Tracheoesophageal Prosthesis Malfunction - A Case Report.

Tracheoesophageal prosthesis (TEP) is an artificial connection between the trachea and esophagus allowing air into the upper esophagus from the trachea thereby vibrating it. TEPs give patients who lose their vocal cords to laryngectomies a tracheoesophageal voice. A potential complication of this is silent aspiration of gastric content. We present a case of a 69-year-old female with a TEP placed after a laryngectomy for laryngeal cancer who presented to the hospital with shortness of breath and hypoxia. She was initially treated for a presumed diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations but continued to be hypoxic despite aggressive medical management. Further evaluation revealed silent aspirations as a consequence of TEP malfunction. Through our case report we urge clinicians to consider this differential diagnosis, as the clinical presentation of silent aspiration among patients with a TEP can be easily mistaken for a COPD exacerbation. A large number of patients with TEPs are smokers with underlying COPD. LEARNING POINTS: TEPs give patients who lose their vocal cords to laryngectomies a tracheoesophageal voice.A potential complication of TEPs is silent aspiration around or through the TEP, causing coughing and even recurrent aspiration pneumonitis or pneumonia.Patients with TEPs typically have extensive smoking histories and underlying COPD or CHF which can have exacerbations that are similar in presentation.

Drug-Induced Liver Injury Secondary to Turmeric Use.

Turmeric is a herbal medication and spice which has been used for thousands of years in traditional Eastern medicine for its flavour, colour, and purported anti-inflammatory, antioxidant, antineoplastic and antimicrobial properties. It has recently garnered interest and popularity worldwide for these reasons. While turmeric supplements are generally safe, some reports of toxicity are emerging. Compounds like piperine are added to turmeric to enhance its bioavailability, potentially contributing to its toxicity. Here, we describe a 55-year-old woman with progressive jaundice and elevated bilirubin and liver enzymes but no evidence of acute liver failure. She was treated with N-acetyl cysteine (NAC) for 24 hours and liver function tests (LFTs) were closely monitored. As a downtrend in LFTs was noted and the patient remained asymptomatic, she was discharged with close outpatient follow-up. LFTs eventually normalized 2 months after the initial presentation. Clinicians must keep this differential in mind when evaluating acute liver injury. With our case report, we question the utility of NAC in non-acetaminophen-related liver injury and encourage further studies. LEARNING POINTS: Eliciting information on recent drug or supplement use should be part of comprehensive history-taking to evaluate acute liver injury.Turmeric supplements which may contain piperine to enhance bioavailability are a potential source of acute liver injury.The role of N-acetyl cysteine in managing non-acetaminophen-related liver injury is unclear and further studies are required.

Trazodone Overdose Manifesting as Hypotension and QT Prolongation.

Trazodone is a medication used to treat major depressive disorder (MDD). It is in the serotonin-antagonist-and-reuptake-inhibitor class of medications with anti-cholinergic effects. Trazodone is known for its sedative effects and is hence often prescribed in those with MDD with concurrent insomnia. While few, there have been reports of patients overdosing on trazodone and developing QTc prolongation leading to fatal arrhythmias such as torsades des pointes and variable atrioventricular blocks. We present a case of a 45-year-old female with a past medical history of MDD and anxiety, who presented with dizziness, transient ataxia, and urinary incontinence following ingestion of five 100 mg trazodone tablets. Although her vitals were initially stable on admission, her EKG was concerning for QTc prolongation of 502 ms. A few hours later, she started developing hypotension and progressive QTc prolongation, with a peak of 586 ms. Given the high risk of decompensation, the patient was admitted to the ICU for further care where she received adequate supportive management in the form of fluid resuscitation, electrolyte repletion, serial EKGs every hour, and telemetry monitoring for arrhythmias, with eventual improvement in her clinical condition. Trazodone poisoning, while rare, can be fatal and hence requires close monitoring to prevent complications. Clinicians must be aware of these possible adverse outcomes when managing trazodone toxicity.