Adverse effects of erenumab on cerebral proliferative angiopathy: A case report.

BACKGROUND: Cerebral proliferative angiopathy is a vascular malformation associated with compromised blood-brain barrier and with migraine-like headache. Treating blood-brain barrier-compromised patients with erenumab, an anti-calcitonin gene-related peptide receptor monoclonal antibody, may be risky. CASE: We describe a case of a 22-year-old chronic migraine patient with cerebral proliferative angiopathy who presented to our hospital in status epilepticus 2 d after his first dose of erenumab. Serial magnetic resonance imaging (MRI) studies demonstrated progressive areas of diffusion restriction including the brain tissue adjacent to the cerebral proliferative angiopathy, bilateral white matter and hippocampi. His 6-month post-presentation magnetic resonance imaging was notable for white matter injury, encephalomalacia surrounding cerebral proliferative angiopathy and bilateral hippocampal sclerosis. He remains clinically affected with residual symptoms, including refractory epilepsy and cognitive deficits. CONCLUSION: The evidence presented in this case supports further investigation into potential deleterious side effects of erenumab in patients with compromised blood-brain barrier, such as individuals with intracranial vascular malformations.

Puberty and resultant increased bone turnover as a possible etiology of an increased lead concentration in a pre-adolescent girl.

Introduction: We present a case in which puberty likely resulted in an increased lead concentration in a pre-adolescent girl.Case report: A 12-year-old girl was referred to the pediatric environmental health clinic (PEHC) after her blood lead level (BLL) was found to be elevated to 30 µg/dL (reference <5 µg/dL). She had been seen in the PEHC 6 years previously for management of a BLL as high as 36 µg/dL. Fifteen months prior to her repeat PEHC referral, her BLL had been 10 µg/dL. In those intervening 15 months, she grew 10.42 cm. Thyroid studies were normal. Four months after re-referral, her osteocalcin concentration, a marker of bone turnover, was 212 ng/mL (normal 9-42 ng/mL in adults >18 years); 10.5 months after the peak BLL of 32 mcg/dL, her BLL was 16 µg/dL, osteocalcin was 69 ng/mL, and her rate of growth had declined to 0.20 cm/30 days (peak: 1.07 cm/30 days). No external source of her exposure was found.Discussion: Osteocalcin concentrations and plotting the changes in growth velocity over time may assist clinicians in determining if pubertal growth is playing a role in unexpectedly increased BLL discovered in adolescents for whom no external source of lead exposure can be found.

Massive lamotrigine and bupropion overdose resulting in status epilepticus without cardiovascular collapse.

An 18 year-old woman presented to an outside hospital with seizure activity after a massive ingestion of lamotrigine, bupropion, trazodone, buspirone, and possibly isoretinoin. Her initial vital signs were remarkable for tachycardia (120 bpm). She was intubated for airway protection. For treatment of status epilepticus, she received a total of 12 mg of IV lorazepam along with a lorazepam infusion titrated to 15 mg/hr, a propofol infusion of unknown dosing, and phenobarbital 650 mg. She was transferred to a receiving hospital. Her initial ECG at the receiving hospital showed a QRS of 117 ms which narrowed with 50 mEq of sodium bicarbonate after approximately 6 hours. She required norepinephrine intermittently for blood pressure support for approximately 2 days. The patient had no dysrhythmias. EEG showed no epileptiform activity from approximately 11 hours-32 hours post ingestion. At the receiving hospital, her serum lamotrigine concentration was 109 mcg/mL (reference 3.0-14.0 mcg/mL) 7 hours after ingestion. Her bupropion concentration was 92 ng/mL (reference 50-100 ng/mL). She was extubated on hospital day 5 and discharged to a psychiatric facility on hospital day 13.

An Update on Childhood Lead Poisoning.

Childhood lead poisoning is a multi-faceted, complex condition, which affects not only the child's health and well-being, but also the family's housing security, economic status, job security, and stress level. This review updates the emergency department clinician on the management of childhood lead poisoning. Infants and children are at higher risk than adults for lead exposure due to their smaller size and proportionately larger dose of ingested toxins, their proximity to ground dirt and indoor dust, their energy and curiosity, their oral exploratory and pica behaviors, their proportionately larger daily water and milk intake, and dietary preferences that differ markedly from those of adults. Pediatric health care providers working in the emergency department can provide medical management, as well as preventive counseling and guidance, to parents of children presenting with evidence of acute or chronic lead poisoning.

Combination Clearance Therapy and Barbiturate Coma for Severe Carbamazepine Overdose.

A 15-year-old female subject presented comatose, in respiratory failure and shock, after the intentional ingestion of ∼280 extended-release 200-mg carbamazepine tablets with a peak serum concentration of 138 µg/mL (583.74 µmol/L). The patient developed clinical seizures and an EEG pattern of stimulus-induced rhythmic, periodic, or ictal discharges, suggestive of significant cortical dysfunction. Due to the extremely high drug serum concentration and clinical instability, a combination of therapies was used, including lipid emulsion therapy, plasmapheresis, hemodialysis, continuous venovenous hemodiafiltration, and endoscopic intestinal decontamination. The patient's elevated serum lactate level with a high mixed venous saturation suggested possible mitochondrial dysfunction, prompting treatment with barbiturate coma to reduce cerebral metabolic demand. The serum carbamazepine concentration declined steadily, with resolution of lactic acidosis, no long-term end-organ damage, and return to baseline neurologic function. The patient was eventually discharged in her usual state of health. In the laboratory, we demonstrated in vitro that the active metabolite of carbamazepine hyperpolarized the mitochondrial membrane potential, supporting the hypothesis that the drug caused mitochondrial dysfunction. We thus successfully treated a life-threatening carbamazepine overdose with a combination of modalities. Future studies are required to validate this aggressive approach. The occurrence of mitochondrial dysfunction must be confirmed in patients with carbamazepine toxicity and the need to treat it validated.

A Case Report of Reversible Takotsubo Cardiomyopathy after Amphetamine/Dextroamphetamine Ingestion in a 15-Year-Old Adolescent Girl.

Stimulant medications are used in the treatment of attention deficit hyperactivity disorder and serious cardiac complications can occur when these medications are abused. We present a 15-year-old adolescent girl who was found to have a Takotsubo cardiomyopathy after acute amphetamine/dextroamphetamine ingestion.

Methods in obtaining split-thickness skin grafts from skin reduction surgery specimens.

BACKGROUND: To devise a method for obtaining bacterial culture-negative split-thickness skin grafts from specimens removed from living donors undergoing skin reduction surgery. METHODS: Specimens were obtained from patients undergoing abdominal skin reduction surgery in inpatient and outpatient surgical settings. Skin specimens were cleaned in a method adapted from the former Yale Skin Bank's methods. The specimens were attached to the autoclave container for the dermatome using towel clips or sutures to provide tension. Normal saline clysis was injected subdermally and a Padgett Electric Dermatome was used to obtain skin grafts. These were then photographed and discarded. RESULTS: Eight specimens were obtained from seven women and one man. The mean age was 46.6 years and mean weight at time of surgery was 87.7 kg. Bacterial cultures obtained from all specimens were negative. All procured grafts were transparent, with visible dermis, suggesting that they could be used in a clinical setting. CONCLUSION: Bacterial culture-negative split-thickness skin grafts can be obtained from skin reduction surgery specimens, offering a potential source of split-thickness allograft during regional or national shortages.

A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening.

Sodium bicarbonate is a well-known antidote for tricyclic antidepressant (TCA) poisoning. It has been used for over half a century to treat toxin-induced sodium channel blockade as evidenced by QRS widening on the electrocardiogram (ECG). The purpose of this review is to describe the literature regarding electrophysiological mechanisms and clinical use of this antidote after poisoning by tricyclic antidepressants and other agents. This article will also address the literature supporting an increased serum sodium concentration, alkalemia, or the combination of both as the responsible mechanism(s) for sodium bicarbonate's antidotal properties. While sodium bicarbonate has been used as a treatment for cardiac sodium channel blockade for multiple other agents including citalopram, cocaine, flecainide, diphenhydramine, propoxyphene, and lamotrigine, it has uncertain efficacy with bupropion, propranolol, and taxine-containing plants.

Needle-entry angle for lumbar puncture in children as determined by using ultrasonography.

OBJECTIVE: The purpose of this study was to evaluate the angle for performing lumbar punctures in children aged 0 to 12 years. We hypothesized that the angle changes for different stages of development. METHODS: Children aged 0 to 12 years who presented to the Yale-New Haven Children's Hospital at a low-acuity triage level, in need of a lumbar puncture, their accompanying siblings and authors' children were eligible for the study. Subjects in 3 age groups were recruited and grouped as follows: group 1, 0 to 12 months; group 2, 12 to 36 months; and group 3, 3 to 12 years. Ultrasound images of the L3-L4 and L4-L5 lumbar space were taken with subjects in the lateral recumbent and sitting positions. The angle from the interspinous space to the skin was measured. RESULTS: Thirty-six subjects were included. The mean angles in the lateral recumbent and sitting positions were group 1, 47.8° (SD: 8.2) and 51.1° (SD: 8.5), respectively; group 2, 58.8° (SD: 6.8) and 59.6° (SD: 5.5); and group 3, 60.5° (SD: 6.6) and 61.9° (SD: 4.0). The results of group 1 were significantly different from those of groups 2 or 3 in both positions (lateral recumbent P = .00526 and 0.00160; sitting P = .0499 and .00282). CONCLUSIONS: The angle for lumbar puncture was more acute for infants than for older children in this study. Future studies should assess the difference in success rates of lumbar punctures when clinicians have knowledge of these angles.