Severe Case of Oral Baclofen Withdrawal Resulting in Mechanical Ventilation.

Abrupt baclofen withdrawal may be life-threatening with varied neuropsychiatric manifestations. We present a case of baclofen withdrawal necessitating intubation. A 58-year-old female with a history of undiagnosed muscle spasticity presented with worsening extremities tremors, paresthesia, and weakness for 2 days. Initial vitals included temperature 103 F, tachycardia, hypertension, and tachypnea. Examination revealed coarse tremors of all extremities. Inflammatory markers, blood, and urine culture were negative. Head and spine imaging were non-diagnostic. Meningitis and seizure were ruled out. She continued worsening with hallucinations, hyperpyrexia, ocular clonus, and profound muscle rigidity. The patient was intubated for respiratory distress and transferred to intensive care unit (ICU). Further history revealed running out of oral baclofen 3 days ago. Baclofen was restarted with symptomatic improvement. The patient was extubated after 2 days and discharged to a rehabilitation facility. Oral or intrathecal baclofen is thought to inhibit spinal nerves reducing muscle spasm and pain. Abrupt stoppage causes activation of dopamine and noradrenergic receptors causing muscle spasms, tremors, hyperpyrexia, delusions, hallucination, and delirium. Severe cases can mimic meningoencephalitis, seizure disorder, or neuroleptic malignant syndrome. Symptoms usually develop in 1 to 3 days of cessation and can be life-threatening if unrecognized timely. Treatment includes supportive therapy, re-administration of baclofen, or use of benzodiazepines, propofol, dexmedetomidine; however, no specific guidelines have been established. To the knowledge of the authors, this is the first case of oral baclofen withdrawal requiring intubation. We found only 3 reported cases of intrathecal baclofen withdrawal necessitating intubation.

Warm Autoimmune Hemolytic Anemia as the Initial Presentation of Systemic Lupus Erythematosus (SLE): A Case Report.

BACKGROUND Autoimmune hemolytic anemia is an acquired disorder resulting in the presence of antibodies against red blood cell (RBC) antigens causing hemolysis. Autoimmune hemolytic anemia is of 2 types, Warm antibody mediated and cold agglutinin disease. Warm autoimmune hemolytic anemia (warm agglutinin disease) usually presents with fatigue and other constitutional symptoms and is diagnosed by the presence of IgG antibodies. The disease can occur as idiopathic or secondary to other autoimmune diseases, infections, or even malignancies. The systemic lupus erythematosus (SLE) is an autoimmune disease prevalent in young females. Autoimmune hemolytic anemia can occur as a part of the SLE spectrum however warm autoimmune hemolytic anemia as the initial manifestation of SLE is extremely rare. CASE REPORT Here, we describe a unique case of a 32-year-old woman who presented with vague clinical presentation found to have warm autoimmune hemolytic anemia and further immunological and inflammatory work-up during and after hospitalization lead to the diagnosis of systemic lupus erythematosus. CONCLUSIONS The systemic lupus erythematosus (SLE) is an autoimmune chronic inflammatory disease with unclear etiology affecting multi organs. Variable presentation in addition to the lack of definite pathognomonic features or tests makes the diagnosis of SLE challenging. On the whole autoimmune hemolytic anemia can not only be part of other disease processes but can be an initial presentation, highlighting the importance of thorough work-up in patients presenting with autoimmune hemolytic anemia to aid in timely diagnosis and management of underlying secondary conditions. It is important for providers to be aware of various disease spectrums that contain autoimmune hemolytic anemia for day-to-day clinical practice.

Coronary vasospasm as an etiology of recurrent ventricular fibrillation in the absence of coronary artery disease: a case report.

Background: Vasospastic angina (VA), or Prinzmetal's angina, is characterized by symptoms of coronary angina caused by coronary vasospasm, usually in the absence of atherosclerotic changes. It typically presents with chest pain, which can be accompanied by transient electrocardiographic changes, if visualized during the attack. It can also rarely present with severe manifestations of acute myocardial angina, ventricular fibrillation, or cardiac arrest. Case presentation: We present a case of a 50-year-old Caucasian male who initially presented to the hospital with chest pain and was diagnosed with VA. Later, he was brought to the hospital by emergency medical services later with ventricular fibrillation, despite normal coronary anatomy on angiogram. He was managed with placement of an intra-cardiac defibrillator (ICD) for secondary prevention. The patient continued to have recurrent episodes of ventricular fibrillation with associated ICD shocks, and had multiple admissions to the hospital with similar presentations. Symptoms and arrhythmia improved after optimizing antianginal therapy. Conclusions: Ventricular fibrillation can be an uncommon but severe manifestation during VA crises. In cases with normal coronary vasculature, it is important to recognize VA as a cause of recurrent ventricular fibrillation in order to optimize medical management for prevention of fatal arrhythmias.

COVID-19 pericarditis mimicking an acute myocardial infarction: a case report and review of literature.

The novel coronavirus disease (Covid-19) continues to spread all over the world with acute respiratory distress syndrome and multiorgan failure being a significant cause of morbidity and mortality. The involvement of the cardiovascular system is associated with increased mortality and there have been various manifestations reported in the literature. We present a case of a patient requiring intensive care unit (ICU) admission for acute respiratory distress syndrome from Covid-19 who developed ST elevations in inferior leads in electrocardiogram (ECG) and elevated troponins. The changes resolved in serial ECG accompanied by normalization of blood troponin levels. His subsequent echocardiogram did not reveal any abnormalities in wall motion or heart function leading to a diagnosis of focal pericarditis mimicking an acute myocardial infarction. We also present a review of literature on various cardiac manifestations reported so far in cases of Covid-19.

Nasopharyngeal Swab for COVID-19 Test Necessitating Mechanical Ventilation and Tracheostomy.

We present the first-ever reported case of massive epistaxis following nasopharyngeal (NP) swabbing requiring intubation and tracheostomy. A 67-year-old male with a mechanical aortic valve on warfarin presented from a nursing home to the emergency department with hypoxia. NP swab for coronavirus disease 2019 (COVID-19) was obtained, immediately followed by significant epistaxis. Patient desaturated to low 80s requiring intubation for airway protection and hypoxemic respiratory failure. Anterior nasal packing was performed. The COVID-19 test resulted negative. Extubation was unsuccessful on days four and nine. The patient subsequently underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient was transferred to sub-acute rehabilitation with a tracheostomy tube on minimal ventilator support. The World Health Organization (WHO) has recommended obtaining an NP swab in COVID-19 suspects to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using reverse transcriptase polymerase chain reaction (PCR).A study found that NP swabbing was associated with epistaxis in approximately 5-10% of the cases. Nursing home populations are at higher risk for COVID-19 and also reported to have increased use of oral anticoagulation for chronic atrial fibrillation with other co-morbidities (high CHADVASc score) which may increase bleeding risk with NP swabbing. Less invasive methods such as salivary and mid-turbinate sampling, nasal swab or saliva can be a better alternative sample for detecting SARS-CoV-2 as recommended by the Centers for Disease Control and Prevention (CDC) and suggested by FDA. Positive PCR testing beyond nine days of illness is likely due to persistent dead virus particles and thus repeat testing is not suggested. Obtaining a history of bleeding diathesis, use of oral anticoagulants and consideration of NP anatomy is advised before swabbing. This case report raises the concern against inadvertent NP swabbing in cases with a low pretest probability of COVID-19 infection with higher bleeding risk.

Factitious Disorder Masquerading as a Life-Threatening Anaphylaxis.

Factitious disorder is a psychiatric disorder in which sufferers intentionally fabricate physical or psychological symptoms in order to assume the role of the patient, without any obvious gain. We present a case of a 23-year-old female with chronic urticaria who presented with dyspnea, dysphasia, mild generalized erythema, abdominal cramps, and headache. She was tachypneic and hypotensive. This was her third admission with similar symptoms within the last 7 months. Tryptase, complement, anti-SM/RNP, Sjogren, Scl-70, C3, and C4 were negative. Computed tomography-guided bone marrow biopsy showed no mast cells. Flow cytometry did not show any immunophenotypic reaction. Other possible differentials including pregnancy, autoimmune disorders, and infections including hepatitis, thyroid disorder, and age-related malignancies were ruled out. After a thorough review, malingering disorder was ruled out, but we noticed the patient's intent of assuming a sick role. Later, the patient was diagnosed with major depressive disorder. Factitious anaphylaxis can present with multiple presentations including a life-threatening condition that mimics true anaphylaxis. A better approach would be thorough clinical evaluation and early multidisciplinary involvement. This case highlights the importance of further evidence-based studies in factitious disorder to decrease the disease burden and reduce the health care cost.

Avascular necrosis in systemic sclerosis patients: a case-based review of demographics, presentation, and management.

Avascular necrosis (AVN) is a pathologic process involving death of bony tissue resulting from loss of blood supply from various causes. Various traumatic and nontraumatic causes of AVN are known, including systemic autoimmune diseases. AVN has been well described in patients with autoimmune diseases such as systemic lupus erythematosus, but in systemic sclerosis (SSc) patients, there have been limited case reports and case series. There have only been three case reports of AVN in multiple anatomic sites (multifocal AVN) reported in SSc patients in the literature. We present a case of multifocal AVN in an SSc patient and a review of literature on the previously reported cases of SSc-related AVN in terms of demographics, clinical presentation, and management. To our knowledge, this is the only literature review of reported AVN cases in SSc patients.

Thinking Outside the Lungs: A Case of Disseminated Abdominal Tuberculosis.

BACKGROUND Extrapulmonary tuberculosis (TB) occurs in up to one-fifth of all cases of TB, with abdominal TB accounting for 5% of all cases. It is an uncommon diagnosis in the Western world, where it is primarily identified in immigrant and immunocompromised populations. CASE REPORT We review a case in which a 47-year-old Nepalese woman with a history of cognitive dysfunction secondary to epilepsy presented with decreased appetite and diffuse abdominal pain. She was hypoxic and febrile on initial exam, and imaging indicated lung consolidation, right-sided pleural effusion, and thickening and nodularity of the omentum with patchy wall thickening of the colon. After failing to improve on a standard antibiotic regimen for treatment of pneumonia and colitis, the differential was broadened to include TB. Interferon-g release assay was subsequently found to be positive, and omental and peritoneal biopsies were obtained. The patient was started on an empiric course of rifampin, isoniazid, ethambutol, pyrazinamide, and pyridoxine. Laboratory testing revealed no immunochemical evidence of Mycobacterium species, however, Ziehl-Neelsen acid-fast stain was positive with rare acid-fast bacilli identified. CONCLUSIONS Peritoneal TB carries significant morbidity and mortality if undiagnosed or untreated. Diagnosis is challenging in the absence of a single test that can confirm or exclude this condition. In combination with clinical suspicion, it is crucial to explore history regarding socio-epidemiology (travel, incarceration, occupation, homelessness, sick contacts) and immunological risk (drug use, chemotherapy) in patients with constitutional symptoms.

The Role of Brain Natriuretic Peptide as a Prognostic Marker for Sepsis.

Brain natriuretic peptide (BNP) is a neurohormone released in response to volume expansion and increased pressure. It is commonly used to assist in the diagnosis and management of heart failure. BNP can also play an important role as a biomarker in septic shock; however, elevations of BNP in conditions other than sepsis or cardiac dysfunction limits its use as the sole prognostic marker in patients hospitalized with sepsis. Further relationships regarding laboratory value and correlation with severity of illness need to be established with larger prospective studies to develop consensus regarding a cut-off point for optimum sensitivity and specificity in predicting in-hospital mortality related to sepsis.

Atypical presentation of an elderly male with autoimmune encephalitis: anti-LG1 limbic encephalitis.

INTRODUCTION: We present a case of an elderly male with anti-LG1 limbic encephalitis involving hypothalamus presenting with acute changes in mental status and persistent hyperthermia. CASE REPORT: A 74-year-old male presented to the hospital with fever and chills. He had also been evaluated by his PCP for changes in his mental status, trouble remembering things, and following directions while driving. A lumbar puncture was performed, and empiric meningitis coverage was initiated. His LP results were not suggestive for any infectious process. An MRI showed bilateral hippocampal edema. As an infectious workup was non-revealing and other causes were ruled out, with the concern for paraneoplastic or autoimmune encephalitis, patient was started on high dose steroids and plasma exchange while results of antibodies for autoimmune and paraneoplastic encephalitis were awaited. After plasmapheresis and a course of steroids, the patient's mental status began to slowly improve. He was discharged from the hospital and on subsequent neurology office visit, his serum autoimmune encephalitis panel returned positive for anti-LGI 1 antibodies. Further management consisted of outpatient rituximab infusion. DISCUSSION: Diagnosis of limbic encephalitis can be challenging and can present with symptoms of limbic dysfunction. A modest index of suspicion of limbic encephalitis should be kept in adults with altered mental changes. Early recognition and initiation of therapy can be crucial in the management of patients with autoimmune encephalitis and can prevent permanent cognitive impairment and damage.

Takotsubo Cardiomyopathy in a Nonagenarian With Urosepsis.

Takotsubo cardiomyopathy (TCM) is a rare but reversible myocardial left ventricular (LV) dysfunction, which mimics acute coronary syndrome (ACS) without the presence of significant coronary artery disease (CAD). Emotional stressors may include the death of kin or a life-threatening medical diagnosis whereas physical stressors include infections, endoscopic procedures, exacerbation of asthma, or systemic disorders. A 90-year-old female presented to the ED with nausea, intermittent chest heaviness, and generalized weakness for a duration of three days. Her troponin-I was elevated and an electrocardiogram (EKG) showed T-wave inversions in leads V2-V6 and no ST-segment changes. An echocardiogram (ECHO) revealed an ejection fraction (EF) of 35%-40% with anteroapical hypokinesis. She underwent cardiac catheterization showing nonobstructive CAD. She was diagnosed with pan-sensitive Escherichia coli urosepsis and started on ceftriaxone. She improved clinically and was discharged. A repeat ECHO done a month later showed normal EF. Urosepsis-induced TCM has rarely been reported in the literature. Physicians should have a high index of suspicion of TCM in patients with symptoms mimicking ACS in the presence of a physical stressor like an infection. We report the case of TCM, which resulted from a urinary tract infection (UTI) in an elderly female.

Prevalence of Cancer in Rheumatoid Arthritis: Epidemiological Study Based on the National Health and Nutrition Examination Survey (NHANES).

Rheumatoid arthritis (RA) is a multi-system autoimmune disease with significant morbidity and healthcare burden. It is an inflammatory condition and has been associated with lymphomas, with or without the presence of immunosuppressive therapy. However, the association of rheumatoid arthritis with other malignancies has been inconsistent. We used the data from a population-based National Health and Nutrition Examination Survey (NHANES) for epidemiological study to evaluate the association between RA and the incidence of cancer. Using the data collected between 2011 and 2014, we were able to determine the incidence of cancer in 11,262 patients. Incidence of cancer was increased in patients with RA with an odds ratio of 1.632 (95% confidence interval [CI]: 1.239-2.151; p=0.0005). Breast cancer (CA) and prostate CA were the most common types of cancer (each diagnosed in 16.22% individuals) and lung CA and lymphomas found in 1.35% of individuals. It is also important to be aware of increased risk and adequately screen patients for malignancies during the course of treatment and follow up of rheumatoid arthritis. Further large prospective studies are required to determine the association of the RA or its treatment and the risk of malignancies.