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Tuberculous pachymeningitis is a rare disease that should be suspected in patients with chronic headaches, focal neurological signs, and magnetic resonance imaging (MRI) findings of dural thickening. We report the case of a 62-year-old male who presented with chronic headaches for over a year, progressive right-sided vision and hearing loss for six months, and progressive dysphagia for a month. On investigation, MRI showed dural thickening, cerebrospinal fluid showed lymphocytic pleocytosis with high protein and normal glucose levels, and biopsy of the dural matter showed necrotizing granulomas with Langhans giant cells. The patient responded well to antitubercular treatment and steroids. Follow-up MRI 24 months later showed almost complete resolution of meningeal enhancement. Though tuberculosis is an uncommon cause of pachymeningitis, it should be considered, as it responds well to treatment.

Takotsubo cardiomyopathy, also called stress cardiomyopathy, is a form of reversible cardiomyopathy that occurs during periods of emotional or physical stress. There are many variants of takotsubo. They are classified depending on the region of hypokinesis: the most common four variants include the apical/typical variant (left ventricular apical hypokinesis), the midventricular type (midventricular hypokinesis), the basal type (basal hypokinesis), and the focal type (isolated segmental dysfunction of the left ventricle). Rarely takotsubo presents as a global variant where there is global left ventricular hypokinesis. Takotsubo cardiomyopathy has had an increasing incidence since the COVID-19 pandemic. We report a case of a 29-year-old woman with no prior cardiac history who presented with a seizure and was found to have COVID-19. The patient's echocardiogram showed global cardiomyopathy, a rare type of takotsubo cardiomyopathy.

Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.

Case Description: A 56-year-old man with a history of hypertension, diabetes, hyperlipidemia, and ischemic stroke 2 years ago presented with left-sided weakness, unsteady gait, and vomiting for 12 hours. The patient was vitally stable, and examination revealed dysarthria, left ataxic hemiparesis, and chronic right facial droop. Magnetic Resonance Imaging (MRI) brain showed an evolving acute infarct in the left superior cerebellum with trace petechial hemorrhage, chronic small right posterior inferior cerebellar infarct, and chronic bilateral cerebellar lacunar infarcts. The patient had an implantable loop recorder placed after his previous stroke, which did not show any arrhythmias on interrogation. MRI Angiography of the head/neck did not show large vessel occlusions. Transesophageal echocardiography (TEE) ruled out a patent foramen ovale but did reveal multiple filamentous structures (<5mm in size) on the atrial side of the posterior mitral valve leaflet (figure 1); these were consistent with fibrin valve strands, or Lambl’s excrescences (LE). Anticoagulation therapy was started, and surgical excision was recommended. Discussion: LE are rare fibrous/filamentous valvular strands caused by wear and tear at the closure lines of left-sided heart valves. LE can be associated with thromboembolic strokes and acute coronary syndromes; however, it can also be found incidentally. TEE is the gold standard in diagnosis. This is a middle-aged man without a clear cause of ischemic strokes, subsequently found to have LE on the mitral valve. There is a paucity of evidence on the management of LE due to its rarity. Prior case reports suggest the use of antiplatelets/anticoagulants in symptomatic patients and surgery in cases of recurrent thromboembolic episodes refractory to conservative treatment. Given multiple strokes, this patient was started on anticoagulation and will be evaluated for surgery. Further high-powered studies are needed to guide management.