Metformin toxicity in the intensive care unit: A case series and review of the literature.

Metformin toxicity is a life-threatening condition with high morbidity and mortality. Toxicity predominantly occurs in the setting of acute renal dysfunction, as the drug is solely eliminated by the kidneys. While this risk is widely known to clinicians, diagnosing metformin toxicity is challenging because commercially available serum metformin levels require days to weeks to result. Therefore, the intensivist must rely on medical history, clinical presentation, and routine laboratory findings to make the preliminary diagnosis. Treatment of metformin toxicity includes supportive fluid hydration, vasopressors, and emergent hemodialysis (HD). We report three critically ill patients who had near-fatal severe metformin-induced lactic acidosis. Their metformin levels were markedly higher than the toxicity threshold reported by the Federal Drug Agency. These patients made a prompt and complete recovery after the initiation of HD. We also review the pathophysiology, clinical presentation, diagnosis, and treatment of metformin toxicity.

Patient Living with Human Immunodeficiency Virus and Depression with High HIV Viral Load Presenting for Evaluation of Root Caries.

A 26-year-old man living with HIV and depression presents with symptoms of tooth sensitivity. His laboratory studies are all within normal limits except for a high viral load. The patient does not require any special dental management protocol and should be treated like other patients, with his laboratory studies reviewed every 6 months to 1 year. HIV is now a chronic medical conditions, with most patients having stable disease if they are compliant with their medications. Universal infection control protocols should be followed for all patients regardless of their HIV status.

Dental Extraction in a Patient Living with Human Immunodeficiency Virus with Neutropenia and Thrombocytopenia.

A 34-year-old male patient living with human immunodeficiency virus (HIV) presents to the dental clinic with a 1-week history of throbbing tooth pain. He was referred by an oral medicine specialist for evaluation and treatment. The patient presents with very low absolute neutrophil, platelet, and cluster of differentiation (CD) (also T-helper cell) 4+ cell counts, as well as a high HIV RNA/viral load. Determining factors for dental management before extraction of the offending teeth were the absolute neutrophil count and platelet counts.

A 50-Year-Old Woman Living with Human Immunodeficiency Virus and Comorbid Conditions, Presenting for Scaling and Root Planing.

A 50-year-old female patient with a history of HIV, uncontrolled diabetes, hyperlipidemia, hypertension, and chronic hepatitis C presents for dental evaluation and treatment because of bleeding gums. This article discusses modifications to her dental management with respect to her various medical conditions. Noninfectious comorbid conditions especially diabetes, cardiovascular disease, and hyperlipidemia are common findings in patients with HIV. Modifications to dental treatment should not be based solely on HIV RNA (viral load) and CD4+ cell count. Dentists can play a role in ensuring patients' comorbid medical conditions are well managed.

Patient Living with Human Immunodeficiency Virus with a History of Chronic Obstructive Pulmonary Disease and Experiencing Oxygen Desaturation During Dental Treatment.

A 60-year-old male patient living with HIV, with a medical history of chronic obstructive pulmonary disease and persistent cough, presents to the dental clinic with rampant caries and multiple missing teeth. He had an average oxygen saturation of 84% observed while taking his vital signs. The authors discuss the management of this patient during routine dental treatment.

Patient Living with Human Immunodeficiency Virus with Gingival Pain and Oral Soreness (Red and White Lesions).

A 34-year-old male patient with poorly controlled HIV/AIDS presented with symptoms consistent with oral candidiasis and necrotizing ulcerative gingivitis. He was treated with systemic antifungal agent and topical and systemic antibiotics.

Abiotrophia defectiva Endocarditis: An Easy Miss.

Subacute endocarditis often presents with an indolent course. A potentially lethal form generated by infection with Abiotrophia defectiva may be easily overlooked early in its presentation. This report discusses the case of an 18-year-old male discovered to have severe endocarditis after presenting to the emergency department with the chief complaint of foot pain.

Papillary fibroelastoma arising from the left atrial free wall.

Primary cardiac tumors are rare. Papillary fibroelastomas represent the second or third most common benign cardiac tumor and the most common one associated with heart valves. Nonvalvular endocardial location of this tumor is extremely rare. We present a case of a papillary fibroelastoma arising from the left atrial (LA) free wall.