Methotrexate-Induced Cutaneous Ulcers: A Rare Side Effect.

Methotrexate is often prescribed for the treatment of autoimmune conditions. There are many well-known side effects of methotrexate, a lesser known side effect is methotrexate-induced cutaneous ulceration. Only eight cases have been reported in the literature. Here we report a ninth case report of methotrexate-induced cutaneous ulceration in a 73-year-old female who had recently had her methotrexate dose increased for her seronegative rheumatoid arthritis. She presented to the emergency department with painful ulcerative nodules on her hands. In addition, laboratory evaluation found her to be pancytopenic. Methotrexate was discontinued and patient was given a dose of leucovorin. Within a couple weeks of methotrexate discontinuation, the ulcers resolved. Our case in addition to a review of the literature suggests that methotrexate-induced cutaneous ulceration may be an indication of life-threatening pancytopenia.

Portosystemic Shunt Leading to Encephalopathy in a Non-Cirrhotic Patient.

While portal-systemic encephalopathy is a common entity in cirrhotic patients, it is less frequent in non-cirrhotic patients. We are reporting a case of a 68-year-old female who presented with unresponsiveness for the second time in six months. She underwent extensive evaluation for liver disease with ultrasonography and computerized tomography of the abdomen, testing for causes of liver disease including testing for viral hepatitis was negative. A liver biopsy was done clearing any doubt about the presence of significant liver disease or clinically significant portal hypertension. With absence of liver disease hence lower likelihood of portal-systemic encephalopathy (PSE) we evaluated for other causes of encephalopathy with unremarkable neuroimaging including brain MRI and head CT, unremarkable CSF analysis and EEG showing no seizure activity. Given the negative workup and the high ammonia level with the significant clinical response to ammonia lowering therapy we further evaluated the patient for other causes of PSE with Doppler ultrasonography of the liver and eventually angiography of the portal system with the high suspicion for a portosystemic shunt as a cause of her encephalopathy. A shunt from the inferior mesenteric vein to the left renal vein was diagnosed and successfully occluded utilizing coil embolization. The patient recovered normal mentation and was eventually discharged home. This case sheds light on the importance of diagnosing portosystemic shunts leading to encephalopathy, as occlusion of the shunt can correct the encephalopathy and help prevent further episodes.

Safe and Effective Triglyceride-Lowering Therapy for Hypertriglyceridemia Associated Pancreatitis: Insulin Mono-therapy in a Non-Diabetic Patient.

This report was prepared to describe a case in which insulin monotherapy was efficacious for the management of hypertriglyceridemia-associated pancreatitis (HGTP) in a patient who was not diabetic. Currently, there are no definite clinical guidelines or standards of practice for nondiabetic HGTP. Apart from insulin infusion, other regimens include plasmapheresis and heparin administration, both of which carry significant risks. We reported a case of a non-diabetic male with HTGP (triglyceride greater than 3,000 mg/dL) who was successfully managed with an insulin infusion. This resulted in achieving a level below 1,000 mg/dL within 28 hours of the initiation of therapy. The patient was discharged without additional incident in 72 hours. We believe that insulin monotherapy for HGTP is efficacious in non-diabetic patients and should be the regimen of choice.

A Case of IVIG-Induced Aseptic Chemical Meningitis.

Intravenous immunoglobulin (IVIG) is a commonly used and generally well-tolerated medication. Common side effects include flu-like symptoms such as fevers, headaches, myalgia, fatigue, and nausea. One of the more rare side effects is aseptic meningitis, with a reported incidence rate of around 0.067 percent of all IVIG infusions. In this paper, we describe a 47-year-old female patient with a history of myasthenia gravis who presented with a headache, neck pain, and neck stiffness while undergoing IVIG infusions for a myasthenia crisis. On admission day, the patient was afebrile with stable vital signs. A physical examination revealed nuchal rigidity and tenderness with no focal neurological deficits. Cerebrospinal fluid (CSF) cytology noted an elevated white blood cell (WBC) count of 1,138 cells/µL with a neutrophil predominance (96 percent). CSF red blood cell count was unremarkable at 1 cell/µL. The patient's IVIG infusions were stopped, suspecting chemical meningitis. Given the markedly elevated CSF WBC count with neutrophil predominance, she was started on vancomycin and ceftriaxone to also cover for bacterial meningitis. The patient's meningeal signs and symptoms significantly improved 24 hours after admission. Given the clear temporal relationship to IVIG administration and the rapid improvement of symptoms, IVIG-induced aseptic meningitis is strongly suspected. The patient's antibiotics were discontinued. Forty-eight hours after stopping IVIG and 24 hours after discontinuing antibiotics, her meningitis symptoms completely resolved with the use of analgesics alone. The patient was then discharged uneventfully. CSF viral and bacterial studies, including a gram stain and cultures, did not result in anything noteworthy. Our case presents an interesting diagnostic dilemma where drug-induced (IVIG) aseptic meningitis mimics bacterial meningitis clinically and on CSF analysis. The clear temporal relationship to IVIG administration and the rapid resolution of symptoms upon stopping the drug can aid in the diagnosis of this rare event and help doctors avoid the use of unnecessary antibiotic therapy.

Atrial Fibrillation Induced by Carbon Monoxide Poisoning and Successful Treatment with Hyperbaric Oxygen.

Carbon monoxide (CO) intoxication is one of the major public health hazards which may go unnoticed as this is a colorless, odorless and tasteless gas. The manifestations of the CO poisoning are far-reaching. Although CO affects almost every organ in the body, cerebral and myocardial involvement are predominant due to the hypoxia-induced cellular damage. The mainstay treatment is providing high-flow oxygen and in some instances hyperbaric oxygen therapy. In the literature, there have been few cases of CO poisoning-induced atrial fibrillation (AF) reported. We hereby report an AF caused by CO toxicity in a young male patient and successful conversion to sinus rhythm with the hyperbaric therapy.

Hodgkin's Lymphoma Presenting as a Cavitary Lung Lesion.

Hodgkin lymphoma (HL) typically presents in the nodal regions at an early stage of the disease. Occasionally, patients can present with disease in extranodal regions. We report a case of HL in a 25-year-old female who presented to the emergency department following a motor vehicle accident with incidental findings of pulmonary cavitary lesions, fever, tachycardia, anemia, leukocytosis and thrombocytosis. This case illustrates the difficulty in diagnosis when the disease presents in extranodal regions with nonspecific systemic symptoms. Complete workup for infectious and autoimmune etiology was performed and found to be negative. CT guided biopsy and bronchoscopy failed to yield the diagnosis; a video-assisted thoracoscopic surgery was necessary to obtain the diagnosis of advanced-stage HL in this patient.