Rogin Subedi

Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome

Kounis syndrome (KS) is a hypersensitivity coronary disorder induced by exposure to drugs, food, environmental and other triggers. Vasospastic allergic angina, allergic myocardial infarction (MI) and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three main variants of this syndrome. We reviewed 175 patients who fulfilled the definition of one of the three types of KS. The epidemiology, diagnostic findings, management and complications were reviewed in this article.

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.

Chylous ascites as a complication of intraabdominal Mycobacterium avium complex immune reconstitution inflammatory syndrome

ABSTRACT Chylous ascites is an uncommon finding of triglyceride-rich lymph in the peritoneal cavity. There are a variety of reported etiologies for chylous ascites; however, the reporting of chylous ascites among AIDS/HIV-positive patients is quite uncommon. This finding as a complication of immune reconstitution inflammatory syndrome is even more unusual. Here we report a case of an HIV-positive man with a history of colonic Mycobacterium avium complex who developed chylous ascites in the setting of increasing CD4 counts and decreasing viral load, suggestive of immune reconstitution inflammatory syndrome.

Spontaneous tumor lysis syndrome in small cell lung cancer

ABSTRACT Tumor lysis syndrome is a set of metabolic disturbances that can be seen during the destruction of tumor cells and is an oncologic and metabolic emergency. The syndrome is rare in those with solid tumors, and even more rare in those with solid tumors who have not yet received chemotherapy. We present a case of tumor lysis syndrome in a patient with small cell lung cancer.

Flecainide toxicity in renal failure

ABSTRACT Flecainide, a class Ic antiarrhythmic, is used for the prevention of paroxysmal supraventricular tachycardia, paroxysmal atrial fibrillation/flutter, and sustained ventricular tachycardia. Flecainide is primarily metabolized by the liver and to a lesser extent (30%) is excreted unchanged in the kidney. We present a case of flecainide toxicity in the setting of renal impairment that was successfully treated with intravenous sodium bicarbonate.

More than a drink: A rare anaphylactic reaction to sparkling water

Anaphylaxis is a potentially life threatening, type I hypersensitivity reaction which can occur within seconds to minutes after exposure to an allergen. Sulfites have been implicated in causing such reactions with symptoms ranging from mild to potentially life threatening. Here we present a patient who had an anaphylactic reaction secondary to exposure to sulfites found in sparkling water.

Carotid artery dissection: a rare complication of Eagle syndrome.

Carotid artery dissection is a significant cause of ischaemic stroke in all age groups and accounts for a large percentage of strokes in young patients. Carotid dissection can be caused by trauma, underlying connective tissue disease, hypertension, mechanical injury or can be spontaneous. We present an exceedingly rare case of carotid dissection caused by an elongated styloid process, causing direct mechanical damage to the carotid artery.

A novel case of Raoultella planticola osteomyelitis and epidural abscess.

A spinal epidural abscess is the collection of pus in the epidural space, and is a potentially life-threatening condition that requires early detection and prompt management. Almost two-thirds of cases are caused by Staphylococcus aureus, followed by Gram-negative bacilli which account for approximately 16% of cases. Raoultella planticola is an emerging pathogen, and is an extremely rare cause of invasive infection in humans. It has been reported to cause urinary tract infections, pneumonia, bacteraemia, cholangitis, cholecystitis, conjunctivitis and soft tissue infections. We report the first case, to our knowledge, of R. planticola osteomyelitis and spinal epidural abscess.

Review of potential drug interaction between Oseltamivir and Warfarin and why it is important for emergency medicine physicians

Oseltamivir is a very commonly prescribed anti-viral medication by the Emergency Medicine (EM) physicians for the prophylactic and therapeutic treatment of Influenza infection. While the drug interaction of Warfarin with various antibiotics is known, the drug interaction between Oseltamivir and Warfarin is not common. We present a case where an 83-year female patient, on Warfarin for Pulmonary Embolism, had worsening of coagulopathy after she was started on Oseltamivir. The INR was monitored daily in our patient and Warfarin was stopped when the INR became supra-therapeutic. Our patient did not have any minor or major bleeding complication. This is the first reported case of Oseltamivir related worsening coagulopathy in patient on Warfarin to the best of our knowledge. Keeping in mind the possible interaction between the two as it was evident in our case and few other published reports, we recommend monitoring the INR closely in patients using Warfarin after they are started on Oseltamivir therapy.

The curious case of a cardiac tamponade in the hypertensive patient presenting as abdominal fullness

Cardiac tamponade is a medical emergency consisting of an accumulation of fluid in the pericardial space which is rapidly progressing and fatal. Because cardiac tamponade is ultimately a clinical diagnosis, mindful consideration for atypical presentations is essential for the reduction of mortality in the acute setting. Our patient was a 77year-old female admitted after presenting with general malaise, weakness, somnolence, altered mental status and urinary incontinence found to have CML (chronic myeloid leukemia) on confirmatory bone marrow biopsy after suspicions arose from a leukocytosis of 34,000 cells per mcL with 85% neutrophils and elevated blasts (8%). Initial vital signs revealed mild tachycardia, mild tachypnea and blood pressure elevated to 162/84mm Hg along with a temperature of 38.7°C and oxygen saturation of 96% on 2l by nasal cannula. She received the standard of care for a community acquired pneumonia and was started on treatment with decitabine as further work-up was unremarkable. An abdominal CT performed for abdominal fullness later displayed a large pericardial effusion. Repeat echocardiography exhibited right atrial diastolic collapse, inferior vena cava dilatation (IVC) without inspiratory collapse >50% and the large pericardial effusion consistent with tamponade. The blood pressure remained hypertensive until she suddenly went into cardiac arrest after being intubated for a pericardial window and expired. Our case highlights the need to keep cardiac tamponade as a differential in the hypertensive individual with abdominal complaints as atypical presentations can obscure diagnosis, delay treatment and increase mortality.