Cocaine-Induced Bronchial Laceration: A Rare Incidence.

Tracheobronchial injuries are either traumatic or iatrogenic but can be lethal in a high dependency setting if not managed promptly. There are few reported cases of cocaine-induced airway damage and barotrauma due to thermal or ischemic injury and increased intra-alveolar pressure. We present a sui generis case of cocaine-induced bronchial laceration with pneumomediastinum which was challenging to diagnose based on the patient's recent history of hospitalization, as well as the patient's reluctance to share the history of cocaine use. The patient was successfully managed conservatively. Here, we discuss the mechanism involved and the various treatment options available, along with the role of early involvement of the multidisciplinary team to deliver the best possible outcome.

Foreign Body Aspiration Getting Weird: Crack Pipe Aspiration.

Inhalation of cocaine derivatives is associated with a number of pulmonary and systemic complications. We report a case of less recognized complication, the aspiration of a metallic object used as a screen for crack cocaine abuse. A 42-year-old female presented with a two-day history of gradually worsening cough and a history of "food aspiration." Her lung examination revealed wheezing and fine crackles with diminished air entry at the left base. A chest X-ray revealed an 8 mm radiopaque foreign body overlying the region of the left lower lobe bronchus, with a confirmatory computed tomography scan of the chest. An urgent bronchoscopy revealed a metallic foreign body impacted into the left lower lobe bronchus proper, soon after the takeoff of the superior segment, which was removed with forceps. The patient signed out against medical advice soon after. Though relatively uncommon, this case highlights a possible complication associated with crack cocaine abuse that may require emergent intervention.

Cardiac Arrhythmia Secondary to Loperamide Abuse and Toxicity.

Loperamide is a synthetic, over-the-counter, antidiarrheal medication that is widely available and used for the treatment of diarrhea. It is a peripherally acting opioid agonist acting mostly on the µ-opioid receptors in the gut. It was thought to be a very safe medication up until very recently, as the bioavailability of the drug is very low. At significantly higher doses, it is able to cross the blood-brain barrier and mimic the effects of centrally acting opioids. However, at these significantly high doses it also leads to significant cardiotoxic consequences. Here we present a case of a 31-year-old male with significant cardiotoxicity secondary to misuse and abuse of loperamide.

An Intriguing Case of Acute Encephalopathy: Lesson Learned from a Constipated Man.

Hyperammonemia is a common cause of encephalopathy encountered in an intensive care unit (ICU). Absence of pre-existing liver disease may misguide a clinician and cases of non-cirrhotic hyperammonemia may be missed in ICU leading to life-threatening outcomes such as cerebral edema and herniation. A critical care physician must look beyond liver cirrhosis as a cause of hyperammonemia so that infrequent but potentially reversible causes of encephalopathy are not missed, and patient treatment is not jeopardized.

An Unusual Case of Iatrogenic Tracheal Diverticulum Found in a Mechanically Ventilated Patient: To Treat or Not to Treat.

A tracheal diverticulum is an out pouching arising from the wall of the trachea, and its lumen is in communication with the tracheal lumen. It is a small air collection in the para-tracheal region and is an infrequently encountered clinical entity. This condition is often found incidentally on thoracic imaging and should be considered when para-tracheal air is present. It can be congenital or acquired. In the absence of symptoms, management is mainly conservative with close monitoring for complications such as para-tracheal abscess. We present a case of iatrogenic tracheal diverticulum that formed likely due to increased cuff pressure of the mispositioned endotracheal tube seated against a tracheal wall already vulnerable to injury due to multi-organ failure.

A Case Report of Secondary Spontaneous Pneumothorax Induced by Vape.

Electronic cigarettes (referred here as E-cigarettes or vapes) are devices that contain heated nicotine/cannabinol vaporized aerosol solution for consumption. While long-term toxicities of E-cigarettes are unknown, the acute adverse events of vaping that have occurred are concerning. There have been variations of pneumonitis presentations so far, however, very few case reports have been shown to have a complication of a pneumothorax. We hereby present a case of a 35-year-old male who presented with spontaneous pneumothorax and pneumonitis due to vaping.

Quantification of Ricinine and Abrine in Human Plasma by HPLC-MS-MS: Biomarkers of Exposure to Ricin and Abrin.

Ricin and abrin are toxic ribosome-inactivating proteins found in plants. Exposure to these toxins can be detected using the biomarkers ricinine and abrine, which are present in the same plant sources as the toxins. The concentration of the biomarkers in urine and blood will be dependent upon the purification of abrin or ricin, the route of exposure, and the length of time between exposure and sample collection. Here, we present the first diagnostic assay for the simultaneous quantification of both ricinine and abrine in blood matrices. Furthermore, this is the first-ever method for the detection of abrine in blood products. Samples were processed by isotope-dilution, solid-phase extraction, protein precipitation and quantification by HPLC-MS-MS. This analytical method detects abrine from 5.00 to 500 ng/mL and ricinine from 0.300 to 300 ng/mL with coefficients of determination of 0.996 ± 0.003 and 0.998 ± 0.002 (n = 22), respectively. Quality control material accuracy was determined to have <10% relative error, and precision was within 19% relative standard deviation. The assay's time-to-first result is three hours including sample preparation. Furthermore, the method was applied for the quantification of ricinine in the blood of a patient who had intentionally ingested castor beans to demonstrate the test was fit-for-purpose. This assay was designed to support the diagnosis of ricin and abrin exposures in public health investigations.

Brain on fire: anti-N-methyl-D-aspartate-receptor encephalitis associated with ovarian teratoma.

INTRODUCTION: Anti-N-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis is the most common antibody-defined autoimmune neuronal disorder. It may present with psychiatric symptoms, decreased consciousness, and hypoventilation. DATA SOURCES: A 33-year old female presented with agitation and psychotic symptoms following a flu-like illness. She was treated for a presumed psychiatric disorder before she developed seizures and respiratory failure. An extensive workup including routine blood work, brain imagining, electroencephalography, and cerebrospinal fluid analysis was unremarkable. After a prolonged hospital stay requiring multiple antiepileptic drugs and sedatives, a computerized tomography of the abdomen revealed an ovarian tumor. Immunosuppressive therapy was initiated and the tumor was resected, when anti-NMDAR encephalitis was suspected. The diagnosis was confirmed following a positive anti-NMDAR antibody. CONCLUSION: Anti-NMDAR encephalitis should be considered in the differential diagnosis of a diverse array of conditions. This case report emphasizes the importance of investigating such patients since proper treatment could potentially prevent neurologic complications or death.