Inhaled nitrous oxide-induced functional B12 deficiency

2021 ◽  
Vol 14 (3) ◽  
pp. e240447
Author(s):  
Yorissa Padayachee ◽  
Chris Richards ◽  
Owen Morgan
Keyword(s):  
Adverse Effect ◽  
Emergency Department ◽  
Nitrous Oxide ◽  
Low Cost ◽  
Lower Limbs ◽  
Ataxic Gait ◽  
Mri Brain ◽  
History Of ◽  
B12 Deficiency ◽  
Thoracic Cord

Recreational nitrous oxide (N2O) is commonly used among young people partly due to its low cost and accessibility, and awareness of its potential adverse effects is poor in this group. One such adverse effect is degeneration of the spinal cord due to its disruption of DNA synthesis by inactivating cobalamin (B12).A 19-year-old man presented to the emergency department with a 4-week history of worsening paraesthesia in his fingers and lower limbs, and weakness in the hands and lower limbs for 2 weeks. On examination, he had an ataxic gait, reduced power of grip strength and ankle movements, and impaired sensation in the lower limbs. An MRI brain and spine revealed myelopathy of the cervical and thoracic cord.On further questioning, he reported recreational N2O inhalation. His symptoms improved after stopping this and he was treated with supplementation of B vitamins. Education strategies regarding the risks of N2O misuse are indicated.

scholarly journals Seizures induced by recreational abuse of bupropion tablets via nasal insufflation

CJEM ◽  
2010 ◽  
Vol 12 (02) ◽  
pp. 158-161 ◽  
Author(s):  
Daniel Kim ◽  
Brian Steinhart
Keyword(s):  
Adverse Effect ◽  
Emergency Department ◽  
Initial Visit ◽  
Limited Data ◽  
Changing Trends ◽  
Treatment Of Depression ◽  
History Of ◽  
Clonic Seizures ◽  
The Difference ◽  
Oral Doses

ABSTRACTBupropion is a newer generation antidepressant that is commonly used for treatment of depression and for smoking cessation. Seizures are a frequently reported adverse effect of bupropion in therapeutic oral doses; however, there are limited data about the consequences of nasal insufflation of bupropion. We report the case of a patient who presented to the emergency department (ED) with a recent history of generalized tonic–clonic seizures whose etiology was initially a diagnostic mystery. After an initial visit to another ED, the patient presented to our ED later that day with a recurrence of the seizures after crushing and nasally insufflating oral bupropion tablets. We review important implications of this case to emergency medicine, including the potential for abuse of bupropion, the difference between intranasal and oral administration, the changing trends in the etiology of drug-related seizures and the importance of examining the nares in patients with unexplained seizure and delirium.

scholarly journals Guillain-Barré syndrome associated with COVID- 19 vaccination: a case report

2021 ◽  
Vol 10 (1) ◽  
pp. 268
Author(s):  
Vinod John ◽  
Jiya Thankam Koshy ◽  
Nikhil Gladson ◽  
Vimod K. Wills
Keyword(s):  
Adverse Effect ◽  
Acute Onset ◽  
Lower Limbs ◽  
Guillain Barre Syndrome ◽  
Guillain Barré Syndrome ◽  
History Of ◽  
Guillain Barré ◽  
Progressive Weakness ◽  
Relevant Factors

Several reports and studies are being conducted to this day based on the safety profile of COVID-19 vaccines. COVID-19 vaccination inducing GBS is a rare adverse effect and is likely to be causal. Though, there are reports concerning the relation between coronavirus infections and GBS, the pathogenic mechanism and relevant factors behind COVID-19 vaccines inducing GBS are still not being corroborated so far. Guillain-Barre syndrome is the principal cause of acute flaccid paralysis with a prevalence rate of 2 in 100, 000 people per year. We illustrate a 55 years old female patient who presented with acute onset paraesthesia and progressive weakness of bilateral lower limbs and gait imbalance of 5 days duration to the Hospital during the first week of September. Her symptoms occurred within 2 weeks of the first dose of the ChAdOx1-n-CoV-19 (Covishield) vaccine proving a major possibility of vaccine-induced neurological adverse effect as she didn't have any likely significant history of illness or allergies in the past rather than type 2 diabetes mellitus. This report aims to highlight the incidence and to ruminate upon this matter while evaluating any GBS cases in the current eras of the COVID-19 pandemic and vaccination.

scholarly journals A case of carbamazepine-induced vitamin B12 deficiency and neuropathy

2018 ◽  
Vol 8 (1) ◽  
pp. 166
Author(s):  
Ilathamizhan Jayakumar ◽  
Jayanthi Mathaiyan
Keyword(s):  
Vitamin B12 ◽  
Vitamin B12 Deficiency ◽  
Clonic Seizure ◽  
Tonic Clonic Seizure ◽  
Lower Limbs ◽  
Probability Method ◽  
Drug Induced ◽  
Family History Of Diabetes ◽  
History Of ◽  
B12 Deficiency

Drug induced Neuropathy is seen commonly in patients undergoing treatment with drugs like phenytoin, dapsone, isoniazid etc. Carbamazepine is a drug used in the treatment in the treatment of focal seizure, generalized tonic - clonic seizure and trigeminal neuralgia. It is presented a case of carbamazepine induced vitamin B12 deficiency and neuropathy. A 21 year old male presented to our hospital with complaints of history of slipping of footwear while walking, numbness, impairment of balance and unsteadiness of gait in both lower limbs. Detailed history revealed the patient was on treatment with carbamazepine for tonic - clonic seizure for three months. He is non- smoker, non -alcoholic, not on treatment with other drugs and there is no family history of diabetes mellitus/ sensory neuropathy. On examination power was normal on both lower limbs, vibration sensation was decreased in both lower limbs, sensation was reduced, joint position was affected in bilateral toe and ankle reflex was absent. Vitamin B12 level was found to be 83pg/ml. The patient was discontinued from carbamazepine and started on vitamin B12 therapy and the symptoms subsides slowly. Causality assessment done by WHO- UMC probability method and Naranjo Adverse Drug Reactions Probability Scale showed “Probable” association.

WED 011 Subacute combined degeneration of the cord: laugh until you are weak

2018 ◽  
Vol 89 (10) ◽  
pp. A2.3-A2
Author(s):  
Francis Anna ◽  
Matar Maz
Keyword(s):  
Nitrous Oxide ◽  
Peripheral Neuropathy ◽  
Neurological Examination ◽  
Mri Findings ◽  
Subacute Combined Degeneration ◽  
Blood Tests ◽  
Mri Brain ◽  
Sensory Modalities ◽  
History Of ◽  
The Right

A 33 year old lady presented to her GP with a 2 week history of numbness affecting her thighs. Routine blood tests revealed normal haemoglobin and folate levels with a borderline B12 concentration of 103 ng/L. Over the subsequent 2 weeks the numbness spread to involve her feet and her hands. Despite commencing cobalamin injections her symptoms continued to progress. She was admitted to hospital 4 weeks after the onset of symptoms with disabling sensory ataxia.All reflexes were either absent or elicited only with reinforcement. Plantars were downgoing. There was impairment of all sensory modalities in a glove-and-stocking distribution, with proprioception accurate at the ankle on the right and the knee on the left. Her gait was broad-based. The remainder of the neurological examination was unremarkable.A full peripheral neuropathy screen revealed no abnormality. An MRI spine showed longitudinally extensive myelitis mainly affecting the dorsal cord extending from C4 to T3. MRI brain and lumbar puncture were pristine.Guided by the MRI findings direct questioning elicited a long history of frequent recreational nitrous oxide use. We review the accumulating literature regarding nitrous oxide-induced subacute combined degeneration of the cord and explore the pathophysiological mechanisms underlying it.

Aspergillus Spondylodiscitis After Spinal Stenosis Surgery: A Case Report

2020 ◽  
Vol 5 (3 And 4) ◽  
pp. 155-160
Author(s):  
Mohsen Aghapoor ◽  
◽  
Babak Alijani Alijani ◽  
Mahsa Pakseresht-Mogharab ◽  
◽  
...  
Keyword(s):  
Antifungal Drugs ◽  
The Body ◽  
Lower Limbs ◽  
Lumbar Pain ◽  
Case Presentation ◽  
Delay In Diagnosis ◽  
Death Case ◽  
Therapeutic Results ◽  
History Of ◽  
Probable Diagnosis

Background and Importance: Spondylodiscitis is an inflammatory disease of the body of one or more vertebrae and intervertebral disc. The fungal etiology of this disease is rare, particularly in patients without immunodeficiency. Delay in diagnosis and treatment of this disease can lead to complications and even death. Case Presentation: A 63-year-old diabetic female patient, who had a history of spinal surgery and complaining radicular lumbar pain in both lower limbs with a probable diagnosis of spondylodiscitis, underwent partial L2 and complete L3 and L4 corpectomy and fusion. As a result of pathology from tissue biopsy specimen, Aspergillus fungi were observed. There was no evidence of immunodeficiency in the patient. The patient was treated with Itraconazole 100 mg twice a day for two months. Pain, neurological symptom, and laboratory tests improved. Conclusion: The debridement surgery coupled with antifungal drugs can lead to the best therapeutic results.

A Rare Case of Bilateral Incarcerated Obturator Hernias and a Right-Side Femoral Hernia

2020 ◽  
pp. 1-3
Author(s):  
Jinping Xu ◽  
Jinping Xu ◽  
Ruth Wei ◽  
Salieha Zaheer
Keyword(s):  
Emergency Department ◽  
Abdominal Pain ◽  
Femoral Hernia ◽  
Rare Case ◽  
Hernia Recurrence ◽  
High Morbidity ◽  
Diagnostic Challenge ◽  
Abdominal Ct ◽  
Abdominal Ct Scan ◽  
History Of

Obturator hernias are rare but pose a diagnostic challenge with relatively high morbidity and mortality. Our patient is an elderly, thin female with an initial evaluation concerning for gastroenteritis, and further evaluation revealed bilateral incarcerated obturator hernias, which confirmed postoperatively as well as a right femoral hernia. An 83-year-old female presented to the outpatient office initially with one-day history of diarrhea and one-week history of episodic colicky abdominal pain. She returned 4 weeks later with diarrhea resolved but worsening abdominal pain and left inner thigh pain while ambulating, without changes in appetite or nausea and vomiting. Abdominal CT scan then revealed bilateral obturator hernias. Patient then presented to the emergency department (ED) due to worsening pain, and subsequently underwent hernia repair. Intraoperatively, it was revealed that the patient had bilateral incarcerated obturator hernias and a right femoral hernia. All three hernias were repaired, and patient was discharged two days later. Patient remained well postoperatively, and 15-month CT of abdomen showed no hernia recurrence.

Neglected woman with hyperemesis gravidarum leading to Wernicke encephalopathy

2020 ◽  
Vol 13 (12) ◽  
pp. e238545
Author(s):  
Papa Dasari ◽  
Smitha Priyadarshini
Keyword(s):  
Grey Matter ◽  
Hyperemesis Gravidarum ◽  
Intravenous Fluids ◽  
State Of Health ◽  
Wernicke Encephalopathy ◽  
Periaqueductal Grey ◽  
Mri Brain ◽  
Good State ◽  
Periaqueductal Grey Matter ◽  
History Of

A teenage primigravida at 13 weeks of gestation presented with hyperemesis gravidarum of 45 days and a history of giddiness and inability to walk due to involuntary movements of limbs and eyes since 2 days. She was treated with intravenous fluids, thiamine and antiemetics. MRI brain showed hyperintensities in bilateral dorsomedial thalami, periaqueductal grey matter in T2-weighted and FLAIR images. A diagnosis of Wernicke encephalopathy was made and she was managed in intensive care unit and received injection thiamine as per the guidelines and her weakness and ataxia improved over 3 weeks and she was discharged at 17 weeks of pregnancy in good state of health.

Economic Consequences of War

1943 ◽  
Vol 3 (S1) ◽  
pp. 1-8
Author(s):  
Curtis P. Nettels
Keyword(s):  
Low Cost ◽  
Economic Consequences ◽  
Competitive Advantages ◽  
Competitive Position ◽  
The Past ◽  
History Of ◽  
Costs Of Production ◽  
Foreign Competitors

One influence of war has repeatedly asserted itself in the past—an effect on the costs of production and on the competitive position of the industries and firms of victorious or neutral nations. This subject needs more study, but certain facts suggest a hypothesis, of three parts. First: war expands some industries or concerns, increases their efficiency, enables them to operate, at the end of the struggle, on a comparatively low-cost basis, intensifies their competitive advantages, and improves their position in relation to foreign competitors. Second: war—for the duration—bolsters up some high-cost units by enabling them to sell at a profit all they can produce. The end of the war places such high-cost units at a disadvantage in the process of absorbing the shocks of the transition to a peacetime economy. Third: the history of postwar periods usually exhibits a sharp contest between such low-cost and high-cost enterprises. While “low cost” and “high cost” may refer to the relative positions of units within the same country, in most of this discussion, the terms will be applied to the producers of one country (either victor or neutral) to mean that their costs are low or high in comparison with those of their foreign competitors.

scholarly journals A141 SPONTANEOUS ESOPHAGEAL PERFORATION: AN UNREPORTED COMPLICATION OF LYMPHOCYTIC ESOPHAGITIS

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 128-129
Author(s):  
A LAGROTTERIA ◽  
A W Collins ◽  
A Someili ◽  
N Narula
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Case Report ◽  
Proton Pump Inhibitor ◽  
Proton Pump ◽  
Esophageal Perforation ◽  
Distal Esophagus ◽  
Chest Discomfort ◽  
History Of ◽  
Lymphocytic Esophagitis

Abstract Background Lymphocytic esophagitis is a new and rare clinicopathological entity. It is a histological pattern characterized by lymphocytic infiltrate without granulocytes. Its etiology and clinical significance remains unclear. The clinical manifestations are typically mild, with reflux and dysphagia the most commonly reported symptoms. Aims We describe a case report of spontaneous esophageal perforation associated with lymphocytic esophagitis. Methods Case report Results A previously well 31-year-old male presented to the emergency department with acute food impaction. His antecedent symptoms were acute chest discomfort and continuous odynophagia following his most recent meal, with persistent globus sensation. The patient had no reported history of allergies, atopy, rhinitis, or asthma. A previous history of non-progressive dysphagia was noted after resuscitation. Emergent endoscopy revealed no food bolus, but a deep 6 cm mucosal tear in the upper-mid esophagus extending 24 to 30 cm from the incisors. Chest computed tomography observed small volume pneumoperitoneum consistent with esophageal perforation. The patient’s recovery was uneventful; he was managed conservatively with broad-spectrum antibiotics, proton pump inhibitor therapy, and a soft-textured diet. Endoscopy was repeated 48 hours later and revealed considerable healing with only a residual 3-4cm linear laceration. Histology of biopsies taken from the mid and distal esophagus demonstrated marked infiltration of intraepithelial lymphocytes. There were no eosinophils or neutrophils identified, consistent with a diagnosis of lymphocytic esophagitis. Autoimmune indices including anti-nuclear antibodies and immunoglobulins were normal, ruling out a contributory autoimmune or connective tissue process. The patient was maintained on a proton pump inhibitor (pantoprazole 40 mg once daily) following discharge. Nearly six months following his presentation, the patient had a recurrence of symptoms prompting representation to the emergency department. He described acute onset chest discomfort while eating turkey. Computed tomography of the chest redemonstrated circumferential intramural gas in the distal esophagus and proximal stomach. Conclusions Esophageal perforation is a potentially life-threatening manifestation of what had been considered and described as a relatively benign condition. From isolated dysphagia to transmural perforation, this case significantly expands our current understanding of the clinical spectrum of lymphocytic esophagitis. Funding Agencies None

scholarly journals Red Blood Cell Transfusion in the Emergency Department: An Observational Cross-Sectional Multicenter Study

2021 ◽  
Vol 10 (11) ◽  
pp. 2475
Author(s):  
Olivier Peyrony ◽  
Danaé Gamelon ◽  
Romain Brune ◽  
Anthony Chauvin ◽  
Daniel Aiham Ghazali ◽  
...  
Keyword(s):  
Emergency Department ◽  
Logistic Regression ◽  
Blood Cell ◽  
Red Blood Cell ◽  
Cross Sectional Study ◽  
Red Blood Cell Transfusion ◽  
Cross Sectional ◽  
Acute Bleeding ◽  
History Of ◽  
Rbc Transfusion

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53–3.94), and older age (OR: 1.02/year; 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

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