Endophthalmitis in an Elderly Patient - A Case of Delayed Transfer and Successful Management

Introduction: Endophthalmitis is a severe and potentially sight-threatening condition that demands immediate attention and intervention. It is characterized by inflammation and infection within the eye, typically caused by bacterial or fungal organisms entering the eye, often following surgery or trauma. Usually present with sudden, severe eye pain, redness, decreased vision, and photophobia. As endophthalmitis can rapidly progress and cause irreversible damage to the eye, it is considered a true ocular emergency. Case presentation: An 80-year-old woman, known to have Insulin-dependent Type 2 Diabetes mellitus and a history of breast cancer, arrived at the Emergency Department (ED) with persistent and worsening pain in her right eye for three days. She also experienced purulent discharge, sensitivity to light (photophobia), and swelling of the right eyelid, eventually preventing her from opening her eye. The patient denied fever, chills, trauma, or recent use of contact lenses. On examination, she exhibited conjunctival swelling (chemosis), painful eye movement (ophthalmoplegia), pus around the eyelashes, and a clouded cornea, which had worsened since admission. Initially, the patient had blurred vision that progressed to a sensation of flashing lights in her right eye. To address the suspected diagnosis of endophthalmitis, the patient started on Cefipime, Levaquin, and moxifloxacin eye drops. Plans were made to transfer her to another facility for intra-vitreal antibiotic administration. However, due to the unavailability of on-call ophthalmologists in the local area, the patient and her husband decided to drive to the Emergency Department of the University of San Antonio, seeking expedited access to Ophthalmology services. The risks, including potential permanent vision loss due to delayed care, were explained to them before their decision. Consequently, the patient was discharged and transferred to San Antonio for further management. During a follow-up call three days later, the patient\u27s husband confirmed that she received intra-vitreal antibiotics. The patient reported being able to perceive hand movements in her right eye, indicating an improvement in vision. However, a surgical evaluation was still pending to assess the need for additional interventions and minimize the risk of complications. Discussion: Transferring endophthalmitis patients to the Ophthalmology surgeon center(OSC) is paramount in preventing vision loss. The dedicated Ophthalmology surgeon center(OSC) has the resources, expertise, and advanced diagnostic tests to manage endophthalmitis accurately. Prompt treatment with intravitreal antibiotics and vitrectomy, if needed, can halt the progression of infection and minimize damage. Timely and specialized care prevents permanent vision loss

Comatose Deception, Benzodiazepine masquerade of Myxedema Coma

Introduction: Myxedema coma is a life:-threatening condition due to severe hypothyroidism or long-standing untreated hypothyroidism. This condition can be triggered by factors such as infection, exposure to certain medications, or other stressors on the body. Symptoms of myxedema coma include hypothermia, altered mental status, and fluid accumulation. This condition can be life threatening and requires immediate medical attention. Benzodiazepines are often prescribed to address various conditions such as anxiety, sedation, and seizures. However, they have significant side effects including drowsiness, sedation, low blood pressure, and slow heart rate. These side effects can mimic symptoms of other conditions such as myxedema coma. In this case we describe a patient who initially appeared to have overdosed on benzodiazepines but was later diagnosed with myxedema coma. Case Presentation: A 49-year-old lady presented to the emergency department in an obtunded state and decreased respiratory drive. Earlier that day, she accidentally ingested a fish burger despite having a fish allergy, and experienced wheezing, facial swelling, and vomiting. She self-administered an epinephrine pen to manage the allergic symptoms. She was found unconscious by her daughter, who promptly called emergency medical services (EMS). Although no signs of an allergic reaction observed, EMS noted bradycardia and a reduced respiratory drive and administered naloxone and flumazenil which mildly improved her symptoms. The patient\u27s medical history included post-traumatic stress disorder, generalized anxiety disorder, bipolar type one, fibromyalgia, and hypothyroidism with inconsistent medication (levothyroxine) adherence. Her medication regimen included clonazepam (2mg twice daily), trazodone (100mg twice daily), tizanidine (4mg twice daily), fluoxetine (20mg daily), and temazepam (50mg twice daily). She was not taking levothyroxine at that time daily. Her daughter reported a progressive decline in strength, fatigue, weight gain, hoarse voice, dyspnea on exertion, and cold intolerance over the recent months. During assessment, vital signs indicated a temperature of 97 degrees Fahrenheit, bradycardia (56), respiratory rate (10), blood pressure 93/38, oxygen saturation of 85% on room air, and body mass index of 55. Physical examination revealed obesity, acute distress, constricted pupils (2-3), a short supple neck, audible inspiratory stridor, tenderness in the left upper quadrant of the abdomen, and 2+ pitting edema in bilateral lower extremities. Laboratory findings revealed hypercarbia (31.7 mmol/L), reduced glomerular filtration rate (39.4 ml/min/1.73 mm2), elevated thyroid-stimulating hormone (179 uIU/ml), and low free thyroxine (0.1 ng/dl) levels. With a Popoveniuc score of 80, she met the diagnostic criteria for myxedema coma and was promptly started on levothyroxine. Conclusion: Initial diagnosis of benzodiazepine overdose was questioned due to consistent use, confirmed by pharmacy refill dates, and most importantly lack of typical symptoms of overdose and response to treatment. Later it was proved that noncompliance with levothyroxine led to myxedema coma triggered by benzodiazepines which worsened her condition. This case emphasizes the need for vigilance in distinguishing between benzodiazepine side effects and other conditions. Timely recognition and appropriate treatment, such as levothyroxine initiation, are crucial in managing myxedema coma and preventing life-threatening complications

A Case of Recently Diagnosed Uncontrolled Hyperthyroidism Associated with Bilateral Pulmonary Embolism

Background: Pulmonary embolism (PE) is a relatively common acute cardiovascular disorder with considerable mortality, despite advances in diagnosis and treatment. In 25 to 50% of first-time cases, no readily identifiable risk factor can be found. Several studies have suggested hyperthyroidism to be a potential hypercoagulable and hypofibrinolytic state. In this case, we present a patient with uncontrolled hyperthyroidism with incidental bilateral PE. Case Presentation: A 47-year-old Hispanic lady with past medical history of recently diagnosed hyperthyroidism who was not compliant with medical therapy, presented to the emergency department with 4-hour history of chest pain. She described it as sudden onset, pressure-like pain that occurred during exertion and radiated to the back. She had associated palpitations, diarrhea, arthralgias and dyspnea that did not improved with rest. She also states having poor appetite and some weight loss for at least 1 year. The patient does mention having been diagnosed with hyperthyroidism one month ago by an endocrinologist in Mexico, who prescribed her propranolol and methimazole, which she was not taking as prescribed. Her vital signs were temperature of 98.1, heart rate of 124, respiratory rate of 18 and blood pressure of 112/84 mm Hg with a SpO2 of 99% on room air. Upon physical examination, she was alert, anxious and in mild distress. She was tachycardic, with no murmur or gallop and lungs were clear to auscultation. She did not have any skin lesions. Laboratory findings were remarkable for elevated D-dimer of 643, alkaline phosphatase of 228 with liver function tests within normal range and troponin I of 0.27. Thyroid function test revealed TSH of 0 uLU/mL, total T3 493 ng/dl, free T3 22.5 pg/ml, T3 uptake of 62.5 %, total T4 24.9 ug/dl and free T4 of 5.06 ng/dl. CT of the chest with contrast revealed subsegmental bilateral lower lobe pulmonary emboli. It also revealed a soft tissue prominence within the anterior mediastinum. Thyroid US revealed an enlarged thyroid gland with heterogeneous echotexture and hyperemic Doppler flow, compatible with active thyroiditis. Burch-Wartofsky score was 35 points. Patient was admitted for uncontrolled hyperthyroidism with impending thyroid storm as well as bilateral PE with possible right heart strain. She was started on Propranolol, Methimazole, potassium iodide and heparin drip. Patient status overall improved and Echocardiogram revealed EF 60-65% without signs of right heart strain. Thyroid workup then revealed TSI of 297, positive ANA with nuclear pattern and TPO of 151 IU/mL. She was later discharged with Eliquis, methimazole and propranolol for close follow up. Conclusions: Hyperthyroidism has well known effects on the cardiovascular system, however, further data suggests that it modifies physiologic processes of hemostasis, leading to bleeding or thrombosis. This is due by upregulating adhesion molecules and endothelial marker proteins. Most studies have shown that hyperthyroidism is related to venous thromboembolism risk, however just a few have focused on specifically its association with PE. There are currently no recommendations in regard to prophylactic anticoagulation in hyperthyroid state, however physicians should be alert for possible thrombotic events with these patients

An Unusual Presentation of the Severe Hypothyroidism Presenting As Shortness of Breath

Background: Hypothyroidism is defined as failure of the thyroid gland to produce sufficient thyroid hormone to meet the metabolic demands of the body. Untreated hypothyroidism can contribute to hypertension, dyslipidemia, infertility, cognitive impairment, and neuromuscular dysfunction. It may occur as a result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. Primary gland failure can result from the congenital abnormalities, autoimmune destruction, iodine deficiency, and infiltrative diseases. Patients can clinically present with weight gain, cold intolerance, depression, muscle fatigue, poor concentration, and menstrual irregularities. The best laboratory test for the thyroid assessment is serum TSH test. If the TSH is elevated the serum free thyroxine (T4) should be done. Therefore, here we present a case of the young lady with severe hypothyroidism presenting with shortness of breath. Case Discussion: A 31 year old lady with no known significant past medical history presented to the emergency department complaining of the shortness of breath which has been ongoing from last 6 months. She also mentioned that she has been more constipated than usual and attributed her symptoms to constipation. On further evaluation, vitals on admission were HR of 50s and BP 90/50s. The orthostatic vital signs were performed and were negative. The physical examination was positive for hair loss, dry skin, muffled heart sound and pallor of conjunctiva was noted. Further the labs were drawn and significant labs showed hemoglobin of 5.4 g/dl, CK of 344 u/L, LDL of 182 mg/dl. 1 unit of packed red blood cells was given and simultaneously Chest X Ray was done which showed boot shaped heart and EKG was done which showed sinus bradycardia. Another set of blood was collected for the lactic acid, troponin and TSH. All were normal except TSH was 257.34 uIU/ml. The patient was diagnosed with severe hypothyroidism and further free T4 was 0.4ng/dl which was significantly low. Started on the Levothyroxine 1.6 micrograms/kg/day which rounded up as 100 micrograms daily for her. As soon as the levothyroxine was given, within 1 hour her heart rate and blood pressure and her symptoms started resolving. Bedside ultrasound was done which showed the moderate pericardial effusion, which was cause of the dyspnea. The patient was worked up for the autoimmune hypothyroidism and everything was negative, therefore was patient was safely discharged home with Levothyroxine 100 micrograms and advised to follow up with the PCP for the dose titration. Conclusion: The main learning point from this is that severe hypothyroidism can disguise in different ways and present differently. The key point is to have sharp suspicion for the hypothyroidism if chest xray shows boot shaped heart and bradycardia. The pericardial effusions can occur in patients with severe untreated hypothyroidism and can be just treated with the oral levothyroxine and pericardial effusion will resolve eventually

When medications collide: Demystifying Drug-Induced Hyponatremia in a complex medical case

Introduction: Hyponatremia, defined as serum sodium below 135mEq/L( normal range:136-145mEq/l), is a medical emergency associated with various complications. Sodium is an important electrolyte that helps regulate fluid balance and nerve/muscle function. Severe hyponatremia may not show obvious symptoms initially but can eventually manifest as nausea, vomiting, fatigue, impaired movement, and in extreme cases, seizures, coma, respiratory failure, or even death. Thiazide diuretics have been associated with hyponatremia with a sodium level as low as 99mEq/L. In our case, the patient was on bumetanide, a loop diuretic and she developed hyponatremia which worsened with additional metolazone treatment to a sodium level of 102mEq/L with minimal symptoms. Case presentation: An 82-year-old woman presented to emergency department in South Texas with dyspnea, cough, weakness, fatigue, and headache. She had a history of depression, dementia, obesity, arthritis, osteoporosis, hypertension, hyperlipidaemia, coronary artery disease, chronic atrial fibrillation, and hypertrophic obstructive cardiomyopathy with mitral regurgitation. Her medication regimen included amlodipine 5mg daily, apixaban twice daily, bumetanide 1mg daily, metolazone 2.5mg daily, metoprolol succinate 100mg daily, simvastatin 20mg daily, prednisone 10mg for 5 days, hydrocodone-acetaminophen every 4 hours as needed, and multiple drugs for dementia and depression including aripiprazole 5mg nightly, brexpiprazole 1mg daily, clonazepam 1mg three times daily, donepezil 5mg nightly, duloxetine 60mg twice daily, and zolpidem12.5 mg nightly. On initial evaluation, her vital signs were within normal range, and her BMI was 38.7. On physical examination, she was in mild distress, with diminished breath sounds at the bi-basilar lobes, and poor inspiratory effort. She had a normal heart rate and rhythm with a 3/6 harsh mid-peaking systolic ejection murmur loudest at the left mid-sternal border and a 2/6 harsh systolic ejection murmur at the apex consistent with HOCM. Labs revealed severe hyponatremia (sodium of 102) along with hypokalemia (2.8mEq/L), hypochloremia (70mEq/L ), hypo-osmolarity (serum osmolarity of 227mOsmol/kgH2O and urine osmolarity of 324), and urine sodium of 43mEq. The patient was admitted to the ICU for hypo-osmolar hypovolemic hyponatremia and pneumonia. She received appropriate treatment, including fluid resuscitation and antibiotics. Throughout her ICU stay, she remained neurologically stable with caution exercised to prevent rapid correction of sodium levels. Over six days, serum sodium gradually normalized and stabilized at 133. The patient recently had metolazone 2.5 mg daily added to her usual bumetanide 1 mg daily in February 2023 to optimize her heart failure regimen. She also took multiple antipsychotic and antidepressant medications, contributing to her chronic hyponatremia. The combination of diuretic therapy, antipsychotic medication, and antidepressant medication(duloxetine) were identified as the probable causes. Conclusion: Recording on of the lowest serum sodium levels in a minimally symptomatic patient, this case emphasizes the importance of recognizing drug-induced hyponatremia in patients with complex medical histories and multiple medications. Careful assessment and monitoring of medication regimens, particularly in older adults, are crucial to minimize the risk of drug interactions and adverse effects. Collaborative efforts among healthcare providers are essential to optimize medication management and prevent complications associated with hyponatremia and its correction

Exploring the Long-Term Consequences of Neglected Hypothyroidism Patient at South Texas: A Case Report

Introduction: Hypothyroidism is a condition caused by the thyroid gland\u27s insufficient production of thyroid hormones. This affects 13.95% of the population according to data from this year. Long-term untreated hypothyroidism, which is not frequently seen, can lead to serious health concerns as well as apparent physical signs like fatigue, cognitive difficulties, dry skin, hair loss, and constipation. While most of the people in the US may be able to receive treatment for this debilitating disease, there are specific vulnerable populations that due to socioeconomic difficulties, may not have access to medications. Case Presentation: A 52-year-old Hispanic woman with a known history of hypothyroidism diagnosed 20 years ago who had not received treatment, presented to the emergency department after experiencing generalized weakness and syncopal episodes for months. She stated that even though she knew of her disease, she was not able to afford the medication for a while. Upon assessment, the patient appeared weak and fatigued, without signs of respiratory distress. Physical examination revealed clinical signs of hypothyroidism, including cold, pale, and dry skin, but there was no evidence of lower extremity swelling, suggestive of myxedema. Initial laboratory showed several abnormalities. A Hg of 8.8, Hct 25.8, Plt 179 Na 132 creatinine 1.3, AST 37, ALT 31, Lipase 479, . TSH of 146, T4 free 0.1, BNP 479. Orthostatic vital signs and a digital rectal exam were negative. EKG reported sinus rhythm, rate 95, Axis normal, QTc 447, and chest x-ray with AP view suggestive of cardiomegaly The patient was started on levothyroxine at an initial dose of 88 mcg daily and after a couple of days, her symptoms started to improve. Discussion: The consequences of chronic, untreated hypothyroidism can be severe, as demonstrated in this case. The patient presented with a range of physical changes that are now rare to see since we have a way to supply the same hormone. These changes further highlight the negative impact of untreated hypothyroidism on the body, increasing the risk of complications such as mental changes and anemia. Prompt initiation of levothyroxine therapy is crucial to alleviate the symptoms and restore normal thyroid function. This case emphasizes the importance of early diagnosis and appropriate management to mitigate the adverse effects of hypothyroidism and ensure the patient\u27s overall well-being. It also demonstrates the need for better healthcare access to different vulnerable populations who still do not have access to this medication. Therefore, early diagnosis and appropriate thyroid hormone replacement therapy are crucial in managing this condition\u27s effects

Evaluation of Vitamin B12 levels in patients with Type 2 Diabetes Mellitus taking Metformin in the ambulatory care setting

Background: Metformin is the most widely used oral, anti-hyperglycemic medication, prescribed to more than 100 million people across the entire globe (1). Although Metformin has proven beneficial for patients with pre-diabetes, type 2 diabetes, insulin resistance, and PCOS, studies have also shown its use may be associated with vitamin B12 deficiency. Due to a lack of screening criteria, B12 deficiency is likely unrecognized in the ambulatory setting. Our project aimed to improve screening for vitamin B12 deficiency in our clinic amongst patients with diabetes on long-term metformin therapy. Methods: Clinic data was collected from July 1st, 2020, to July 1st, 2022, for a retrospective analysis. After analyzing the initial data, our intervention was initiated as a lecture educating our UTRGV-DHR internal medicine residents on vitamin B12 screening in patients taking Metformin. After the intervention, clinic data was securely collected from January 13th, 2023, to March 1st, 2023, for proper analysis to compare the rates of vitamin B12 screening before and after the intervention. Results: Of 266 patients in our preintervention data, 164 met the exclusion criteria. Of the remaining 102 patients, 18 were appropriately screened for B12 deficiency in the setting of metformin use, equivalent to 17.65% of the total population. Only three patients were found to have B12 deficiency, and all of them received appropriate treatment. After the intervention, the patient´s charts were again evaluated to assess for change in the screening rate. Of the initial 102 patients who met the selection criteria, only 53 were followed up post-intervention. Eight patients were screened for vitamin B12 deficiency, equivalent to 15.09% of the total population. Of these eight patients, two patients did not have a result available on the medical records, four patients had normal B12 levels, and two patients were found to have B12 deficiency. Only 1 of 2 patients received appropriate treatment since the second patient was also lost to follow-up. Conclusion: Our intervention did not result in an increased screening rate for B12 deficiency in the ambulatory setting. Despite our efforts, our project had multiple limitations, including an underserved patient population, elevated test costs, a high rate of patients lost to follow-up, and the impact of COVID-19 in healthcare during 2020 and 2021. Further studies are needed to evaluate if Vitamin B12 should be part of the routine screening of Diabetic patients on Metformin

Enhancing appropriate statin therapy in Type 2 Diabetic patients aged between 40-75 years at Graduate Medical Education (GME) Internal Medicine clinic

Background: The prevalence of type 2 diabetes mellitus (T2DM) is significantly higher in Rio Grande Valley than the rest of the United States. T2DM patients have an elevated risk of Atherosclerotic cardiovascular disease (ASCVD), and clinical trials have demonstrated the beneficial effects of statin therapy on ASCVD. A quality-improvement project was implemented in the GME Internal Medicine (IM) Clinic at Doctors Hospital at Renaissance to improve statin therapy appropriateness. Methods: T2DM patients aged 40-75 were selected from the GME IM Clinic visits from July 2021 to October 2021 for baseline data and from January 2022 to April 2022 after implementing our interventions, which included education of the new practice guidelines of statin therapy in T2DM to the internal medicine residents, as well as development of a clinical decision support tool designed to assess the indication and intensity of statin therapy. Exclusion criteria included patients without T2DM, ages above 75/below 40 years of age, and missing information for ASCVD risk stratification. Statin appropriateness was determined according to the American Diabetes Association standards in diabetes management. Results: The number of patients in the four months after the exclusions pre-intervention and post-intervention were 153 and 207, respectively. Overall, 71.9% (n=110) of the patients pre-intervention were receiving an appropriate statin therapy; the number increased to 80% (n=166) post-intervention (p = 0.003), considered statistically significant using t-test analysis. Of the total patients (N=43) with inappropriate statin therapy, 37% (n=16) had inadequate dose, and 63% (n=27) were not receiving any statin in the pre-intervention cohort. This percentage of inadequate statin dose and no statin therapy decreased to 65% (n=27) and 35% (n=14), respectively post-intervention. Conclusion: Appropriate statin therapy has been shown to reduce all-cause mortality by 19% in T2DM. Appropriateness of statin therapy was increased by 10%, and more than 50% reduction of patients without receiving any statin therapy, after our intervention. Effective implementation of new guidelines regarding risk stratification and prevention of ASCVD in T2DM age 40-75 years of age may be challenging. Barriers such as physicians\u27 adoption and knowledge regarding new guidelines can be overcome with appropriate tools and education, such as those implemented in our project