Intraoperative methadone: Proceed with care.

A recent review suggests minimal respiratory depression (RD) after perioperative methadone, while another identified RD in up to 37 percent of patients. A meta-analysis is equivocal. At our institution, five of 75 opioid naive patients (6.6 percent) given perioperative methadone received naloxone. We report three of these cases in detail. Two others were discovered during an electronic medical record search for opioid naïve patients who received methadone plus naloxone during their anesthesia care. Our five patients indicate that RD owing to methadone can occur with excessive perioperative adjuvant medications and/or in patients who are taking home central nervous system depressants. We define perioperative adjuvant medications as medications given by the anesthesiologist prior to induction and intraoperatively. The risks and benefits of perioperative methadone administration, specifically in patients who received post-operative naloxone, deserve further investigation.

Enterovirus-Induced Severe Rhabdomyolysis and Acute Fulminant Liver Failure in an Immunocompetent Adult Requiring Liver Transplantation: A Case Report.

The authors report a case of a young healthy adult with severe rhabdomyolysis and acute fulminant liver failure with multiple organ dysfunction syndromes (MODS), possibly from an enterovirus infection. To the best of our knowledge, this is the first-ever reported case of enterovirus-induced rhabdomyolysis and acute liver failure (ALF) in an immunocompetent adult. It is vital that the treating physician be aware of the association between viral infections, viral myositis, and severe rhabdomyolysis with acute liver failure, which can facilitate the optimal management of such patients. Prompt recognition may provide an opportunity for early interventions, including intravenous immunoglobulin and liver transplantation, if warranted.

An enigmatic brainstem posterior fossa ganglioglioma in an adult.

Ganglioglioma is a rare central nervous system neoplasm representing 0.4% to 1.7% of all brain tumors and most frequently occurs in the pediatric population with an incidence of 7.6%. These tumors are usually slow-growing and well-circumscribed solid or cystic lesions. Gangliogliomatosis infrequently occurs in the frontal lobe, pineal gland, basal ganglia, hypothalamus, and optic chiasm, with very few reports of brainstem ganglioglioma. We report a case of a 35-year-old female who initially presented with headache, vertigo, ataxia, saccadic dysfunction, dysarthria, and dysmetria for several years due to an unknown etiology. Her brain imaging showed multiple lesions in the pons and the cerebellum with cystic changes and size reduction and enlargement over the next few years while her neurological symptoms continued to worsen. The patient received courses of steroid treatment that improved her neurological symptoms, suggesting an inflammatory component of her disease. Extensive workup for an inflammatory or infectious etiology was unfruitful and two brain biopsies were inconclusive. A third biopsy showed atypical glial nuclei, binucleated cells, and Rosenthal fibers and the presence of BRAF V600E mutation was detected. The diagnosis of gangliogliomatosis was consequently established. This case illustrates that gangliogliomatosis may present with the waxing-and-waning neurological signs and symptoms. It can masquerade inflammatory processes in the central nervous system on brain imaging and deserves careful consideration in the diagnosis of patients with an indolent course of neurological deterioration.