A 62-year-old woman with chronic kidney disease stage 4, sleep apnoea on continuous positive airway pressure and recent admission for acute-on-chronic diastolic heart failure presented to emergency room with weakness. She was hypotensive and had symptomatic bradycardia in the 30 s secondary to hyperkalaemia and beta-blockers, raising concern for BRASH syndrome. Antihypertensives were immediately held. Potassium-lowering agents (with calcium gluconate for cardiac stability) were begun, as were fluids and dopamine for vasopressor support. The patient was admitted to intensive care unit and electrophysiology was consulted. Over the next 2 days, the patient clinically improved: she remained off dopamine for over 24 hours; potassium levels and renal function improved; and heart rate stabilised in 60 s. The patient was eventually discharged and advised to avoid metolazone, bumetanide and carvedilol, with primary care provider and cardiology follow-up.
A 71-year-old female with history of right lower lobe (RLL) lesion (noted six years ago on chest x-ray [CXR]) and 45-pack year smoker presented to the Emergency Room for shortness of breath (SOB). She reported two months of worsening SOB, productive cough, and unintentional weight loss. Physical exam revealed RLL wheezes. Her oxygen saturation was 89% on room air. Admission labs showed leukocytosis and elevated procalcitonin (Table 1). Initial imaging demonstrated a large RLL multiloculated lung abscess (LA) (Figure 1). We initiated oxygen and intravenous (IV) broad spectrum antibiotics. Coronavirus 2019 (COVID-19) came back positive and hydroxychloroquine was started. Thoracentesis of the LA revealed Streptococcus (Strep) anginosus that was susceptible to penicillins. The patient was then switched to Amoxicillin for 4 weeks. Repeat Computed Tomography (CT) of chest after 4 weeks revealed RLL consolidation evolution with decreased parenchymal fluid loculations (Figure 2). The pulmonologist restarted Amoxicillin for 4 weeks, ordered repeat COVID-19 testing, and referred to oncology.
A 61-year-old woman with no significant previous medical history presented to an urgent care facility with generalised rash, flushing and abdominal pain after eating mahi-mahi. She was diagnosed with an allergic reaction and discharged home. Later she experienced severe acute abdominal pain and multiple episodes of vomiting, which prompted her to go to the hospital. On admission, the patient had an elevated white count, lipase, amylase and C reactive protein with normal liver enzymes and bilirubin. Imaging showed acute pancreatitis that was suspected to be secondary to scombroid poisoning. This was confirmed by elevated immunoglobulin E and histamine levels. The acute pancreatitis was treated with pain management and supportive treatment. Scombroid poisoning is a well-recognised disease, however, acute pancreatitis secondary to this is rare as only two cases have been reported in the literature, one with codfish and the second an unknown type of fish.
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