Broward Health Medical Center

Introduction: Management of acute ischemic stroke in the setting of concurrent aortic dissection presents a clinical dilemma due to conflicting hemodynamic goals. Stroke management typically avoids significant blood pressure reduction to preserve cerebral perfusion, whereas acute aortic dissection requires anti-impulse therapy to minimize aortic wall stress. Description: A 72-year-old male with hypertension and BPH presented as a stroke alert with right facial droop and left-sided weakness (NIHSS 28). Initial imaging revealed an intimal flap in the aorta, prompting CT angiography, which showed a Stanford type A dissection extending from the aortic root to the right femoral and left common iliac arteries. Visceral branches involved included the IMA, SMA, celiac, and right carotid arteries, with associated right cerebral infarction. tPA was not contraindicated. Esmolol and nicardipine infusions were started with goals of systolic BP < 120 mmHg and HR < 60 bpm. Given the early stage of potential stroke evolution, neurointerventional radiology supported emergent surgical repair. Cardiothoracic surgery performed emergent repair with hemiarch graft replacement, moderate hypothermic circulatory arrest, and antegrade cerebral perfusion. Postoperatively, BP was maintained around 140 mmHg with HR < 100 bpm using norepinephrine, nitroglycerin, and nicardipine infusions. CT brain revealed right frontoparietal and occipital infarcts in a watershed pattern. The patient eventually woke up and able to follow commands except persistent left upper extremity weakness. Discussion: Concurrent ischemic stroke and aortic dissection demand careful, individualized hemodynamic management. Prioritizing aortic protection may risk cerebral hypoperfusion, while maintaining cerebral perfusion may exacerbate aortic wall injury. This case emphasizes the importance of tailored decision-making to navigate conflicting therapeutic goals and reduce morbidity in critically ill patients.

Introduction: Data supporting the use of seizure prophylaxis are limited in mild traumatic brain injury (mTBI), and the role of antiseizure medication (ASM), including levetiracetam (LEV) remains unclear. This study aims to evaluate the effect of LEV compared to no ASM prophylaxis on outcomes in mTBI. Methods: This was a single-center retrospective cohort study at a Level I trauma center of patients admitted between June 2022 and Dec 2023. Included patients had an admission GCS of 13-15 and at least one ICU day. Patients who received LEV for ≥2 days within 48 hours of admission were compared to those who received no ASM for prophylaxis. The primary outcome was discharge disposition. Secondary outcomes included discharge GCS, in-hospital mortality, ICU and hospital LOS, and seizure incidence. Results: Of the 301 patients included, 135 were in the LEV group and 166 in the no ASM group. Patients were predominantly male (68.4%) with a mean age of 61.1 years. Falls were the most common mechanism of injury (50%). Notably, the LEV group had a significantly higher median Injury Severity Score (17 vs. 12, p < 0.001), more subdural hematoma (44.4% vs. 30.1%, p = 0.010), and underwent neurosurgical intervention more frequently (21.5% vs. 3.0%, p < 0.001). Extracranial injuries were more prevalent in the no ASM group (63.7% vs. 61.4%, p= 0.687). There was no difference in discharge disposition, with most patients discharged to home or home health (63.0% vs. 63.9%, p = 0.873). Median GCS at discharge was 15 [IQR 14–15] in the LEV group vs. 15 [IQR 15–15] in the no ASM group (p < 0.001). The LEV group received more medications with antiseizure effects (70.4% vs. 48.2%, p < 0.001) and more medications known to lower seizure threshold (45.2% vs. 27.7%, p = 0.001). ICU LOS (6.3 vs. 3.2 days, p < 0.001) and hospital LOS (11 vs. 6.6 days, p = 0.002) were longer in the LEV group. There were more seizures in the LEV group (3.7% vs 0, p = 0.017). There was no difference in in-hospital mortality (3.7% vs. 1.8%, p = 0.255). Conclusions: LEV prophylaxis was not associated with a more favorable discharge disposition to home or home health in patients with mTBI. Patients receiving LEV had longer hospital and ICU stays, suggesting that LEV may be used in more severely ill patients.

Dermatologic and musculoskeletal presentations in pediatric patients can pose significant diagnostic challenges, particularly when findings are atypical, persistent, and resistant to therapy. We present a diagnostically complex case of a 13-year-old male with a history of multiple psychiatric comorbidities who developed progressive bilateral pedal edema, bullous lower extremity lesions with excoriations, and severe pain, all symptoms seemingly refractory to antibiotics. Despite initial concern for skin and soft-tissue infection, symptoms persisted, prompting inpatient evaluation and an expanded serologic workup. Screening for immunologic and infectious causes, including human immunodeficiency virus (HIV) and sexually transmitted infections, revealed a new diagnosis of HIV-1 acquired through non-perinatal transmission. The patient was concurrently diagnosed with atypical IgA vasculitis, raising consideration of infectious versus drug-related triggers based on his medication regimen. Although vasculitis is uncommon in HIV-positive patients, and IgA vasculitis is even rarer, this case emphasizes the importance of a broad differential diagnosis in pediatric patients with multisystem involvement. Ultimately, close attention to atypical presentations can ensure timely diagnoses and better care for patients facing similarly complex conditions.

Walking is a fundamental activity of daily living that is often taken for granted despite the prevalence of plantar foot pain among adults. Ultrasound serves as a valuable tool for assessing plantar foot pain due to its accessibility and affordability and the superior resolution of high-frequency transducers. Differentiating between the various entities that cause plantar foot pain requires special attention to patient positioning, transducer choice, machine settings, and diagnostic maneuvers. By leveraging proper scanning technique and recognizing sonographic hallmarks, ultrasound practitioners can enhance evaluation of plantar foot pain, providing definitive diagnoses in many cases and guiding further management. This review highlights sonographic techniques and key imaging findings for common plantar foot abnormalities, including soft-tissue masses, inflammatory and infectious conditions, traumatic injuries, and vascular abnormalities. Additionally, MRI will be discussed as a useful adjunct when further imaging assessment is required.

Advances in tissue engineering have enhanced our understanding of wound healing, leading to more effective management of acute and chronic wounds. Bioengineered skin constructs are increasingly favored for their minimal invasiveness and efficacy. Full-thickness neck wounds in premature neonates pose unique reconstructive challenges due to limited treatment options, high infection risk, and the potential for contracture formation. We present a rare case of an infected neck/shoulder wound in a premature infant with immunodeficiency. Following surgical debridement, a bilayered cellular skin substitute, Apligraf (Organogenesis Inc., Canton, USA) was applied to promote wound closure. Given the lack of reports describing the use of Apligraf for complex neck wounds in premature infants, this case demonstrates its potential as a viable reconstructive option in this vulnerable population, achieving early and cosmetically acceptable closure.

Basal cell carcinoma (BCC) is a locally invasive skin malignancy that can affect the periocular region, often posing significant reconstructive challenges when recurrent or inadequately treated. We report the case of an 80-year-old male with a history of multiple facial BCC excisions who presented with progressive left facial tissue loss and vision loss. Biopsy confirmed recurrent BCC, and positron emission tomography computed tomography (PET-CT) revealed a hypermetabolic mass involving the left orbit, zygoma, and maxillary sinus without distant metastasis. The patient underwent radical oncologic resection, including orbital exenteration, maxillectomy, lateral rhinotomy, ethmoidectomy, and resection of the zygoma and pterygopalatine fossa. Reconstruction involved a split calvarial bone graft for skeletal support and a radial forearm free flap for soft tissue coverage. Pathology showed a 4.7 cm tumor with invasion into conjunctiva, muscle, and bone, and involvement of the deep margin. He recovered well, received adjuvant radiation therapy, and later underwent revision surgery for hardware exposure, with no malignancy identified on pathology. This case illustrates the importance of a multidisciplinary approach and long-term follow-up in managing complex, recurrent periocular BCC to optimize oncologic control and reconstructive outcomes.

Native vertebral osteomyelitis (NVO) is an infection of the vertebral bodies and intervertebral discs that can result in significant morbidity if diagnosis or treatment is delayed. A 35‑year‑old man with chronic low‑back pain underwent a lumbar platelet‑rich plasma (PRP) injection. Approximately four months after the procedure, he developed new-onset low‑back pain that progressively worsened over the course offour weeks, accompanied by intermittent fevers and bilateral leg weakness. Magnetic resonance imaging (MRI) revealed L4-L5 discitis with adjacent end‑plate involvement, consistent with NVO. Blood cultures were negative, and two computed tomography (CT) guided biopsies failed to yield sufficient material for pathogen identification. Empiric broad‑spectrum antimicrobial therapy was initiated. The patient's treatment course was complicated by drug‑induced transaminitis and vancomycin flushing syndrome, requiring several regimen modifications. He ultimately stabilized on intravenous daptomycin and levofloxacin and was discharged with plans for six weeks of outpatient therapy and close follow‑up. This case highlights PRP injection as a potential iatrogenic source of NVO. Clinicians should maintain a high index of suspicion for spinal infection in patients presenting with new or worsening back pain weeks to months after minimally invasive spinal procedures. Early imaging, multidisciplinary management, and patient counseling on post-procedure infection risks are critical, especially when culture data are unavailable and empiric therapy must be carefully adjusted over time.

Abstract Introduction: Pericardial cysts are rare congenital anomalies, accounting for approximately 7% of mediastinal masses. These fluid-filled structures are typically located in the anterior and middle mediastinum and are generally asymptomatic, often discovered incidentally during imaging. However, they can cause symptoms such as chest pain, cough, or dyspnea when compressing nearby structures. Lung adenocarcinoma, a common type of non-small cell lung cancer, frequently presents with nonspecific respiratory symptoms. This case report highlights the rare coexistence of a pericardial cyst and lung adenocarcinoma, presenting significant diagnostic and therapeutic challenges. Case Presentation: A 38-year-old male, a never-smoker with a medical history of autism, major depressive disorder, and seizure disorder, presented to the emergency department with a one-month history of persistent dry cough. He denied hemoptysis, fever, fatigue, or dyspnea. His initial vital signs and laboratory results were unremarkable. A chest x-ray revealed a rounded density in the anterior right mediastinum. A contrast-enhanced CT scan of chest confirmed a large, fluid-filled mediastinal mass consistent with a pericardial cyst (measuring 8.0 x 8.2 x 7.0 cm), along with numerous sub-centimeter nodules in bilateral lungs. A transthoracic echocardiogram demonstrated a large cystic structure adjacent to the right atrium. Due to the size of the cyst and the persistence of symptoms, the patient underwent video-assisted thoracoscopic surgery for resection of the cyst and wedge biopsy of the right lung nodules. Pathological analysis revealed adenocarcinoma in the lung nodules. Further staging revealed metastasis to the bone and brain. After an oncology consultation, the patient was initiated on chemotherapy for metastatic lung adenocarcinoma, with follow-up in the outpatient setting. Discussion: The coexistence of a pericardial cyst and lung adenocarcinoma is exceedingly rare, posing significant diagnostic challenges. While most pericardial cysts are asymptomatic, they can occasionally cause symptoms such as cough, chest pain, or dyspnea by compressing nearby structures. In rare cases, complications such as pericarditis or cardiac tamponade may arise. In this patient, imaging initially revealed a pericardial cyst and pulmonary nodules. Further evaluation and biopsy confirmed metastatic adenocarcinoma. Imaging modalities like CT and MRI are essential in distinguishing benign pericardial cysts from other mediastinal masses. Conclusion: This case illustrates the rare coexistence of benign and malignant thoracic conditions, highlighting the need for thorough investigation when concurrent findings, such as pericardial cysts and pulmonary nodules, are present. In young, non-smoking patients, malignancy can be easily overlooked. Comprehensive evaluation is essential for early diagnosis and effective treatment.