Hyponatremia is an expected electrolyte resultant in diabetic ketoacidosis (DKA) that presents secondary to the dilutional effect of hyperglycemia. However, hypernatremia in DKA is a rare presentation, more common in the pediatric population, that rides poor morbidity and mortality. We describe three cases of patients presenting with DKA and hypernatremia with altered sensorium and share details on pathophysiology and treatment that expand our understanding amongst clinicians.
Background: A pyogenic liver abscess (PLA) is the most frequently observed subtype of liver abscess in the western world. The disease has been subjected to a remarkable change. We aimed to investigate the recent trend in pyogenic liver abscess's epidemiology, clinical, microbiological, and risk factors features. Methods: A retrospective analysis of medical records was done for the patients diagnosed with PLA from January 2000 to June 2018. The institutional review board approved the study. Results: We identified 113 patients with PLA, 60% were males, with a mean age of 54 ± 20 years, and 58 ± 19 years old for males and females, respectively (p = 0.298), with an increasing annual incidence in 2012-2013, and 2016-2017 (Figure 1). Fever and right upper quadrant abdominal pain were the most common symptoms (65%, 55%, respectively). Forty percent of the patients had Biliary tract diseases like cholecystitis or biliary intervention as cholecystectomy or ERCP, and 20% had diabetes mellitus (Table 1). The abscess culture was obtained in 96 cases, 37 cases were negative (39%), 27 cases showed polymicrobial growth (28%) and 15 cases showed Escherichia coli (16%) (Figure 2). The abscess cultures were mostly negative in the first 5 years, then changed to Streptococcus anginosus, and polymicrobial growth in the last four years. Conclusions: PLA is more common in males with a recent increase in incidence. Culture negative PLA was observed in patients who were empirically treated with antibiotics. Polymicrobial was the most common identifiable organism with a change in the microbiological trend every 5 years.
Hybrid argon plasma coagulation (HybridAPC® [HAPC]) is an evolution of the standard argon plasma coagulation (APC) technology, where the application of APC is preceded by highpressure needleless submucosal injection. APC is indicated for the ablation of benign and dysplastic mucosal lesions, such as vascular malformations or Barrett's mucosa. HAPC offers safety and efficacy advantages over standard APC because the submucosal injection acts as a heat sink that disperses energy. This ensures that the underlying muscularis propria remains unaffected, and only the mucosal layer is coagulated in its entirety. An 81-year-old Hispanic male was found to have a 1.2-cm mucosal nodule along the incisura of the stomach. Pathology of the biopsy specimen revealed high-grade dysplasia, and he subsequently underwent endoscopic ultrasound examination, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a uT1N0Mx endosonographic staging. He then underwent endoscopic submucosal dissection of the lesion. Pathology of the excised specimen confirmed the presence of multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. Surveillance endoscopy confirmed the persistence of diffuse intestinal metaplasia. He was then treated with widespread HAPC due to the presence of underlying diffuse intestinal metaplasia in the stomach. HAPC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients, 96% achieved complete macroscopic remission of Barrett's mucosa after a median of 3.5 APC sessions, and 85% achieved complete histological remission. HAPC is a promising therapeutic modality as a thermal injury is targeted, and the depth of injury is contained. This provides immediate procedural efficacy and safety benefits, and reduces subsequent complications when compared with standard APC. We anticipate that the applications of HAPC will continue to grow, as this modality is adopted into common procedural parlance. This case appears to be the first to describe the use of HAPC for definitive treatment of diffuse intestinal metaplasia.
Cerebral amyloidoma is a rare form of amyloidosis with a localized tumor like an amyloid deposition in the brain composed of insoluble fibrillary protein with cross beta-sheet conformation. Its usual presentation includes vision loss, seizures, behavioral changes, cognitive decline, and recurrent headaches. It has a benign course with a slow progression, and it is not associated with dissemination. We report a case of a 65-year-old Caucasian woman who presented with symptoms of progressively worsening cognitive dysfunction of six months' duration. From CT of the brain, it was found that she had a right frontal and left parietal hemorrhagic mass with a large amount of vasogenic edema and a midline shift. MRI showed heterogeneously enhancing hemorrhagic mass of 5.2 cm x 2.6 cm x 3.6 cm in size, with a satellite lesion. Initially, this was suspected to be a high-grade glioma vs. metastatic hemorrhagic lesions. She underwent stereotactic biopsy of the mass, and histopathology was consistent with cerebral amyloidoma with marked IgA lambda plasma cell differentiation. She did not have any evidence of systemic amyloidosis, and therefore, she is being clinically observed with a regular follow-up and annual CT surveillance. She has remained stable over the past two years, although she has residual cognitive dysfunction. Cerebral amyloidoma can mimic malignant central nervous system (CNS) neoplasms and should be considered as a differential of any single or multiple mass lesions occurring in the white matter region of the brain with a characteristic appearance of "hyperdense lesions" on CT. It is a benign disease with no metastatic potential that usually resolves entirely after resection.
A traumatic neuroma is a well-known complication after acute trauma to a peripheral nerve; the nerve tries to re-establish continuity by an orderly growth of axons from the peripheral to distal stump through the proliferation of Schwann cells. However, this process is not always perfect, and aberrant repair gives rise to a neuroma. We present a 50-year-old female who underwent an initial colonoscopy for change in bowel habits and was found to have a 7 mm submucosal lesion in the proximal rectum. Endoscopic ultrasound was done which showed a hypoechoic lesion in the submucosal plane without muscularis propria invasion. The patient underwent successful cap-assisted endoscopic mucosal resection of the lesion without complication. Pathology of the specimen revealed a traumatic rectal neuroma with immunostaining positive for S100. However, this patient did not have any known risk factors such as previous surgery including polypectomy or hemorrhoidectomy or any previous rectal manipulation. Interestingly, this is the second case of traumatic rectal neuroma reported in the English-language literature.
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