A Case of a Thrombotic Storm (Arterial and Venous) in Nephrotic Syndrome.

Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, hyperlipidemia, and a hypercoagulable state. Nephrotic syndrome may lead to several complications, including, but not limited to, increased risk of infection, respiratory distress, and thromboembolism. There are several etiologies of nephrotic syndrome with various predisposing factors ranging from idiopathic, autoimmune diseases, infections (human immunodeficiency virus, hepatitis C virus, hepatitis B virus), drugs, and heavy metal poisoning. Here, we report the case of a 37-year-old male who presented with worsening exertional dyspnea and bilateral lower extremity swelling. He was found to have simultaneous multiple acute thromboses in both the venous and arterial systems in the setting of worsening renal function. Further investigation revealed that the patient had membranous nephropathy. Initiation of anticoagulation and immunosuppression made a significant difference in his survival. Vascular thromboembolic (VTE) complications may be the initial presentation that prompts patients with nephrotic syndrome to seek medical care. As such, clinicians must have a high index of suspicion in patients presenting with concurrent VTE and nephrotic-range proteinuria. In addition, given that treatment modalities for the various etiologies of nephrotic syndrome differ considerably, it is also essential to distinguish the type of nephrotic syndrome in a patient, which dictates the treatment algorithm.

Fractional exhaled nitric oxide and mortality in asthma and chronic obstructive pulmonary disease in a national cohort aged 40 years and older.

BACKGROUND: Little is known about Fractional concentration of exhaled Nitric Oxide (FeNO) as a predictor of mortality in persons with asthma or chronic obstructive pulmonary disease (COPD). OBJECTIVE: This study tested the hypotheses that FeNO level ≥ 25 ppb was associated with mortality in a national cohort of persons with asthma or COPD age ≥ 40 years. METHODS: In the 2007-2012 National Health and Nutrition Examination Survey (NHANES), FeNO was measured using an electrochemical sensor. Mortality was determined through 2015 using linkage to the National Death Index. Weighted Cox proportional hazards survival analysis was performed taking the complex survey design into account using STATA V.17. RESULTS: Among the 611 participants with current asthma, 5.16% died during the follow-up period. FeNO ≥ 25 ppb was associated with a hazard ratio (HR) of 0.20, (p = 0.006, 95% CI:0.068-0.618) alone or with little change after controlling for confounding variables. Due to effect modification, the analysis was repeated in persons with and without a history of emergency department (ED) visit for asthma in the previous year. In 522 persons without ED visits, FeNO ≥ 25 ppb was significantly associated with mortality HR 0.094, 95 CI 0.034-0.26, p < 0.001. In 83 persons with ED visits no significant association remained after controlling for all confounders. (Six persons were omitted from this analysis due to missing data on confounders in the extended regression model.) Among 614 with COPD, FeNO ≥ 25 ppb was not associated with mortality. CONCLUSION: In persons with current asthma at baseline, FeNO ≥ 25 ppb was associated with reduced hazard of mortality during follow up among those with no history of ED visits in the previous year. No significant association of FeNO with mortality was seen in persons with COPD.

A Case Report on Atypical Presentation of Metastatic Prostate Cancer.

The lung is a common site for metastatic cancers such as colorectal and breast cancer but an uncommon site for prostate cancer. The treatment modalities for primary and metastatic lung malignancies differ considerably; therefore, it is essential to distinguish between them. Here, we present a patient with solitary metastatic lung cancer with prostate as the primary source, which was initially considered a primary lung nodule considering his risk factors. The patient later developed other lung nodules and successfully underwent resection of these nodules with no bone involvement at the time. Follow-up computed tomography (CT) of the chest revealed two other new lung nodules and pleural effusion, and magnetic resonance imaging (MRI) of the pelvis showed bone involvement. The patient was started on gonadotropin-releasing hormone therapy with subsequent downtrending prostate-specific antigen (PSA). Although uncommon, prostate cancer can metastasize to the lungs; hence, clinicians must always have a high index of suspicion when a patient presents with a lung nodule, especially with a prior history of prostate cancer.

Tricyclic antidepressant overdose treated with adjunctive lipid rescue and plasmapheresis.

Tricyclic antidepressant poisoning remains a major cause of morbidity and mortality, particularly in the setting of suicidal attempts. The current standard of care for treatment is the administration of sodium bicarbonate infusion. Adjunctive lipid emulsion therapy and plasmapheresis have received attention recently. We report an 18-year-old patient who was successfully managed with lipid emulsion and plasmapheresis as adjuncts to sodium bicarbonate treatment and review some of the recent literature.

Noncirrhotic hyperammonemia causing relapsing altered mental status.

Hyperammonemia is a recognized cause of encephalopathy. However, it is commonly seen in patients with liver disease. The clinical entity of noncirrhotic hyperammonemia is now being increasingly recognized. We report a man who presented to our hospital with relapsing altered mental status later diagnosed as noncirrhotic hyperammonemia.