Primary small cell neuroendocrine cancer of adrenal gland: a rare extrapulmonary small cell cancer.

Small cell cancer is an aggressive neoplasm of neuroendocrine origin that is most commonly found in the lungs. However, up to 5% of cases can be extrapulmonary. These have been reported to be located in the gastrointestinal and genitourinary systems and rarely in other locations. Only five prior cases of small cell cancer have been reported where the primary lesion is at the adrenal gland. Here we present the case of a female patient in her mid-50s who presented with right upper quadrant pain and was diagnosed with metastatic small cell carcinoma of the adrenal gland. The patient received palliative chemotherapy for her metastatic cancer and was ultimately admitted to hospice after progression of her disease. This case and the accompanying literature review highlight a rare manifestation of extrapulmonary small cell cancer.

Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.

Duration of in-hospital cardiopulmonary resuscitation and its effect on survival.

OBJECTIVE: This study aims to determine the correlation between the duration of cardiopulmonary resuscitation (CPR) and the return of spontaneous circulation (ROSC) in an in-hospital cardiac arrest cohort. METHODS: All patients (age ≥ 17 years) who underwent CPR at our institution from 2015 to 2017 were included. The primary endpoint was ROSC or death. A total of 88 patients were included in the study. The Pearson correlation of CPR duration with the establishment of ROSC was calculated using the IBM SPSS, version 25. RESULTS: In all, 88 patients who received CPR, 55% (n = 48) experienced ROSC and survived. The remaining 45% (n = 40) of the total and 56% (n = 27) of those with ROSC died during the same hospitalization (Fig. 1). Among the 48 patients with ROSC, the documented duration of their CPR was about 10 min on average in comparison with 27.5 min CPR for patients who did not achieve ROSC (Fig. 2). Among all the patients, there was a negative correlation between the duration of the CPR and the establishment of ROSC. This is shown in Fig. 3. CONCLUSION: Our study shows that CPR duration is inversely associated with the establishment rates of ROSC. Most of the benefits of CPR can be achieved in the first 15 min, and a further increase in the duration of CPR provides a minimal gain. Still, survival was achievable till 38 min in some cases, and the ideal duration of resuscitation should remain a bedside decision taking into consideration the whole clinical picture.

Anastrozole-induced liver injury after a prolonged latency: a very rare complication of a commonly prescribed medication.

Anastrozole is an aromatase inhibitor that has been used more frequently over the last decade especially for oestrogen receptor-positive breast cancer. It has a relatively safe side effect profile. However, occasionally it has been associated with serious adverse events. Here, we present the case of a 58-year-old woman who presented with significantly elevated liver enzymes 4 years after starting anastrozole. She was not taking any other medications and an extensive workup did not reveal any other cause for her liver injury. The patient's liver enzymes normalised after discounting the anastrozole. She scored 4 on the updated Roussel Uclaf Causality Assessment Method grading system which was possible for drug-induced liver injury. A review of the literature revealed six prior cases of anastrozole-related liver injury. Anastrozole should be considered as a possible culprit in patients who develop an unexplained acute liver injury.

The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis.

BACKGROUND: Syncope is a symptom complex comprising of a brief loss of consciousness leading to a transient decrease in cerebral blood flow that resolves completely. 2D-transthoracic echocardiography (TTE) is a useful tool to detect underlying structural heart disease, which can lead to syncope, e.g., aortic stenosis, atrial masses. This study aimed to find the subgroups of patients with syncope who would benefit the most from a TEE. METHODS: We did a retrospective chart review of all patients aged 18 years or older, admitted to our hospital with a primary diagnosis of syncope between January 2015 and January 2017 to determine the frequency and findings of echo in all these patients. The baseline characteristics, demographics were taken into account for the inclusion of these patients into the study. RESULTS: A total of 369 patients were initially studied, but only 139 patients were included in the final analysis based on inclusion criteria. Among the high-risk patients (i.e., abnormal Physical exam and/or abnormal EKG, population), 43.75% had significant echocardiographic finding. While among low-risk patients (i.e., normal EKG and exam), 10% (9/91) had a significant finding. Patients with abnormal EKG or examination findings were 7.08 times (95% CI = 2.89-17.3) more likely to have an abnormal echocardiogram (P < 0.001). CONCLUSION: Our study suggests that the diagnostic yield of 2D-TTE in the absence of abnormal physical exam and/or abnormal EKG is very limited and may add an extra burden on the finances and resources of both the patient and the hospital.

Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication.

Amiodarone is an antiarrhythmic agent that is used commonly in clinical practice. It is associated with many side effects, the most common being pulmonary manifestations. Interstitial pneumonitis is one of the most common complications, however rarely amiodarone can cause diffuse alveolar haemorrhage (DAH) too. We describe the case of a 73-year-old woman who presented with shortness of breath and haemoptysis 4 days after starting amiodarone. She was diagnosed with amiodarone-induced DAH based on imaging and bronchoalveolar lavage. She was treated with intravenous and then oral steroids, and amiodarone was discontinued. The patient made a significant clinical and radiological recovery. She was discharged 10 days after her presentation. This case highlights a rare but potentially life-threatening complication of a commonly used medication.

Herpes Simplex Esophagitis in Immunocompetent Patients: A Rare But Easily Managed Condition.

Herpes simplex (HS) is an opportunistic infection, primarily in immunocompromised patients, caused by herpes simplex virus. Oral and genital mucosa are the most commonly involved sites; it is rare for HSV to invade the esophagus and cause esophagitis, especially in immunocompetent patients. Here, we present a case where an immunocompetent patient presented with HS esophagitis, which had evolved into esophageal ulcers. He was successfully treated with acyclovir. Subsequently, we did a comprehensive literature search and tabulated all the possible complications and management plans of previously reported cases of HS in immunocompetent patients.

Importance of Basal Metabolic Index in the Diagnosis of Heart Failure With B-Type Natriuretic Peptide.

BACKGROUND: Increased basal metabolic index (BMI) is associated with decreased levels of B-type natriuretic peptide (BNP). This makes the diagnosis of the congestive heart failure challenging in the obese population. We sought to determine the association and strength of the relationship between the two variables. METHODS: The association between BMI and BNP was examined in 405 patients utilizing a retrospective chart review in a single center study. Pearson correlation and regression analyses were performed to identify trends. BNP trends were also correlated with age. RESULTS: The mean age of patients was 77 years with 45% men and 55% women. Mean BNP level was 1,158 standard deviation (SD) ± 1,537. Mean BMI was 33 SD ± 28. BNP levels were found to be inversely related to increasing BMI (P value < 0.001). Using a cut-off of 3,500 pg/mL, there was a linear negative correlation on the dotted graph. In regression analysis the measure of effect of BMI on BNP levels was -0.90 pg/mL. There was no significant association between age and BNP levels (P = 0.90). CONCLUSIONS: Irrespective of age, obese patients have lower BNP levels, complicating the diagnosis of heart failure exacerbation in such patients. Our results suggest that BNP levels in patients with BMI greater than 33 should be adjusted 9 pg/mL per unit increase in BMI.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) do not always represent multiple myeloma: diffuse large B cell lymphoma presenting with CRAB symptoms in a 69-year-old man.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) are a constellation of signs and symptoms that are collectively referred to as the CRAB features. When present together, multiple myeloma (MM) should be at the top of the differential diagnosis. We present a 69-year-old man who presented with severe body aches and bone pain in his ribs and pelvis, associated with fatigue and constipation. He was found to have hypercalcaemia, acute kidney injury, anaemia and numerous lytic lesion on chest imaging. Physical examination and imaging were unremarkable for any enlarged lymph nodes. The patient was initially suspected to have multiple myeloma, however, serum and urine protein electrophoresis, and serum free light chain assays were negative. The patient was ultimately diagnosed with diffuse large B cell lymphoma based on a bone marrow biopsy. This case highlights the fact that presence of hypercalcaemia, renal dysfunction, anaemia and bone lesions are not usually specific for MM.

Rapid onset type-1 diabetes and diabetic ketoacidosis secondary to nivolumab immunotherapy: a review of existing literature.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor that is increasingly used for various malignancies, both as a first line agent and as salvage therapy. Being a PD-1/PD-1 ligand checkpoint inhibitor, it is known to cause autoimmune inflammation of various organs and has been associated with thyroiditis, insulitis, colitis, hepatitis and encephalitis to name a few. There are increasing reports of nivolumab leading to acute onset fulminant type 1 diabetes and diabetic ketoacidosis (DKA). We present a case of a 68-year-old man who developed DKA after 2 doses of nivolumab for metastatic melanoma. He was found to have type 1 diabetes, but no diabetes related antibodies were positive. He recovered from diabetes and continues to use insulin 1 year after his diagnosis. This case and associated review illustrates the importance of educating and monitoring patients who start nivolumab therapy regarding this potentially life threatening complication.

Human cytomegalovirus pneumonia in an immunocompetent patient: a very uncommon but treatable condition.

Human cytomegalovirus (CMV) is a double-stranded DNA virus that can cause widespread severe infection in immunocompromised individuals but is more typically a subclinical infection in immunocompetent individuals. Rarely, it can cause a serious infection in immunocompetent individuals. Here, we describe a 36-year-old otherwise healthy male who presented with fever, cough and malaise who was diagnosed with CMV pneumonia. He made a rapid recovery after initiation of ganciclovir and has been doing well on follow-up visits. We performed a comprehensive review of CMV pneumonia in immunocompetent individuals and have summarised the prior 16 reported cases of CMV pneumonia in immunocompetent patients. This article highlights the importance of considering CMV as a cause of pneumonia even in immunocompetent individuals, especially when the more common causes have been excluded. Early diagnosis allows prompt treatment and potentially complete recovery.

Percutaneous removal of a retained appendicolith causing recurrent perihepatic abscesses between the liver and diaphragm.

Many cases of appendicitis can be associated with appendicoliths. These may sometimes be lost during appendectomies and may be lodged in the body. Most of these cases lead to recurrent abscess formation, and these appendicoliths invariably need removal. Typically, this used to be done as an open surgery or laparoscopically. Here we describe the case of a transcutaneous removal of an appendicolith that was lodged between the liver and diaphragm that led to recurrent perihepatic abscess formation in a 24-year-old otherwise healthy man. The patient made a successful recovery without any recurrence. A transcutaneous approach to remove a retained appendicolith may be a feasible, a safe and an easy method to extract appendicoliths that are accessible for transcutaneous removal.

Cardiac tamponade and purulent pericarditis secondary to an oesophageal pericardial fistula as an initial presentation of squamous cell carcinoma of the oesophagus.

Pericardial effusions resulting in a cardiac tamponade have previously been reported with oesophageal cancers. However, most of these cases have been reported in association with radiation and chemotherapy. Rarely as oesophageal pericardial fistuls (OPF) have been reported as the culprits in causing pericardial effusions in patients with oesophageal cancers. Here we present the case of a 61-year-old woman who presented clinically with cardiac tamponade. She was found to have an OPF due to oesophageal squamous cell cancer that resulted in a purulent pericardial effusion. She underwent a median sternotomy, pericardial decompression, and mediastinal debridement. An oesophageal stent was attempted unsuccessfully. The patient refused any more aggressive treatments and was discharged to a hospice where she passed away 13 days after presentation. This case and the associated literature review highlights an unusual presentation of oesophageal cancer and an uncommon cause of cardiac tamponade.

Cardiac arrest in a young healthy male patient secondary to kratom ingestion: is this 'legal high' substance more dangerous than initially thought ?

Kratom is a psychoactive herb that has stimulant properties at low doses and has opioid-like properties at higher doses. It has been used for centuries in southeast Asia as a stimulant but has gained increasing popularity as a substitute for opioids in western countries as it is easily available. As most cases of kratom use involve other drugs too, the Food and Drug Administration (FDA) has stopped short of restricting kratom due to difficulty in assessing the adverse effects of kratom alone. We present the case of a young healthy 35-year-old man who suffered a cardiac arrest due to kratom use with no other coingestants. He was subsequently intubated and found to have systolic dysfunction and small brain infarcts. Fortunately, he made a successful recovery and was discharged after a stay at thebehavioural health centre. Our case highlights the potential adverse effects of kratom and the need to regulate its use.

ST-Segment Elevation Myocardial Infaction Alert During the Night Shift, A Misfortune for the Patient or an Overstatement?

BACKGROUND: Conflicting data exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on intervention timings. It is believed that short staffing at night hours may lead to a lapse in the delivery of effective, efficient and timely medical intervention. METHODS: A retrospective single-center study was performed, and a total of 436 patients were randomized into two groups. Group A had 279 patients who had the heart catheterization done during the daytime (between 6 am and 6 pm), while group B had 157 patients who had the same intervention performed at night (between 6 pm and 6 am). RESULTS: Door to balloon (DTB) time during the day was about 16 min shorter than the DTB time at night (81.29 ± 3.26 vs. 97.30 ± 8.54) with no statistical difference (P = 0.051). The mean troponin rise during the day was 1.94 ± 10.60 SEM (95% confidence interval (CI): -22.70 to 18.90) higher than night troponin levels (71.75 ± 7.18 vs. 69.80 ± 7.18), but P value was 0.85. The left ventricular ejection fraction (LVEF) fall for daytime was 0.93% vs. 0.90% for night time patients (P = 0.94). CONCLUSION: There is no significant difference in the mean DTB time, the rise in troponin, fall in LVEF, readmission rates, or mortality, and hence no negative effects on patient outcomes based on the patient's time of presentation between the two groups.

A not so happy ending: coital cephalgia resulting from an acute non-traumatic intraparenchymal haemorrhage in a female with no comorbidities.

A sexual headache or coital cephalgia is a headache associated with sexual activity and is a well-recognised condition. It is usually benign, primary and self-limiting. However, occasionally sexual headaches can result from more sinister causes. Intraparenchymal and subdural haemorrhages have been reported as secondary causes of sexual headaches. We present the case of a 61-year-old woman with no comorbidities who presented acutely with a sexual headache and vision loss, and was found to have an occipital and parietal intraparenchymal haemorrhage. She was normotensive and after extensive workup was found to have no predisposing condition for her haemorrhage. The patient had an uneventful recovery with physical rehabilitation and had regular follow-ups, with no residual weakness. She was in a completely normal state of health 1 year after her event, and continued to be off any medications.

Role of echocardiography in diagnostic evaluation of patients admitted to observation unit.

BACKGROUND: Syncope is a transient loss of consciousness due to transient decrease in cerebral perfusion. Syncope accounts for a 3-6% of all emergency department visits. Etiology of syncope can be neural, cardiogenic, or vascular. Previous studies have evaluated the types and management of syncope. Echocardiography is a commonly used test in the evaluation of causes of syncope. Whether the benefit compared to financial burden of this diagnostic study is in all subsets of syncope cases remains unclear. AIM: To evaluate the impact of echocardiography in the diagnostic evaluation of syncope and to evaluate the subset of patients that would benefit more from this diagnostic imaging. METHODS: We performed a retrospective chart review of patients > 18 years of age with a primary diagnosis of syncope in a period of January 1st 2015-January 31st 2017. Our inclusion criteria included patients > 18 years of age who were admitted to the observation floor with the primary complaint as syncope, had a normal or abnormal physical examination for syncope, had a normal or abnormal electrocardiogram during admission, had an echocardiography performed at admission. Our exclusion criteria included patients with seizures, hypoglycemia, myocardial infarction, patients who didn't get echocardiography, and patients who had a positive marker of cardiac injury. RESULTS: A total of 369 patients were initially identified with a primary diagnosis of syncope, however only 120 of these patients fulfilled our inclusion and exclusion criteria. A total of n=25 of included patients had either an abnormal physical exam or abnormal echocardiography. Among this "high risk" group, 24% (n=6) of the patients had an abnormal finding on their transthoracic echocardiography. On the other hand, in the "low risk" group with a normal physical examination and electrocardiogram (EKG), 14 had a trans-thoracic echocardiography (TTE) positive for cause of syncope, that led to a change in medication, workup, or intervention in 6.7% (n=8) of the patients. CONCLUSION: The analysis of our study suggested that the diagnostic yield of transthoracic echocardiography in syncope is very limited in the absence of an abnormal physical exam or electrocardiogram, and it increase the health care cost burden with no additional benefits.