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Metformin was cleared by the continuous veno-venous hemodialysis modality of continuous renal replacement therapy in this metformin overdose. Although a fatal outcome occurred in this patient, its utility in other patients with metformin overdose should be investigated.

ABSTRACT. We present the unique case of a previously healthy, 2-year-old boy with resistant hypercalcemia and hypertension resulting from an unintentional overdose with an imported vitamin D supplement. The patient presented initially to the emergency department with colic and constipation and was discharged after a benign physical examination. The symptoms persisted and, on the second visit, the patient was found to have a serum calcium level of 14.4 mg/dL. Despite therapy with intravenously administered 5% dextrose solution at onehalf normal strength, furosemide, calcitonin, and hydrocortisone, the calcium concentration increased to 15.0 mg/dL on the second hospital day and did not decrease until the fourth hospital day, when it fell to 13.9 mg/dL. The vitamin D concentration peaked at 470 ng/mL on hospital day 3. With additional questioning, the mother revealed that she had been giving her son a daily dose of 1 ampule of Raquiferol, an imported vitamin D supplement, instead of the recommended 2 drops per day. Each ampule contained 600 000 IU of vitamin D; therefore, the boy received a total of 2 400 000 IU over 4 days. The patient's hypercalcemia persisted for 14 days and was complicated by persistent hypertension. No renal, cardiac, or neurologic complications were noted. At discharge, the vitamin D concentration was still elevated at 389 ng/mL and the total calcium level had decreased to 11 mg/dL. The boy made a complete clinical recovery. This case highlights the need for caution when using imported and/or unregulated medicines, as well as the dangers of parental dosing errors. 7 Although the skin has the ability to metabolize cholesterol to a vitamin D precursor, it is unclear exactly how much sunlight one needs daily to metabolize sufficient amounts of vitamin D effectively. 8 In addition, health care providers and organizations, including the Centers for Disease Control and Prevention, have recommended decreased exposure to direct sunlight and the liberal use of sunscreens to prevent skin cancer. 9 Because vitamin D is used so readily, it is important to understand how dosing errors can lead to overdoses with potentially life-threatening consequences.Vitamin D is 1 of 4 fat-soluble vitamins. With parathyroid hormone, it regulates calcium homeostasis tightly. When the serum calcium level is low, calcitriol, the biologically active form of vitamin D, restores homeostasis through increased dietary calcium absorption through the gut and through increased bone resorption. Dietary sources of vitamin D are limited to fish, oysters, and dairy products. In the United States, milk is fortified with vitamin D, and some forms of butter, margarine, cereals, and fruit juices also are fortified. Unfortunately, most individuals in the United States do not eat the necessary 2 servings of a vitamin D-fortified food in a day to ensure adequate dietary intake of vitamin D. 10 To make up for this deficit, these people should rely on adequate sun exposure; however, if these patients adhere to the recommendation of the Cente...

Background: Endometriosis is a clinical condition that affects up to 10% of the women of reproductive age. Endometriosis is characterized by the presence of endometrial tissues outside the uterine cavity and can lead to chronic pelvic pain, infertility and, in some cases, to ovarian cancer.

A 34-year-old male with lumbar disc disease and surgery was placed on gabapentin daily for chronic back pain. He remained on a steady dose of 8000 mg/day for 9 months, almost doubled what is considered therapeutic. He ran out of medication, was unable to refill his prescription for 2 days and presented to the emergency department in status epilepticus. There was no previous history of seizure disorder and he was on no other medications. A medical evaluation for an alternative etiology of his seizures was negative. Although gabapentin withdrawal has been previously reported and usually consists of anxiety, diaphoresis, and palpitations, this is the first reported patient with generalized seizures and status epilepticus secondary to gabapentin withdrawal.

Abstract. The authors report a case of a 41-year-old mentally disabled man with bipolar disorder who presented to the emergency department with altered mental status. He was found to have a significantly elevated ammonia level (377 M/L) with no signs of hepatic insufficiency. His coma and hyperammonemia were attributed to his chronic valproate therapy. This patient had the highest serum ammonia level ever reported with a therapeutic valproate level in the absence of any other anticonvulsant therapy, metabolic abnormality, or hepatic dysfunction. The authors discuss this case and review the current literature on hyperammonemia in valproic acid therapy and the use of L-carnitine in these patients.

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