Clozapine Intoxication in a Patient on Chronic Use With a Short-Term Noncompliance.

Clozapine has been associated with various adverse effects at both subtherapeutic and standard doses. These adverse effects are most commonly seen during the initiation of therapy in treatment-naïve patients. However, reports of intoxication in patients with long-term use of clozapine are yet to be documented. We highlight the case of a 42-year-old gentleman who had been on long-term clozapine use and presented with an altered mental status after being resumed on full standard doses without careful titration of clozapine after a short period of medication noncompliance. His workup in the hospital was largely unremarkable, and his presentation was attributed to the resumption of clozapine without medication titration. This is the first case to demonstrate the necessity of careful titration regardless of previous treatment history and highlights that patients should be started on clozapine at low levels to avoid the possibility of acute intoxication.

A Rare Presentation of Cardiac Aspergilloma in an Immunocompetent Host: Case Report and Literature Review.

Cardiac aspergilloma is exceptionally rare with only a handful of cases reported and majority of them being in immunocompromised patients. Here, we present a case of cardiac aspergilloma involving the right and left ventricle in an immunocompetent patient that initially presented with acute limb ischemia. He was later found to have a cardiac mass with histopathological diagnosis confirming Aspergillus species. Despite aggressive medical and surgical interventions, the patient had an unfavorable outcome due to low suspicion of invasive fungal endocarditis given his immunocompetent status. Cardiac aspergilloma should remain in the differential diagnosis of immunocompetent patients as early clinical suspicion will result in early treatment and decreased mortality. Novel therapies are required to decrease mortality in the future from this fatal disease.

Murine Typhus Presenting with Acute Psychosis and Disseminated Intravascular Coagulation: A Case Report.

Murine typhus is an endemic infectious disease caused by Rickettsia typhi and is transmitted by fleas. It typically causes a mild illness with symptoms of fever, rash, headache, chills, and non-specific gastrointestinal complaints. However, there have been no reported cases in the literature of murine typhus infection causing symptoms of acute psychosis and disseminated intravascular coagulation (DIC). A 30-year-old female with a history of gastric bypass and chronic pain syndrome presented to the emergency department with altered mental state and fever. She developed vivid visual hallucinations, DIC, and hypoxia with pulmonary opacities, ultimately requiring intubation. Magnetic resonance imaging (MRI) showed leptomeningeal enhancement with unremarkable cerebrospinal fluid (CSF) studies. Serum murine typhus serology came back positive. Doxycycline therapy was initiated, which resulted in complete patient recovery. This case shows that murine typhus infection may present with acute psychosis and can mimic DIC, leading to diagnostic confusion. MRI sequences may show leptomeningeal enhancement, which has never been reported before in patients with typhus. Early neurological imaging using advanced MRI sequences for patients presenting with altered sensorium, visual hallucinations, and symptoms similar to thrombotic thrombocytopenic purpura (TTP) may help with early diagnosis, decreased hospital stay, and better prognosis.

Staphylococcus Toxin-Mediated Motor Polyneuropathy.

Staphylococcus aureus infection is known to cause a variety of neurologic complications, most involving the CNS, however, rarely have cases of S. aureus affecting the peripheral nervous system been reported in literature. We report a case of S. aureus toxin-mediated motor polyneuropathy in a patient presenting with acute flaccid quadriplegia. CASE SUMMARY: A 64-year-old female with mantle cell lymphoma on oral chemotherapy with ibrutinib presents with malaise and progressive ascending bilateral lower extremity weakness. Blood cultures resulted positive for methicillin-sensitive S. aureus, and she was initiated on antibiotics. Imaging studies and laboratory workup were negative for other causes of acute flaccid quadriplegia. Patient had complete resolution of her neurologic deficits with antibiotic therapy. It was determined that the likely diagnosis was Staphylococcus toxin-mediated motor polyneuropathy. CONCLUSIONS: Staphylococcal-mediated motor polyneuropathy resulting in acute flaccid quadriplegia is a rare but treatable complication of bacteremia and should remain a diagnosis of exclusion.