Murine Typhus Presenting with Acute Psychosis and Disseminated Intravascular Coagulation: A Case Report.

Murine typhus is an endemic infectious disease caused by Rickettsia typhi and is transmitted by fleas. It typically causes a mild illness with symptoms of fever, rash, headache, chills, and non-specific gastrointestinal complaints. However, there have been no reported cases in the literature of murine typhus infection causing symptoms of acute psychosis and disseminated intravascular coagulation (DIC). A 30-year-old female with a history of gastric bypass and chronic pain syndrome presented to the emergency department with altered mental state and fever. She developed vivid visual hallucinations, DIC, and hypoxia with pulmonary opacities, ultimately requiring intubation. Magnetic resonance imaging (MRI) showed leptomeningeal enhancement with unremarkable cerebrospinal fluid (CSF) studies. Serum murine typhus serology came back positive. Doxycycline therapy was initiated, which resulted in complete patient recovery. This case shows that murine typhus infection may present with acute psychosis and can mimic DIC, leading to diagnostic confusion. MRI sequences may show leptomeningeal enhancement, which has never been reported before in patients with typhus. Early neurological imaging using advanced MRI sequences for patients presenting with altered sensorium, visual hallucinations, and symptoms similar to thrombotic thrombocytopenic purpura (TTP) may help with early diagnosis, decreased hospital stay, and better prognosis.

Unusual case of gastroparesis leading to severe gastromegaly with demyelinating disease as a rare cause.

INTRODUCTION: Gastroparesis is an entity of symptomatic abnormal gastric emptying, with diabetes mellitus, postsurgical and idiopathic etiologies accounting for majority of the cases. CASE REPORT: We report the case of a young African American female, who presented with abdominal discomfort, inability to tolerate a regular diet and intermittent episodes of numbness, tingling and cramps in her extremities. CT scan of the abdomen and pelvis showed a massively distended stomach, compressing the intestines and liver. A gastric emptying study revealing markedly worsened gastroparesis. Severe gastroparesis causing massive gastromegaly secondary to multiple sclerosis was diagnosed. CONCLUSION: This case illustrates severe gastromegaly that is rarely seen to this extent and identifies multiple sclerosis (MS) as a rare cause of gastroparesis. MS should be considered in the differential diagnosis of gastroparesis in appropriate clinical settings.

Dabigatran: a cause of hematologic emergency.

Dabigatran etexilate, a direct thrombin inhibitor, has become an alternative to warfarin for stroke prevention in patients with nonvalvular atrial fibrillation. There remains a concern about its overdose and life-threatening hemorrhage because of unavailability of appropriate coagulation tests to monitor and antidotes to reverse its effects. There are no clinical data about its safety in patients with fluctuating renal function. Multiple bleeding events reported with dabigatran have prompted the U.S. Food and Drug Administration to further investigate these reports. Four clinical cases with life-threatening bleeding, strategies that were used to achieve hemostasis and a brief literature review to demonstrate the hematologic emergency caused by dabigatran are presented in this study.

Esophageal perforation: a rare complication of transesophageal echocardiography in a patient with asymptomatic esophagitis.

Transesophageal echocardiography (TEE) is a commonly used procedure in patients with suspected endocarditis. A rare but dreadful complication of this procedure is perforation of the esophagus. We report the case of an elderly female with multiple comorbidities, who presented with polyarticular septic arthritis. TEE was performed to rule out endocarditis. Though the standard procedure protocol was followed, she developed esophageal perforation. It was managed with esophageal stenting but she developed multiorgan failure and did not survive. This case highlights the potential of severe morbidity and mortality associated with TEE. Appropriate screening must be done and high-risk individuals must be identified before such procedures are attempted.

Recurrent midventricular ballooning, a rare phenomenon.

Takotsubo cardiomyopathy is characterized by transient systolic ballooning of apical or mid segments of the left ventricle (LV) mimicking acute myocardial infarction in the absence of obstructive epicardial coronary artery disease. Recurrences remain rare and most recurrence case reports are about apical ballooning or typical Takotsubo cardiomyopathy. We present a rare case of recurrence in mid ventricular ballooning or atypical variant of Takotsubo cardiomyopathy. This case highlights the importance of future follow-up and potential of recurrence even in atypical variants.

Two cases of daptomycin-induced eosinophilic pneumonia and chronic pneumonitis.

We present 2 elderly patients who developed lung infiltrates associated with eosinophilia during intravenous daptomycin treatment. Both patients improved quickly after daptomycin was stopped and steroid treatment was initiated. However, complete recovery did not occur, and both patients became chronically steroid dependent.

Osteomalacia presenting as pain syndromes of uncertain etiology.

Vitamin D deficiency can result in symptomatic osteomalacia which may cause bone pain and muscle weakness. Two patients with symptomatic osteomalacia after gastric bypass surgery are discussed.