A Case of Acupuncture Induced Pneumothorax.

With various forms of alternative medicinal practices gaining popularity, there is an increase in complications arising from these practices. Acupuncture, which originated in China, and now practiced worldwide as a form of traditional medicine, is generally considered safe; however, rare life-threatening complications can occur following its practice. Here we present the case of a 63-year-old male who presented to the emergency department with symptoms suggestive of pneumothorax. Upon further history, the patient disclosed that he had recently undergone acupuncture treatment for chronic elbow pain.

Drug-Induced Liver Injury From Sacubitril-Valsartan Versus a Single Dose of Acarbose.

Numerous known medications can induce liver injury. Sacubitril-valsartan was approved by the Food and Drug Administration in 2015 for use in patients with chronic heart failure to reduce the rate of cardiovascular death and hospitalizations related to heart failure. There are yet to be any reported cases of drug-induced liver injury secondary to sacubitril-valsartan use. Acarbose is well known to be associated with liver failure, but typically liver injury occurs months after initiation of therapy. Here, we report the case of a 76-year-old woman who developed acute liver failure after one month of sacubitril-valsartan use and one day after being prescribed acarbose.

Losartan-induced Severe Hepatic Injury: A Case Report and Literature Review.

Medications have been known to cause adverse drug reactions that affect various organs; these are mostly reversible reactions that improve with the cessation of the culprit medication. Losartan is an angiotensin-one receptor blocker which has been approved by the Food and Drug Administration (FDA) for the treatment of arterial hypertension. Fatigue, anemia, weakness, and cough are some of the common adverse effects of losartan. Acute hepatic injury has rarely been reported as an adverse effect of losartan. We report a case of a 61-year-old female with severe hepatic injury secondary to losartan use. None of the cases reported so far had such a high elevation of liver enzymes as seen in our patient.

An Intensive Care Unit Outbreak of Acute Respiratory Distress Syndrome due to Human Metapneumo Virus Infection.

Human metapneumo virus is an emerging cause of upper and lower respiratory tract illness with increasing reports of a varied spectrum of disease over all age groups. We report an outbreak of 6 cases of human metapneumo virus infection in the intensive care unit of a metropolitan tertiary care center over 6 weeks, leading to severe acute respiratory distress syndrome. We report the subsequent favorable outcomes due to the institution of extracorporeal membrane oxygenation.

Allopurinol-Induced Stevens-Johnson Syndrome.

Allopurinol is a first line agent in treating gout, but it also carries the risk of severe side effects. Stevens-Johnson syndrome (SJS) is one of the life threatening severe cutaneous adverse reactions caused by allopurinol. The severity of the severe cutaneous adverse reactions can be categorized based upon the area of skin involvement: (1) erythema multiforme major limited to 1-2 % of the body surface area (BSA); (2) SJS involving <10% of the BSA, (3) SJS and toxic epidermal necrolysis overlap involving 10-30% of the BSA and (4) toxic epidermal necrolysis syndrome involving >30% of the BSA. SJS can be caused by drugs and viruses, the former being more frequent. We report a case of an 85-year-old Han-Chinese female who developed SJS after ingestion of allopurinol 8 days prior to the hospitalization. The patient also had concomitant acute viral illness, which complicated the clinical scenario causing acute renal failure and hemodynamic compromise.

Neisseria cinerea in a Post-splenectomy Patient: A Rare Potentially Fatal Bacteremia.

Neisseria cinerea is a commensal which usually resides in the human respiratory tract. Very rarely, the organism finds its way into the bloodstream causing severe bacteremia. So far, very few cases of Neisseria bacteremia have been reported. We report a case of a 78-year-old male, post-splenectomy, who presented with high fever, cough and shortness of breath. The patient was initially managed for septic shock with fluid resuscitations, vasopressors and broad-spectrum antibiotics. Later, the blood cultures grew gram-negative coccobacilli, Neisseria cinerea. The patient was successfully treated with intravenous ceftriaxone. This is the first case ever of Neisseria cinerea bacteremia in a post-splenectomy patient and ninth case overall. This case illustrates that the physicians should maintain heightened awareness for Neisseria cinerea bacteremia in post-splenectomy patients.

Severe Pulmonary Hypertension Due to Adult-Onset Still's Disease.

A 29-year-old female with adult-onset Still's disease (AOSD) presented with progressive shortness of breath both on rest and on exertion, increased abdominal girth, and swelling in both legs. She was on oral prednisone and was recently started on canakinumab (interleukin-1 antagonist) for joint pain and rash of AOSD. Echocardiogram showed severely dilated right ventricle, dilated pulmonary artery, moderately reduced right ventricular systolic function, but with normal left ventricular systolic function. Computed tomography with contrast ruled out pulmonary embolism. Blood tests ruled out other rheumatologic diseases. The patient was diagnosed with right-sided heart failure likely secondary to AOSD. Right heart catheterization was needed but could not be performed because of severely dilated pulmonary artery. The patient was transferred to a higher center for further management and possible cardiopulmonary transplant.

Sputum Smear and Culture-negative Tuberculosis with Associated Pleural Effusion: A Diagnostic Challenge.

Tuberculosis (TB) is an important cause of morbidity and mortality in the United States. Due to the unpredictable or nonspecific nature of its clinical presentations, TB can be a diagnostic challenge for physicians. In 2013, 23% of reported TB cases were culture-negative in the United States; in New York City, this was approximately 27%. The increasing number of sputum smear- and culture-negative TB patients is a serious concern because misdiagnosis and delayed treatment can lead to increased morbidity and mortality and increased infectious transmission. We report a case of a 26-year-old-female recent immigrant, who was initially managed for community-acquired pneumonia but was later found to have TB with complicated pleural effusion, despite having multiple smear- and culture-negative sputum specimens, Xpert Mycobacterium tuberculosis (MTB)/resistance to rifampin (RIF) assay (real-time polymerase chain reaction (PCR)) and pleural fluid analysis. She improved clinically on anti-tuberculosis therapy and, later, the diagnosis was confirmed by pleural biopsy.

A Diagnostic Surprise: Primary Hodgkin's Lymphoma of the Lung.

An 81-year-old male presented to the emergency room with a 3-month history of progressive shortness of breath, productive cough with white sputum, and generalized weakness with 10-pound weight loss in 2 months. On presentation, the patient was afebrile, with blood pressure of 93/55 mm Hg and oxy-hemoglobin saturation of 92% on 2 liters of oxygen via nasal cannula. Complete blood count with differential was significant for white count of 12 400/mL. Brain natriuretic peptide level was 454 ng/mL. Postero-anterior chest radiograph showed multiple round opacities in the lung fields. Computed tomography scan of the chest confirmed multiple round densities in both the lung fields along with mild mediastinal lymphadenopathy. Core needle biopsy was performed. Immunohistochemical stains were positive for CD30 and CD15 in a population of large atypical cells amid a background of CD3-positive nonneoplastic cells. These results were in support of the diagnosis of classical Hodgkin's lymphoma of the lung with histological appearance confirming nodular sclerosis type. The patient was started on chemotherapy but was readmitted in 20 days for acute respiratory distress and suffered cardiac arrest and subsequently died. This case highlights the fact that although primary pulmonary Hodgkin's lymphoma of the lung is a rare entity, it should be thought of as a differential while evaluating lung masses. In these cases, definite diagnosis can only be made by biopsy and histology. Early commencement of chemotherapy and regular follow-up with oncology is essential.

Mixed Adenoneuroendocrine Carcinoma of the Gastroesophageal Junction: A Rare Find.

Neoplastic lesions that demonstrate neuroendocrine features are rare. However, esophageal tumors containing both adenocarcinomatous and neuroendocrine components are exceedingly rare. Mixed adenoneuroendocrine carcinomas (MANECs) are gastrointestinal tumors with both adenocarcinomatous and neuroendocrine differentiation. They have a tendency for early metastases but clinically manifest relatively late. Imaging studies are often nonspecific with regard to tumor type, and a histopathologic study of biopsy material is required for definitive diagnosis. The overall prognosis is poor. The current report describes a rare case of gastroesophageal MANEC tumor, with approximately 60% neuroendocrine and 40% adenocarcinomatous components. Since there is a dearth of concrete management guidelines for MANECs, we present possible management options to add to the existing literature.