It is well documented that central nervous system (CNS) infections may lead to syndrome of inappropriate anti-diuretic hormone secretion (SIADH), but diagnosing these can prove difficult in patients with atypical presentations. We present a case of SIADH and muscle weakness in a patient without typical signs of CNS infection who was tested and diagnosed with neuroborreliosis based largely on her likelihood of exposure. This case indicates the need for Lyme testing in patients with unexplained SIADH who live in endemic areas. The patient was an 83-year-old female with a history of type 2 diabetes and hypertension, who presented from her primary care physician’s office when her sodium was found to be 123 mEq/L. Her sole symptom was proximal muscle weakness. The diagnosis of SIADH was reached based on laboratory data. A trial of fluid restriction was initiated, but neither her sodium nor her muscle weakness improved. Lyme testing was performed as the patient lived in an endemic area and was positive. Lumbar puncture showed evidence of neurologic involvement. After realizing the appropriate treatment for hyponatremia in this case, intravenous ceftriaxone was started, and patient’s sodium levels improved and muscle weakness resolved. Studies show that SIADH is associated with CNS infections, likely related to the inflammatory cascade. However, the atypical presentation of neuroborreliosis for our patient delayed the appropriate diagnosis and treatment. Our case demonstrates the need to screen for Lyme disease in endemic areas in patients presenting with neurologic symptoms and SIADH.
Introduction: The dexamethasone (DEX) implant is an FDA approved treatment for diabetic macular edema, non-infectious posterior uveitis, and macular edema secondary to branch or central retinal vein occlusions. We describe a case of anterior chamber (AC) migration of a DEX implant in a patient with a history of congenital glaucoma and perform a review of the literature on this particular complication, summarizing the common risk factors, subsequent complications, and management options. Case description: A 46-year-old female with a history of congenital glaucoma, status post cataract extraction with insertion of intraocular lens, pars plana vitrectomy, and Baerveldt tube implant in the left eye was referred for post-operative cystoid macular edema (CME). The patient underwent insertion of a DEX implant, resulting in improvement in her CME. After the fourth implant was injected, the patient noticed a white line in her eye while looking in the mirror after doing jumping jacks. Slit lamp examination confirmed migration of the implant into the AC. Ultimately, the patient was taken to the operating room, where her implant was removed via bimanual vitrectomy through an anterior approach. Conclusion: This case report and literature review explores the ophthalmic structural changes specific to congenital glaucoma which may have predisposed this eye to anterior migration of the DEX implant. The purpose of this review is to detail the anatomic changes that may increase the risk of anterior chamber implant migration in patients with congenital glaucoma so that physicians may be aware of these risks when selecting patients for this implant.
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