No abstract

Methicillin-resistant Staphylococcus aureus (S. aureus) (MRSA), resistant to all antibiotics including Vancomycin, has been reported in Japan, USA, Canada and Brazil. Hence, the main objective of this study was to evaluate the possible presence of Vancomycin resistant or intermediate S.aureus in Karachi. A total of 850 clinical isolates were collected from two civil hospitals in the city between February 2006 and January 2007. They were identified using standard bacteriological methods.Sensitivity to recommended antibiotics was determined by disc diffusion, agar dilution, and E-test quantitative minimum inhibitory concentration (MIC). Susceptibility to natural or semi-natural products was determined by the agar dilution method. Out of 850 isolates, 250 were MRSA, of which 22% were resistant to 4 µg/ml Vancomycin, 24% to 8 µg/ml, 15.2% to 16 µg/ml, 10% to 20 µg/ml, and 13.2% to 30 µg/ml; the remaining 15.6% were sensitive to all used concentrations. Although we did not detect any Vancomycin-resistant S. aureus (VRSA), we found that 13% of the strains were intermediates (VISA), i.e. resistant to 30 µg/ml of Vancomycin. Because of the continuously increasing prevalence of VISA, it is imperative to minimize the use of Vancomycin. Indeed, the drug should only be prescribed for the treatment of documented, culture-proven infections with MRSA that are not susceptible to routine or alternative agents. This should help avoid the consequences of the development of Vancomycin resistant S. aureus (VRSA) in our environment.

It is well demonstrated in the literature that cocaine use has been well linked to the formation of various forms of acute and chronic cardiovascular problems including but not limited to acute coronary syndromes. However, cocaine has been commonly associated with coronary vasospasms and less commonly with myocardial infarction and the formation of atrial thrombus. Through this case presentation, we illustrate the findings of a 35-year-old gentleman with history of cocaine use presenting with acute coronary syndrome and complicated by thrombus formation. Furthermore, through this report, we illustrate in a patient with no other risk factors and at a young age, how chronic cocaine use or even a history of usage may result in complications even weeks after its consumption.

Cardiac troponins are the most sensitive and specific markers of myocardial injury. In fact, the Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction (MI) states that troponins are the preferred cardiac marker for detecting myocardial injury. For the aforementioned reasons, troponin levels are routinely ordered for patients presenting to the emergency department with chest pain, dyspnea, syncope, or any other possible presentations of MI. While troponin levels do reflect the extent of myocardial damage, they do not necessarily indicate myocardial ischemia in a subset of patients. Elevated troponin levels can be due to a wide array of mechanisms in the absence of myocardial ischemia and injury. Thus, relying solely on troponin levels, in the presence of a normal electrocardiogram (ECG), to diagnose myocardial ischemia can lead to unnecessary and expensive invasive testing. It is therefore important for the clinician to keep in mind the varying causes of troponin elevations in order to provide the highest value care to the patient. We present a case and review of literature regarding patients who present with elevated troponin levels in the absence of any coronary artery disease.

Key Clinical MessageAcute fulminant liver failure and acute renal failure are devastating complications caused by many drugs. The use of N‐acetylcysteine has been well established in acetaminophen toxicity, but it remains controversial in other cases. Dialysis is a very effective method of removing certain drugs from the system. With the invention of new street drugs such as “synthetic marijuana,” it may be beneficial in patients whom the substances ingested are unknown. We report a case of a 42‐year‐old male who developed acute fulminant hepatic failure and acute renal failure, who was cured with dialysis, N‐acetylcysteine, and other supportive measures.

Myocarditis can present in many different forms and can be overlooked by more life-threatening conditions. At times it may mimic conditions such as acute myocardial infarction and although it may have features highly suggestive of myocarditis, other etiologies need to be excluded. Thus, due to its clinical presentation, lab findings, and electrocardiogram analysis, it often can be confused with other conditions, making it a diagnostic dilemma of uncertainty. Myopericarditis is normally caused by viral infections, most common of which is coxsackievirus. Here we report a case of a 52-year-old gentleman who presented with a clinical picture of acute myocardial ischemia versus dissection, which overlooked a rather less threatening etiology of myopericarditis.

Cystic lesions of the pancreas are more frequently recognized due to the widespread use of improved imaging techniques. There are a variety of pancreatic cystic lesions with different clinical presentations and malignant potentials, and their management depends on the type of the cysts. Although the early recognition of a cystic neoplasm with malignant potential provides an opportunity of early surgical treatment, the precise diagnosis of the cystic neoplasm can be a challenge, largely due to the lack of reliable biomarkers of malignant transformation. We report a case of a large, multicystic neoplasm within the body and tail of the pancreas complicated by elevated erythropoietin, which is likely related to the malignant transformation of the pancreatic neoplasm.

Key Clinical MessageHeadache is one of the most common clinical entities, and has a long list of differential diagnoses; however, one of the more uncommon causes of postural headache is spontaneous intracranial hypotension. It is important that clinicians be aware of this condition, as it is often overlooked, leading to invasive and unnecessary diagnostic testing. A good history and physical exam, paired with an MRI of the brain is sufficient to make the diagnosis of SIH, relieve the symptomology of the patient in a quick and efficient manner, and avoid costly invasive procedures.