A 58-Year-Old Woman with Gallstones, Chronic Pancreatitis, and Pancreatic Pseudocyst Presenting with Pleural Effusion Due to a Pancreaticopleural Fistula.

BACKGROUND Pancreaticopleural fistula (PPF) is a rare complication of acute and chronic pancreatitis. PPF results from the release of pancreatic enzymes, either from a damaged pancreatic duct or pancreatic pseudocyst. This report is of a 58-year-old woman with a history of chronic pancreatitis associated with gallstones who had a known pancreatic pseudocyst that was being managed conservatively and who presented to the Emergency Department with pleural effusion due to a PPF. CASE REPORT A 58-year-old woman with past medical history of gallstone pancreatitis with subsequent development of pancreatic pseudocyst (being managed conservatively) presented with a 2-week history of progressive exertional shortness of breath. Physical examination indicated decreased breath sounds on the right lower lung fields. A chest X-ray revealed possible subphrenic free air. Laboratory test results were unremarkable except for elevated D-dimer levels. Computed tomography angiography revealed a large right-sided pleural effusion, which led to thoracentesis and the results illustrated elevated amylase levels. Magnetic resonance cholangiopancreatography was done, which showed pancreatic pseudocyst and possibly a fistula. Pancreatic enzymes were not checked in pleural fluid, as diagnosis was established with the presence of amylase and imaging findings. The patient felt better clinically after thoracentesis with volume removal and was discharged. She later underwent endoscopic ultrasound, which revealed a pancreatic duct leak requiring stent placement. CONCLUSIONS Pleural effusions rarely occur secondary to PPF. Physicians must be wary of the presentation, especially in patients with a history of a conservatively managed pancreatitis pseudocyst. Early diagnosis and management can lead to prevention of long-term morbidity and mortality.

Hypercalcaemia Caused by Sunflower Seeds and Calcium Carbonate Supplements.

INTRODUCTION: Hypercalcaemia is commonly associated with malignancy or endocrinological disorders. However, sometimes it can occur due to increased oral intake of calcium. We present an interesting case of hypercalcaemia due to ingestion of sunflower seeds and calcium carbonate supplements. CASE DESCRIPTION: We present the case of a 53-year-old man with history of T-cell lymphoma and gastroesophageal reflux disease who was brought to the emergency room due to altered mental status, nausea, vomiting and abdominal pain. His calcium level was 3.30 mmol/l (normal value 2.23-2.58 mmol/l). Imaging studies were unremarkable. The patient was hydrated with normal saline and calcium levels improved. Once he was more coherent, he disclosed that he had consumed significant amounts of sunflower seeds and calcium carbonate supplements, which were considered to be the cause of his hypercalcaemia. CONCLUSION: Hypercalcaemia is common and can lead to critical illness. Although hypercalcaemia is frequently associated with endocrinological disorders, sometimes the presentation is secondary to increased intake. The consumption of sunflower seeds and antacids containing calcium carbonate can cause symptomatic hypercalcaemia. It is important to recognize rare causes of hypercalcaemia in order to treat it in a timely manner and prevent recurrence. LEARNING POINTS: Hypercalcaemia can occur due to excessive intake of sunflower seeds and calcium carbonate supplements.Hydration and cessation of oral supplements can result in rapid reversal of hypercalcaemia.It is important to obtain a complete history in order to determine the aetiology of hypercalcaemia.

A Case of Evans Syndrome and Unstable Angina.

Evans syndrome (ES) is characterized by autoimmune hemolytic anemia (AIHA) and immune-mediated thrombocytopenia. It is more common in the pediatric population than in adults. ES has been reported to be associated with thrombotic events and rarely can lead to acute coronary syndrome (ACS). There have been only a few reported cases of ACS secondary to ES. We present an interesting case of ES with unstable angina (UA) which had a limited response to oral and intravenous (IV) steroids requiring rituximab. A 64-year-old male with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus and coronary artery disease, presented to the emergency room complaining of a 2-week history of chest pain, shortness of breath and hematuria. Physical examination indicated splenomegaly but was otherwise unremarkable with no petechiae or rash. Labs showed hemoglobin of 9.6 g/dL, platelet count 58 × 103/µL, troponin < 0.03 ng/mL, lactic acid 2.5 mmol/L and with parameters indicative of hemolysis, evidenced by elevated lactate dehydrogenase, low haptoglobin and elevated bilirubin levels. Electrocardiography (EKG) demonstrated ST depression in leads I, aVL, V5 - V6 and T wave inversions in lead III and aVL, which were new compared to previous EKG. Peripheral blood smear indicated spherocytes. Direct antiglobulin test was positive for immunoglobulin G (IgG). Patient was admitted for ES and initially treated with oral prednisone 80 mg daily. He was also diagnosed with UA thought to be possibly secondary to ES. He then underwent cardiac stress test which showed mild reversible inferior apical ischemia. Cardiac catheterization revealed 95% stenosis of proximal left circumflex artery requiring single drug eluding stent placement and dual antiplatelet therapy. Patient continued to have anemia despite blood transfusions, although platelet count improved. Prednisone was transitioned to high-dose IV dexamethasone, and patient was also started on rituximab which resulted in stabilization of anemia. The presentation of ES with ACS is a rare occurrence. ACS can be challenging to manage as stent placement may be required followed by dual antiplatelet therapy. Treatment of ES involves steroids followed by rituximab, IV immunoglobulin (IVIG) or splenectomy for non-responsive cases. Early intervention and management can prevent mortality and morbidity.

ADDITION OF DULAGLUTIDE FOR A HIGH-DOSE INSULIN REQUIRING PATIENT WITH TYPE 2 DIABETES MELLITUS: A REMARKABLE RESPONSE.

OBJECTIVE: Despite the availability of several new classes of antidiabetic medications, a large proportion of patients with diabetes mellitus fail to achieve optimal glycemic control. Adding glucagon-like peptide-1 receptor agonists (GLP1 RAs) to basal insulin regimens has shown to improve glycemic control in type 2 diabetes mellitus (T2DM). METHODS: We present a patient with T2DM who had marked improvement in glycemic control accompanied by weight loss and a decrease in insulin requirement after adding weekly dulaglutide to U500 regular insulin. RESULTS: A 56-year-old man with T2DM, class III obesity (weight 314 pounds, body mass index 46.4 kg/m2), and hyperlipidemia had uncontrolled glycemia with a hemoglobin A1c (HbA1c) of 9.7% (83 mmol/mol) despite using high-dose insulin therapy and metformin. Physical examination was unremarkable except for obesity. His HbA1c remained high despite increments in insulin dosage up to 400 units per day. A few months after adding dulaglutide to his regimen, the patient's HbA1c declined to 6.3% (45 mmol/mol) despite significant reduction in daily insulin dosage to 20 units (94% decrease), which was accompanied by a 20-pound weight loss. CONCLUSION: The patient had a dramatic decrease in HbA1c, weight, and insulin requirement after treatment with dulaglutide. In the literature we could only find 1 study where a GLP1 RA (liraglutide) was successfully used in 15 patients receiving U500 insulin (average dose 197 ± 72 units/day). However, their reductions in weight and HbA1c were markedly less than observed in our patient. GLP1 RAs should be considered in patients with T2DM who require high-dose insulin therapy.

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PATIENTS REFERRED TO PSYCHIATRIC UNIT IN A TERTIARY CARE HOSPITAL.

BACKGROUND: Very few studies from Pakistan have examined the profile of patients seen by psychiatrists in general hospital. The aim of this research is to describe the clinical and demographic characteristics of patients referred to the psychiatric unit of a general hospital over a one year period. METHODS: This cross-sectional study was conducted at the Ayub Teaching Hospital, Abbottabad, from January 1st to December 31st 2012. All patients being referred to psychiatry were included in the study over one year period. The information was recorded on a structured questionnaire and analysed the data using SPSS-19.0. RESULTS: Out of the 105 patients referred to the psychiatric unit, 74 (72.3%) were females. A total of 69 (68.5%) patients were married. More than half were uneducated and only number 4 (3%) patients had university qualification. Housewives made up 64.4% of the patient population followed by students (11%). Majority 55 (53%) had less than Rs. 5000/ monthly income. About 30% patients were shifted to psychiatry ward while, nearly one tenth were discharged. In 35% cases the psychiatrist was asked to help in the management, while in 50% cases only opinion was sought. Aggressive and threatening behaviour was source of concern in majority of patients for the primary team while 34% exhibited suicidal behaviour. Depression was most frequent diagnosis in 45 43% patients, followed by conversion disorder 19 (17%) and delirium 16 (14%). CONCLUSION: The rate of psychiatric referrals is dismal with only one third of the patients being transferred to the psychiatric ward. The major psychiatric diagnosis was depression. Patients with aggressive and threatening behaviour were more frequently referred.