglycemia resulting in diabetic ketoacidosis (DKA) which requires insulin. Rarely are pituitary tumors responsible for generalized convulsions except when they are too large. We hereby present two cases, the first is that of a 26-year-old female who presented with new onset status epilepticus, DKA with a 1-year history of diabetes mellitus (DM). On examination, she had clinical features of acromegaly. The second case is that of a 34-year-old female who presented with new onset status epilepticus, hyperglycemia with a history of recently diagnosed DM, and features of gigantism. In both cases, their diagnosis was confirmed by elevated serum GH and later by elevated insulin-like growth factor type 1 levels, and CT of the head demonstrating large pituitary macroadenoma. The importance of clinical history and examination, as well as investigations is vital in the recognition of acromegaly. The prognosis of acromegalic patients depends on early clinical recognition and tumor size reduction by either medical or surgical therapy. Learning points Conditions such as status epilepticus and DKA may be clinical presentations in patients presenting with acromegaly. Seizures are rare in people with pituitary adenoma and typically occur when the tumor invades the suprasellar area due to mass effect on the brain. This article shows how best we were able to manage the acromegaly complications in a low resource setting. Hyperprolactinemia in acromegaly may be due to disruption of the normal dopaminergic inhibition of prolactin secretion due to mass effect of the macroadenoma, and around 25% of GH-secreting adenomas co-secrete prolactin.
Systemic lupus erythematosus (SLE) is a relapsing and remitting autoimmune disease characterized by multi-organ involvement. The relapsing pattern is known as a lupus flare-up. Women have a higher incidence than men with a sex ratio of 9:1. 1 The disease can manifest as nonspecific symptoms and involve organs including musculoskeletal, dermatological, renal, neuropsychiatric, hematological, pulmonary, gastrointestinal, cardiac, vascular, ocular, endocrine, and obstetric. 2 Having achieved remission status, flare-ups are estimated to occur in up to 25% of SLE patients within 1-2 years and up to 65% within 5-10 years. A quarter of the flare-up cases is classified as severe and the rest are of mild and moderate severity. An index for measuring lupus disease activity is the systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K). Activity categories are defined based on the SLEDAI scores: 0 = no activity, 1-5 = mild activity, 6-10 = moderate activity, 11-19 = high activity, and ≥20 = very high activity. 3 A SLEDAI-2K score increase of more than 3 can be an outcome of a lupus flare-up. The commonly involved organs in flare-ups are the mucosa and skin, the musculoskeletal system (arthritis), the hematological system and kidneys (lupus nephritis). It can also affect the central nervous system causing neuropsychiatric symptoms, cerebrovascular disease, and seizure disorder. 4 Neuropsychiatric involvement in SLE affects both the central and peripheral nervous system. Central involvement may be diffuse or localized. Diffuse disease includes cognitive decline, memory impairment, depression, and psychiatric disorders. Central disorders include seizures with or without cerebrovascular disease are reported in up to 50% of patients
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