An Unusual Case of Giant Cell Arteritis.

Giant cell arteritis (GCA), also known as temporal arteritis (TA), is a systemic autoimmune inflammation of medium and large arteries. It is the most common vasculitis affecting adults older than 50, with an incidence of 20/100,000 and an average age of onset of 70. Typically, patients initially present with new-onset headaches, visual changes and disturbances, jaw claudication, arthralgias, and tender or swollen temporal or occipital arteries. Our patient is a 73-year-old male who presented to the emergency room with 10 days of bilateral headache radiating to the occipital area associated with fevers, persistent chills, generalized weakness, and a headache described as constant, dull, 9 out of 10 pain, and minor pain with neck flexion. Lab work revealed an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The patient had tender palpation to his temples and due to a high suspicion of giant cell arteritis, he was started on high-dose steroids with rapid relief of his symptoms. Biopsy showed evidence of active non-granulomatous vasculitis and confirmed bilateral temporal arteritis within the context of the clinical setting. GCA patients are more likely to be women and typically present with unilateral headache (66% of GCA), jaw claudication (50%), fevers (50%), and transient visual loss (16-54%). Here, we describe a 73-year-old male with a past medical history of cerebral vascular accident (CVA), diabetes, and cancer that presented with 10 days of bilateral headaches and fevers. Unlike the usual presentation, our patient denied any vision and joint pain changes, and the temporal arteries were not stiff to palpation. This patient presentation is unique to previous reports in the limited display of symptoms and absence of the most commonly associated manifestations. Although his presentation supported GCA, the features of elevated ESR and CRP, headache, and fever were too general to diagnose GCA exclusively, and his additional symptoms of rhinorrhea and sinus pain more likely supported infection. Our case indicates the importance of maintaining a high index of clinical suspicion for GCA in the elderly population presenting with headaches and elevated ESR and CRP. GCA, also known as temporal arteritis (TA), is a systemic autoimmune inflammation of medium and large arteries. Typically, patients initially present with new-onset headaches, visual changes and disturbances, jaw claudication, arthralgias, and tender or swollen temporal or occipital arteries. Diagnosis requires high clinical suspicion, and treatment revolves around high doses of steroids.

Isolated Superior Mesenteric Artery Dissection: An Unusual Etiology of Epigastric Pain.

Abdominal pain is a very common presentation in the emergency department (ED). The pain is often well-characterized and leads to the diagnosis, but often, the presentation is vague and nonspecific. Superior mesenteric artery (SMA) dissection is a rare cause of abdominal pain that presents with nonspecific epigastric pain and is common in males, middle age, and patients of Asian descent. A high index of suspicion is usually helpful with imaging modalities such as computer tomography (CT) scan and ultrasonography in experienced hands. A prompt diagnosis is vital to managing this disease which may range from non-surgical intervention with supportive therapy to invasive endovascular procedures and surgery. Here, we report a case of an isolated SMA dissection presenting with vague abdominal symptoms and highlight the need to explore the vascular etiology of abdominal pain as their diagnosis is often difficult and may result in irreversible bowel injury when missed.

A Rare Case of New-Onset Ulcerative Colitis in a Nonagenarian.

Ulcerative colitis (UC) is one of two major types of inflammatory bowel disease (IBD). It is defined as a chronic idiopathic inflammatory disease limited to the colorectal mucosal layer and characterized by relapsing and remitting episodes of inflammation. UC almost invariably involves the rectum and extends proximally in a continuous distribution to part or the entire colon. Development of disease after 75 years of age is uncommon, with new-onset over the age of 80 accounting only for 1% of all new diagnoses. We present a case of a new onset UC in a 90-year-old patient presenting with painless hematochezia.

Non Ischemic Cardiomyopathy in a 54-Year-Old Khat Consuming Yemeni Male Presenting with Worsening Exertional Dyspnea, T Wave Inversions in V5-V6 and Normal Coronary Artery Angiography.

BACKGROUND Khat (Catha edulis) is a plant cultivated in Ethiopia, East African, and the Arabian Peninsula. Long-term khat consumption has been associated with increased rates of periodontal diseases, esophagitis, psychosis, and cardiovascular issues such as cerebrovascular accidents, myocardial ischemia, and ischemic cardiomyopathy (CM). We report a case of khat-induced non-ischemic CM in a patient with no other known cardiovascular risk factors and highlight a cardiovascular effect of chronic khat consumption. CASE REPORT A 54-year-old Yemeni man with no known medical history but a chronic khat chewer presented with worsening exertional dyspnea for 6 months and associated pedal edema. Laboratory studies were remarkable for elevated B-type natriuretic peptide (BNP). Electrocardiogram (EKG) revealed normal sinus rhythm with non-specific T wave inversions (TWI) in V5-V6. A computed tomography (CT) scan of the chest showed bilateral pleural effusions with interlobular septal thickening. Transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (LVEF) of 16-20% and global CM. Coronary angiography revealed normal coronaries. CONCLUSIONS Chronic khat consumption is being recognized as a dangerous habit with serious health consequences and its association with ischemic CM is well documented. The findings of ischemic cardiac changes of acute coronary syndrome in a patient with normal coronary arteries raises the possibility that khat toxicity was associated with coronary artery spasm due to its amphetamine-like stimulatory effects. Although further research is required to substantiate this relationship, it is imperative that khat consumption be considered a risk factor when assessing for CM.

Interpretation of Parathyroid Hormone Levels in Renal Impairment.

Distinguishing between acute kidney injury and chronic kidney disease (CKD) in an emergency setting may pose a conundrum for physicians, especially when a patient's medical history and records are unknown. Parathyroid hormone (PTH) has proved valuable as a marker of CKD and is frequently assayed for this reason. The use of PTH as a sole marker of CKD may be misleading in certain conditions, and for this reason, physicians need to interpret PTH values with caution. In patients with no existing medical records, it is vital to consider their overall clinical picture, an accurate interpretation of urinalysis and urine microscopy, and the PTH values when making the initial management decisions.

Ketamine-Induced Syndrome of Inappropriate Antidiuretic Hormone Secretion and Hyponatremia.

Ketamine is a dissociative anesthetic commonly used for the induction and maintenance of anesthesia and has a well-known role in analgesia. However, it also has the potential for addiction, which can lead to neurological, psychological, systemic, and biochemical consequences. In this case report, we are highlighting a rare case of a young Asian female with Ketamine addiction who presented with urinary complaints. The patient was found to have hyponatremia and laboratory tests were consistent with a syndrome of inappropriate antidiuretic hormone (SIADH) release in the absence of other causes.

Health-Related Quality of Life Among HIV-Infected Children and Its Association With Socio-Demographic, Clinical and Nutritional Variables: A Comparative Approach.

BACKGROUND: The human immunodeficiency virus (HIV) infection and its treatment impact the child's life as well as that of their caregivers. As therapeutic advances are made in the field, improved survival has shifted the focus from morbidity and mortality to quality of life. This study aims to compare the health-related quality of life (HRQoL) of children living with HIV in comparison with an HIV-negative control group and determine its relationship with socio-demographic, clinical, and nutritional variables. METHOD: This was a multi-center cross-sectional comparative study involving 274 participants (137 per group) carried out in tertiary and secondary level healthcare facilities in Nigeria. Socio-demographic, clinical, and nutritional variables were obtained using a researcher-designed data collection sheet. HRQoL was measured using the Paediatrics Quality of Life Inventory (PedsQL 4.0), while caregivers' burden was assessed using the Zarit-Burden Interview (ZBI). A comparison of the health-related quality of life of the cases and the control group was done using an independent t-test. The predictors of HRQoL among the cases were measured using multivariate stepwise linear regression analysis. RESULT: The overall health-related quality of life of HIV-infected children and those of the HIV-negative control group were similar. However, there was a significant difference in the school and psychosocial functioning domains between the two groups with HIV-positive children scoring lower in these domains. For HIV-positive children, being from upper social class (p = 0.01, R2 = 0.098), male gender (p = 0.005, R2 = 0.063), higher scores in the caregiver burden scale (p = 0.009, R2 = 0.150) and more disease severity (p < 0.001, R2 = 0.321) were significant predictors of lower health-related quality of life. CONCLUSION: The findings of this study show that the overall health-related quality of life of HIV-positive children was similar to that of age- and sex-matched HIV-negative control group. This finding gives clinicians some optimism that with adequate treatment, HIV-positive children will have better outcomes not only in mortality but in psychosocial variables such as quality of life. In addition, the finding on the relationship between caregiver burden and HRQoL underscores the need to focus on family-based interventions to improve the burden of caregiving on family members involved in the care of HIV-positive children.

Recognizing Kounis Syndrome: A Report of Type 2 Kounis Syndrome and a Brief Review of Management.

Kounis syndrome is an underdiagnosed medical condition and represents acute coronary syndrome in the setting of allergic reaction. With the increasing prevalence of allergic reactions, more cases of Kounis syndrome are being reported in the literature. Recognizing patients with acute coronary syndrome during an episode of anaphylaxis may be difficult due to symptom overlap; hence, a high index of suspicion must be maintained. This is vital as the management of Kounis syndrome requires meticulous use of medications as some pharmacological agents beneficial to acute coronary syndrome may be detrimental for the ongoing anaphylaxis and vice versa. We report a case of type 2 variant of Kounis syndrome following severe anaphylaxis to nuts to highlight the need for clinicians to suspect Kounis syndrome when managing patients with anaphylaxis and chest symptoms.

Tirofiban: A Rare Cause of Thrombocytopenia in a Patient Undergoing Percutaneous Coronary Intervention.

Patients admitted to the hospital can develop thrombocytopenia due to multifactorial causes. It can be pseudo-thrombocytopenia or true thrombocytopenia. Among patients admitted for chest pain, coronary angiography (CAG) is a common diagnostic test to evaluate patients for coronary artery disease (CAD). Normally, patients undergoing angiogram receive antiplatelets and anticoagulants pre-catheterization, and platelet aggregation inhibitor agents are sometimes used during and after CAG like in patients with high thrombus burden. Glycoprotein IIb/IIIa receptor inhibitors are a type of platelet antiaggregant agents that can cause severe thrombocytopenia in few cases.  We present a case of a 68-year-old patient who came to the emergency department with inferior wall ST-segment elevation myocardial infarction and underwent angiography and had percutaneous coronary intervention (PCI) done. He was administered tirofiban during the angiogram that caused acute severe thrombocytopenia decreasing platelets count to 4000/microliter within one day. Patients' platelets gradually recovered after platelets transfusion.

Hospitalization Rates, Prevalence of Cardiovascular Manifestations and Outcomes Associated With Amyloidosis in the United States.

Background Amyloidosis is a multisystem disease characterized by the deposition of misfolded insoluble precursor protein fibrils in several organs including the heart. Cardiac amyloidosis can result in a wide range of complications that may lead to significant morbidity and mortality. However, contemporary data in the United States (US) on cardiac amyloidosis is scarce despite these negative consequences. In view of this lack of contemporary data, we sort to assess the prevalence, trends of hospitalization, and outcomes of cardiovascular manifestations in amyloidosis. We also explored this retrospective data for factors that may be associated with in-hospital mortality of amyloidosis hospitalization. Methods We used the national (nationwide) inpatient sample (NIS) database from January 1, 2007 - December 31, 2014, of adult hospitalizations. We studied the prevalence and trends of hospitalizations of amyloidosis among patient with or without cardiovascular co-morbidities. Results We identified 137,797 amyloidosis hospitalizations from 2007 to 2014 of which 87,164 (63.2%) had cardiovascular manifestations. The overall mean age was 70.3±12 years. There were more males (54.5%) overall. The trend of amyloidosis hospitalizations increased significantly from 2007 through 2014 (34 to 73 per 100,000, Ptrend <0.001) and in-hospital mortality decreased from 8.4 to 6.8 per 100 amyloidosis hospitalizations, Ptrend <0.001). Conclusion Our study showed that hospitalizations of amyloidosis have increased considerably over the past decades with a concurrent decline in in-hospital mortality. Despite this decline and after adjusting for other factors, amyloidosis hospitalization with cardiovascular manifestations was still associated with higher in-hospital mortality. Screening of patients with amyloidosis for cardiovascular manifestations should be more accessible to prevent undesired outcomes.

Low-Dose Baclofen-Induced Encephalopathy in a Healthy Young Adult: Is Baclofen Toxicity Dose-Dependent?

Baclofen is a commonly used medication for managing muscle spasticity with the potential of causing life-threatening adverse effects, including encephalopathy as well as withdrawal symptoms including confusion and hallucinations following abrupt discontinuation. Severe toxicity with baclofen is common in patients with kidney disease, hence the importance of dose reduction and monitoring in patients with renal impairment. This article reports a case of encephalopathy with low-dose baclofen in an otherwise healthy young adult concurrently taking ibuprofen and baclofen and aims to underscore the importance of potential drug interaction and patient education when initiating baclofen.

Paradoxical Thromboembolic Ischemic Stroke Following Tissue Plasminogen Activator Instillation for Clogged Central Venous Dialysis Catheter.

Central venous catheters including dialysis catheters are a potential source of venous thrombosis and pose a risk for paradoxical embolic events including ischemic stroke and systemic embolism in patients with a patent foramen ovale (PFO). The adult population with a PFO and patients with a central venous dialysis catheter (CVDC) are at increased risk of a paradoxical embolic event. Since bubble study is not routinely done during echocardiogram in a patient with CVDC, it is difficult to identify at-risk patients for paradoxical embolic events during catheter manipulation, especially for clogged CVDC. We report a rare case of a 79-year-old lady with end-stage renal disease on hemodialysis (HD) using a CVDC who developed a paradoxical embolic ischemic stroke following the use of tissue plasminogen activator (tPA) for unclogging a dialysis catheter. We aimed to highlight the existing risks of thromboembolism associated with the long-term use of central CVDC, especially the potential risk of paradoxical embolism and ischemic stroke with the use of tPA for management of clogged dialysis catheters. We emphasize the questionable need for a bubble study echocardiogram in all patients requiring long-term dialysis catheters.

Disseminated BCG sepsis following intravesical therapy for Bladder Carcinoma: A case report and review of literature.

Intravesical instillation of Bacillus-Calmette-Guerin (BCG), a live-attenuated-strain of Mycobacterium bovis, is an established treatment for superficial bladder carcinoma. Although generally well tolerated, 1/15,000 patients can develop life-threatening disseminated-BCG-infection typically soon after the procedure, a condition colloquially termed BCG-osis. Side-effects of intravesical BCG instillation including fever, chills, fatigue are common but BCG-osis is rare and severe, oftentimes requiring intensive care unit admission and triple anti-TB-therapy as in this case. It is therefore important for clinicians to recognize this possibility as the absence of specific signs and symptoms, coupled with the fastidious nature of the Mycobacteria, pose a diagnostic dilemma in the acute setting. Our case highlights this potential rare iatrogenic side effect of intravesical BCG treatment and the risk associated with non-treatment of BCG-osis.

Autoimmune polyglandular syndrome type 1: a case report and brief review.

Autoimmune polyglandular syndrome (APS) type 1 is a rare autoimmune disorder inherited in an autosomal recessive pattern due to loss of function of the AIRE gene and defective removal of self-reactive T-lymphocytes during the process of thymic T cell maturation. Its manifestation starts early in life with the cardinal clinical disorders being one of muco-cutaneous candidiasis, Addison's disease, and hypoparathyroidism. Recognizing the syndromic nature of one autoimmune disease will facilitate an active search for other conditions which would allow early detection, management, follow-up, and most importantly patient education and counselling to avoid potential complications. We present the case of a young immigrant with multiple endocrinopathies and mucocutaneous candidiasis who presented with features of adrenal insufficiency. Our aim was to briefly review APS type 1 as a disease entity and to highlight the importance of patient education in its management.

Quadricuspid Aortic Valve: Report of Two Cases and Brief Review.

Quadricuspid aortic valve (QAV) is a rare congenital cardiac defect characterized by the presence of four aortic valve leaflets of equal or varying sizes. Even rarer is its clinical presentation with aortic stenosis. Diagnosis of QAV could be challenging but is of great importance as patients often present with progressive aortic regurgitation. We present 2 cases of QAV presenting differently: one with aortic stenosis requiring valve replacement and the other with aortic regurgitation requiring close monitoring.

Stroke risk stratification in atrial fibrillation: a review of common risk factors.

Atrial Fibrillation (AF) has become a major global health concern being the most common sustained arrhythmia in clinical practice. Risk factors for AF include congestive heart failure, hypertension, increasing age and diabetes. Many of these factors also increase the risk for thromboembolism and ischemic stroke in AF patients. Great efforts have been made from the latter part of the 20th century towards developing an ideal stroke risk stratification tool in AF with the aim of reducing the incidence of stroke in AF patients and the limiting unnecessary use of thromboprophylaxis. The thromboembolic risks posed by AF with valvular heart disease are an important subgroup that contributes to a significant proportion of stroke in AF patients globally. We review the evolution of stroke risk stratification and summarize the guidelines for stroke prevention in non-valvular AF as well as AF with valvular heart disease, and the most recent recommendations on stroke prevention in AF patients. Abbreviations: AF: Atrial Fibrillation; ACS: Acute Coronary Syndrome; CAD: Coronary Artery Disease; CCF: Congestive Cardiac Failure; DM: Diabetes Mellitus; EHRA: Evaluated Heartvalves, Rheumatic or Artificial; ICH: Intracranial Hemorrhage; NOACs: Novel Oral Anticoagulants; OAC: Oral Anticoagulants; PAD: Peripheral Arterial Disease ; TIA: Transient Ischemic Attack; VHD: Valvular Heart Disease.

Anaplastic Pleomorphic Xanthoastrocytoma Presenting with Musical Hallucination.

Musical hallucinations are a relatively rare form of auditory hallucination characterized by hearing of music in the absence of any external stimuli. This phenomenon has been linked to both psychiatric and structural lesions. We present the case of a previously healthy young male whose presentation with musical hallucinations led to the diagnosis of a rare tumour, anaplastic pleomorphic xanthoastrocytoma.

A Rare Case of Spontaneous Cardiac Tamponade Induced by Concomitant Use of Rivaroxaban and Amiodarone.

Rivaroxaban is a direct oral anticoagulant (DOAC) approved as an important alternative to warfarin in patients with nonvalvular atrial fibrillation. We report the case of an 87-year-old man with past medical history of nonvalvular atrial fibrillation on rivaroxaban and recently started amiodarone for pulseless ventricular tachycardia who presented to our hospital with intermittent chest pain and was diagnosed with spontaneous hemopericardium causing cardiac tamponade. The culprit drugs were discontinued, and the patient was treated with emergent pericardiocentesis. Both rivaroxaban and amiodarone are substrates for the CYP3A4 hepatic pathway, and concomitant use can result in increased plasma rivaroxaban levels causing an increased propensity to bleeding. While most physicians are cognizant of the need for renal dosing of rivaroxaban, this article aims to increase awareness of its interactions with drugs that are also metabolized through the same hepatic CYP450 pathway.

Obstructive Jaundice due to Pancreatic Involvement as an Initial Presentation of Adult Acute Lymphoblastic Leukemia.

Acute lymphoblastic leukemia (ALL) is a heterogeneous group of lymphoid disorders characterized by monoclonal proliferation and expansion of immature lymphoid cells in the bone marrow, blood, and other organs. It commonly presents with nonspecific symptoms such as lethargy, easy bruising, and weight loss. In this article, we present the case of a 48-year-old male who presented to the hospital with painless jaundice resulting from pancreatic infiltration, initially thought to be due to pancreatic or hepatobiliary malignancy. He was later diagnosed with ALL by lymph node biopsy and peripheral blood flow cytometry immunophenotyping and was transferred to a cancer treatment centre for unilateral bone marrow biopsy and further management. Our case highlights the rare occurrence of pancreatic infiltration in ALL.

Sub-acute effect of N(G)-nitro-l-arginine methyl-ester (L-NAME) on biochemical indices in rats: Protective effects of Kolaviron and extract of Curcuma longa L.

BACKGROUND: Kolaviron (KV) (biflavonoid from Garcinia kola) and extract of Curcuma longa (CL) are frequently used in folk medicine for treatment of hypertension. One of their mechanisms of action is to enhance antioxidant properties in animals. N(G)- nitro- l- arginine methyl- ester (L- NAME) is L- arginine analogue, which by binding to Nitric Oxide Synthase (NOS) may induce hypertension partly due to increase in tissues oxidative stress. OBJECTIVES: To investigate the effect of L- NAME on some biochemical indices and the possible protective effect of KV or CL. MATERIALS AND METHODS: Four groups consisting of 6 rats each were used. One group served as control, second group received L- NAME (40 mg/kg/day). Third and fourth groups were treated with KV and CL, respectively and also received L- NAME. KV and CL were given at a dose of 200 mg/kg/day. RESULTS: L- NAME caused a significant (P <0.05) increase in the levels of serum urea, creatine kinase and alanine aminotransferase relative to controls. L- NAME treated rats had markedly decreased hepatic catalase (CAT), superoxide dismutase (SOD), glutathione- S- transferase (GST) and reduced glutathione (GSH) levels. Precisely, L- NAME decreased CAT, SOD, GST and GSH by 48, 52, 76 and 40%, respectively. L- NAME intoxication significantly decreased (P <0.05) renal GSH and SOD levels. Also, L- NAME caused a significant (P <0.05) induction of lipid peroxidation (LPO) in the animals. Administration of KV or CL with L- NAME caused significant (P <0.05) inhibition of LPO and augments tissue antioxidant indices. CONCLUSION: These results confirm the adverse effect of L- NAME on biochemical indices and, the ability of kolaviron or Curcuma longa to ameliorate the alterations.