Acquired Thrombotic Thrombocytopenic Purpura (TTP) Presenting With Synthetic Cannabinoid Use.

Synthetic cannabinoids (SCs) have become commercially available throughout the United States as manufacturers circumvent regulations with labels stating "not for human consumption" with misleading advertisements, resulting in the consumption of products that are not safe or regulated. We present a case report of a middle-aged woman exhibiting altered mental status secondary to SC use who was found to have severe thrombocytopenia and hemolytic anemia. She was later confirmed to have thrombotic thrombocytopenic purpura (TTP) through ADAMTS13 testing. TTP is one of several platelet-related disorders presenting with findings of hemolytic anemia and thrombocytopenia. The presence of altered mental status is typically used as a symptomatic differentiator between hemolytic uremic syndrome, immune thrombocytopenic purpura, and TTP. SCs can cause superimposed altered mental status, which, in the setting of a concomitant platelet disorder, can complicate the standard workup and prolong the time to a final diagnosis. This case serves as an essential reminder that collecting detailed social history and promptly recognizing laboratory abnormalities is critical for early recognition of TTP, as the diagnosis is time-sensitive and delays in recognition can lead to significant morbidity and mortality.

Severe Hyponatremia (96 mmol/L) Secondary to Primary Polydipsia and Pneumonia.

A 63-year-old man who presented to the hospital with altered mental status and decreased responsiveness was found to have severe symptomatic hyponatremia with a sodium level of 96 mmol/L and pneumonia. The patient was admitted to the medical intensive care unit for septic shock and acute severe hyponatremia. He was intubated for airway protection, and treated with 3% hypertonic saline bolus and antibiotics. After four days, sodium levels were corrected to 128 mmol/L, and the patient was extubated and downgraded to the medical floor. This case demonstrates one of the lowest recorded sodium lab values ever and the patient was successfully treated and discharged home with appropriate outpatient appointments.

A Neurosyphilis Case Mimicking Herpes Simplex Virus Encephalitis in an African American Male.

Neurosyphilis is one form of a multisystemic sexually transmitted disease caused by Treponema pallidum. Although typical presentations of neurosyphilis have become less common in the post-antibiotic era, a rising trend of atypical presentations can mimic other diagnoses like herpes simplex and autoimmune encephalitis. In this case, we diagnosed neurosyphilis in a patient with clinical and radiological features similar to herpes simplex encephalitis. We emphasize the need for a diagnostic approach combining imaging namely MRI, lumbar puncture, and use of treponemal and non-treponemal tests so that neurosyphilis cases with atypical neuroimaging findings are not overlooked.

Altered Mental Status in an Octogenarian: How Frequently Should Serotonin Syndrome Be Considered?

Serotonin toxicity, an adverse consequence of elevated serotonin levels in the brain, poses a considerable threat to life. Antidepressants, frequently prescribed for various conditions in older adults, such as depression, anxiety, and sleep disturbances, significantly contribute to this risk. The elderly are particularly vulnerable due to multiple comorbidities, cognitive decline, medication interactions, polypharmacy, and chronic kidney disease. This case underscores the critical importance of considering serotonin syndrome as a potential diagnosis in patients using serotonin and norepinephrine reuptake inhibitors, especially within vulnerable populations. Here, we present the case of an 89-year-old female who presented with altered mental status and a hypertensive emergency. Following a thorough examination and exclusion of alternative causes of acute encephalopathy, serotonin syndrome induced by the use of venlafaxine and oxycodone was diagnosed.

An Abnormal Presentation of Rocky Mountain Spotted Fever: A Case Report.

The intracellular coccobacilli Rickettsia rickettsii causes Rocky Mountain Spotted Fever, a potentially fatal illness. This bacterium is transmitted to humans through a tick vector. Patients classically present with a triad of symptoms, including fever, headache, and a rash that begins on the extremities and spreads proximally to the trunk. Diagnosis of this disease can prove difficult when patients have unusual symptoms, such as hypertensive crisis. In this case report, we present a 29-year-old male who arrived at the emergency room with altered mental status and a hypertensive crisis after his family reported one week of changes in his behavior. The patient had no evidence of ticks, tick bites, fever, or rash. Positive findings in the emergency room included a WBC of 14.9 × 109. All other physical exams, imaging, and laboratory findings were non-contributory. The patient was promptly given IV hydralazine to control his blood pressure and empiric IV ceftriaxone for potential infection, and he was admitted for observation. Over the course of three days, WBC levels decreased, and his altered mental status improved. On day 3, the patient remembered a tick crawling across his hand, and this prompted the ordering of immunoglobulin levels for tick-borne illnesses. IgM for RMSF was positive. This case presentation illustrates the need for clinicians to keep the potential diagnosis of RMSF high on the differential, even in the presence of a paucity of symptoms, as prompt treatment with doxycycline can be lifesaving. This case may also be one of the first reported in the literature of hypertension being a symptom of Rocky Mountain Spotted Fever. It is plausible, however, that this patient's hypertension was due to an acute stress response.

A Rare Case of Varicella-Zoster Virus Encephalitis Presenting With Lost Ability to Play the Piano in an Immunocompetent Pediatric Patient.

Varicella-zoster virus (VZV) is a member of the alpha-herpesvirus family, which can occasionally cause severe neurological complications such as encephalitis. In this case report, we discuss a rare finding of VZV encephalitis in which an immunocompetent pediatric patient, vaccinated against varicella, presented with altered mental status and no vesicular rash. A 15-year-old male presented to the Emergency Department with progressively worsening altered mental status over the past three days. The patient's mother stated that he was exhibiting frequent memory lapses as well as the sudden loss of the ability to play the piano. After admission to the pediatric general floor, lumbar puncture was performed and cerebrospinal fluid analysis returned positive for VZV, confirmed by polymerase chain reaction. The patient was then started on intravenous (IV) acyclovir at a dose of 650 mg every 8 hours to treat VZV-induced encephalitis. While the patient continued to have intermittent episodes of confusion and headaches, his overall condition improved, and by day 4, he was able to resume playing the piano and ukulele. The patient was discharged on day 8 with no home medications, and a follow-up with this primary care physician was scheduled. This patient is one of only four recorded cases of VZV encephalitis in immunocompetent children. It is extremely rare to encounter pediatric patients with this diagnosis and, as such, can elude physicians when developing differential diagnoses. If VZV is suspected, a lumbar puncture should be performed promptly, and, if confirmed, IV acyclovir should be started. Furthermore, this case highlights the need for future research with regard to VZV and potential predisposing factors in immunocompetent patients.

Heroin Inhalation Leukoencephalopathy: An Overlooked Entity in the Opioid Epidemic.

Heroin inhalation leukoencephalopathy (HIL) is a rare complication of vaporized heroin inhalation leading to white matter degeneration resulting in a range of neurologic disturbances including softened speech, cerebellar ataxia, behavioral changes, cerebellar gait abnormalities, and even respiratory failure resulting in death in the most severe cases. Magnetic resonance imaging (MRI) most commonly demonstrates bilateral hyperintensities affecting the basal ganglia, periventricular white matter, and cerebellum. In this case report, we present a relatively mild case of HIL in a young female patient to describe the characteristic challenges associated with the condition's presentation, diagnosis, and treatment. While healthcare workers everywhere are addressing a complex and ever-changing opioid epidemic, we strive to raise awareness about HIL as only one of a variety of complications resulting from opioid use disorder.

Steroid-Responsive Encephalopathy Associated With Autoimmune Thyroiditis Masquerading Sepsis.

A 72-year-old male presented with a fever and altered mental status. While initially diagnosed with sepsis due to cholangitis, he continued to decline and had seizures that complicated the course. After extensive workup, he was found to have anti-thyroid peroxidase antibodies and diagnosed with steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT). He showed remarkable improvement with glucocorticoids and intravenous immunoglobulins. SREAT is a rare autoimmune encephalopathy characterized by elevated serum titers of antithyroid antibodies. SREAT needs to be listed as a differential diagnosis in a patient with encephalopathy of unclear causes, and the presence of antithyroid antibodies is a hallmark of the entity.

Atypical Presentation of Carbon Monoxide Poisoning With Aphasia.

We present a patient with carbon monoxide poisoning with a single focal neurological deficit. The patient was found by emergency medical services (EMS) to be resting in his truck with a generator running nearby. On arrival, the patient was hemodynamically stable. The patient was aphasic but did not exhibit any other focal or lateralizing deficits. He was able to communicate by writing clearly and coherently on a sheet of paper. His initial carboxyhemoglobin was 29%, confirming the diagnosis of carbon monoxide poisoning. He was treated with 100% O2 via a non-rebreather mask and regained his speech during his ED (emergency department) course. The patient was ultimately hospitalized for continued oxygen treatment and serial examinations. This case highlights the varied presenting symptoms of carbon monoxide poisoning as well as the importance of including a broad differential diagnosis while working up patients with a focal neurologic deficit.

Looking Beyond the Bleed: A Case Report.

Cerebral venous thrombosis (CVT) can be one of the most challenging diagnoses to make in a patient with an undifferentiated headache. A missed diagnosis of the condition can lead to catastrophic consequences, as seen in the case described here. There needs to be a high index of clinical suspicion for CVT as the diagnosis involves imaging modalities that are not frequently used in the emergency setting. This case report demonstrates how the classic avenues of headache workup can miss this diagnosis. It also illustrates how delayed diagnosis can present in the extremis and have unsalvageable outcomes.

Unexplained Bromide Toxicity Presenting as Hyperchloremia and a Negative Anion Gap.

A high serum bromide level can cause erroneously high serum chloride levels measured through routine assays. Here, we describe a case of pseudohyperchloremia in which routine labs showed a negative anion gap and elevated chloride levels measured with ion-selective assay. The serum chloride level was found to be lower when measured with a chloridometer that employs a colorimetric method of quantification. The initial serum bromide level was elevated at 1100 mg/L that was confirmed by repeating the test that again showed an elevated level of 1600 mg/L and appeared to cause erroneous hyperchloremia when using conventional serum chloride quantification methods. Our case highlights lab errors and factitious hyperchloremia as a cause of the negative anion gap caused by bromism, even without a clear history of bromide exposure. The case also underscores the importance of chloride measurement using both colorimetric methods and ion-selective assay in the case of hyperchloremia.

Distinguishing Curable from Progressive Dementias for Defining Cancer Care Options.

The likelihood of a diagnosis of dementia increases with a person's age, as is also the case for many cancers, including melanoma and multiple myeloma, where the median age of diagnosis is above 60 years. However, patients diagnosed with dementia are less likely to be offered invasive curative therapies for cancer. Together with analysis of diet and medication history, advanced imaging methods and genetic profiling can now indicate more about syndromes causing the neurological symptoms. Cachexia, malnutrition, dehydration, alcohol consumption, and even loneliness can all accentuate or cause the "3Ds" of dementia, delirium and depression. Many common drugs, especially in the context of polypharmacy, can cause cognitive difficulties resembling neurodegenerative disease. These syndromes may be reversed by diet, social and caregiver changes, and stopping potentially inappropriate medications (PIMs). More insidious are immune reactions to many different autoantigens, some of which are related to cancers and tumors. These can induce movement and cognitive difficulties that mimic Alzheimer's and Parkinson's diseases and other ataxias associated with aging. Paraneoplastic neurological syndromes may be reversed by directed immunotherapies if detected in their early stages but are best treated by removal of the causative tumor. A full genetic workup should be done for all individuals as soon as possible after diagnosis, to guide less invasive treatments suitable for frail individuals. While surgical interventions may be contraindicated, genetic profile guided immunotherapies, oral treatments, and radiation may be equally curative in a significant number of cancers.

Bilateral Stroke: A Case Report.

We present the case of a 74-year-old woman, functionally independent in her daily activities, with a medical history notable for hypertension and dyslipidemia. She presented to the emergency room with an altered level of consciousness, opening her eyes only to pain, no verbal response, and flexion withdrawal from pain coupled with a Glasgow Coma Scale of 7. The intensive care unit was promptly summoned, and the patient was intubated and admitted to intensive care. Comprehensive laboratory assessments revealed no abnormalities and an initial cerebral CT scan showed no acute changes. A subsequent CT scan performed 24 hours post-event disclosed bilateral ischemia affecting the territories of the anterior and middle cerebral arteries. Regrettably, this catastrophic event precluded any potential for recovery. Consequently, the decision was made not to pursue further investigations to determine the underlying cause. The medical team opted for supportive treatment and comfort measures. Tragically, the patient died on the 37th day of hospital admission.

A Unique Case of Hypothyroidism Causing Pancytopenia With Literature Review.

Severe endocrinopathies can lead to pancytopenia. Hypothyroidism can affect any organ system including hematopoietic, resulting mainly in a normochromic normocytic anemia. Rarely, in severe hypothyroidism, all hematopoietic cell lines can be affected, resulting in pancytopenia. We, hereby, would like to discuss a case of hypothyroidism with worsening pancytopenia, which gradually improved after repletion with levothyroxine. Although pancytopenia is not a common feature of hypothyroidism, this case highlights the importance of hypothyroidism being considered as one of the differentials.

COVID-19 Encephalopathy Presenting As New-Onset Seizure: A Case Report.

Since its outbreak, it's been well-documented that coronavirus disease 2019 (COVID-19) can present with wide variety of neurological manifestations in absence of the usual respiratory symptoms. We report one such severe neurological manifestation of SARS-CoV-2 infection. To our knowledge, this is the first reported case of COVID-19 encephalopathy with CSF and MRI findings in the United Arab Emirates. We present a case of a 52-year-old female who presented with complaints of altered mentation, anosmia, headache, dizziness, weakness, lethargy, and vomiting. While in the emergency department she developed two generalized tonic-clonic seizure episodes, a more pronounced delirium, and tachypnea which required intubation. She was then admitted to the intensive care unit (ICU). She was COVID-19 positive and subsequent MRI revealed encephalopathy. She was discharged from ICU and was under long-term care at the time of case documentation.

Severe Agitation as an Unusual Presentation of Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children (MIS-C) is a rare hyperinflammatory syndrome that mainly affects children after a primary infection with coronavirus disease 2019 (COVID-19), with the possibility of severe and lethal complications. We report a case of a unique presentation of MIS-C in a four-year-old boy who presented with severe agitation, muscle spasms, and two days of fever. Other findings consistent with MIS-C were revealed later, and he was managed with intravenous immunoglobulin (IVIG) and steroids. He showed a dramatic response of improvement and was discharged. This case report aimed to raise health professionals' awareness about the atypical presentations of MIS-C and the importance of early diagnosis, treatment, and follow-up MIS-C cases to avoid complications affecting children's lives.

Ornithine Transcarbamylase Deficiency Presenting as Acute Encephalopathy After Strabismus Surgery.

Acute encephalopathy with an unclear etiology is a common presentation to the hospital. We describe the case of a 50-year-old male who presented with a one-day history of slurred speech, nausea, insomnia, and altered mental status. His surgical history was notable for a strabismus surgery two days ago. He presented with elevated ammonia levels that continued to increase. Metabolic studies were suggestive of hyperammonemia secondary to ornithine transcarbamylase (OTC) deficiency triggered due to fasting prior to the strabismus surgery. OTC gene sequencing confirmed the diagnosis of OTC deficiency. We summarize the current case reports in the literature and review the treatment options for OTC deficiency. Our case occurred after a low-risk outpatient strabismus surgery and is a good example of maintaining a broad differential and revising the suspected diagnosis constantly.

Pregabalin Toxicity-Induced Posterior Reversible Encephalopathy Syndrome.

Pregabalin, a prescription medication typically used for neuropathic pain, has increasingly been overused and abused. We present a unique case of a 51-year-old woman with a history of polysubstance use disorder and on methadone therapy who presented to the emergency department with altered mental status after consuming an unknown supratherapeutic amount of pregabalin. She was stabilized and discharged. Within 24 hours, she ingested another 1000mg of pregabalin, presenting again with altered mental status, along with tachycardia and hypertension. Computed tomography (CT) without contrast and fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) revealed subcortical white matter edema in the bilateral frontal and occipital lobes as well as the left parietal lobe, suggestive of posterior reversible encephalopathy syndrome (PRES). The patient recovered after four days of supportive treatment with an antihypertensive and an antiepileptic. PRES is a neurological phenomenon in which vasogenic edema, most commonly accumulating in the posterior parieto-occipital white matter, causes headaches, altered mental status, and seizures. To our knowledge, there has not been an established link between pregabalin toxicity and PRES, and the awareness of this potential complication can help in the early diagnosis and management of the disease to prevent further progression.

Encephalopathy in Cirrhosis: Prevention and Management.

Hepatic encephalopathy (HE) is a major neuropsychiatric complication of cirrhosis. The clinical manifestations of HE ranges from mild confusion, disorientation to altered behaviour and coma in advanced stages. HE is an important cause of recurrent admissions in liver cirrhosis patients. HE is the most common cause of altered mentation in a patient of liver cirrhosis. Lactulose and rifaximin are approved treatment options for the treatment of HE. In patients who have localised neurological signs or are not improving with lactulose and rifaximin should be investigated for other causes of altered sensorium.

Confusion, Hallucinations, and Primary Polydipsia: A Rare Presentation of Neurosarcoidosis.

Neurosarcoidosis is a rare manifestation of sarcoidosis that can exhibit a variety of neuropsychiatric symptoms and can present independently of pulmonary or other systemic symptoms. This is the case of a 51-year-old African American male who presented with recurrent episodes of auditory and visual hallucinations, confusion, seizures that did not respond to antiepileptics, and recent-onset primary polydipsia. In the emergency department, he did not have meningeal signs, focal neurologic deficits, or a fever. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse meningeal enhancement. The patient underwent a lumbar puncture (LP), with cerebrospinal fluid (CSF) analysis notably revealing an elevated angiotensin-converting enzyme (ACE), an elevated CD4:CD8 ratio, and a negative infectious panel, while computed tomography (CT) imaging showed bilateral hilar lymphadenopathy. He also had an endobronchial ultrasound (EBUS) with biopsy which did not reveal granulomas. Although sarcoidosis requires granulomas for a definite diagnosis, studies and symptoms were consistent with neurosarcoidosis, and this can suggest that the disease was isolated to the central nervous system (CNS). This case highlights the need for further understanding of psychiatric symptoms as a sign of isolated neurosarcoidosis.