Toxicological Emergencies.

Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.

Neurological Emergencies in the Intensive Care Unit.

Neurological emergencies carry significant morbidity and mortality, and it is necessary to have a multidisciplinary approach involving the emergency physician, the neurologist, the intensivist, and the critical care nursing staff. These disorders can be broadly divided into noninfectious and infectious etiologies. In this article, we review a few of the neurological emergencies that present to the neurological intensive unit, with emphasis on convulsive status epileptics, myasthenia gravis, Guillain-Barré syndrome, meningitis, encephalitis, and brain abscess.

COVID-19: Diagnostic Testing and Challenges.

Coronavirus disease-2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. Following this, there has been a rapid development in policies and strategies to contain and mitigate the pandemic. One of such strategies involves the development and utilization of testing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative organism of COVID-19. In this article, we explore the diagnostic modalities for COVID-19 based on the available information to date.

Guillain-Barré syndrome following the first dose of SARS-CoV-2 vaccine: A temporal occurrence, not a causal association.

Safety monitoring is of paramount importance for vaccines authorized for emergent use (EUA) by the US Food and Drug Administration (FDA) against SARS-CoV-2. Mass immunization is an essential tool to end the current pandemic, but vaccine surveillance is necessary to identify any potentially associated harms. At the same time, probability of temporal bias should be borne in mind before making conclusions about causality between the vaccine and an attributable undesired effect. We report a case of Guillain-Barré syndrome after the first dose of SARS-CoV-2 vaccine and believe this is a temporal, rather than causal association.

Lemierre's Syndrome: A Case Series.

Lemierre's syndrome (LS) is a potentially fatal complication of oropharyngeal infection, resulting in contiguous suppurative thrombosis of the internal jugular vein (IJV) and septic emboli. It is most commonly associated with Fusobacterium necrophorum (F. necrophorum), though other pathogens have also been implicated in its pathogenesis. The incidence of LS had so significantly decreased that it was referred to as "the forgotten disease." However, cases of LS have shown a resurgence, which may be partly attributed to an overreliance on a negative group A beta-hemolytic streptococcal rapid antigen detection test (RADT), commonly referred to as "rapid strep test." Clinicians must maintain a very high index of suspicion for LS in patients with persistent sequelae from tonsillopharyngitis who have a negative RADT.

Bartonella Endocarditis Presenting as Recurrent Cerebral Mycotic Aneurysm.

Bartonella henselae is a known cause of culture-negative endocarditis, which can be difficult to diagnose without a high clinical suspicion as specific diagnostic testing is required.  We report the case of a 48-year-old male who presented with altered sensorium. A CT of the head showed left-hemispheric intracranial hemorrhage (ICH) likely secondary to ruptured left posterior cerebral artery (PCA) fusiform aneurysm seen on catheter cerebral angiogram, which was treated with endovascular embolization. The patient had a significant history of mitral valve prolapse; however, a transthoracic echocardiogram (TTE) was negative for any vegetation. Blood cultures were also negative. A year later, he presented with another ICH in the PCA territory and was found to have a new left distal PCA aneurysm, which was again treated with endovascular embolization. During that hospitalization, an echocardiogram showed myxomatous changes in the mitral valve with severe mitral regurgitation; however, blood cultures were negative. Further queries about the patient's social history revealed that his spouse had been a cat owner in 2018, which prompted Bartonella henselae testing. The blood work showed elevated immunoglobulin G (IgG) titers for which he was placed on antibiotics. A follow-up catheter angiogram detected a new distal middle cerebral artery (MCA) M4 branch aneurysm treated with surgical clipping. The aneurysm tested positive for Bartonella henselae on polymerase chain reaction (PCR) testing. The patient subsequently underwent successful mitral valve replacement, which also was positive for Bartonella henselae on PCR testing; however, the Warthin-Starry stain was negative. This case demonstrates how a comprehensive history along with persistent evaluation for the underlying etiology of cerebral aneurysms can lead to the diagnosis of Bartonella henselae endocarditis. Cerebral mycotic aneurysms are known complications of endocarditis; however, the underlying infection can be difficult to diagnose. Recognition of this culture-negative endocarditis is critical for the appropriate treatment and management of patients to prevent morbidity and mortality.

Disseminated Gonococcal Infection Complicated by Prosthetic Joint Infection: Case Report and Genomic and Phylogenetic Analysis.

Neisseria gonorrhoeae infections have been increasing globally, with prevalence rising across age groups. In this study, we report a case of disseminated gonococcal infection (DGI) involving a prosthetic joint, and we use whole-genome sequencing to characterize resistance genes, putative virulence factors, and the phylogenetic lineage of the infecting isolate. We review the literature on sequence-based prediction of antibiotic resistance and factors that contribute to risk for DGI. We argue for routine sequencing and reporting of invasive gonococcal infections to aid in determining whether an invasive gonococcal infection is sporadic or part of an outbreak and to accelerate understanding of the genetic features of N gonorrhoeae that contribute to pathogenesis.

Abdominal Pain, an Atypical Presenting Symptom of Granulomatosis with Polyangiitis.

Granulomatosis with polyangiitis (GPA) formerly known as Wegener's granulomatosis, is an anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). It is an uncommon disease with an estimated prevalence of 3 in 100,000 individuals with an equal distribution in both sexes. It is characterized by necrotizing granulomatous vasculitis that primarily affects the upper and lower respiratory tracts and the kidneys.  Our patient's initial presentation was abdominal pain with no typical pulmonary or renal manifestations. Along the course of her hospitalization, she had multiple episodes of drop in hemoglobin and a steady increase in serum creatinine which was thought to be due to IV contrast nephropathy. With this case, we project the need for a high index of clinical suspicion to make an early diagnosis, especially in patients with atypical symptoms such as abdominal pain, and acknowledge the fact that IV contrast can possibly act as a second hit in underlying GPA, unmasking the active renal symptoms of the disease.

Hashimoto's encephalopathy: a rare cause of delirium.

Cognitive impairment is a frequent presentation of patients who come to the hospital. We report a case of a patient who presents with a common symptom, however, with a rare disease. This is an 84-year-old woman with a history of hypertension and atrial fibrillation who was reported to have confusion of 3 weeks. Investigations, including a complete blood count, MRI imaging of the brain, cerebrospinal fluid analysis and paraneoplastic screen, were all negative. Of note, thyroid peroxidase antibody was elevated. She did not have a history of thyroid disease. Following this, an assessment of Hashimoto encephalopathy was made. She was started on steroids and she showed remarkable recovery within 2 months, therefore, confirming the diagnosis. This case report emphasises the need to consider Hashimoto's encephalopathy as a differential for delirium especially when other common aetiologies have been ruled out.

Lesson of the month 1: To stop a fit, but swinging low.

This is a case of an elderly woman who presented to our emergency room with an episode of a witnessed fall. The past medical history of the patient was significant for post-stroke epilepsy for which she was on oxcarbazepine. Initial blood work showed a white cell count of 4.5, haemoglobin of 12.4, and platelet count of 15,000. Peripheral blood smear showed normal platelet and red cell morphology without clumping. The patient's history suggested that she was recently started on oxcarbazepine prompting discontinuing of the drug. The platelet count improved from 15,000 cells/mL to 80,000 cells/mL on discharge.Antiepileptic medications have been reported to cause various blood dyscrasias in the literature. There are few studies that report the association of carbamazepine and thrombocytopenia and much fewer written about oxcarbazepine. Thrombocytopenia appears to be an uncommon reported side effect of oxcarbazepine; more commonly reported side effects include dizziness, tiredness, memory problems and headache. The treatment of antiepileptic drug-associated thrombocytopenia is discontinuing the medication and monitoring the platelet counts. In few cases, immunoglobulin infusion is required. Antiepileptic drug-associated thrombocytopenia is difficult to predict and so it is imperative to monitor the platelet level when antiepileptic drugs are started and even after the medication is switched to a different one.

Seasonal variation in mortality secondary to acute myocardial infarction in England and Wales: a secondary data analysis.

BACKGROUND: Acute myocardial infarction (AMI) is a leading cause of death globally. Increase in AMI mortality during winter has also been identified in existing literature. This has been associated with low outdoor and indoor temperatures and increasing age. The relationship between AMI and other factors such as gender and socioeconomic factors varies from study to study. Influenza epidemics have also been identified as a contributory factor. OBJECTIVE: This paper aims to illustrate the seasonal trend in mortality due to AMI in England and Wales with emphasis on excess winter mortality (EWM). METHODS: Monthly mortality rates per 10 000 population were calculated from data provided by the UK Office for National Statistics (ONS) for 1997-2005. To quantify the seasonal variation in winter, the EWM estimates (EWM, EWM ratio, Excess Winter Mortality Index) for each year were calculated. Negative binomial regression model was used to estimate the relationship between increasing age and EWM. RESULTS: The decline in mortality rate for AMI was 6.8% yearly between August 1997 and July 2005. Significant trend for reduction in AMI-associated mortality was observed over the period (p<0.001). This decline was not seen with EWM (p<0.001). 17% excess deaths were observed during winter. This amounted to about 20 000 deaths over the 8-year period. Increasing winter mortality was seen with increasing age for AMI. CONCLUSION: EWM secondary to AMI does occur in England and Wales. Excess winter deaths due to AMI have remained high despite decline in overall mortality. More research is needed to identify the relationship of sex, temperature, acclimatisation, vitamin D and excess winter deaths due to AMI.