Background: The 'Spiked Helmet' is an electrocardiogram (EKG) finding occasionally seen in critically ill patients characterized by ST segment elevation usually represented as a 'spike and dome' pattern with elevation in the EKG baseline prior to the R wave and adjoining ST segment elevation resembling the German military helmet of the Prussian Empire. In the few cases reported in literature, this finding has been associated with very poor clinical outcomes, including in-hospital death. Although ST elevation is not uncommon in critically ill patients, these findings of a 'Spiked Helmet' sign are often transient and typically not associated with acute coronary syndrome. Case presentation: A 56-year-old male was found unresponsive by his relatives at home. It was an unknown the time that he had been unconscious. When the emergency medical services arrived, patient was found to be in pulseless electrical activity (PEA). Patient achieved return to spontaneous circulation (ROSC) 15 minutes after initiation of advanced cardiac life support protocol. An electrocardiogram done immediately post ROSC showed ST elevations in inferior and lateral leads. Patient was brought to the hospital as a ST elevated myocardial infarction (STEMI) arrest. The EKG revealed the Helmet sign in leads aVL and II, also ST segment elevation was noted in V1, V2, V3 and ST segment depression was noted in V5 and V6. Troponin was negative at the time of initial evaluation but trended up gradually during the hospitalization. A computed tomography (CT) pulmonary angiogram was negative for pulmonary embolism. A head CT showed diffuse anoxic brain injury. Patient was started on the hypothermia protocol. Upon family request patient was terminally extubated two days into hospital stay and expired shortly after. Conclusion: Although we are yet to fully understand the significance of the 'Spiked Helmet' Sign, this case report and literature review offers a comprehensive overview of the reported cases and draws important links and clues from them.
Female urethral diverticular cancer is a very rare entity with only around 100 cases reported so far in literature and accounts for <1% of all malignancies. In this article, we present a 47-year-old African American female with repeated hospital visits for urinary retention, hematuria, and urinary tract infections. Initial computed tomography imaging and cystoscopy was unremarkable except for a distended urinary bladder. Subsequent magnetic resonance imaging and corresponding cystoscopy eventually indicated the presence of a urethral diverticulum. She underwent urethral diverticulectomy and was found to have a mass arising from urethral diverticulum extending to vaginal walls. Her biopsy was suggestive of invasive adenocarcinoma in advanced stages, for which she subsequently underwent a total pelvic exenteration. Next-generation sequencing of the tumor showed CDKN2A/B loss, MSI-stable, and low TMB, thereby ruling out the options for targeted therapies. Extensive literature search and expert opinions were sought for her case since no consensus exists regarding the optimal therapeutic approach due to the rarity of this tumor. A final decision was made to treat her with platinum-based chemotherapy. Different treatment approaches including neoadjuvant chemoradiation followed by surgery, surgery followed by adjuvant chemotherapy, and surgery followed by chemoradiation have been tried. Platinum-based chemotherapy has generally been preferred based on an extensive literature search. Multimodality treatment approach seems to be the current approach to management for advanced stages for better overall survival. This case illustrates the challenges faced in making diagnosis and treatment decisions due to the rarity of this type of tumor and lack of consensus in the treatment approach.
Background: Healthcare related bacterial endocarditis represents a significant portion of endocarditis seen today. Suspicion for these infections should be particularly high in patients with chronic indwelling central venous catheters, and most notably, in patients with hemodialysis catheters. These infections may have a predilection for the superior vena cava due to proximity of the catheters to the great veins of the neck. Transthoracic echocardiography and/or trans-esophageal echocardiography should be done promptly in patients in which there a high suspicion for such infections, in order to identify these lesions, and guide appropriate management with either antibiotics or surgical intervention. Case presentation: We present a 59-year-old female with multiple comorbidities including diabetes mellitus and end-stage renal disease requiring dialysis via an anterior chest wall catheter, who presented with fever, chills, and abdominal pain. She was found to have pus in and around her catheter. Further evaluation with trans-esophageal echocardiography revealed the presence of a superior vena cava vegetation extending into the right atrium. She received a 6 week course of appropriate antibiotics with repeat trans-esophageal echocardiography showing a significant reduction in the size of the vegetation. Patient remained afebrile, and without leukocytosis and negative blood cultures for the remainder of her hospital stay.
INTRODUCTION: Focal nodular hyperplasia is a benign tumor of the liver, second most common after hemangioma. Most commonly, it is incidentally found in reproductive-aged women. It accounts for 8% of all primary liver tumors. Radiologically these regenerative nodules closely mimic intrahepatic cholangiocarcinoma and may be misdiagnosed leading to fatal outcomes. In most cases, the histopathological examination of a biopsy specimen establishes a definitive diagnosis. It is a rare entity for FNH to present in cirrhotic liver and as multiple nodular lesions (>5 in number). CASE DESCRIPTION/METHODS: An obese 66-year-old woman with a past medical history of diabetes presented with recurrent episodes of hematemesis and melena. Physical examination revealed a soft abdomen with hepatomegaly. Laboratory examination revealed microcytic anemia with hemoglobin of 7.1 g/dL and MCV of 73 fL. Liver function tests were within normal limits. Esophagogastroduodenoscopy revealed bleeding medium sized gastric body ulcer which was clipped. Abdominal computed tomography (Fig. A) and Magnetic resonance imaging (Fig. B) revealed multiple ( >5) ill-defined slow enhancing liver lesions, the largest of which measured 5.7 × 7.8 × 7.4 cm mass. Hepatitis screen and tumor markers including CA 19-9, CEA, AFP were negative. Liver cirrhosis was thought to be secondary to nonalcoholic steatosis as her work up did not reveal any other cause. Magnetic resonance cholangiopancreatography (Fig. C) revealed cirrhotic liver and multifocal lesions including a 9 × 8.1 × 11.9 cm mass in the right lobe and additional multiple small lesions in the left lobe all showing a rim of enhancement in the arterial phase, centripetal enhancement in venous phase, delayed washout in late phase and with associated overlying capsular retraction. Biopsy of the liver lesions revealed focal nodular hyperplasia with underlying fibrosis (Fig. D, E). with no evidence of malignancy. Our case is a very rare mimic of multifocal cholangiocarcinoma due to similarities radiologically which without a biopsy could have led to a misdiagnosis and wrong management. DISCUSSION: FNH usually presents as a single lesion in a normal liver parenchymal tissue. When diagnosed and symptomatic, treatment modalities include surgical removal or in some cases, trans-arterial chemoembolization. Our patient is a very unique case of FNH presenting as multinodular lesions in a cirrhotic liver. Since she remains asymptomatic, she will be actively monitored with a regular ultrasound screening.
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