Baclofen Withdrawal With Reversible Posterior Leukoencephalopathy Syndrome: Bacterial Meningitis Mimicker.

BACKGROUND: The intrathecal baclofen (ITB) pump is an effective treatment for patients with spasticity unresponsive to oral medication. CASE REPORT: A 31-year-old woman with spinal cord injury sequelae was admitted to the emergency department due to sudden headache and excessive confusion. The patient was on ITB for lower limb spasticity. On presentation, her vital signs revealed blood pressure of 171/106 mm Hg, heart rate of 141 beats/min, and temperature of 39.0°C. Antibiotics were promptly administered intravenously for suspicion of bacterial meningitis. Based on magnetic resonance imaging and cerebrospinal fluid findings, as well as clinical signs such as marked lower limb spasticity, the final diagnosis was determined to be baclofen withdrawal syndrome complicated by reversible posterior leukoencephalopathy syndrome (RPLS). Improved consciousness was quickly achieved on blood pressure control. Resolution of spasticity was achieved after intravenous midazolam and intrathecal baclofen via lumbar puncture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Baclofen withdrawal syndrome is the leading differential diagnosis for impaired consciousness and fever among patients using ITB pumps. Moreover, baclofen withdrawal syndrome mimics a wide variety of conditions, including sepsis. This unique case was complicated by intrathecal baclofen withdrawal syndrome coexisting with RPLS, thus presenting more similarly to bacterial meningitis than the usual baclofen withdrawal, due to marked headache, altered consciousness, and generalized convulsive symptoms. In addition to general withdrawal management, commencement of antihypertensive therapy for RPLS may have an immediate effect on the improvement of impaired consciousness.

Severe Drug-Induced Liver Injury From Over-the-Counter Medication.

Drug-induced liver injury (DILI) is difficult to diagnose as it presents with a wide variety of clinical manifestations and there is no established specific biomarker. However, clinicians require expertise in diagnosing DILI as it can lead to critical illness, is relatively common, and can be caused by a variety of drugs, herbal medicines, and supplements. A 67-year-old male was admitted to the hospital with a fever, jaundice, and fatigue. Abdominal ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography revealed no morphological abnormalities in the hepatobiliary system. On the third day of hospitalization, the liver damage and acute kidney injury progressed, and the patient was transferred to our intensive care unit. To further investigate the cause of multiple organ damage, the patient underwent repeated history taking and additional laboratory testing. In addition to the common causes of hepatic and renal damage, we also tested for rickettsiosis and leptospirosis, as the patient reported partaking regularly in outdoor leisure activities. On day seven of hospitalization, the patient recalled taking over-the-counter herbal flu medications approximately five days prior to admission; therefore, we suspected DILI and performed a drug-induced lymphocyte stimulation test (DLST). The DLST was positive for one drug. As other causes had been ruled out, the patient was diagnosed with severe DILI. The clinical course of the patient was observed with the patient's laboratory data and fever improving spontaneously. This case taught us several important lessons for the investigation of liver injury. Firstly, even with over-the-counter drugs, liver injury can be severe. Secondly, while the DLST is available for investigating DILI, false positives, especially for medicinal herbs, should be noted, and it is necessary to adequately rule out other diseases. Finally, when the cause of liver injury is unclear, patient history taking should be repeated carefully.

Severe acute respiratory distress syndrome caused by Otsujito.

Background: Kampo prescriptions can cause drug-induced lung injury (DLI) and acute respiratory distress syndrome (ARDS). However, severe respiratory failure induced by Otsujito (OJT) is extremely rare. High-dose steroid pulse therapy is generally given to patients with severe DLI. Case Presentation: A 63-year-old man with respiratory distress was admitted to our hospital. The patient was diagnosed with severe ARDS caused by OJT, which had been prescribed 4 weeks prior to admission. Thus, OJT was discontinued, and intensive care for ARDS, including ventilation and prone positioning, was implemented. His respiratory condition rapidly improved after treatment with an initial methylprednisolone dose (1.5 mg/kg/day). He was extubated on day 4 and discharged on day 16. The steroid dose was gradually reduced and discontinued by day 116. Conclusion: A severe case of ARDS caused by OJT was successfully treated with low-dose steroids and specialized intensive care.

Chest Pain Diagnosed as Acute Leukemia: Focus on Coagulation Abnormalities Rather Than White Blood Cell Count.

Chest pain is an important symptom for emergency physicians. It is one of the most common causes for admission in emergency departments. Acute leukemia (AL) rarely causes chest symptoms due to ostalgia, and it is difficult to diagnose leukemia as the cause of chest pain. An 83-year-old woman with no history of trauma presented to the emergency department with a one-day history of severe chest pain. There were no abnormalities on electrocardiography, echocardiography, specific biomarkers for cardiac injury, or contrast computed tomography of the chest and pelvis. The white blood cell count was normal, but the patient had prominent thrombocytopenia with platelets of 68,000/µL, prothrombin time-international normalized ratio (PT-INR) of 1.2, activated partial thromboplastin time (APTT) of 25.3 s, and D-dimer of 73.55 µg/mL. Due to the holiday, blast cells could not be measured on the same day. The next day's examination revealed blast cells in the peripheral blood. The patient was admitted to the hematology department and discharged three months later. This case suggests the need to consider AL in chest pain associated with coagulation abnormalities and thrombocytopenia, regardless of the white blood cell count.

Hyperthyroidism With Non-chylous Ascites: A Case Report.

Ascites is the accumulation of fluid in the abdominal cavity and is commonly attributed to various etiologies, including portal hypertension and peritoneal diseases. Hyperthyroidism is rarely associated with ascites, which is typically chylous and accompanied by high central venous pressure. We present a unique case of a 57-year-old woman with untreated hyperthyroidism who manifested non-chylous ascites without evidence of high venous pressure. Initially presenting with left lower leg pain, the patient presented with leg edema, abdominal distention, and diarrhea. A range of diagnostic tests ruled out common etiologies of ascites, such as liver cirrhosis, renal impairment, heart failure, infection, and malignancy. Ascites was characterized by low triglyceride levels, while no evidence of high venous pressure was found. Notably, the patient showed decreased levels of rapid turnover proteins, suggesting hypercatabolism and insufficient protein synthesis due to hyperthyroidism. Upon the initiation of antithyroid therapy, the patient's symptoms markedly improved. In conclusion, this report highlights a rare manifestation of hyperthyroidism that resulted in non-chylous ascites without high venous pressure. This underscores the need to include hyperthyroidism in the differential diagnosis of unexplained ascites, particularly in cases in which classical hyperthyroid symptoms are absent.

Retrospective observational study of changes in serum cytokines and adiponectin with continuous plasma exchange with dialysis therapy for severe COVID-19.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a marked increase in the inflammatory cytokines, IL-6 and IL-18. Blood purification therapy aimed at controlling cytokines is one treatment option; however, evidence of its effectiveness is needed. Plasma exchange with dialysis (PED) is a blood purification method involving selective plasma exchange with dialysate flowing through the outer hollow fiber of the plasma separator. In this retrospective study, we investigated the efficacy of continuous PED (cPED) over 48 h in five patients with severe COVID-19. METHODS: We assessed changes in IL-6 and IL-18, as well as adiponectin (APN). RESULTS: There were no significant differences in changes in IL-6 and IL-18, but there was a marked improvement in cases with abnormally high IL-6 and IL-18 levels at baseline. APN, which inhibits inflammatory cytokines, was significantly elevated post-cPED. CONCLUSION: Our results suggest that cPED therapy is an effective treatment for COVID-19.