Infective endocarditis (IE) is a rare infection of the inner lining of the heart and valves, mainly affecting those with pre-existing heart problems. Patients usually present with fever and other non-specific systemic symptoms such as malaise, myalgia, and night sweats. However, IE may have unusual presentations, making its diagnosis even more challenging. Here, we report an unusual case of IE presenting as confusion.A 51-year-old man presented to the emergency department complaining of confusion for three days. Upon physical examination, there was an evident holosystolic murmur at the apex radiating to the axilla and an early decrescendo diastolic murmur at the left lower sternal border. Laboratory tests including white blood cell count and C-reactive protein were elevated. Transthoracic and transesophageal echocardiogram showed severe mitral regurgitation and aortic regurgitation, in addition to the presence of a mobile mass suspected to be vegetation on each of the mitral and aortic valves. Magnetic resonance imaging of the brain was performed which revealed ischemic lesions of possible embolic origin. Mitral and aortic valve replacement was performed successfully, and the patient recovered well.Our case emphasizes the possibility of unusual presentations in patients with IE, with confusion being one of them. It is important for physicians to always consider the diagnosis of IE in patients presenting with neurological symptoms of unclear origin.

Background:Presumed ocular histoplasmosis syndrome (POHS) occurs secondary to infection with Histoplasma Capsulatum (HC), which is an endemic organism in many tropical areas, especially in the United States. However, it has never been proven that HC directly causes POHS, hence the name presumed ocular histoplasmosis syndrome. Patients are usually asymptomatic, but some may present with blurring of central vision. Case Report:A 15-year-old girl, previously healthy, presented with a 2-months history of visual disturbance of the right eye. On physical examination, the visual acuity of the left eye was 20/20 while the right eye was only seeing “hand motion”. Fundus exam of the right eye showed juxtapapillary infiltrates with serous macular detachment, and small retinal and choroidal lesions, while the left eye showed only some small retinal and choroidal lesions. Fluorescein angiography of both eyes showed evidence of chorioretinitis with probable choroidal neovascularization (CNV). The diagnosis of POHS was made and the patient was treated with bevacizumab injections. Follow-up was done clinically and through spectral domain optical coherence tomography (SD-OCT) and showed marked improvement at the level of the macular thickness and CNV. Conclusion: Diagnosing POHS can be quite challenging, especially in cases coming from non-endemic areas. Our case emphasizes the importance of considering POHS in patients presenting with visual disturbance, even in these non-endemic areas, through a careful clinical evaluation and appropriate imaging modalities.

Background:  Cardiac sarcoidosis (CS) is a rare pathology that affects the middle-aged population. Its diagnosis, as well as its treatment, can be quite challenging, especially dealing with device management. We hereby discuss a case of CS, managed by a biventricular pacemaker in a 43-year-old man. Case Report: A 43-year-old male presented to the emergency department with a 15-day history of chronic cough and worsening dyspnea. On examination, he was found to be bradycardic in the context of a third-degree heart block on ECG as well as bilateral hilar lymphadenopathy on chest radiography. Based on these findings, cardiac sarcoidosis was suspected. A temporary right internal jugular transvenous pacemaker was implanted in the right ventricle and empiric corticosteroid management was commenced. Lung tissue biopsies were obtained via bronchoscopy and were positive for granulomas consistent with a diagnosis of sarcoidosis.  Even though the patient showed a partial positive response to corticosteroid treatment, he required a permanent pacemaker. A dual-chamber implantable cardioverter-defibrillator (ICD) was implanted and the patient was discharged on prednisone. His follow-up plan consisted of serial echocardiography and consideration of a new coronary sinus lead in the event of left ventricular dysfunction in the future. Conclusion: Cardiac rhythm management in the context of CS is often difficult, with decisions that need to be made between a pacemaker, a defibrillator, or a cardiac resynchronization device. The idea that biventricular pacing has a preventative role against heart failure in patients with normal left ventricular ejection fraction and CS deserves more attention and discussion.

Background: Compartment syndrome is a well-known entity, but it is rare in the pediatric population, and its diagnosis is quite challenging. We report a case of an acute compartment syndrome (ACS) of the hand, developed after a crushing trauma, in a 14-month-old boy. Case Report: A 14-month-old boy presented to the Emergency Department following a crushing trauma to his right hand. The patient had a progressive swelling of the right hand and agitation. On physical examination, the right hand was tense, swollen, with areas of skin necrosis and blisters, along with increased agitation upon palpation. Laboratory tests revealed elevated white blood cells, creatinine kinase, and erythrocyte sedimentation rate. Radiographic imaging showed deviated diaphyseal fractures in the second, third, fourth, and fifth metacarpals. A diagnosis of ACS of the hand was made. After draining the blisters, multiple fasciotomies were carried out to all 11 compartments of the hand. The metacarpal fractures were managed conservatively with a wrist splint for one month. A clinical and radiological follow-up after 7 months showed a complete functional recovery of the right hand and consolidation of the 2nd, 4th, and 5th metacarpal fractures, while the 3rd metacarpal fracture showed pseudoarthrosis. Conclusion: Compartment syndrome of the hand in children is a rare condition, and its clinical picture may differ from that in adults, leading to a misdiagnosis or late diagnosis in many cases. Our case emphasizes the importance of a careful clinical evaluation in children post-trauma to diagnose such a condition.

Around 10-20% of sinusitis have a dental etiology. Odontogenic sinusitis is generally caused by periodontitis, peri-implantitis, periapical pathology, or oroantral communication. Ectopic teeth are a rare cause of chronic odontogenic sinusitis. We present a rare case of chronic sinusitis caused by five ectopic teeth.A 39-year-old-female patient presented to our clinic with complaints of facial pain over the left cheek, ipsilateral nasal obstruction, ipsilateral rhinorrhea, and coughing over the last five years. Physical examination revealed a febrile patient. There was an ipsilateral purulent nasal discharge of yellow color. Inspection of the oral cavity revealed the absence of the following maxillary teeth: left first and second premolars, in addition to the left first, second, and third molars. There was also tenderness upon palpation of the left maxillary sinus. Computed tomography (CT) scan of the maxillary sinus revealed hyperdense structures in the left maxillary sinus surrounded by soft tissue, representing the missing premolar and molar teeth. The patient was treated with amoxicillin-clavulanate and corticosteroid, which partially relieved her symptoms.Our case presents an unusual case of chronic sinusitis that was found to be a consequence of five ectopic teeth in the maxillary sinus. A careful physical examination and an appropriate imaging modality are indispensable for the diagnosis of such a rare phenomenon.