“Guitar pick sign,” also referred to as posterior globe tenting, is a radiological surrogate marker of tense orbit and profound vision loss. It is seen commonly in traumatic retrobulbar hemorrhage and carotico-cavernous fistula and less frequently in orbital cellulitis, subperiosteal abscess, and invasive fungal infections. We report a case series of Coronavirus disease-19–associated rhino-orbito-cerebral mucormycosis with guitar pick sign, of which none survived, and discuss the causative pathomechanisms, severity grade, and the clinical relevance of this unique radiological finding.
A 62-year-old female presented first in 2016 with recurrent right-sided frontal headaches, nasal block and seizures of seven years duration. There was no history of any systemic disease. Clinical examination was unremarkable. The evaluation showed rhino-sinusitis and right frontal pachymeningitis on magnetic resonance imaging (MRI), normal cerebrospinal fluid analysis, serum angiotensin-converting enzyme levels and negative antinuclear antibodies. Serum immunoglobulin-G4 (IgG4) level was 2410 mg/dL (< 135 mg/ dL-normal). Dural biopsy was conclusive of IgG4-related disease (IgG4-RD). She was treated with intravenous Rituximab (three cycles of 2-g each 6-months apart). Oral prednisolone was also given for the initial two months. She improved symptomatically and was lost to follow-up. She again presented in September 2021 with a history of rightsided constant ocular pain, proptosis, with an intact vision of one-month duration. MRI of the brain and orbits showed abnormal soft tissue enhancing lesions in ethmoidal and sphenoidal sinuses extending into the right medial orbital cavity abutting the medial rectus and compressing the optic nerve along with abnormal enhancing duramater overlying the floor of the anterior cranial fossa (Fig. 1a, b). The rightsided globe is deformed with posterior scleral tenting, giving an appearance of a "guitar pick" (Fig. 1c, d). Her symptoms resolved after treatment with oral prednisolone and rituximab. Confirmatory histopathology is shown (Fig. 1e, f)."Guitar pick sign", also referred to as posterior globe tenting, is a radiological sign seen in acute and subacute orbital pathologies with a rapid increase in intraorbital pressure. These changes cause anterior displacement and
Background: The ever-increasing impact of drugs on the environment has added an altogether new dimension of monitoring, assessing and documenting the known and unknown drug effects on our fragile environment in the form of ecopharmacovigilance. This study was carried out to document the drug disposing behavior and awareness of the concept of ecopharmacovigilance among the medical faculty of a tertiary care Medical Hospital.Methods: A detailed, structured, anonymous questionnaire consisting of both open and close ended essential queries on drug disposal practices was prepared and response obtained from the participants which included an agglomeration of teaching faculty and the clinicians of various disciplines of the Institute.Results: 97.87% of the participants obtained drugs in excess which included a majority of solid (68.12%) and liquid (31.88%) dosage forms. The maximum medicines obtained in excess included analgesics and antipyretics (89.36%), anti-asthmatics (15.22%), and anti-emetics (13.48%). 82.8% of the respondents were unaware of the proper drug disposal technique and 94.7 % of the respondents practiced open disposal of the drugs.Conclusions: An abysmally low level of awareness about ecopharmacovigilance and unhealthy, irrational method of drug disposal was documented in our study. Appropriate training of those who handle drugs in hospitals and healthcare establishments is the need of the hour.
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