Christ Ordookhanian’s research while affiliated with University of California, Riverside and other places

Charcot neuroarthropathy (CNA) is a progressively debilitating condition characterized by joint destruction and deformity due to neuropathy and mechanical trauma. It is most seen in patients with uncontrolled diabetes mellitus and resulting secondary peripheral neuropathy. Misdiagnosis is common, as the initial presentation of erythema, swelling, and warmth can mimic conditions such as cellulitis or osteomyelitis, and radiographic images may resemble that of severe trauma. Early recognition is crucial to prevent complications, including chronic deformity, ulceration, and amputation. In this case, a 42-year-old male patient with no documented medical history presented to the emergency department (ED) with worsening left ankle and foot pain after rolling his ankle on a flat surface. Imaging revealed acute, intra-articular fractures of the left hindfoot involving the talus, cuboid, navicular, and lateral cuneiform, with associated joint dislocations and severe soft tissue edema. These findings, initially concerning for severe limb trauma, in fact, represented that of CNA after underlying uncontrolled diabetes mellitus was diagnosed. While CNA is most commonly associated with diabetic peripheral neuropathy, it should not be excluded in the absence of a documented medical history of diabetes mellitus. Given the potential for misdiagnosis, early collaboration among specialists was essential in providing the patient with an accurate clinical determination. Early immobilization and offloading prevented further joint destruction, highlighting the critical role of early intervention in mitigating long-term complications such as chronic deformity or amputation.

Background Managing electrolyte abnormalities is one of the cornerstones of properly caring for and managing hospitalized patients. Typically, electrolyte derangements are managed by direct repletion, volume status correction, or hemodialysis; however, the persistence of electrolyte abnormalities despite utilizing appropriate initial strategies requires further investigation. Case Description A 72-year-old male presented to the emergency department with weakness 2 months post-exploratory laparotomy with ileostomy for small bowel perforation complicated by intra-abdominal infection. The patient was treated for sepsis and imaging revealed intra-abdominal and abdominal wall abscesses. After drainage, recovery was complicated by treatment of refractory hypomagnesemia in the context of zinc supplementation. Discussion If initial electrolyte repletion measures do not provide the intended benefit, investigating secondary causes of refractory electrolyte abnormalities is necessary. While hypomagnesemia is one of the least common electrolyte derangements seen within the general acute care hospital setting, in facilities with relatively high volumes of bariatric or gastrointestinal surgical patients, keeping the phenomenon of zinc-induced hypomagnesemia in mind becomes more crucial due to its frequent use in those settings. Conclusion This case highlights the effects of excess high-dose zinc supplementation in a patient without zinc deficiency in the postoperative period who developed treatment-resistant hypomagnesemia due to zinc-induced impairment of magnesium absorption as well as gastrointestinal and renal losses. LEARNING POINTS Zinc supplementation can cause hypomagnesemia.

Tension pneumothorax is characterised by progressive air accumulation in the pleural space leading to increasing intrathoracic pressure and haemodynamic instability. Pneumothorax is generally observed following blunt or penetrating trauma, though spontaneous pneumothorax can also occur in patients with risk factors. This case highlights the potential for severe complications in an otherwise healthy patient with tension pneumothorax resulting from a ground‐level fall onto an absorbent soft surface with mild indirect thoracic trauma. Initial respiratory status coupled with asthma history was worrisome for asthma exacerbation; however, imaging confirmed tension pneumothorax, later complicated by persistent air leak associated with apical blebs, corrected surgically.

Sepsis is a serious condition involving life-threatening infection-driven immune response and organ dysfunction. In the emergency department (ED), patients at high risk for sepsis or those with suspected sepsis are managed with a standardized protocol which includes empiric broad-spectrum antibiotic therapy pending blood culture results and susceptibilities, if applicable. While the benefits generally outweigh the risks, this approach may lead to complications, including allergic reactions, gastrointestinal irritation, acute kidney injury, and even financial toxicity, particularly in cases of contaminated blood cultures. We describe a case of a 68-year-old woman who presented to the ED with clinical signs of infection, and an initial workup significant for leukocytosis without a clear source of infection. Blood cultures were obtained and the patient was discharged with azithromycin. She was recommended to follow up with her primary care provider. However, the blood cultures grew coagulase-negative, gram-positive cocci and the patient was asked to return to the ED for admission. She was treated with intravenous vancomycin and subsequently developed acute kidney injury (AKI). Further investigation revealed that the blood cultures were contaminated with Staphylococcus epidermidis due to improper blood sampling techniques. This case highlights the risks associated with empiric antibiotic treatment of patients with suspected bacteremia, the implications associated with improper blood culture collection technique leading to false positive results, and the importance of interpreting a laboratory result within the context of the patient’s clinical status rather than relying solely on Systemic Inflammatory Response Syndrome (SIRS) criteria.

A normal daily routine turns critical in seconds, and a biophysical maneuver that is instinctual leads to a rapid decline in a young healthy patient without any warning or precipitating signs. The Valsalva maneuver is a commonly used term for the act of bearing down that affects the vagus nerve, resulting in systemic changes primarily within the autonomic nervous system. This paper reviews a case in which a young man engaging in the Valsalva maneuver was later found unconscious and presented to the emergency department. Neuroimaging revealed a large middle cerebral artery stroke along with an undiagnosed temporal arachnoid cyst, without any significant historical medical records. The resulting course of this disease remained an interesting area of inquiry. This case highlights a rare but intricate interplay of several major physiological functions that collectively contribute to the unexpected demise of a young and healthy patient.

Excessive ethanol consumption is associated with an increased risk of developing health complications, especially in individuals with pre-existing thrombocytopenia and cirrhosis. Here, we describe a case of a patient with a history of alcoholic cirrhosis, hypertension, and thrombocytopenia, presenting with significant decline following an incidence of binge drinking. Radiography identified a large non-lobar intraparenchymal hemorrhage. However, due to severe thrombocytopenia that was unresponsive to platelet therapy, the possibility of pursuing any form of surgical intervention was negated. Surgical contraindication and a lack of response to subsequent medical management contributed to the family's decision to opt for conservative medical treatment and comfort care. This case showcases the potential for liver cirrhosis in the setting of chronic alcohol use disorder to pave the way for terminal intracerebral hemorrhage.

The post-operative realm for hepatic transplant patients presents many challenges, but of them all, we take a deeper dive into an increased risk of associated cerebrovascular events. Cerebrovascular diseases, such as cerebral arteriovenous malformation (AVM), are a leading cause of death following a liver transplant. We present a unique case of a liver transplant patient who presented with no brainstem reflexes three months into the post-transplant period. Imaging studies revealed a ruptured AVM within the foramen magnum and cervicomedullary junction, as well as substantial cerebral hemorrhage. While establishing the exact cause of the AVM is not as trivial as it may appear, side effects associated with post-transplantation management regimens and possible congenital factors do shed some light on notable considerations. Given the potential damage associated with ruptured AVMs, poor patient outcomes are unfortunately not as rare as one would hope. This case highlights a rare but highly possible occurrence for cerebrovascular complications, specifically AVM rupture linked to liver transplantation and the systemic changes associated with a procedure as invasive as liver transplantation.

Stroke is among the leading causes of death in the United States, and with our aging population, it will remain a pertinent obstacle in the acute setting. While the field of neuroradiology has advanced tremendously over the years, particularly in improving what we can visualize and quantify, the phrase "time is brain" yet dominates acute stroke management. Optimizing diagnostic protocols for suspected stroke requires a careful balance of data acquisition and speed, as well as taking into account available resources. We present a case of a middle-aged patient with notable risk factors for stroke presenting to the emergency department with altered mental status and suspected stroke. Radiography revealed a large subacute subdural hematoma (SDH) with a mild mass effect on the surface of the brain. The evaluation was supplemented by a computed tomography (CT) and perfusion cerebral blood flow (CBF) study indicating cortical ischemia with penumbra from the SDH compression. SDH evacuation was successfully performed, and patient recovery was achieved within the intensive care unit (ICU). Rapid data acquisition via CBF with CT imaging is crucial for guiding treatment decisions for SDHs. While protocols for ischemic stroke are well-established, SDH protocols are not studied. Thus, we discuss the value of a multimodal CT imaging approach, including CBF studies, in SDH evaluation.

Spinal cord injury (SCI), particularly of the traumatic variety, is a relatively common condition that disproportionately affects the elderly. Cases of SCI with nontraumatic etiologies in the geriatric population have increased over the last 20 years, however. Pannus formation, resulting from chronic inflammation of the spine, is one such etiology that may progress to SCI and potentially result in rapid neurological degeneration. Here we describe a case of an elderly woman who presented with a sudden onset of quadriplegia without a history of trauma. Radiography revealed upper cervical instability and fracture due to the presence of a large erosive pannus formation. Unfortunately, in the context of severe SCI, the reversibility of neurological decline is not always guaranteed. Additionally, surgical intervention is not always appropriate, especially among the elderly population, where medical management and end-of-life care are more often delivered.