Sridhar Badireddi

Pulmonary Talcosis With Intravenous Drug Abuse

Talc has been known to cause lung disease, via inhalation or intravenously. A good history along with radiological correlation will often reveal the diagnosis. However, most intravenous drug abusers are reluctant to give a history of exposure, and most diagnoses are made after lung biopsy. We

Respiratory Failure Secondary to Relapsing Polychondritis

Diffuse airway narrowing of the trachea or main bronchus may result from various autoimmune connective tissue diseases. A careful clinical and pathological evaluation is warranted given the broad differential diagnosis. Relapsing polychondritis (RP) is a rare multisystem disorder that primarily

Vitamin D Deficiency in Patients With Neuromuscular Diseases With Chronic Respiratory Failure

BACKGROUND The prevalence and clinical implications of vitamin D deficiency have never been studied in patients with underlying neuromuscular diseases complicated with chronic respiratory failure. The aim of this study is to demonstrate the prevalence of vitamin D deficiency, its relationship with other bone markers, and mode of nutrition. MATERIALS AND METHODS Serum 25-hydroxyvitamin D (25[OH]D) levels along with calcium, serum albumin, and phosphorus levels were obtained from 57 patients with chronic respiratory failure due to underlying neuromuscular diseases. These levels were obtained during their first visit to a chronic respiratory diseases clinic. Data with regard to nutrition, respiratory muscle function, and level of mobility were also obtained at the same time. RESULTS Seventy-five percent of patients had serum 25(OH)D levels ≤ 30 ng/mL. There is a negative correlation between parathyroid hormone and 25(OH)D levels (P = .006) and corrected calcium levels (P = .066). Serum 25(OH)D levels varied with the mode of nutrition. Patients on enteral nutrition had the highest serum levels of 25(OH)D, whereas combined oral and tube feeds had the lowest 25(OH)D levels (P = .006). CONCLUSION Low serum 25(OH)D levels are highly prevalent in patients with neuromuscular disease and chronic respiratory failure. The route of nutrition has an impact on these levels.

Acute Thyrotoxic Bulbar Myopathy with Encephalopathic Behaviour: An Uncommon Complication of Hyperthyroidism

Objective. Acute thyrotoxic bulbar palsy is rare, severe, and rapidly progressive. We describe a case of thyrotoxicosis with bulbar palsy, encephalopathy, and pyramidal tract dysfunction. Case Report. 64-year-old white male with toxic multinodular goiter presented with rapid atrial fibrillation. He had mild tremor, normal cranial nerve examination, 4/5 strength in all extremities, normal reflexes, and down going plantars. TSH was low at 0.09 (normal: 0.34–5.6 uIU/mL), and free T4 was high at 5.22 (normal: 0.47–1.41 ng/dL). Despite optimal AV nodal blockade, he had persistent rapid atrial fibrillation. He later developed cervical dystonia, rigidity, clonus, dysarthria, dysphagia, vocal cord palsy, and absent gag reflex. Thyroid storm was suspected. Neuroimaging and cerebrospinal fluid cultures were nondiagnostic. Acetylcholine receptor antibodies were negative. Swallow ability was impaired with heavy secretions. Remarkable improvement in symptoms was noted after initiation of treatment for thyroid storm. Conclusion. Pyramidal tract symptoms and bulbar palsy may occur with thyrotoxicosis. Cranial nerve involvement and encephalopathy raise a question of primary brain mechanism causing bulbar palsy. This is reversible with prompt treatment of thyroid storm.

Images in clinical medicine. Mandibular tori.

n engl j med 370;5 nejm.org january 30, 2014 e8 A 79-year-old man was admitted to the medical intensive care unit because of acute respiratory failure, cardiogenic shock, acute kidney injury, and urinary tract infection. He had a long-standing history of cor pulmonale. Incidentally, he was noted to have abnormalities on the lingual surface of the lower jaw. Three bony outgrowths were seen and diagnosed as mandibular tori (also known as tori mandibulares). The patient reported no history of a chewing disability, dysphagia, dysarthria, oral ulcers, or sleep disturbances associated with the oral findings. The patient recovered from cardiogenic shock and was discharged home. Tori are benign exostoses, and in most cases, the finding is incidental and requires no intervention, as in this case. Possible reasons for extirpation would be the need for prosthetic treatment and the need for a potential source of grafts, as in periodontal surgery.