A Case of Chronic Wernicke Encephalopathy (WE): An Underdiagnosed Phenomena.

Wernicke encephalopathy (WE) is the most common neurological complication of thiamine deficiency in patients who have a background of chronic alcohol use disorder. WE is characterized by acute onset of confusion, gait ataxia, and oculomotor dysfunction. Prompt treatment with parenteral thiamine leads to improvement. Untreated WE has mortality rates of up to 20% and many cases progress to the more chronic Korsakoff syndrome. Cases of untreated WE in which symptoms last beyond the acute phase and become chronic are rarely found in the literature. Here, we present a case of a 64-year-old female having a background of chronic alcohol use disorder presenting with symptoms of gait ataxia, recurrent falls, and decreased concentration. These symptoms had progressed over a period of nine months. The patient was seen by her family physician and several specialists undergoing many diagnostic studies with inconclusive results. Ultimately, with a high index of suspicion for thiamine deficiency, she was admitted for IV thiamine treatment. Upon follow-up in the clinic, the patient reported improvement in her balance and concentration further confirming the initial suspicion of WE with thiamine deficiency as the cause of her symptoms. This case corroborates the existence of WE as a chronic phenomenon in addition to the more commonly reported acute WE. Furthermore, this case highlights the importance of recognizing WE as a potential cause of chronic neurological symptoms in people with alcohol-related disorders and the role of IV thiamine in treatment.

Spontaneous Retroperitoneal Hematoma: A Rare Presentation of Polyarteritis Nodosa.

Spontaneous retroperitoneal hematoma is a rare clinical entity that is most commonly caused by renal tumors and vascular disease. In this article, we present a case of spontaneous retroperitoneal hemorrhage caused by polyarteritis nodosa in a patient who presented with severe left flank pain. He underwent computed tomography angiography of his abdomen that showed left retroperitoneal hematoma, which was followed by arteriogram that showed multiple bilateral renal artery aneurysms with active extravasation, findings consistent with polyarteritis nodosa. The patient underwent successful coiling of the bleeding vessel that secured the bleeding and was started on high-dose prednisone, which resulted in resolution of his symptoms.

A Rare Case of Raoultella planticola Urinary Tract Infection in a Patient With Immunoglobulin A Nephropathy.

Raoultella planticola is a gram-negative, aerobic, nonmotile mostly found in environments with high prevalence in soil and water. This organism is a very rare human pathogen as only 29 cases of Raoultella planticola-related infections have been reported until 2017, with only 7 cases in the United States. Only 3 cases of urinary tract infection secondary to R planticola have been reported, 1 in a pediatric patient and 2 in adults. In this article, we present a case of R planticola urinary tract infection in a 65-year-old male with immunoglobulin A nephropathy. On investigation, the patient was found to be septic and empirical antibiotic was started for gram-negative coverage. The patient showed remarkable improvement and discharged on oral antibiotic for 7 days. R planticola rarely cause infection in humans, with overall good prognosis.

Clostridium difficile Colitis Leading to Reactive Arthritis: A Rare Complication Associated With a Common Disease.

The relationship between reactive arthritis and enteric infections caused by Yersinia enterocolitica, Campylobacter jejuni, and Salmonella typhimurium is well documented. Clostridium difficile colitis is a less recognized cause of reactive arthritis. We present a case of a 58-year-old woman with Clostridium difficile colitis complicated by reactive arthritis. A 58-year-old woman with no significant past medical history presented to our hospital with complaints of nonbloody watery diarrhea, abdominal pain for the past 1 week, and right knee pain starting 1 day prior. The patient had recently used antibiotics for a respiratory tract infection. On examination, the patient had a swollen and erythematous right knee. While in the hospital the patient also developed a similarly painful and swollen left knee. The patient was found to be positive for C difficile toxin in stool. Synovial fluid analysis of both the knee joints revealed a sterile and inflammatory fluid, negative for crystals and showing no growth on gram stain. We diagnosed the patient with reactive arthritis secondary to C difficile colitis once all other causes of the bilateral knee joint symptoms were ruled out with appropriate laboratory and imaging studies. Treatment with oral vancomycin and an anti-inflammatory was initiated, and the patient had complete resolution of symptoms. This case illustrates the importance of recognizing C difficile colitis as a potential differential for reactive arthritis under the appropriate circumstances. The treatment of reactive arthritis is mainly supportive and treating the underlying cause, which happens to be C difficile in this case.

Opana ER (Oxymorphone)-Induced Thrombotic Microangiopathy: An Atypical Presentation in a Patient With Hepatitis C.

Oxymorphone is a semisynthetic extended release opiate used to treat moderate to severe chronic pain. The Food and Drug Administration approved the oral form of oxymorphone available as Opana and Opana ER (extended release) since 2006. The Food and Drug Administration and the Centers for Disease Control and Prevention issued warning against intravenous use of Opana ER. We are presenting a case report of a 37-year-old female with a history of active intravenous drug abuse who presented to our hospital with acute kidney injury. Urinalysis showed red blood cell sediments, many dysmorphic red blood cell casts along with nephrotic range proteinuria of 12 g/deal per day. Kidney biopsy showed microscopic thrombotic microangiopathy (TMA) involving glomeruli and vessels. Further workup was undertaken for TMA, and apart from mildly elevated lactate dehydrogenase of 380 (normal <243), active hepatitis C, and slightly low ADAMTS-13 (55%), there was no other laboratory evidence of TMA. On literature search, we found that intravenous injection of chronic Opana ER has been reported to cause TMA resulting in chronic kidney disease. Our patient also admitted to use of intravenous Opana ER abuse for the past 5 years. She had a normal platelet count and an absence of schistocytes, which makes it an atypical presentation of TMA resulting in chronic kidney disease in an opiate user. We strongly urge physicians to avoid prescribing opiates for chronic pain, especially Opana ER, which if injected intravenously for recreational purposes can lead to serious side effects like TMA. Treatment is mainly supportive and avoidance of drug in future.

A Rare Case of Sphingomonas paucimobilis Meningitis in the Absence of Cerebrospinal Fluid Pleocytosis.

Sphingomonas paucimobilis is a nonfermentative gram-negative bacillus of low pathogenicity. The organism has been involved in causing a wide range of infections in community and hospital settings. Only 3 cases of meningitis caused by this organism have been reported so far. We report a rare case of S paucimobilis meningitis who presented with atypical symptoms. A 50-year-old female presented with headache, dizziness, chills, shakiness, and neck pain along with nuchal rigidity. On physical examination, severe neck rigidity along with decreased range of motion was noticed. Her cerebrospinal fluid showed gram-negative rods, and she was started on meropenem. The cerebrospinal fluid grew S paucimobilis sensitive to meropenem. She subsequently showed significant improvement and was discharged home on intravenous meropenem for 21 days and showed complete recovering in 5 weeks.

Invasive Listeria monocytogenes Gastroenteritis Leading to Stupor, Bacteremia, Fever, and Diarrhea: A Rare Life-Threatening Condition.

Listeria monocytogenes is a gram-positive, rod-shaped organism that can cause serious infections such as meningitis, invasive gastroenteritis, and endocarditis. Every year 1600 people in the United States are affected, with significant mortality of 260 people annually. Listeria gastroenteritis has the third highest mortality rate among all the food-borne infection. Invasive listeriosis most commonly affect pregnant women, those in extremes of ages, people with comorbid diseases, and people with weakened immune response. In this article, we present a rare case of invasive Listeria gastroenteritis in an 83-year-old female with multiple comorbid conditions and past medical history of type 2 diabetes mellitus and multiple risk factors who was brought to the hospital with altered mental status. She had history of fever, abdominal pain, and watery diarrhea up to 14 episodes in 24 hours for the last 7 days. Her stool culture grew Listeria monocytogenes sensitive to penicillin. She was started on penicillin for 2 weeks. She had subsequently complete resolution of fever, diarrhea, and abdominal pain. High index of suspicion is the key to ensure timely initiation of appropriate empirical treatment in the setting of invasive gastroenteritis, especially in people who have high risk factors for listeriosis. We recommend raising awareness in the health care profession about invasive listeriosis in the need of time. Intravenous ampicillin or penicillin G is the treatment of choice, with meropenem as an alternative.