An Unusual Case of Pyogenic Liver Abscess Caused by Community-acquired Methicillin-Resistant Staphylococcus aureus
Hepatic abscesses are the most common type of visceral abscesses. The annual incidence is estimat... more Hepatic abscesses are the most common type of visceral abscesses. The annual incidence is estimated at 2.3 cases per 100,000 people and is more common in men than women. A considerable proportion of pyogenic liver abscesses are caused by hepatobiliary pathologies. However, it may also result from hematogenous seeding from the systemic circulation. Most pyogenic liver abscesses are polymicrobial in nature consisting of anaerobic and enteric gram-negative bacilli species. Less than 10% of cases are caused by Staphylococcus aureus. Of these, few are caused by Methicillin-resistant Staphylococcus aureus (MRSA) and even fewer from the community-acquired strain. The clinical manifestations of pyogenic liver abscesses usually include fever, abdominal pain and non-specific symptoms like nausea, vomiting, malaise, anorexia and weight loss. Treatment of pyogenic liver abscesses consists of source control with drainage and antibiotic therapy tailored to the isolated causative organism. We present a case of a 51-year-old Caucasian man who presented with severe right upper quadrant abdominal pain of 5 days in duration. Abdominal Computed Tomography (CT) showed a 7.7 by 6.0 centimeter multi-loculated mass in the right hepatic lobe with other scattered foci throughout the liver. The abscess was aspirated with a pigtail drain placed under CT guidance. The aspirated culture grew MRSA sensitive to Doxycycline and Trimethoprim/Sulfamethoxazole.
Angiotensin-converting enzyme (ACE) inhibitors are amongst the commonest prescribed medications i... more Angiotensin-converting enzyme (ACE) inhibitors are amongst the commonest prescribed medications in the United States and considered to be the leading causes of drug induced angioedema. High bradykinin levels stimulate vasodilation and increased vascular permeability of the post-capillary venules and allow for plasma extravasation into the submucosal tissue, leading to angioedema. Usually, the angioedema occurs within the first week of exposure to therapy, but cases occurring after years of stable ACE inhibitor usage are not uncommon. Here, we present a 43-year-old Caucasian female who developed acute respiratory failure requiring mechanical ventilation secondary to ACEi-induced angioedema after five years of Lisinopril usage. This case will help to increase physicians' awareness that this potentially fatal complication can still occur after years of ACE inhibitor usage.
Pulmonary Carcinoid Tumorlets: A Rare Cause of Chronic Intractable Cough
Chronic cough is a common presenting complaint in pulmonary clinics. We present a patient who had... more Chronic cough is a common presenting complaint in pulmonary clinics. We present a patient who had undergone extensive work up for chronic intractable cough that was finally diagnosed as diffuse pulmonary carcinoid tumorlets. Pulmonary tumorlet is an incidental finding at histopathologic examination of lung parenchyma that is often located adjacent to bronchogenic tumors or carcinoid tumors or particularly in lung scarred by bronchiectasis or other chronic inflammatory processes. Tumorlets are usually smaller than 5 mm in diameter and are multiple. Tumorlets are composed of small uniform cells that appear cytologically benign; they tend to form compact aggregates or nests and may grow into the mucosa of the airways. Also, tumorlets, like carcinoids, contain neurosecretory granules and have distinctive electron microscopic and immunohistochemical findings. Our case is a 61 year old Caucasian female, non-smoker, was followed in pulmonary clinic because of chronic dry cough which was associated with dyspnea and wheezing. Normal physical examination except for occasional wheezes. Pulmonary function test showed restrictive pattern, FEV1 75%, FEV1/FVC 88% and TLC 67% of predicted. High resolution chest CT had shown multiple non-calcified well circumscribed pulmonary nodules scattered throughout the lungs, the largest 5 mm. She had been treated as a case of asthma. Inhaled bronchodilators and corticosteroids partially improved her symptoms. Later her cough had become intractable with worsening exertional dyspnea. Otolaryngology evaluation and EGD had been inconclusive. Bronchoscopy with bronchoalveolar lavage and multiple transbronchial biopsies came with normal results. VATS biopsy showed multiple small nodules less than 1 cm in the right upper, middle, and lower lobes, predominantly peripheral lesions. The lesions were found to represent carcinoid tumorlets. Usually the lesions are asymptomatic and discovered incidentally on CT scan and can be confused with metastases, however they can present with chronic cough or dyspnea.
Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinysta... more Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinystalia johimbe, as well as from the bark of the unrelated South American tree Aspidosperma quebracho-blanco. It is commonly sold as a dietary supplement for the purpose of enhancing libido, weight loss and natural bodybuilding aids. Yohimbine has high affinity for the α 2-adrenergic receptor, moderate affinity for the α 1 receptor, dopamine D 2 receptor, and weak affinity for the dopamine D 3 receptors and some of the serotonin receptors. Depending on dosage, Yohimbine can either increase or decrease systemic blood pressure (through vasoconstriction or vasodilation, respectively). We present a 51-year-old male who presented with substernal chest pressure and the sensation of a "pounding heart" after starting Yohimbine as a dietary supplement. He was found to have type II myocardial injury characterized by elevated troponin levels. We propose that the mechanism for this was 1) elevation of blood pressure and sinus tachycardia causing myocardial ischemia due to increased myocardial oxygen demand and supply mismatch, 2) cardiac norepinephrine release causing direct non-ischemic norepinephrine mediated myocardial injury and 3) increased sympathetic outflow mediated coronary vasoconstriction and spasm causing ischemia.
Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is ... more Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is a rare disease that occurs in ~1% or less of all osteomyelitis. It can result from direct inoculation from traumatic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. We present a case of a 32-year-old female with a history of Intravenous drug abuse who presented with localized left-sided chest pain. A CT thorax contrast study was obtained that showed edema around the anterior aspects of the left 3rd to fifth ribs and involves the inferior border of the pectoralis muscle with buckling of the left 4th rib with fluid density in the fascial planes. Subsequently, an MRI was done that revealed the pathological fracture of the anterior aspect of the left forth rib with evidence of osteomyelitis of the left 4th and 5th ribs, as well as early insufficiency fracture of the left fifth rib. Blood cultures were negative. She was treated conservatively with empiric antibiotics due to lack of seeding and bacteremia.
Acute Respiratory Failure Secondary to Persistent Lobar Atelectasis in Ehlers-Danlos Syndrome Patient and the Role of Connective Tissue Disease in Altering the Mechanical Properties of the Lungs
Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective-tissue disorders ch... more Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective-tissue disorders characterized by joint hypermobility, cutaneous fragility, and hyperextensibility. The collagen defect has been identified in at least six of the many types of Ehlers-Danlos syndrome. Changes in the mechanical properties of the bronchial airways and lung parenchyma may trigger the observed increased tendency of the airways to collapse and lung atelectasis. This is a case of a 33 year old Caucasian female who presented with acute hypoxic respiratory failure secondary to persistent right lower lobe atelectasis despite optimal medical management, pulmonary toilet, and multiple bronchoscopies. She also had an incidental finding of lung arteriovenous malformation (AVM) which can occur in EDS patients.
A Fatal Case of Prochlorperazine-Induced Neuroleptic Malignant Syndrome: A Case Report and Literature Review
Neuroleptic malignant syndrome (NMS) is a medical emergency associated with the use of neurolepti... more Neuroleptic malignant syndrome (NMS) is a medical emergency associated with the use of neuroleptics and antiemetics. NMS is characterized by a distinctive clinical syndrome of altered mental status, rigidity, hyperthermia, and autonomic dysfunction. NMS occurs as a result of changes in presynaptic or postsynaptic dopamine signaling. Central D2 receptor blockade in the hypothalamus, nigrostriatal pathways, and spinal cord leads to increased muscular rigidity and tremor via extrapyramidal pathways. Hypothalamic D2 receptor blockade results in an elevated temperature set point and impairment of heat-dissipating mechanisms. The reported mortality rates for NMS vary between 5 to 20 percent and the occurrence of medical complications and disease severity are the strongest predictors of mortality. This is a case of a 51 year old Caucasian female who presented with altered mental status, temperature of 109°F, diffuse muscular rigidity and autonomic dysfunction manifested as labile blood pressure, tachypnea, hypoxemia and tachycardia after consuming 18 tablets of Prochlorperazine over three days for gastrointestinal upset. Her clinical presentation and laboratory work up were consistent with NMS and she developed fatal complications and multi-organ dysfunction secondary to Prochlorperazine-induced neuroleptic malignant syndrome.
Concurrent Occurrence of Chylothorax and Chyloperitoneum in Non-Hodgkin's Lymphoma
Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is... more Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. Chylothorax is classified as non-traumatic or traumatic. Non-traumatic chylothorax is mainly caused by malignant etiologies accounting for more than 50% of chylothorax diagnoses. Lymphoma is the most common etiology. Chyloperitoneum is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity, which can occur as a result of trauma or obstruction of the lymphatic system. Chylous ascites is an uncommon finding that can be caused by malignancy, cirrhosis and lymphatic disruption after abdominal surgery. The combination of chyloperitoneum and chylothorax is rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. The Patient is an 82 year old Caucasian male who presented with worsening shortness of breath and abdominal distension. Chest X-ray showed moderate left sided pleural effusion. Bedside ultrasound-guided paracentesis and thoracentesis revealed milky ascetic and pleural fluid respectively. Triglyceride level was 271 mg/dl in the ascetic fluid, and 221 mg/dl in the pleural fluid. Pleural fluid was exudative with lymphocytic predominant cell count and negative cytology. Lymph node biopsy confirmed Non-Hodgkin’s Lymphoma causing the concurrent chylothorax and chyloperitoneum.
An Unusual Case of Pyogenic Liver Abscess Caused by Community-acquired Methicillin-Resistant Staphylococcus aureus
Hepatic abscesses are the most common type of visceral abscesses. The annual incidence is estimat... more Hepatic abscesses are the most common type of visceral abscesses. The annual incidence is estimated at 2.3 cases per 100,000 people and is more common in men than women. A considerable proportion of pyogenic liver abscesses are caused by hepatobiliary pathologies. However, it may also result from hematogenous seeding from the systemic circulation. Most pyogenic liver abscesses are polymicrobial in nature consisting of anaerobic and enteric gram-negative bacilli species. Less than 10% of cases are caused by Staphylococcus aureus. Of these, few are caused by Methicillin-resistant Staphylococcus aureus (MRSA) and even fewer from the community-acquired strain. The clinical manifestations of pyogenic liver abscesses usually include fever, abdominal pain and non-specific symptoms like nausea, vomiting, malaise, anorexia and weight loss. Treatment of pyogenic liver abscesses consists of source control with drainage and antibiotic therapy tailored to the isolated causative organism. We present a case of a 51-year-old Caucasian man who presented with severe right upper quadrant abdominal pain of 5 days in duration. Abdominal Computed Tomography (CT) showed a 7.7 by 6.0 centimeter multi-loculated mass in the right hepatic lobe with other scattered foci throughout the liver. The abscess was aspirated with a pigtail drain placed under CT guidance. The aspirated culture grew MRSA sensitive to Doxycycline and Trimethoprim/Sulfamethoxazole.
Angiotensin-converting enzyme (ACE) inhibitors are amongst the commonest prescribed medications i... more Angiotensin-converting enzyme (ACE) inhibitors are amongst the commonest prescribed medications in the United States and considered to be the leading causes of drug induced angioedema. High bradykinin levels stimulate vasodilation and increased vascular permeability of the post-capillary venules and allow for plasma extravasation into the submucosal tissue, leading to angioedema. Usually, the angioedema occurs within the first week of exposure to therapy, but cases occurring after years of stable ACE inhibitor usage are not uncommon. Here, we present a 43-year-old Caucasian female who developed acute respiratory failure requiring mechanical ventilation secondary to ACEi-induced angioedema after five years of Lisinopril usage. This case will help to increase physicians' awareness that this potentially fatal complication can still occur after years of ACE inhibitor usage.
Pulmonary Carcinoid Tumorlets: A Rare Cause of Chronic Intractable Cough
Chronic cough is a common presenting complaint in pulmonary clinics. We present a patient who had... more Chronic cough is a common presenting complaint in pulmonary clinics. We present a patient who had undergone extensive work up for chronic intractable cough that was finally diagnosed as diffuse pulmonary carcinoid tumorlets. Pulmonary tumorlet is an incidental finding at histopathologic examination of lung parenchyma that is often located adjacent to bronchogenic tumors or carcinoid tumors or particularly in lung scarred by bronchiectasis or other chronic inflammatory processes. Tumorlets are usually smaller than 5 mm in diameter and are multiple. Tumorlets are composed of small uniform cells that appear cytologically benign; they tend to form compact aggregates or nests and may grow into the mucosa of the airways. Also, tumorlets, like carcinoids, contain neurosecretory granules and have distinctive electron microscopic and immunohistochemical findings. Our case is a 61 year old Caucasian female, non-smoker, was followed in pulmonary clinic because of chronic dry cough which was associated with dyspnea and wheezing. Normal physical examination except for occasional wheezes. Pulmonary function test showed restrictive pattern, FEV1 75%, FEV1/FVC 88% and TLC 67% of predicted. High resolution chest CT had shown multiple non-calcified well circumscribed pulmonary nodules scattered throughout the lungs, the largest 5 mm. She had been treated as a case of asthma. Inhaled bronchodilators and corticosteroids partially improved her symptoms. Later her cough had become intractable with worsening exertional dyspnea. Otolaryngology evaluation and EGD had been inconclusive. Bronchoscopy with bronchoalveolar lavage and multiple transbronchial biopsies came with normal results. VATS biopsy showed multiple small nodules less than 1 cm in the right upper, middle, and lower lobes, predominantly peripheral lesions. The lesions were found to represent carcinoid tumorlets. Usually the lesions are asymptomatic and discovered incidentally on CT scan and can be confused with metastases, however they can present with chronic cough or dyspnea.
Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinysta... more Yohimbine is an Indoloquinolizidine alkaloid derived from the bark of the African tree Pausinystalia johimbe, as well as from the bark of the unrelated South American tree Aspidosperma quebracho-blanco. It is commonly sold as a dietary supplement for the purpose of enhancing libido, weight loss and natural bodybuilding aids. Yohimbine has high affinity for the α 2-adrenergic receptor, moderate affinity for the α 1 receptor, dopamine D 2 receptor, and weak affinity for the dopamine D 3 receptors and some of the serotonin receptors. Depending on dosage, Yohimbine can either increase or decrease systemic blood pressure (through vasoconstriction or vasodilation, respectively). We present a 51-year-old male who presented with substernal chest pressure and the sensation of a "pounding heart" after starting Yohimbine as a dietary supplement. He was found to have type II myocardial injury characterized by elevated troponin levels. We propose that the mechanism for this was 1) elevation of blood pressure and sinus tachycardia causing myocardial ischemia due to increased myocardial oxygen demand and supply mismatch, 2) cardiac norepinephrine release causing direct non-ischemic norepinephrine mediated myocardial injury and 3) increased sympathetic outflow mediated coronary vasoconstriction and spasm causing ischemia.
Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is ... more Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is a rare disease that occurs in ~1% or less of all osteomyelitis. It can result from direct inoculation from traumatic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. We present a case of a 32-year-old female with a history of Intravenous drug abuse who presented with localized left-sided chest pain. A CT thorax contrast study was obtained that showed edema around the anterior aspects of the left 3rd to fifth ribs and involves the inferior border of the pectoralis muscle with buckling of the left 4th rib with fluid density in the fascial planes. Subsequently, an MRI was done that revealed the pathological fracture of the anterior aspect of the left forth rib with evidence of osteomyelitis of the left 4th and 5th ribs, as well as early insufficiency fracture of the left fifth rib. Blood cultures were negative. She was treated conservatively with empiric antibiotics due to lack of seeding and bacteremia.
Acute Respiratory Failure Secondary to Persistent Lobar Atelectasis in Ehlers-Danlos Syndrome Patient and the Role of Connective Tissue Disease in Altering the Mechanical Properties of the Lungs
Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective-tissue disorders ch... more Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective-tissue disorders characterized by joint hypermobility, cutaneous fragility, and hyperextensibility. The collagen defect has been identified in at least six of the many types of Ehlers-Danlos syndrome. Changes in the mechanical properties of the bronchial airways and lung parenchyma may trigger the observed increased tendency of the airways to collapse and lung atelectasis. This is a case of a 33 year old Caucasian female who presented with acute hypoxic respiratory failure secondary to persistent right lower lobe atelectasis despite optimal medical management, pulmonary toilet, and multiple bronchoscopies. She also had an incidental finding of lung arteriovenous malformation (AVM) which can occur in EDS patients.
A Fatal Case of Prochlorperazine-Induced Neuroleptic Malignant Syndrome: A Case Report and Literature Review
Neuroleptic malignant syndrome (NMS) is a medical emergency associated with the use of neurolepti... more Neuroleptic malignant syndrome (NMS) is a medical emergency associated with the use of neuroleptics and antiemetics. NMS is characterized by a distinctive clinical syndrome of altered mental status, rigidity, hyperthermia, and autonomic dysfunction. NMS occurs as a result of changes in presynaptic or postsynaptic dopamine signaling. Central D2 receptor blockade in the hypothalamus, nigrostriatal pathways, and spinal cord leads to increased muscular rigidity and tremor via extrapyramidal pathways. Hypothalamic D2 receptor blockade results in an elevated temperature set point and impairment of heat-dissipating mechanisms. The reported mortality rates for NMS vary between 5 to 20 percent and the occurrence of medical complications and disease severity are the strongest predictors of mortality. This is a case of a 51 year old Caucasian female who presented with altered mental status, temperature of 109°F, diffuse muscular rigidity and autonomic dysfunction manifested as labile blood pressure, tachypnea, hypoxemia and tachycardia after consuming 18 tablets of Prochlorperazine over three days for gastrointestinal upset. Her clinical presentation and laboratory work up were consistent with NMS and she developed fatal complications and multi-organ dysfunction secondary to Prochlorperazine-induced neuroleptic malignant syndrome.
Concurrent Occurrence of Chylothorax and Chyloperitoneum in Non-Hodgkin's Lymphoma
Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is... more Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. Chylothorax is classified as non-traumatic or traumatic. Non-traumatic chylothorax is mainly caused by malignant etiologies accounting for more than 50% of chylothorax diagnoses. Lymphoma is the most common etiology. Chyloperitoneum is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity, which can occur as a result of trauma or obstruction of the lymphatic system. Chylous ascites is an uncommon finding that can be caused by malignancy, cirrhosis and lymphatic disruption after abdominal surgery. The combination of chyloperitoneum and chylothorax is rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. The Patient is an 82 year old Caucasian male who presented with worsening shortness of breath and abdominal distension. Chest X-ray showed moderate left sided pleural effusion. Bedside ultrasound-guided paracentesis and thoracentesis revealed milky ascetic and pleural fluid respectively. Triglyceride level was 271 mg/dl in the ascetic fluid, and 221 mg/dl in the pleural fluid. Pleural fluid was exudative with lymphocytic predominant cell count and negative cytology. Lymph node biopsy confirmed Non-Hodgkin’s Lymphoma causing the concurrent chylothorax and chyloperitoneum.
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