Keyvan Ravakhah

Elevated Serum Cardiac Troponin I Level in a Patient after a Grand Mal Seizure and with No Evidence of Cardiac Disease

The World Health Organization recognizes biochemical markers of myocardial injury as one of the three criteria for the diagnosis of acute myocardial infarction. We report the first case of elevated troponin I in a patient after a grand mal seizure in the hospital, with no evidence of myocardial infarction and no rhabdomyolysis. Cardiac catheterization and two-dimensional echocardiographic findings were normal. Four months later, the patient was readmitted, again having experienced a grand mal seizure. She was asymptomatic for cardiac disease in both instances. There was a temporal correlation between troponin I levels and seizures. Studies have shown that a troponin level above 3.5 ng/mL implies significant myocardial injury. Our patient had troponin I values as high as 5.5 ng/mL and 6.3 ng/mL. This case implies that troponin I can be significantly increased after a grand mal seizure, and with low clinical suspicion for myocardial injury this abnormality should be disregarded.

Esophageal Papillomatosis from Human Papilloma Virus Proven by Polymerase Chain Reaction

Human papilloma viruses (HPVs) are known to infect the genitourinary tract, the skin, the anal canal, and the upper respiratory tract. Esophageal papillomas and especially HPV-induced squamous papillomas of the esophagus are rare. The authors report a case of extensive HPV-induced esophageal polyposis, which was probably sexually transmitted. The 53-year-old female patient presented with chronic diarrhea and had occult blood in the stool. She underwent esophagogastroduodenoscopy, at which time multiple esophageal polyps were observed and biopsy specimens obtained. Histologic evaluation was consistent with benign papillomas. Polymerase chain reaction and DNA hybridization of the biopsied tissue specimens confirmed the diagnosis of HPV infection. Because of our observation and because of HPVs relationship to cervical and esophageal cancer, further evaluation of HPV as the cause of esophageal papillomatosis and as a risk factor for esophageal cancer is warranted.

Coinfection with Giardia lamblia and Clostridium difficile after Use of Ranitidine

A 49-year-old man presented with a 3-week history of vomiting and diarrhea. He reported foamy stools but no blood or melena and had crampy epigastric pain. He denied usage of antibiotics. He had been taking ranitidine for intermittent epigastric pain for the last few months and noted an 11-pound weight loss during the 3 weeks before admission. Stool was positive for Clostridium difficile toxin and Giardia lamblia antigen. Cultures and occult blood tests were negative. Oral metronidazole, 500 mg 3 times a day, was administered, and the patient was hydrated. The diarrhea resolved, and patient was discharged on the fourth hospital day. Prior antibiotic therapy is the most common risk factor for C difficile colitis. This patient developed concomitant infection with C difficile and G lamblia while he used ranitidine. He had no other risk factors for these infections. Hence, we propose that ranitidine-induced hypochlorhydria predisposed this patient to the enteric infections.

Advanced cardiac life support events in a community hospital and their outcome: evaluation of actual arrests

To evaluate resuscitation efforts for patients with cardiac and/or pulmonary arrest in our hospital a retrospective study was conducted and compared with available data from other community teaching hospitals. Records of 131 consecutive patients of ages 16-98 who received resuscitation according to Advanced Cardiac Life Support protocols were reviewed. Short-term survival (return of spontaneous circulation) and discharge-from-the hospital survival were measured. Nineteen patients (15%) were excluded from the study because the information recorded on the code record sheet was insufficient. Overall short-term survival rate was 34.8%. Resuscitations in the Emergency Room were evaluated separately, because most of them were initiated outside of the hospital. Their short-term survival was 14%, but none of them survived to be discharged. Out of 69 inpatient resuscitative efforts, 33 were successful (47.8%). Of these 33 nine (13.0%) left the hospital. The rest expired during the same hospitalization. Short-term survival for patients after coronary artery bypass graft surgery was 60% (6 of 10) and 30% (3 of 10) were discharged home. Forty percent of official code records were incomplete. We concluded that better education and more emphasis on record-keeping are mandatory, with the main burden falling upon the nurse in charge to have received more precise instruction. Contrary to published data, women did not have a better survival than men (P > 0.05). There was no difference in outcomes between resident physician directed codes compared to attending physician directed codes (P > 0.05). The mean age of inpatient short-term survivors was 69.0 (+/- 13.2) years and that of non-survivors 69.8 (+/- 15.7) years (P > 0.05). Post-bypass surgery patients had a better survival than non-surgical patients, but the difference was significant (P > 0.05). Survival in our hospital was comparable to one hospital and worse than another (34.8% vs. 39.6% or 63.0%). Despite success, prognosis after arrest remain poor.

Subacute Combined Degeneration of the Spinal Cord From Folate Deficiency

Subacute combined degeneration of the spinal cord is a rare neurologic complication of folate deficiency. Progressive gait disturbance, weakness, confusion, and depression developed in a 39-year-old man. He had taken phenobarbital for more than 2 years. He was bedbound, with new loss of position and vibration senses in the lower extremities. His hemoglobin was 2.9/dl, mean corpuscular volume 122 fl, vitamin B12 428 pg/ml, and folate 1 ng/ml. Peripheral blood and bone marrow showed mega-loblastic anemia. Serum methylmalonic acid and homocysteine levels were consistent with folate deficiency, not B12 deficiency. Treatment with folate and packed erythrocytes resulted at 4 months in overall improvement, including walking. Position sense was restored, and vibration sense had become nearly normal. The authors found no cause for folate deficiency except phenobarbital.

Adenoviral Bronchopneumonia in an Immunocompetent Adult: Computed Tomography and Pathologic Correlations

&NA; Acute febrile lung disease associated with “patchy ground‐glass pattern” on high‐resolution computed tomography (HRCT) of the lung in an immunocompromised patient is suggestive of Pneumocystis carinii pneumonia; however, in an immunocompetent young person, it is suggestive of an atypical pneumonia, including viral bronchopneumonia. We studied a 31‐year‐old man who presented with fever, cough and hypoxemia. HRCT showed bilateral patchy ground‐glass opacification. HIV test was negative and lung biopsy specimen grew adenovirus on viral culture. Histopathology of the lung was compatible with bronchopneumonia. In patients without HIV who present with acute lower respiratory infections and patchy ground‐glass opacification on HRCT, adenoviral bronchopneumonia should be included in the differential diagnosis.