Malignant hyperthermia is a syndrome characterized by elevated temperature, heart rate, respiratory rate, and muscle rigidity, which eventually leads to a hypermetabolic state with rhabdomyolysis and increased oxygen consumption. It's typically seen in patients with genetic mutations predisposing them to a reaction after administration of anesthetics or depolarizing muscle relaxants, but there have been reported cases in response to other agents. Here we present a case of a patient who developed malignant hyperthermia after receiving insulin infusion for hyperosmolar hyperglycemic state. CASE PRESENTATION:A 24-year-old male with no significant past medical history who presented to the hospital for weakness and difficulty sleeping. In the ED the patient's blood glucose level was 1,635 on CMP with anion gap of 30. His lactic acid level was 3.5 before IV fluid resuscitation. In addition, admission ABG was found to have a pH 7.261, pCO2 33.8, and paO2 83.2 on room air. Vitals were BP 124/75, HR 130, RR 16, and Temp 97.5 F. Over the course of the next 12 hours, the patient's mental status started to decline. CT scan of the brain was performed, and was negative for acute intracranial pathology. He developed his first temperature of 102 F about 12 hours into his admission. The patient had already received 7L of normal saline and was receiving 1/2NS for maintenance fluids, which was then switched to D5W when the BG reached 250. After 20 hours of continued insulin drip for HHS and maintenance IV fluids his temperature increased to 103 F and he started to develop unstable tachyarrhythmias. He was cardioverted twice for supraventricular tachycardia which was unsuccessful. Further hemodynamic decline necessitated the patient to be intubated for airway protection and initiation of vasopressors. Subsequently he spiked a continued fever of 108 F which was not responsive to cooling blankets or tylenol. Patient was given two doses of dantrolene and his temperature was successfully lowered. Unfortunately the patient was already in multiorgan failure and DIC which resulted in cardiopulmonary arrest.DISCUSSION: There have been cases where a preservative cresol in insulin has caused individuals with susceptible genetics to malignant hyperthermia to develop the syndrome. Most known cases of malignant hyperthermia occur in individuals with ryanodine receptor (RYR1) or dihydropyridine receptor mutation (DHP) mutation. In a patient who did not receive the known triggers for malignant hyperthermia, the diagnosis was not on our differential until he had a persistent fever of 108 F. CONCLUSIONS:This case highlights a rare and potentially life threatening presentation of new onset diabetes mellitus. The mortality rate of malignant hyperthermia is 70-80% despite early recognition and treatment. We want to bring light to this potential complication to spread more awareness.

INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is bleeding in the alveolar space caused by the interruption of basement membrane in the alveolar-capillary interface. It typically is associated with vasculitic disorders, but in rare cases it has been seen in patients using anticoagulant and antiplatelet agents. Here we present a case of DAH where the etiology is not completely distinguishable from vasculitic vs anticoagulant causes. CASE PRESENTATION:A 79 y/o female with PMHx of HTN, rheumatoid arthritis with daily low-dose prednisone, atrial fibrillation on Pradaxa, and hypothyroidism presented to the hospital for shortness of breath and atypical chest pain. She was involved in a minor MVC 2 days prior, for which no injuries were sustained.Initial vitals in the ED were stable, except for hypoxia requiring 2L NC. CXR showed infiltrates in the both lungs and CTA revealed extensive alveolar parenchymal opacities in the RUL, RML, RLL, lingula, and LLL. Overnight she continued to desaturate despite increasing supplemental oxygen, ultimately requiring intubation. At this time her Hgb was found to be 5.6 from 7.3 on admission. She was then transfused PRBCs and given praxbind. A bronchoscopy was then performed revealing bloody secretions in all lung segments, confirming diffuse alveolar hemorrhage.Over the next few days she required multiple blood transfusions and daily bronchoscopy for alveolar lavage. In addition, she was given high dose steroids (Solumedrol 500mg IV Q6H) and a dose of methotrexate for possible vasculitic etiology due to history of RA. The autoimmune workup showed ESR >100, positive perinuclear p-ANCA (1:320) & ANA, but was negative for Glomerular BM Ab, Atypical pANCA, CCP IgG/IgA Ab, Cytoplasmic C-ANCA, RF negative, & C3/C4 were within normal limits. Coagulopathy panel showed PT 17.9, INR 1.58, PTT 40.9, D-dimer 734. DISCUSSION:The treatment of DAH largely consists of supportive care, however, addressing the potential reversible etiologies is important. First, all anticoagulation should be discontinued with immediate administration of the reversal agent if possible. In addition, any suspicion for vasculitis should promptly be treated with steroids and biologic agents. Fortunately, we were able to administer praxbind to reverse the anticoagulant, as well as, administer steroids & methotrexate. Despite maximizing medical therapy, our patient continued to decline. Although her coagulation studies were within normal limits and most of the rheumatologic workup was unremarkable, there was a positive p-ANCA. This positive test alone is not specific for the diagnosis of certain vasculitic diseases, thus with this outlier alone, it was not convincing enough to correlate our patient medical condition with vasculitis.CONCLUSIONS: Given the variety of etiologies of DAH, this case highlights the importance of a complete work-up and management of suspected causes.

INTRODUCTION:Lung cancer in young non-smokers is rare however it is associated with significant morbidity and mortality. This is further complicated when diagnosis occurs late in the disease course. CASE PRESENTATION:We present the case of a 35 year old female who presented with left sided facial droop and ptosis, blurry vision, and left sided facial and arm numbness that progressively worsened over 3 days. Her past medical history was significant for lower back pain of 4 months duration which prompted two prior emergency department visits. A CT scan of the brain performed in the emergency department on the current visit showed a multifocal hyperdense lesion in the supratentorial and infratentorial parenchyma. This was followed with a contrast MRI that demonstrated at least 63 heterogeneously enhancing intraparenchymal nodules ranging from 1 mm to 25 mm in size. These results prompted a chest x-ray that showed a 9 cm masslike infiltrate in the right upper lobe. A CT of the chest confirmed a 4 cm spiculated mass in the right upper lobe and enlarged paratracheal and sub-carinal lymph nodes. The patient denied any history of smoking or occupational exposures that would predispose for lung cancer and her family history was negative for cancer. A CT guided biopsy was performed on the lung mass and pathology showed Napsin-A positive adenocarcinoma. The patient's neurological symptoms improved with dexamethasone therapy and was discharged to follow with radiation and medical oncology.

We present a case of persistent MRSA (methicillin-resistant staphylococcus aureus) catheter-related bloodstream infection (CRBSI) secondary to an infected atrial thrombus. We focus on the novelty and utility of the devices used to retrieve the atrial mass. CASE PRESENTATION:A 64-year-old female with a past medical history of stroke, type 2 diabetes mellitus, hypertension, and end-stage renal disease requiring hemodialysis presents to our emergency department from her nursing home due thrombotic occlusion of her dialysis catheter, preventing her from receiving necessary dialysis.On the physical exam, the patient is alert and oriented only to person, appearing to be at her baseline. She is febrile at 100.8 F (38.2 C). Cardiac exam reveals normal sinus rhythm with no murmurs. Pulmonary exam is clear to auscultation bilaterally. No focal neurologic deficits are appreciated. No integumentary evidence of immunologic, embolic, or thrombotic events are seen.Initial lab work is significant for a leukocytosis of 29.1 with a neutrophilic predominance. Transthoracic echo revealed trace mitral regurgitation with no apparent lesions or vegetations. Transesophageal echocardiogram revealed a large mobile pedunculated mass originating in the superior vena cava (SVC) and extending into the right atrium; no vegetations or septal defects were appreciated.The patient underwent percutaneous thrombectomy of the mass with the Inari FlowTriever, a device normally used for massive pulmonary emboli extraction. Cultures of both the catheter tip and the extracted mass grew MRSA. The patient was synergistically treated with a Daptomycin and Ceftaroline regimen for a total of four weeks. Repeat blood cultures resulted negative, confirming appropriate clearance of her bacteremia.DISCUSSION: Dialysis catheters are essential to end-stage renal disease patients, but like most treatment modalities, there are complications associated with them. CRBSIs can result in extended antibiotic management, removal of hardware, and even death, if not treated. Among other bacteria, MRSA can result in a 30 to 50% mortality. Diagnosis of a cardiac source can be made with a transthoracic or transesophageal echocardiogram, yielding sensitivities of 86% and 95%, respectively. Assuming the nidus for infection is removed, systemic antibiotic therapy normally consists of two to three weeks of specialized therapy. Depending on the positioning of a central venous catheter, a vegetation can form in the SVC or right atrium, usually forming from turbulent flow and friction against the vessel lumen or endocardium. Surgery or percutaneous thrombectomy can be used to remove a cardiac mass in this location. CONCLUSIONS:In our patient, we were able to tailor the use of the Inari FlowTriever for the less invasive percutaneous thrombectomy, ultimately leading to the resolution of the patient's bacteremia and shift in prognosis.