"I Can't Move My Arms and Legs": A Rare Cause of Hypokalemia-Induced Quadriparesis.

Hypokalemia is a relatively common electrolyte abnormality in hospitalized patients. Severe hypokalemia (<2.5 mEq/L) can lead to profound muscle weakness or paralysis, especially in the setting of acute onset of hypokalemia. Multiple mechanisms of hypokalemia have been described, such as decreased potassium intake, increased losses, and increased transcellular shift of potassium. Drugs can rarely cause hypokalemia by one of the above-mentioned mechanisms. Here, we report a case of cocaine use leading to severe hypokalemia manifesting as quadriparesis. The aggressive repletion of potassium led to a complete resolution of muscular weakness.

Peritonsillar Phlegmon: An Addition to the Spectrum of COVID-19.

The coronavirus disease 2019 (COVID-19) epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in December 2019 in Wuhan, China, then declared to be a pandemic associated with substantial morbidity and mortality. It has shown to exhibit a vast array of symptoms, among which fever, shortness of breath, and cough are the most commonly reported. Lymphadenopathy and tonsillar enlargement is a less common finding reported with this infection. This case describes a patient with tonsillar inflammation which was complicated by peritonsillar phlegmon, with negative throat culture and positive COVID-19 test, suggesting a COVID-19-related etiology of the disease. After the literature search, to the best of our knowledge, this is the first reported case of COVID-related peritonsillar inflammation and phlegmon formation.

Hypercalcemia Due to Paraneoplastic Production of 1,25- Dihydroxyvitamin D in a Young Female with Dysgerminoma.

Humoral hypercalcemia of malignancy (HHM) can be caused by ectopic paraneoplastic production of 1, 25 dihydroxy vitamin D due to the hyperactivity of the 1 alpha-hydroxylase enzyme. We present a case of a 19-year-old female who was admitted with bilateral dysgerminomas and significant hypercalcemia. Hypercalcemia was initially managed medically and then resolved with the surgical resection of the tumors. Although most cases are attributed to a high parathyroid hormone-related peptide (PTHrP) and bone metastases, <1% of cases can result from paraneoplastic production of 1,25 dihydroxyvitamin D due to increased activity of 1 alpha-hydroxylase.This is one of the rare cases of hypercalcemia, which not only adds to the limited number of cases of hypercalcemia associated with dysgerminoma but also is the first case report showing that vitamin D can be a paraneoplastic factor itself.

Dapagliflozin-induced Late-onset Euglycemic Diabetic Ketoacidosis.

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a class of oral hypoglycemics that improve glycemic control by increasing the urinary excretion of glucose. They gained widespread popularity because they not only showed improved glycemic control but also had a favorable effect on weight loss, blood pressure, and cardiovascular mortality. One of their rare side effects is euglycemic diabetic ketoacidosis (eDKA) although the diagnosis is sometimes difficult to make due to near-normal glucose levels. We present a case of eDKA in a patient who presented with confusion, acute kidney injury (AKI), and metabolic acidosis after having an influenza-like illness with a minimally elevated blood glucose of 187 mg/dL. She had already stopped taking dapagliflozin (an SGLT-2 inhibitor) two weeks before the presentation. She was initially treated as sepsis and required hemodialysis. Later on, metabolic acidosis was attributed to eDKA from dapagliflozin, which resolved after the administration of intravenous insulin. Her eDKA developed while she had already stopped dapagliflozin two weeks ago, which makes this an interesting case finding. It is one of those rare cases where dapagliflozin led to a delayed complication of eDKA.

Non-Sustained Ventricular Tachycardia as a Sign of Lung Cancer.

The leading cause of death due to malignancy in the USA is lung cancers. They can be divided into small cell lung cancer and non-small cell lung cancer. Of the latter, adenocarcinoma comprises the majority of lung cancers. Manifestations of lung cancer can be divided into thoracic, extra-thoracic and paraneoplastic syndromes. We describe a case of ventricular tachycardia in a patient who presented with dysphagia, ultimately found to have a non-small cell lung cancer invading the esophagus and heart.

Nivolumab-induced adrenalitis.

Immune checkpoint inhibitors (ICIs) are an evolving class of drugs for the treatment of various cancers; for example, their use is recommended as a second-line chemotherapy for non-small cell lung cancer. With the expanding use of ICIs, we are discovering their unique side effects, called immune-related adverse events (irAEs), which can impair gastrointestinal, hepatic, dermatological, endocrine and other systems. Nivolumab is an ICI that blocks the human programmed death receptor-1 (PD-1) on T cells to prevent the interaction between the receptor, PD-1, and human programmed death ligand-1 expressed on tumour cells. Here, we report a case of a 65-year-old woman with recurrent lung adenocarcinoma who was treated with nivolumab and developed immune-related adrenalitis, which was managed with hydrocortisone and fludrocortisone. This case highlights the importance of understanding the irAEs of ICIs to allow prompt recognition and management of life-threatening complications of the treatment.

A Case of Fibroelastoma with Widespread Embolism to the Brain, Kidney, and Spleen.

Cardiac papillary fibroelastoma (CPF) is the second most common primary cardiac tumor, which is diagnosed incidentally or with embolic phenomena, mostly in the form of a transient ischemic attack (TIA) and stroke. We present a case of a 58-year-old female who presented with fatigue and low-grade fever and was found to have multiple systemic infarcts. Her blood cultures and transthoracic echocardiography (TTE) were negative, ruling out infective endocarditis. However, transesophageal echocardiography (TEE) revealed a mobile mass at the aortic valve. The mass was surgically removed, and the aortic valve was repaired. The histological examination of the mass finally revealed a papillary fibroelastoma. To our knowledge, this is the first reported case where fibroelastoma presented with splenic and renal infarcts in combination with the cerebral infarcts. Since cardiac fibroelastoma can cause embolization to the cerebral, splenic, and renal vessels, we, therefore, advocate that it should be considered as one of the possible causes of widespread embolism. We also stress upon the importance of doing TEE in case of a suspected cardiac mass, as the TTE is more likely to give false-negative results.

Sudden death due to pulmonary embolism after minor ankle surgery.

Venous thromboembolism prophylaxis guidelines are clear for major orthopaedic surgeries, but data regarding ankle surgery are insufficient. Death from pulmonary embolism (PE) after ankle surgery is rare with the frequency of less than 0.037%. 1 We present a case of a fatal PE after ankle surgery to raise awareness about this rare but potentially fatal complication. Our patient had a left ankle fracture status postsurgical fixation and was discharged without venous thromboembolism (VTE) prophylaxis. Twenty days later, she presented with a sudden onset of dyspnoea and palpitations and was diagnosed to have extensive right-sided PE. Intravenous heparin and thrombolytics were given, but she had multiple pulseless electrical activity arrests, developed disseminated intravascular coagulation and died. Our case depicts an unusual complication of ankle surgery and highlights the importance of considering VTE as one of the complications. Medical personnel should evaluate the need for VTE prophylaxis after ankle surgery on a case to case basis.