Lincoln Hospital

About: Lincoln Hospital is a healthcare organization based out in New York, New York, United States. It is known for research contribution in the topics: Population & Emergency department. The organization has 1033 authors who have published 929 publications receiving 14486 citations. The organization is also known as: Lincoln Medical and Mental Health Center & Lincoln Hospital.

Clinicopathological conference: A case of more than a sprained ankle.

Abstract: A 35-year-old African American woman presented to the emergency department (ED) with the chief complaint of pain in the right ankle after falling down several steps. Upon further questioning, the patient admitted that she had fallen down the stairs because she had had trouble seeing them. She described complete vision loss in the left eye for four days before ED arrival after painless, progressive blurring of two weeks’ duration. Additionally, while in the ED, she began to complain of headache and right eye pain, with blurring of vision. Before the onset of these new visual symptoms, she had never had any ophthalmologic ailments. Review of systems was significant only for chronic sinus congestion and frequent epistaxsis over the prior one to two months. Her past medical history included pregnancy-induced hypertension and an allergy to amoxicillin. She was not taking any medications and did not abuse tobacco, illicit drugs, or alcohol. Physical examination showed normal vital signs and in general, a well appearing woman who was complaining only of ankle pain and swelling. Thorough examination of her head, ears, nose, and throat showed a normocephalic/atraumatic head and an otherwise normal examination. The ocular examination showed intact extraocular muscles, an afferent pupillary defect of the left eye, and no light perception with the left eye. The right eye had a reactive pupil and a visual acuity of 20/40. Slit lamp examination result was normal bilaterally. The fundoscopic examination showed blurred disc margins bilaterally, consistent with papilledema. Examination of the neck, heart, lungs, and abdomen was normal. Extremity examination showed edema and tenderness over the right lateral malleolus, without ecchymosis or bony deformity. Ambulation was possible with the assistance of a cane but was limited secondary to pain. Routine laboratory analysis included a complete blood count and chemistry profile, rapid plasma reagin (RPR), sedimentation rate, angiotensin converting enzyme (ACE) level, lysozyme, rheumatoid factor, antinuclear antibody, and a Lyme titer. Additionally, the patient had ankle radiographs taken, which were normal; her chest radiograph and head computed tomography (CT) scan are presented for review in Figures 1, 2a, and 2b. Upon review of the head CT scan, medical therapy was immediately started and neurosurgery was consulted. The head of the bed remained elevated. Repeated examinations showed declining visual acuity of the patient’s right eye. Routine laboratory results were normal, except for an elevated sedimentation rate (ESR) of 34. The patient was transferred to a tertiary care center for further evaluation and treatment.

A unique case of leptomeningitis associated with rheumatoid-like arthritis and naegleria fowleri. (P6.316)

Abstract: Objective: To report a case of coinciding leptomenigitis, rheumatoid-like arthritis and naegleria fowleri (NF). Case report: A 62 year old healthy male visiting from Shanghai presented to Stony Brook University Hospital after a fall following three days of bilateral leg weakness and fever. In the preceding month he used neti pot irrigation for sinus congestion. Brain MRI revealed leptomeningeal enhancement. CSF analysis showed pleocytosis and negative cultures. Empiric treatment included vancomycin, cefepime, metronidazole and acyclovir. He was discharged with a diagnosis of aseptic leptomeningitis. A partial seizure 6 days later and worsening symptoms prompted readmission. Seizures resolved with valproic acid. Repeat brain MRI was unchanged. CSF flow cytometry showed reactive T cells. Brain biopsy findings included: acute and chronic leptomeningitis, multinucleated giant cells and necrosis. Altered mentation and paresis attributed to post-surgical cerebral edema developed. Symptoms improved with dexamethasone. Rheumatoid factor (RF) and cyclic citrullinated peptide antibodies (CCP) were elevated. He continued to improve on prednisone. After discharge, the New York State Department of Health (NYS DOH) reported polymerase chain reaction (PCR) on CSF from the first admission was consistent with Naegleria species. A real-time PCR on brain DNA was positive for NF. He was asymptomatic and Amphotericin B was not initiated. He returned to China only with a prednisone taper. At lower doses of prednisone and after 3 months, all symptoms returned including arthritis, seizures and leg weakness. While hospitalized in China, PCR of CSF was negative for NF. There was edema on brain MRI. He received high dose prednisone, rituximab and intravenous immunoglobulin. He has recovered with tapering prednisone and methotrexate. Conclusions NF in brain tissue coincided with new onset rheumatoid arthritis and leptomeningitis. These findings have not been previously documented. Disclosure: Dr. Rodriguez Alvarez has nothing to disclose. Dr. Mirchandani has nothing to disclose. Dr. Khan has nothing to disclose. Dr. Medin has nothing to disclose. Dr. Seidman has nothing to disclose. Dr. Madison-Antenucci has nothing to disclose. Dr. Espina has nothing to disclose. Dr. Teal has nothing to disclose. Dr. Mergen has nothing to disclose.