Severe Hypomagnesemia Caused by Proton-Pump Inhibitors in a Patient With an Ostomy.

Proton pump inhibitors (PPIs) are commonly used for many gastrointestinal issues, such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and Zollinger-Ellison syndrome. Many patients are on life-long daily therapy with this class of medications. The adverse effects of long-term use of PPI have been studied, and over the last two decades, a link between hypomagnesemia and PPI has been established. In addition, other electrolyte derangements can also ensue, such as hypokalemia and hypocalcemia. Losses through the gastrointestinal or renal systems may also be responsible for this electrolyte disturbance. In this case, we present a "perfect storm" of a patient who, in addition to having ongoing gastrointestinal losses through an ostomy, had severe hypomagnesemia to less than 1 mg/dL compounded by PPI use. Through its unique mechanism of action on intestinal epithelial cells, PPI use in certain settings can potentially be catastrophic. Severe hypomagnesemia may manifest as tetany, convulsions, tremors, arrhythmias, or torsades de pointes.

Alarming Eosinophilia From Dobutamine Infusion.

A 49-year-old male with a history of nonischemic heart failure with reduced ejection fraction, hypertension, diabetes was admitted for cardiogenic shock. Treatment started with a high dose of dobutamine infusion. While the patient's volume status improved, his clinical status declined as he became febrile and hypotensive. He was found to have severe dobutamine-induced eosinophilia, corrected only upon dobutamine cessation and steroid administration. A comprehensive investigation ruled out other potential etiologies. Peripheral eosinophilia is a rare adverse effect associated with dobutamine, leading to a significant deterioration in already decompensated patients.

Manubriosternal Joint Involvement as a Presenting Feature of Axial Spondyloarthritis.

Anterior chest wall pain is a feature of axial spondyloarthritis that is understudied. It is rarely the presenting symptom, and when present, may suggest severe disease. We present the case of a 35-year-old female with recurring presentations of debilitating chest pain, subsequently diagnosed with axial spondyloarthritis. Awareness of this presentation can lead to earlier diagnosis and treatment of patients presenting with manubriosternal joint involvement as their initial symptom of axial spondyloarthritis.