An obscure case of hepatic subcapsular hematoma.

Spontaneous liver bleeding is often reported in preeclampsia. It is otherwise rare and has been linked to gross anatomical lesions and coagulopathy. We report a case of subcapsular hematoma of the liver without any apparent lesion and in the absence of coagulopathy. A 41-year-old male, paraplegic for 16 years, presented to the emergency department 3 days after sudden onset of right upper quadrant and shoulder pain. He had been on vitamins and 5,000 units subcutaneous heparin 12-hourly at the nursing home for the last month. He was in no distress, afebrile, with stable vitals. Physical examination showed a diverting colostomy, tender hepatomegaly and sacral decubiti. A fecal occult blood test was negative. There was spastic paraplegia below the level of T12. Two days after admission, the patient was afebrile and hemodynamically stable. PTT, PT, liver profile, BUN and creatinine were all normal, however his hemoglobin had dropped from 11.3 to 7.6 g/dl. An abdominal CT scan revealed an isolated 9.0 × 1.8 cm subcapsular hematoma. The patient received blood transfusion in the intensive care unit and was discharged 7 days later. In conclusion, spontaneous liver hemorrhage occurs in the nonobstetrical population in the setting of gross anatomical lesions or coagulopathy. This is the first report of an isolated subcapsular liver hematoma.

Pretracheal abscess following two weeks of endotracheal intubation.

Pretracheal abscess due to endotracheal intubation has not been reported in literature. We present a case of a female patient who was admitted with acute hypercapnic respiratory failure. Patient was initially managed with noninvasive ventilation but eventually was intubated after sustaining a cardiac arrest. She could not be extubated because of poor weaning parameters, so a tracheostomy was planned. During surgery, a pretracheal abscess was found with destruction of the second, third, and fourth tracheal rings and intact posterior tracheal wall. The possible risk factors, mechanism of injury, and preventive strategy of tracheal complication of intubation are discussed.

Devic syndrome: a diagnostic dilemma.

Neuromyelitis optica (NMO, also known as Devic syndrome or Devic disease) is a rare clinical entity. Early recognition and prompt treatment can save patients from long-term disability, especially in themonophasic variant of disease. A 24-year-old African American female presented with high-grade fever for 1 day associated with frontal headache, photophobia, and 2 episodes of nonbloody vomiting. She had a history of nonitchy vesicular rash with sudden diminution of vision in the left eye 2 weeks ago. Over the next 24 hours, she developed progressively worsening weakness and numbness in her left arm and left leg, which later involved all limbs. Left eye vision was reduced to light perception with light and accommodation reflexes intact. Lumbar puncture showed lymphocytic pleocytosis with elevated protein. On day 2, neurological examination exhibited quadriparises with hypereflexia and clonus. Magnetic resonance imaging showed diffuse hyperintense signals in the spinal cord in cervical and lumbar regions. An assessment of neuromyelitis optica was made. Anti-NMO antibodies were negative. On day 3, she was intubated because of progressive dyspnea. Plasmapheresis resulted in rapid improvement in respiratory and neurological status. She was extubated on the second day and transferred to floor on day 4. Later, the patient was discharged.

Disseminated Mycobacterium avium intracellulare infection in an "immunocompetent" host.

We are reporting the case of a 37-year-old immunocompetent patient who presented with anterior chest wall swelling, jaw swelling and pain, back pain, night sweats, and unintentional weight loss. He underwent mediastinoscopy with lymph node biopsy, which revealed caseating and noncaseating granuloma and special stains positive for acid-fast bacteria. Cultures from two different sites surprisingly grew Mycobacterium avium intercellulare (MAI), and a diagnosis of disseminated MAI was made. He was switched from antituberculous treatment to MAI treatment.

Inappropriate Use of Intravenous PPI for Stress Ulcer Prophylaxis in an Inner City Community Hospital.

BACKGROUND: Proton pump inhibitors (PPIs) are used for the treatment and prophylaxis of variety of acid peptic conditions including stress ulcers. There has been a persistent practice of their inappropriate use for stress ulcer prophylaxis. Purpose of our study was to measure the inappropriate use of Intravenous Proton Pump Inhibitors for stress ulcer prophylaxis and to estimate the financial burden. METHODS: We carried out a retrospective, analytic study from July 2008 to June 2009 in internal medicine department. Hospital pharmacy records were used to identify all patients who received IV PPI during hospital stay. Seventy-five percent of records were randomly chosen (n=1104). PPI application was defined as indicated according to AGA guidelines. RESULTS: Intravenous proton pump inhibitor (IV PPI) was prescribed for 68.5% of patients without any proper indication. The estimated cost of medication for inappropriate IV PPIS use during the study year was 18337 USD. CONCLUSIONS: A more rational use of PPI will have better impact on health care cost and is likely to add to patient safety. KEYWORDS: Inappropriate use of PPI; Stress ulcer prophylaxis; Healthcare cost.