Paradoxical Excitation Following Intravenous Lorazepam Administration for Alcohol Withdrawal - A Case Presentation and Literature Review.

Benzodiazepines are commonly used medications which are clinically useful towards the treatment of alcohol withdrawal, seizures, anxiety disorders, among other indications. Benzodiazepine use is also known to cause the rare phenomenon of paradoxical excitation whose mechanism has many postulated theories. We report this rare presentation of paradoxical excitation with the use of lorazepam in a 50-year-old male being treated for alcohol withdrawal. We also review the underlying pathophysiology, pharmacology, and current literature as it relates to this excitation. An inability to recognize this adverse effect and to appropriately withhold the agent may adversely affect a patient's course of treatment in the inpatient setting.

Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature).

There is significant morbidity and mortality associated with the presence of coronary artery disease (CAD) in the setting of orthotopic liver transplantation in patients with end-stage liver disease. The prevalence of CAD in this cohort is similar to, if not higher, than the general population. Several studies show improved survival rates for patients with obstructive CAD who undergo percutaneous coronary intervention (PCI) and support a low threshold for PCI in these patients. However, a few studies have failed to show improved mortality associated with PCI in this cohort. This review hopes to highlight the current recommendations regarding the assessment of CAD in patients with end-stage liver disease who are orthotopic liver transplantation candidates and describe the outcomes of PCIs.

Eculizumab as a Treatment for Hyper-Haemolytic and Aplastic Crisis in Sickle Cell Disease.

BACKGROUND: Patients with sickle cell disease can experience various crises including sequestration crisis, haemolytic crisis and aplastic crisis. Due to alloantibody formation, transfusion alloantibodies can cause a haemolytic crisis. Treatment involves avoiding packed red blood cell transfusions, as well as intravenous immunoglobulin, steroids and eculizumab to decrease the chances of haemolysis. CASE DESCRIPTION: We report the case of a 42-year-old man who was found to have worsening anaemia after packed red blood cell transfusion with evidence suggestive of haemolytic crisis. Due to reticulocytopenia, aplastic crisis was also suspected and later confirmed via parvovirus IgG and IgM titres. The patient did not improve with steroid and intravenous immunoglobulin therapy and was treated with eculizumab as a salvage therapy. CONCLUSION: Concurrent hyper-haemolytic crisis and aplastic crisis should be suspected in patients with features of haemolysis and reticulocytopenia. Prompt recognition and treatment with eculizumab are paramount in those who fail steroid and intravenous immunoglobulin treatment. LEARNING POINTS: Treatment of hyper-haemolytic and aplastic crisis in sickle cell disease with eculizumab offers therapeutic benefit.A high index of suspicion for hyper-haemolytic crisis and aplastic crisis should be maintained in those with haemolytic features as well as reticulocytopenia in the setting of sickle cell disease.

Outcomes of Renal Function in Cardiogenic Shock Patients With or Without Mechanical Circulatory Support.

BACKGROUND: The objective of the study was to compare the renal outcomes in patients presenting with all-cause cardiogenic shock who were supported by either Impella devices (Abiomed, Danvers, MA), intra-aortic balloon pump (IABP), or vasopressors alone. Outcomes of cardiogenic shock remain poor even with the advancement of early revascularization and circulatory supportive care. Percutaneous mechanical circulatory support (MCS) device has emerged as an effective strategy in protecting end organ function especially renal function during high risk percutaneous coronary intervention (PCI) and in patients with cardiogenic shock. Currently, comparative data amongst various MCS modalities and their association with improvement of renal function in cardiogenic shock patients have not been well characterized. METHODS: Data from New Jersey Cardiac Catheterization Data registry of cardiogenic shock patients from a single tertiary care institution that underwent cardiac catheterization and the modality used to treat were obtained, either with Impella devices, IABP, or treatment with vasopressors alone. Retrospective chart review was conducted to assess the incidence of acute kidney injury (AKI) on patients with cardiogenic shock prior to and after cardiac catheterization and renal function was evaluated over the course of 96 h after cardiac catheterization. Statistical analysis was performed to ascertain significant difference in creatinine and estimated glomerular filtration rate (eGFR) in patients who received Impella devices, IABP, or were treated with vasopressors alone. RESULTS: A total of 61 all-cause cardiogenic shock patients met the inclusion and exclusion criteria and were included in the study with 19 receiving IABPs, 15 receiving Impella devices, and 27 treated with vasopressors alone. Baseline characteristics among these three groups did not show any statistically significant difference. A total of 29 cardiogenic shock patients had experienced AKI prior to cardiac catheterization in which those receiving Impella devices showed statistically significant decrease in creatinine and increase in eGFR at 72 and 96 h (P < 0.05) compared to baseline. Within the same cohort, Impella group showed statistically significant lower creatinine at 96 h when compared to IABP. Patients that experienced AKI after cardiac catheterization did not show any statistically significant changes in renal function regardless of modality used. CONCLUSION: The results of our study suggest that Impella devices improve renal function in all-cause cardiogenic shock patients who experience AKI prior to undergoing cardiac catheterization.

Use of Impella CP Device in Off-Pump Coronary Artery Bypass Graft Surgery.

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.

Mixed Cryoglobulinemia Syndrome (MCS) due to untreated hepatitis B with uncommon presentation: case report and literature review.

BACKGROUND: The mixed cryoglobulinemia (MC) syndrome is a systemic inflammatory syndrome that causes small-to-medium vessel vasculitis due to cryoglobulin-containing immune complexes most commonly caused by chronic hepatitis C virus (HCV), and rarely by chronic hepatitis B virus (HBV). Its clinical presentation is significantly varied, with manifestations ranging from purpura, arthralgia, and myalgia to more severe neurologic and renal involvement. Pulmonary involvement as organizing pneumonia, alveolar hemorrhage, and pulmonary vasculitis have been reported, but appear to be quite rare. CASE PRESENTATION: We report an uncommon case of a patient who presented with primary pulmonary syndrome without renal involvement in the setting of MC, due to untreated chronic hepatitis B infection. Early diagnosis and consequent institution of glucocorticoids, B-cell-depleting monoclonal antibody and antiviral therapy led to a favorable outcome and prevented any fatal sequelae. CONCLUSION: Pulmonary compromise in MC syndrome is very uncommon and carries a high rate of mortality. Therefore, in patients with HBV presenting with hemoptysis, physicians must carry a high clinical suspicion for alveolar hemorrhage secondary to cryoglobulinemic vasculitis.

Pseudoaneurysm Development after Free Wall Rupture Post Myocardial Infarction.

Background: According to the World Health Organization, cardiovascular disease is the number one cause of death globally, claiming millions of lives each year with an increasing prevalence. Myocardial infarction (MI) makes up a large sum of these deaths each year. While MI in itself is lethal, there are several complications that can increase the morbidity and mortality of an MI, such as left ventricular wall rupture and aneurysms. Case Presentation: We present a case of an elderly male with an extensive cardiac history who presented with a non-ST segment myocardial infarction (NSTEMI) managed with percutaneous coronary intervention. Hours after, he became hemodynamically unable and was found to have a pseudoaneurysm of the left ventricle. Despite aggressive efforts, his pseudoaneurysm ruptured and he ultimately succumbed to his condition. Conclusions: Left ventricular pseudoaneurysm is usually seen after myocardial infarctions with a rupture rate of up to 45% leading to a mortality rate of about 50%. While cardiac catheterization with left ventriculography is the gold standard for diagnosis, echocardiography can also be used as an alternative. Treatment is emergent cardiac surgery but still holds a high operative risk. Therefore, patients may be medically stabilized and managed prior to ultimate surgical intervention.

Aggressive Staphylococcus lugdunensis Endocarditis in a Young Healthy Patient: A Case Report.

Staphylococcus lugdunensis (S. lugdunensis) is a ß-hemolytic coagulase-negative staphylococcus causing skin and soft tissue infections with an increasing incidence. Commonly found as normal flora in the perineal region, S. lugdunensis has been found in rare cases of infective endocarditis causing increased morbidity and mortality. We present a case of a previously healthy young male diagnosed with S. lugdunensis-caused infective endocarditis. A 31-year-old male with no significant past medical history, who presented to the emergency department with acute onset crushing substernal chest pressure and dyspnea with profuse sweating following 1-week-long febrile illness and malaise. The initial electrocardiogram (ECG) showed diffuse ST depressions in all precordial leads, consistent with an acute coronary syndrome. Emergent transthoracic echocardiogram revealed an ejection fraction (EF) of 45% with severe aortic insufficiency with emanating from a torn right coronary cusp. The patient had a cardiac arrest, and recovery of spontaneous circulation (ROSC) was obtained after 13 min. He subsequently underwent mechanical aortic valve replacement surgery. The native valve specimen cultures grew S. lugdunensis. Postoperatively and after a long course of antibiotics, the patient fully recovered without complications. S. lugdunensis is a common organism with increasing incidence that can lead to significant morbidity and mortality if not properly detected and treated. We hope this case presentation would support emergency valve replacement surgery in patients with S. lugdunensis-suspected infective endocarditis.

Cocaine-Induced Giant Bullous Emphysema.

BACKGROUND: Emphysematous bullae, defined as airspaces of greater than or equal to one centimeter in diameter, have a variety of etiologies such as tobacco use and alpha-1 antitrypsin being the most common. Emphysematous bullae have also been reported in patients using cocaine usually involving the lung periphery and sparing the central lung parenchyma. We present a case of a male with a history of cocaine abuse found to have a singular giant emphysematous bulla occupying >95% of the right hemithorax requiring video-assisted thoracic surgery (VATS) with a favorable outcome. Case Presentation. A 50-year-old male with a history of chronic cocaine abuse was found unresponsive in the field and given multiple doses of naloxone without any improvement in mental status. On presentation to the emergency department, chest X-ray as well as CT scan of the chest were performed which were suggestive of an extensive pneumothorax of the right lung requiring placement of a chest tube. The patient was subsequently intubated and underwent bronchoscopy with right chest VATS which found a giant bulla encasing the entire right pleural cavity. During the procedure, he underwent resection of the bullae and a partial right pleurodesis. After the procedure, patient's respiratory status significantly improved, and he was discharged in a stable condition. CONCLUSION: Cocaine use is a rare but identifiable factor that can cause giant bullous emphysema (GBE) resulting in severe complications and even death. The purpose of this case presentation is to support early identification and treatment of GBE using bullectomy with VATS, improving outcomes and decreasing morbidity and mortality.

Management of Acute Kidney Injury in the Setting of Acute Respiratory Distress Syndrome: Review Focusing on Ventilation and Fluid Management Strategies.

Acute respiratory distress syndrome (ARDS) is a major cause of mortality in adults with acute hypoxic respiratory failure and can predispose those afflicted to develop acute kidney injury (AKI). In the setting where AKI and ARDS overlap, incidence of mortality, length of intensive care unit stay, and complexity of management increases drastically. Lung protective ventilation strategy and conservative fluid management are the main focus of therapy in patients with ARDS, but have major implications on renal function. This review aims to provide concise discussion of pathophysiology, ventilation, and fluid management strategies as it relates to AKI in the setting of ARDS.

Mechanism and Effect of Beta-Blockers on Pancreatic Adenocarcinoma: A Literature Review.

Pancreatic adenocarcinoma has a poor 5-year survival rate despite many advancements in pharmacotherapies. Studies have suggested the involvement of ß-adrenergic pathway in the progression of pancreatic adenocarcinoma. Animal experiments and retrospective trials have reported the use of beta-blockers as potential chemo-preventative agents. This review aims to discuss ß-adrenergic physiology as it relates to the progression of pancreatic adenocarcinoma and review outcomes on the use of beta-blockers for its treatment.

Amiodarone-Induced Thyroid Storm Causing Sustained Monomorphic Ventricular Tachycardia Treated With Plasmapheresis: A Challenging Clinical Case.

Thyroid storm is a rare endocrine emergency with a high mortality rate approaching 20%. It manifests with the exaggerated symptoms of hyperthyroidism including hyperpyrexia, hypotension, cardiac arrhythmias, and death. The mainstay of treatment includes supportive intensive care and initiation of thionamides, beta blockers, corticosteroids, and if necessary anti-arrhythmics in the presence of refractory ventricular arrhythmias. We describe a case of amiodarone-induced thyrotoxicosis and thyroid storm leading to refractory ventricular tachycardias treated with plasmapheresis when anti-arrhythmic therapy became contraindicated. Amiodarone-induced thyroid storm can lead to monomorphic ventricular tachycardia. Under the circumstances of limited medical therapies, plasmapheresis can be an effective treatment option.