Divey Manocha

Infliximab-induced aseptic meningitis

Infliximab is a commonly used biologic agent in the treatment of various autoimmune diseases. Although it is generally well tolerated in most patients, infliximab has been associated with some rare but serious adverse events. Aseptic meningitis is one such distinctly uncommon side effect. We present the case of middle-aged white patient, who presented with fever and headache within a few days of starting the infliximab therapy and was diagnosed with infliximab-induced aseptic meningitis after a complete workup. To our knowledge, this is the fifth case of infliximab-induced aseptic meningitis reported in literature. Because of atypical presentation, the diagnosis can be easily missed. It is vital to increase awareness of this potentially severe side effect among internists and community physicians.

Safety profile of high-dose statin therapy in geriatric patients with stroke.

Objectives Use of high-dose statin therapy (HDST) in patients with stroke became standard clinical practice after the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study, in which the mean age of the study population was approximately 63 years. Little data are available on the adverse effects of statins when used in high doses in adults older than 65 years. The objective of this study was to assess the magnitude of adverse effects of HDST in geriatric patients. Methods This single-center, retrospective, case-control study was conducted at Upstate Medical University, Syracuse, New York. All patients older than 65 years admitted between 2008 and 2011 to the hospital’s Upstate Stroke Center with acute stroke were eligible. Electronic medical records of 200 eligible patients were reviewed to collect demographic, clinical, and laboratory data. Patients on HDST (cases) were compared with those on low doses (controls) using the &khgr;2, Fisher exact (two-sided), and Student t tests. Results One hundred cases (mean age 80.5 ± 7.7 years) were compared with 100 controls (mean age 78.9 ± 6.4 years). Sixty-seven percent were taking simvastatin. Ninety percent of the cases compared with 81% of the controls had ischemic stroke. The prevalence of elevated alanine aminotransferase (13%) and myositis (4%) was significantly higher in the cases than in the controls. Fourteen percent of the cases reported myalgias, 9% had nausea, and 6% had diarrhea. Seventy-three cases had low-density lipoprotein levels <100 mg% and 41% of the cases had mean glycated hemoglobin levels ≥6.5%. Conclusions The use of HDST in older adult patients with acute stroke is associated with a significantly increased burden of liver enzyme elevation and myalgias.

Colorectal Cancer Associated with Streptococcus anginosus Bacteremia and Liver Abscesses

Streptococcus anginosus is part of the normal flora of the human gastrointestinal tract. Their ability to cause abscesses is very unique and sets them apart from the rest of the streptococci groups. While an association of group D streptococcus bacteremia and endocarditis with colorectal carcinoma is well established, S. anginosus infections are rarely implicated with colonic malignancy. We present a case of a 62-year-old male who presented to the hospital with fatigue and generalized abdominal pain. Computed tomography of the abdomen revealed multiple liver abscesses and rectal thickening. Blood cultures were found to grow S. anginosus bacteria. Colonoscopy revealed a rectal mass which was later confirmed to be rectal adenocarcinoma. This case presents an association between S. anginosus bacteremia and presence of colorectal cancer which has been highlighted in only a few case reports in literature. This should prompt clinicians to screen for colorectal cancer in patients with S. anginosus bacteremia.

Life-Threatening Metabolic Coma Caused by Levofloxacin

Patients with diabetes mellitus are often susceptible to hypoglycemic episodes while on therapy. Most of these are attributed to inappropriate dosing of hypoglycemic agents, dietary indiscretion, or acute illness. Medications being used concomitantly should be reviewed closely when the etiology of hypoglycemia is unclear. A fifty-six-year-old woman with a history of diabetes mellitus (on metformin monotherapy) was found unresponsive at home. Her fingerstick glucose was 15 mg/dL for which she received 50% dextrose intravenously. The patient never had any previous documented hypoglycemic episodes. She had recently been diagnosed with pneumonia and was prescribed oral levofloxacin therapy. The patient had taken 4 doses of levofloxacin before the onset of hypoglycemia. These episodes recurred over the next 2 days needing close intensive care unit monitoring, dextrose infusion, and glucagon administration. Basic blood/urine investigations, cortisol and thyroid profile were normal except for low blood glucose and renal insufficiency (serum creatinine 1.4 mg/dL and creatinine clearance 42 mL/min). HbA1c was 6.8% (4.4%-6.4%), insulin 51.3 μU/mL (2.6-24.9 μU/mL), IGF-1 301 ng/mL (27-223 ng/mL), and C peptide 9.3 ng/mL (0.8-3.5 ng/mL). These levels were elevated but were deemed nondiagnostic because of fluctuating glucose values after glucagon administration. A blood screen for sulfonylureas and metaglinides was negative. A seventy-two-hour fast was performed to rule out hyperinsulinemic hypoglycemic syndromes; however, blood glucose values remained consistently above 120 mg/dL during this period. Thus, after exclusion of other causes, we utilized the adverse drug reaction probability scale and concluded that hypoglycemia was probably related to recent use of levofloxacin.

Esophageal dissecans: a rare life-threatening presentation of recurrent pemphigus vulgaris.

Esophagitis dissecans superficialis (EDS) is a rare condition characterized by sloughing of the mucosal layer of the esophageal lining, usually triggered by an environmental/immune insult. It is associated with blistering diseases such as pemphigus vulgaris (PV), bullous pemphigoid, and epidermolysis bullosa. Oral mucosa is the most commonly (50%) affected site in PV, but esophageal involvement has only been rarely reported. The most common presentation of EDS includes dysphagia and odynophagia, but overt gastrointestinal bleeding is a distinctly uncommon. We present a unique case of EDS presenting with melena in which diagnostic endoscopy enabled to diagnose and establish link with patients remote history of PV. Early suspicion and identification of this treatable condition can reduce morbidity and mortality in these patient populations by decreasing severity and recurrence of bleeding.

Unusual Case of Acute Intestinal Obstruction

Chronic NSAID use can cause diaphragm like strictures within the bowel leading to intestinal obstruction. This rare entity is called diaphragm disease. Preoperative diagnosis is extremely difficult. NSAID related injury should be considered in patient with intestinal obstruction of unclear etiology. We hereby present an interesting case of a 46 years old lady with significant history of long term naproxen use, who presented with nausea, vomiting and abdominal pain. She was diagnosed with acute intestinal obstruction. She received a trial of conservative management which was unsuccessful. Exploratory laparotomy with segmental resection of ileum was done subsequently. Histopathology showed mucosal ulceration, inflammation and focal sub mucosal fibrosis consistent with diaphragm disease. Patient recovered well in the post operative period. Keywords NSAIDS; Acute Intestinal Obstruction; Diaphragm Disease

Vancomycin leading to lupus flare in an elderly lady: a case report

Elderly lady underwent right eye surgery for vitreous clot removal. 72 hours later, she complained of pain, redness and swelling in operated eye. Endophthalmitis was diagnosed. She was started on piperacillin/ tazobactam and vancomycin. Evisceration was required. Coagulase negative Staphylococci were isolated and vancomycin was continued postoperatively. She was discharged on home intravenous vancomycin therapy. Admitted one week later with painful oral ulcers, fever and diffuse erythmatous body rash. Vancomycin and other medications were stopped. Investigations revealed elevated double-stranded deoxyribonucleic acid and anti histone antibodies. Skin biopsy was suggestive of lupus rash. She was started on 60 mg of oral prednisone, improved dramatically and discharged to home.

Crack lung: cocaine-induced lung injury

A 31-year-old female presented with acute onset shortness of breath and chest pain. She had a past medical history of cocaine abuse and agreed that she used cocaine 2 days prior to presentation. On admission, her vitals …

Cytomegalovirus Colitis Mimicking Rectal Carcinoma in a Young Immunocompetent Patient.

Cytomegalovirus (CMV) infection is often seen in immunocompromised patients. Rarely, immunocompetent patients may present with CMV as a self-limiting, flu-like illness, though a few cases of significant organ-specific complications have been reported in these patients. We report a case in which a previously healthy man presented with hematochezia and an obstructing rectal mass thought to be rectal adenocarcinoma. Biopsy was positive for CMV, which was treated with full resolution of rectal mass confirmed with colonoscopy and barium contrast enema. This is the first reported case of CMV colitis mimicking rectal adenocarcinoma in an immunocompetent patient.

Intravenous immunoglobulin-associated renal failure in a patient with post-transfusion purpura.

Intravenous immunoglobulin (IVIG), initially developed for immunodeficiency disorders, has now been used for multiple autoimmune diseases and infections. These are generally well tolerated, with few adverse effects. Acute kidney injury has been described in very rare instances. We report an interesting case of a 59-year-old African American male with a pertinent history of diabetes mellitus, hypertension, endocarditis, and peripheral vascular disease, who was diagnosed with post-transfusion purpura. He was then treated with IVIG and subsequently developed an acute worsening of renal function in a time span of 3 days. The etiology remained elusive even after an extensive workup. Renal biopsy was done finally, which showed findings suggestive of osmotic nephropathy that was traced to the sucrose used as a stabilizing agent in the IVIG. In light of the increasing use of IVIG, it is therefore highly recommended that clinicians are well aware of this side effect of IVIG.