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History: A 56 year old female presented to ED with 1 episode of GTC seizure. Neurological examination was normal except for postictal confusion. NCCT brain showed multiple calcified granuloma, some showing perilesional oedema in the frontal, parietal & occipital lobes. Routine CXR showed typical rice-grain-shaped calcification in the chest wall muscles. Xray thigh and forearm were ordered which showed similar lesions. What’s the diagnosis?

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History: A 14 year-old boy presented with progressive proximal weakness of the lower limbs starting at 4 years of age followed by involvement of the upper limbs. He is the product of a consanguineous marriage. Clinically, he had flaccid quadriparesis with wasting and contractures without any sensory or neurological involvement. His weakness worsened leading to an inability to walk without support by the age of 8 and total wheelchair dependence by the age of 11. He was frequently admitted to hospital with chest infections. The patient’s creatine kinase was 2600 IU/L (normal 50–150 IU/L) and muscle biopsy from left quadriceps showed rounded small muscle fibres with evidence of degeneration and an absence of dystrophin protein. What’s the diagnosis?

Answer: Duchenne muscular dystrophy is a X-linked recessive genetic disorder.

Cause: Gene mutation of dystrophin protein.

Signs and symptoms: Muscle weakness, scoliosis, Respiratory Infections, Gowers’s sign.

Diagnosis: Creatine kinase (CPK-MM), DNA test, Muscle biopsy, Prenatal tests.

Treatment:

• Corticosteroids such as prednisolone and deflazacort lead to short-term improvements in muscle strength and function up to 2 years.
• The medication eteplirsen, a Morpholino antisense oligo for the treatment of mutations amenable to dystrophin exon 51 skipping.
• The medication ataluren (Translarna) is approved for use in the European Union.
• The antisense oligonucleotide golodirsen (Vyondys 53) was approved for medical use in the United States in 2019, for the treatment of cases that can benefit from skipping exon 53 of the dystrophin transcript.
• The Morpholino antisense oligonucleotide viltolarsen (Viltepso) was approved for medical use in the United States in August 2020, for the treatment of Duchenne muscular dystrophy (DMD) in people who have a confirmed mutation of the DMD gene that is amenable to exon 53 skipping.
• Casimersen (Amondys 45) was approved for medical use in the United States in February 2021, and it is the first FDA-approved targeted treatment for people who have a confirmed mutation of the DMD gene that is amenable to exon 45 skipping.

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History: A 24-year-old male presented to the hospital with a cough productive of reddish sputum and shortness of breath of 6 days duration. The exam showed a left testicular mass. What’s the finding in the chest x-ray?

Answer: Cannonball metastases refer to multiple large, well-circumscribed, round pulmonary metastases. The primary tumors for these lesions can be remembered with the help of this mnemonic:

CRESP
Mnemonic
C: choriocarcinoma
R: renal cell carcinoma
E: endometrial carcinoma
S: synovial sarcoma
P: prostate carcinoma

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History: A 60 yr old male had developed livedo reticularis on the left side of his face after he underwent stenting and balloon dilation of the left common carotid artery. Shivering, sweating, and confusion developed immediately after artery dilation, along with a left gaze preference, dysarthria, and hemiparesis on the right side of his body. Angiography showed a patent left internal carotid artery and an occluded distal left facial artery. No IC bleed on NCCT head. What’s the diagnosis?

Answer: The patient was transferred to the ICU, where MRI angiography of the brain revealed infarctions in the territory of the left middle cerebral artery with patent vasculature. An acute embolic stroke and cholesterol embolization syndrome of the face was diagnosed. In cholesterol embolization syndrome, atherosclerotic plaque contents from large-caliber arteries embolize to smaller arteries and lead to vascular occlusion, inflammation, and end-organ damage. Livedo reticularis is one of the most common skin manifestations of the syndrome. The patient received supportive care in the ICU. The livedo reticularis resolved 1 week after the event, but the neurologic deficits persisted at the time of his discharge from the hospital.

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History: A healthy 1-year-old boy with the unremarkable medical history presented to a private clinic for a routine examination. Flushing & gustatory sweating was noted on the child’s left cheek. What’s the diagnosis?

Answer: Auriculotemporal nerve syndrome (Frey’s syndrome, Baillarger’s syndrome, Dupuy’s syndrome, or Frey-Baillarger syndrome) usually manifests as immediate unilateral or bilateral flushing, sweating in the distribution of the auriculotemporal nerve, or both in response to gustatory or tactile stimuli. In adults, this syndrome is a well-recognized sequela of parotid surgery, trauma, or infection. It occurs rarely in children, most often noted after the introduction of solid food. The flushing is often attributed erroneously to food allergy. It typically begins at 2–6 months of age when solid foods, mostly fruit, are introduced. Occurring within a few seconds of eating, it has a peculiar distribution in a triangular area that extends from the tragus of the ear to the midpoint of the cheek. It is not associated with sweating and persists for 20–60 min. The flushing continues to occur for up to 5 years. In adults, gustatory sweating is the predominant feature of auriculotemporal nerve syndrome; flushing happens less often. One-half of pediatric patients with this symptom were delivered with forceps assistance, which possibly causes trauma to the nerve. The likely mechanism is a misdirection of parasympathetic fibers along sympathetic pathways during the nerve regeneration that follows trauma. This may account for erythema when eating. The emergence of symptoms several months after the proposed trauma (usually 3–6 months) is probably related to the time required for nerve regeneration, and it is possible that vigorous chewing causes intense stimulation of the parotid gland.

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