Dalvir Gill

Case report: Cocaine-induced takotsubo cardiomyopathy

lease cite this article in press as: Gi 2017), http://dx.doi.org/10.1016/j. tp://dx.doi.org/10.1016/j.hjc.2017 09-9666/a 2017 Hellenic Society of ense (http://creativecommons.org/ Cocaine is the second most common illicit drug used, and it is the most common cause of drug-related death. Cocaine is a sympathomimetic agent, and it acts by blocking the presynaptic reuptake of norepinephrine and dopamine, leading to an accumulation of these neurotransmitters at the postsynaptic terminal. This results in overstimulation of alphaand beta-adrenergic receptors. The peak effects of cocaine occur within 1-90 min after exposure and can last anywhere from 15 min to 2-3 h depending on the route of administration. Exposure to cocaine can result in hypertensive crisis, vascular complications including cerebral vascular accidents of either thrombotic or hemorrhagic origin, aortic dissection or rupture, and vasculitis. It most commonly affects the cardiovascular system, increasing the risk for myocardial ischemia, coronary artery spasm, myocardial infarction, atherosclerosis, myocarditis, cardiomyopathy, and arrhythmias. The association of cocaine use with Takotsubo cardiomyopathy is a rare occurrence. In this report, we present the case of a 41-year-old male who developed Takotsubo cardiomyopathy with cocaine use Figure 1.

Rare Manifestation of Digoxin Toxicity: Right Bundle Branch Block

A 76-year-old female, with medical history significant for systolic congestive heart failure, who presented to the emergency department with lethargy and abdominal pain with diarrhea for the past 3 weeks. Due to hypotension, the patient received multiple boluses of isotonic saline and was started on norepinephrine. Laboratories were significant for severe digoxin toxicity (29 ng/mL), in setting of acute kidney injury. Electrocardiogram (EKG) revealed a new right bundle branch block (RBBB). She was given Digibind and her repeat digoxin level was 20 ng/mL. Repeat EKG showed resolved RBBB. This case identifies that patients with digoxin toxicity are at risk for RBBB. This is a rare finding and is not commonly recognized. Emergency medicine physicians are often the first to encounter patients with digoxin toxicity and need to be aware of such EKG findings.

Takotsubo Cardiomyopathy with Guillain-Barré Syndrome

A 70-year-old woman presented with progressive lower extremity weakness and heaviness accompanied with chest pain. Troponin T was elevated, and an echocardiogram showed a left ventricular ejection fraction of 30% and a hypokinetic left ventricular apex. Neurophysiologic testing was consistent with Guillain-Barré syndrome, which was treated with intravenous immunoglobulin therapy. Repeat echocardiogram showed an improved left ventricular ejection fraction and no left ventricular wall motion abnormalities. Takotsubo cardiomyopathy is a rare complication of Guillain-Barré syndrome; less than 10 cases have been reported.

Consideration of alternative causes of lactic acidosis: Thiamine deficiency in malignancy

Lactic acidosis is a common metabolic acidosis characterized by increased serum lactate and is usually associated with a decreased blood pH. Lactic acidosis has many different causes but has been differentiated into type A, hypoxic causes, and type B, non-hypoxic causes. Tissue hypoxia, type A, is the most common cause, usually secondary to processes such as sepsis and multi-organ failure. Type A must be differentiated from type B in the correct clinical setting as treatments are vastly different. Type B causes may include drug side-effects, toxins, enzymatic defects, inherited or acquired, any of which may lead to overproduction or underutilization of lactate. However, as most clinicians are more familiar, and likely more initially concerned with hypoxic etiologies, evaluation is directed toward finding the source of hypoperfusion or hypoxia, and thus generally leading to a delay in discovering a type B cause (or mixed type A and type B). Here we describe a case of lactic acidosis in the setting of thiamine deficiency thought to be secondary to advanced lung cancer. The purpose of this paper is to bring awareness to the clinician to consider other causes of lactic acidosis when evaluating a patient.

Takotsubo cardiomyopathy associated with Miller-Fisher syndrome

51-year-old female who presented with progressive paresthesia, numbness of the lower extremities, double vision, and trouble walking. Physical exam was remarkable for areflexia, and ptosis. Her initial EKG showed nonspecific ST segment changes and her Troponin T was elevated to 0.41ng/mL which peaked at 0.66ng/mL. Echocardiogram showed a depressed left ventricular ejection fraction to 35% with severely hypokinetic anterior wall and left ventricular apex was severely hypokinetic. EMG nerve conduction study showed severely decreased conduction velocity and prolonged distal latency in all nerves consistent with demyelinating disease. She was treated with 5days of intravenous immunoglobulin therapy to which she showed significant improvement in strength in her lower extremities. Echocardiogram repeated 4days later showing an improved left ventricular ejection fraction of 55% and no left ventricular wall motion abnormalities. Takotsubo cardiomyopathy is a rare complication of Miller-Fisher syndrome and literature review did not reveal any cases. Miller-Fisher syndrome is an autoimmune process that affects the peripheral nervous system causing autonomic dysfunction which may involve the heart. Due to significant autonomic dysfunction in Miller-Fisher syndrome, it could lead to arrhythmias, blood pressure changes, acute coronary syndrome and myocarditis, Takotsubo cardiomyopathy can be difficult to distinguish. The treatment of Takotsubo cardiomyopathy is supportive with beta-blockers and angiotensin-converting enzyme inhibitors are recommended until left ventricle ejection fraction improvement. Takotsubo cardiomyopathy is a rare complication during the acute phase of Miller-Fisher syndrome and must be distinguished from autonomic dysfunction as both diagnoses have different approaches to treatment.

Gemcitabine associated pseudocellulitis: A missed diagnosis

We report a case of a 51-year-old male with past medical history significant for cholangiocarcinoma presented with two weeks of worsening bilateral lower extremity swelling and erythema. Patient has been on active chemotherapy for his cholangiocarcinoma with Gemcitabine weekly infusions. Physical exam was significant for bilaterally petechial rash coalescing into ecchymoses over the dorsum of the feet, sparing soles and toes, which dissipated into thinning petechiae more proximally. On labs he did not have any leukocytosis, his platelet count was 50 × 103/µL and basic metabolic panel was benign. Patient was started on Vancomycin for presumed cellulitis. Lower extremity ultrasound Doppler ruled out deep venous thrombosis. Patient did have biopsies bilaterally on his legs, which showed hypersensitivity reaction consistent with the diagnosis of pseudocellulitis. His Vancomycin was discontinued and his symptoms improved. Our case further supports that pseudocellulitis is underrecognized and underreported, potentially leading to unnecessary antibiotic exposure and unnecessary diagnostic work-up as seen unfortunately in our patient. Unnecessary antibiotic exposure is increasing the risk for clostridium difficile and or antibiotic resistance, therefore awareness of this reaction is critical, as to avoid unnecessary antibiotics, and costly diagnostic workups.

Screening of Celiac Disease in Patients With Sarcoidosis

Sarcoidosis and celiac disease (CD) are both autoimmune disorders, which have been associated with class II haplotype HLA-DR3, DQ2. Literature demonstrates this combination is more prevalent in the Irish population. Celiac disease is caused by the ingestion of gluten, where the predisposed population (HLA BQ2 or BQ8 carriers) develop antibodies against gluten peptides. The prevalence of celiac disease ranges from 1:70 to 1:300 in most countries. More importantly, however, is the association between celiac disease and cancers, mainly B cell lymphoma and gastrointestinal cancers. Sarcoidosis is a multisystem granulomatous disorder most often found in lung parenchyma and related lymph nodes. Diagnosis of celiac disease in a patient with sarcoidosis has special importance, including implication for the treatment of both diseases. A 35-year-old woman who was diagnosed with biopsyproven sarcoidosis developed a complex clinical course over time. Her sarcoidosis was complicated by diffuse inflammatory arthritis, which involved her shoulders, knees, ankles, hands, and wrist. She also complained of significant and prolonged morning stiffness, but work-up for systemic lupus and rheumatoid arthritis was negative. Her sarcoidosis was otherwise stable, except for occasional flares treated with short courses of Medrol (Pfizer, New York, NY). Although her chest x-ray, computed tomography scan of the thorax, and pulmonary function tests remained stable over the course of 6 years, she started experiencing recurrent nonbloody watery diarrhea. These episodes occurred up to 7-8 times per day or night and were accompanied by abdominal cramping and generalized weakness. Over time, the patient developed other symptoms such as nonspecific dermatitis, hair loss, and oral ulcers.

Alcohol withdrawal induced posterior reversible encephalopathy syndrome

Received: January 13, 2017; Accepted: February 08, 2017; Published: February 11, 2017 Posterior Reversible Encephalopathy Syndrome (PRES) is a neurological condition characterized by various clinical findings and imaging abnormalities. Patients can present with a myriad of symptoms ranging from headaches and confusion to seizures and focal neurologic deficits (hemiparesis, aphasia) [1-3]. We report a rare case of PRES induced by acute, malignant hypertension associated with alcohol withdrawal.

Sjogrenâs Syndrome in a Patient with Maculopapular Cutaneous Mastocytosis

We report a case of a 42-year-old female with past medical history significant for cutaneous mastocytosis who presented with complains of progressive dry eyes, and dry mouth for the past few weeks. Her vital signs were remarkable for blood pressure of 106/71 mmHg, pulse of 86 beats per minute, temperature of 36.7°C (98.1°F) (oral), and respiratory rate of 16 breaths per minute. Physical exam was significant for bilateral dryness in eyes, cracks at the corners of the mouth, dry and smooth tongue. Lab work revealed a benign blood count and chemistry. Sedimentation rate was elevated at 25 mm/hr, CRP was also elevated at 11.1 mg/L, and ANA with speckled pattern was elevated at 1250 1/dil. Speckled pattern was elevated at 1250 1/dil. Hence patient was managed with muscarinic agonists such as cevimeline and pilocarpine, which improved her symptoms. We report a rare case of a patient with maculopapular cutaneous mastocytosis who develops Sjogren’s syndrome. Literature review revealed that in the past there have been case reports which linked systemic mastocytosis to Sjogren’s syndrome, however there are no case reports of maculopapular cutaneous mastocytosis linking to Sjogren’s syndrome. Clinicians need to be aware that even the milder form of mastocytosis, cutaneous type, can also be associated with Sjogren’s syndrome. Absence of well defined histopathological features and lack of clinical awareness can delay its diagnosis and treatment.

Successful Treatment of Lung Abscess with Pigtailed Catheter after Failure with Antibiotics and Surgical Debridement

Necrotizing pneumonia is a rare complication of pneumonia as it could lead to lung abscess, septic shock and respiratory failure. 80%-90% of lung abscess are successfully treated with antibiotics, however surgical intervention is required in refractory cases1. Mortality rates are high despite thoracotomy and lobectomy, ranging from 15%-20% [1]. An alternative therapy is percutaneous tube drainage.