Acute Psychosis Related to Primary Hyperparathyroidism in a Patient With Bipolar Disorder.

Primary hyperparathyroidism (PHPT) can cause hypercalcemia secondary to high parathyroid hormone secretion. Hyperparathyroidism- and hypercalcemia-related acute psychotic symptoms can be challenging to diagnose in patients with mental health-related disorders, and it should be considered a possible differential in these patients besides medications. It can sometimes be the first manifestation of the disease, and diagnosis can be challenging, especially in patients with a previous psychiatric history without checking their biochemistry profile. The hypercalcemia severity can vary from mild to severe, and signs and symptoms may also vary depending on the calcium levels. Hypercalcemia can cause neuropsychiatric dysfunction, and patients may present with confusion, agitation, delusions, and hallucinations. We present a case of a 54-year-old patient with a previous history of bipolar disorder and a recent diagnosis of depression and schizophreniform disorder, who presented to the emergency department with acute agitation, violent behavior, and disorientation. She was being managed by the community mental health team at a local behavioral health hospital for new onset psychosis over the past few months. She was refusing blood tests prior to hospital admission. Calcium level on laboratory tests was 3.54 mmol/l, and parathyroid hormone level was 45 pg/ml. She was managed with intravenous fluids initially, followed by zoledronic acid (4 mg intravenously over 15 minutes). She was then commenced on cinacalcet 30 mg twice daily initially, which was later increased to 60 mg twice daily. Ultrasound of the neck demonstrated a large left parathyroid mass, and she underwent left parathyroidectomy as an urgent outpatient. She has remained asymptomatic, and her psychiatry symptoms resolved following parathyroidectomy.

A Rare Presentation of Acute Renal Failure Secondary to Rhabdomyolysis in a Patient Due to Atorvastatin Requiring Short-Term Renal Replacement Therapy.

Renal failure secondary to rhabdomyolysis due to statins is quite rare. We present a case of a 57-year-old patient who developed acute renal failure due to rhabdomyolysis secondary to atorvastatin. Interestingly, this patient had a similar presentation 27 years ago requiring dialysis only once resulting in complete resolution of symptoms. He presented to the hospital generally feeling unwell and then developed generalized body ache. He had an extremely elevated creatinine kinase level of 116,000 and it went up to 145,000. His urine dip was negative for nitrites and was positive for blood and protein. He was commenced on intravenous fluids. He also had a computerized tomographic scan of the kidneys, ureters, and bladder, which showed some fat stranding around both kidneys likely inflammatory in origin. His creatinine level continue to rise despite intravenous fluids and was acidotic on blood gases. He also tested positive for COVID-19 on day 7 of admission and eventually needed dialysis. His renal functions improved to baseline post dialysis and kidney functions returned to normal. His autoimmune screen was negative and his renal functions remained normal on a follow-up visit.

A Case Report on the Incidental Diagnosis of a Left Atrial Myxoma in a Patient Presenting With Right Shoulder Pain and Inter-scapular Back Pain.

Primary cardiac tumors are rare, and myxoma is a rare benign primary cardiac tumor in adults, commonly found within the left atrium. The presentation can vary from patients being asymptomatic to pulmonary embolism or stroke. Smaller atrial myxomas are usually asymptomatic, however, larger ones can cause symptoms such as dyspnea, orthopnea, cough, peripheral edema, palpitations, and fatigue. We present a case report of a 72-year-old patient presenting with right shoulder pain and chest pain on breathing to the accident and emergency department. The patient was complaining of right shoulder pain for five days and pleuritic chest pain for the last 48 hours. Initial electrocardiogram showed normal sinus rhythm, however, repeat electrocardiograms showed atrial fibrillation. An echocardiogram showed a homogeneous, relatively round mass seen in the left atrium, close to the inter-atrial septum, and close to the roof of the left atrium, and the patient underwent surgical removal of the benign tumor.

Resolution of Thyrotoxicosis-Associated Pulmonary Hypertension With Treatment of Thyrotoxicosis: A Case-Based Report and Literature Review.

We present a case of a 41-year-old Afro-Caribbean female, who was diagnosed with thyrotoxic Graves' disease. She had a past medical history of hypertension and was on amlodipine and valsartan. There was no significant family history of note. She initially presented to Emergency Department with palpitations and excessive sweating. Her thyroid-stimulating hormone was <0.02mu/L and free triiodothyronine (T3) 29.5pmol/L at the time of diagnosis. The thyroid peroxidase antibody test was negative. She was started on carbimazole 15mg once daily and propranolol 40mg twice daily. She remained non-compliant to treatment for over two years and missed most outpatient clinic appointments and her condition remained poorly controlled during this time period. She was re-admitted to the hospital after 18 months, with high output congestive cardiac failure. An echocardiogram showed pulmonary hypertension and her right ventricular systolic pressure was measured to be 70-75mmHg. She was started on Lugol's iodine 0.2mls three times daily, propranolol 40mg three times daily, cholestyramine 4 gram four times a day, propylthiouracil 100mg four times a day. After 3 weeks of treatment, she became euthyroid and her pulmonary hypertension improved dramatically with treatment. She underwent total thyroidectomy after a few weeks and biopsies confirmed the findings of Graves' disease.

Arrhythmogenic Right Ventricular Cardiomyopathy in a Patient Experiencing Out-of-Hospital Ventricular Fibrillation Arrest Twice: Case Report and Review of the Literature.

We present a case of a 62-year-old male who was admitted to the hospital with out-of-hospital ventricular fibrillation (VF) arrest. He had a VF arrest in 2011 and was admitted to another hospital. He had several investigations excluding cardiac magnetic resonance imaging, all of which were normal. He was playing tennis on both occasions when he experienced the VF arrest. His electrocardiogram on admission showed AF with partial right bundle branch block, inverted T waves in V1-V2, low voltage QRS complexes, ventricular ectopic in lead V1-V2, and prolonged QTc. His echocardiogram showed normal left ventricular function and a dilated right ventricle. Cardiac magnetic resonance imaging showed a dilated RV cavity size with impaired systolic function and dyskinetic region in the mid-ventricular free wall proximal to the insertion of the moderator band and late gadolinium enhancement in both right and left ventricles insertion points and mid-wall late gadolinium enhancement in the basal inferolateral wall suggestive of arrhythmogenic right ventricular cardiomyopathy. He had a single chamber VVI implantable cardioverter-defibrillator fitted for primary prevention and was discharged home. He had outpatient follow-up and showed good improvement and his implantable cardioverter-defibrillator checks were satisfactory and did not experience any shocks.

COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search.

Myocarditis is one of the complications reported with COVID-19 vaccines, particularly both Pfizer-BioNTech and Moderna vaccines. Most of the published data about this association come from case reports and series. Integrating the geographical data, clinical manifestations, and outcomes is therefore important in patients with myocarditis to better understand the disease. A thorough literature search was conducted in Cochrane library, PubMed, ScienceDirect, and Google Scholar for published literature till 30 March 2022. We identified 26 patients eligible from 29 studies; the data were pooled from these qualifying case reports and case series. Around 94% of patients were male in this study, the median age for onset of myocarditis was 22 years and 85% developed symptoms after the second dose. The median time of admission for patients to hospitals post-vaccination was three days and chest pain was the most common presenting symptom in these patients. Most patients had elevated troponin on admission and about 90% of patients had cardiac magnetic resonance imaging (CMR) that showed late gadolinium enhancement. All patients admitted with myocarditis were discharged home after a median stay of four days. Results from this current analysis show that post-mRNA vaccination myocarditis is mainly seen in young males after the second dose of vaccination. The pathophysiology of vaccine-induced myocarditis is not entirely clear and late gadolinium enhancement is a common finding on CMR in these patients that may indicate myocardial fibrosis or necrosis. Prognosis remains good and all patients recovered from myocarditis, however further studies are advisable to assess long-term prognosis of myocarditis.

Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Patient Taking Lamotrigine: A Case Report Based Literature Review.

A 29-year-old patient presented to the hospital with worsening generalized rash for the last two days from a mental health facility. The patient was commenced on lamotrigine two weeks earlier, and he developed fever and generalized macular rash on his body. His blood tests showed deranged liver function tests (LFTs) and clotting with raised eosinophil count, and he was treated for lamotrigine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient was commenced on prednisolone 50 mg once daily with a proton pump inhibitor cover, and lamotrigine was suspended on advice from Dermatology. The patient showed improvement after 3-4 days of treatment. His skin biopsy showed prominent suppurative granulomatous folliculitis, mild perivascular chronic inflammation, and red blood cell extravasation, including the rare eosinophil. He was weaned off from prednisolone by 5 mg weekly and had complete resolution of symptoms.

Prevalence of Depression in Patients With Post-Acute Coronary Syndrome and the Role of Cardiac Rehabilitation in Reducing the Risk of Depression: A Systematic Review.

Patients with acute myocardial infarction (AMI) or ischaemic heart disease are at risk of developing anxiety and depression. This systematic review aims to identify the various risk factors and the role of cardiac rehabilitation in reducing the risk of depression in patients after AMI. In this review, we included data on the prevalence of depression in patients post-AMI for the years 2016-2017 from a cardiac rehabilitation unit at Morriston Hospital, Swansea, a primary coronary angioplasty centre. Results from our meta-analysis were compared with the findings of previous studies. Our data showed the prevalence of depression to be 14% pre-cardiac rehabilitation and 3% post-cardiac rehabilitation. A meta-analysis of seven studies showed the prevalence to be approximately 20-35% depending on the type of questionnaire or screening method used. Gender, marital status, age, and sedentary lifestyle were found to be risk factors for depression post-acute coronary syndrome (ACS). Females, patients aged >65 years, and those who were single, lived alone, or widowed were at a higher risk of depression, and patients with sedentary lifestyles were more likely to have post-ACS depression. Depression in patients post-myocardial infarction was also associated with increased mortality and morbidity risk as well as higher hospital re-admission and future cardiac events. The meta-analysis showed significant publication bias, studies with negative results were less likely to be published, and the study data were heterogeneous. The pooled estimate for depression estimated using the random-effects model was 1.78 (95% confidence interval = 1.58-2.01).

Acute Renal Impairment in Patients Due to Paracetamol Overdose in the Absence of Hepatic Impairment.

In general, paracetamol poisoning is associated with hepatotoxicity and very rarely with renal impairment in the absence of significant hepatic impairment. Paracetamol poisoning associated with renal impairment is rare, and it is mostly associated with hepatotoxicity. Most patients with acute renal impairment show a pattern of acute tubular necrosis or injury based on their blood, clinical presentation, and imaging. The level of injury was found to be associated with the dose of paracetamol taken. We describe a case of a 22-year-old patient presenting to the hospital with abdominal pain, back pain, and two episodes of vomiting after 36 hours of an intentional paracetamol overdose of 60 tablets. His lab results showed raised creatinine levels and C-reactive protein (CRP) despite normal liver function tests. His paracetamol and salicylate levels were not checked on his initial presentation. He was given N-acetyl cysteine (NAC) treatment for paracetamol overdose and had computed tomography of kidneys, ureters, and bladder (CT KUB) the following day, which showed mild, uncomplicated sigmoid diverticula. He was discharged the next day, but was readmitted two days later with severe abdominal pain and worsening renal function. He had an magnetic resonance imaging (MRI) abdomen that showed coronal/axial wedge like areas of relative hypo-intense change in the T2 acquisition. He received intravenous fluids and antibiotics, and his renal function improved. He was discharged home with outpatient follow-up and appeared to be fully recovered.