Splenic injury is usually seen with penetrating or blunt abdominal trauma. It is also one of the rare complications of colonoscopy. Various patient and procedural factors have been reported to increase the risk of this dreaded complication. We present a case of splenic injury after outpatient colonoscopy where intraabdominal adhesions from previous abdominal surgeries were presumed to be the cause of splenic injury. Our patient had improved outcomes with timely diagnosis and intervention.
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is known to affect different organs in the body. Nervous system involvement is common and can manifest as neurological or neuropsychiatric symptoms. A 23-year-old female with no significant past medical history, presented with nausea and vomiting for two weeks and unusual behavior for three days. Brain magnetic resonance imaging (MRI) showed small vessel ischemic changes and abnormal T2 flair/periventricular signal. Lab workup was positive for anti-dsDNA antibodies. The patient was diagnosed with SLE; positive serology and multisystem involvement including neurologic, serositis, and musculoskeletal system. Acute onset of abnormal behavior and memory problems were attributed to lupus cerebritis. The patient was started on methylprednisolone and had significant improvement in neurologic status within the next two days.
INTRODUCTION: Nitrous oxide (N2O) is used in the medical field for its analgesic, anxiolytic and anesthetic properties. It also has abuse potential due to hallucinogenic effects. N2O abuse can lead to hyperhomocysteinaemia which is associated with increased risk of thrombosis. Herein, we present a case of pulmonary embolism associated with N2O abuse. CASE PRESENTATION:A 27-year-old African American female presented to the emergency department with shakes, and numbness of the lower extremities for 2 days. She had history of peripheral neuropathy and vitamin B12 deficiency. She was on norgestimate-ethinyl estradiol for contraception. She had been abusing 50 cartridges of whippits for many years. On presentation her vitals and physical exam were normal. Blood work revealed normocytic anemia with hemoglobin of 10.4 g/dl (12.0 -15.8 g/ dL) and leukopenia with white blood cell count of 3.38 x 103/mcL (N:4.00 -12.00 x 103/mcL). The metabolic panel was normal. D-dimer was elevated at 2.67 mcg/mL FEU (N:<0.5 mcg/mL FEU). Serum troponin level was normal, and EKG showed sinus rhythm. CT angiography of the chest showed bilateral filling defects in the lobar, segmental and subsegmental branches of the right upper, middle, and lower lobes as well as a segmental branch of the left upper lobe. Further work-up revealed low vitamin B12 <146 pg/ml (N: 213-816 pg/ml) and elevated homocysteine at 48 umol/L (N: 4-13 umol/L). Factor V Leiden screen was negative. Patient was started on therapeutic low molecular weight heparin and supplemented with Vitamin B12. She was discharged on Apixaban.DISCUSSION: There is a paucity of literature on N2O causing venous thromboembolism (VTE). N2O causes irreversible inactivation of vitamin B12 which is a co factor for methionine synthetase. This leads to hyperhomocysteinaemia which results in a hypercoagulable state. Our patient while abusing nitrous oxide, was also on norgestimate-ethinyl estradiol which further increased the risk of VTE. Use of Vitamin supplementation in decreasing the homocysteine levels remains controversial. Stopping the N2O use is vital in preventing recurrent thrombosis.
Drug-induced lung injury includes a wide spectrum of diseases. Disease-modifying antirheumatic drugs (DMARDs), especially methotrexate, are a well-known cause of lung damage. An association between leflunomide and lung toxicity has been reported in the literature, but actual incidence remains unknown. CASE PRESENTATION:A 66-year-old Caucasian female presented to the emergency department with worsening dyspnea on exertion for 3 days and chest pressure for 1 day. She had a history of right nephrectomy for renal cell cancer 13 years ago, rheumatoid arthritis (RA), and stage 3 chronic kidney disease. She was started on Leflunomide 1 month ago for RA. She was a nonsmoker. Vital signs on presentation were pulse 102/min, blood pressure 156/95mmHg, respiratory rate 24/min, oral temperature 98.5 F, and SpO2 88-90% breathing on room air. Lung exam revealed bilateral rales more on left than right. Blood work showed normal cell count and metabolic panel other than elevated creatinine 1.19 mg/dl (N: 0.6-1.0 mg/dl). Cardiac workup was unremarkable. Chest X-ray showed right basal atelectasis. CT angiography of the chest did not show pulmonary embolism but bilateral apical mosaic attenuation and right middle and left lower lobe alveolar opacities were noted. The patient was started on antibiotics for community-acquired pneumonia and supplemental oxygen via nasal cannula. Further workup including serum ANA, ANCA panel, ESR, CRP, procalcitonin, and respiratory pathogen panel was unremarkable. Despite getting antibiotics patient's symptoms did not improve. She was started on methylprednisone 62.5 mg IV followed by oral prednisone 40 mg daily due to concern of drug-induced lung injury. The patient's respiratory status improved, and she was discharged in the next 48 hours with oral prednisone taper. Leflunomide was discontinued. A repeat CT scan of the chest in 3 months showed resolution of the above-mentioned abnormalities.DISCUSSION: RA is a multisystem disease and has various pulmonary manifestations. DMARDs used to treat RA are also known to cause lung damage. Determining the relationship between these medications and adverse pulmonary events is challenging. Leflunomide-induced ILD generally occurs after a duration of 2-13 weeks of treatment. Common imaging findings are bilateral diffuse, patchy ground-glass opacities or consolidation usually in upper, anterior, and central fields. Honeycombing can also be seen. Factors that increase the risk of ILD are a history of methotrexate use, pre-existing ILD, and cigarette smoking. Management involves drug discontinuation, high-dose corticosteroids, and cholestyramine washout.CONCLUSIONS: Leflunomide can cause pneumonitis either as monotherapy or in conjunction with methotrexate. A high degree of suspicion is required to suspect this complication so that it can be managed effectively.
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