A rare case of acute respiratory distress syndrome secondary to acute lithium intoxication.

Lithium carbonate is a widely administered antimanic drug used for the treatment of bipolar disorder, schizoaffective disorder, and depression. Despite the established clinical efficacy of lithium, its usage must be approached with caution due to its narrow therapeutic index. Lithium poisoning results in multisystem toxicity, and characteristic clinical manifestations are directly correlated to serum lithium concentration. We describe a rather rare but fatal side effect of lithium: acute respiratory distress syndrome (ARDS) in a 46-year-old female on lithium for the treatment of bipolar disease. She was referred for generalized weakness, found in hemodynamic compromise, and had laboratory data significant for a lithium level of 3.3 mmole/L, needing emergent hemodialysis. Subsequently, she developed hypoxic respiratory failure requiring intubation. Her chest x-rays showed new bilateral pulmonary edema, the computed tomography scan showed extensive alveolar consolidation and V/Q scan of low probability for pulmonary embolism. She underwent 3 dialysis sessions and supportive care and was able to be extubated in 5 days. To our knowledge, 4 cases of ARDS after the onset of lithium toxicity have been documented. All patients presented with altered mental status at serum lithium levels ranging from 3.8 to 4.9 mmole/L and cardiogenic etiologies in addition to other likely causes of ARDS were ruled out in each case. The patients were treated with saline hydration (50%) or hemodialysis (50%), indicating that hemodialysis may be a permissive factor in lithium-associated ARDS development rather than a required component. Taken together, we believe that lithium is a likely culprit in the initiation of ARDS and propose the addition of ARDS to the family of clinical manifestations of severe lithium toxicity.

Pulmonary hypertension in end-stage renal disease.

Pulmonary hypertension associated with end-stage renal disease (ESRD) is an important yet under-recognized condition and can lead to life-threatening complications. The pathogenesis of pulmonary hypertension is peculiar in ESRD, and understanding it is important to recognize such patients at the earliest and commence appropriate treatment. Many studies have discovered the prevalence of pulmonary hypertension to be up to 80% in ESRD and have been associated with increased mortality. WHO has classified pulmonary hypertension in renal failure to be in group 5, a group defined by unclear multifactorial etiologies. Moreover, there is an improvement with renal transplant and closure of AV fistula, thus confirming the contribution from these. The pharmacological management of pulmonary hypertension in this unique population is not very different from other etiologies. However, one should understand that pulmonary hypertension as such, could be multifactorial, and other secondary causes of pulmonary hypertension should also be recognized and treated accordingly. In this article, we will discuss the concept of pulmonary hypertension in ESRD in detail and the options of treatment.

Multiple Cutaneous Metastases as Initial Presentation in Advanced Colon Cancer.

Skin metastases from advanced colorectal cancer are relatively rare and occur most often when the cancer is advanced, following the spread to other organs. Cutaneous metastases occur in about 3% of advanced colorectal cancers. We present an extremely rare case of a 68-year-old woman with advanced ascending colon adenocarcinoma that presented with multiple rapidly progressing painless cutaneous metastatic lesions with no other distant metastases. Of all the tumors, breast cancer most commonly spreads as cutaneous metastasis is followed by lung, colorectal, renal, ovarian, and bladder cancers. Cutaneous metastases can present in a variety of clinical manifestations, such as a rapidly growing painless dermal or subcutaneous nodule with intact overlying epidermis or as ulcers. In cases where the cutaneous deposit is isolated, as in visceral metastasis, there is a role for radical management such as wide local excision and reconstruction. In our patient, since she had multiple cutaneous metastases she began treatment with palliative systemic combination chemotherapy.

Colonic Mucosal Ulceration and Gastrointestinal Bleeding Associated with Sevelamer Crystal Deposition in a Patient with End Stage Renal Disease.

End stage renal disease (ESRD) population account for 1.9 per patient year of hospital admissions annually. ESRD population are at increased risk of bleeding secondary to use of anticoagulation during hemodialysis and uremia induced platelet dysfunction. Gastrointestinal bleeding accounts for 3-7% of all deaths in ESRD population. Lower gastrointestinal bleeding refers to blood loss from a site in the gastrointestinal tract distal to the ligament of Treitz. It is usually suspected when a patient complains of hematochezia. It is different from patients presenting with hematemesis that suggests bleeding from upper gastrointestinal tract. Common causes of lower gastrointestinal bleed include diverticulosis, ischemia, hemorrhoids, neoplasia, angiodysplasia, and inflammatory bowel disease. ESRD patients are known to retain phosphate alone or in combination with calcium which has been associated with high mortality. Sevelamer is a phosphate binder used widely in ESRD population. The known side effects of sevelamer include metabolic acidosis, vomiting, nausea, diarrhea, dyspepsia, abdominal pain, constipation, flatulence, fecal impaction, and skin rash. We are reporting a unique case of a 56-year-old female with end stage renal disease on sevelamer hydrochloride who presented with gastrointestinal bleeding and underwent a right hemicolectomy found to have sevelamer-induced mucosal ulceration and crystal deposition in the colonic mucosa. This case report highlights the fact that, with widespread use of this medication in the patients with chronic kidney diseases, physicians should be aware of this underrecognized entity in the differential diagnosis of gastrointestinal bleed in ESRD patients.

Group A Streptococci-Associated Necrotizing Fasciitis following Cat Bite in an Immunocompromised Patient.

Necrotizing soft tissue infections are characterized clinically by fulminant tissue destruction, systemic signs of toxicity, and high mortality. Accurate diagnosis and appropriate treatment must include early surgical intervention and antibiotic therapy. Mortality rate is very high and could be even higher in an immunocompromised host. We present a 57-year-old female with history of rheumatoid arthritis on oral corticosteroid and methotrexate therapy with painful swelling of the left hand following a cat bite that was diagnosed as having group A streptococcus pyogenes-associated necrotizing fasciitis. Treatment with ampicillin-sulbactam, Clindamycin, and surgical debridement was performed. In spite of all the adequate therapy she succumbed to death from streptococcal toxic shock and related complications after thirty-two days of treatment in intensive care unit. Necrotizing fasciitis is an uncommon but life-threatening complication in immunocompromised hosts. Tissue infections in cat bite wounds are commonly caused by pathogenic bacterium known as Pasteurella multocida. Group A streptococcal infections are not reported following cat bites. A high index of suspicion must be maintained to suspect group A streptococcal associated necrotizing fasciitis following cat bites and an early medical and surgical intervention should be made for any best possible outcome.