The coronavirus disease 2019 (COVID-19) virus primarily affects the pulmonary system, but neurological manifestations and complication of COVID-19 has been reported in abundance in the literature. We present a case of a middle-aged Caucasian male who was brought to the emergency department for altered mental status. His chief complaints were neurological rather than respiratory. A positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction (RT-PCR) nasal swab confirmed the diagnosis. Brain imaging showed mildly dilated ventricles with no other acute findings. As the patient did not require oxygen, he was treated with remdesivir alone without corticosteroids, which is also a precipitating factor of psychosis but, unfortunately, thickly used in practice. That led to remarkable results in full recovery without exposing the patient to steroid therapy. We strongly believe that remdesivir alone is sufficient in treating COVID-19-induced encephalopathy in a patient who does not require oxygen, and evidence supports this practice.

Stercoral colitis (SC) is a rare inflammatory colitis that occurs due to increased intraluminal pressure from impacted fecal content in the colon. Chronic constipation is the major risk factor for this condition. Delayed diagnosis is associated with high morbidity and mortality, with complications ranging from colonic perforation to intestinal ulcers. Patients usually present with non-specific symptoms, with advanced cases presenting with acute abdomen pain. This condition can be fatal if not recognized early and promptly treated. Early detection can often be difficult in elderly patients with dementia, stroke, or other neurologic disorders that cause altered mental status (AMS). Therefore, AMS in patients with severe constipation should be a substantial reason to consider stercoral colitis as a differential diagnosis. Here, we describe a case of stercoral colitis in a 59-year-old woman with non-verbal cerebral palsy who had acute metabolic encephalopathy from her stercoral colitis and was successfully treated with colonoscopic fecal disimpaction and an aggressive bowel regimen.

Molybdenum cofactor deficiency (MoCD) represents a spectrum, with some individuals experiencing significant signs and symptoms in the neonatal period and early infancy (termed early-onset or severe MoCD) and others developing signs and symptoms in childhood or adulthood (termed late-onset or mild MoCD). Individuals with early-onset MoCD typically present in the first days of life with severe encephalopathy, including refractory seizures, opisthotonos, axial and appendicular hypotonia, feeding difficulties, and apnea. Head imaging may demonstrate loss of gray and white matter differentiation, gyral swelling, sulci injury (typically assessed by evaluating the depth of focal lesional injury within the sulci), diffusely elevated T2-weighted signal, and panlobar diffusion restriction throughout the forebrain and midbrain with relative sparring of the brain stem. Prognosis for early-onset MoCD is poor, with about 75% succumbing in infancy to secondary complications of their neurologic disability (i.e., pneumonia). Late-onset MoCD is typically characterized by milder symptoms, such as acute neurologic decompensation in the setting of infection. Episodes vary in nature but commonly consist of altered mental status, dystonia, choreoathetosis, ataxia, nystagmus, and fluctuating hypotonia and hypertonia. These features may improve after resolution of the inciting infection or progress in a gradual or stochastic manner over the lifetime. Brain imaging may be normal or may demonstrate T2-weighted hyperintense or cystic lesions in the globus pallidus, thinning of the corpus callosum, and cerebellar atrophy.

In this report, we present an unusual and multifactorial case of severe hyponatremia with important clinical implications. The decedent was a 42-year-old woman who was discovered at her place of residence with altered mental status and profuse watery diarrhea. The scene was significant for numerous empty water bottles. She was transported to the emergency department of a local medical center and rapidly became obtunded. Imaging demonstrated cerebral edema with impending herniation. Serum chemistry was significant for severe hyponatremia (116 mEq/L) with decreased serum osmolality (245 mOsm/kg), suggestive of water overload. Over a brief course of hospitalization, she continued to deteriorate and brain death was pronounced. After brain death, she underwent organ donation. Subsequent autopsy examination demonstrated global cerebral edema with evidence of herniation. Toxicology examination of antemortem blood was positive for methamphetamine (1900 ng/mL) and amphetamine (100 ng/mL). An incidentally identified colon polyp was submitted for microscopic evaluation, which revealed the presence of Cryptosporidium, the likely cause of her diarrheal illness. Death was attributed to severe hyponatremia through the combined effects of excessive water consumption and loss of fluid and electrolytes from cryptosporidiosis, in turn leading to cerebral edema and brain herniation. Acute methamphetamine intoxication was a contributing condition.

Hypercalcemic crisis due to severe decompensated hypercalcemia represents a life-threatening medical emergency leading to renal failure and altered mental status. Hypercalcemic crisis most commonly results from hypercalcemia of malignancy, undiagnosed primary hyperparathyroidism, granulomatous diseases, and medication-induced hypercalcemia. Commonly prescribed medications like thiazide diuretics, lithium therapy, and teriparatide are among the medications known to cause hypercalcemia. Here, we describe a case of the hypercalcemic crisis caused by excessive calcium carbonate ingestion emphasizing physicians to be aware of this potentially life-threatening adverse effect of a widely available over-the-counter acid reflux medication and educate patients regarding the same.

BACKGROUND Methanol can cause many acute complications when ingested, either intentionally or accidentally. One rare complication is cerebral hemorrhage, which can present with focal neurologic deficits, decreased consciousness, and fixed, dilated pupils. With vigilant monitoring of patients in the acute period of toxicity, rapid identification, and initiation of treatment, outcomes can potentially be improved in these patients. CASE REPORT We present a case of a 42-year-old man who presented after ingestion of windshield wiper fluid. Initial symptoms started with fatigue and altered mental status, but he quickly developed abdominal pain and became obtunded. CT initially showed no acute hemorrhage or other pathology, but on day 2, despite receiving fomepizole, bicarbonate, and dialysis, the patient became hypotensive and showed loss of cranial nerve reflexes, and repeated CT head scans showed acute intracranial hemorrhage with mass effect. CONCLUSIONS Although the exact mechanism of intracranial hemorrhage and necrosis following methanol intoxication remains uncertain, we know beyond doubt that it can progress rapidly and lead to severe and irreversible complications, so identifying and treating it immediately is essential. In this case, methanol ingestion was known on presentation, antidote and renal replacement therapy were initiated within hours of ingestion, yet our patient still suffered fatal brain hemorrhage. Important warning signs of acute hemorrhage include loss of cranial nerve reflexes and decrease in consciousness, so these findings warrant further evaluation and prompt neuroimaging, especially in high-risk patients like the one in this report.

The first COVID-19 lockdown resulted in enforced quarantine of heavily affected areas with social isolation and related measures by several governments to slow the spread of the disease. The general population experienced several mental and lifestyle changes. Herein, we aimed to evaluate the metabolic and psychological effects induced by lifestyle changes during COVID-19 self-isolation among an Apulian overweight/obese cohort with metabolic disturbances. The study assessed anthropometric data (weight, abdominal circumferences), dietary habits (adherence to the Mediterranean diet, junk food score), lifestyle habits (i.e., smoking, and physical activity), levels of stress and anxiety, and depression. Subjects underwent bioumoral exams before and after self-isolation to monitor glycemic and lipid profiles. A total of 245 subjects (M:F = 118:127) have been included in the study. After lockdown, the number of obese subjects significantly increased in both sexes, and was higher in females than in males (P < 0.0001). Glycemic and lipid profiles worsened, with higher levels of insulinemia, lower levels of HDL cholesterol, and higher levels of triglycerides in females than in males. Adherence to the Mediterranean diet and consumption of junk foods were altered in both groups, especially in females. Psychological aspects were significantly higher in females than in males. Finally, work activities and familial status strongly affected the metabolic and psychological profile. In conclusion, COVID-19 self-isolation induced changes in lifestyle and dietary habits with psychological distress and detrimental effects on metabolic patterns, which were more pronounced in female gender.

Pancreatic neuroendocrine tumors (PanNETs) are a heterogeneous group of neoplasms with increasing incidence and an ill-defined pathobiology. Although many PanNETs are indolent and remain stable for years, a subset may behave aggressively and metastasize widely. Thus, the increasing and frequent detection of PanNETs presents a treatment dilemma. Current prognostic systems are susceptible to interpretation errors, sampling issues, and do not accurately reflect the clinical behavior of these neoplasms. Hence, additional biomarkers are needed to improve the prognostic stratification of patients diagnosed with a PanNET. Recent studies have identified alterations in death domain-associated protein 6 (DAXX) and alpha-thalassemia/mental retardation X-linked (ATRX), as well as alternative lengthening of telomeres (ALT), as promising prognostic biomarkers. This review summarizes the identification, clinical utility, and specific nuances in testing for DAXX/ATRX by immunohistochemistry and ALT by telomere-specific fluorescence in situ hybridization in PanNETs. Furthermore, a discussion on diagnostic indications for DAXX, ATRX, and ALT status is provided to include the distinction between PanNETs and pancreatic neuroendocrine carcinomas (PanNECs), and determining pancreatic origin for metastatic neuroendocrine tumors in the setting of an unknown primary.

We present a 35-year-old male with ulcerative colitis initially admitted for a flare-up who then presented with altered mental status and was found to have extensive cerebral venous sinus thrombosis on computed tomography imaging. The patient underwent successful partial recanalization of the superior sagittal sinus and bilateral transverse sinuses using the Penumbra Indigo® Aspiration System with improved outcomes. To our knowledge, this is the first reported use of this device in the treatment of cerebral venous sinus thrombosis.

We analyzed the clinical characteristics and outcomes of patients with Streptococcus suis meningitis in Liuzhou, China, to improve diagnostic accuracy and lower the chances of misdiagnosis. The major clinical manifestations, auxiliary examination results, treatment strategies, treatment efficacy, and follow-up results of 17 consecutively admitted patients with S. suis meningitis were evaluated. The most common clinical manifestations were fever (15/17), sensorineural hearing loss (13/17), headache (11/17), and altered mental status (8/17). In addition, 64.71% of the patients had residual symptoms of sensorineural hearing loss at discharge, and moderate disabilities occurred in 68.75% of the patients in the form of sensorineural deafness (11/17) and hemiparesis (1/17). The cerebrospinal fluid (CSF) of nine patients was used for metagenomic analysis with next-generation sequencing. The metagenomic analysis of CSF of four patients was positive, whereas blood and CSF cultures were negative. The average modified Rankin Scale (mRS) and Activities of Daily Living (ADL) scores improved significantly at the 6-month follow-up compared with those at admission (P < 0.05). There was no correlation between altered mRS and ADL scores and the CSF findings (P > 0.05). Early administration of antibiotics can prevent sensorineural hearing loss. Early CSF metagenomic analysis may be superior to blood and CSF culture.

Deep brain stimulation (DBS) of the nucleus accumbens (NAc) (NAc-DBS) is an effective solution to refractory obsessive-compulsive disorder (OCD). However, evidence for the neurobiological mechanisms of OCD and the effect of NAc-DBS is still lacking. One hypothesis is that the electrophysiological activities in the NAc are modulated by DBS, and another hypothesis is that the activities of neurotransmitters in the NAc are influenced by DBS. To investigate these potential alterations, rats with quinpirole (QNP)- induced OCD were treated with DBS of the core part of NAc. Then, extracellular spikes (SPK) and local field potentials (LFP) in the NAc were recorded, and the levels of relevant neurotransmitters and related proteins were measured. Analysis of SPK revealed that the firing rate was decreased and the firing pattern was changed after NAc-DBS, and analysis of LFP showed that overall power spectral density (PSD) levels were reduced after NAc-DBS. Additionally, we found that the relative powers of the theta band, alpha band and beta band were increased in OCD status, while the relative powers of the delta band and gamma band were decreased. This pathological pattern of power distribution was reformed by NAc-DBS. Furthermore, we found that the local levels of monoamines [dopamine (DA) and serotonin (5-HT)] and amino acids [glutamate (Glu) and gamma-aminobutyric acid (GABA)] in the NAc were increased in OCD status, and that the expression of the two types of DA receptors in the NAc exhibited an opposite change. These abnormalities could be reversed by NAc-DBS. These findings provide a more comprehensive understanding about the function of the NAc in the pathophysiology of OCD and provide more detailed evidence for the potential effect of NAc-DBS.

Methemoglobinemia is a rare, life-threatening condition that occurs when the body is exposed to oxidative stress. We present the case of a 72-year-old female with a past medical history of hypertension, obesity, dyslipidemia, and heart failure who was admitted to the emergency department with altered mental status and respiratory failure. After admission, we also identified an atrioventricular block 2:1, anemia, and skin discoloration. We performed endotracheal intubation and started mechanical ventilation due to respiratory failure; however, the patient retained an oxygen "saturation gap" despite adequate ventilation. In the initial laboratory evaluation, methemoglobinemia was found to be 13%, reaching a maximum level of 16%. An electroencephalogram revealed status epilepticus after her admission to the intensive care unit. Despite all efforts and supportive care, methylene blue therapy was never attempted, and the patient died. Our case emphasizes the importance of a high index of suspicion for methemoglobinemia, especially in the presence of an oxygen "saturation gap," and that despite relatively low levels of methemoglobinemia, it can have a more severe clinical presentation in patients with comorbidities. In these patients, a reduced threshold for administering methylene blue should be taken into account.

Sepsis is a life-threatening organ dysfunction that is caused by a dysregulated host response to infection. Sepsis may be caused by bacterial, fungal, or viral pathogens. The clinical manifestations exhibited by patients with severe coronavirus disease 2019 (COVID-19)-related sepsis overlap with those exhibited by patients with sepsis from secondary bacterial or fungal infections and can include an altered mental status, dyspnea, reduced urine output, tachycardia, and hypotension. Critically ill patients hospitalized with severe acute respiratory syndrome coronavirus 2 infections have increased risk for secondary bacterial and fungal infections. The same risk factors that may predispose to sepsis and poor outcome from bloodstream infections (BSIs) converge in patients with severe COVID-19. Current diagnostic standards for distinguishing between (1) patients who are critically ill, septic, and have COVID-19 and (2) patients with sepsis from other causes leave healthcare providers with 2 suboptimal choices. The first choice is to empirically administer broad-spectrum, antimicrobial therapy for what may or may not be sepsis. Such treatment may not only be ineffective and inappropriate, but it also has the potential to cause harm. The development of better methods to identify and characterize antimicrobial susceptibility will guide more accurate therapeutic interventions and reduce the evolution of new antibiotic-resistant strains. The ideal diagnostic test should (1) be rapid and reliable, (2) have a lower limit of detection than blood culture, and (3) be able to detect a specific organism and drug sensitivity directly from a clinical specimen. Rapid direct detection of antimicrobial-resistant pathogens would allow targeted therapy and result in improved outcomes in patients with severe COVID-19 and sepsis.

Cerebral salt wasting syndrome (CSWS) is defined as a renal loss of sodium in cerebral disorders causing hyponatremia and loss of extracellular fluid volume. Similar laboratory findings may be seen in other conditions such as syndrome of inappropriate antidiuretic hormone secretion (SIADH). A 58-year-old male visited our emergency department because of the sudden development of seizures during sleep. Magnetic resonance imaging revealed subtle high signal intensity in the right hippocampus on diffusion-weighted imaging. Ictal rhythmic discharges were observed in the concordant area. Altered metal status, polyuria and laboratory test findings including hyponatremia were compatible with CSWS. After hydration and salt replacement, his mental state and hyponatremia gradually recovered. For diagnosing CSWS, meticulous physical examinations including analysis of fluid balance are essential. CSWS should be considered in patients with hyponatremia and polyuria. Accurate diagnosis of CSWS and SIADH is crucial as the treatment plans for these two conditions are completely different.

Recent evidence from psycho-economics shows that when the price of an item decreases to the extent that it becomes available for free, one can observe a remarkable increase of subjective utility toward this item. This phenomenon, which is not observed for any other price but zero, has been termed the zero-price effect (ZPE). The ZPE is attributed to an affective heuristic where the positive affect elicited by the free status of an item provides a mental shortcut biasing choice towards that item. Given that the ZPE relies on affective processing, a key role of the ventromedial prefrontal cortex (vmPFC) has been proposed, yet neuroscientific studies of the ZPE remain scarce. This study aimed to explore the role of the vmPFC in the ZPE using a novel, within-subject assessment in participants with either an acquired (lesion patients) or degenerative (behavioural-variant frontotemporal dementia patients) lesion of the vmPFC, and age-matched healthy controls. All participants were asked to make a series of choices between pairs of items that varied in price. One choice trial involved an equal decrease of both item prices, such that one of the items was priced zero. In contrast to controls, patients with both vmPFC-lesion and behavioural-variant frontotemporal dementia showed marked reductions in zero-related changes of preference in pairs of gift-cards, but not for pairs of food items. Our findings suggest that affective evaluations driving the ZPE are altered in patients with focal or degenerative damage to the vmPFC. This supports the notion of a key role of the vmPFC in the ZPE and, more generally, the importance of this region in value-based affective decision-making. Our findings also highlight the potential utility of affective heuristic tasks in future clinical assessments.

Cerebral venous thrombosis (CVT) is a cerebrovascular disorder caused by complete or partial occlusion of the cerebral venous and sinus system. The etiology has been attributed to hypercoagulability and pro-thrombotic states, leading to raised intracranial pressures that often manifest as headaches and focal neurological deficits. However, the multifactorial nature of CVT can create a diagnostic conundrum for clinicians. We describe a unique case of a 16-year-old female who presented with convulsions, postictal confusion, and drowsiness followed by residual weakness of her extremities. She initially presented to the primary care center with headache, high-grade fever, and altered mental status and was empirically treated for pyogenic meningitis. The patient failed to improve with a week of antibiotics and was referred to the tertiary care center for urgent attention. On presentation, the patient developed VI and VII cranial nerve palsy. Subsequently, MRI images showed filling defects in the superior sagittal, right transverse, and sigmoid sinuses with right parietal gyral T1 hyperintensity and T2 hypo-intensity. She was diagnosed with septic CVT based on sinus venous thrombosis and venous infarction, probably secondary to meningococcal pneumonia. It can be challenging to distinguish between both conditions as their presentations overlap. Moreover, cranial nerve palsy is an infrequent manifestation of CVT, with unclear pathogenesis. We highlight the role of neuro-imaging in the early detection of CVT and bring to light the unfamiliar symptoms and a more varied clinical spectrum that may hinder the diagnosis in a limited-resource setting. Future research should be explicitly modeled to improve the diagnostic efficiency of CVT and improve outcomes in younger patient populations.

Tension pneumocephalus (TP) is a rare neurosurgical emergency due to the rise of intracranial pressure from air in the cranial cavity. Tension pneumocephalus' clinical presentation ranges from headache, visual alterations, altered mental status, and death. Given its nonspecific clinical presentation, tension pneumocephalus is usually diagnosed via computed tomography (CT) imaging. Open burr hole craniotomy is the preferred treatment method for tension pneumocephalus. Subdural evacuating port system (SEPS) drains have, however, seen increased utilization in neurosurgery due to decreased possibilities for infections, reduced seizure probability, and better outcomes post-surgery, especially for elderly patients. In this article, we present the case of a 67-year-old female with postoperative tension pneumocephalus after the evacuation of an acute subdural hematoma. The patient became symptomatic from tension pneumocephalus, which was evacuated using a subdural evacuating port system drain. Post-drain placement, the patient had a radiographic and clinical resolution of her tension pneumocephalus. Thesubdural evacuating port system is a useful adjunctive tool for treating tension pneumocephalus.Given the favorable characteristic profile of subdural evacuating port system drains compared to open surgical modalities, further inquiry should be pursued to analyze the feasibility of establishing subdural evacuating port systems as a less invasive treatment alternative.

Background and objective Around 25-30% of elderly patients present to emergency departments (ED) with altered mental status (AMS), with hypercalcemia being one of the metabolic causes. Elderly patients, due to their multiple vulnerability factors and relative homeostenosis, are susceptible to alterations in mental state at even milder grades of hypercalcemia. There is a trend of overzealous prescription of higher doses of vitamin D in elderly patients for various ailments, which often exceeds the requirements of the patients. In this study, we aimed to establish vitamin D toxicity (VDT) as an underlying cause of AMS in elderly patients presenting to the hospital. Methods This was a descriptive case study conducted at a tertiary care university hospital in North India, from January 2015 to March 2020 for a total duration of five years. Elderly patients (aged ≥60 years) who were admitted with VDT as a cause for underlying hypercalcemia were included. The evaluation included patient history regarding the dosage of vitamin D received, route of administration, and biochemical parameters, such as serum calcium, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D [25(OH)D], and albumin. All other potential causes for hypercalcemia and AMS were ruled out concurrently. Results A total of 19 patients were enrolled in the study, with a mean age of 72.3 years (range: 62-86 years). All patients had received injectable vitamin D formulation. The mean serum calcium among the patients was 12.52 ± 1.12 mg/dL (range: 11.2-15.7 mg/dL), whereas the mean 25(OH)D was 196.34 ± 70.44 ng/mL (range: 107-356 ng/mL). The mean cumulative vitamin D supplement intake was 2.594 ± 0.841 million IU (range: 1.2 million-4.2 million IU). While six patients had mild hypercalcemia, 12 had moderate, and one person had severe hypercalcemia, with altered sensorium (85%) being the most common complaint for presenting to ED, followed by generalized weakness (15%). Conclusion VDT can manifest with AMS as an initial presenting complaint. The geriatric population, due to various underlying vulnerability factors, is more susceptible than their younger counterparts. We strongly recommend that in elderly patients, higher doses of vitamin D should be prescribed only after checking their serum levels, and frequent monitoring of vitamin D should be performed.