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Background: Encephalopathy due to hyperammonemia is most often found in a setting of cirrhosis. However, it can also result from increased hepatic venous pressures, which can damage zone three hepatocytes and result in elevated serum ammonia. Case summary: This report focuses on the unique case of a 43-year-old woman, who presented with confusion in the setting of hyperammonemia due to congestive hepatopathy from an iatrogenic aorto-right ventricular fistula. The patient underwent percutaneous repair of the fistula with resolution of encephalopathy and notable improvement in symptoms. The patient attended all follow-up appointments and was contacted five and eight months after admittance for updates regarding her recovery and permission to publish this case. Discussion: This exceedingly rare case has not been reported in the literature and highlights the historically narrow differential for hyperammonemic encephalopathy given the prevalence of cirrhosis and potential reversibility of such a case.
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Corticosteroids have several widely documented adverse effects. However, there is no systematic study evaluating the frequency and associations of corticosteroid-induced mania. We report a case of corticosteroid-induced mania in a patient that previously tolerated higher doses of steroid therapy without neuropsychiatric symptoms. Although there is evidence suggesting a dose-dependent relationship, previous tolerance has not been proven to correlate with reduced frequency of developing mania or psychosis on the reintroduction of the medication. Therefore, patients restarting steroids should proceed carefully, even when receiving low doses.
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Microscopic polyangiitis (MPA) is an autoimmune small-vessel vasculitis often positive for perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA), or anti-myeloperoxidase (MPO), that classically affects the lungs, kidneys, and skin. Several atypical presentations of MPA involving other organs have also been reported in the literature. We report a unique case of a patient who presented with rare presentations of MPA: hearing and vision loss, dysphagia, renal dysfunction. Despite the atypical nature of her symptoms, her p-ANCA serology was positive and kidney biopsy was consistent with MPA. Regardless of the bizarre nature of a patient's symptoms, we highlight the importance of considering MPA as a differential diagnosis in the setting of positive p-ANCA serology.
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Importance: Standard tools used to diagnose pulmonary edema in acute decompensated heart failure (ADHF), including chest radiography (CXR), lack adequate sensitivity, which may delay appropriate diagnosis and treatment. Point-of-care lung ultrasonography (LUS) may be more accurate than CXR, but no meta-analysis of studies directly comparing the 2 tools was previously available. Objective: To compare the accuracy of LUS with the accuracy of CXR in the diagnosis of cardiogenic pulmonary edema in adult patients presenting with dyspnea. Data Sources: A comprehensive search of MEDLINE, Embase, and Cochrane Library databases and the gray literature was performed in May 2018. No language or year limits were applied. Study Selection: Study inclusion criteria were a prospective adult cohort of patients presenting to any clinical setting with dyspnea who underwent both LUS and CXR on initial assessment with imaging results compared with a reference standard ADHF diagnosis by a clinical expert after either a medical record review or a combination of echocardiography findings and brain-type natriuretic peptide criteria. Two reviewers independently assessed the studies for inclusion criteria, and disagreements were resolved with discussion. Data Extraction and Synthesis: Reporting adhered to the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two authors independently extracted data and assessed the risk of bias using a customized QUADAS-2 tool. The pooled sensitivity and specificity of LUS and CXR were determined using a hierarchical summary receiver operating characteristic approach. Main Outcomes and Measures: The comparative accuracy of LUS and CXR in diagnosing ADHF as measured by the differences between the 2 modalities in pooled sensitivity and specificity. Results: The literature search yielded 1377 nonduplicate titles that were screened, of which 43 articles (3.1%) underwent full-text review. Six studies met the inclusion criteria, representing a total of 1827 patients. Pooled estimates for LUS were 0.88 (95% Cl, 0.75-0.95) for sensitivity and 0.90 (95% Cl, 0.88-0.92) for specificity. Pooled estimates for CXR were 0.73 (95% CI, 0.70-0.76) for sensitivity and 0.90 (95% CI, 0.75-0.97) for specificity. The relative sensitivity ratio of LUS, compared with CXR, was 1.2 (95% CI, 1.08-1.34; P < .001), but no difference was found in specificity between tests (relative specificity ratio, 1.0; 95% CI, 0.90-1.11; P = .96). Conclusions and Relevance: The findings suggest that LUS is more sensitive than CXR in detecting pulmonary edema in ADHF; LUS should be considered as an adjunct imaging modality in the evaluation of patients with dyspnea at risk of ADHF.
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Insuficiência Cardíaca/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Radiografia Torácica/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito , Valor Preditivo dos TestesRESUMO
OBJECTIVES: This study assesses the safety and effectiveness of balloon catheters used as instruments in sinus surgery in a "real-world" multicenter registry of 1,036 patients across 27 US otolaryngology practices. METHODS: Data were collected by standardized chart review with centralized database administration for all consecutive functional endoscopic sinus surgeries that included the use of balloon catheters across the 18-month time period from December 2005 to May 2007. RESULTS: Balloon catheters were used in 3,276 peripheral (maxillary, frontal, and sphenoid) sinuses, for an average of 3.2 sinuses per patient. There were no major adverse events related to the use of balloon catheter instruments. The revision rate was 1.3% of sinuses treated with a balloon catheter after an average follow-up of 40.2 weeks. Sinus symptoms were improved in 95.2%, unchanged in 3.8%, and worse in 1.0% of patients. Postoperative sinus infections were significantly less frequent and less severe compared to infections before surgery. The results were consistent across all patient categories, including balloon-only patients and revision patients. CONCLUSIONS: Use of balloon catheters as instruments in sinus surgery appears to be relatively safe and effective and to improve the patient's quality of life. The results are consistent and generalizable across a wide range of sinusitis patients and physician practices. The complication rates, revision rates, and patient symptom improvement rates all compare favorably with previously reported results of functional endoscopic sinus surgery.