Albuterol-Induced Type B Lactic Acidosis: Not an Uncommon Finding.

Lactic acidosis (LA) is usually a medical emergency diagnosed by laboratory evaluation in emergency rooms (ERs) and hospital settings in critically ill patients. LA is classified into two major types based on pathophysiology; type A results from tissue hypoxia and/or hypoperfusion and type B results from deranged metabolic activity in the cells in the absence of hypoxia/hypoperfusion. Prompt evaluation and treatment are essential to prevent morbidity and mortality, especially in patients with type A LA. Most cases of LA are due to type A (hypoperfusion/hypoxia). However, with increased testing of lactic acid levels in ERs and hospitals, we are encountering a few cases of type B LA as well. Diagnosing the exact type is crucial because of differences in management. We here describe a patient with albuterol-induced type B LA, which resolved after discontinuing the albuterol breathing treatments.

Staphylococcus warneri: Skin Commensal and a Rare Cause of Urinary Tract Infection.

Coagulase negative Staphylococci often grow in cultures and form one of the most abundant flora among skin microbiome. It is important and challenging to identify and treat clinically significant infections caused by these organisms. Prosthetic devices, catheters and conditions causing immunocompromised states are the risk factors for such infections. We describe a case of clinically significant and symptomatic urinary tract infection (UTI) in a 65-year-old man with liver cirrhosis caused by Staphylococcus warneri which forms <1% of Staphylococcal skin flora. He was treated successfully with fluoroquinolone antibiotic based on culture results. It is important to understand potential of this organism to cause serious infections which warrant culture-directed antibiotic therapy.

Multiple Intracranial Tuberculomas with an Intra-medullary Spinal Cord Tuberculoma in a Pediatric Patient.

Central nervous system (CNS) tuberculosis (TB), caused by Mycobacterium tuberculosis (MT), is a severe form of TB, which presents as meningitis, cerebritis, abscesses, spinal tuberculous arachnoiditis, and rarely tuberculomas. CNS TB is prevalent in the underdeveloped or developing world and is common in malnourished, alcoholics, children, young adults, immunocompromised, and cancer patients. Intracranial tuberculomas (ICT) can present with symptoms and signs of focal neurological deficits with or without systemic manifestations. ICT is the least common presentation of CNS TB. Medical management with anti-TB drugs and steroids is the mainstay of treatment, while surgical intervention is usually reserved for refractory cases. Here, we present the case of a 10-year-old Indian American girl with headaches, diplopia, fever, and neck pain diagnosed with ICT and intramedullary spinal cord tuberculoma.

A Case of Histoplasmosis with Central Nervous System Relapse after Itraconazole Therapy Needs Further Research.

Central nervous system (CNS) histoplasmosis occurs in 5-20% of all cases and is most commonly seen in immunosuppressed patients who have acquired immunodeficiency syndrome (AIDS) or have received organ transplant. The prevalence of histoplasmosis in patients greater than 65 years old between the years of 1999-2008 in the state of Texas was about 2-3 cases per 100,000 patients year. Since 1990 with the discovery of Triazoles, itraconazole (ICZ) has become the standard initial and suppressive therapy in patients with mild-moderate histoplasmosis without CNS involvement. However, poor penetration of ICZ into the brain, in vitro fluconazole resistance and lack of controlled-trials pose challenge in the treatment of cerebral histoplasmosis.

Euglycemic Diabetic Ketoacidosis in a Young Pregnant Woman Precipitated by Urinary Tract Infection.

Diabetic ketoacidosis (DKA) is a life-threatening diabetic complication and medical emergency. Euglycemic DKA (EKDA) is a variant of DKA with normal range glucose levels. The condition can be difficult to diagnose due to the misleading euglycemic levels. Pregnancy, infection, low-calorie intake, and use of insulin are some of the common etiologies of EDKA. We report a case of a young, pregnant female, with type I diabetes mellitus, in her third trimester admitted with EKDA. The EKDA was triggered by urinary tract infection (UTI), and the patient had other etiologies that have predisposed her to EKDA. Along with the case presentation, we discuss the common etiologies, pathophysiology, and management of EKDA. Euglycemic DKA is a life-threatening emergency that needs to be recognized early and treated aggressively, especially in pregnant patients, to avoid deleterious effects to maternal and fetal health.

Isolated Area Postrema Syndrome Presenting as Intractable Nausea and Vomiting.

Neuromyelitis optica (NMO) is a disease of central nervous system, characterized by demyelination and axonal damage mostly involving optic nerves and spinal cord. Usually these patients present with symptoms related to optic neuritis or myelitis with a typical relapsing course. Some patients present with less common symptoms involving brain stem like nausea and vomiting, especially those involving area postrema (AP) located in dorsal medulla. International panel for NMO diagnosis revised criteria in 2015 and came up with a unifying term NMO spectrum disorders (NMOSD) instead of NMO. Patients with NMO having AP involvement are grouped under area postrema syndrome (APS). Usually patients with AP symptoms also have neurological symptoms upon presentation. Here we present a rare case of an NMO who presented with isolated APS with no other neurological symptoms.

Dahl's Sign: An Indicator of Severe Chronic Obstructive Pulmonary Disease.

Dahl's sign, a clinical sign in which areas of thickened and darkened skin seen on the lower thighs and/or elbows, is seen in patients with severe chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, congestive heart failure (CHF), and chronic moderate to severe persistent asthma. The aim of our present report is to create awareness and encourage providers to lay emphasis on physical examination in every medical examination that can give clues to the severity of the underlying disorder.

Hemichorea Induced by Non-ketotic Hyperglycemia in a Caucasian Woman.

Chorea is a disorder characterized by irregular, involuntary, hyperkinetic movements and has various causes. One unusual cause is hyperglycemia. This case involves a 76-year-old diabetic Caucasian female who developed gait disturbances, hemichorea of the face and limbs, and slurred speech over two to three weeks. She was found to have glucose level of 690 mg/dL with HbA1c of 14.7%. Head CT demonstrated hyperdensity in the left basal ganglia and mild involvement of right basal ganglia. Treatment with insulin alleviated her symptoms. The exact pathophysiology is unknown; however, many theories exist.

Calciphylaxis: A Deceiving Cellulitis.

Calciphylaxis is a rare and serious disorder seen most in end-stage renal disease (ESRD) patients on dialysis. It is associated with the calcium deposits in small and medium blood vessels of the skin and subcutaneous tissues resulting in painful skin lesions, plaques, ulcerations, gangrene, and secondary infections. The aim of our present report is to create awareness and encourage providers to consider calciphylaxis in the differential diagnosis of cellulitis in the appropriate clinical setting.

Hypertension and diabetes mellitus in adult and pediatric survivors of allogeneic hematopoietic cell transplantation.

Hypertension and diabetes are frequent early complications of allogeneic hematopoietic cell transplantation (HCT); however, their long-term outcomes are not well known. We conducted a retrospective cohort study to describe the risk factors and natural history of post-HCT hypertension and diabetes in 180 consecutive adult (n = 106) and pediatric (n = 74) allogeneic HCT recipients from 2003-2005 who had survived for 1 year post-HCT. The pediatric patients were less likely than the adult patients to have pre-HCT hypertension and diabetes, smoking history, or high-risk disease and more likely to receive myeloablative (MA) conditioning. All patients were followed until at least 2 years post-HCT; of these 1-year survivors, 156 (87%) were alive at 2 years. Acute or chronic graft-versus-host disease (aGVHD, cGVHD) occurred in 118 (66%) patients; of these, 24% received cyclosporine (CsA) for >12 months and 47% received prednisone for >12 months. Within 2 years post-HCT, 126 (70%) had hypertension and 54 (30%) had diabetes. Rates were similar for the adult recipients (hypertension, 68%; diabetes, 30%) and the pediatric recipients (hypertension, 73%; diabetes, 30%). At 2 years post-HCT, in the patients with hypertension, hypertension had not resolved in 34%, and among patients with diabetes, diabetes had not resolved in 32%. On multivariate analyses, exposure to CsA increased the risk of developing hypertension post-HCT (relative risk, 1.6; 95% confidence interval [CI], 1.1-2.5; P = .03), but did not affect its persistence at 2 years. Exposure to high-dose corticosteroids (cumulative prednisone dose of > 0.25 mg/kg/day) increased the likelihood of developing diabetes (relative risk, 3.6; 95% CI, 1.7-7.5; P < .01) and for having persistent diabetes at 2 years post-HCT (relative risk, 4.1; 95% CI, 1.0-18.2; P = .05). Hypertension and diabetes are frequent early complications of allogeneic HCT, but subsequently resolve in a large proportion of recipients in the first 2 years after transplantation. Continued monitoring and treatment of hypertension and diabetes is necessary in allogeneic HCT survivors, especially in those exposed to high doses of corticosteroids.