Atraumatic trismus induced by duloxetine: an uncommon presentation of acute dystonia

2021 ◽  
Vol 14 (2) ◽  
pp. e237065
Author(s):  
May Honey Ohn ◽  
Jiann Lin Loo ◽  
Khin Maung Ohn
Keyword(s):  
Chest Pain ◽  
Vital Signs ◽  
Mouth Opening ◽  
Acute Dystonia ◽  
Emergency Presentation ◽  
First Case ◽  
Uncommon Presentation ◽  
Physical Examinations ◽  
Laryngeal Involvement ◽  
Oral Diazepam

Atraumatic trismus can be one of the presentations of medication-induced acute dystonia, particularly by antipsychotics and less commonly antidepressants. A case of an unusual emergency presentation of atraumatic trismus on initiation of duloxetine is reported. The patient was a 40-year-old woman experiencing sudden difficulty in mouth opening and speaking due to a stiffened jaw after taking 5 days of duloxetine prescribed for her fibromyalgia-related chest pain. Assessment of vital signs is prudent to ensure there is no laryngeal involvement. Other physical examinations and her recent investigations were unremarkable. She was treated for acute dystonia and intravenous procyclidine was given together with oral diazepam. Her symptoms improved immediately and her duloxetine was suggested to be stopped. To our knowledge, this is the first case of isolated trismus induced by duloxetine. Clinicians should be aware of this risk, especially considering the limitation of important physiological functions (such as swallowing, eating, etc) associated with this condition.

Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating

2003 ◽  
Vol 8 (5) ◽  
pp. 4-12
Author(s):  
Lorne Direnfeld ◽  
James Talmage ◽  
Christopher Brigham
Keyword(s):  
Upper Extremity ◽  
Radicular Pain ◽  
Illness Behavior ◽  
Orthopedic Surgeon ◽  
First Case ◽  
Clinical Presentations ◽  
Whole Person ◽  
Physical Examinations ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).

Aneurysm of sinus of Valsalva: uncommon presentation

2011 ◽  
Vol 19 (6) ◽  
pp. 422-426
Author(s):  
Raja Saravanan Elumalai ◽  
Kirthivasan Vaidyanathan ◽  
Madhu Sankar Nainar ◽  
Govini Balasubramaniam ◽  
Susan George
Keyword(s):  
Chest Pain ◽  
Cardiac Tamponade ◽  
Transthoracic Echocardiography ◽  
Surgical Repair ◽  
Interventricular Septum ◽  
Acute Onset ◽  
Sinus Of Valsalva ◽  
Uncommon Presentation

A 28-year-old man presented with acute onset of chest pain. Transthoracic echocardiography confirmed an aneurysm of the sinus of Valsalva dissecting into the interventricular septum. During the next 12 h, the aneurysm enlarged to involve the entire interventricular septum, and the patient developed features of cardiac tamponade. He underwent successful surgical repair.

Extrapyramidal Symptoms with Ritonavir/Indinavir Plus Risperidone

2002 ◽  
Vol 36 (5) ◽  
pp. 827-830 ◽  
Author(s):  
Deborah V Kelly ◽  
Lizanne C Béïque ◽  
M Ian Bowmer
Keyword(s):  
Adverse Effect ◽  
Drug Interaction ◽  
Case Report ◽  
Vital Signs ◽  
Extrapyramidal Symptoms ◽  
Suspected Drug ◽  
Tic Disorder ◽  
Acute Dystonia ◽  
Active Moiety ◽  
Case Summary

OBJECTIVE: To report a case of suspected extrapyramidal symptoms (EPS) in a patient initiated on ritonavir and indinavir while taking risperidone for a tic disorder. CASE SUMMARY: A 35-year-old white man with AIDS received risperidone 2 mg twice daily for treatment of a Tourette's-like tic disorder. Ritonavir and indinavir were initiated, and 1 week later, he experienced significantly impaired swallowing, speaking, and breathing, and worsening of his existing tremors. Ritonavir and indinavir were discontinued. On the same day, the patient increased the risperidone dosage to 3 mg twice daily. Symptoms continued to worsen over the next 3 days. All investigations and laboratory parameters were unremarkable, and vital signs were stable. Risperidone was discontinued and clonazepam initiated. Three days later, the patient's symptoms were significantly improved. DISCUSSION: The symptoms described herein are consistent with neuroleptic-induced acute dystonia and potentially neuroleptic-induced parkinsonism. We believe this adverse effect occurred as a result of a drug interaction between ritonavir/indinavir and risperidone. Based on the pharmacokinetics of these medications, we hypothesize that inhibition of CYP2D6 and CYP3A4 by ritonavir and indinavir may have resulted in an accumulation of the active moiety of risperidone, which may explain the occurrence of EPS in this patient. CONCLUSIONS: This is the second published case report describing a suspected drug interaction with ritonavir, indinavir, and risperidone. Caution is warranted when risperidone is prescribed with ritonavir/indinavir, and possibly with other antiretrovirals that inhibit the same pathways.

scholarly journals Guideline adherence among prehospital emergency nurses when caring for patients with chest pain: a prospective cohort study

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Kristoffer Wibring ◽  
Markus Lingman ◽  
Johan Herlitz ◽  
Lina Blom ◽  
Otto Serholt Gripestam ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Chest Pain ◽  
Acetylsalicylic Acid ◽  
Hospital Discharge ◽  
Guideline Adherence ◽  
Vital Signs ◽  
Pharmaceutical Treatment ◽  
Emergency Nurses ◽  
Prehospital Emergency

Abstract Background The emergency medical services (EMS) use guidelines to describe optimal patient care for a wide range of clinical conditions and symptoms. The intent is to guide personnel to provide patient care in line with best practice. The aim of this study is to describe adherence to such guidelines among prehospital emergency nurses (PENs) when caring for patients with chest pain. Objective To describe guideline adherence among PENs when caring for patients with chest pain. To investigate whether guideline adherence is associated with patient age, sex or final diagnosis of acute myocardial infarction on hospital discharge. Methods Guideline adherence in terms of patient examination and pharmaceutical treatment was analysed in a cohort of 2092 EMS missions carried out in 2018 in Region Halland, Sweden. Multivariate regression was used to describe how guideline adherence is associated with patient age, sex and diagnosis on hospital discharge. Results Guideline adherence was high regarding examination of vital signs (93%) and electrocardiogram (ECG) registration (96%) but lower in terms of pharmaceutical treatment (ranging from 28 to 90%). Adherence was increased in cases in which the patient ended up with acute myocardial infarction (AMI) as diagnosis on discharge. Patients with AMI were given acetylsalicylic acid by PENs in 50% of cases. Women were less likely than men to receive treatment with acetylsalicylic acid and oxycodone. Conclusions Guideline adherence among PENs when caring for patients with chest pain is satisfactory in terms vital signs and ECG registration. Regarding pharmaceutical treatment guideline adherence is defective. Improved adherence is mainly associated with male sex in patients and a diagnosis of AMI on hospital discharge. Defective adherence excludes measures known to improve patients’ prognoses such as treatment with acetylsalicylic acid.

Abstract P263: Symptomatic Post-Acute SARS-CoV-2-Infection Hypertension Syndrome

Hypertension ◽  
2021 ◽  
Vol 78 (Suppl_1) ◽  
Author(s):  
Lauren East ◽  
Zainab Mahmoud ◽  
Amanda Verma
Keyword(s):  
Blood Pressure ◽  
Chest Pain ◽  
Vital Signs ◽  
Wilcoxon Test ◽  
Initial Visit ◽  
Office Visits ◽  
Paired Data ◽  
Cardiology Clinic ◽  
Blood Pressures

Introduction: The Post-COVID Cardiology Clinic at Washington University evaluates and treats patients with ongoing cardiovascular symptoms following acute COVID-19 infection. One clinical manifestation seen in the clinic is an increase in blood pressure, with associated symptoms like chest pain. Our investigation aims to describe the increase in blood pressure seen in symptomatic patients presenting to the Post-COVID Cardiology Clinic. Methods: The study employed a retrospective cohort design of consecutive adult patients who presented between September 2020 to May 2021 with cardiovascular symptoms following COVID-19 infection. Demographic information, symptoms, vital signs, and follow-up visit data were collected for the patients. To determine a baseline blood pressure, two blood pressure readings from office visits prior to COVID-19 infection were averaged. The blood pressure values were compared between baseline and cardiology office visits using a non-parametric Wilcoxon test for paired data. Results: One-hundred patients were included in the cohort (mean age 46.4 years (SD 46.4); 81% (81) female). At the initial visit, there was a significant increase in systolic (median 128 mmHg) and diastolic (median 83.5 mmHg) blood pressure from baseline (systolic median 121.5, p=0.029; diastolic median 76, p<0.001). All patients with an increase in blood pressure reported symptoms like chest pain. In the subset of 36 (36%) patients that have followed up, 35 (97%) patients were prescribed a new anti-hypertensive or required an increased dose of a prior anti-hypertensive at their initial visit. Blood pressures at follow-up were not significantly different from baseline (median systolic delta= 1.0mmHg, diastolic delta= -1.0mmHg; p>0.05), and 83% (30) reported improvement in symptoms. Conclusions: Patients presenting with cardiovascular symptoms post-acute COVID-19 show increased blood pressure when compared to blood pressure prior to infection. During subsequent follow-up appointments, patients showed improvement in their blood pressure and symptoms. While the pathophysiology has yet to be determined, it is likely related to the effects of a proinflammatory state, endothelial dysfunction, dysautonomia, or altered effects of the RAAS.

Junctional Epidermolysis Bullosa of the Larynx

PEDIATRICS ◽  
1986 ◽  
Vol 78 (1) ◽  
pp. 172-174
Author(s):  
MARGARET A. KENNA ◽  
SYLVAN E. STOOL ◽  
SUSAN B. MALLORY
Keyword(s):  
Case Report ◽  
Epidermolysis Bullosa ◽  
Minor Trauma ◽  
Junctional Epidermolysis Bullosa ◽  
First Case ◽  
New Variant ◽  
Genetically Determined ◽  
Dermatologic Disease ◽  
Hereditary Epidermolysis Bullosa ◽  
Laryngeal Involvement

Epidermolysis bullosa is a rare genetically determined, dermatologic disease in which minor trauma causes blister formation.1 A new variant of hereditary epidermolysis bullosa, generalized atrophic benign epidermolysis bullosa, junctional form, has been recently reported.2 Airway involvement has not been a notable feature of this disease. We report the first case of an infant having benign junctional epidermolysis bullosa with laryngeal involvement. CASE REPORT An 11-month-old white boy with known junctional epidermolysis bullosa and mild stridor since birth was referred by his dermatologist for increasing stridor of 24 hours duration. He was initially thought to have croup; however, conservative treatment with mist and racemic epinephrine did not improve his symptoms.

Apical hypertrophic cardiomyopathy: an uncommon cause of exertional chest pain in children

2019 ◽  
Vol 29 (12) ◽  
pp. 1533-1535 ◽  
Author(s):  
Qu-ming Zhao ◽  
Lan He ◽  
Fang Liu
Keyword(s):  
Chest Pain ◽  
Hypertrophic Cardiomyopathy ◽  
Apical Hypertrophic Cardiomyopathy ◽  
Cardiac Angiography ◽  
First Case ◽  
Asymptomatic Children

AbstractApical hypertrophic cardiomyopathy is an uncommon morphologic variant of hypertrophic cardiomyopathy, which is rarely diagnosed in childhood. To date, very few cases of asymptomatic children younger than 18 years have been reported in the literature. To the best of our knowledge, this is the first case of paediatric apical hypertrophic cardiomyopathy presenting with exertional chest pain, with characteristic electrocardiographic, echocardiographic, MRI, and cardiac angiography findings.

Integrating heart rate variability, vital signs, electrocardiogram, and troponin to triage chest pain patients in the ED

2018 ◽  
Vol 36 (2) ◽  
pp. 185-192 ◽  
Author(s):  
Jeffrey Tadashi Sakamoto ◽  
Nan Liu ◽  
Zhi Xiong Koh ◽  
Dagang Guo ◽  
Micah Liam Arthur Heldeweg ◽  
...  
Keyword(s):  
Heart Rate ◽  
Heart Rate Variability ◽  
Chest Pain ◽  
Vital Signs ◽  
Pain Patients

Dengue Virus Associated Hemophagocytic Syndrome with Neurogical Manifestations in Children: A Case Report.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4516-4516
Author(s):  
Yadira Soler-Rosario ◽  
Nilka J. Barrios ◽  
Ricardo Garcia ◽  
Alicia Fernandez-Sein ◽  
Enid Rivera
Keyword(s):  
Bone Marrow ◽  
Virus Infection ◽  
Dengue Virus ◽  
Hemophagocytic Syndrome ◽  
Conflicts Of Interest ◽  
Neurological Manifestations ◽  
Positive Serology ◽  
Dengue Virus Infection ◽  
First Case ◽  
Uncommon Presentation

Abstract Abstract 4516 Dengue fever, caused by dengue virus, can cause increased vascular permeability, which leads to a bleeding diathesis or disseminated intravascular coagulation known as Dengue Hemorrhagic Fever (DHF). Hemophagocytocytic Syndrome (HPS) with neurological manifestations is an uncommon presentation of DHF. There are no reports of virus associated with HPS and neurological manifestations in the pediatric literature. Hemophagocytic Syndrome (HPS) is a clinico-pathologic entity characterized by proliferation of T lymphocytes and macrophages leading to cytokine overproduction. HPS may be diagnosed in association with malignant, genetic, or autoimmune diseases. Dengue virus is considered non-neurotropic, however neuroinvansion has been reported. We present the case of a 10 month old female patient who developed DHF, manifested with upper GI bleeding, hypotension and pancytopenia. The infant subsequently developed dengue shock syndrome, with thrombocytopenia, intravascular hemolysis, coagulopathy, elevated transaminase, hyperbilirubinemia, and creatine kinase (CK) of 2,876U/L. She required artificial hemodynamic and blood components support. During her course of illness, she developed ecchymosed, purpuric bullae lesions of the skin in the distal upper extremities. Her IgM ELISA for Dengue virus was positive. Bone marrow aspiration and biopsy was diagnostic for HPS. The patient was initiated on IV steroids and antibiotics therapy. An improvement was noticed on day 8 of illness and was weaned off completely of all artificial support by the day 9. A complete recovery of her hematological, transaminase, billirubin, and coagulation parameters was noticed on day 12. A repeated bone marrow aspirate and biopsy examination was normal. Patient's recovery was significant by muscle weakness (MCG grade ≤3), hypotonia, reduced tendon reflex and increased CK suggestive of possible myositis. The cerebrospinal fluid and magnetic resonance imaging studies of the brain were normal. She was given IV immunoglobulin (500mg/kg) for 2 consecutive days with remarkable neurological improvement including a normal CK (56U/L).She was weaned of steroids completely on day 20.Dengue virus infection was confirmed by a positive serology result at the convalescent stage. On day 23 she had a complete clinical recovery. To our knowledge, this is the first case reported of dengue virus-associated HPS and neurological manifestations in a pediatric patient with DHF. Clinicians should consider that the occurrence of HPS and neurological manifestations in children could de due to dengue virus infection. Disclosures: No relevant conflicts of interest to declare.

Primary aspergillosis of the larynx associated with CD4+ T lymphocytopenia

2002 ◽  
Vol 116 (4) ◽  
pp. 304-306 ◽  
Author(s):  
Mitsuhiko Nakahira ◽  
Shuji Matsumoto ◽  
Naoko Mukushita ◽  
Hiroaki Nakatani
Keyword(s):  
T Lymphocytes ◽  
Respiratory System ◽  
Healthy Subjects ◽  
Primary Infection ◽  
Immunocompromised Host ◽  
Cell Mediated Immunity ◽  
Defence Mechanisms ◽  
First Case ◽  
Marked Decline ◽  
Laryngeal Involvement

The purpose of this study was to report the first case (to our knowlege) of primary laryngeal aspergillosis in a patient with underlying CD4+ T lymphocytopenia. Laryngeal involvement of Aspergillus is more commonly seen as a part of a wider infection involving the respiratory system in an immunocompromised host. However, primary infection of the larynx is extremely rare. Although there were 12 cases of primary laryngeal aspergillosis previously reported in healthy subjects, there is no known study describing immunological findings in detail. We report a case of primary laryngeal aspergillosis in a healthy 79-year-old male. The examination of his immunity subsequently revealed that there was a marked decline in the number of CD4+ T lymphocytes and a decrease in the ratio of CD4+ to CD8+. It is suggested that it is essential to examine the defence mechanisms, specifically cell-mediated immunity in a patient showing primary laryngeal aspergillosis.

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