Ranjita Pallavi

An Unsuspected Cause of Hyponatremia: Beer Potomania

To the Editor: A 68-year-old woman with metastatic left breast infiltrating ductal carcinoma undergoing active chemotherapy was evaluated for complaints of fatigue, muscle cramps, dizziness, lack of appetite, loss of weight, and gait instability for 2 weeks. She denied fever, nausea, vomiting, diarrhea, gastrointestinal bleeding, chest pain, cough, shortness of breath, palpitations, and lower extremity swelling. There was no history of falls. Her past medical history was significant for left breast cancer diagnosed in 2010 treated with neoadjuvant chemotherapy followed by left mastectomy. She had no allergies. She was not on any other medications. She denied smoking, alcohol abuse, or use of illicit drugs. Physical examination was notable for a cachectic and disheveled woman with a body mass index of 17.5 kg/m. She had mild pallor with lack of skin turgor and orthostatic hypotension. Cardiac, respiratory, and neurological examinations were unremarkable. Laboratory results were notable for mild chronic normocytic normochromic anemia, serum sodium 119 mmol/L (normal 137–147 mmol/L), serum potassium 2.8 mmol/L (normal 3.6–5.2 mmol/L), normal renal and hepatic function, normal coagulation profile, normal cortisol and glucose levels, thyroid-stimulating hormone 3.388 lIU/mL (normal 0.35–4.8 lIU/mL), albumin 2.5 g/ dL (normal 3.7–5.1 g/dL), serum alcohol 220 mg/dL, uric acid 3.2 mg/dL (normal 3.5–7.2 mg/dL), serum osmolality 277 mOsm/kg (normal 277–302 mOsm/kg), urine osmolality 79 mOsm/kg (normal 50–1,000 mOsm/kg, average range 500–800 mOsm/kg), and urine sodium 8 mmol/L. Computed tomography of the head was negative for acute changes. The woman’s vague neurological complaints and laboratory parameters suggested a diagnosis consistent with water intoxication. On further questioning, family members said that she had been drinking significant amounts of beer over the past several days, suggesting a diagnosis of “beer potomania.” She was initially hydrated with 0.9% normal saline to correct orthostatic hypotension and subsequently treated with 3% hypertonic saline, with normalization of her serum sodium levels over several days. She received thiamine to prevent Wernicke’s encephalopathy and lorazepam to treat alcohol withdrawal. She had a good recovery and received appropriate counseling for alcohol addiction.

A case of phosphaturic mesenchymal tumor.

Phosphaturic mesenchymal tumors (PMTs) are rare and found to be commonly associated with phosphaturia and oncogenic osteomalacia. They commonly affect middle-aged adults and are located mostly in the extremities. Most of them are benign with only a few metastatic cases described in the literature. PMT-mixed connective tissue (PMTMCT) type is the most common PMT. Though most cases of PMTMCT have been associated with oncogenic osteomalacia and phosphaturia, there have been many reports of nonphosphaturic variants of this tumor with no clinical or laboratory evidence of tumor-induced osteomalacia. However, most of these nonphosphaturic variants previously described were not metastatic. We describe an unusual case of PMTMCT with widespread osseous metastases and without evidence of tumor-induced osteomalacia or phosphaturia.

More than meets the eye: the ‘pink salmon patch’

Ocular adnexal lymphomas account for 1–2% of all non-Hodgkins lymphomas. Conjunctiva is the primary site of involvement in one-third of cases. We present a case of a 47-year-old Hispanic woman who presented with left eye itching and irritation associated with a painless pink mass. Physical examination revealed the presence of a ‘pink salmon-patch’ involving her left medial conjunctiva. Orbital CT showed a subcentimeter left preseptal soft tissue density. Biopsy revealed a dense subepithelial lymphoid infiltrate comprised predominantly of B cells that did not coexpress CD5 or CD43. These findings were consistent with B-cell marginal zone lymphoma. Further staging assessment did not reveal disseminated disease. She had stage 1E extranodal marginal zone lymphoma as per Ann Arbor staging system. She received external beam radiotherapy to her left eye with complete resolution of the lymphoma in 2 months and continues to remain tumour free at 8-month follow-up. She will be followed up closely for development of any local (unilateral or contralateral eye) or systemic recurrence in the long run.

Stroke in a Young Woman as a Presenting Manifestation of Membranous Nephropathy.

Stroke is one of the most severe complications of nephrotic syndrome (NS), only a few cases have been reported in previous literature. Some of those cases are not clear about whether the stroke was purely caused by NS because they also had other risk factors for stroke, such as old age, hypertension. A recent study showed that serum albumin less than 2.8 g/dL is a risk factor for thromboembolic events (venous thromboembolic events). Anticoagulation is suggested for patients with NS with low albumin by KIDIGO guideline 2012. Here, we describe a case in which a young patient presented with stroke as an initial symptom of membranous nephropathy (MN). A 36-year-old woman with no medical history came to the emergency room for left side weakness. Computed tomography of head showed right middle cerebral artery infarct. She was healthy and had no history of hypertension or peripheral vascular disease. She was not taking any medication before admission and did not have any toxic habits. She had nephrotic range of proteinuria with no active sediment in urine analysis, serum albumin of 1.7 g/dL, normal renal function, elevated blood pressure on admission, and no signs of left ventricular hypertrophy. All coagulopathy workup was negative. The renal biopsy showed MN. She was started on Coumadin and treated with steroids and cyclophosphamide. Four months after the stroke, she still could not perform daily activity independently. This case illustrates that stroke can be an initial symptom of MN, and it is important we detect and anticoagulate this high-risk group of patients before their developing stroke. Urine analysis is an inexpensive screening tool for NS and should be considered as an initial workup for a young patient who presents with stroke.

Prolonged Hemodialysis: An Antidote for Metformin-Associated Lactic Acidosis.

Lactic acidosis is a rare and potentially lethal complication of metformin therapy. We present a case of a middle-aged diabetic man with metformin-induced acute lactic acidosis successfully managed with timely hemodialysis.

Hyperammonemia: A Silent Killer.

Hyperammonemia is most commonly associated with liver disease. Nonhepatic causes of hyperammonemia are uncommon. We present a case of nonhepatic hyperammonemia that turned fatal within a short period of time and discuss the possible treatment modalities for the same.

Fatal Bleeding in an Elderly Woman

discrimination as transudate or exudate using Light’s criteria is commonly used to identify the etiology of pleural effusions, but Light’s criteria have only 64% sensitivity in identification of transudative fluid of cardiac origin. Current studies using a pleural fluid NTproBNP value of more than 1,500 pg/mL in discriminating effusions of cardiac origin estimate its sensitivity and specificity to be 94%. The NT-proBNP levels in serum and pleural fluid have also been shown to correlate closely. Because of the rarity of unilateral effusion in congestive heart failure and this individual’s comorbidities, pleural fluid NT-proBNP was used to ascertain the etiology of the fluid. This case illustrates that, when a diagnosis is considered in addition to heart failure, evaluation of NT-proBNP level in pleural fluid is a good diagnostic tool in determining whether the etiology of the effusion is cardiac.

Pruritus in an elderly man

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