An Unusual Presentation of Vitamin B12 Deficiency Associated With Massive Splenomegaly, Hemolytic Anemia, and Pancytopenia: A Case Report.

Deficiency of vitamin B12 usually presents with symptoms of anaemia or neurological dysfunction. We report a case of a young lady who was found to be vitamin B12 deficient with massive splenomegaly, haemolytic anaemia, and pancytopenia. She was thoroughly investigated for other causes of similar presentation. Her symptoms and blood count drastically improved after two weeks of therapy with vitamin B12 supplementation. After reviewing the literature on unusual cases of vitamin B12 deficiency, our case is a very interesting read as it serves as a reminder for health care providers to be alert for these manifestations, which can be treated by simply replacing vitamin B12.

Late-Onset Euglycemic Diabetic Ketoacidosis in a Patient With Massive Stroke Requiring Decompressive Craniectomy: A Case Report.

Euglycemic diabetic ketoacidosis (DKA) is a well-recognized adverse effect associated with the use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. Early recognition of this medical emergency and timely intervention can prevent the notorious consequences of this serious complication. However, this form of DKA can easily be masqueraded by normal serum glucose levels. This article describes a 49-year-old man diagnosed with type 2 diabetes mellitus (DM) on dapagliflozin who presented with a large right-sided middle cerebral artery (MCA) stroke complicated by euglycemic DKA, developed 72 hours after stopping the drug. This case is unique considering that dapagliflozin's half-life is only 12.9 hours, and the body completely eliminates it within 72 hours. But our patient developed DKA features after the elimination window. Hence, this case highlights the importance to consider euglycemic DKA in the presence of ketonemia and metabolic acidosis in a patient who is a chronic SGLT-2 inhibitor user even if the drug was discontinued several days before the patient's presentation.

Bilateral Thalamic Infarction Secondary to Thrombosis of Artery of Percheron.

The artery of Percheron (AOP) is a rare anatomical variation emerging from the posterior circulation and supplies both thalami in the brain. As per the literature, the AOP infarction constitutes less than 2% of all stroke cases. AOP infarctions are usually caused by a combination of risk factors and a predisposing vascular territory. The areas most affected by AOP are the paramedian thalami with or without the involvement of the midbrain. AOP can be challenging as it is infrequent and mostly can be missed on the initial scans. We present a 58-year-old previously healthy male known to have hypertension with poor follow-up who presented with dysarthria and facial weakness, which he felt after waking up from sleep. After the initial physical examination and investigations, a preliminary diagnosis of stroke was made. As the patient was worked up for the stroke, his symptoms improved, and he was back to his baseline function within 48 hrs of presentation. What came to our surprise was that the stroke workup, including the initial CT scan with an angiogram, blood works (Hba1c and lipid panel), echocardiogram of the heart (ECHO), and Holter monitor was all unremarkable until an MRI head was done, which showed bilateral thalamic acute-sub acute infarct. This shows that AOP can be easily missed as it may not appear on the initial scans and workup and needs an adequate radiological study for diagnosis. Although some cases of AOP infarction are reported in the literature, the presentation with transient mild symptoms makes our case an interesting one.