IJCR (2018), Volume 2

Overdose by calcium channel blocker (CCB) antihypertensive agents has been shown to be a cause of significant morbidity and can often be fatal. (1) Although overdoses of calcium-channel blockers and beta blockers are uncommon, they have a high mortality rate, and management may be complicated. (2) Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. (3) We report a case of severe Amlodipine/Atenolol overdose that was refractory to multiple therapeutic approaches but rapidly responded to plasmapheresis. We describe the case of a previously healthy 25-year-old lady presented after ingesting 30 tablets of Amlodipine 5 mg/Atenolol 50 mg in a suicide attempt. The patient was initially managed with fluid resuscitation, calcium boluses, glucagon bolus, methylene blue boluses and multiple vasoactive agents. Hyperinsulinemic euglycemic therapy was initiated when hypotension persisted despite conventional treatments but was stopped later due to life threatening hypoglycemia and hypokalemia. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels as knowing that amlodipine is highly protein bound. Plasmapheresis is a procedure used to remove pathologic substances from a patient’s blood that has proven useful in some cases of drug overdose. (1) A dramatic improvement of cardiovascular stability was already observed during plasmapheresis. The primary outcomes were to reduce mortality and improve hemodynamic parameters. The secondary outcomes included reduce length of stay in intensive care unit, duration of vasopressor use and functional outcomes. (4) Conclusion: This case demonstrates that a Plasmapheresis can be effective in restoring hemodynamic stability in severe calcium channel blocker toxicity and recommend its use in patients with calcium channel blocker toxicity that is not responsive to traditional therapies.

Systemic lupus erythematosus (SLE) is often associated with various systemic manifestations, from peripheral cytopenias to renal involvement or neuropsychiatric symptoms. Here, we present a patient in whom the cause of fever and altered mental status was unknown despite repeated lumbar punctures, but later became elucidated following the development of rash and lymphadenopathy with subsequent biopsies. This case demonstrates a unique presentation of Kakuchi-Fujimoto Disease, a necrotizing lymphadenitis manifesting in association with SLE and autoimmune hepatitis. Further, this case illustrates the proclivity of autoimmune disorders to occur concurrently.

Background:The outcomes of techniques employed for depigmentation are varied and no one method can be deemed as ideal. The present case series is an evaluation of 4 popular depigmentation procedures `carried out today. Material and methods: 5 patients with non-syndrome associated gingival hyperpigmentation in all 4 quadrants based on Dummetts scoring criteria were included. Healing and pain were assessed following depigmentation carried out by scalpel, bur, electro surgery and laser in the 4 quadrants respectively and followed up for a period of 2 years. Results: Healing following Scalpel method and laser were better than bur and electro surgery. Post-operative pain was less with the use of scalpel and laser when compared to the other 2 techniques at the end of 1month. Pain was still evident at the site of electro surgery at the end of 2 months. However at the end of 3, 6 months and 1 and 2 years there was no difference in all 4 techniques. Conclusion: Better treatment outcomes were observed with the scalpel and laser techniques than bur and electrosurgery.

Sigmoidal intussusception protrusion through the anus is extremely rare and has only been reported a few times. The majority of cases of prolapsed sigmoid intussusception in adults have an underlying bowel pathology such as carcinoma, polyps, or benign neoplasms, which are usually discovered intra-operatively. Our case is a 25-year old male patient, previously healthy, with no history of constipation or straining, who presented with a painless prolapsed mass out of the anus. It is very unusual for a young healthy male to present suddenly with such a complaint. After failed attempts to reduce the prolapsed segment under general anesthesia, laparotomy was performed and the prolapsed mass was determined to be an intussuscepted sigmoid. Hartmann procedure was performed. 9 cm of the sigmoid was resected. Findings were consistent with a healthy but edematous prolapsed sigmoid colon.

Warfarin is a widely used anticoagulant agent with a large spectrum of indications for prevention and treatment of thromboembolic complications. Despite its low cost, warfarin and all other vitamin K antagonist (VKA) use has several limitations, including narrow therapeutic index requiring frequent laboratory monitoring to prevent complications related to under- and over-anticoagulation. The concomitant use of medications may alter the metabolism of warfarin by inducing or inhibiting the cytochrome P450-2C9, resulting in a decrease or increase in anticoagulant effect. In this setting, interactions between warfarin and antibiotics have been described. These interactions represent one of the problems with VKA use in the clinical setting. We aimed to report four cases where the prescription of antibiotics without proper control of anticoagulation levels led to major hemorrhagic complications.

A 54 year old female presented with a short history of dyspnoea on exertion and pain right hypochondrium, radiating to back. X-Ray chest showed a well-defined opaque mass in the posterior mediastinum. A computed Tomography (C T) scan chest done revealed a thick walled cystic lesion in the posterior mediastinum compressing the right lower lobe bronchus along with minimal pleural effusion on same side. Ultrasound guided aspiration was done and clear watery fluid aspirated. Standard postero-lateral thoracotomy was under taken and the whole cystic mass was excised. Postoperative period was uneventful. Histopathological examination of the cyst wall revealed it to be a cystic schwannoma.

Minimal change disease (MCD) accounts for 10-15% of idiopathic nephrotic syndrome in adults. Patients typically present with nephrotic range proteinuria, hypertension, microscopic hematuria and can even progress to acute renal failure. MCD can be primary (idiopathic) or secondary from etiologies such as cancer, medications, autoimmune conditions and infections. The link between infectious etiologies for MCD is important to recognize, since MCD tends to show a good response to treatment of the underlying cause. Influenza A has been reported as a secondary cause of MCD and rarely, influenza A, not B, can also present with liver failure. We present an atypical case of a 60-year-old female with no past medical history who presented with liver failure along with acute kidney injury and nephrotic range proteinuria. She was diagnosed with liver failure and secondary MCD from influenza B, the first reported case, and made a full recovery with treatment of Influenza B.

A woman with Crohn’s disease with prior resection presented with a one-year history of persistent abdominal pain. The small bowel follow-through radiograph demonstrated the presence of two strictures in the small intestine due to adhesive scarring. Opting for conservative management, the patient underwent a specialized manual physical therapy regimen. Following treatment, the patient experienced significant decrease of abdominal pain and improved biomechanical function. Radiologic imaging revealed complete resolution of both strictures. Manual physical therapy may be a viable non-operative option to manage small bowel strictures or obstruction.

The association between spinal tumors with hydrocephalus and intracranial hypertension is rare, and the exact mechanism has remained uncertain. We present a case of L4/5 intraspinal schwannoma presenting as positional headache, with the aim to discuss the underlying pathophysiology and alert clinicians of the possibility of lower spinal tumor as a differential diagnosis of headache.

Bilateral septic arthritis is a rare presentation and when present is seen in the elderly resulting in morbidity and mortality. We present a 79 year old lady who died as a result of complications arising from bilateral septic arthritis.