A Case of Takotsubo Cardiomyopathy Precipitated by Thyroid Storm and Diabetic Ketoacidosis with Poor Prognosis.

UNLABELLED: Takotsubo cardiomyopathy (TCMP) is known as stress cardiomyopathy, and long-term prognosis is generally excellent if recovering from an acute stage. Both thyroid storm and diabetic ketoacidosis (DKA) are reported to be rare causes of TCMP. However, there are no studies discussing TCMP as induced by a combination of thyroid storm and DKA, and the prognosis is unknown. Herein we report an 81-year-old female with type-2 diabetes mellitus initially presenting with palpitation, chest tightness, and gastrointestinal symptoms. She was further diagnosed as TCMP after echocardiogram and coronary angiography, and DKA was confirmed later. However, the patient's general condition didn't improve under proper treatment. Thereafter, thyroid storm was discovered fortuitously. Despite appropriate treatment, the patient finally expired due to acute respiratory distress syndrome progression. This rare case reminds us that despite TCMP being a transient cardiomyopathy with good prognosis, physicians should survey the possible underlying disease cautiously to avoid catastrophic clinical outcome. KEY WORDS: Acute respiratory distress syndrome; Diabetic ketoacidosis; Stress cardiomyopathy; Takotsubo cardiomyopathy; Thyroid storm.

Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report.

RATIONALE: Lithium has been used to treat bipolar disorder. Lithium has a narrow therapeutic index, with a therapeutic level between 0.6 and 1.5 mEq/L. The possible complications of lithium overdose include altered mental status, hand tremor, muscle weakness, nausea, vomiting, diarrhea, seizure, syncope, and arrhythmia. Lithium intoxication can be fatal and is difficult to diagnose in patients without a history of lithium intake. The occurrence of serious cardiac arrhythmias is rare in lithium intoxication. PATIENT CONCERNS: An 81-year-old man was brought to the emergency department because of consciousness disturbance for 2 days. According to his daughter, he had a history of hypertension and diabetes. Recently, his family also observed slurring of speech and easy choking. The physical examination findings were unremarkable. DIAGNOSIS: Blood examination only revealed impaired renal function. Twelve-lead electrocardiography revealed sinus rhythm with first-degree atrioventricular block. Chest radiography revealed mediastinal widening. The blood pressures obtained from the 4 limbs showed no significant differences. Subsequently, brain computed tomography revealed no obvious intracranial lesion. A neurologist was consulted, and a recent ischemic stroke could not be ruled out. While in the observation area, his systolic blood pressure decreased to <90 mm Hg and he showed bradycardia, and 12-lead electrocardiography revealed an AV block and long pulse. Contrast-enhanced chest computed tomography revealed no evidence of aortic dissection. Another family member reported a history of lithium intake for bipolar disorder for >30 years. Blood examination revealed a lithium concentration of 2.65 mEq/L. INTERVENTIONS: A nephrologist was consulted, and emergency hemodialysis was indicated. Dopamine was administered for his shock status via a right neck central venous catheter. OUTCOMES: His lithium level gradually declined after the hemodialysis, and blood pressure and consciousness level improved subsequently. The patient was discharged 9 days later in a stable condition. LESSONS: If an emergency physician encounters a patient with altered consciousness and arrhythmia with cardiogenic shock, the patient's drug intake history should be carefully reviewed to rule out cardiovascular problems on the basis of the patient's clinical condition.

A survival case of intravenous paraquat intoxication: A case report.

RATIONALE: Paraquat, an agent highly toxic to humans and animals, is a widely used herbicide and also commonly used for suicide attempts in Taiwan. The most common route of intoxication is oral ingestion, and parenteral poisoning is respectively rare. PATIENT CONCERNS: A 39-year-old illicit abuser of heroin and amphetamine injected 0.5 mL of 24% paraquat directly into his right cephalic vein due to hallucination. The patient was brought to our emergency department for management 4 hours after injection. He was fully conscious and had normal vital signs. Systemic review showed mild dyspnea, abdominal pain and right wrist pain over the injection site. The only abnormal physical finding was erythema over the injection site and epigastric tenderness. DIAGNOSIS: Laboratory investigations, including complete blood count, liver and renal function, and electrolytes initially yielded normal results. Urinalysis showed normal findings except a positive urine paraquat test (4+). The initial plasma paraquat concentration was 0.51 µg/mL. INTERVENTIONS: He was admitted to the intensive care unit and underwent one session of charcoal hemoperfusion therapy. Acute kidney injury developed on the fourth day after intoxication, with the level of serum creatinine rising rapidly from 0.96 to 4.57 mg/dL and the daily urine output decreased noticeably from > 2000 to 900 mL. The serum creatinine level improved gradually with adequate fluid supplementation. OUTCOMES: The patient was discharged 13 days later in a stable condition. LESSONS: Intravenous paraquat intoxication is rare. Patients who suffer from intravenous intoxication may not directly suffer from mucosal irritation, but the clinical onset of systemic effects is more immediate and lethal. The prognosis of paraquat poisoning is determined by the time of poisoning and the plasma paraquat concentration before treatment. Proudfoot's curve provides a simple method of predicting the survival rate. The most effective mode of management is extracorporeal therapy, and immunosuppressive or antioxidant therapies have shown insufficient evidence of benefit.

Questions Frequently Asked of Healthcare Professionals: A 2-Year Data Survey Conducted at a Medical Center.

In this descriptive, retrospective study, we analyzed the types of questions posed by healthcare professionals to drug counselors at a medical center and the types of provision of pharmaceutical advice solicited to improve pharmaceutical care quality and establish clear directions for clinical pharmacist training. We collected 8,558 questions posed by healthcare professionals (physicians, 38%; pharmacists, 39%; nurses, 23%) from the electronic drug information record system from May 2013 to April 2015 in one medical center. Overall, 52% and 45% of calls came from outpatient and inpatient departments, respectively. Telephone was the main route of provision of pharmaceutical advice (total, 6,035 questions; 72%), and hospital/electronic formulary was the main reference type (43%). The top 10 topics were dosage, alternatives, drug name, usage, adverse drug reactions, medication suggestion, drug compatibility, national health insurance criteria, mechanism, and indications. Pharmacological classification inquiries most frequently addressed antimicrobial agents (20%), and vancomycin was the top single drug. Finally, 67% of calls were completed in 5 minutes. Our results suggest that the systematic organization of issues into a searchable database would reduce inquiry durations and improve work efficiency. Furthermore, the availability of various search tools and methods would quickly provide healthcare professionals with provision of drug information needed to improve patient medication safety.