Ana Marcella Rivas

High Flow Nasal Cannulas for Oxygenation: An Audit of Its Use in a Tertiary Care Hospital.

Background:High flow nasal cannulas (HFNCs) provide humidified oxygen at higher flow rates and higher FiO2s than conventional delivery devices and are typically used in special care units. There is limited information on their use in general hospital settings. Methods:The medical records of all patients who were treated with HFNC during the calendar year 2014 were retrospectively reviewed to collect information on age, sex, indications, arterial blood gases when available, O2 saturations and outcomes. Results:One hundred six patients received oxygen supplementation by HFNC in their hospital in 2014. The average age was 61.6 ± 16.2 years; 62 patients were men. The indications for HFNC included dyspnea (1 patient), hypoxemic respiratory failure (101 patients) and hypercapneic respiratory failure (4 patients). The PaO2 increased from 68.2 ± 16.3 mm Hg to 83.1 ± 32.2 mm Hg (N = 32, P = 0.02) with the change to HFNC. The O2 saturation increased from 93.1 ± 4.5% to 95.1 ± 3.0% (N = 106, P = 0.00015). The mean duration of use was 4.3 ± 3.7 days. Sixty-five patients did not require intubation or noninvasive ventilation (NIV). Sixteen required NIV, 16 required intubation and 9 required both. The overall mortality was 15%. Conclusions:HFNC oxygen therapy is used relatively frequently in their hospital on surgical and medical services. PaO2s and O2 saturations improved when patients were switched to this mode of oxygenation, but some patients subsequently required NIV and/or intubation. Patients on HFNC need careful monitoring for deterioration in their respiratory status.

Thyroid hormone resistance and its management

The syndrome of impaired sensitivity to thyroid hormone, also known as syndrome of thyroid hormone resistance, is an inherited condition that occurs in 1 of 40,000 live births characterized by a reduced responsiveness of target tissues to thyroid hormone due to mutations on the thyroid hormone receptor. Patients can present with symptoms of hyperthyroidism or hypothyroidism. They usually have elevated thyroid hormones and a normal or elevated thyroid-stimulating hormone level. Due to their nonspecific symptomatic presentation, these patients can be misdiagnosed if the primary care physician is not familiar with the condition. This can result in frustration for the patient and sometimes unnecessary invasive treatment such as radioactive iodine ablation, as In the case presented herein.

Choriocarcinoma presenting with thyrotoxicosis.

We describe a 26-year-old man with metastatic choriocarcinoma who presented with hyperthyroidism associated with elevated β-human chorionic gonadotropin (B-HCG) and respiratory failure secondary to diffuse lung metastasis. After the first cycle of chemotherapy, the concentration of B-HCG dramatically decreased and the patient became euthyroid, allowing us to discontinue antithyroid medications. The patients hyperthyroidism was caused by stimulation of the thyroid gland by high B-HCG levels, as shown by the marked improvement of the patients thyroid function panel after chemotherapy.

Diffuse Idiopathic Skeletal Hyperostosis and Familial Hypocalciuric Hypercalcemia: A Unique Association in a Young Female

Abstract:Familial hypocalciuric hypercalcemia (FHH) is a cause of lifelong hypercalcemia resulting from inactivated mutations in the calcium sensing receptor gene. Diffuse idiopathic skeletal hyperostosis (DISH) is an under diagnosed condition that leads to ossification of ligaments and entheses of the spine and peripheral skeleton. We describe a 45-year-old diabetic woman with hypercalcemia secondary to FHH who developed dysphagia because of external esophageal compression from DISH. The patient had no additional identifiable risk factors for DISH except for diabetes mellitus. An association between FHH and DISH has not been previously reported. Although most cases of hypercalcemia are found to have decreased bone mineralization, inactivation of calcium sensing receptor may induce a promitogenic response to hypercalcemia resulting in increased bone density. However, a causal association between FHH and DISH remains unproven.

Giant craniopharyngioma in an adult presenting with new onset seizure

A 43-year-old man presented to the emergency department after experiencing a first episode seizure. No further information was available at presentation as the patient was confused on his arrival. On physical examination, vital signs were normal. The patient was confused, and his Glasgow Coma Score was 12(E3V4M5). Initial workup included complete blood count, electrolytes and ECG were normal. Thyroid function tests, insulin growth factor-1 and plasma random cortisol level were within the normal range. Testosterone levels were low, and luteinising hormone was inappropriately normal. CT demonstrated a cystic mass with peripheral calcification measuring 6.0×4.5×3.9 cm. The lesion originated from the pituitary fossa and expanded superiorly distorting the third ventricle and the left lateral ventricle causing hydrocephalus (figure 1). A pituitary MRI confirmed these findings (figure 2). The patient underwent a craniotomy with mass resection. The procedure was uneventful. Pathology demonstrated nodular whorls and irregular trabeculae of …

Acute necrotizing esophagitis presenting with severe lactic acidosis and shock

Abstract Acute necrotizing esophagitis, also known as “black esophagus,” is typically characterized by a circumferential, friable black mucosal surface and preferentially involves the distal esophagus. It predominantly affects elderly men and presents as an upper gastrointestinal bleed. We describe a 60-year-old man with an acute upper gastrointestinal bleed and sepsis and subsequently acute necrotizing esophagitis.

BILATERAL ADRENAL MYELOLIPOMAS PRESENTING AS ACUTE ADRENAL INSUFFICIENCY IN AN ADULT WITH CONGENITAL ADRENAL HYPERPLASIA

Introduction Adrenal myelolipomas are relatively rare, benign tumors composed of adipocytes and myeloid cells that arise in response to chronic adrenocorticotropic hormone (ACTH) stimulation. We present the case of bilateral adrenal myelolipomas in a patient with untreated congenital adrenal hyperplasia (CAH) presenting with acute adrenal insufficiency and severe virilization. Case A 39-year-old Hispanic adult, who raised as a male, presented with nausea, vomiting, and hypotension. Phenotypically, he was a man of short stature. He was noted to have hyperpigmentation of the skin, gingiva and nail beds. Genital examination revealed micropenis and no palpable testes. Laboratory testing was significant for hyponatremia, hyperkalemia, a low cortisol and elevated ACTH, consistent with primary adrenal insufficiency. An abdominal computerized tomography showed 6×4.5×5 cm right and 2.3×1.4×2.5 cm left adrenal masses with radiological characteristic of myelolipomas. A magnetic resonance imaging of pelvis revealed a...

Toxoplasma Infection in an Immunocompetent Host: Possible Risk of Living with Multiple Cats

A 32-year-old man presented with agitation, headache, and confusion. He was immunocompetent and had been living with multiple cats for many years. His vital signs were stable. He was afebrile. Multiple blood tests did not show any serious problem. Brain magnetic resonance imaging (MRI) revealed multiple ring-enhancing white matter lesions. Cerebrospinal fluid analysis did not show any signs of infection. Based on a presumptive diagnosis of multiple sclerosis, high-dose corticosteroid treatment was started. However, this caused worsening of the symptoms and increased the size of the lesions. Corticosteroids were discontinued and biopsy was done. Biopsy of the lesions confirmed Toxoplasma gondii infection, and treatment with pyrimethamine/sulfadiazine was initiated. Treatment decreased the size of the lesions dramatically. Toxoplasma infection of the central nervous system (CNS) is rare in immunocompetent hosts. Living with multiple cats is believed to be a risk factor for Toxoplasma infection in immunocompetent hosts.

Newly diagnosed acromegaly presenting with hypertriglyceridemic pancreatitis with normal amylase and lipase levels.

The incidence of hypertriglyceridemia in acromegaly is three times higher than in the normal population, and it is the most common dyslipidemia in acromegaly. We present a case of hypertriglyceridemic pancreatitis confirmed by imaging, with normal pancreatic enzymes. Hypertriglyceridemia in this patient was likely secondary to acromegaly. The hypertriglyceridemic pancreatitis appears to be secondary to somatotrophic pituitary adenoma.