T-Wave Inversion After Escitalopram Overdose: A Case Report.

Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used due to their comparatively less cardiotoxic effects than tricyclic antidepressants. Corrected QT interval (QTc) prolongation is the most common electrocardiography (ECG) change that has been encountered with SSRI overdose. This case report is about a 22-year-old woman who was brought to the emergency department (ED) with an alleged history of consumption of 200 mg of escitalopram. Her ECG showed T-wave inversions in anterior leads one to five, which reverted (in leads four and five) the next day with supportive management. After 24 hours, she developed dystonia, which resolved with mild doses of benzodiazepine. Hence, ECG changes like T-wave inversions may occur even with a small overdose of an SSRI without any significant adverse effects.

Wellen's Syndrome: A Rare Case.

Wellen's syndrome is associated with critical stenosis of the left anterior descending coronary artery. Based on the electrocardiography (ECG) pattern, Wellen's syndrome can be classified into type 1 (deeply inverted T-waves, mainly in lead V2 and V3) or type 2 (biphasic T-waves). T-wave abnormalities are often also found in V1 and V4 and rarely in V5 and V6. The pattern of ECG changes correlates with proximal left anterior descending artery stenosis. This characteristic ECG pattern is a sign of impending myocardial infarction and is equivalent to ST-elevated myocardial infarction. Often, these subtle findings in ECG get misinterpreted or the severity associated with this goes unrecognized. Hence, for emergency physicians, it is important to recognize such uncharacteristic ECG changes for better and timely management of patients. We present this case of Wellen's pattern in which the coronary lesion was in the left circumflex coronary artery, right coronary artery, and diagonal-1.

Huge Renal Angiomyolipoma Mimicking a Renal Cell Carcinoma: A Case Report.

Renal angiomyolipoma is a benign mesenchymal tumor composing adipose tissue, smooth muscle, and blood vessels. Despite being benign, the tumor sometimes can be aggressive with a locoregional and venous extension. Here, we present a case of a 48-year-old female who presented with a lump in the abdomen for two months, which was initially small and gradually increased in size associated with pain. Ultrasound of abdomen-pelvis showed ill-defined heterogeneous lesion arising from left kidney showing few hypoechoic and calcific focus within it. Contrast-enhanced computed tomography suggested an exophytic mass lesion with a central scar and calcification measuring 13 x 11 cm indicating renal cell carcinoma. Based on the benign nature and being well encapsulated, the patient was taken up for a left radical nephrectomy. However, the final histologic assessment concurred with renal angiomyolipoma.

Diabetic Ketoacidosis and COVID-19: A Retrospective Observational Study.

Background Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM), mainly type 1 DM. DM is one of the comorbidities recognized as the predictor of the severity in COVID-19-positive patients. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness (COVID-19) has a bidirectional association with DM. DM is a state of chronic inflammatory condition and hyperglycemia that predisposes one to acquire an exaggerated form of COVID-19 infection. Moreover, in recent literature, it has been established that SARS-CoV-2 is capable of directly damaging beta cells of the pancreas, thereby inducing new-onset diabetes in previously non-diabetics. Hence, new-onset diabetes and severe metabolic consequences of pre-existing diabetes, such as DKA, are seen in COVID-19-positive patients. DKA in patients with COVID-19 may increase the risk of mortality and lead to poor prognosis. Methods This retrospective observational study includes 25 patients who presented to our hospital with DKA secondary to COVID-19 infection as a triggering factor. Demographic parameters, medical history, physical examination, laboratory tests including reverse transcriptase polymerase chain reaction test (RT-PCR), chest X-ray, treatment administered, clinical course, and outcomes were recorded. All data were computed and analyzed using SPSS Version 22.0 (IBM Corp., Armonk, NY, USA). Results Of the 25 cases, 14 were females, and a statistically significant difference was seen in the values of blood sugar (367 mg/dL), D-dimer, ferritin, blood urea nitrogen (BUN), and anion gap among males and females (p < 0.050). The males had higher mean values of blood sugar (367 mg/dL), BUN (60.63 mg/dL), D-dimer (1.09 mcg/mL), and ferritin (821.23 mcg/mL) than females, whereas females had a higher anion gap (20.85) than males. A negative correlation was seen between D-dimer and the following biochemical investigations in COVID-19 patients: serum bicarbonate, anion gap, chloride, BUN, creatinine, sodium, potassium, magnesium, and phosphorous. COVID-19 can present with atypical symptoms in patients with high blood sugar levels. Diabetics are more likely to experience effects on multiple organs compared to non-diabetic patients who mainly have lung involvement. Hence, a high degree of suspicion is essential to diagnose DKA early in COVID-19 patients. Conclusion These cases show that DKA can be precipitated by COVID-19 in a significant number of patients and that the presence of diabetes can also exaggerate the underlying COVID-19 infection, a bidirectional relationship. All cases were COVID-19-positive presenting with features characteristic of DKA. SARS-CoV-2 was precipitating factor of DKA. Patients with newly diagnosed diabetes or pre-existing diabetes were equally susceptible to DKA. Due to the high prevalence of both illnesses (DM and COVID-19) in our country, a high level of suspicion is required to detect DKA early and improve the outcome of COVID-19-related life-threatening hyperglycemic consequences.

Adult Onset Vanishing White Matter Disease: A Rare Case Report.

Vanishing white matter disease (VWMD) is the most common childhood-onset inheritable progressive leukodystrophy disorder, which exclusively affects the white matter of the brain. It shows mutations in one of the five eukaryotic translation initiation factor 2B1-5 genes following an autosomal recessive pattern, of which eIF2B5 mutation is the most frequent. These genes play a vital role in the translation and regulation of protein synthesis and mutation in them leads to a dysregulation of the cellular stress response, which in particular disrupts myelination and affects oligodendrocytes and astrocytes while sparing the neurons. Stressful situations, for example, head trauma, sudden fright, acute psychological stress, or infection, provoke severe and rapid neurological deterioration. Although it is more common in childhood, we report a case of an adult presenting with signs and symptoms of VWMD, such as abusive behavior, emotional liability, and motor incoordination. To our knowledge, this is the first case of adult-onset VWMD in Maharashtra, India, confirmed by magnetic resonance imaging (MRI) of the brain.

Clinical Profile of Patients Presenting With Sepsis to the Emergency Department of a Tertiary Care Hospital in Wardha During the COVID Pandemic (June 2020-June 2021).

Background Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock, multi-organ dysfunction, and death occur in severe cases with reduced blood flow to vital organs. Sepsis contributes to 15-20% of all global deaths. Through this study, we intend to evaluate the clinical profile and study the common blood investigatory panels along with organisms causing sepsis in patients presenting with sepsis in the emergency department during the COVID pandemic. In addition, the study was also done to estimate the prevalence of sepsis and compare patients having sepsis with serum lactate, sepsis with Systemic Inflammatory Response Syndrome (SIRS) criteria, and sepsis with quick Sepsis Related Organ Failure Assessment (qSOFA) score. Method Observational retrospective study to evaluate patients presenting with sepsis diagnosed by the Third International Consensus Definitions for Sepsis and Septic Shock" criteria presenting to the emergency department of Acharya Vinoba Bhave Rural Hospital (AVBRH) affiliated to Jawaharlal Nehru Medical College (JNMC), Wardha during COVID pandemic (June 2020-June 2021). Results The majority of the patients presented with fever (42%), and very few presented with altered mental status (8%). Seventy-four percent of the study population did not show any bacterial growth on blood culture, but out of the remaining 26%, blood culture, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pnemoniae were the significant microbes. Amongst qSOFA, SIRS criteria, and serum lactate as a screening tool for sepsis, SIRS is the most sensitive for screening sepsis patients. Conclusion Staphylococcus aureus, Pseudomonas aerugenosa, and Klebsiella pneumoniae were the major contributors in the development of sepsis in COVID-19-associated infection. The presence of raised leukocyte counts and serum lactate should alarm clinicians of possible sources of infection. The timely initiation, rapid de-escalation of empirical antibiotics, and strict compliance with infection control practices should be accomplished to reduce the occurrence of multidrug resistance organisms.

Moyamoya Disease From an Otolaryngologist's Perspective: A Rare Case.

Moyamoya disease is characterized by narrowing of cerebral blood vessels and is progressive in nature. We present the case of a 21-year-old female patient who was a known case of Down's syndrome and presented with right-sided facial muscle weakness and was initially suspected of having cholesteatoma, but no evidence for the same was found after extensive radiological investigations. The suspicion of a central nervous system pathology was raised due to the clinical findings of dysphasia and supranuclear facial palsy. Magnetic-resonance angiography (MRA) was suggestive of findings of early Moyamoya disease. After a Neurologist consultation, the patient was started on conservative management with anti-platelet drugs and Statins and had symptomatic improvement. The patient was advised regular follow-up and had no fresh episodes of similar complaints.

COVID-19 Vaccination a Cause of Guillain-Barré Syndrome? A Case Series.

Guillain-Barré syndrome (GBS) is a rare autoimmune neuropathic disorder of peripheral nerves usually following an infection or on rarer occasions following vaccinations, but the exact underlying pathophysiology is still unclear. The most common etiology of GBS is a bacterial infection caused by Campylobacter jejuni. Viral infections like Zika virus, Epstein-Barr virus, and Cytomegalovirus also add to the list of GBS etiology. COVID-19 (SARS-CoV-2) has also been reported to cause GBS. Vaccines like the rabies vaccine, influenza vaccine, and poliovirus vaccine account for a very small fraction of Guillain-Barré syndrome. GBS as an adverse effect of COVID-19 vaccination was not reported by the Vaccine Adverse Event Reporting System (VAERS), but an update was later released in the course of the pandemic from FDA news, reporting several patients developing GBS after receiving the COVID-19 vaccine. In this case series, we discuss five cases that developed the GBS post-COVID-19 AstraZeneca vaccine, along with its pathophysiology, management, and outcome.