United States

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a distinct clinical syndrome with characteristic radiographic abnormalities on imaging. Although the pathogenesis of PRES is not fully understood, abnormal cerebral blood flow regulation likely contributes to its development. As arterial blood pressure rises in the cranium, the blood-brain barrier is disrupted. Efflux of fluid into the brain parenchyma, producing vasogenic edema. Many factors can lead to the development of PRES including and not limited to: hypertension, acute kidney injury, sepsis, illicit drug use, and pharmacological agents. Toxins and substances that increase the sympathetic activity of the CNS system can drastically potentiate the effects of PRES. We report a case of PRES secondary to these conditions.

Case: 64-year-old female with PMHx of hypertension, atrial fibrillation, and recurrent UTI who presented to the hospital due to altered mental status. On the morning of admission, the patient was found confused, nonverbal, and tremulous in her left arm by the patient’s daughter. Furthermore, the patient&#39;s daughter noticed empty bottles of tramadol and kratom around the patient. On ED presentation, the patient was hypertensive and afebrile. Urinalysis revealed heavy pyuria, and urine culture showed 100,000+ ESBL-positive E.coli. The patient was started on IV antibiotics. CT head was negative for hemorrhages/infarct. On day 2, the patient was found confused, ANOx1, and unable to follow commands. Bedside EEG was inconclusive for seizures. CT Head Stroke w/o contrast significant for no acute intracranial hemorrhage and mild to moderate vasogenic edema involving the bilateral frontal lobes. The patient loaded on Kreppa. On day 3, the patient was observed at the bedside to have multiple seizures. MRI head was remarkable for vasogenic and cortical edema within the bilateral, occipital, and parietal subcortical white matter suggesting PRES. On day 4, the patient was transferred to ICU. She was intubated, sedated, and placed on mechanical ventilation. The patient started on IV seizure medication and prophylaxis. Continuous EEG is remarkable for ninety-three focal seizures, the majority are from proper posterior quadrant onset during the next twenty-four hours. On the subsequent days, the patient was detected to be actively seizing on continuous EEG despite anti-seizure medications, being intubated, sedated, and on mechanical ventilation.


Discussion/Conclusion: Case reports and studies have been reported to link multiple agents causing seizures and PRES. Though not fully understood, toxins that increase the sympathetic activity of the CNS system can drastically potentiate the effects of PRES. Identifying, treating, and managing the underlying etiology, in addition to careful treatment of hypertension and seizure management is crucial for the management of PRES. The prognosis of PRES is typically favorable if recognized and treated early, with symptom improvement or resolution in a few days to several weeks.

AMA Research Challenge 2023

A Multifactorial Analysis of Posterior Reversible Encephalopathy Syndrome 

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a distinct clinical syndrome with characteristic radiographic abnormalities on imaging. Although the pathogenesis of PRES is not fully understood, abnormal cerebral blood flow regulation likely contributes to its development. As arterial blood pressure rises in the cranium, the blood-brain barrier is disrupted. Efflux of fluid into the brain parenchyma, producing vasogenic edema. Many factors can lead to the development of PRES including and not limited to: hypertension, acute kidney injury, sepsis, illicit drug use, and pharmacological agents. Toxins and substances that increase the sympathetic activity of the CNS system can drastically potentiate the effects of PRES. We report a case of PRES secondary to these conditions.

Case: 64-year-old female with PMHx of hypertension, atrial fibrillation, and recurrent UTI who presented to the hospital due to altered mental status. On the morning of admission, the patient was found confused, nonverbal, and tremulous in her left arm by the patient’s daughter. Furthermore, the patient's daughter noticed empty bottles of tramadol and kratom around the patient. On ED presentation, the patient was hypertensive and afebrile. Urinalysis revealed heavy pyuria, and urine culture showed 100,000+ ESBL-positive E.coli. The patient was started on IV antibiotics. CT head was negative for hemorrhages/infarct. On day 2, the patient was found confused, ANOx1, and unable to follow commands. Bedside EEG was inconclusive for seizures. CT Head Stroke w/o contrast significant for no acute intracranial hemorrhage and mild to moderate vasogenic edema involving the bilateral frontal lobes. The patient loaded on Kreppa. On day 3, the patient was observed at the bedside to have multiple seizures. MRI head was remarkable for vasogenic and cortical edema within the bilateral, occipital, and parietal subcortical white matter suggesting PRES. On day 4, the patient was transferred to ICU. She was intubated, sedated, and placed on mechanical ventilation. The patient started on IV seizure medication and prophylaxis. Continuous EEG is remarkable for ninety-three focal seizures, the majority are from proper posterior quadrant onset during the next twenty-four hours. On the subsequent days, the patient was detected to be actively seizing on continuous EEG despite anti-seizure medications, being intubated, sedated, and on mechanical ventilation.


Discussion/Conclusion: Case reports and studies have been reported to link multiple agents causing seizures and PRES. Though not fully understood, toxins that increase the sympathetic activity of the CNS system can drastically potentiate the effects of PRES. Identifying, treating, and managing the underlying etiology, in addition to careful treatment of hypertension and seizure management is crucial for the management of PRES. The prognosis of PRES is typically favorable if recognized and treated early, with symptom improvement or resolution in a few days to several weeks.

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Acute pancreatitis is a common condition with various possible etiologies. The most common causes include gallstones and alcohol, followed by metabolic, structural, and iatrogenic causes accounting for 20 – 25% of the cases. Hyperlipidemia in the form of hypertriglyceridemia and chylomicronemia accounts for 15-20% of the total cases attending lipid clinics in US. The conventional methods of treatment of severe hypertriglyceridemia are dietary restriction and lipid lowering medications, mainly fibric acid derivatives. In the medical literature, use of insulin infusion to treat hypertriglyceridemia induced acute pancreatitis is still under reported.

Hypertriglyceridemia induced acute pancreatitis treated with parenteral insulin; a possible alternative to plasmapheresis in resource limited setting: a case report

Introduction:
Purple Urine Bag Syndrome (PUBS) is a rare manifestation of bacteriuria that results in a pathognomonic purple discoloration of the urine catheter and collection bag. The accepted hypothesis for this phenomenon is bacterial production of pigment molecules in alkalotic urine. It is historically associated with females with prolonged indwelling urinary catheterization and chronic constipation. Here, we describe an atypical case of PUBS. 

Case Presentation:
A 73-year-old female with prior ischemic stroke, atrial flutter, and urinary retention presented to the emergency department with decreased urine output and lower abdominal pain. She had an indwelling foley catheter exchanged one month prior to presentation. She denied fevers, chills, and constipation. Physical exam revealed a confused woman with dry mucous membranes and suprapubic tenderness. Dark brown urine was present in a purple foley bag and tubing. Labs were significant for serum creatinine of 2.72 mg/dL, BUN of 51.4 mg/dL, and leukocytosis of 13.3 TH/cmm. Foley catheter was exchanged. Urinalysis revealed elevated protein, pH of 8.5, bacteria, and leukocytes. Ceftriaxone and vancomycin were started for treatment of sepsis secondary to urinary tract infection (UTI). Urine culture grew Citrobacter freundii and Escherichia coli, so antibiotics were deescalated to ceftriaxone alone. Her suprapubic pain and mental status improved, and her acute kidney injury resolved after intravenous fluids. Upon discharge, she was scheduled for follow up with Urology for further testing for possible neurogenic bladder and recommendations regarding indwelling foley catheter.

Conclusion:
Much about the manifestation of PUBS is still unknown. It is thought that constipation creates an environment where dietary tryptophan is increasingly produced, converted into indole by intestinal bacteria, and then absorbed by the portal circulation to be conjugated into indoxyl sulfate. Bacteria with phosphatase and sulfatase enzymes convert this compound into indoxyl which oxidizes in alkaline urine to pigmented indirubin and indigo. These pigments interact with the plastic in the catheter bags to produce a violet hue. However, this has not been uniformly proven in all cases. Additionally, many studies have shown that constipation is not always present either. The only true requirements are an indwelling catheter and UTI. Because PUBS is typically observed in patients with recurrent UTIs, it is important to consider modifiable risk factors to prevent future infections, such as prompt replacement of indwelling catheters and bowel regimens. Healthcare workers and patients can be assured that although unusual, the purple discoloration of PUBS is generally benign and not indicative of any underlying pathology except bacteriuria or UTI.

A Colorful Case of Purple Urine Bag Syndrome

Background
Streptococcus agalactiae, or group B streptococcus (GBS) is a pathogen that can cause a wide array of clinical syndromes, especially in immunocompromised patients. This rarely being the etiology of meningitis complicated by cerebral abscess and endocarditis concurrently with septic emboli.

Case Presentation
We present the case of a 62 year old female who was brought to the ED due to altered mental status, and was found to be in nonconvulsive status epilepticus. Patient had poor dentition and imaging showed an avidly enhancing mass in the right parietal gland. She was treated for status epilepticus while further infectious workup was performed. Lumbar puncture was suspicious for bacterial meningitis and the patient was treated with empiric antibiotics. CSF cultures grew GBS. MRI brain was performed which showed abnormal air/fluid in the left parietal region which was suspicious for cerebral abscess. Drainage was deferred due to antiplatelet and anticoagulant use. Patient was stabilized and discharged to a rehab facility. The patient later developed AMS and decompensated. She was found to have bacterial endocarditis and TAVR was performed and the patient was treated with outpatient IV antibiotics. Follow-up MRI showed absence of any brain lesions and the patient gradually recovered. 

Conclusion 
Meningitis with GBS is rare but may be seen with increasing frequency in the adult population. Cerebral abscess secondary to strep agalactiae meningitis is a incredibly rare phenomenon. Furthermore, our patient may have developed endocarditis secondary to her poor dentition leading to septic emboli, which lead to her osteomyelitis. Overall, the case highlights the need to be cognizant of abnormal presentations of disease and treat appropriately and strictly adhering to the infectious disease guidelines. 


Streptococcus agalactiae meningitis and endocarditis complicated by septic emboli and a possible cerebral abscess in an elderly patient

Background: Metformin is a widely prescribed medication for the management of type 2 diabetes. It is known to have a high safety index, however it can cause serious adverse effects such as lactic acidosis, particularly in patients with chronic kidney disease. Elderly patients are at higher risk of developing Metformin-Associated Lactic Acidosis (MALA) due to aging kidney. We aim to highlight the importance of early adjustment of metformin and propose development of guidelines with higher estimated glomerular filtration rate (eGFR) for deprescribing metformin in older adults in contrast to younger population. 

Case Presentation: An 82 year old male with a past medical history of Diabetes, Chronic kidney disease 2, Atrial fibrillation on apixaban, Stroke and Chronic stage 4 sacral decubitus ulcer was sent to the emergency department (ED) for altered mental status. He was admitted to the intensive care unit for management of septic shock, PEA cardiac arrest and acute hypoxemic respiratory failure requiring intubation. Labs showed lactic acidosis and anion gap metabolic acidosis in the setting of no infectious source. Patient had chronic kidney disease with acute renal failure on metformin. He was diagnosed with Metformin Associated Lactic Acidosis. 

Discussion: This case highlights the potential risks associated with metformin use in older adults with CKD and AKI from infections, dehydration and decreasing oral intake due to acute illness, aging or dementia. There are expected physiological changes in the aging kidney including cellular dysfunction and nephrosclerosis that can cause unexpected kidney injury in older adults causing their eGFR to drop acutely. Age-related changes in renal function and decreased clearance of drugs place elderly patients at higher risk of developing MALA. New guidelines for higher eGFR for deprescribing metformin should be considered in older adults. This could prevent morbidity, mortality and adverse outcomes in the frail older diabetic population. 


Metformin Associated Lactic Acidosis in an Elderly Patient: A Case Report

Background
In the United States, approximately 294,000 suffer from spinal cord injury (SCI). There are an estimated 17,810 new cases each year. People with SCIs are susceptible to the same medical conditions as their non-injured counterparts. Some conditions may be more difficult to diagnose in SCI patients based on presenting symptoms.

Case Presentation
A 70-year-old female with past medical history of T4 paraplegia presented with subacute onset of pruritic rash and acute onset shoulder and orofacial weakness. The rash began on her shoulders before spreading diffusely; an initial outpatient trial of oral and topical steroids did not improve symptoms. Two weeks following the rash onset, the patient noted proximal shoulder weakness described as 30% of her baseline strength. Notably, the patient’s husband passed away two weeks prior to presentation. Review of systems was positive for diminished appetite, fatigue, chills, abdominal distension, constipation, weakness, and rash. On physical exam, the patient had numerous pink/violaceous papules and plaques noted on extremities, chest, back, and head. Skin biopsy showed dermatomyositis. Steroids were started and rheumatology workup was significant for positive antinuclear antibody and elevated creatinine kinase. CT abdomen/pelvis showed enhancing omental nodularity, concerning for carcinomatosis. Tumor markers were notable for elevated CA-125. Omental biopsy revealed metastatic adenocarcinoma of Mullerian origin. Upon discharge, the patient was diagnosed with paraneoplastic dermatomyositis secondary to ovarian cancer with oncology follow-up and steroid therapy for dermatomyositis.

Discussion
It is important to keep a broad differential diagnosis in patients presenting with a chief complaint of weakness, particularly in those with SCI in which new onset weakness may be difficult to assess clinically. Dermatomyositis and Polymyositis are important diagnoses to consider, particularly when the weakness is symmetric and proximal. Patients with SCI may not note these hallmark symptoms, so one must utilize the full physical exam. Classic dermatomyositis skin findings can clue the examiner into the potential diagnosis even in the absence of assessable weakness. In adult-onset disease, the risk is approximately 20%–32% for an associated internal malignancy, making it imperative to make a diagnosis to ensure a prompt oncologic workup is completed. Additionally, weakness is a commonly noted symptom of bereavement, which may lead providers to attribute similar symptoms to somatic complaints when social history aligns. Our case illustrates the importance of maintaining a broad differential in patients whom weakness is difficult to elicit and not anchoring on social history when evaluating a subjective chief complaint like weakness.


Weakness in a patient with spinal cord injury: A broad differential is key


Background
The recent regulation of xylazine, a veterinary sedative and analgesic, has exposed its escalating threat to public health. The growing misuse of xylazine due to its sedative effects and its concomitant use with opioids like fentanyl for cost-cutting further intensifies the opioid crisis. Xylazine use poses significant risks, including overdose, addiction, withdrawal, and severe tissue damage at the injection site. Xylazine acts on the central nervous system via alpha-2-receptor agonism. This case highlights the challenges of outpatient management of xylazine withdrawal and wound care, emphasizing the immediate need for effective interventions to address this public health issue.

Case Presentation
We report the case of a 41-year-old female on a methadone maintenance program who presented to the clinic with a large necrotic wound on her left forearm. The patient reported injecting xylazine into the wound multiple times daily. Initial assessment revealed a multistage wound with eschar covering a significant portion of the forearm. Despite the alarming features of the wound, the patient declined hospitalization and residential drug treatment. A decision was made to closely monitor her as an outpatient with treatment goals to discontinue xylazine use, prevent wound infection, and facilitate wound healing. The treatment plan included doxycycline for infection prophylaxis and wound care with collagenase, followed by Medihoney dressing. Withdrawal symptoms were managed using clonidine, gabapentin, and ondansetron, which were prescribed cautiously due to their abuse potential. With pharmacologic interventions and close outpatient follow-up, the patient stopped using xylazine and adhered to the treatment plan. The wound transitioned from necrotic to viable tissue, but an exposed extensor tendon necessitated a referral to a higher level of care, which the patient declined.

Discussion
Managing xylazine withdrawal and xylazine-associated wounds in an outpatient setting is challenging due to limited guidelines, medication misuse potential, and patients' hesitance toward hospitalization. Tailored treatment plans, close monitoring, and patient collaboration are vital. Wound care is crucial in preventing further deterioration and facilitating tissue regeneration. However, specialized management for the exposed extensor tendon was declined. Managing xylazine withdrawal with limited medication quantities and close monitoring presented additional challenges. The success of this outpatient management relied on collaboration and communication, fostering compliance and therapeutic alliance. This case highlights the challenges of managing xylazine misuse and emphasizes the need for individualized approaches and further research.

Managing Xylazine Misuse in Outpatient Settings: Challenges and Interventions

Metaplastic breast cancer (MBC) is a rare, aggressive subtype that often presents unilaterally as a high-grade large tumor with solid or cystic components compared to other forms of breast cancer. MBC was only recently recognized as a distinct pathologic diagnosis, so knowledge is limited in its pathogenesis, patient demographics, presentation, or standard treatment guidelines. Although knowledge is limited, MBC is most commonly diagnosed in women between the ages of 55 to 60 and is often chemotherapy resistant and reoccurs. MBC carries a poor prognosis with a survival rate of less than 1 year for patients with distant metastasis. We present a case of MBC diagnosed in a 28 year-old Afghani female that presented with increasingly worsening swelling and erythema of her left breast, without any other classical signs of breast cancer including skin dimpling, nipple changes or discharge, or fever. This patient demonstrates an unusual presentation of rare metaplastic breast cancer in a younger patient than normally diagnosed, further showing the unpredictable nature of this disease. Further research to improve diagnosis, treatment, and survival rates of patients with metaplastic breast cancer is needed with further exploration of targeted therapies and increased familiarity of the disease for the publication of standard treatment guidelines. 


Presentation of Rare Triple Negative Metaplastic Breast Cancer in a 28 year-old Female: A Case Report

INTRODUCTION
Mondor’s disease (MD) is a rare, self-limited, benign thrombophlebitis
(manifesting as a palpable cord-like induration) which typically resolves in 4-8
weeks without any specific treatment. We present a Mondor’s disease patient who has had the lesion for over a decade without a formal diagnosis.

CASE PRESENTATION
An 81-year-old female with a history of bilateral mastectomy (right breast in
(1996 and left breast in 2001) with subsequent right-sided mammoplasty and
left-sided implant, presented to the emergency department and admitted after a
mechanical fall.

She was incidentally found to have a beady, non-tender, cord-like structure in
the periumbilical region; the overlying skin appeared normal (Figure 1). The
patient stated this lesion had been present for over 10 years with prior
symptomatic management with oral analgesics. A doppler ultrasound (Figure 2)
revealed no blood flow and confirmed the diagnosis of Mondor's disease.
The patient opted for conservative management, therefore no further treatment
was administered.

DISCUSSION
Mondor's Disease is caused by a sclerosing thrombophlebitis of superficial
veins in the breast and commonly the anterior thoracoabdominal wall, which
usually resolves within 1-2 months. MD is a rare entity, with approximately 500
cases described in medical literature.

Possible risk factors include breast cancer, mammoplasty, trauma, muscular
strain, venous compression from clothing/bandages and intravenous drug use.
Essentially linked to Virchow’s Triad. The male to female ratio has been quoted
as 3:1; however, published cases are mostly females.

MD is characterized by the onset of a subcutaneous cord-like induration; the
overlying skin is usually normal and freely mobile. MD is a clinical diagnosis
confirmed by history and physical examination with confirmation by a doppler
ultrasound showing absent blood flow within the vein.

A standardized management for MD has not been established due to its rarity
and its tendency for spontaneous resolution within 1-2 months. In painful cases,
NSAIDs have been demonstrated to be effective in pain relief.
Administration of subcutaneous low molecular weight heparin (LMWH) has
been reported as effective in counteracting the blood hypercoagulability in the
acute phase in some cases of MD.

Our case is unique because Mondor’s disease is a self-limiting condition which
usually resolves in a few weeks however, our patient had MD for over a
decade. Currently there is no guideline for long term management for chronic
cases.

CONCLUSION 
Physicians should consider Mondor's disease for patients who present with cord like structure within the thoracoabdominal wall in the setting of a previous breast cancer, mammoplasty, or breast augmentation. The patient may be reassured that in the majority of the cases presentation is self limited.


It's still there? A patient presenting with Mondor's disease

Methanol is a highly toxic, colorless, volatile alcohol that is present in homemade beverages, paint removers, windshield liquid, anti-freeze, shellac, and perfumes. Although uncommon in the United States, methanol poisoning can occur with improper distillation of spirits. Over 50% of morbidity and mortality associated with methanol poisoning is accidental in nature and therefore preventable. Methanol poisoning, even in small quantities of 50 to 100 ml, is associated with severe complications such as permanent blindness.


Methanol Poisoning Presenting With Bilateral Basal Ganglia Hemmorhage

Introduction


Clozapine is an atypical antipsychotic, which has offered a ray of hope to many patients afflicted by treatment resistant schizophrenia including treating its positive symptoms and bipolar disorder. Nevertheless, the drug`s side effect profile limits its use. This case report emphasizes that the side effects are not solely confined to clozapine but can be dosage related and can be potentiated by anticholinergics.
Recent studies show that the case fatality rate is as high as 27.5 % in patients affected by gastrointestinal hypomotility rather than agranulocytosis.


Case presentation
A 34‐year‐old man was brought to the emergency department in refractory circulatory shock following a 2‐day history of profound diarrhea, abdominal distension, and vomiting. GCS score was below 8, Patient was intubated and transferred to ICU.
His medical history is significant for Resistant Bipolar disorder type 1 and chronic constipation. He was on quetiapine, benztropine and clozapine. Clozapine was gradually increased from 100 to 450 mg a day over three months that worsened his constipation despite being on senna.


He was resuscitated with crystalloids and started on vasopressors. Labs showed Acute kidney injury, rhabdomyolysis, and elevated liver enzymes. CT of the abdomen pelvis without contrast revealed fecal impaction with diffuse enterocolitis with distal colonic obstruction. The patient was treated initially with crystalloids, bowel rest, nasogastric decompression, and broad-spectrum antibiotics. Patient required enema and manual disimpaction. Enteral feeds were started. Patient`s ICU stay was prolonged secondary to relapse of his symptoms including agitation and anxiety requiring dexmedetomidine. He was transferred to floors on lorazepam and quetiapine on day 10 and discharged on day 30 with 100 mg of clozapine and benztropine.




Discussion
Randomized controlled trials (RCTs) have demonstrated significant decline in hospital admissions and length of stay following the initiation of clozapine in individuals with bipolar disorder and schizophrenia, along with an increase in quality-adjusted life years (QALYs). However, the relative prevalence of intestinal side effects associated with clozapine, ranging from constipation and ileus to bowel perforation are reported to be as high as 33%. Consequently, it is crucial to implement measures that allow for its continued use to benefit patients, rather than replacing it with alternative treatments. 
Conclusion
We offer the following suggestions to patients on clozapine:
Increased surveillance for bowel dysfunction and proactive management of early bowel dysmotility by ensuring daily bowel opening.
Add an extra dose of osmotic laxative with colonic stimulant monthly if needed.
Xray abdomen every 3 months.


Next from AMA Research Challenge 2023

Hypertriglyceridemia induced acute pancreatitis treated with parenteral insulin; a possible alternative to plasmapheresis in resource limited setting: a case report

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