46 year old male with past medical history of schizoaffective disorder and chronic lower back pain, was admitted for management of worsening depression and anxiety. He was started on gabapentin, 300mg twice daily for his back pain and anxiety symptoms. His only other medication was hydrocodone. Over next few days, he started developing worsening bilateral lower extremity edema. He did not have any cardiovascular related symptoms. Physical exam was only significant for 3+ pitting edema with all laboratory values and imaging being unremarkable. Gabapentin was discontinued and his lower extremity swelling improved over subsequent days. Incidence of pedal edema with gabapentin use is approximately 7 to 7.5% with all studies being in elderly patients receiving doses above 1200 mg/day. This case illustrates that lower doses of gabapentin can also cause this adverse effect. It is important to recognize this adverse effect because gabapentin is used in conditions like diabetic neuropathy, which is associated with multiple co-morbidities that can give rise to bilateral leg swelling. Presence of gabapentin induced leg swelling can thus confound the clinical picture.
Altered mental status (AMS) is a challenging symptom, commonly encountered in the acute hospital setting. We present a challenging case of AMS where an early assessment could have potentially prevented a complicated hospital course. A 42-year-old male presented to emergency room with chest pain. He was tachycardic, hypotensive and electrocardiogram showed new ST depressions. He underwent emergent cardiac catheterization showing triple vessel disease with placement of intra-aortic balloon pump, followed by CABG. Post-operatively he could not be extubated and had persistent fever, tachycardia and deterioration in mental status. Initial work up for fever and AMS was unremarkable. He was treated with broad spectrum antibiotics and beta blockers but remained intubated, febrile, and altered. Thyroid function tests done around second week of hospitalization revealed TSH < 0.03uU/ml, fT4 > 4.5 ng/dl, T3 411.9 ng/dl, thyroid stimulating immunoglobulin 269%. A thyroid sonogram revealed diffusely enlarged, heterogeneous and hypervascular thyroid lobes. He was started on stress doses of steroids, propylthiouracil and continued on beta blocker. Within the next 72 hours his heart rate, fever and mental status improved and he was extubated. Thyroid storm, also referred to as thyrotoxic crisis, is an acute life threatening hypermetabolic state induced by excessive release of thyroid hormones in a patient with thyrotoxicosis. It is often precipitated by an acute event such as surgery, trauma, infection or iodine load. The Burch and Wartofsky scoring system is helpful in distinguishing this from severe thyrotoxicosis. It should always be kept in the differential diagnosis of AMS, fever, tachycardia of unknown cause.
In our patient, HSV was confined to the larynx, without evidence of local or systemic disease. Localized HSV laryngitis has been attributed to suppressed cellmediated immunity from HIV, chemotherapy, and prolonged corticosteroid use. In contrast, our patient was likely susceptible to HSV infection from damaged laryngeal mucosa from prior radiation exposure. Vrabec et al. noted the importance of maintaining a high index of suspicion of HSV laryngitis in patients who fail extubation, as was evident in this patient. Our case demonstrates that HSV can present at an atypical anatomic site and cause extensive damage, compromising airway patency if left untreated.Case Report: Spinocerebellar Ataxia Type 7 (SCA-7) is a pathological condition stemming from CAG repeat expansions. The CAG expansions induces propagation of the ataxin-7 protein, with subsequent rapid progression of multi-organ tissue infiltration. An increasing number of pathological repeats may represent prognostic indicators for patients; with larger repeats correlating with worse prognosis. We report a 2 month old female with global hypotonia, intermittent hypoxemia, and a family history notable for walking difficulty and visual impairment across multiple generations, consistent with autosomal dominant inheritance. Echocardiogram revealed a Patent Ductus Arteriosus (PDA); Catheterization demonstrated Coarctation of Aorta, type B as well as elevated trans-pulmonary gradient, responsive to oxygen and inhaled Nitric Oxide. The patient underwent end to end aortic anastomoses and PDA resection via lateral thoracotomy. Morbidity included chronic anasarca secondary to capillary leak syndrome; respiratory failure and inability to wean from ventilatory support due to global hypotonia necessitating tracheostomy; chronic renal failure with azotemia; concentric left ventricular hypertrophy-cardiomyopathy in the absence of residual aortic gradient; and visual evoke potentials consistent with blindness. DNA testing revealed a normal Karyotype (46,XX) and 78 CAG repeats of ataxin-7 gene protein.Repeats between 35 to 300 are known to be associated with pathology, while normal alleles contain 4 to 34 CAG units. The patient died within 3 mo of surgical repair; autopsy revealed septic pneumonia and cardiomyopathy as a cause of death. The longitudinal course of SCA-7 is unknown, as are the correlation between the repeat expansion sequences, clinical signs and symptoms, cardiomyopathy and neuropathology. Case reports of infantile SCA-7 suggests life expectancy of less than one year. Coarctation of Aorta has never been described in conjunction with SCA-7, making the post-operative course challenging when encountering multiorgan manifestations seen with this rarely described syndrome.
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