Myxedema coma is a life-threatening manifestation of hypothyroidism associated with altered mental status, hypothermia, and symptoms related to the slowing of other organ systems. It can occur as a culmination of severe, longstanding hypothyroidism or be precipitated by acute stressors such as infection, myocardial infarction, cold exposure, and surgery in patients with poorly controlled hypothyroidism. Given the high mortality rate and acuity with which the disease presents, treatment with thyroid hormone replacement should be initiated upon suspicion of the disease even prior to obtaining laboratory confirmation. Stress doses of hydrocortisone should also be given until coexisting adrenal insufficiency is excluded. We present a case of a 58-year-old male who presented to the emergency department after being found on the floor of his house. Physical examinations and laboratory results were significant for myxedema coma and the patient was given levothyroxine with improvement of symptoms and mild change in thyroid hormone levels during hospitalization.
INTRODUCTION:Sarcoidosis is a multisystem, inflammatory disorder with infiltration of noncaseating granulomas into various organs of the body. Pneumothorax is a potential but rare complication of late-stage sarcoidosis. Pneumothorax with persistent air leak after prolonged thoracostomy drainage is an indication for more aggressive procedures such as video-assisted thoracoscopy (VATS) pleurodesis. Endobronchial valve placement is an emerging technique that can be used in such patients, especially in poor operative candidates. We report a patient with stage IV Sarcoidosis presented with a large tension pneumothorax with persistent air leak, that was resolved after placement of two endobronchial valves.CASE PRESENTATION: 54-year-old African American female with a history of sarcoidosis, diagnosed 8 years ago, presented with sudden right chest pain and dyspnea. Chest X-ray and CT chest showed right-sided tension pneumothorax. Previous CT chest imagings showed innumerable cysts and bullae replacing the upper lobes and reticulonodular pattern of the lower lobes (Figure 1). A right chest tube was inserted but with persistent air leak for more than 7 days and worsening pneumothorax (Figure 2). Two endobronchial valves were then placed in the right upper lobe bronchi with complete re-expansion of the lung and resolution of the pneumothorax in 6 days (Figure 3). The patient was then discharged.DISCUSSION: Pneumothorax occurs only in 2 % of the sarcoidosis patients (1). It usually happens due to rupture of subpleural bullae or necrosis of subpleural granuloma (2). Bronchial obstruction with peripheral air trapping, retraction and collapse of the surrounding inflamed pulmonary parenchyma, and the destruction of the inflamed alveoli are the main mechanisms for bullae formation in sarcoidosis (3,4). Pneumothorax with persistent air leak despite chest tube drainage is an indication for videoassisted thoracoscopy (VATS) pleurodesis or stapling of the air leak (5). Endobronchial valves are emerging devices with FDA approval for only emphysema reduction in COPD patients or prolonged air leaking after lung surgery. Our case showed complete resolution of the air leak and pneumothorax after endobronchial valve placement in a patient with a secondary spontaneous pneumothorax.CONCLUSIONS: Further studies are needed to be conducted for the use of endobronchial valves for other indications besides emphysematous patients and post lung surgery. It has the potential to become an invaluable resource for secondary spontaneous pneumothorax, especially in poor surgical candidates.
Cardiac and neurological disorders are the main broad etiologies for loss of consciousness. Ictal bradycardia syndrome refers to epileptic discharges that profoundly disrupt normal cardiac rhythm, resulting in cardiogenic syncope during the ictal event. Convulsive syncope is a well-described phenomenon in both adults and children in which abrupt cerebral hypoperfusion leads to brief extensor stiffening and nonsustained myoclonus. Sick sinus syndrome or tachycardia bradycardia syndrome is a common cause of arrhythmias in the elderly secondary to sinus node dysfunction.We present a case of a 91-year-old male who presented with generalized seizure with associated bradyarrhythmias with telemetry showing sinus rhythm, followed by severe bradycardia, followed by Ventricular tachycardia, followed by an episode of asystole, which likely precipitated seizures as a result of cerebral hypoperfusion. The patient had a permanent dual-chamber pacemaker. He was discharged on antiepileptics as his EEG was abnormal, which might indicate an underlying predisposition.
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