Hyperparathyroidism (HPT) causes an elevation of parathyroid hormone (PTH). This can result in elevated calcium levels, which can cause bone, kidney, muscle, gastrointestinal, and neuropsychiatric symptoms, including psychosis. Our report presents a unique case of an elderly woman who presented to the emergency department in an unconscious state with a working diagnosis of metabolic encephalopathy secondary to sepsis and urinary tract infection. Despite fluids and antibiotic treatment, the patient showed hallucinations. The acuteness of her psychotic episodes prompted the medical team to further investigate the cause of her hallucinations. Additional labs revealed HPT, which she had never been diagnosed with prior to the hospital admission. Our patient's novel clinical presentation revealed elevated PTH and normal calcium levels as the cause of her psychosis. We determined that the normal calcium levels were due to the patient's calcium loss secondary to acute kidney injury. Cinacalcet administration showed resolution of the patients' hallucinations, highlighting the importance of PTH screening even in normocalcemic patients. In this report, we present a rare clinical presentation of acute psychosis in the setting of undiagnosed normocalcemic HPT.
Schwannomas are benign peripheral nerve sheath tumors typically found in the neck, flexor surfaces of the extremities, mediastinum, posterior spinal roots, cerebellopontine angle, and retroperitoneum. Pleural schwannomas are a type of neoplasm that arises from autonomic nerve fiber sheaths in the pleura and rarely originate in the thoracic cavity. These schwannomas tend to be asymptomatic, benign, and slow-growing neoplasms. Although pleural schwannomas commonly occur in males, our report highlights a unique presentation of a pleural schwannoma presenting as musculoskeletal-type chest pain in an adult female. Our patient's diagnosis of pleural schwannoma was supported after X-Ray, Computed Tomography (CT) Scan, and Positron Emission Tomography (PET) Scan imaging was complete. All imagining and immunohistochemical staining yielded pleural schwannoma as the final diagnosis. We aim to bring awareness to the necessity of imaging and histopathological staining in atypical clinical cases of pleural schwannoma. Our novel case highlights pleural schwannoma as a differential diagnosis for patients with intermittent, musculoskeletal-type chest pain.
Bouveret syndrome (BS) is a rare but serious complication of gallstone ileus that can cause gastric outlet obstruction secondary to a gallstone impacted in the pylorus or proximal duodenum. Gallstones pass from the gallbladder to the GI tract via a cholecystoenteric fistula that forms as a result of chronic inflammation and adhesions between the biliary system and GI tract. Although the case we are presenting is of a 53-yearold Hispanic male, females and the elderly are particularly at an increased risk of this condition. BS can present as typical mechanical obstruction symptoms that include nausea, vomiting, and diffuse abdominal pain. The vague symptoms patients present with makes the diagnosis difficult and often delayed, which can be fatal. In our case, the diagnosis of BS was supported by a CT with contrast, MRI, and an esophagogastroduodenoscopy (EGD) study. Our patient underwent an exploratory laparotomy after the diagnosis was made, and the stone was removed. Here, we aim to raise awareness of the importance of early recognition, and immediate action in establishing an early diagnosis of BS in patients presenting with nonspecific abdominal symptoms, which can prevent mortalities.
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