Amoxicillin-induced bullous erythema multiforme: a case report.

Introduction: Bullous erythema multiforme (BEM), an immune-mediated, acute condition, frequently includes erosion affecting the oral, genital, and/or ocular mucosa in addition to discrete target-like lesions on the skin. BEM has been linked to various factors, including infections, medications, malignancy, autoimmune disease, immunization, and radiation. Case presentation: Here, we report a case of a 38-year-old married woman who presented with symptoms of reddish-raised, fluid-filled and painful, nonpruritic lesions along with the swelling of bilateral hand and feet. This patient had a history of taking some unrecorded ayurvedic medication for bloating and abdominal pain in a background of antibiotic use before exhibiting the dermatological symptoms of BEM 2 days later. She was successfully managed with ampicillin and cloxacillin, acyclovir and prednisolone. Clinical discussion: A few incidence of BEM after the administration of amoxicillin has been reported, which precipitated only after consuming ayurvedic medication. BEM has a clinical diagnosis with biopsy rarely required. Here, the hypersensitivity reaction induced by the antibiotic itself or by altering the immune response to the concomitant consumed herbal medicine could explain the BEM. Conclusion: Physicians should note that amoxicillin can trigger BEM, regardless of its use with ayurvedic drugs. Antibiotics should be used with caution, especially in patients with a history of BEM.

High-Altitude Exposure and Cerebral Venous Thrombosis: An Updated Systematic Review.

Kharel, Sanjeev, Suraj Shrestha, Samriddha Raj Pant, Suman Acharya, Amit Sharma, Santosh Baniya, and Sanjeeb S. Bhandari. High-altitude exposure and cerebral venous thrombosis: an updated systematic review. High Alt Med Biol. 24:167-174, 2023. Background: High altitude (HA) may increase the risk of cerebral venous thrombosis (CVT). Differentiating it from other HA illnesses is crucial for prompt treatment and better outcomes. We aimed to summarize the clinical data, etiology, and risk factors of this poorly understood entity at an HA. Materials and Methods: A systematic literature search of various databases, including PubMed, Embase, and Google Scholar, was done using relevant keywords; cerebral venous thrombosis; HA, up to May 1, 2022. Results: A total of nine studies, including 75 cases of CVT at HA (3,000-8,848 m), with 66 males and 9 females, were included in this review. Headache and seizure were the most common clinical presentations. Smoking, drinking habits, and the use of oral contraceptive pills (OCP) were the most common risk factors for the development of CVT. Similarly, various underlying hypercoagulable states were also present among cases of CVT associated with HA exposure. Conclusion: Our review concludes that HA exposure can predispose individuals with risk factors such as preexisting hypercoagulable states, smoking, drinking habits, and use of OCP to an increased risk of CVT.

Breakage of an orogastric tube in a critically Ill patient: a case report.

Orogastric and nasogastric tubes are common methods of enteral feeding. Although the methods of tube feeding are simple, these methods are not free of complications. Case presentation: This case report describes a 58-year-old patient with the diagnosis of stroke, in whom there was breakage of an orogastric tube during a prolonged ICU stay. Clinical discussion: Early enteral feeding in patients without any contraindications is associated with improved organ survival and recovery, and decreased incidence of infections, which decreases the ICU stay and improves the overall outcome. Nasogastric and orogastric tubes are the most commonly inserted feeding tubes. Breakage of an orogastric tube is a rare complication that can occur due to manufacturing defects, exposure to a harsh acidic environment, and forceful flushing of an obstructed tube. Conclusions: Timely identification of the broken feeding tube can help the treating clinicians retrieve it easily even with the help of a laryngoscope in selected patients.

Severe hyponatremia as an atypical manifestation of pituitary macroadenoma: a case report.

Pituitary macroadenoma most commonly presents with visual disturbances, headache, and other symptoms secondary to adeno hypophyseal hormonal deficiencies and usually alleviates after tumor resection. Pituitary adenomas may be the cause of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing hyponatremia, although so far, there have only been a few documented cases. Here, we present a case of pituitary macroadenoma with SIADH and hyponatremia. This case has been reported in line with CARE (CAse REport) criteria. Case presentation: We present a case of a 45-year-old woman who presented with symptoms of lethargy, vomiting, altered sensorium, and seizure. Her initial sodium level was 107 mEq/l, plasma and urinary osmolality were 250 and 455 mOsm/kg, respectively, and her urine sodium level was 141 mEq/day, suggestive of hyponatremia due to SIADH. MRI scan of the brain revealed approximately 14×13×11 mm pituitary mass. Prolactin and cortisol levels were 41.1 ng/ml and 5.65 µg/dl, respectively. Clinical discussion: Hyponatremia can result from various diseases, making it hard to identify the cause. A pituitary adenoma is a rare cause of hyponatremia due to SIADH. Conclusion: Pituitary adenoma rarely might be the cause of SIADH presenting as severe hyponatremia. So, in case of hyponatremia due to SIADH, clinicians should keep pituitary adenoma as well in their differential diagnoses.

MRI of the brain mimicking autoimmune encephalitis in Sjögren syndrome with chorea: a case report.

Neurologic manifestations in primary Sjögren syndrome (SS) range in prevalence from 8 to 49%, and most of the studies suggest a prevalence of 20%. The incidence of SS patients developing movement disorders is about 2%. Case presentation: The authors herein report a case of a 40-year-old lady with MRI of the brain mimicking autoimmune encephalitis in SS who presented with chorea. Her MRI findings revealed T2 and FLAIR (fluid-attenuated inversion recovery) high signal intensity areas in bilateral middle cerebellar peduncles, dorsal pons, dorsal midbrain, hypothalami, and medial temporal lobes. Clinical discussion: There is still no evidence to support the definite use of MRI in characterizing the central nervous system involvement in primary SS, especially due to overlapping findings with age and cerebrovascular disease. Multiple areas of increased signal intensity in periventricular and subcortical white matter in FLAIR and T2-weighted image is commonly seen in primary SS patients. Conclusion: It is crucial to consider autoimmune diseases like SS as a cause of chorea in adults, even in those whose imaging findings are suggestive of autoimmune encephalitis.

Wallerian degeneration in the brain after organophosphorus poisoning: a case report.

The type, quantity, and potency of the organophosphorus compound (OPC) taken determine the symptoms of OPC poisoning as well as their severity. The exact etiology for organophosphorus (OP) poisoning delay neuropathy regulating Wallerian degeneration is still unknown. Case Presentation: We report here a rare case of a 25-year-old lady with Wallerian degeneration in the brain found in an MRI in a patient after OPC ingestion. MRI of the brain, in our case, shows Wallerian degeneration of the corona radiata, internal capsule, and midbrain. Clinical Discussion: Some OPCs can lead to OP-induced delayed neuropathy, a form of delayed neurotoxicity in humans (OPIDN). The distal axonopathy's (in OPIDN) morphological pattern resembles Wallerian degeneration, which happens in vitro following nerve damage. Although delayed Wallerian degeneration from organophosphate poisoning often affects the peripheral nervous system, it can also affect the central nervous system. Rehabilitation therapy combined with appropriate nursing care has been demonstrated to improve the disease. Conclusion: Central nervous system involvement after OP poisoning is rare, and MRI of the brain and spinal cord can document evidence of Wallerian degeneration after OP poisoning.

Pontine and bilateral cerebellar lesion in osmotic demyelination syndrome associated with uncontrolled type II diabetes mellitus: a case report.

Osmotic demyelination syndrome (ODS) as a result of the hyperosmolar hyperglycemic state is rare and can present with variable neurological manifestation due to lysis of myelin sheath. Case presentation: A 44-year diabetic male presented with complaints of sudden onset, progressive bilateral weakness in lower limbs, and slurring of speech for the past 1.5 months. Cerebellar examination showed a bilaterally impaired finger nose test, dysdiadochokinesia, impaired heel shin test, and an impaired tandem gait. MRI brain (T2 and fluid-attenuated inversion recovery sequences) showed high signal intensity in the central pons and bilateral cerebellum. With a diagnosis of ODS with poorly controlled diabetes, he was treated with insulin, metformin, and supportive measures following which his symptoms subsided gradually. Clinical discussion: A rapid correction of hyponatremia is considered the most common cause of ODS. Variations in plasma glucose levels, a rare cause of ODS, can cause an abrupt osmolality change causing pontine and extrapontine myelinolysis. Prevention of rapid correction of hyponatremia and rapid changes in plasma osmolality in vulnerable patients is the mainstay of treatment. Conclusions: Clinical features, imaging studies, and monitoring of serum osmolality, serum glucose, and electrolytes aid in diagnosis and favorable outcomes for the patient.

Idiopathic recurrent pyoderma gangrenosum with cobalamin deficiency in a 62-year-old male: a case report.

Pyoderma gangrenosum (PG) is a rare, neither infectious nor gangrenous, neutrophil-mediated inflammatory dermatosis. In 50-70% of cases, systemic disease is the underlying cause, and the remaining is idiopathic. Case Presentation: The authors here present a case of a 62-year-old male with a history of recurrent ulcer over the dorsum of hand diagnosed with recurrent PG with cobalamin deficiency treated with intralesional steroid injection and topical antibiotics along with intramuscular vitamin B12 injections. The patient returned after a year with a history of swelling in the left hand for 1 week, which was managed with intravenous antibiotics. Clinical Discussion: The most common kind of PG is ulcerative, which accounts for around 85% of cases that have been found. Ulcerative PG begins as small, painful erythematous or violaceous papules and pustules that quickly develop into ulcers with an exudative, mucopurulent, hemorrhagic base or with areas of necrosis and high, well-defined, serpiginous, violet-blue, or metallic grey borders, which are its defining feature. Glucocorticoids, along with a wide range of additional systemic immunomodulatory medication as alternatives and antibiotics to prevent infection are used for treatment. Conclusion: PG is a rare form of neutrophilic dermatosis that can be difficult to diagnose and treat. PG has a mixed nutritional deficiency and a history of ulcers. It is crucial to have a high degree of suspicion when making a diagnosis, as well as to look for associated diseases and start treatment as soon as possible.

A Case of Pembrolizumab-Induced Diabetic Ketoacidosis and Hyperthyroidism in a Patient With Recurrent Esophageal Adenocarcinoma.

Immune checkpoint inhibitors (ICI) such as program cell death protein 1 (PD-1) inhibitors are widely used for the treatment of patients with recurrent, locally advanced or metastatic, gastric or gastroesophageal (GE) junction adenocarcinoma. Immune-related adverse events (irAE) such as endocrinopathies have been reported after patients received ICI. We report a case of pembrolizumab-induced hyperthyroidism and type 1 diabetes mellitus (DM1) presenting with diabetic ketoacidosis (DKA). A 53-year-old African American male with no history of diabetes or hyperthyroidism was treated with two cycles of pembrolizumab for recurrent GE junction adenocarcinoma after which he was admitted with hyperthyroidism (thyroid stimulating hormone [TSH] 0.070mIU/L, free thyroxine 1.85mIU/L) and DKA (pH 7.06, glucose 583 mg/dL, beta-hydroxybutyrate 8.63 mmol/L, anion gap 27 meq/L). The patient was treated with intravenous insulin and aggressively hydrated. Given the lack of other precipitating factors for the two endocrinopathies, it was determined that the most likely etiology was recent treatment with pembrolizumab (a PD-1 inhibitor). In our case, pembrolizumab monotherapy developed two irAE (hyperthyroidism and DKA), which is unique as most combined immunotherapy regimens are associated with the development of multiple endocrinopathies. Our case emphasizes the importance of baseline monitoring of thyroid function and blood glucose prior to the start of ICI to monitor and evaluate patients with immune-related adverse events, including endocrinopathies.

Pembrolizumab-induced encephalitis in a patient with renal cell carcinoma post nephrectomy: A case report.

A new category of immune-related adverse effects has been identified due to increasing use of immune checkpoint inhibitor therapy to treat solid organ cancers. Pembrolizumab approved for renal cell carcinoma also has neurological immune-related adverse effects causing long-term morbidity. We here present a case of renal cell carcinoma post nephrectomy with suspected pembrolizumab (anti-PD-1)-induced encephalitis presenting as light headedness and dizziness treated with high dose of corticosteroid and intravenous immunoglobulin. Lumbar puncture was performed which showed elevated protein, nucleated cells with lymphocyte predominant, suggestive of chemical meningitis. Scans were found to be normal while electroencephalogram showed diffuse cerebral dysfunction indicating encephalopathy. The patient was under pembrolizumab treatment so encephalitis was suspected. Clinical attention is necessary when patients receiving immune checkpoint inhibitors appear with new neurological symptoms to prevent long-term morbidity or even possible mortality.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study.

Introduction: The most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal. Methods: This prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries. Results: The majority of the patients were in the age group 50-59 years in male and 40-49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality. Conclusions: Perforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

Primary dedifferentiated liposarcoma of the breast: A case report.

Primary breast liposarcoma is an extraordinarily rare breast malignancy. Histological subtypes including dedifferentiated are confirmed after a thorough histopathological and immunohistochemistry analysis. Liposarcoma of the breast can mimic other breast lesions. Long-term follow-up is needed due to the risk of local recurrence and delayed dedifferentiation.

Thyrotoxic periodic paralysis in a patient with Graves' disease: A case report.

Introduction and importance: Thyrotoxic periodic paralysis (TPP) is a rare and often misdiagnosed, hypokalemic periodic paralysis with features of mainly recurrent acute limb weakness with good treatment outcome if diagnosed early. Case presentation: We here report a case of a 25-year-old male with a history of recurrent bilateral upper and lower limbs weakness resolved by potassium infusion later found to have Thyrotoxicosis (Graves' disease). MRI scans of the brain had no abnormal finding while thyroid scintigraphy showed diffuse toxic goiter. Clinical discussion: Graves' disease shares a majority of TPP while, other causes like toxic adenoma, thyroiditis, toxic multinodular goiter, amiodarone induced thyrotoxicosis, levothyroxine intoxication and thyrotropin (TSH) producing pituitary adenoma are also associated with TPP. The management of thyrotoxicosis by medical therapy, surgery or radioactive iodine therapy is the mainstay of treatment of TPP patients. For the treatment of acute attacks, potassium administration is necessary keeping in mind the problem of hyperkalemia because of excess doses of potassium as it shifts to extracellular space. Conclusion: TPP should be considered as a differential in the cases of limb weakness and the secondary causes especially Thyrotoxicosis and precipitating factors should be identified.

Giant ovarian mucinous cystadenocarcinoma: A case report.

Giant ovarian tumors are rare in the present day due to the early diagnosis and treatment. However, owing to the large size, it can often compress the inferior vena cava and sudden decompression of it during the removal can lead to hemodynamic instability with disastrous outcomes.

Evaluation of portal venous system in post splenectomised beta-thalassemic children: A prospective study in a tertiary care hospital.

Background: Splenectomy is a palliative management technique in children with ß-thalassemia. Portal thrombosis is the most dreaded complication after splenectomy that requires fast diagnosis, effective therapy, and good follow-up to prevent protal hypertension. Thus, there is the importance of constant evaluation of portal venous system through Color Doppler Ultrasound. This cohort study aimed to observe the changes in the portal venous system in post-splenectomised ß-thalassemic children. Material and methods: This is a prospective observational cohort study carried out on all the pediatric patients who have undergone splenectomy in Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh from 2017 to 2019 for ß-thalassemia. The color doppler of the portal venous system was done within the 7th to 10th post-operative day and after 3 months. Outcomes like mean the caliber of the portal vein, mean velocity within the portal vein, and color Doppler findings like Portal Vein Thrombosis (PVT) and Pathological change in Mean Volume (PMV) were calculated and compared in two headings: pre-operative period and postoperative period (7-10 POD and 3 months) with the help of paired t-test. Results: Twenty-Eight ß-thalassemia patients with a mean age of 10.43 ± 3.91 years planned to undergo splenectomy were included in our study. The pre-operative mean caliber and mean velocity of the portal vein were not statistically significant when compared after the postoperative period (7-10 POD and 3 months). But, continuous changes in portal vein were seen that could lead to normalization or pathological changes. Conclusion: There are physiological and pathological changes in portal vein following splenectomy that could lead to varied complications like portal vein thrombosis and portal hypertension. Color Doppler Ultrasound findings along with close follow-up help in minimizing the pathological changes and complications.

Risk factors for recurrent intussusception after successful reduction in pediatric patients in a tertiary care hospital of Nepal: A prospective study.

Background: Intussusception is defined as the invagination of one segment of intestine into another segment of intestine. It may recur because of persistence or return of some factor responsible for the primary intussusception. Various risk factors have been reported but still not well elucidated. Materials and methods: This is the prospective observational study. In this study, 78 patients, age <16 years with diagnosis of intussusception between June 2019 and April 2020 who had successful reduction with either hydrostatic reduction and/or operative reduction in Teaching Hospital were enrolled in the study. This is study of early recurrence as patients were followed up to a period of 1 month for recurrence of intussusception. The recurrent cases were thus identified and various variables were compared between recurrent and non-recurrent cases by univariable and multivariable analysis. Results: Among 78 patients, 13 patients (16.7%) had recurrent intussusception. In the univariable analysis model, the significant risk factors for recurrence of intussusception analyzed were duration of symptoms of 48 h or more, fever, blood in stool and palpable mass. While after multivariable analysis, we found that the significant risk factors for recurrence of intussusception were duration of symptoms ≥48 h (OR = 5.32, p-value = 0.047), Fever (OR = 17.32, p-value = 0.001), palpable mass (OR = 24.12, p-value = 0.017). Conclusion: Attention and awareness among pediatricians about these sonographic and clinical risk factors especially symptoms for recurrence are needed to minimize pre-hospital delay and identify patients in risk of recurrence. This ultimately helps to improve care for pediatric patients with recurrent intussusception.

Prognostic significance of mean platelet volume in patients with lung cancer: a meta-analysis.

OBJECTIVE: The mean platelet volume (MPV) is a measure of platelet size, and it is considered a surrogate marker of platelet activation. Because the correlation between platelet count/size and lung cancer prognosis remains unclear, this meta-analysis comprehensively evaluated the prognostic significance of MPV among patients with lung cancer. METHODS: A systematic search of PubMed, Embase, Google Scholar, and additional sources of relevant studies were conducted with no language restrictions from inception to 7 May 2021. Overall survival (OS) and disease-free survival (DFS)/progression-free survival (PFS), as well as their hazard ratios (HR) and 95% confidence intervals (CIs), were pooled to evaluate the relationship between MPV and survival. The study protocol was registered on PROSPERO. RESULTS: Eleven studies involving 2421 patients with lung cancer were included in our analysis. Nine studies including only patients with non-small cell lung cancer were included in the meta-analysis. Our analysis revealed no significant associations of MPV with OS (HR = 1.09, 95% CI = 0.84-1.41) and DFS/PFS (HR = 1.13, 95% CI = 0.58-2.20). CONCLUSION: Pretreatment MPV levels did not display prognostic significance in patients with NSCLC. Large-scale prospective studies and a validation study considering ethnicity and lung cancer staging are warranted.

Esophageal Perforation following Accidental Ingestion of a Razor Blade.

Background: Ingestion of sharp foreign bodies is uncommon and often underreported. It can present with esophageal perforation which is a life-threatening complication requiring prompt diagnosis and management. Case Presentation. We report a case of accidental ingestion of a razor blade in a chronic alcoholic who presented with hematemesis after an esophageal perforation, the diagnosis of which was confirmed by radiology. Conclusion: Early recognition of esophageal perforation is crucial for early intervention. Proper history taking and radiological investigations are a key to reaching a diagnosis.

BRCA1/BRCA2 mutation spectrum analysis in South Asia: a systematic review.

OBJECTIVE: Breast cancer (BC) is the most common form of cancer among Asian females. Mutations in the BRCA1/BRCA2 genes are often observed in BC cases and largely increase the lifetime risk of having BC. Because of the paucity of high-quality data on the molecular spectrum of BRCA mutations in South Asian populations, we aimed to explore these mutations among South Asian countries. METHODS: A systematic literature search was performed for the BRCA1 and BRCA2 gene mutation spectrum using electronic databases such as PubMed, EMBASE, and Google Scholar. Twenty studies were selected based on specific inclusion and exclusion criteria. RESULTS: The 185delAG (c.68_69del) mutation in exon 2 of BRCA1 was the most common recurrent mutation and founder mutation found. Various intronic variants, variants of unknown significance, large genomic rearrangements, and polymorphisms were also described in some studies. CONCLUSIONS: The South Asian population has a wide variety of genetic mutations of BRCA1 and BRCA2 that differ according to countries and ethnicities. A stronger knowledge of various population-specific mutations in these cancer susceptibility genes can help provide efficient strategies for genetic testing.