E-cigarette or Vaping Use-Associated Lung Injury (EVALI) in a Hispanic male during the COVID-19 pandemic

Background: Electronic cigarette or vaping product use–associated lung injury established the relationship between vaping products and lung injury. Overlapping clinical manifestations may mimic those of other respiratory conditions including COVID-19. Multiple radiographic findings including diffuse, bilateral, ground-glass infiltrates with lower-lobe predominance, eosinophilic pneumonia, and diffuse alveolar damage have been described. It is important to consider this as an alternative diagnosis, particularly in patients with respiratory symptoms and a history of vaping in the last 90 days due to increased risk of COVID-19 infection and worse outcomes. Case presentation: A 25-year-old male with a history of polysubstance abuse and frequent E-cigarette use presented to the ED after losing consciousness. He was cyanotic and required emergent intubation due to severe acute hypoxemic respiratory failure. Initial chest CT reported extensive amount of bilateral scattered infiltrates with air bronchograms (Image 1a). Broad spectrum antibiotics were started due to high suspicion of aspiration pneumonia and CIWA protocol was started in setting of alcohol withdrawal symptoms. The patient was successfully extubated on day 5 of admission. Repeat Chest CT on day 9 showed improvement in dense perihilar infiltrates; perihilar interstitial increased markings were seen extending to the lung peripheries from residual pneumonitis versus subsequent fibrotic changes/scarring (Image 1b). Conclusion: EVALI has grave consequences on the respiratory system, including acute pathologies such as diffuse alveolar injury, acute fibrinous pneumonitis, and acute respiratory failure requiring noninvasive or invasive ventilation as well as chronic respiratory conditions. Among the most common culprits identified in the mechanism of EVALI are Vitamin E acetate, nicotine and THC. Furthermore, multiple drug users are at higher risk of more serious complications. More studies and clinical trials are needed to better understand the pathophysiology of EVALI and to explain short- and long-term effects of vaping

A case of pericardial effusion: Aid of bedside ultrasound in clinical decision making

Background: In life-threatening conditions, such as cardiac tamponade, we need to recognize signs of impending decompensation in a timely manner. Point of care ultrasound is non-invasive and is readily available, particularly in a resource limited setting. In this case, we present a patient with worsening pericardial effusion and the importance of bedside cardiac ultrasound. Case presentation: A 76-year-old male with stage IV adenocarcinoma of the lung was admitted for worsening dysphagia for 3 days and decreased oral intake. He was normotensive but was tachycardic with muffled heart sounds. CT of the chest demonstrated a significant pericardial effusion. Bedside ultrasound to evaluate the extent of pericardial effusion revealed significant circumferential effusion, right systolic atrial collapse, and non-variable IVC, signs of pre-tamponade physiology. Given these findings, cardiology was emergently consulted who recommended transfer to a higher level of care facility. Thus, point of care ultrasound helped in making an immediate decision prior to clinical decompensation of the patient. Conclusion: Point of care ultrasound can help in making critical decisions in resource-limited settings. In this patient, a large effusion with pre-tamponade physiology was identified on bedside ultrasound. Early recognition during bedside ultrasound can help reach a diagnosis before clinical deterioration. Our case highlights the importance of point of care ultrasound as a tool to reinforce critical thinking and help expedite rational decision-making processes

Rare Atypical Presentation of Ogilvie Syndrome in a Hispanic Man

Background: Ogilvie syndrome (OS) also known as acute pseudo-obstruction of the colon is a bowel motility disorder characterized by features of intestinal obstruction in the absence of an anatomical or mechanical cause. Typical presentation is with abdominal distension but atypical and more rare presenting features have also been reported including respiratory distress. Thus, we present the first case of Ogilvie syndrome presenting with respiratory distress in a Hispanic man. Case Presentation: A 71-year-old gentleman with a history of diabetes mellitus, functional quadriplegia and other comorbidities was brought to the ED via EMS on account of altered metal status and constipation for about three days. Pertinent findings from the examination showed a chronically ill looking gentleman with a GCS of 8/15, respiratory rate of 34, pulse oximeter saturating at 86% on ambient air, and the usage of accessory muscles. Abdominal examination showed a mildly distended abdomen with tympanitic percussion notes and hypoactive bowel sounds in all the quadrants. Digital rectal examination revealed soft non bloody loose brown stools. Three was global muscle wasting and reduced muscle strength. Blood gas showed a pH of 7.12, pCO2- 117.4 and pO2- 74 suggestive of severe hypoxic and hypercapnic respiratory acidosis. Plain KUB X-ray and CT scan showed significant colonic distension with no fecal or anatomic obstruction. Patient was intubated for airway protection and abdominal distension was managed conservatively with discontinuation of enteral feeding, nasogastric tube decompression, potassium and magnesium replacement. Management can be escalated in patients who failed to respond to conservative measures or in those with complications like intestinal ischemia and perforation. in patients with colonic diameter \u3e 12 cm who failed 48 to 72 hours (about 3 days) of conservative therapy, pharmacologic therapy with neostigmine can be used. Conclusion: Our patient responded to conservative measures including withholding of enteral feeding, nasogastric tube decompression, potassium and magnesium replacement. Management can be escalated in patients who failed to respond to conservative measures or in those with complications like intestinal ischemia and perforation. In patients with colonic diameter \u3e 12 cm who failed 48 to 72 hours (about 3 days) of conservative therapy, pharmacologic therapy with neostigmine can be used

Gestational headaches: characteristics and influencing factors in South-Western Nigeria

Background: Headache is one of the common neurological diseases in pregnancy but its pattern and influencing factors are yet to be determined in our environment in Nigeria. The aim of this study was to determine the prevalence and characteristics, as well as the modifying factors for gestational headaches in Ogbomoşo, Nigeria.Methods: This study was a bi-institutional cross-sectional descriptive study. Three hundred and eight (308) eligible pregnant women attending the ante-natal care of the Ladoke Akintola University of Technology and Ogbomoso South local government hospitals in Ogbomoso were recruited consecutively, between November10, 2012 and February 28, 2013. Using an interviewer administered questionnaire, socio-demographic, obstetrics and headache related variables were obtained from eligible pregnant women. Gestational headaches were characterized using the international classification of headache disorders II (ICHD-II). The prevalence of migraine and tension type headache were determined before and during pregnancy. Improvement rates (defined by reduced headache frequency and severity) were determined.Results: The prevalence of Headaches before and during pregnancy was 25% and 23.3% respectively (P = 0.661).Migraine prevalence was 8.4% and 5.5% before and during pregnancy respectively (P = 0.34); while the prevalence of Tension-Type Headaches (TTH) was 16.5% and 17.9% before and during pregnancy (P = 0.63). Improvement rate was 100% for migraine and 85.5% for TTH. Multiple logistic regressions revealed that poor personal income, unemployment and multi-parity were predictive factors for headaches in pregnancy.  Conclusions: Migraine and Tension type headaches were prevalent in this population and they are worsened by poor personal income, unemployment and multi-parity. Interventions and programs to subsidize antenatal care may prevent gestational headaches in this population.

Determinants of resumption of vaginal intercourse in puerperium period in Ogbomoso: consideration for early use of contraceptives

Background: Early postpartum period for mothers is characterized with high demand for neonatal care, adjusting to sudden withdrawal of hormones of pregnancy and dealing with sexual desires of the husband. The study aimed at determines the timing, factors influencing postpartum resumption of vaginal intercourse and the contraceptive usage.Methods: Women in puerperium were interviewed with structured questionnaire on their socio-demographic status, obstetric history, sexual activities, contraception usage and reason for sexual abstinence.Results: About 40% (143) of participants had resumed vaginal intercourse within puerperium with mean resumption period of 3.2 ± 1.8 weeks. Only 12% (48) of them used modern contraceptive. Educational status (P <0.001); occupation (P <0.001); educational status of the husband (P <0.001); occupation of the husband (P <0.001); parity (P <0.05); husband’s income (P <0.05) and use of modern contraception (P <0.001) showed significant statistical difference between the women who had resumed vaginal sexual intercourse and those who have not. Logistic regression showed that educational status of the participants (OR = 0.48, CI = 0.246-0.938; P = 0.032) and parity (OR = 0.34, CI = 0.196-0.591; P = 0.001) were the most significant factors associated with early resumption of vaginal intercourse. One hundred and eighty-five (72%) of women who were yet to resume coitus, did so because of fear of pregnancy.Conclusions: Significant number of women resumed vaginal intercourse during the puerperium despite low contraception usage. There is need to initiate a contraception method before discharge home following delivery.  

Prevalence of gastrointestinal symptoms and related drug use among pregnant women of South-Western Nigeria

Background: Gastrointestinal (GI) symptoms are quite common in pregnancy but there is paucity of data in regard to their frequencies in the south-western part of Nigeria. This study was conducted to determine the prevalence of various gastrointestinal symptoms and related drug use among south-western Nigerian women.Methods: A cross-sectional multicenter study involving three centers in two states of south-western Nigeria from March to August 2014. A composite questionnaire consisting of demographic data, anthropometric indices, obstetrics information, a list of gastrointestinal symptoms and drug usage was administered to 420 consecutive healthy pregnant women at various gestational ages. Data were analysed and presented as means ±S.D, frequencies and percentages.  Relationships between categorical variables were explored with chi-square test. A 5% significance level (p < 0.05) was considered significant.Results: Respondents had age range of 18-43years and a mean of 27.26 (±4.98). The commonest gastrointestinal symptom was nausea (46.9%), followed by vomiting (45.0%) and then anorexia (36.2%). Excessive salivation, heart burn, constipation, regurgitation, and bloating had frequencies of 35.5%, 28.3%, 20.7%, 19.0% and 18.3% respectively. Epigastric pain was the least frequent among the symptoms (16.9%).The association between the parity of respondents and each of the GI symptoms was not statistically significant. But associations between educational status and excessive salivation and anorexia were statistically significant (P-value of 0.018 and 0.023 respectively). Subjects with heartburn had the highest drug usage (23.5%), followed by those with vomiting (22.8%). Subjects with excessive salivation (2%) had the least drug intake.Conclusions: Gastrointestinal symptoms are common among pregnant women of south-western Nigeria. There is need for the physician to be abreast with the prevalence of the common pregnancy related GI problems in the particular locality of practice and the appropriate way to manage them.

Severe Hypercalcemia: Unusual Life-threatening Presentation of Addison’s Disease

Background: Addison’s Disease, also known as primary adrenal insufficiency, is a rare disorder of the adrenal gland typically characterized by the combination of cortisol and mineralocorticoid deficiencies in addition to electrolyte abnormalities including hyponatremia and hyperkalemia. Addison\u27s disease is an uncommon cause of hypercalcemia. We present a rare case of hypercalcemia in the setting of primary adrenal insufficiency. Case Presentation: Our patient is 43-year-old Hispanic lady with no reported medical history who presented to the Emergency Room for evaluation of intractable nausea and vomiting of about a month duration. Clinical examination revealed a lethargic, dehydrated, and hypotensive lady. Initial laboratory findings revealed severe hypercalcemia of 15.4 mg/dl (N: 8.6-10.4). Serum AM Cortisol level was low \u3c 0.5ug/dl ( N: 7-25ug/dl) and Adrenocorticotropic Hormone (ACTH) level was elevated 612 pg/ml ( N: 7.2-63.3pg/ml) confirming the diagnosis of Addison’s disease. However, laboratory investigations and imaging studies into other causes of hypercalcemia were unremarkable. She was admitted, rehydrated, placed on pressors, Calcitonin, Hydrocortisone and Fludrocortisone . Her symptoms improved with resolution of hypercalcemia. Conclusion: Though rare, Addison’s disease should always be considered by physicians in the work up for hypercalcemia. This high index of suspicion improved the outcome in the management of this patient

Severe Hypokalemia Secondary to Distal Renal Tubular Acidosis in a Hispanic Man

Introduction: Renal tubular acidosis is a rare renal disorder that can cause severe electrolyte imbalances which can be life threatening. Case: A 21-year-old man presented to the ED on account of generalized weakness and body aches of one day duration. He reported no past medical history other than a previous episode of similar symptoms with improvement after IV hydration and electrolytes replacements about 2 months prior. He was not taking any medications and denied vomiting, diarrhea nor any significant family history. He admitted to alcohol and marijuana use. Physical examination was significant for reduced muscle power, tone, and reflexes in all extremities. He was unable to move his limbs against gravity. Admission laboratory findings revealed severe hypokalemia 1.1 mEq/L, metabolic acidosis with bicarbonate of 10.1 and EKG showed QT prolongation. Patient received a total of about 200 mEq of potassium through a central line in 24 hours with serum level of 3.7mmol/l in addition to intravenous bicarbonates with a resolution of the presenting symptoms. Discussion: The causes of hypokalemia are broad however a methodical approach can be helpful to rule out the many causes and narrow down the differential diagnosis. Distal RTA is caused by the inability of the distal renal tubule to secrete hydrogen ions due to the selective failure of activity or expression of the H+-ATPase. Conclusion: This case underscores the importance of systematic approach to the evaluation of patients with hypokalemia to uncover the cause of the underlying disease before life threatening complications occur. Our patient remains under close follow up

Emergency Total Proctocolectomy in an Uninsured Hispanic Man with Colorectal Adenocarcinoma Secondary to Familial Adenomatous Polyposis

Background: FAP is a rare genetic disorder classically inherited in an autosomal dominant pattern, which affects about 1 in 8 300 individuals (1). The Hispanic population has limited data regarding the spectrum of FAP mutation and clinical manifestation, although there is significant anecdotal evidence that the prevalence might be higher, with one only known Hispanic familial cancer registry in Puerto Rico (2). Case Presentation: We are reporting the case of a 25-year-old Hispanic gentleman with a strong family history of Familial Adenomatous Polyposis (FAP) and Colorectal Cancer (CRC) who presented for evaluation of abdominal pain, recurrent bloody stools, and profound weight loss. Initial Hb was 7.2 g/dL, and abdominal examination showed generalized rigidity and tenderness worse in the left lower quadrant. Colonoscopy revealed multiple large, non-bleeding polyps in the entire colon and up to the dentate line. The pathology report was positive for tubulovillous adenoma. The patient underwent an emergency laparoscopic-assisted proctocolectomy with Brooke ileostomy. The surgical pathology report showed grade 2 moderately differentiated adenocarcinoma. Immunohistochemical stains were positive for the expression of MLH1, PMS2, MSH2, and MSH6 mismatch repair proteins. His hospital course was uneventful, and he was discharged home to follow up with medical oncology, surgery, and primary care. Conclusion: To reduce the associated healthcare costs and morbidity and mortality of cancer in general, especially those with associated strong risk factors such as FAP and CRC, early genetic counseling, timely screening, appropriate risk-reducing medical and surgical interventions, and regular lifetime follow-up of index cases are crucial. It is also imperative to promote health literacy, especially in communities with low socio-economic status who are often at a disadvantage. Lastly, there is a need for continued research on FAP, especially in minority populations, with increased promotion and use of familial cancer registries to reduce the overall burden

Molecular and phenotypic identification of Candida isolates from pregnant women in Ogbomoso, Southwestern Nigeria

Background: Vulvovaginal candidiasis (VVC), often referred to as a yeast infection is a common gynaecologic disease, affecting 3 out of 4 women in their lifetimes. More than 40% of affected women will have 2 or more VVC episodes, and infection occurs more frequently in pregnant women. This study was carried out to provide information on the appropriate diagnostic method required to differentiate the causative agents of VVC among pregnant women.Methods: In this study, vaginal specimens were collected from one hundred (100) pregnant women aged between 17-44 years and of gestation age of 14-36 weeks who were attending antenatal clinic at LAUTECH Teaching Hospital, Ogbomoso. The species identification was performed using chromogenic medium, induction of fungal germ tube formation, and PCR using universal primers of internal transcriber spacer (ITS1 and ITS4); (ITS1 [5′-TCCGTAGGTGAACCTGCGG-3’] and ITS4 [5′-TCCTCCGCTTATTGATATGC-3’]) and Candida albicans-specific primers [5’-GGTTTGCTTGAAAGACGGTAG-3’] and [5’-AGTTTGAAGATATACGTGGTAG-3’] that target sequences site of the intergenic spacer region (ITS) of the fungal rRNA genes (18S and 28S) were used for this assay.Results: Forty (40) Candida species from 100 specimens were isolated in Saboraud dextrose agar (SDA) medium. Of 19 strains of C. albicans that were identified by chromogenic agar (CHROMagar), 17 were confirmed as true positive by PCR while 2 were false positive. The CHROMagar had 89.4% sensitivity and 90.4% specificity. In comparison, GTT was better in correctly identifying those strains that were confirmed as C. albicans by PCR (Sensitivity=94%) while CHROMagar was better in identifying the strains that were not confirmed as C. albicans by PCR (Specificity=90.4%).Conclusions: The combine uses of chromogenic agar and PCR have the advantage of efficient differentiation and identification of Candida species