An evaluation of suspected cases of Hantavirus infection admitted to a tertiary care university hospital in Düzce, Turkey, between 2012 and 2018

Background/aim: Hantavirus is a rodent borne zoonosis caused by the members of the virus family Bunyaviridae, genus Hantavirus. In this study, we aimed to determine the role of peripheral blood leukocyte ratio in differential diagnosis of Hantavirus disease. Materials and methods: The medical records of patients at the Düzce University Medical Faculty were examined retrospectively. A total of 20 patients diagnosed with hantavirus infection confirmed by serologic tests were included in the study (Group 1). The other group consisted of 30 patients suspected of hantavirus infection but found negative (Group 2). Demographic, clinical and laboratory characteristics, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte (LMR) ratios of both groups were compared. Results: As a result of the istatistics analysis, no difference was found between the groups' age, sex, and clinical complaints except lethargy-weakness (P = 0.004) and diarrhea (P < 0.001). Hemogram analysis showed a significant difference between the groups in terms of leukocyte, hemoglobin, hematocrit, platelet, mean platelet volume (P < 0.05) and PLR (P = 0.001) and LMR (P = 0.003) values from peripheral blood leukocyte ratios. Conclusion: In conclusion, NLR, PLR, and LMR ratios may be useful for clinicians in differential diagnosis of Hantavirus in patients presenting with similar symptoms of Hantavirus disease.

Isolated second-phase diabetes insipidus post-transsphenoidal surgery.

A 57-year-old woman presented with severe lethargy, dizziness and nausea 1 week after transsphenoidal resection of a growth hormone secreting pituitary adenoma. She was found to have severe hyponatremia of 115 mmol/L. Importantly, she was neurologically intact and clinically euvolaemic. Her fluid intake was restricted and her sodium levels increased to 131 mmol/L over 4 days. She made a full recovery.She was diagnosed with isolated second-phase diabetes insipidus, a state of symptomatic hypoosmolar hyponatremia that usually occurs 7-10 days after transsphenoidal surgery. The sodium levels improve with fluid restriction.

Clozapine toxicity: a cautionary palliative care tale.

OBJECTIVE: This case report presents an unusual case of clozapine toxicity secondary to reduced smoking habit mimicking a patient approaching end of life. METHODS: It is a cautionary tale for palliative care specialists, perhaps unaware of the effect of cigarette smoke on metabolism of this antipsychotic, to be aware of. RESULTS: Following specialist advice and change of antipsychotic medication, this patient's condition improved to the point that he was discharged from the hospice. CONCLUSION: Palliative care specialists should be aware that reducing cigarette consumption can alter metabolism of clozapine, potentially causing drug accumulation and toxicity with features which mimic deterioration towards end of life. Specialist advice should be sought in such a situation.

Elevated Lipase in an Infant with Altered Mental Status.

The pancreatic enzymes lipase and amylase serve important functions in digestion/absorption of fats and polysaccharides. Measurement of these enzymes is often used in the emergency department to rule out acute pancreatitis in patients with nonspecific abdominal pain. In acute pancreatitis, serial measurements of plasma lipase and amylase typically follow a predictable temporal pattern of rise-and-fall kinetics: lipase levels rise within 4 to 8 hours, crest at 2× to 50× the upper reference limit at 24 hours, and decline to normal concentrations in 7 to 14 days. In situations in which the duration and magnitude of pancreatic enzyme elevation are more transient, clinicians should consider alternative causes for enzyme elevation. In this case report, incidental discovery of elevated lipase in an African American baby girl who ingested oxycodone resulted in additional laboratory and radiological work-up. Stronger awareness of exogenous influences on gastrointestinal motility may have prevented the need for further testing in this patient.

A Healthy Toddler With Fever and Lethargy.

A 21-month-old previously healthy girl presented to the emergency department initially with fever, rhinorrhea, and poor oral intake. She was subsequently discharged from the hospital on amoxicillin for treatment of acute otitis media but presented hours later on the same day with continued poor oral intake, decreased urine output, and lethargy. The patient was afebrile on examination without a focal source of infection or evidence of meningismus, but she was lethargic and minimally responsive to pain and had reduced strength in the upper and lower extremities. Initial laboratory analysis revealed leukocytosis with a neutrophil predominance and bandemia, hyponatremia, mild hyperkalemia, hyperglycemia, elevated transaminases, a mild metabolic acidosis, glucosuria, ketonuria, and hematuria. Follow-up tests, based on the history and results of the initial tests, were sent and led to a surprising diagnosis.

Phenytoin-induced hypothermia.

A 60-year-old man with cerebral palsy and epilepsy was admitted with acute lethargy and deterioration in coordination. He was noted to be hypothermic at 35°C on admission. Routine work-up revealed toxic levels of phenytoin. No cause of hypothermia could be identified but as his phenytoin levels normalised, his body temperature also improved. There are three other reported cases of phenytoin- induced hypothermia in the literature. Could this be a rare cause of hypothermia?

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department.

OBJECTIVES: To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). DESIGN: Preplanned, secondary analysis of a prospective observational study. SETTING: Tertiary care, academic ED. PARTICIPANTS: A total of 424 patients in the ED, 65 years or older, including all chief complaints. MEASUREMENTS: We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. RESULTS: Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. CONCLUSIONS: The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Pyruvate Carboxylase Deficiency Type C: A Rare Cause of Acute Transient Flaccid Paralysis with Ketoacidosis.

Pyruvate carboxylase (PC) is a biotin-containing enzyme that is responsible for the adenosine triphosphate-dependent carboxylation of pyruvate to oxaloacetate, a key intermediate in the tricarboxylic acid cycle. PC deficiency (OMIM 266150) is a rare autosomal recessive metabolic disease, causing elevation of pyruvate, lactate, and alanine. Three types of PC deficiency have been described in the literature; A, B, and C. Type A PC deficiency, also called infantile or North American type, is characterized by infantile onset acidosis, failure to thrive, and developmental delay. The second subtype or type B, the neonatal or French form, presents usually in the neonatal period, mostly in the first 72 hours of life with severe lactic acidosis, truncal hypotonia, and seizures. The third type is called type C, is extremely rare with few cases published in the literature. In this case report, we present an 11-month-old girl who presented with acute flaccid paralysis, lethargy, and constipation with elevated ketones and lactate. She was confirmed genetically and biochemically to have PC deficiency type C. The patient's unusual presentation expands the clinical phenotype of this extremely rare disease.

Using the NANA toolkit at home to predict older adults' future depression.

BACKGROUND: Depression is currently underdiagnosed among older adults. As part of the Novel Assessment of Nutrition and Aging (NANA) validation study, 40 older adults self-reported their mood using a touchscreen computer over three, one-week periods. Here, we demonstrate the potential of these data to predict future depression status. METHODS: We analysed data from the NANA validation study using a machine learning approach. We applied the least absolute shrinkage and selection operator with a logistic model to averages of six measures of mood, with depression status according to the Geriatric Depression Scale 10 weeks later as the outcome variable. We tested multiple values of the selection parameter in order to produce a model with low deviance. We used a cross-validation framework to avoid overspecialisation, and receiver operating characteristic (ROC) curve analysis to determine the quality of the fitted model. RESULTS: The model we report contained coefficients for two variables: sadness and tiredness, as well as a constant. The cross-validated area under the ROC curve for this model was 0.88 (CI: 0.69-0.97). LIMITATIONS: While results are based on a small sample, the methodology for the selection of variables appears suitable for the problem at hand, suggesting promise for a wider study and ultimate deployment with older adults at increased risk of depression. CONCLUSIONS: We have identified self-reported scales of sadness and tiredness as sensitive measures which have the potential to predict future depression status in older adults, partially addressing the problem of underdiagnosis.

Premonitory symptoms in migraine: A cross-sectional study in 2714 persons.

AIM: To describe the frequency and number of premonitory symptoms (PS) in migraine, the co-occurrence of different PS, and their association with migraine-related factors. METHODS: In this cross-sectional study, a validated questionnaire was sent to Finnish migraine families between 2002 and 2013 to obtain data on 14 predefined PS, migraine diagnoses, demographic factors, and migraine characteristics. The estimated response rate was 80%. RESULTS: Out of 2714 persons, 2223 were diagnosed with migraine. Among these, 77% reported PS, with a mean number of 3.0 symptoms compared to 30% (p < 0.001) and 0.5 symptoms (p < 0.001) among 491 persons with non-migraine headaches. Yawning was the most commonly reported symptom (34%) among migraineurs. Females reported PS more frequently than males (81 versus 64%, p < 0.001) and experienced a higher number of different symptoms (mean 3.3 versus 1.8, p < 0.001). All measures of migraine severity were associated with a higher burden of PS. Light and sound sensitivity showed the highest co-occurrence (kappa = 0.51, 95% CI 0.47-0.55). In a generalized linear model, age, gender, higher frequency, duration and intensity of headache, reduced working capacity, most aura symptoms, and associated symptoms of the headache phase were significantly associated with an increased in the number of PS. CONCLUSION: PS are experienced by a majority of migraineurs. More severe migraine is associated with a higher burden of PS. Since the material was not entirely representative of the general population of migraineurs, caution should be exercised in generalizing the results.

Are mothers always right? When acute meningitis is something more.

A 22-month-old girl with a history of a congenital occipital cutaneous cyst was brought to the paediatric emergency department for lethargy and occipital headache. She had been discharged 5 days before for acute meningitis without bacterial isolates. At physical observation, she presented with irritability and neck hyperextension, with negative meningeal signs. CT scan revealed a vermian cyst and hydrocephalus. She was submitted to neurosurgery with removal of an infected midline dermoid cyst with a fistulous track to the skin. Surgery was successful and without complications. During follow-up, the child was asymptomatic with normal psychomotor development.