Indoxacarb poisoning presenting as methemoglobinemia: A case report.

A 34-year-old Sri Lankan man presented with multiple episodes of vomiting following accidental ingestion of 100 ml of indoxacarb (Avaunt). He had a significant saturation gap (discrepancy between oxygen saturation [98%] in blood gas analysis and saturation on pulse oximetry [70%] in finger pulse oximetry), the color of the blood was muddy brown, and the methemoglobin level (60%) was high in the blood gas analysis. A diagnosis of methemoglobinemia secondary to indoxacarb poisoning was made, and he was treated with methylene blue with a favorable outcome. Methemoglobinemia secondary to indoxacarb poisoning is extremely rare, and clinicians should be aware of this important complication. Methemoglobinemia secondary to indoxacarb poisoning has a favorable outcome if recognized and treated promptly.

Surgical outcomes and stoma-related complications in inflammatory bowel disease in Saudi Arabia: a retrospective study.

BACKGROUND: The prevalence of inflammatory bowel diseases (IBD), Crohn's (C) and ulcerative colitis (UC) has increased in Saudi Arabia during the past decade. Even though medical treatment is first-line therapy, most patients require surgery during the course of the disease. Stoma creation complications in IBD are underreported in the literature of the Middle East and especially in Saudi Arabia. OBJECTIVES: Report the postoperative, stoma and peristomal complications following stoma creation in (C) versus UC. DESIGN: Retrospective cohort study. SETTINGS: Tertiary care center. PATIENTS AND METHODS: Patients with IBD who underwent stoma creation for either UC or CD between August 2015 and July 2020 were included. The diseases were compared to assess their characteristics and association to postoperative, stoma and peristomal complications. All complications were reported over a 90-day duration from the surgery. Patients younger than 14 years of age were excluded. MAIN OUTCOME MEASURES: Postoperative complications, stoma and peristomal complications in IBD patients who underwent stoma creation. SAMPLE SIZE: 50. RESULTS: Of 50 IBD patients underwent stoma creation, 32 patients (64%) were diagnosed with CD and 18 patients (36%) with UC. Most of the procedures in both groups were laparoscopic and elective. Low BMI and serum albumin were more prevalent in the CD group. Postoperative complications were higher in the CD patients compared to the UC patients (CD 40.6% vs UC 11.1%, P=.028) with the most common complication being abdominal collection[a]. Stoma complications were comparable between the two groups (UC 16.7% vs CD 15.6%). However, peristomal complications were higher clinically in UC patients in comparison with the CD patients (UC 61.1% vs CD 37.5% P=.095) with the most common complication being skin excoriation (UC 44.4% vs CD 37.5%). CONCLUSIONS: CD has significantly higher postoperative complications compared to UC. Peristomal complications were high in both groups and had a negative impact on quality of life. Therefore, comprehensive stoma education and regular outpatient follow ups are recommended to improve the overall outcomes. LIMITATIONS: Retrospective and conducted in one academic institution with a small sample size.

Splanchnic venous thrombosis and recurrent spontaneous abortion due to latent essential thrombocytosis revealed after 20 years: Case report.

ABSTRACT: A 50-year old housewife presented to our department with recurrent pain and bluish discoloration of bilateral lateral two toes for 1 year. She had multiple thrombotic complications (portal vein thrombosis, small bowel ischemia, and recurrent abortions) at the age of 30 years for which a cause was not identified. She had a long asymptomatic period of 20 years following that and was diagnosed to have essential thrombocytosis (ET) when she was admitted with digital ischemia. She was started on hydroxyurea and aspirin. She had significant improvement in her ischemic symptoms and the platelet counts and white blood counts came down on follow-up. We present a patient with multiple thrombotic complications during the masked phase of ET (with normal platelet counts) which was not reported previously to the best of our knowledge. A very long asymptomatic period of 20 years between the first thrombotic event and the later events revealing the diagnosis of ET is unusual.

Chronic Tubulointerstitial Nephritis and Peripheral Neuropathy Probably Due to Pantoprazole Mimicking Systemic Disease.

The coexistence of peripheral neuropathy and chronic tubulointerstitial nephritis in a patient can be secondary to various diseases including-connective tissue disorders, sarcoidosis, IgG4-related disease, heavy metal poisoning, plasma cell dyscrasias, and drugs. A 70-year old woman was admitted with fatigue for 4 months and numbness of both lower limbs for 6 months. She had antral gastritis and was on treatment with pantoprazole for 1 year. On evaluation, she had peripheral neuropathy and chronic tubulointerstitial nephritis which was suspected to be secondary to pantoprazole after ruling out other causes. We present a patient with multiple complications (peripheral neuropathy and chronic tubulointerstitial nephritis) likely associated with pantoprazole which was not reported in the literature previously to the best of our knowledge.

A Phosphaturic Mesenchymal Tumor Presenting as Reversible Metabolic Myopathy.

Tumor-induced osteomalacia (TIO) is a disorder in which the clinical signs and symptoms of osteomalacia and the biochemical abnormalities of hypophosphatemia, phosphaturia, and low serum levels of 1,25(OH)2 Vitamin D3 are secondary to a neoplasm. A 33-year-old woman presented with musculoskeletal pain and proximal myopathy with a duration of 2.5 years which was treated with Vitamin D supplements. On the basis of the biochemical tests and histopathology, she was reevaluated and found to have TIO secondary to a phosphaturic mesenchymal tumor. The tumor was resected (limb salvage with endoprosthesis), and she had no pain or weakness at followup. The case reminds the readers to consider the possibility of TIO when evaluating patients with isolated hypophosphatemia, which may lead to long-term disability and prolonged morbidity if untreated. Early recognition and diagnosis of TIO is crucial since resection of the tumor usually reverses its manifestations.

Posterior reversible encephalopathy syndrome secondary to malignancy-associated hypercalcemia: A case report.

Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical syndrome usually characterized by a range of neurological manifestations and distinctive neuroimaging findings reflecting vasogenic edema. PRES has been described in the context of various clinical settings including: renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders and eclampsia. Hypercalcemia is rarely associated with PRES. We report a patient with lung cancer presenting as PRES secondary to hypercalcemia.

Erythema induratum of bazin - Skin lesions with pyrexia of unknown origin undiagnosed for 4 years.

Erythema induratum of Bazin is characterized by chronic, tender, erythematous, indurated subcutaneous nodules on the lower extremities caused by tuberculin hypersensitivity. A 21-year-old woman presented with recurrent episodes of multiple erythematous scaly lesions over both lower limbs below the knee and low-grade fever for 4 years. She was treated from various outside hospitals with multiple courses of antibiotics and nonsteroidal anti-inflammatory drugs without improvement. The histopathology of the skin lesion was suggestive of erythema induratum. She had complete resolution of her skin lesions and fever following 6 months of treatment with antitubercular drugs. A delay in the diagnosis of rare presentations of tuberculosis can result in the administration of ineffective and potentially damaging treatments.

Tuberculous peritonitis complicated by immunologic cerebral vasculitis.

A 53-year-old female was admitted with ascites for 3 weeks, decreased response, and weakness of right upper and lower limbs for 1 day. Peritoneal biopsy showed necrotizing granulomatous inflammation, and cartridge-based nucleic acid amplification test for tuberculosis (TB) of biopsy was positive without rifampicin resistance. Magnetic resonance imaging brain showed multiple foci of diffusion restriction in bilateral cerebral hemisphere and cerebellum, suggestive of acute infarcts. After ruling out the secondary causes of cerebral infarction by appropriate tests and demonstrating that there was no evidence for tuberculous meningitis or direct injury, it was concluded that the reason for multiple cerebral infarctions in this patient is likely to be immunologic injury secondary to TB. Multiple cerebral infarctions secondary to immunologic injury in TB were reported only once previously.

Reversible cerebellar ataxia and bipolar disorder secondary to tuberculous adrenalitis.

Addison's disease is primary adrenal insufficiency which is most commonly due to an autoimmune disease. Patients usually presents with fatigue, anorexia, gastrointestinal complaints, salt craving, and orthostatic hypotension. Rare manifestations during presentation can result in diagnostic dilemma. A 53-year-old male presented with cerebellar ataxia and bipolar disorder secondary to Addison's disease (due to tuberculous adrenalitis) which improved following treatment with steroids. We describe a patient with Addison's disease who presented with two rare manifestations which to our knowledge is the first such report.

Metastatic tuberculous chest wall and massive psoas abscesses in an immunocompetent patient.

Extrapulmonary tuberculosis (TB) is rare in immunocompetent healthy adults. TB of the chest wall accounts for 1%-5% of all cases of musculoskeletal TB. Psoas abscess can be either primary or secondary to diseases like Pott's spine. We describe a patient with massive lower chest wall abscess extending to abdominal muscles and an asymptomatic large psoas abscess detected on imaging due to spine TB which responded well to antitubercular therapy and drainage without surgical measures. The concomitant presence of a massive chest wall abscess and psoas abscess due to TB in an immunocompetent patient was not reported previously.