Severity-of-Illness Scores and Discharge Disposition in Patients Admitted to Long-Term Acute Care Hospitals.

BACKGROUND: After an intensive care unit (ICU) admission, nearly 20% of survivors of chronic critical illness require admission to a long-term acute care hospital (LTACH) for continued subspecialty care. The effect of the burden of medical comorbidities on discharge disposition after LTACH admission remains unclear. METHODS: A retrospective cohort study was performed involving patients with chronic critical illness who were discharged from the medical ICU and admitted to an LTACH between 2016 and 2018. The patients' Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Nutrition Risk in the Critically Ill (NUTRIC), and Charlson Comorbidity Index (CCI) scores at the time of LTACH admission were calculated from electronic medical records. The mean scores on each instrument were compared by discharge disposition. RESULTS: A total of 156 patients were admitted to the LTACH from the medical ICU between 2016 and 2018. They had a mean (SD) age of 61.5 (13.3) years, a mean (SD) body mass index of 28.1 (8.3), a median (IQR) ICU stay of 16.3 (1-108) days, and a median (IQR) LTACH stay of 38.2 (1-227) days. Patients who were discharged home had lower mean (SD) APACHE II (14.6 [5.0] vs 18.2 [5.4], P = .01), SOFA (3.3 [2.1] vs 4.6 [2.1], P = .03), NUTRIC (3.3 [1.4] vs 4.6 [1.4], P = .001), and CCI (4.3 [2.5] vs 6.1 [2.8], P = .02) scores on admission to the LTACH than those who were not discharged home. CONCLUSION: Severity-of-illness scores on admission to an LTACH can be used to predict patients' likelihood of being discharged home.

Disseminated Cryptococcosis in an Immunocompromised Patient with Altered Mental Status and a Lung Nodule.

Introduction: Disseminated cryptococcosis is an opportunistic infection that commonly affects the central nervous and respiratory systems and is often fatal in immunocompromised host patients. Diagnosing disseminated cryptococcosis is challenging at times due to the nonspecific presentation, resulting in delayed treatment and increased mortality. Case presentation: A 48-year-old man presented with altered mental status and shortness of breath requiring intubation. Medical history was significant for rheumatoid arthritis, diabetes mellitus, chronic kidney disease, sarcoidosis, and polymyalgia rheumatica. Home medications included prednisone, methotrexate, and tocilizumab. Computed tomography chest revealed multifocal pneumonia with a cavitary nodule with halo sign. One week after extubation, the patient remained confused. Lumbar puncture (LP) was positive for Cryptococcus neoformans within 5 days. Bronchoalveolar lavage (BAL) yielded similar results on fungal culture one month later. Conclusion: An immunocompromised host patient who presents with altered mental status with concomitant lung nodules should have disseminated cryptococcosis as a differential diagnosis. CT chest commonly demonstrate peripheral lung nodules with cavitation, air bronchograms, halo sign, and/or enlarged mediastinal lymphadenopathy, as found in our patient. If the clinical suspicion for disseminated cryptococcosis is high, an LP should be performed, as BAL results may often be delayed since Cryptococcus grows slowly from the lungs. Empiric antifungals should be started immediately, given increased mortality if treatment is delayed.

A case of fatal disseminated adenovirus and drug-resistant Pneumocystis pneumonia in a patient who received chemotherapy for mantle cell lymphoma.

Adenovirus (ADV) may cause severe complications in hematopoietic stem cell transplant recipients, but disseminated ADV infections in patients who received chemotherapy alone for hematological malignancies are poorly understood due to the rarity of cases. Concomitant infection with Pneumocystis (PCP) is extremely rare. Despite being diagnostically challenging, a more specific workup needs to be initiated with a low threshold in patients who are exposed to agents with the potential to suppress T cells. We report a fatal case of disseminated ADV and drug-resistant PCP pneumonia in a patient with mantle cell lymphoma who had only received combination chemotherapy. A 75-year-old man who was diagnosed with mantle cell lymphoma 10 months prior was admitted for mild hypoxic respiratory failure. Bendamustine, Rituximab, Cytarabine regimen had resulted in complete remission of his lymphoma, with the last cycle of chemotherapy administered 3 months prior to admission. CT of the chest revealed ground-glass opacities concerning pneumonia. Initial laboratory tests were remarkable for mild leukopenia. The respiratory viral panel was only positive for ADV. He did not respond to empiric antibiotics for community-acquired pneumonia and Trimethoprim / Sulfamethoxazole given later for positive Beta D Glucan (BDG) suggestive of Pneumocystis pneumonia. Then, he developed hemorrhagic cystitis, followed by liver and renal function derangement that prompted checking serum ADV viral load by polymerase chain reaction (PCR). This test took 1 week to return, with a viral load of 50, 000 copies/mL suggesting disseminated ADV infection. Despite initiation of Cidofovir, multi-organ failure continued to progress, and the follow-up viral load had doubled on Day 2. The patient passed away the same day shortly after transition to comfort care. T cell suppression seems to be a risk factor for disseminated ADV disease. Clinicians may need to maintain a low threshold to send serum quantitative ADV PCR when symptoms are not improved by antimicrobial treatment for more conventional infections in patients who received agents that are known to suppress T cells, such as Bendamustine.

Guillain-Barre syndrome secondary to COVID-19 infection: A case report.

Guillain-Barre syndrome (GBS) is a rare autoimmune disease that often manifests as a post-viral complication. However, its association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. We present a rare case of GBS secondary to COVID-19 infection complicated by rapidly progressive sensorimotor deterioration resistant to plasma exchange therapy.

Spontaneous Oropharyngeal Hemorrhage Complicated by Cirrhosis, Resulting in Hemorrhagic Shock.

BACKGROUND Spontaneous oropharyngeal hemorrhage is rare and is often associated with other predisposing factors. This can result in hemodynamic instability in the presence of other bleeding sources. It is oftentimes difficult to diagnose due to its limitations to visual inspection of the oropharyngeal structures. It is commonly mistaken for hemoptysis or hematemesis upon initial evaluation. Trauma, infection, pulmonary pathologies (ie, lung cancer or tuberculosis), gastrointestinal pathologies (ie, esophageal/gastric varices, Mallory-Weiss tears, esophagitis), coagulopathies, medications, and prolonged intubation have been shown to increase the risk of oropharyngeal hemorrhage. CASE REPORT A 54-year-old man with a medical history of alcohol use disorder, liver cirrhosis, portal hypertension, and gastric varices presented with altered mental status. He was subsequently intubated for airway protection. Bleeding from the oropharynx was later found. Esophagogastroduodenoscopy (EGD) and bronchoscopy were unrevealing. Computed tomography angiography (CTA) of the head and neck revealed active bleeding of the right posterior pharyngeal artery, which was emergently embolized. Over the next few days, he continued to bleed from the oropharynx and became hemodynamically unstable. CTA abdomen showed bleeding from gastric varices and large-volume hemoperitoneum with multiple sources of active bleeding from the liver, duodenum, and jejunum. CONCLUSIONS We present a rare case of spontaneous oropharyngeal hemorrhage and gastric variceal bleeding resulting in hemorrhagic shock in a cirrhotic patient with multiple predisposing factors. If a patient presents with spontaneous oropharyngeal hemorrhage, clinicians should consider bleeding from the oropharynx if EGD and bronchoscopy are unrevealing. Thus, an emergent CTA of the head and neck should be strongly considered to further evaluate a potential source of active bleeding, as delayed diagnosis can be life-threatening.

Lamotrigine-Induced Lupus With Aseptic Meningitis and Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome characterized by disordered immune activation resulting in cytokine storm and inflammation. We present a 27-year-old woman who had a fever and diffuse rash after recently starting lamotrigine. She developed meningismus and polyarthralgia. Laboratory results revealed cytopenia, elevated serum aminotransferases, hypofibrinogenemia and elevated ferritin. Cerebrospinal fluid analysis suggested aseptic meningitis. Antinuclear antibody and rheumatoid factor serologies were positive, complement levels of C3 were decreased, and antihistone antibody was negative. A bone marrow biopsy demonstrated hemophagocytic macrophages and the diagnosis of HLH was made. The patient was empirically started on high-dose intravenous dexamethasone following which both her mental status and laboratory indices markedly improved. Lamotrigine has been shown to induce lupus-like syndrome, aseptic meningitis, and HLH, but not concomitantly. Our patient was recently started on lamotrigine, likely inducing her underlying undiagnosed lupus, in addition to, resulting in aseptic meningitis and a cytokine storm leading to HLH.

Insulin Edema Syndrome due to Rapid Glucose Correction in a Diabetic Patient.

Edema resulting from the initiation of insulin therapy or intensification of glycemic control is a rare and under-recognized complication. In this report, we present a case of a 46-year-old patient with insulin-dependent diabetes mellitus (IDDM) who avoided insulin treatment due to associated peripheral edema. Though rare, this phenomenon is typically seen in patients with elevated glucose levels who are initiated on insulin treatment, resulting in rapid correction and tight control of glucose levels. The diagnosis of insulin-induced edema is made after other causes of acute edema are ruled out. Furthermore, in this case report, we will also discuss the postulated mechanisms for the edema-causing property of insulin.

The Effect of a Dedicated Lung Mass Clinic on Lung Nodule Follow Up.

Introduction: With the increased use of computed tomography (CT) imaging, lung nodules are found yearly requiring tracking and guideline directed follow up imaging. We describe the structure of a clinic dedicated to lung nodule tracking, patient education and the outcomes of lung nodule follow up. Methods: Patient electronic medical record charts were reviewed for lung nodules requiring tracking to determine if a follow up study was ordered, completed by the patient, and completed in an appropriate time frame. Patients were grouped based on referral to pulmonary clinic, lung mass clinic, or no subspecialty clinic. 700 CT reports were extracted from the electronic medical record of which 350 (50%) had lung nodules reported on CT, and 111 (15.9%) were lung nodules that additionally recommended discrete follow up in the radiologist report at the Veterans Health Administration hospital in Baltimore. Of these 111 patients, 95% were male and 5% were female. The mean age of the population was 66.3 ± 7.7 years. Results and Discussion: Patients seen in the lung mass clinic had a statistically significant higher rate of the follow up study being ordered by the provider. The lung mass clinic also had a higher percentage of patients who completed the study and completed the study within the recommended time frame, however, this was not statistically significant. Conclusion: A dedicated lung mass clinic should be considered as a method of improving lung nodule tracking with the added benefit of patient education and multidisciplinary care.

Antipsychotic Medication-Induced Hyperthermia Leading to Cerebrovascular Accident: A Case Report.

Antipsychotic medications are used in the management of schizophrenia. Antipsychotic medications treat both positive and negative symptoms via the dopamine D2 receptor and serotonin 5-HT2A blockade pathway. Side effects include hyperprolactinemia, prolonged QTc, and neuroleptic malignant syndrome. However, antipsychotic medication-induced hyperthermia potentiating a cerebrovascular accident (CVA) is a rare side effect that is less well known. A 47-year-old male presented to the emergency department (ED) via emergency medical services for altered mental status. He was given naloxone without improvement in mental status. His glucose was 110 mg/dL. Upon presentation to the ED, he was hyperthermic (106.7 degrees Fahrenheit) and tachycardic (heart rate of 160's beats/minute). Home medications included risperidone and fluphenazine. After the resolution of his hyperthermia, he had a right-sided facial droop concerning a cerebrovascular accident. Magnetic resonance imaging (MRI) of the brain confirmed an early/acute subacute right cerebellar infarction. The patient received optimal treatment; his mental status returned to baseline, and he was discharged home without antipsychotic medications. Patients who are prescribed antipsychotics should be aware of the potentially fatal adverse events that can occur from these medications. Thermoregulation may be impaired in these patients, resulting in significant hyperthermia, in which case antipsychotic medications should be discontinued.

COVID-19 Presenting as Recurrent Pericardial Effusion.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) emerged from Wuhan, China, in 2019, causing coronavirus disease 19 (COVID-19) and creating a global pandemic affecting millions of people worldwide. Though COVID-19 primarily affects the pulmonary structures, deleterious effects can also occur in the cardiac system. We present a case of a patient with recurrent pericardial effusions secondary to COVID-19 infection, an unusual cardiovascular manifestation of this disease. A 47-year-old man presented with altered mental status and tested positive for COVID-19. He left against medical advice and later presented two weeks later with pleuritic chest pain associated with shortness of breath. His symptoms were attributed to a moderate- to large-sized pericardial effusion, without evidence of tamponade, as confirmed by echocardiography. The fluid was removed by pericardiocentesis; analysis was negative for malignant cells, inflammatory markers, or microbiologic studies. Reaccumulation of the fluid necessitated placement of a pericardial window, resulting in the resolution of his symptoms. There are limited case reports demonstrating the association of pericardial effusion with COVID-19 infection. The effusion is likely secondary to the inflammatory response leading to capillary leakage, resulting in pericardial fluid traversing the serous pericardium. In addition to other demonstrated cardiovascular effects, COVID-19 appears to be associated with recurrent pericardial effusion. Due to the rise in COVID-19 cases, it is essential to consider pericardial effusion as a rare but potential complication of this virus. The pericardial effusion can be the primary clinical manifestation, recurrent in nature, and potentially result in tamponade physiology.

Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation - can we find a proper balance?

BACKGROUND & AIMS: Survivors of critical illness requiring prolonged mechanical ventilation (PMV) are predisposed to malnutrition, muscle wasting, and weakness. There is a lack of data regarding nutrition adequacy among these patients, and although nitrogen balance has been studied as a marker of adequate protein intake in healthy individuals and acutely critically ill patients, it has not been well studied in critically ill patients with PMV. The purpose of this study was to determine if patients requiring PMV admitted to a long-term acute care hospital (LTACH) achieved registered dietitian (RD) recommended goals for energy and protein intake and if the recommendations were adequate to avoid negative nitrogen balance. METHODS: Using a retrospective, cohort study design, patients requiring PMV who had orders for 24-h urine collections for urea nitrogen (24hrUUN) were included. Energy and protein intake was calculated from chart documentation of dietary intake for the 24-h period during which patients underwent a 24hrUUN. Nitrogen intake was estimated from protein intake. Dietary intake was compared to RD-recommendations to determine the percentage of RD-recommendations achieved. Nitrogen balance was calculated as nitrogen intake minus nitrogen loss, with negative balance categorized as less than -1. RESULTS: Subjects (n = 16) were 38% male and 75% African American (mean age 61.5 ± 3.2 years; mean BMI 27.5 ± 2.5 kg/m2). Duration of LTACH hospitalization was 26.5 (6-221) days. Mean energy and protein intake was 21.7 ± 2.9 kcal/kg/d and 1.1 ± 0.1 g/kg/d, respectively, which corresponded to 86% of both RD energy and protein recommendations. Ten patients achieved a positive nitrogen balance (mean 0.9 ± 1.1 g). In addition, there was a positive linear relationship between protein intake and nitrogen balance (r = 0.59, p = 0.016). CONCLUSION: Survivors of critical illness requiring PMV achieved a high percentage of RD-recommended protein and calories, and prevented a negative nitrogen balance in a majority of patients. Increasing protein intake can prevent a negative nitrogen balance. Future studies should evaluate whether these patients are able to maintain a steady state of nitrogen intake and excretion over time and how this affects time to and/or success of weaning.

A successful case of extracorporeal membrane oxygenation for COVID-19: walking home without oxygen supplementation.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from Wuhan, China in December 2019 and is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19). Approximately one-third of the patients with COVID-19 require intensive care unit (ICU) admission, and almost 30% of the patients develop acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used as salvage therapy for severe ARDS. The role of ECMO in the treatment of COVID-19 remains unclear, although there is emerging evidence that this approach may be an effective salvage therapy for severe ARDS. Case Presentation: We present a case of a previously healthy 39-year-old Hispanic male who presented to the hospital with flu-like symptoms, including headache, fatigue, and myalgia for 8 days in late April 2020. He denied dyspnea on exertion. The patient's symptoms progressed, resulting in pneumonia and acute respiratory distress syndrome (ARDS). The patient was managed with prone positioning, convalescent plasma and veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 35 days. The patient successfully recovered and was able to ambulate independently and was discharged home from an acute care hospital without oxygen supplementation on hospital day 63. Conclusion: We present one of the first few documented cases of ECMO for severe ARDS due to COVID-19. After a prolonged hospital course requiring VV-ECMO, the patient was discharged home from an acute care hospital without oxygen requirement and ambulated independently, likely as a result of daily aggressive mobility-focused rehabilitation.

Human Metapneumovirus Pneumonia Precipitating Acute Respiratory Distress Syndrome in an Adult Patient.

Acute respiratory distress syndrome (ARDS) is often due to direct lung injury, trauma, surgery, or infection. Making a definitive diagnosis may be difficult initially, as clinical manifestations are nonspecific until the disease progresses. We present a case of human metapneumovirus (hMPV) pulmonary infection precipitating ARDS. A 51-year-old woman presented with one week of pleuritic chest pain, dyspnea, wheezing, subjective fever, and productive cough prior to presentation. Her medical history was significant for human immunodeficiency virus (HIV) with an unknown CD4 count and viral load, pulmonary sarcoidosis, asthma, and being an active smoker. On admission, the patient was dyspneic and using accessory muscles to breathe. She was afebrile and hypotensive. Physical examination revealed bilateral diffuse crackles. Her white blood cell (WBC) count was 7.7 K/mcL. A chest radiograph demonstrated bilateral lung opacifications suggestive of pneumonia, possibly Pneumocystis jiroveci pneumonia (PJP). Broad-spectrum antibiotics, including PJP treatment, corticosteroids, and fluids, were started. The patient received approximately 4 liters of intravenous fluids; yet, she remained hypotensive and required norepinephrine. Chest computed tomography (CT) demonstrated bilateral consolidations. Arterial blood gas (ABG) showed a partial pressure of oxygen (PaO2) of 55 mmHg. The patient was intubated for acute hypoxemic respiratory failure and had a PaO2/fraction of inspired oxygen (FiO2) < 100. Repeat ABG within 12 hours showed a potential of hydrogen (pH) of 7.34, partial pressure of carbon dioxide (pCO2) of 42 mmHg, and a PaO2 of 130 mmHg. Bronchoalveolar lavage revealed only hMPV. The patient was managed supportively and extubated three days later. She was discharged home without oxygen requirement. hMPV causes respiratory infections, most commonly in the extremes of age and immunocompromised patients. The treatment is supportive. Our patient developed acute hypoxemic respiratory failure secondary to an hMPV infection. hMPV pneumonia should be considered as a differential diagnosis in patients with severe respiratory illness and ARDS in order to promote antibiotic stewardship.

Pancolitis Associated With COVID-19 Infection: A Case Report.

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 infection commonly affects the pulmonary system, ranging from being asymptomatic to having mild upper respiratory tract infection symptoms, to having severe cases causing multi-organ failure. However, COVID-19 infection involving the gastrointestinal (GI) tract leading to pancolitis is an extremely rare complication. We present a rare case of a patient who presented with pancolitis and on testing for admission found to be positive for COVID-19. We will explore the GI tropism and the mechanism of COVID-19 infection with gastrointestinal symptoms of pancolitis.

The Effect of High Protein and Mobility-Based Rehabilitation on Clinical Outcomes in Survivors of Critical Illness.

BACKGROUND: Protein supplementation and mobility-based rehabilitation programs (MRP) individually improve functional outcomes in survivors of critical illness. We hypothesized that combining MRP therapy with high protein supplementation is associated with greater weaning success from prolonged mechanical ventilation (PMV) and increased discharge home in this population. METHODS: We conducted a retrospective analysis assessing the effects of an MRP on a cohort of survivors of critical illness. All received usual care (UC) rehabilitation. The MRP group received 3 additional MRP sessions each week for a maximum of 8 weeks. Subjects were prescribed nutrition and classified as receiving high protein (HPRO) or low protein (LPRO), based on a recommended 1.0 g/kg/d, and then the subjects were categorized into 4 groups: MRP+HPRO, MRP+LPRO, UC+HPRO, and UC+LPRO. RESULTS: A total of 32 subjects were enrolled. The MRP+HPRO group had greater weaning success (90% vs 38%, P = .045) and a higher rate of discharge home (70% vs 13%, P = .037) compared to UC+LPRO group. The MRP+HPRO group had a higher, nonsignificant rate of discharge home compared to the MRP+LPRO (70% vs 20%, P = .10). CONCLUSIONS: Combining high protein with mobility-based rehabilitation was associated with increased rates of discharge home and ventilator weaning success in survivors of critical illness. Further studies are needed to evaluate the role of combined exercise and nutrition interventions in this population.

Anti-synthetase syndrome in a patient with recurrent episodes of pulmonary embolism: a case report.

Anti-synthetase syndrome (ASS) is characterized by myositis that is associated with progressive interstitial lung disease (ILD). The prognosis of the disease is affected by the type and degree of pulmonary involvement. We report a rare case of ASS with positive Anti-EJ antibody presenting with a combination of recurrent deep vein thrombosis/pulmonary embolism (DVT/PE) and progressive ILD. This case demonstrates the delayed diagnosis of ASS and the association of thromboembolic disease and ASS. Physicians should have a high index of suspicion for ASS, as early diagnosis and management alters the morbidity and prognosis of patients with ASS. ABBREVIATIONS: ASS: Anti-synthetase syndrome; Ab: Antibody; Ag: Antigen; ANA: Anti-nuclear antibodies; CK: Creatine kinase; CRP: C-reactive protein; DVT: Deep Vein Thrombosis; ESR: Erythrocyte Sedimentation Rate; ILD: Interstitial lung disease; PE: Pulmonary Embolism; CTA: CT Angiography.

Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness.

BACKGROUND: Survivors of prolonged ICU admissions are bedridden and immobilized for an extended period of time. These patients often are discharged to long-term acute care hospitals (LTACHs) for continued medical care and rehabilitation. Early ambulation has been associated with improved functional outcomes and lower readmission rates in hospitalized patients. The aim of this study was to determine the association between ambulatory status and discharge disposition in survivors of prolonged ICU stays who were admitted to an LTACH. METHODS: We performed a retrospective cohort study of 285 survivors of prolonged ICU stays who were admitted to a university-affiliated LTACH facility from 2010 to 2013. Outcomes of interest included comparing the relationship between ambulatory status and disposition status (ie, home vs acute rehabilitation facility, nursing home, readmission to an ICU, or death). RESULTS: The mean age of our cohort was 59.0 ± 15.3 y, with 129 (45%) males, 148 (52%) African-American, 123 (43%) white, and 14 (5%) of subjects other races. Most of these subjects were transferred from a medical ICU (68%). The median ICU and LTACH lengths of stay were 25.5 (13-38.8) d and 34.0 (14-64) d, respectively. Thirty-eight (13.3%) subjects were discharged home, 25 (8.7%) to an acute rehabilitation facility, 70 (24.6%) to a nursing home, 139 (48.8%) were readmitted to an ICU, and 13 (4.6%) died. Of 285 total subjects, 74 (26%) ambulated during physical therapy, while 211 (74%) subjects never ambulated. Of those who ambulated, 24 (32.4%) went home, whereas 14 of 211 (6.6%) subjects who did not ambulate went home (P < .001). CONCLUSIONS: The ability to ambulate was associated with a greater likelihood of being discharged home in survivors of prolonged ICU stays who were admitted to an LTACH. These results suggest that mobility training for survivors of prolonged ICU stays in LTACH facilities should be strongly emphasized to improve their likelihood of being discharged home.

Cocaine as a rare cause of locked-in syndrome: a case report.

INTRODUCTION: In the United States, cocaine is a commonly used drug of abuse. It is also a recognized contributing factor for both hemorrhagic and ischemic strokes. However, cocaine-induced basilar artery thrombosis has rarely been reported in the literature. CASE PRESENTATION: Our patient was a 51-year-old African American woman with a history of polysubstance abuse who presented to the emergency department for acute behavior changes. Later, during admission, she had a dramatic decrease in motor strength in all extremities and a positive Babinski reflex bilaterally. The results of her toxicology reports were positive for cocaine; in addition, results of magnetic resonance angiography and magnetic resonance imaging were consistent with acute thrombosis and subsequent infarction of the basilar artery. Her mental status improved, but she was only able to communicate via movements of her eyes. CONCLUSION: Our patient developed locked-in syndrome after use of cocaine. Given the prevalence of its use in the United States, cocaine use should be included among the potential causes of locked-in syndrome.

Carcinoid tumor causing ileoceccal intussusception in an adult patient.

Introduction: Little is known about adult intussusception, but current evidence suggests that malignancy, polyps, and diverticula are usual etiologies. We present a case of adult ileoceccal intussusception secondary to carcinoid tumor. Case Presentation: A 53-year-old African American male presented with hematochezia and non-radiating constant left upper quadrant pain accompanied by nausea and vomiting. CT of the pelvis demonstrated a pathognomic 'target' sign, consistent with ileoceccal intussusception and early small bowel obstruction. Two years prior to this current presentation, the patient had experienced an episode of hematochezia for which he underwent colonoscopy and polypectomy, with subsequent pathology results negative for colon cancer. He denies diarrhea, constipation, weight loss, decreased appetite or skin flushing. Due to persistent symptoms of bowel obstruction, he underwent exploratory laparotomy. During the surgery a white-colored, chalky mass indicative of penetrating tumor was noted 13 cm proximal to the ileocecal valve. An extended right hemi-colectomy followed the discovery of the mass. Pathology showed a well-differentiated neuroendocrine tumor consistent with carcinoid tumor. Evaluation for metastatic disease using 5-HIAA and chromogranin A was unremarkable, and the resection of the right colon carcinoid tumor was felt to be curative. Conclusion: It is uncommon for adults to present with intussusception; in such cases, malignancy should be ruled out as an underlying cause. Carcinoid should be listed among the other secondary causes, which include inflammatory bowel disease, diverticulitis, polyps, scar tissue, adhesions, and lipomas. Abbreviation: CT (Computer tomography), 5-HIAA (5-hydroxyindole acetic acid), NCCN (National Comprehensive Cancer Network).