Faculty Bibliography

A typical vasovagal response is characterized by bradycardia and paradoxical vasodilation. It is oftentimes self-limited and spontaneously reversible; however, severe cases can result in significant complications. This report describes a case of profound vasovagal syncope with subsequent cardiac arrest in the setting of receiving a trigger point injection. This patient presented to an outpatient clinic for ultrasound-guided left trapezius, levator scapulae, and rhomboid trigger point injections for relief of myofascial pain. One milliliter of 1% lidocaine was injected into the first trigger point when she stated she felt dizzy before becoming unresponsive without palpable peripheral pulses. The patient regained consciousness following cardiopulmonary resuscitation (CPR). Considering the frequency of office based pain procedures, it is important to recognize the potential serious complications associated with procedures frequently thought to be benign.

Case Description: Patient presented for medial knee pain and swelling she noticed 3 weeks ago after mountain skiing. She did not recall any injures at that time, nor prior. On exam there was no instability with cruciate or collateral ligament testing. Full strength and sensation. Mild fullness of knee was appreciated. She had tenderness to palpation proximal to the medial joint line. A diagnostic ultrasound exam was performed of medial knee which revealed a well circumscribed hyperechoic mass within vastus medialis. An MRI was ordered and the patient was referred to an oncologic surgeon for biopsy.
Setting(s): Outpatient clinic.
Patient(s): 55F without significant PMH. Assessment/Results: MRI showed 2.7x1.7x1.5cm ovoid circumscribed indeterminate mass within the vastus medialis muscle. A CT scan was additionally ordered at the request of the musculoskeletal radiologist to help rule out internal calcification from traumatic/inflammatory conditions prior to performing biopsy. The CTscan was negative for internal calcium. Subsequent core needle biopsy result proved mass to be lowgrade spindle cell lesion, further characterized by fluorescence in situ hybridization testing to be nodular fasciitis. The patient elected to monitor mass at 6-month intervals for progression, with option for excision in future. MRI at 6 months showed interval decreased volume of mass.
Discussion(s):Without sonographic evidence of a mass, the working diagnosis for medial knee pain in a middle-aged woman with swelling after a skiing trip is traumatic arthropathy. If this patient had not been scanned, she could have gone through a course of conservative treatment including therapy with an incorrect diagnosis and possible exacerbation of symptoms.
Conclusion(s): This case illustrates the utility of diagnostic ultrasound in clinic to provide good patient care through accurate diagnosis

Case Description: Patient with history of HIV, who presented with two weeks of progressive right lower extremity sensory loss and left hemiparesis. Exam was consistent with Brown-Sequard Syndrome (BSS) with left upper and lower extremity weakness, impaired pinprick sensation throughout right lower extremity, and decreased temperature sensation throughout right upper and lower extremity.
Setting(s): Hospital Inpatient Unit Patient: 50-year-old male with Brown-Sequard Syndrome (BSS). Assessment/Results: MRI cervical spine revealed focal nodular enhancement at the left C5-C6 spinal cord with associated extensive cord signal changes and expansion from C2-T1. Labs were notable for elevated inflammatory markers, elevated angiotensin-converting enzyme (ACE) and CSF protein. Chest CTwas significant for mediastinal and left perihilar lymphadenopathy. Bronchoscopy revealed endobronchial studding and non-caseating granulomas most consistent with sarcoidosis. He was started on methylprednisolone for spinal neurosarcoidosis with improvement in strength.
Discussion(s): Sarcoidosis is a multiorgan system disease characterized by noncaseating granulomas. Sarcoidosis involving the spinal cord (spinal neurosarcoidosis) is rare. Moreover, the diagnosis of spinal neurosarcoidosis is challenging due to its significant variability in clinical findings and lack of definitive laboratory or imaging characteristics. In patients with HIV the diagnosis might be even more difficult since there are numerous HIV-associated pathogenic processes that can lead to spinal cord dysfunction. Research on the coexistence of HIV and sarcoidosis has also shown that sarcoidosis can develop during the restoration of Tcell immunity associated with antiretroviral therapy (Immune Reconstitution Inflammatory Syndrome). This phenomenon as well as the diagnostic challenges highlights the importance of considering neurosarcoidosis in the differential of patients with myelopathy, especially patients with HIV.
Conclusion(s):We report an unusual case of neurosarcoidosis presenting as BSS in a patient with HIV. Although neurosarcoidosis is rare, this case underscores the importance of considering this diagnosis in patients presenting with myelopathy and its significance in patients with concurrent HIV

Case Description: A 57-year-old male who had been doing weightlifting, "reverse" pull-ups, and strenuous neck motions presented after competing in a pull-up contest. After 20 pull-ups, he experienced a sudden electrical shock-like pain in his left upper scapular region with radiation to his left arm followed by whole arm burning. With pain gradually improved, he noticed weakness of left hand grip with numbness of ulnar side of forearm/hand. Without remarkable neck pain, he was given a clinical diagnosis of left brachial plexus injury and referred for electrodiagnostic test.
Setting(s): Clinic Patient: 57-year-old male Assessment/Results: Normal ulnar and medial antebrachial sensory nerve conduction were against lower trunk/medial cord injury. Electromyography (EMG) was indicative of left C8/T1 radiculopathy with evidence of partial denervation/reinnervation in abductor pollicis brevis, flexor carpi ulnaris, first dorsal interosseous, and C8/T1 paraspinal muscles. With negative EMG of finger extensors, T1 radiculopathy was suggested. Magnetic resonance imaging (MRI) showed left posterolateral disc herniation into T1-2 neuroforamina with compression of the exiting left T1 nerve root. Patient was educated on appropriate neck exercises and positioning. Three months post-injury patient reports improved left grip strength with resolution of pain and numbness.
Discussion(s): Isolated T1 radiculopathy is rarely reported as it is clinically and electrophysiologically difficult to separate from C8 radiculopathy. In our case, combined EMG result of positive C8/T1 muscles and negative C7/8 muscles with left T1 root compression on MRI confirmed T1 radiculopathy. The mechanism of injury in this patient is unclear, however, combined local muscles' fast contractions with prolonged neck hyperextension may have caused the T1/2 disc herniation.
Conclusion(s): T1 radiculopathy and disc herniation at T1-2 are not commonly reported and it may happen during strenuous pull-ups with improper cervical posture. With the overabundance of new exercise fads, many involving timed competitions, it is important to counsel patients on proper form to help prevent acute disc herniations

Case Description: A 42-year-old female secretary presented with acute painful swelling of her wrist and hand numbness. She complained of stabbing pain in her hand for 2 weeks without an inciting event and a painful, palpable cyst on her left forearm for 1 week, associated with numbness/tingling on the dorsum of her left hand and forearm. Pain was worse after prolonged computer use and with twisting motions. On examination, there was a fluid-filled cyst proximal to left ulnar wrist crease. Left digits 3-4 were tender to palpation and digits 3-5 were cool to touch. Allen's test was positive for ulnar artery occlusion. Ultrasound revealed occlusion of the ulnar artery from the distal forearm to Guyon's canal. Magnetic resonance angiography revealed occlusion of the distal ulnar artery with aneurysmal expansion indicating hypothenar hammer syndrome. The patient was referred for surgery and underwent ulnar artery excision of aneurysm with vein graft.
Setting(s): Outpatient clinic Patient: 42-year-old female secretary Assessment/Results: Hypothenar hammer syndrome after computer use.
Discussion(s): Hypothenar hammer syndrome is a rare, limb threatening diagnosis caused by repetitive trauma to the hypothenar eminence resulting in injury to the ulnar artery at the level of Guyon's canal. This has been described in middle-aged men with occupations such as manual laborers or mechanics and athletes who experience repetitive trauma to the palm such as in mountain biking or baseball. To our knowledge, this syndrome has rarely been seen in a younger female as a result of prolonged computer use. It is important to identify this condition in order to get appropriate treatment in a timely matter. The use of Doppler ultrasound is beneficial to hasten referral to the appropriate specialist.
Conclusion(s): It is important to consider the diagnosis of hypothenar hammer syndrome when evaluating a patient for wrist pain and numbness in order to prevent serious complications including limb ischemia

Description: The patient was a 65-year-old man with visual hallucinations after a right pontine infarct which improved without pharmacological intervention. He had dementia, hypertension, diabetes, and tobacco use. He was admitted to acute inpatient rehabilitation where he was noted to have visual hallucinations. He reported seeing furniture and objects that were not there. He had Lilliputian hallucinations which involved seeing objects smaller than they were in reality. The patient understood his hallucinations were not real and was not perturbed by them. Sleep disturbance was present. Prior electroencephalography was negative for seizures. Medications were reviewed for causes of hallucinations and ropinirole was stopped, but hallucinations persisted.
Setting(s): Academic Acute Inpatient Rehabilitation Hospital Results: The patient had peduncular hallucinosis and quetiapine was considered. However, due to his cardiovascular risk factors and dementia leading to increased risk of cardiovascular events with atypical antipsychotics, it was not given. As his hallucinations were not affecting his function and were non-threatening to the patient, the decision was made not to treat his hallucinations. His hallucinations became less frequent with time.
Discussion(s): Our case presents a patient who experienced peduncular hallucinosis after a pontine infarct, a rare neurologic disorder that can occur after a patient sustains damage to the midbrain, pons, or thalamus. Patients experience visual hallucinations that are often realistic. They can have Lilliputian hallucinations and sleep disturbances. The option to treat with atypical antipsychotics is available, however, given the risks associated with such medications and the self-resolving nature of the hallucinations in this case, their use was not necessary.
Conclusion(s): Our case is one of the few reported incidences of peduncular hallucinosis. Pharmacological intervention may not be required given its self-limited nature