A 31-year-old woman presented with acute alcoholic hepatitis, jaundice, anemia, and hypertriglyceridemia following ethylene glycol poisoning. She had no previous history of anemia or gastrointestinal bleeding. Laboratory findings were consistent with acute hemolytic anemia. She was diagnosed with Zieve syndrome and was managed with supportive measures. Zieve syndrome is a rare occurrence with only a handful of published case reports. Although rare, the diagnosis should be on the differential in this subgroup of patients to avoid unnecessary and invasive diagnostic interventions.
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We present a 64-year-old woman with past medical history of psoriasis and alcoholic liver cirrhosis who presented with a diffuse, erythematous, and scaly rash. Pertinent medications included topical triamcinolone 0.1% cream. She was started on oral prednisone 40 milligrams (mg) and oral cyclosporine 150 mg daily and was continued on topical triamcinolone. After the administration of two doses of this regimen, the serum creatinine increased to 1.76 mg/dL, and serum potassium increased to 6.7 mEq/L. The serum creatinine continued to uptrend to 2.42 mg/dL, and the glomerular filtration rate (GFR) decreased to 20 mL/min. The patient was emergently hemodialyzed. The patient was placed on an extended steroid taper, alleviating the psoriatic rash. However, the patient needed to be placed on a steroid-sparing regimen. Because of its rarity and ensuing complications, erythrodermic psoriasis must be identified and managed promptly. Cyclosporine is currently the first-line treatment. However, initiation of this therapy in our patient resulted in an acute kidney injury (AKI). Even though a steroid taper assisted in alleviating erythroderma, a steroid-sparing regimen needed to be started. This led to the consideration of alternate methods of therapy for further management of erythrodermic psoriasis with renal impairment.
Babesiosis is increasing in the elderly due to an age‐related decline in immunity. Prompt diagnosis with blood smear and PCR prevent life‐threatening complications, like DIC and HLH. Studies focusing on pathophysiology and risk factors are needed.
Nontraumatic and spontaneous intercostal and intrathoracic herniations are defined as protrusions of intra-abdominal contents through acquired or congenital defects of the abdominal and thoracic walls without any proceeding trauma and are sparsely reported in the literature with less than 35 detailed case reports reported in the literature worldwide. Most of these cases result from abdominal trauma and are considered surgical emergencies. The content of these herniations, as reported in the literature, have classically been lungs and intra-abdominal organs. We report a case of nontraumatic intercostal and intrathoracic liver herniation, which was managed conservatively given minimal liver injury and rapidly improving symptoms.
Choreoathetoid movement secondary to cocaine use is a well-documented phenomenon better known as “crack dancing.” It consists of uncontrolled writhing movements secondary to excess dopamine from cocaine use. We present a 32-year-old male who had been using cocaine for many years and was recently started on paroxetine, a selective serotonin reuptake inhibitor (SSRI) for worsening depression four weeks before presentation. He had been doing cocaine every 2 weeks for the last three years and had never “crack danced” before this episode. The authors have conducted a thorough literature review and cited studies that suggest “crack dancing” is associated with excess dopamine. There has never been a documented case report of an SSRI being linked with “crack dancing.” The authors propose that the excess dopaminergic effect of the SSRI lowered the dopamine threshold for “crack dancing.” There is a communication with the Raphe Nucleus and the Substantia Nigra, which explains how the SSRI increases dopamine levels. This is the first documented case of an SSRI facilitating the “crack dance.”
unit admission, packed red blood cells transfusion, and transient norepinephrine infusion. Repeat computed tomography abdomen and pelvis (Figures 1 and 2) showed mild worsening of the large right gluteal hematoma without any active extravasation. Rotational thromboelastometry (ROTEM) showed good clot formation without any coagulopathy. Patient was transferred to the medical floor after stabilization of her medical condition and subsequently discharged home.Tyrosine kinase inhibitors including dasatinib have an essential role in the management of CML. Patients may require indefinite tyrosine kinase inhibitor therapy and it is very important to be aware of their potential adverse effects. Fatigue, headache, edema, rash, and hypertension are the common adverse effects. 1 Congestive heart failure, pleural effusion, arrhythmia, pulmonary hypertension, and bleeding are more significant adverse effects. 1,2 Among TKIs, dasatinib is most frequently associated with bleeding. Studies have reported a bleeding rate ranging 12%-40% due to dasatinib. 3 Dasatinib can cause bleeding in the upper gastrointestinal tract (22%), lower gastrointestinal tract (59%), gingiva (11%), vagina (5%), and nares (3%). 4 Dasatinib can cause bleeding even in the absence of thrombocytopenia suggesting a possible hemostatic defect. The exact mechanism by which dasatinib causes bleeding is unknown. However, it is suspected that dasatinib may alter platelet aggregation by impairing arachidonic acid and epinephrine-induced platelet aggregation and by inhibiting kinases in platelet homeostasis (SFK, LYN, FYN). Inhibition of SFK prevents platelet aggregation and adhesion. 5 Dasatinib has been shown to induce higher and faster rates of major molecular response and complete cytogenetic response when compared with imatinib. 6 Because dasatinib is used more frequently as a first line agent of CML management, clinicians should be cognizant of potential unique hemorrhagic presentations from its use. Our patient experienced spontaneous gluteal hematoma because of dasatinib use, which is rare. It will be worthwhile reporting this potential adverse effect of dasatinib to the current literature.
INTRODUCTION: A non-traumatic intercostal hernia is sparsely reported and is defined as a protrusion of intra-abdominal contents through acquired or congenital defect of the abdominal and thoracic walls. There have been individual cases reporting such herniation of lungs, small and large bowel, omentum, and liver. We describe a case in which a patient had both intercostal and diaphragmatic liver herniation secondary to increased cough. The literature relies on CT for diagnosis and for assessing damage to liver parenchyma which guides management. While intercostal liver herniations can be surgical emergencies, our case was managed conservatively given minimal liver injury and rapidly improving symptoms. CASE DESCRIPTION/METHODS: A 58-year-old female with a past medical history of hypothyroidism and essential hypertension presented with severe dry cough and nasal congestion for two weeks. Three days before presentation, she noticed a bruise on the right lateral chest wall which gradually increased and became painful with radiation to her back. The patient denied any recent history of trauma to the area. Physical exam revealed dry cough, large palpable tender bulging ecchymosis over right 9th and 10th ribs, and clear lungs. Vitals were unremarkable. Labs were significant for ALT 41, AST 62, CK 493, white count 17.8, platelets 567, INR 0.9 and positive nasal swab for influenza A. CT abdomen showed herniation of uninjured liver between 9th and 10th ribs with abdominal wall soft tissue stranding (or edema) with part of liver herniating through a diaphragmatic defect into the thoracic cavity (“hump sign”). Surgical services were consulted, and the patient was managed conservatively with opiate analgesia, IV hydration with normal saline, cough suppression, Tamiflu, and discharged with medical and surgical follow up. DISCUSSION: In patients with poor abdominal muscle strength having sudden worsening of pain after coughing and physical exam findings consistent with herniation, there should be high suspicion for abdominal and transdiaphragmatic herniation of liver. Given the rarity of such events, these patients can present as a diagnostic challenge and delay in care can result in poor outcomes especially in patients with organ damage. A consensus for management can be difficult due to sparsely reported cases, however, while injured or strangulated liver herniation is a surgical emergency, a conservative approach can be considered for uninjured liver herniation with close medical and surgical follow up.
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