Closed-Eye Visualizations in the Setting of Hyponatremia.

Purpose: To report a case of closed-eye visualizations and to clarify the different types of hallucinations and their etiologies. Methods: Retrospective case report of a patient with closed-eye visualizations secondary to hyponatremia. Clinical findings, physical exam, laboratory assessment, treatment, and disease course from the patient\u27s hospitalization were used in creating this report. Follow-up data after discharge were also obtained. Results: Closed-eye visualizations were diagnosed as secondary to hyponatremia, as they did not occur with the eyes open, and potential alternate causes were excluded. Serum sodium nadir was 119 mEq/L. Symptoms resolved with correction of hyponatremia via fluid resuscitation and electrolyte replenishment. There has been no recurrence of the symptoms. Conclusion: This patient had hallucinations exclusively with the eyes closed, which must be differentiated from the release hallucinations seen with the eyes open in Charles Bonnet syndrome. This patient had no visual loss or retinal disease, which should be suspected in open eye hallucinations

A case of probable Amiodarone-induced pancreatitis in the treatment of atrial fibrillation: a literature review and case report.

Amiodarone is an effective medication used in the treatment of several different arrhythmias. Its most well-known adverse effects include pulmonary fibrosis, thyroid dysfunction, and hepatotoxicity. A less common side effect is acute pancreatitis. A 67-year-old male being treated for atrial fibrillation in rapid ventricular response with Amiodarone developed acute epigastric abdominal pain 24 hours after initiation of therapy. He was diagnosed as having acute pancreatitis based on characteristic findings seen on an abdominal CT scan. Commonly encountered etiologies of pancreatitis were ruled out through a combination of the history, laboratory values, and imaging results. Based on the temporal association of the acute presentation and initiation of Amiodarone therapy, in conjunction with a lack of support for any other etiology, the diagnosis of Amiodarone-induced pancreatitis was made. Within 7 days following the cessation of Amiodarone therapy, the patient\u27s symptoms had completely resolved. Amiodarone-induced pancreatitis is an often overlooked medication association and is one that has been infrequently reported throughout the literature. Given the substantial morbidity and mortality associated with acute pancreatitis, and the ease of treatment (withdrawing Amiodarone), this is a critical side effect that should be recognized in the appropriate clinical setting

B12 Deficiency: An Overlooked Case of Microangiopathic Hemolytic Anemia

Case Presentation: A 32-year-old female with a history of untreated sarcoidosis and gastric bypass surgery with partially treated B12 deficiency in the past, was admitted for shortness of breath with a primary diagnosis of pancytopenia. Patient had not taken B12 injections for close to 2 years. Her labs were consistent with severe pancytopenia (Hemoglobin 5.4, White blood cell count 1.8, Platelets 78000) with lab evidence of massive hemolysis on peripheral smear (schistocytes) and chemistries (severely increased Lactate dehydrogenase 2377, reticulocytes 2.5% and decreased haptoglobin \u3c30). B12 levels (\u3c50) and folate levels (5.4) were severely depressed. Coombs test was negative on two separate occasions. Patient responded to packed red blood cell transfusion, however she continued to show signs of ongoing hemolysis. Hematology was consulted who started patient for possible immune mediated hemolytic anemia with intravenous immunoglobulin and prednisone. We determined that microangiopathic hemolytic anemia can be explained by B12 deficiency alone, given patient’s pancytopenia prior response to B12 injections. Treatment was simplified with discontinuation of intravenous immunoglobulins and initiations of supplementation with B12 injections and oral folate. Patient complete blood count after a month of treatment with B12 injections showed immense improvement in hemoglobin to 12.5 and WBC to 4.1. Discussion: Massive hemolytic anemia is a rare and potentially lethal complication of B12 deficiency. B12 is usually attributed to megaloblastic anemic with severe forms of deficiency causing pancytopenia’s. However, severe B12 deficiency is an under-documented etiology for treatable microangiopathic hemolytic anemia. Severe hemolysis with low reticulocyte counts, schistocytes on peripheral smear and very high Lactate dehydrogenase should raise the suspicion of severe B12 deficiency. Conclusions: B12 supplements in patients with severely depressed B12 levels with hemolysis is a simple fix for an apparently life-threatening condition and avoids the need for unnecessary interventions

AGEP overlap induced by hydroxychloroquine: a case report and literature review.

Acute Generalized Exanthematous Pustulosis (AGEP) is a rare drug reaction manifesting as pustular lesions with surrounding erythema following exposure. The disease is often self-limited and treatment is supportive. It may present in an atypical variant with vesicles that desquamate into erosions, which classifies the disease as an AGEP/SJS Overlap. This overlap syndrome can carry a substantial mortality rate and necessitate elevation in the level of care. Hydroxychloroquine has been implicated in cases of AGEP, and we present a case of AGEP/SJS overlap attributed to this common medication. Given the prevalence of drug eruptions, it is critical for the physicians to recognize and not overlook this rare and potentially fatal dermatological emergency

The utility of S100B level in detecting mild traumatic brain injury in intoxicated patients.

BACKGROUND: S100B is a serum protein known to elevate in patients with brain injury, but it is unknown whether it can predict intracranial pathology in intoxicated patients following mild traumatic brain injury (MTBI). We performed a systematic review and meta-analysis of the English language literature to address this question. MAIN OUTCOMES AND RESULTS: Four prospective cohort trials of serum S100B levels on acutely intoxicated patients with MTBI were included in this meta-analysis. Prevalence of intracranial pathology in the pooled cohort of the intoxicated MTBI patients was 10%, lower than the 15-30% reported in the literature for the general MTBI population. Standard mean difference of serum S100B levels between patients with and without intracranial pathology on CT was 0.73 μg/L (Z = 18.33, P \u3c 0.001). Following sensitivity analysis and hierarchical summary receiver-operating characteristic models, three remaining articles were used for pooled estimates that found that S100B had a sensitivity of 0.96 (95% CI: 0.84-1.00, I2 = 0%) and specificity of 0.63 (95% CI: 0.58-0.68, I2 = 86.8%) with a high negative predictive value (100%, 95% CI: 95.14-100, I2 = 0%) and a negative LR of 0.06 (95% CI: 0.01-0.31). CONCLUSIONS: Serum S100B levels may have utility in ruling out intracranial pathology in intoxicated patients, however more study and comparison with other serum biomarkers of brain injury are necessary before this becomes the accepted standard of care