by Mohammed Al-Sadawi, Rishard Abdul and Samy I. McFarlane
Case Report
Background: Since the introduction of heparin as part of the management of acute coronary syndrome, the occurrence of pulmonary embolism (PE) as a complication of myocardial infarction (MI) have somewhat been unheard of. Given this rarity, its recognition is now a formidable challenge. Case Description: We present a case of a previously well 56-year-old male who presented with typical chest pain radiating to the left arm and dizziness. Initial vital signs revealed a blood pressure of 95/65 mmHg and his heart rate was 42 bpm. Physical exam revealed a middle-aged male in no acute distress with cool extremities, normal heart sounds, no murmurs and flat neck veins. His chest was clear to auscultation, abdomen benign and clinically, he was euvolemic. His first electrocardiogram (EKG) was significant for bradycardia with heart block and junctional escape rhythm and ST depressions in the anteroseptal leads. Subsequent right sided EKG showed sinus bradycardia with ST segment elevations in leads II, III and aVF. Troponin I was 0.95 ng/L [normal <0.04 ng/L] and initial transthoracic echo (TTE) was unremarkable with an ejection fraction (EF) of 55-60%. He was given loading doses of aspirin and clopidogrel, heparin drip initiated, and he proceeded to cardiac catheterization which revealed a 60 % stenotic lesion of the mid LAD and a large filling defect with 100% stenosis of the mid RCA consistent with thrombus. Post procedure TTE revealed an EF of 40%, septal and posterior hypokinesis, right ventricular regional wall motion abnormality of the basal and mid free wall with apical hypercontractility (McConnell's sign) suggestive of PE. CT pulmonary angiography revealed bilateral pulmonary emboli and anticoagulation therapy was initiated. Conclusion: This case illustrates that pulmonary embolism is a potential complication of RV infarction and its early identification is critical for implementation of anticoagulation therapy for this potentially fatal condition if left undiagnosed and untreated.
American Journal of Medical Case Reports. 2019, 7(7), 151-157. DOI: 10.12691/ajmcr-7-7-9
Pub. Date: July 05, 2019
12917 Views1627 Downloads
by Jordonna Brown, Odeth Barrett-Campbell, Yakira David, Carol Luhrs and Samy I. McFarlane
Case Report
The presence of beta human chorionic gonadotropin in the absence of pregnancy warrants further work-up as elevated levels may be seen in trophoblastic disease or germ cell tumors and rarely in solid tumors such as gastric cancers. The signs and symptoms of gastric cancer are vague and as such, the diagnosis is often delayed. Overexpression of the beta-subunit of human chorionic gonadotrophin may be seen in close to 50% of gastric cancers. The implication of this finding is unclear; however, beta human chorionic gonadotropin reactivity may play a role in tumorigenesis and often correlates with an advanced stage at presentation. Herein, we present a case report of a patient with an incidental finding of a positive urinary human chorionic gonadotropin test which led to the diagnosis of advanced gastric cancer.
American Journal of Medical Case Reports. 2019, 7(7), 148-150. DOI: 10.12691/ajmcr-7-7-8
Pub. Date: July 05, 2019
7280 Views1674 Downloads
by Daniela M. Tello, Pramod Theetha Kariyanna, Apoorva Jayarangaiah and Samy I. McFarlane
Case Report
HIV disease continues to be a major public health concern with 36.9 million people reported living with HIV in 2017 [1]. Cardiovascular disease (CVD) is one of serious complications of HIV disease. While control of HIV disease with antiretroviral therapy (ART) has been shown to unequivocally reduce all-cause mortality, ART in itself can paradoxically increase CVD risk in the HIV population. In this report we present a case of 32 year old African American woman with long standing uncontrolled HIV disease resulting in multiple cerebral aneurysms with aneurysmal rupture leading to recurrent strokes. We discuss the disease course and highlight the current literature of HIV vasculopathy, a serious complication of HIV disease associated with increased morbidity and mortality in this vulnerable populations.
American Journal of Medical Case Reports. 2019, 7(7), 145-147. DOI: 10.12691/ajmcr-7-7-7
Pub. Date: July 04, 2019
5956 Views1387 Downloads
by Cilia Nazef and Aazim Arif
Case Report
Background:Ciprofloxacin, a member of the fluoroquinolone class, is a commonly used antimicrobial agent for treatment of both gram positive and gram negative bacterial infections. More commonly encountered adverse effects of ciprofloxacin relate to the gastrointestinal tract and include nausea, diarrhea, abnormal liver enzymes, and risk for Clostridium difficile infection. Other adverse effects include QT prolongation, dysglycemia, and risk for tendon rupture. It has been reported that minor CNS effects, such as dizziness and headaches, can result from the use of ciprofloxacin; however there have been rare occurrences of seizures and hallucinations [3,4]. Case Presentation:A 24 year old male patient presented to the primary care clinic with history of voluminous, watery diarrhea, fever, weight loss and abdominal pain for 10 days and has no significant past medical history. Workup demonstrated a positive fecal occult test and multiple pathogens in stool PCR. He was subsequently diagnosed with polymicrobial infectious gastroenteritis and colitis and was prescribed ciprofloxacin 500 mg twice daily and metronidazole 500 mg twice daily for 10 days. Four days later following antibiotics use, the patient had visited the clinic with complaints of feeling unwell, auditory hallucinations, and suicidal ideations without intent or plan. He was suspected to have ciprofloxacin induced psychosis and was instructed to discontinue ciprofloxacin but to continue taking metronidazole. After a week, the patient reported that his psychiatric symptoms had resolved two days after discontinuing ciprofloxacin.Conclusion:Ciprofloxacin-induced psychosis, albeit uncommon, should be included in the differential diagnosis if a patient begins to show signs and symptoms of psychosis during treatment with ciprofloxacin.
American Journal of Medical Case Reports. 2019, 7(7), 143-144. DOI: 10.12691/ajmcr-7-7-6
Pub. Date: June 27, 2019
5527 Views1344 Downloads1 Likes
by Irsa Munir MD, Talha Mehmood MD, Kaiser Islam, Lina Soni and Samy I. McFarlane
Case Report
Thyrotoxic periodic paralysis is a sporadic entity characterized by hypokalemia and paralysis in the setting of hyperthyroidism. TPP is most commonly described in young Asian males. Studies have shown an association with mutations affecting inward rectifying potassium channels. The pathophysiology involves Na+-K+- ATPase channel causing an increased intracellular shift of potassium ions in the hyperthyroid state and in the presence of another precipitating condition. Most cases of thyrotoxic periodic paralysis are defined in young Asian males of 20-40 years of age, here we present an interesting case of thyrotoxic periodic paralysis in 32-year-old African American male, who presented with sudden onset weakness in the bilateral lower extremity and left upper extremity. Interestingly, the patient also has sensory deficits, a feature not known to be associated with thyrotoxic periodic paralysis.
American Journal of Medical Case Reports. 2019, 7(7), 138-142. DOI: 10.12691/ajmcr-7-7-5
Pub. Date: June 26, 2019
8991 Views1780 Downloads
by Odeth Barrett-Campbell, Joselle Cook, Jordonna Brown, Evelyn Taiwo and Samy I. McFarlane
Case Report
While tumor lysis syndrome is a relatively common oncologic emergency that may occur spontaneously or resulting from cancer directed therapy, it is relatively unusual occurrence in solid tumors, especially neuroendocrine tumors. It is also particularly rare after hepatic trans-arterial embolization. We report a case of a 60-year-old man who had hepatic trans-arterial embolization for metastatic neuroendocrine tumor of the liver of unknown primary, who developed tumor lysis along with post-embolization syndrome. He received aggressive intravenous fluid resuscitation, allopurinol and rasburicase for his tumor lysis syndrome but subsequently had acute renal failure for which he underwent renal replacement therapy. The patient responded well to treatment with complete resolution of his post-embolization syndrome, tumor lysis syndrome and acute renal failure. Our case report highlights the need to consider tumor lysis syndrome in solid tumors. It should be readily recognized and treated given the associated high risk of morbidity and mortality.
American Journal of Medical Case Reports. 2019, 7(7), 135-137. DOI: 10.12691/ajmcr-7-7-4
Pub. Date: June 24, 2019
6179 Views1432 Downloads
by Sanwal Sing Mehta, Muhammad Usman Asghar, Hira Cheema and Krishna Kommineni
Mini Review
Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening cause of acute coronary artery syndrome. Although, SCAD may be attributed to underlying medical illness such as connective tissue disease, vasculitis or atherosclerosis, its occurrence in young healthy females is an uncommon phenomenon. Pregnant females, particularly in their peripartum or post-partum periods are affected the most. The etiology remains unclear but certain factors such as hemodynamic and hormonal changes during pregnancy have thought to play a significant role. Spontaneous coronary artery dissection has a very high mortality rate and physicians should be vigilant when an otherwise young healthy female presents with symptoms of acute coronary syndrome.
American Journal of Medical Case Reports. 2019, 7(7), 133-134. DOI: 10.12691/ajmcr-7-7-3
Pub. Date: June 24, 2019
4984 Views973 Downloads
by Charles J. Kim, Devon McKenzie, Joe K. Joseph, Yasemin Aytaman, Milay Luis Lam, Lina Soni and Samy I. McFarlane
Case Report
Insulinoma is a rare neuroendocrine pancreatic islet cell tumor of which the majority are benign and solitary. Its estimated incidence is 2 to 4 cases per 1 million person-years. We report the case of an 82-year-old female who presented with metastatic insulinoma to the liver and retroperitoneal lymph nodes. It was diagnosed based on positive Whipple’s triad, elevated insulin, elevated C-peptide, and negative insulin auto-antibody. Her disease was initially managed with diazoxide 100 mg orally every 8 hours, octreotide LAR 30 mg intramuscularly every month, and sunitinib 12.5 mg orally three times a day. However, patient had recurrent symptoms and imaging consistent with worsened metastatic insulinoma; and thus, treatment was changed to everolimus 10 mg PO daily. Over the subsequent 10 months, the patient developed progressive shortness of breath and hypoxemia with and oxygen saturation (SpO2) of 89% on room air. Computerized tomography (CT) and lung biopsy were consistent with cryptogenic organizing pneumonia (COP) temporally associated with the initiation of everolimus. She was started on prednisone 1 mg/kg/day and within 48 hours, her symptoms and hypoxemia improved to SpO2 of 98-99% at room air and her repeat CT chest showed marked disease improvement. Given her good response with everolimus, it was continued in conjunction with the prednisone and to this day, patient has had a significant therapeutic response with normoglycemia and stable, well-controlled symptoms. This case is unique because to our knowledge, it is the first reported case of a patient with metastatic insulinoma complicated by the development of cryptogenic organizing pneumonia. It reaffirms the causal association between everolimus and cryptogenic organizing pneumonia that has been reported numerous times in literature. However, there has been no reported cases showing that the COP can be managed with prednisone concurrently with everolimus for the metastatic insulinoma without diminished clinical benefit. While pulmonary complications have been cited as reasons for discontinuation of everolimus therapy, our case report highlights the use of steroids as a viable therapeutic strategy that allows successful therapy with everolimus to be continued. In addition to presenting this case, we will also do a thorough review of the literature surrounding the available therapeutic options of metastatic insulinoma. This will include surgery, somatostatin analogs, antimicrobials, potassium channel activators, VEGF-A inhibitors, alkylating agents and mTOR inhibitors to provide a more in-depth picture of how we treat metastatic insulinoma.
American Journal of Medical Case Reports. 2019, 7(7), 125-132. DOI: 10.12691/ajmcr-7-7-2
Pub. Date: June 18, 2019
10133 Views1688 Downloads
by Maliha Hakim, Mashfiqul Hasan, Mahmudul Islam, Mohammad Akter Hossain, Jobaida Naznin and Saifur Rahman Khan
Case Report
Neurocutaneous disorders are a heterogeneous group of genetic disorders that include Sturge-Weber syndrome (SWS), which is characterized by congenital capillary-venous malformation manifesting as port-wine stain, leptomeningeal angiomatosis and ocular angiomas. Diagnosis is made when at least two of these three areas are involved. Abnormal vessels lead to stasis and congestion resulting in decreased regional perfusion and eventually cause hypoxic brain injury with neuronal loss and gliosis. Seizures are common neurological manifestation in SWS patients and many patients have intractable seizures, eventually leading to motor deficits or developmental and cognitive delays. Here we report a case of a 16-year-old boy who presented with typical port-wine stain and seizure disorder since childhood. Neuroimaging revealed evidence of cerebral vascular malformation ipsilateral to the cutaneous lesion. Seizure was controlled with antiepileptic drugs. Early diagnosis and prompt treatment may reduce the incidence of neurologic sequelae. Proper counselling is necessary to improve compliance.
American Journal of Medical Case Reports. 2019, 7(7), 121-124. DOI: 10.12691/ajmcr-7-7-1
Pub. Date: June 16, 2019
7155 Views1231 Downloads1 Likes