BACKGROUND: Cocaine use (CU) is prevalent in people with HIV (PWH). Both conditions are linked to changes in cognitive functioning and neural network topology. The current study utilizes graph theory to investigate functional connectomics associated with HIV and CU, focusing on disruption of densely connected nodes called hubs.
METHODS: Resting state functional magnetic resonance imaging (fMRI) from 206 adults (ages 22-55 years) were analyzed. A HIV x CU factorial design was implemented with participants in four groups: HIV+CU (n= 41), HIV only (n= 88), CU only (n= 36), and controls (n= 41). Functional connectomes were constructed, and thresholded graph metrics were calculated. Network centrality metrics - betweenness centrality (BC), participation coefficient (PC), and within module degree (WD) - were quantified into hub disruption indices (HDI). For each index, a 2×2 ANCOVA was performed controlling for education.
RESULTS: Participants were 68 % male and 74 % African-American with a mean age of 44.4 years. HIV and CU were associated with hub disruption in all three indices. Interactions were significant for HDI-PC and HDI-WD, such that HIV disease was associated with greater hub disruption among participants without CU, but not among participants with CU. Overall, lower global cognitive functioning was associated with greater hub disruption on all three indices.
CONCLUSIONS: Widespread hub disruption was evident in HIV disease and CU, highlighting topological reorganization in both diseases with neurocognitive effects. Hub-related measures inform functional connectivity disruptions in HIV disease and CU, particularly with respect to changes in network topology throughout the connectome.

Cocaine is a widely abused controlled substance. Cocaine use is associated with a myriad of side effects and a sequelae of consequences secondary to its harmful nature and potential adulterants, the most recently described and less known sequelae being leukoencephalopathy. In our case, we describe a 58-year-old male who presented to the ED with agitation and acute stroke-like symptoms with reported rapid onset. Cocaine induced toxic leukoencephalopathy is a diagnosis of exclusion, thus other etiologies of disease were ruled out in a full neurological and infectious workup; most importantly consisting of extensive brain imaging, alluding to the diagnosis of acute cocaine induced toxic leukoencephalopathy in an individual with a confirmed history of cocaine and cannabinoid abuse. Although there is no targeted therapy for the condition to our knowledge, we utilized a supportive approach to treatment in contrast to other reported treatment modalities which included the use of steroids, plasma exchange, and intravenous immunoglobulin. Furthermore, we describe the clinical evaluation and treatment throughout the patient\'s hospital course with his eventual marked improvement from initial presentation.

Placental abruption is a serious medical condition that can occur during pregnancy, involving the premature separation of the placenta from the inner uterine wall before childbirth. This detachment often leads to severe bleeding, and if conventional methods prove ineffective in managing the bleeding, a hysterectomy may be deemed necessary to ensure the mother\'s safety. This case report details the management of a 22-year-old female, gravida IV, para III, who experienced placental abruption during her fourth pregnancy. An emergent cesarean section resulted in severe postpartum hemorrhage and disseminated intravascular coagulation (DIC). Positive drug tests for cocaine and methamphetamines added further complexity, leading to an unplanned hysterectomy for life-saving measures. This case underscores the critical importance of early recognition, multidisciplinary collaboration, and timely intervention in managing obstetric emergencies within the context of substance abuse.

We present a case here where a 57-year-old South Asian male with disturbed mental status developed multifocal leukoencephalopathy, which we believe was caused by cocaine usage. Cocaine was detected in the urine toxicological sample. Non-acute CT head, with a follow-up brain MRI demonstrating hyperintensity of the T2 FLAIR signal corresponding to diffusion restriction throughout the whole supratentorial white matter, involving semiovale and subcortical U fibres in the occipital lobes as well as posterior frontal and parietal centrum. It was less likely that the patient had posterior reversible encephalopathy syndrome (PRES), which can potentially manifest similarly in a clinical and imaging context because there was no abrupt rise of blood pressure at presentation or during the patient\'s stay. Extensive examinations were conducted to exclude additional factors that may contribute to the patient\'s appearance, including autoimmune, vasculitis, and infectious diseases. Levamisole, a significant chemical that is frequently used to increase the volume of cocaine samples and has been linked to neuronal damage, should be examined in individuals who use cocaine and exhibit these kinds of clinical symptoms. The patient was prescribed 250 mg of methylprednisolone twice daily for five days after it was determined that cocaine-induced neuronal toxicity was the cause of his symptoms. Although no improvement was seen right away, over the course of the next few days, he did exhibit a gradual, albeit slight, improvement in his mental status while residing in the nursing home. It is crucial to comprehend the possible connection between cocaine usage, a commonly abused drug, and people exhibiting similar clinical symptoms. To have a better understanding of the pathophysiology and possible treatment approach, more research is necessary as there is now no recommended therapy regimen.

Mucoceles are benign lesions of salivary glands typically originating from the paranasal sinuses. Intracranial extension and superinfection of these lesions are rare but serious complications of chronic mucoceles. Here, we discuss a patient with a known mucocele, initially lost to follow-up, who presented three years later with headache, purulent rhinorrhea, and intracranial extension of his mucocele with development of an epidural abscess. This case highlights the potential complications of chronic, large mucoceles and emphasizes the importance of thorough evaluation in patients with facial abscesses in the setting of known sinus pathology. Any mucocele with signs of superinfection such as purulent rhinorrhea, abscess near the sinuses, or refractory symptoms should warrant cranial imaging. Mucoceles with evidence of intracranial extension require neurosurgical and/or otolaryngologic evaluation for evacuation and debridement to avoid neurologic injury or devastating infection.

Internal carotid artery dissection is a rare vascular condition with potentially life-threatening consequences, often resulting in intramural hematomas and luminal narrowing. Various etiological factors, including cocaine use, contribute to its occurrence. This case report explores a striking instance of bilateral internal carotid artery dissection in a middle-aged man with a history of chronic cocaine use, shedding light on the intricate relationship between substance abuse and vascular pathology. We present the case of a 47-year-old man with a significant history of chronic cocaine use presented with sudden-onset severe headaches and visual disturbances, including blurred vision and diplopia. Physical examination revealed signs of Horner\'s syndrome and neurological involvement. Diagnostic imaging confirmed bilateral internal carotid artery dissections, primarily on the right side, with mural hematoma formation and luminal narrowing. Immediate management included pain control, blood pressure regulation, and discontinuation of cocaine use. The patient\'s symptoms gradually resolved with anticoagulation therapy, and he was discharged with a comprehensive follow-up plan. This case of bilateral internal carotid artery dissection in a middle-aged man with a history of chronic cocaine use underscores the intricate relationship between this condition and substance abuse. It highlights the need for a comprehensive clinical history to identify potential links between substance use and vascular pathologies. The multidisciplinary approach to diagnosis and management is crucial in optimizing patient outcomes. Addressing substance abuse as a contributing factor to vascular pathology is essential, emphasizing the importance of comprehensive care and support for affected individuals, and contributing valuable insights to the existing literature on vascular pathology.

We present a case of a previously fit and well 28-year-old male who presented to the emergency department with respiratory distress and hypoxia four days after an alleged assault and blunt-force trauma to the chest wall. Initial clinical assessment and imaging suggested a likely diagnosis of delayed massive hemothorax associated with mediastinal shift. However, upon chest drain insertion, a large amount of pus was unexpectedly drained, leading to an immediate improvement in symptoms and restoration of mediastinal anatomy on repeat imaging. Our case illustrates that, although rare, empyemas can reach a significant volume before detection; they are capable of producing radiological and clinical intrathoracic tension configuration and can mimic hemothorax in the setting of trauma.

Background: In the antiretroviral therapy (ART) era, HIV-associated neurocognitive disorders (HAND) remain a considerable challenge for people with HIV, yet not all such disorders can be attributed to HIV alone. This study aimed to: (1) identify factors influencing neurocognitive impairment (NCI) utilizing the NIH Toolbox Cognition Battery (NIHTB-CB) as per the revised research criteria for HAND; (2) ascertain the moderating role of high homocysteine levels in the association between NCI and HIV; and (3) assess the mediating effect of elevated homocysteine levels on this association.Methods: We analyzed data from 788 adults (≥45 years) participating in a study on HIV-related comorbidities in underserved Baltimore communities, using NIHTB-CB to gauge neurocognitive performance. Special attention was given to results from the Dimensional Change Card Sort (DCCS) test within the executive function domain during causal mediation analysis.Results: Overall, HIV was not associated with NCI presence. However, HIV was associated with NCI among individuals with homocysteine >14 μmol/L. Furthermore, HIV was both directly and indirectly associated with NCI in DCCS test scores. Notably, the mediating role of elevated homocysteine in DCCS scores was only observable among individuals who had never used cocaine or had used it for ≤ 10 years, suggesting that extended cocaine use may have a substantial influence on cognitive performance.Conclusions: The findings from this study suggest elevated homocysteine levels may moderate and mediate the association between HIV and neurocognitive impairment.

A 33-year-old male presented with shortness of breath and altered mental status. The urine toxicology test was positive for cocaine and fentanyl. The patient underwent a 2D echocardiogram showing severely reduced ejection fraction (EF) and global hypokinesia. He was diagnosed with cocaine-induced cardiomyopathy, which markedly improved four days later.

Aortic thrombosis without coexisting atherosclerosis is uncommon. Sometimes, aneurysms or dissections can predispose to thrombus in the abdominal or thoracic aorta. However, ascending aortic thrombus in a non-aneurysmal, non-atherosclerotic aorta is a rare occurrence. Although arterial thrombosis has been linked with its use, cocaine-associated thrombus of the ascending aorta has been rarely described. We report a young man with regular use of cocaine presenting with constant, burning, left-sided chest pain. He was found to have a large thrombus in a structurally normal ascending aorta. Medical management with therapeutic anticoagulation was started. Despite an interruption of anticoagulation treatment for two months due to non-compliance, the man survived. This unique case highlights the importance of various vascular complications associated with cocaine use, their early recognition, and their treatment.