A case report of vaping-associated sudden cardiac arrest in a young healthy patient.

Introduction and importance: While vaping has increased significantly among young individuals, the effects of vape aerosol constituents on cardiac electrophysiological dynamics remain unknown. Case presentation: A 22-year-old female with a history of energy vaping presented with cardiac arrest. Found to have no pulse, CPR was started and an initial rhythm of ventricular tachycardia was obtained. Shock was administered with a follow-up rhythm of ventricular fibrillation. She was emergently defibrillated and entered atrial fibrillation with rapid ventricular response. Toxicology and troponins were all negative. Left heart catheterization and cardiac MRI were unremarkable. She was discharged with an external defibrillation vest and a tentative plan for outpatient electrophysiology study in the setting of negative work-up for cardiopulmonary arrest. Clinical discussion: Vaping-induced sudden cardiac arrest may be attributed to a reduction in cardiac repolarization reserve. Exposure to vegetable glycerin and propylene glycol, substances present in nearly all vape products, have been found to incite arrhythmias and disrupt cardiac conduction in animals. Acrolein, an aldehyde byproduct of glycerin, has also been found to induce arrhythmias due to autonomic dysfunction. Increased intracellular calcium concentration and free radical damage, which occur as a result of inhaling particulate matter generated from e-cigarettes, further propagates the risk of arrhythmia. Conclusion: The effects of inhaling vape aerosols remain not fully understood. While there is a perceived notion that nicotine-free aerosols may be harmless, that remains unclear. Further studies are needed to evaluate proarrhythmogenic effects and autonomic dysfunction from the various chemical substances present in vape aerosols.

Classic IgA-Vasculitis With Nephrotic Range Proteinuria - Rare Presentation in an Adult.

IgA vasculitis formerly known as Henoch-Schonlein Purpura is characterized by leukocytoclastic vasculitis and IgA immune complex in small vessels of the affected organ. IgA vasculitis can involve any organ system depending upon the deposition of the IgA immune complex. IgA vasculitis is a clinical diagnosis which manifest with abdominal pain, arthralgia/arthritis, palpable purpura, and kidney involvement. Occasionally, serum IgA levels or skin or kidney biopsy can help in confirming the diagnosis. Treatment is usually supportive, but studies have proved that prednisone or immunosuppressive agents can help in the prevention or progression of the disease. Hereby we present a case of 54-year-old Caucasian male who developed classic tetrad findings of IgA vasculitis most likely after receiving monkeypox vaccine which patient received three weeks prior to presentation to the hospital. Kidney involvement was present but surprisingly proteinuria was above nephrotic range making it as a rare presentation of IgA vasculitis.

Sub-acute Painless Vision Loss Secondary to Neuro-Ocular Syphilis.

There has been a consistent increase in syphilis cases in the United States over the past two decades. The prevalence of neuro-ocular involvement in syphilis is rare; however, with the increase in the prevalence of syphilis in the United States, more frequent encounters with complications of syphilis may be expected. Here, we present a case of sub-acute painless vision loss secondary to neuro-ocular syphilis.

Safety Profile of Mutant EGFR-TK Inhibitors in Advanced Non-Small Cell Lung Cancer: A Meta-analysis.

Background: Despite the use of platinum-based chemotherapy, lung cancer continues to be the leading cause of cancer-related death in the world. To overcome the rate of lung cancer-related death, scientists discovered advanced therapies, including mutant epidermal growth factor receptor-tyrosine kinase (EGFR-TK) inhibitors. Observations: We conducted a meta-analysis to determine the safety profile of mutant EGFR-TK inhibitors in the management of advanced non-small cell lung cancer (NSCLC). Included in this study are 9 phase 3 randomized controlled trials designed to study the safety profile of mutant EGFR-TK inhibitors in patients with advanced NSCLC. The study showed that mutant EGFR-TK inhibitors have an incidence of adverse effects that is less reported when compared with platinum-based chemotherapy. Conclusions: We recommend continuing using mutant EGFR-TK inhibitors in patients with advanced NSCLC especially in patients having mutant EGFR receptors. Adverse effects caused by mutant EGFR-TK inhibitors are significant but are usually tolerable and can be avoided by reducing the dosage of it with each cycle or by skipping or delaying the dose until patient is symptomatic.

Histoplasmosis presenting as colitis and blood dyscrasias in a patient with systemic lupus erythematosus.

A 28-year-old woman with a history of systemic lupus erythematosus on hydroxychloroquine and steroid therapy presented with fever, dysentery, and thrombocytopenia. Marrow aspirate revealed yeast forms of histoplasmosis. She was treated with liposomal amphotericin B followed by itraconazole with resolution of symptoms and marrow recovery.

Subcutaneous gluteal abscess from Trichosporon asahii in an immunocompetent adult.

Fungal infections have been drastically increasing in incidence in recent years, preferentially affecting immunocompromised hosts and causing potentially fatal outcomes. One of the emerging fatal fungal pathogens is Trichosporon asahii, a non-Candida yeast that has been increasingly reported in recent years. Previous literature has described T. asahii as primarily affecting immunocompromised hosts, specifically those who are neutropenic, and causing fatal disseminated infections. Herein, we describe a case of an isolated subcutaneous abscess with T. asahii in an immunocompetent host without overlying skin manifestations or predisposing factors that resulted in complete mycotic cure when treated with voriconazole and terbinafine.

Prognostic importance of deranged sodium level in critically ill patients: A systemic literature to review.

It is common upon admission or during stay at a hospital or intensive care unit (ICU) for patients to present with or acquire a serum sodium abnormality. Hyponatremia, serum sodium level less than 135 mmol/L, frequently associated with critical illnesses such as heart failure and liver cirrhosis, is an indicator of disease severity as well as a risk factor for poor prognosis. Hypernatremia, serum sodium level greater than 145 mmol/L, results due to any ailment disabling a patient's modality of thirst or the ability to relieve it once sensed. Hypernatremia has a more frequent iatrogenic component than hyponatremia. It can develop insidiously among patients through IV fluid administration of saline; both its presentation upon admission and development during stay is associated with mortality. Hyponatremia is associated with increased mortality and its treatment with morbidity as it carries a risk of overcorrection and consequently the development of central pontine myelinolysis. This review article covers the findings, and subsequent correlation between findings sought, of six articles catering to underscore the correlation between sodium disorders and prognosis of hospitalized or critically ill patients. PubMed search engine was utilized to select articles befitting the purpose of this review. Cumulatively, this review article substantiates the need to diligently evaluate and treat serum sodium disorders in hospitalized patients to achieve better prognosis.

Role of immature platelet fraction (IPF) in sepsis patients: A systematic review.

Sepsis is extremely common amongst critically ill patients and requires early diagnosis. Hence, identifying a biomarker that could acknowledge sepsis at its prior stage is of vital significance. Immature platelets are a percentage of circulating platelets that contain RNA and is a newer parameter that is measured using automated hematology analyzers in diagnosing sepsis. This review article discusses 10 articles that reveal the role of immature platelet fraction in predicting the onset of sepsis and its relationship with mortality in sepsis. Literature search was done using PubMed, Scopus and Google Scholar and words like platelet indices and immature platelet fraction were typed in the search bar. The aim of this review article is to present a precise form of data that talk about immature platelet fraction (IPF) and its association with the severity and mortality of sepsis. Five out of 10 articles suggest that immature platelet fraction can predict the onset of sepsis and eight out of 10 articles suggest that increased IPF values are associated with high mortality.

Asymptomatic Bacteriuria (ASB) in diabetic patients: Treat or not to treat: A prospective, observational study conducted at a tertiary care hospital.

BACKGROUND: The term asymptomatic bacteriuria (ASB) refers to the isolation of bacteria in a urine specimen of individuals who denied symptoms of urinary tract infection. Diabetes mellitus (DM) is a disease involving multiple organ systems, hallmarked for its chronicity and thus-forth endless complications including asymptomatic bacteriuria. OBJECTIVES: This study aimed to determine the characteristics of asymptomatic bacteriuria and antibiotic susceptibility pattern amongst patients with diabetes. SETTINGS AND DESIGN: A prospective observational study was conducted at a tertiary care hospital in Karachi, Pakistan. METHODS AND MATERIAL: The study included all those patients with a diagnosis of diabetes with no signs and symptoms of urinary tract infection but showing the growth of an organism in urine culture. Pregnant females and subjects who used antibiotics in last two weeks were excluded. A total of 222 urine cultures were observed prospectively who met the inclusion criteria through non-probability consecutive sampling. RESULTS: Out of 222 urine cultures observed, mean age of subjects were 62.89 ± 13.77 out of which 76% were females, and 61% had a family history of diabetes. The most frequent organisms isolated were Escherichia. Coli (E. Coli), Enterococcus, Klebsiella, Pseudomonas, and Enterobacter species. A total of 20 subjects got dual bacterial growth in their cultures among which 17 subjects had a growth of Enterococcus with any other pathogen causing UTI. Gender, family history of diabetes, levels of HBA1c, and older age groups all were found significantly associated with ASB. CONCLUSIONS: Our study is the first to analyze and study the associated risk factors amongst ASB in DM patients, and to identify the pathogens involved along with assessing their antibiotic resistance profiles. Also, due to the increase resistance to antibiotics we would recommend to use antibiotics in ASB patients only if they have any two or more comorbidities.

Lemierre's syndrome with muscle necrosis and chronic osteomyelitis.

Lemierre's syndrome is a rare disorder characterized by thrombophlebitis of the internal jugular vein and is caused by gram-negative anaerobes, primarily Fusobacterium necrophorum. We report a case of a 20-year-old man who developed chronic osteomyelitis of the femur and myonecrosis of thigh muscles secondary to this syndrome. The diagnosis was made based on clinical presentation and evidence of thrombosis in the internal jugular vein on ultrasound. The patient was initially treated with antibiotics, and anticoagulants were added later due to deep vein thrombosis in the lower limb.

Rhabdomyolysis Causing Renal Failure Following Cardiopulmonary Resuscitation, Cardioversion, and Myocardial Infarction: A Case Report and Review of the Literature.

Rhabdomyolysis is a condition where there is damage of skeletal muscle, causing myoglobin leak into the circulation. We report a case of a 69-year-old female with a history of hypertension, hyperlipidemia, diabetes mellitus, morbid obesity, paroxysmal atrial fibrillation, and chronic kidney disease stage who underwent cardiopulmonary resuscitation following ventricular fibrillation to restore effective cardiac rhythm. After the third attempt of defibrillation she converted to sinus rhythm. Her echocardiography was suggestive of myocardial infarction (MI). On the second day of her hospitalization, she started becoming oliguric and her creatinine started rising up causing acute kidney injury (AKI). The patient's creatinine kinase (CK) level peaked at 6380 u/L (normal range 26-192 u/L), myoglobin was >20,000 ng/mL (normal range 9-83 ng/mL), and myocardial bound (MB) isoenzyme of CK was 4.5 ng/mL (normal range 0-3.6 ng/mL). Plasma creatinine increased to 5.71 mg/dL and ultimately developed renal failure. She was started on hemodialysis. Her cardiac catheterization was suggestive of MI. Our case highlights that MI, cardiopulmonary resuscitation, and cardioversion can be a cause for myoglobinuric renal failure, which has been rarely reported in the literature before.

Acute Sensory-Motor Axonal Neuropathy in a 57-Year-Old Male Presenting With Paresthesia and Distal Muscle Weakness.

Guillain-Barré syndrome (GBS) is a relatively uncommon post-infectious, immune-mediated neurologic disorder with an incidence of 0.5-2/100,000. It is usually preceded by an infection that evokes an immune response that cross-reacts with peripheral nerve components via molecular mimicry. The presentation of this disorder has several forms, including acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller Fisher syndrome (MFS). The case we describe is of a 57-year-old male presenting with sensory features followed by symmetrical ascending paralysis and diagnosed with ASMAN, a recently described subtype of GBS, based on neurological and laboratory findings.

Correlation of Fasting Lipid Profile in Patients With Chronic Liver Disease: A Descriptive Cross-Sectional Study in Tertiary Care Hospital.

INTRODUCTION: Chronic liver disease (CLD) is a term used to describe a wide spectrum of disorders, including idiopathic, infectious, genetic, drug-induced, toxin-induced, and autoimmune disorders. The common consequence of chronic damage to the liver is cirrhosis. Cirrhotic patients are further classified by their severity based on the Child-Pugh scoring system. Currently, Child-Pugh scoring consists of ascites, hepatic encephalopathy (HE), prothrombin time, serum albumin level, and total bilirubin level. Lipid panel in CLD is a great marker in determining the severity of CLD. Method and methodology: It was a descriptive cross-sectional study conducted at a tertiary care hospital. A sample size of 122 was calculated by using a RaoSoft Digital Sample Size Calculator (RaoSoft, Inc., Seattle, WA) in which we used 5% as a margin of error, 95% as confidence interval (CI), 178 as population size, and response distribution as 50%. Non-complicated CLD patients having age in between 15 and 80 years with no cirrhotic complications including HE, spontaneous bacterial peritonitis, hepato-pumonary, or hepato-renal syndrome were included in our study; the rest of the CLD patients were excluded from our study. RESULTS: The mean age of the study population was 47.09 ± 12.30 years with more than half of the patients lying among the age group 25-50 years. The study population included 76% of males (n=93) and 24% of females (n=29), with a mean age of females higher than the males. Diabetes mellitus (58.19%) was the most frequent comorbidity associated with CLD in subjects included in our study. Parameters of lipid panel were decreased exponentially as the severity of CLD increases from Child score A to C. Total cholesterol, low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), high-density lipoprotein (HDL), and triglyceride (TG) level decreased as the severity increases in our study. The mean model for end-stage liver disease (MELD) score increased as per hypothesized as the severity increases from Child score A to Child score C, respectively. CONCLUSION: Our study concluded that as the severity of CLD increases from Child class A to Child class C, the lipid panel profile decreases exponentially which proved the idea that had been hypothesized at the beginning of our study.

Sodium-Glucose Linked Transporter Inhibitors as a Cause of Euglycemic Diabetic Ketoacidosis on a Background of Starvation.

We present a case of a male diabetic patient with one of the most well-known major complications of diabetes mellitus (DM), i.e., diabetic ketoacidosis (DKA). The finding of euglycemic DKA, or DKA with blood glucose levels of less than 200 mg/dL, is a rare occurrence especially in patients with type II DM. He presented with hypotension and increased anion gap metabolic acidosis on a background of keto diet for weight loss and recent use of sodium-glucose linked transporter inhibitors. He was successfully managed with dextrose water, insulin infusion, and potassium replacement. A ketogenic diet consists of high fat, low carbohydrate, and adequate protein regimen that sends the body into a state of starvation in which high glucagon and low insulin levels lead to the activation of other counter-regulatory hormones, such as epinephrine and cortisol, that causes a rise in the level of free fatty acids in the blood increasing ketone body production. Rarely, sodium-glucose linked transport inhibitors can also cause DKA, with euglycemia instead of hyperglycemia. The finding of plasma glucose levels within normal range prompted patients to maintain and sometimes even lower their insulin dose; even their providers were often misled by the euglycemia that resulted in delayed diagnosis and treatment. Thus, it is imperative to stay aware of the possible clinical presentations in order to intervene in a timely manner and prevent further progression and complications.

First Reported Case of Hyperchloremic Non-Anion Gap Metabolic Acidosis in a Patient Undergoing Continuous Bladder Irrigation for Hemorrhagic Cystitis.

Radiation cystitis can present as gross hematuria and occurs secondary to irritation of the bladder urothelium. Continuous bladder irrigation (CBI) is commonly used for the treatment of hemorrhagic cystitis for evacuation of blood clots and to maintain catheter drainage. Most commonly, CBI is performed using 0.9% sodium chloride. We report a 77-year-old female who developed hyperchloremic non-anion gap metabolic acidosis (H-NAGMA) and pulmonary edema secondary to absorption of 0.9% normal saline (NS) from CBI. In such cases, ringer lactate with low concentration (109 mEq) of chloride as compared to NS (154 mEq) can prove to be a suitable alternative.