Status Cataplecticus Induced by an Abrupt Duloxetine Withdrawal-A Case Report.

ABSTRACT: In persons with narcolepsy type 1, sudden withdrawal of antidepressants can cause status cataplecticus. We describe a 77-year-old female patient with long-standing history of narcolepsy type 1 complaining of recurrent short sudden episodes of whole-body paralysis, with preserved consciousness and memory. Episodes started an hour after her family invited her to celebrate Mother's Day. One week prior, patient had abruptly discontinued duloxetine. Cataplectic episodes resolved within 24 hours after resumption of duloxetine and treatment of hypokalemia. Status cataplecticus has been reported after withdrawal of venlafaxine, fluoxetine, and clomipramine. This is the first report of status cataplecticus due to duloxetine withdrawal. We review the pathophysiology of antidepressant withdrawal-induced status cataplecticus. In persons with narcolepsy type 1, physicians discontinuing any antidepressant should counsel on adverse effects of antidepressant withdrawal and reduce the dose in tapering manner.

Modeling employees' skills for sustainable banking services.

In Bangladesh, more clarity is needed on data that could contribute to the provision of sustainable banking services. Therefore, the qualitative exploration of bank employees' skills to advance contemporary banking careers and services has been rational. Moreover, limited knowledge of what constitutes a sustainable banking career and service inspires this study to adapt to the new normal post-COVID-19. Fifteen experienced employees from the banking industry participated in the interview to accomplish the research. The results from content data analysis showed that technical skills may vary from department to department based on employees' job responsibilities. However, the employee skills are more or less similar for different banks. The results further showed that the banking sector emphasizes the need for honesty from banks' employees, as they maintain a large amount of cash and other types of assets in their vaults. Additionally, the research participants expressed their sentiments regarding other skills, such as patience, smartness, and technological expertise. These skills are needed to carry out the day-to-day operations and achieve high customer satisfaction. Therefore, the study recommends that banks focus on creating an employee base with the skills found in the investigation to develop banking services.

Dapagliflozin-induced Late-onset Euglycemic Diabetic Ketoacidosis.

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a class of oral hypoglycemics that improve glycemic control by increasing the urinary excretion of glucose. They gained widespread popularity because they not only showed improved glycemic control but also had a favorable effect on weight loss, blood pressure, and cardiovascular mortality. One of their rare side effects is euglycemic diabetic ketoacidosis (eDKA) although the diagnosis is sometimes difficult to make due to near-normal glucose levels. We present a case of eDKA in a patient who presented with confusion, acute kidney injury (AKI), and metabolic acidosis after having an influenza-like illness with a minimally elevated blood glucose of 187 mg/dL. She had already stopped taking dapagliflozin (an SGLT-2 inhibitor) two weeks before the presentation. She was initially treated as sepsis and required hemodialysis. Later on, metabolic acidosis was attributed to eDKA from dapagliflozin, which resolved after the administration of intravenous insulin. Her eDKA developed while she had already stopped dapagliflozin two weeks ago, which makes this an interesting case finding. It is one of those rare cases where dapagliflozin led to a delayed complication of eDKA.

Takotsubo cardiomyopathy secondary to haemophagocytic lymphohistiocytosis in HIV patients: a comprehensive review.

Haemophagocytic lymphohistiocytosis (HLH) is an immune dysregulation disorder with variable presentations and non-specific features making it extremely difficult to diagnose early in the clinical course. Here, we are presenting a case of a young man who presented in cardiogenic shock with findings of anterolateral wall ischaemia on ECG. Echocardiography findings were consistent with takotsubo cardiomyopathy (TCM). Cardiac catheterisation showed clean coronary arteries and pulmonary artery pressure measurements showed high output cardiac failure. After extensive workup, the patient was diagnosed with HLH. In spite of aggressive supportive and definitive therapy, he eventually died due to a complicated clinical course. We did a comprehensive literature review and found that this is the first reported case of HLH presenting as TCM as the initial clinical manifestation.

Sudden death due to pulmonary embolism after minor ankle surgery.

Venous thromboembolism prophylaxis guidelines are clear for major orthopaedic surgeries, but data regarding ankle surgery are insufficient. Death from pulmonary embolism (PE) after ankle surgery is rare with the frequency of less than 0.037%. 1 We present a case of a fatal PE after ankle surgery to raise awareness about this rare but potentially fatal complication. Our patient had a left ankle fracture status postsurgical fixation and was discharged without venous thromboembolism (VTE) prophylaxis. Twenty days later, she presented with a sudden onset of dyspnoea and palpitations and was diagnosed to have extensive right-sided PE. Intravenous heparin and thrombolytics were given, but she had multiple pulseless electrical activity arrests, developed disseminated intravascular coagulation and died. Our case depicts an unusual complication of ankle surgery and highlights the importance of considering VTE as one of the complications. Medical personnel should evaluate the need for VTE prophylaxis after ankle surgery on a case to case basis.

Pseudo to pseudo connection: pseudoaneurysm draining into the pseudocyst causing pseudohaemobillia.

Haemosuccus pancreaticus (HP) is an exceedingly rare cause of lower gastrointestinal (GI) bleed where pseudoaneurysm of the peripancreatic vessels ruptures into a pancreatic pseudocyst and blood travel through the pancreatic duct, thereby, draining into GI tract via the ampulla of Vater. 1 We present a case of 65-year-old African-American woman with a history of alcohol abuse presented with melena for 1 day. The contrast-enhanced CT of abdomen/pelvis showed peripancreatic vascular pseudoaneurysm with active haemorrhage. Angiography confirmed the diagnosis of HP and successful transcatheter embolisation was performed.

Gitelman Syndrome: A Rare Cause of Seizure Disorder and a Systematic Review.

Gitelman syndrome is one of the few inherited causes of metabolic alkalosis due to salt losing tubulopathy. It is caused by tubular defects at the level of distal convoluted tubules, mimicking a thiazide-like tumor. It usually presents in late childhood or in teenage as nonspecific weakness, fatigability, polyuria, and polydipsia but very rarely with seizures. It is classically associated with hypokalemia, hypomagnesemia, hypocalciuria, hyperreninemia, and hyperaldosteronism. However, less frequently, it can present with normal magnesium levels. It is even rarer to find normomagnesemic patients of GS who develop seizures as the main complication since hypomagnesemia is considered the principal etiology of abnormal foci of seizure-related brain activity in GS cases. Interestingly, patients with GS are oftentimes diagnosed during pregnancy when the classic electrolyte pattern consistent with GS is noticed. Our case presents GS with normal serum magnesium in a patient, with seizures being the main clinical presentation. We also did a comprehensive literature review of 122 reported cases to show the prevalence of normal magnesium in GS cases and an overview of clinical and biochemical variability in GS. We suggest that further studies and in-depth analysis are required to understand the pathophysiology of seizures in GS patients with both normal and low magnesium levels.

Tilting the balance: hemidiaphragm paralysis leading to right to left cardiac shunt.

Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

An Esophagogram or Tracheobronchogram? A Review of Barium Sulfate Aspiration.

The barium swallow is an important radiological investigation used for the diagnosis of upper gastrointestinal anatomical disorders like esophageal cancer, diverticulum, achalasia, foreign body, among others. Generally, it is believed to be a safe technique with rare complications, but few cases of barium sulfate aspiration have been reported in the literature with multiple complications. We are reporting a case of an elderly male who underwent esophagogram for the workup of chronic dysphagia, aspirated barium sulfate, and went into respiratory failure and circulatory shock several hours later. Moreover, we also did a systematic literature search and reviewed all available articles on aspiration of barium sulfate and its potential complications. We focused on predisposing factors for aspiration, clinical presentation, complications after aspiration, and prognosis with the aim to better understand and manage this condition.

Rovalpituzumab Tesirine: A Novel DLL3-Targeting Antibody-Drug Conjugate.

Small cell lung cancer (SCLC) comprises about 15% of all cases of lung cancer. In recent years, owing to a change in the epidemiology of smoking habits, the incidence of the tumor has decreased; however, it remains a significant challenge to global health. While the tumor has a favorable initial response to chemoradiation, relapse is invariable, and second-line regimens may be intolerable given the severity of side effects. For patients with tumors resistant to second-line regimens, no current standard regimens exist. Rovalpituzumab tesirine is a novel antibody-drug conjugate, targeting delta-like protein 3, fundamental in the downstream cellular signaling for proliferation and apoptosis. This drug is reported to have shown promise in pre-clinical and phase I trials. It appears effective in decreasing tumor burden and is reported to be well tolerated, albeit with a significant adverse effect profile. Currently, it is being studied as part of initial and subsequent line chemotherapeutic regimens; it remains to be seen if this is a viable option in the treatment of SCLC. This may add to the agents that can be used against SCLC, and help improve outcomes.

Spontaneous Lung Herniation Leading to Extensive Subcutaneous Emphysema, Pneumothorax, Pneumomediastinum, and Pneumopericardium.

Spontaneous lung herniation is a rare phenomenon in which the lung parenchyma along with the pleural membranes protrudes outside their usual boundaries and can lead to a wide variety of complications. We are reporting a case of a middle-aged male who presented with chronic obstructive pulmonary disease (COPD) exacerbation with severe bouts of cough. Initial computed tomography (CT) chest was unrevealing, but two days later, he developed spontaneous lung herniation, which was initially managed conservatively, but later it progressed to pneumothorax, pneumomediastinum, with striking CT scan images showing extensive subcutaneous emphysema. Blowhole incisions were done on the anterior chest wall which led to ultimate recovery.

Another "D" in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis.

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of "dietary ketosis" in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless "dietary ketosis" can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet-associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.

Posterior reversible encephalopathy syndrome (PRES) after bevacizumab therapy for metastatic colorectal cancer.

Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognizable neuro-clinical syndrome. Clinical and neurological manifestations of PRES include hypertension, headache, encephalopathy, seizures, and symmetrical white matter changes on brain MRI. Most common precipitants of PRES are acute medical illness, hypertensive crisis, eclampsia, immunosuppressive therapy, and chemotherapy. Bevacizumab is a monoclonal antibody that halts angiogenesis by inhibiting vascular endothelial growth factor. It has gained widespread popularity in oncology world especially for metastatic and recurrent cancers due to its inherent ability to stop angiogenesis; a vital step for tumor growth. Bevacizumab has also been implicated as the cause of PRES due to dysregulation of the blood-brain barrier. We are reporting a case of PRES induced by Bevacizumab in a patient of colorectal cancer.

A deadly prescription: combination of methotrexate and trimethoprim-sulfamethoxazole.

Methotrexate (MTX) is a chemotherapeutic synthetic(s) phase cell cycle inhibitor, and its role has evolved as an immunological agent in autoimmune diseases like rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, etc. Trimethoprim-sulfamethoxazole (TS) is one of the most widely prescribed antibiotics commonly used for urinary tract infections, exacerbations of chronic bronchitis, traveler's diarrhea, and pneumocystis pneumonia. Both MTX and TS can have significantly overlapping side effects involving dermatologic, renal, and hematological systems, and the combination of these can be deadly. Our case is about the combination of MTX and TS that leads to mucocutaneous ulceration, leukopenia, and renal insufficiency. The purpose of this case is to increase awareness of potentially significant toxicity from the combination of MTX with TS. Abbreviations: MTX: methotrexate; TS: trimethoprim-sulfamethoxazole; ED: emergency department; IV: intravenous; GI: gastrointestinal; NSAIDs: nonsteroidal anti-inflammatory drugs.

A case of madness resulting in a fortunate outcome; case report of a psychotic break as a result of cortisol secreting thymic neuroendocrine thymic tumor.

Representing a mere 2-5% of the total thymic malignancies and 0.4% of total carcinoid tumors, primary thymic neuroendocrine tumors (NETs) are the zebras of the thymic neoplasms. They were initially characterized as 'epithelial thymomas'; later, the term carcinoid tumors was coined by Rosai and Higa. These tumors are highly unpredictable in their presentation and prognosis. Coupled with variable clinical presentation, rare pathologic diagnosis and absence of diagnostic and prognostic parameters, it is a challenge for both patients and clinicians. Treatment entails local definitive therapy, symptom control and systemic chemoradiation given either pre or post operatively based on staging and resectability. We hereby report a peculiar case of psychosis that likely resulted from one such rare tumor.

Some neck swellings are serious; a case of Lemierre's Syndrome.

Lemierre's syndrome also termed post-anginal septicemia, is a disease characterized by internal jugular septic thrombophlebitis leading to Fusobacterium septicemia with multiple metastatic foci following an oropharyngeal infection. Diagnosis and management is challenging and can result in fatal consequences due to potential multisystem involvement and multiple complications. We describe here a case of Lemierre's syndrome with multifocal pneumonia, acute renal failure and protracted course of illness over forty days with successful recovery. A brief overview of literature is also presented.

Continuous diphenhydramine infusion and imatinib for KIT-D816V-negative mast cell activation syndrome: a case report.

BACKGROUND: We present the first full case report of the treatment of mast cell activation syndrome with continuous diphenhydramine infusion, which resulted in the improvement of anaphylactic reactions and a decrease in hospital readmission. Furthermore, the patient received imatinib in the absence of the KIT-D816V mutation, which led to further improvement of quality of life. Currently, we are trying to wean this patient off diphenhydramine; if successful, this attempt will represent the first reported case. CASE PRESENTATION: An 18-year-old white girl presented with a flare of mast cell activation syndrome and received epinephrine and steroids. She had failed multiple previous therapies, and her quality of life was affected due to two to three flares/week. She was started on continuous diphenhydramine infusion and imatinib, which led to a decrease in hospital admissions and marked improvement in her quality of life. CONCLUSIONS: Continuous diphenhydramine infusion can provide promising outcomes following the failure of intermittent antihistamine dosing in patients with severe mast cell activation syndrome. Initiating continuous diphenhydramine infusion may be helpful in an intensive care setting when the patient is particularly prone to anaphylaxis and/or the resources needed to manage anaphylaxis are not available outside the intensive care unit. Furthermore, imatinib provides benefits in KIT-D816V-negative mast cell disorders due to other unknown mutations.