Severe Gastroparesis Leading to Hypoglycemia and Subsequent Seizures.

Gastroparesis is a known complication in patients with diabetes mellitus (DM). This disorder has been known to make glycemic control difficult due to diabetic autonomic neuropathy, resulting in an increase in hypoglycemic episodes. On occasion, gastroparesis may be so severe that prokinetic medications and gastric pacemakers are not sufficient to control the symptoms, in which case some patients need to supplement their diet through a jejunal tube (J-tube) to bypass the stomach. Severe or long-lasting hypoglycemia may rarely be associated with epileptic seizures. We present a case of a 47-year-old female with a history significant for type 1 DM complicated by gastroparesis requiring a gastric pacemaker and J-tube placement who presented to the emergency department after having a witnessed seizure. Her glucose at that time was 27 mg/dl (normal 70-110 mg/dl) and she was treated appropriately with dextrose 25% solution and her glucose recovered to 110 mg/dl. Subsequently, seizure activity ceased.

Acute Isolated Thrombocytopenia Secondary to Meloxicam Use: A Case Report.

Meloxicam is a widely used nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain and some inflammatory disorders. One rare side effect is drug-induced thrombocytopenia (DITP), which can result in hemorrhage and death if not treated urgently. This diagnosis can be missed if mistaken for other conditions such as ITP, which is problematic since the mainstay of treatment is medication cessation. We present a case of a 42-year-old Hispanic female who was recently started on meloxicam and presented with petechiae, ecchymosis, and a platelet count of 2 (normal 150-350 K/mm3).

SARS-CoV-2 Complicated by a Large Hemorrhagic Pericardial Effusion.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), primarily a respiratory virus, has also presented with cardiac complications including myocarditis, myocardial infarction, and cardiac arrhythmias. Pericardial effusions are also emerging in the literature as a sequel to this viral infection. A case of a 57-year-old Hispanic female with SARS-CoV-2 infection two months prior with worsening dyspnea on exertion who was found to have a large hemorrhagic pericardial effusion with early tamponade physiology was presented in this article. This case highlights the rare complication and the importance of bedside echocardiogram in patients with recent SARS-CoV-2 infection who present with shortness of breath and other signs of pericardial effusion.

A Case of Intractable Vomiting: Was It the Celiac Artery Compression?

Celiac artery compression syndrome is a rare and poorly understood condition. Compression of the celiac artery by the median arcuate ligament causes intractable nausea, vomiting, and postprandial pain. We present a case of a 55-year-old male with a 50-pound unintentional weight loss and intractable vomiting, whose symptoms persisted despite robotic median arcuate ligament release. He later returned to the emergency department where he was found to have a low gallbladder ejection fraction on imaging indicative of biliary dyskinesia, for which he underwent a cholecystectomy. Eventually, his symptoms improved, and he was able to return to his baseline body weight.

An Unusual Case of Hypoxia: A Case of Right-to-Left Interatrial Shunting in a Patient With a Patent Foramen Ovale and Normal Pulmonary Pressure.

A patent foramen ovale (PFO) is an embryological remnant. Hypoxia in the setting of a PFO is generally attributed to pulmonary hypertension resulting in an increase in right atrial pressure and mixing of venous blood from the right atrium with blood in the left atrium resulting in a right-to-left interatrial shunt (RLIAS), thus deoxygenating it. We present a case of a 64-year-old male with a past medical history of coronary artery disease (CAD) who presented with two weeks of dyspnea on exertion and intermittent chest pressure. He was found to be hypoxic at 87% (normal >95%) with largely normal workup except for left anterior descending (LAD) stenosis, which was stented, and a PFO that was found on transesophageal echocardiogram with normal pulmonary artery pressure (PAP). This case of hypoxia in the setting of a PFO without pulmonary hypertension puts into question the pathophysiology of hypoxia in a PFO and RLIAS.

A Case of Recurrent Embolic Strokes in a Young Female With a Patent Foramen Ovale and Presumed Fibroelastoma.

Patent foramen ovale (PFO) occurs in about 25% of the population. PFO closure has been shown to decrease the risk of stroke in patients with recurrent strokes as compared to those treated with medical therapy alone, with more benefit in those with larger PFO sizes. Percutaneous PFO closure, although minimally invasive, does carry surgical risks, which must also be taken into account. We present a case of a 31-year-old female presenting with a left middle cerebellar artery (MCA) stroke and persistent deficits who was found to have both a PFO and presumed fibroelastoma on her aortic valve. She was treated with aspirin and apixaban and advised to follow up with cardiothoracic surgery once she recovered from her stroke for ultimate PFO closure and removal of the fibroelastoma. Unfortunately, she presented again less than one month later with recurrent cerebrovascular accidents (CVA) requiring urgent PFO closure. Our case stresses the importance of tools such as the Risk of Paradoxical Embolism (RoPE) score index when determining treatment plans for patients with PFO, and possible confounding factors such as the presence of an aortic valve fibroelastoma.

Schwannomatosis Presenting With a Grade IV Glioblastoma: A Case Report and Literature Review.

Schwannomatosis is a rare subset of neurofibromatosis. It is a disease process with a predisposition to schwannomas in the absence of bilateral vestibular schwannomas, which differentiates it from neurofibromatosis 2 (NF2). It is occasionally associated with certain tumors such as malignant peripheral nerve sheath tumors or rhabdoid tumors. Currently, there is limited literature to suggest an association between schwannomatosis and glioblastoma (GB). We present a case of a 55-year-old female with a history significant for schwannomatosis who presented after a witnessed first-time seizure with left facial weakness and slurred speech. She was found to have a 3 cm right-sided ring-enhancing lesion that was excised and found to be a grade IV Isocitrate dehydrogenase (IDH) wildtype GB.

Subacute Combined Degeneration of the Cervical Spine Secondary to Inhaled Nitrous-Oxide-Induced Cobalamin Deficiency.

Nitrous oxide is clinically used as an inhaled anesthetic in surgical and dental procedures. It is also used as an inhaled recreational drug and can be incredibly addictive. It tends to irreversibly oxidize cobalamin (Vitamin B12), rendering it inactive as a coenzyme in the production of methionine. Methionine is required in myelin sheath phospholipid production, and thus overuse of this anesthetic can affect myelin formation. Furthermore, other substrates that require this coenzyme (such as methylmalonate and propionate) accumulate and get incorporated in the myelin sheath, resulting in subacute combined degeneration of the spinal cord. We present a case of a young, avid hunter with a history of polysubstance use to include inhaled nitrous-oxide abuse, prior cocaine use, current marijuana use, and tobacco abuse, who presented with ascending paresthesias without appreciable motor dysfunction. Initial labs showed isolated macrocytosis without anemia in the setting of low vitamin B12 levels. Relevant studies showed elevated methylmalonic acid, normal anti-parietal cell, and anti-intrinsic factor antibodies. Heavy metals screens were negative for high levels of lead, iron, copper, or zinc. Cervical spine MRI demonstrated dorsal cord signal abnormalities without enhancement, in a pattern consistent with vitamin B12 deficiency. The patient was diagnosed with subacute combined degenerative disease secondary to depleted vitamin B12 as a result of recreational inhaled nitrous-oxide abuse. After cessation of nitrous oxide abuse, in addition to three months of B12 replacement, he reported complete resolution of symptoms.

Newly acquired factor VIII deficiency in a male Ex-smoker - A case report.

INTRODUCTION: Acquired hemophilia A (AHA) also known as acquired factor VIII (FVIII) deficiency is an acquired inhibition of coagulation by antibodies that either inhibit the activity or increase the clearance of a clotting factor (FVIII). Mortality in patients presenting with AHA is related to bleeding and hemorrhage, therefore rapid diagnosis and effective treatment are needed. CASE PRESENTATION: We present a case of a 59-year-old male with acquired VIII deficiency presenting with diffuse ecchymosis and bleeding diathesis. The patient was treated successfully with steroids and rituximab. CLINICAL DISCUSSION: It is a rare autoimmune disorder caused by neutralization of Factor VIII by IgG antibodies. This can lead to severe, life threatening bleeding. Treatment involves replacement of FVIII and immunosuppression. CONCLUSION: A key point to successfully treating AHA is to remove inhibitors and stop bleeding. Mortality in patients presenting with AHA is related to the bleeding and hemorrhage, therefore rapid diagnosis and effective treatment are needed.

Round Atelectasis: A Peculiar Pseudotumor Seen on Echocardiogram.

Round atelectasis (RA) is a rare disorder most commonly occurring in the presence of chronic pleural effusions due to the formation of adhesions and resultant pulmonary collapse. The most common culprit to this disease is asbestosis, but other causes of pleural effusions such as congestive heart failure and pneumonia are reported in the literature. RA can occasionally mimic pulmonary cancers and should be identified to prevent the associated morbidity of tumor workup. We present a case of RA seen on echocardiogram, and then later on computed tomography mimicking a pleural tumor in a 58-year-old female with preexisting heart failure and recurrent pleural effusions. Consultation with radiology and recognition of RA prevented the unnecessary potential morbidity and mortality of further workup.

Diabetic Ketoacidosis: Possible Cause of Thrombotic Thrombocytopenic Purpura.

Acquired thrombotic thrombocytopenic purpura (TTP) is an uncommon microangiopathic disorder that can have variable presentations and can be precipitated by a multitude of stressors to the body, most commonly sepsis. TTP is caused by a deficiency of ADAMTS13 leading to intravascular clotting causing thrombocytopenia and microangiopathic hemolytic anemia. TTP can be associated with various other pathologic conditions. One such rare association has been reported with diabetic ketoacidosis (DKA). Here, we present an even less appreciated presentation in association with DKA. A 62-year-old African American male with previously diagnosed prediabetes presented with DKA and developed hemodynamically significant bleeding. He was confirmed to have TTP that responded to plasmapheresis. TTP is a life-threatening illness if not treated urgently with plasmapheresis with or without rituximab. As acquired TTP most commonly occurs during stress on the body, it is important to treat the underlying stressor. Early identification and initiation of appropriate interventions are crucial to reducing mortality associated with TTP. Furthermore, we need to appreciate less commonly associated conditions such as DKA among patients.