Subacute Stroke in Young Hispanic Male With Vertebrobasilar Dolichoectasia

Background: Vertebrobasilar dolichoectasia (VBD) is a rare clinical entity characterized by dilatation, elongation, and tortuosity of the vertebrobasilar arteries. Patients with VBD can present varying symptoms from ischemia, compression of blood vessels, or rarely subarachnoid hemorrhage. Case presentation: A 29-year-old Hispanic man with history of hypertension presented to emergency department with progressive left upper extremity weakness, dizziness, slurry speech, and diplopia of one-week duration. On arrival, the patient was afebrile, heart rate 75 bpm and blood pressure 193/107 mmHg. He was alert and oriented x3. Neurological exam demonstrated decreased strength (4/5) on left upper extremity and left arm pronator drift. In addition, the right eye had partial ptosis and appeared laterally deviated with weak adduction and elevation, consistent with right cranial nerve III palsy. The patient was admitted for further workup ischemic brainstem stroke in a young adult. CT Brain was negative for hemorrhage but revealed vertebrobasilar dolichoectasia. MRI confirmed an area of ischemic stroke in the right medial midbrain at the level of cerebral peduncles involving the oculomotor nucleus. He was conservatively managed for stroke. He is scheduled to follow up with interventional neurology for definitive treatment. Conclusion: Vertebrobasilar dolichoectasia is a rare condition with a prevalence of less than 2% of the population. There is an association with male sex, older age, and hypertension. Currently, there are no guidelines on effective and specific treatments for VBD, which causes life-threatening complications. However, surgical and endovascular approaches are presently being performed

Sickle Cell Anemia In Hispanic-Americans In South Texas: Two Case Reports

Introduction: Sickle cell anemia and traits are well described in the African-American population. Hispanic Americans are an underappreciated community affected by Sickle cell disease, where it affects about every 1 in 16300 live births compared to 1 in every 365 African-American births.Hence, it is essential to acknowledge the incidence in Latin American origin people to provide competent and specific care to these populations. Case Description: Case 1: A 28-year-old Latin-American lady with sickle cell anemia, multiple transfusions, and exchange transfusion in the past presented with complaints of lower back and lower extremity pain. The patient got admitted with acute sickle cell crisis, secondary to suspected pneumonia. It was managed supportively and received multiple PRBC transfusions, was discharged after five days. Case 2: A 32-year-old Latin-American lady with intellectual disability, familial dysmorphic features, sickle cell disease presented to the emergency department with chest pain and shortness of breath, got admitted with acute chest syndrome secondary to sickle cell crisis for further management. She received one PRBC transfusion, after which her symptoms resolved, and discharged home the same day. Discussion: Although only 10 to 15% of patients with sickle cell disease are of Latin origin, the prevalence is higher in areas with a predominantly Hispanic population, such as South Texas.Many of those affected suffer the consequences of sickle cell crisis.Physicians and all other health care providers should be well-versed in managing the disease to provide competent and comprehensive care, especially in such areas

STEC-HUS; Unusual presentation in an elderly female

Background: Hemolytic uremic syndrome (HUS) is a multisystem disease presenting as renal impairment, microangiopathic hemolytic anemia (MAHA) and thrombocytopenia with a peak incidence of 2.1 cases per 100,000 persons/year in general population. Case Description: 81-year-old female with history of Diabetes, presented to us with non-bloody emesis and loose stools. Labs on admission were significant for WBC 17000, Hb 12.5, PLT 241, BUN 74, Cr 8.9 and Lactate 12. She was admitted for severe metabolic acidosis and acute renal failure attributed to metformin use and undifferentiated shock. Patient developed acute worsening of respiratory status due to increasing acidosis requiring intubation. Bicarbonate infusion was started however patient had to undergo emergent dialysis for refractory acidosis. On 3rd day of admission patient developed dysentery which led to Hb drop to 7.1 and platelets to 96. Peripheral smear revealed thrombocytopenia and schistocytes. GI panel was positive for ETEC, EIEC, Shigella toxin producing E. coli (STEC) and Campylobacter. Diagnosis of STEC-HUS was made. Patient was supportively managed with fluid resuscitation, pressors, antibiotics, hemodialysis and transfusions. She demonstrated significant improvement, attained hemodynamical stability off pressors and was eventually extubated. Patient was discharged few days later at her baseline health. Conclusion: It is challenging to diagnose STEC-HUS in older patients as the prevalence is higher in children and adults present with higher hemoglobin and fibrinogen levels. However, we emphasize on considering it as a differential diagnosis especially in elderly presenting with acute renal failure and history of gastroenteritis

Bactrim Induced BRASH Syndrome In Elderly Female: A Case Report

Background: BRASH syndrome is a clinical entity comprising of bradycardia, renal failure, AV blockade, shock, and hyperkalemia. It is a vicious cycle in which AV nodal blockers and hyperkalemia act synergistically to precipitate bradycardia in patients with renal dysfunction resulting in cardiovascular collapse. Case Presentation: 89-year-old lady with history of Stage 4 CKD, hypertension, and diabetes mellitus presented with worsening generalized body weakness. On medication review, she was recently started on bactrim for treatment of a foot ulcer. Other home medications included diltiazem, lisinopril and dulaglutide. Initial vitals were significant for pulse 34, BP 90/35 mmHg and RR 19. Patient appeared somnolent but arousable. EKG was significant for third-degree heart block. Pertinent labs included potassium 6.7 and creatinine 5.8. She was treated with IV fluids and pressors for shock. She received calcium gluconate, insulin, dextrose and sodium polystyrene in the interim, until she was started on emergent dialysis. Following two sessions of dialysis, EKG reverted to sinus rhythm with resolution of complete heart block. She was eventually titrated off pressors. She was discharged on scheduled dialysis and follow up in a nephrology clinic. Conclusion: BRASH syndrome comprises of series of events that perpetuates itself. Caution should be exercised when prescribing bactrim as it might potentiate hyperkalemia, especially in patients with chronic kidney disease who are also on AV nodal blockers. Trimethoprim in Bactrim increases this risk by inhibiting potassium excretion from the kidneys. This could lead to a cycle of clinical events resulting in BRASH syndrome

A Rare Case of Takotsubo Cardiomyopathy In An Elderly Lady During Hospital Stay

Introduction: Takotsubo Cardiomyopathy (TTC) is an acute, reversible form of left ventricular systolic dysfunction, most often triggered by a sudden physical, or less commonly emotional event. Here, we describe a patient who developed Takotsubo Cardiomyopathy during her hospital stay. Case Description: 74-year-old Hispanic lady, a nursing home resident presented to the ED with altered mental status. She was admitted for septic shock due to UTI. Echocardiogram demonstrated normal systolic function, with 60-65% LV ejection fraction. After initiation of antibiotic therapy, she showed clinical improvement with resolution of shock. On day 8 of hospitalization, patient became emotionally upset and her clinical status deteriorated. Troponin peaked at 7.2, CK-MB 29.9, and EKG demonstrated borderline ST-elevation in lateral leads. Repeat echocardiogram demonstrated a significant reduction in the LVEF to 15%, moderately dilated left ventricle with akinesis of the apex and middle third of LV with hyperkinetic base, consistent with Takotsubo Cardiomyopathy. Unfortunately, her condition continued to deteriorate, leading to cardiac arrest and the patient expired. Discussion/Conclusion: There is a paucity in the literature describing the in-hospital occurrence of TTC. A high index of suspicion should be exercised in patients with recent physical or emotional stress with new-onset or refractory shock as the clinical picture of TTS overlaps with ACS