Ryan Dean

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.

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.

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.

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.

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.