Spontaneous Intraperitoneal Hemorrhage (SIPH): A New Differential Diagnosis for Complications Due to Protracted Vomiting.

Spontaneous intraperitoneal hemorrhage (SIPH), or abdominal apoplexy, is a rare complication of protracted vomiting. Although usually seen later in life, increased alcohol consumption may be contributory to the accelerated incidence of SIPH among younger populations. We describe a 22-year-old male who presented with abdominal pain after prolonged retching in the setting of binge drinking. A CT scan identified a highly attenuated intraperitoneal collection measuring 7.6 cm x 11.6 cm x 15.9 cm adjacent to the stomach. Due to hemodynamic instability, exploratory laparotomy was emergently performed and 1600 mL of blood was evacuated. A diagnosis of SIPH was made with bleeding visualized from a short gastric artery. Ultimately, vessel ligation failed to achieve hemostasis at the splenic hilum and a splenectomy was required. Given that a delay in identification may prove fatal, this case highlights the importance of recognizing SIPH as a differential diagnosis for unexplained abdominal pain and shock after persistent vomiting.

Progressive multifocal leukoencephalopathy in a 62-year-old immunocompetent woman.

Progressive multifocal encephalopathy (PML) is a rare demyelinating disease that typically presents in immunodeficient patients. We report a case of a previously healthy 62-Year-Old woman who suffered from an unsteady gait, throbbing headaches, and progressive left-sided weakness and numbness. Stroke was initially suspected based on imaging and symptoms. A series of follow-up magnetic resonance images of the brain showed a right parietal lesion growing in size as the patient became unable to walk and experienced increasing lethargy and confusion. A biopsy of the lesion was positive for the John Cunningham virus (JCV). A diagnosis of PML was made and she was started on mefloquine. No improvement was seen on this treatment and her condition worsened. Although PML remains uncommon in immunocompetent individuals, it cannot be ruled out based on their immune status. Although the exact cause remains uncertain, underlying or transient states of immunosuppression may be responsible for reactivation of the JCV in these patients.

Life-threatening hyperkalemia: a potentially lethal drug combination.

Hyperkalemia is commonly seen in the elderly and is occasionally fatal. Inadvertently combining potassium sparing medications can result in profound hyperkalemia which may result in cardiac dysrhythmias, especially in the setting of chronic kidney disease. An 85 year-old woman on a drug regimen of sotalol, valsartan, spironolactone, and trimethoprim-sulfamethoxazole presented to the emergency department with hypotension and bradycardia. Presumptive treatment for hyperkalemia was started based on her initial electrocardiogram. This diagnosis was later confirmed with a serum potassium value of 10.1 mmol/L. Following pharmacologic treatment, emergency hemodialysis was performed and the patient subsequently recovered. It is known that several drug classes can cause hyperkalemia, with elderly patients at a higher risk of developing this side effect. It is believed that this was a major contributor to the degree of hyperkalemia seen in this patient.