Naphthalene poisoning is a rare form of toxicity that may occur after ingestion, inhalation, or dermal exposure to naphthalene-containing compounds such as mothballs. Clinically, patients present with acute onset of dark brown urine, watery diarrhea, and non-bloody bilious vomiting 48-96 hours after exposure. Vital sign abnormalities include fever, tachycardia, hypotension, and persistent pulse oximetry readings of 84%-85% despite oxygen supplementation. Laboratory workup demonstrates hyperbilirubinemia with indirect predominance, hemolytic anemia, methemoglobinemia, and renal dysfunction. Treatment options include supportive care, red cell transfusion, ascorbic acid, methylene blue, and N-acetylcysteine. We present a case of naphthalene toxicity in a 20-year-old autistic male, who improved with supportive care, red blood cell transfusion, and ascorbic acid.
IntroductionThe obesity epidemic is reflected by increasing numbers of morbidly obese patients being admitted to intensive care units (ICUs). These are complicated patients whose care involves many diagnostic and treatment challenges. We are presenting a fatal case of super obesity, hypoventilation, and multi-organ failure known as malignant obesity hypoventilation syndrome (MOHS).Case presentation35 year old African American gentleman with a body mass index (BMI) of 115 kg/m2 presented to the hospital with respiratory distress. On admission he was noted to have multi-organ dysfunction including respiratory failure, renal failure, cardiac and liver abnormalities. His hospital course was remarkable for recurrent cardiac arrest following extubation, complicated tracheostomy, and progressive organ failure despite medical therapy. After a 30 day hospitalization, patient and family decided on terminal extubation owing to worsening medical condition and lack of therapeutic and disposition options.DiscussionThe super obese present a number of challenges when admitted to the ICU. Patients with respiratory distress are frequently misdiagnosed and treated for asthma and COPD when obesity hypoventilation syndrome (OHS) is more consistent with the clinical picture. OHS in the superobese is often accompanied by multi-system organ dysfunction, a condition with high morbidity and mortality, with limited treatment options. Standard imaging techniques and procedures are made difficult or impossible by body habitus and often require expert intervention. Surgical options have been used in the treatment of the super obese and resulted in rapid weight loss, improvement in respiratory function, as well as improved metabolism and decreased inflammation. The role of surgery in MOHS remains to be elucidated.ConclusionPhysicians should be aware of MOHS as a common condition with high morbidity and mortality. Optimal management remains to be determined.
Apical hypertrophic cardiomyopathy (AHCM) is a rare form of non-obstructive hypertrophic cardiomyopathy. It is rarely reported in African American patients, and more commonly reported in Japanese patients. AHCM involves hypertrophy of the apex of the left ventricle. It is considered to have a benign prognosis in terms of cardiovascular mortality, however arrhythmias and sudden cardiac death have been reported. We report a case of a 49-year-old African American male with a history of hypertension, who presented to the emergency department after in field defibrillation for ventricular fibrillation cardiac arrest with return of spontaneous circulation after 10 minutes of cardiopulmonary resuscitation. Features of left ventricular hypertrophy and deep T-wave inversions in V3-V6 were noted on a 12-lead electrocardiogram which were suggestive of AHCM. Left heart catheterization with left ventriculography and coronary angiography confirmed the diagnosis of AHCM with the classic “ace of spades” sign. This case highlights the rare occurrence of AHCM with ventricular fibrillation cardiac arrest in an African American male, treated with hypertension management, aspirin, atorvastatin and automated implantable cardioverter-defibrillator placement.
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