scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

Successful treatment of dermato-neuro syndrome with plasmapheresis

2020 ◽  
Vol 13 (12) ◽  
pp. e237170
Author(s):  
Jose Maciel Larios ◽  
Jordan Ciuro ◽  
Thomson Sam Varghese ◽  
Susan Elizabeth Lyons
Keyword(s):  
Mental Status ◽  
Rare Case ◽  
Altered Mental Status ◽  
Optimal Management ◽  
Treatment Protocols ◽  
Common Causes ◽  
History Of ◽  
Clonic Seizures ◽  
Neurologic Function ◽  
Rule Out

Altered mental status can have many causes ranging from emergent intracranial pathologies to more insidious, systemic toxic aetiologies. We report a rare case of dermato-neuro syndrome in a 71-year-old man with a known history of scleromyxoedema. The patient initially presented with encephalopathy which quickly progressed to generalised tonic–clonic seizures and coma. While his presentation fits with other, although rare, cases of dermato-neuro syndrome, it is imperative to rule out lethal, more common causes of altered mentation. Due to the rarity and difficulty in diagnosis of dermato-neuro syndrome, there is a significant debate regarding the optimal management as there are no standardised treatment protocols. In our case, the patient was successfully treated with plasmapheresis resulting in improved neurologic function.

scholarly journals Prognostic factors of outcome in adults with non-traumatic altered mental status presenting to emergency department

2019 ◽  
Vol 6 (5) ◽  
pp. 1948
Author(s):  
Sheikh Hilal Ahmad ◽  
Wani A. Mushtaq ◽  
Tak Sajad
Keyword(s):  
Emergency Department ◽  
Prognostic Factors ◽  
Mental Status ◽  
Altered Mental Status ◽  
Low Ph ◽  
Chi Square ◽  
Significant Challenge ◽  
Common Presentation ◽  
History Of ◽  
New Onset

Background: Altered mental status (AMS) is a common presentation in the emergency department (ED) and poses a significant challenge to the emergency physician (EP). The prognosis seems to depend upon many diverse factors, like etiology of AMS patient, clinical variables and various laboratory tests.Methods: The aim of the study was to determine outcome in patients presenting with new onset AMS to emergency department in our population. And further to look for various prognostic factors for death. Adult patients aged >14 years, not having dementia and with no history of trauma, presenting to ED with altered mental status were included in the study.Results: Out of 200 patients, 108 were male and 92 females. Patients having AMS because of poisoning, seizure, intracranial infection all had decreased mortality. Whereas patients having AMS because of stroke, infection, cardiovascular causes had significantly increased mortality. Season, sex, pH, SaO2, TLC, GCS, mean Bp. were associated with increased mortality in patients of AMS presenting to emergency department. The logistic regression model was statistically significant (chi square=39.3, p=0.000). The model predicted 26% of the variance in predicting death and correctly classified 74.6% of patients.Conclusions: The importance of being able to prognosticate AMS patients at outset in emergency is immense.Male sex, low mean BP, low GCS, low pH, low arterial SaO2, and high TLC were predictive of higher death rate in this cohort of patients presenting to emergency department.

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.

scholarly journals Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane

2012 ◽  
Vol 3 (4) ◽  
pp. 270 ◽  
Author(s):  
Hai-yu Xiao ◽  
Yu-xuan Wang ◽  
Teng-da Xu ◽  
Hua-dong Zhu ◽  
Shu-bin Guo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Fast Lane

scholarly journals Sinking Skin Flap Syndrome: Phenomenon of Neurological Deterioration after Decompressive Craniectomy

2018 ◽  
Vol 2018 ◽  
pp. 1-3
Author(s):  
Noman Ahmed Jang Khan ◽  
Saad Ullah ◽  
Waseem Alkilani ◽  
Hassan Zeb ◽  
Hassan Tahir ◽  
...  
Keyword(s):  
Mental Status ◽  
Decompressive Craniectomy ◽  
Rare Case ◽  
Skin Flap ◽  
Altered Mental Status ◽  
Hemodynamic Instability ◽  
Neurological Deterioration ◽  
Normal Anatomy ◽  
Midline Shift ◽  
Ct Head

Sinking skin flap syndrome is rare phenomenon that occurs in patients with large craniectomies. Alteration in normal anatomy and pathophysiology can result in wide variety of symptoms including altered mental status, hemodynamic instability, and dysautonomias. Management is largely conservative. We here present a case of a patient with large craniectomy who was admitted to our hospital with pneumonia. Later on, he developed worsening mental status and CT head revealed sinking skin flap with significant midline shift. This is a very rare case of neurological deterioration after craniectomies, commonly known as sinking skin flap syndrome. To our knowledge, only few cases have been reported so far.

scholarly journals Altered Mental Status and a Retro-auricular Mass

2006 ◽  
Vol 33 (3) ◽  
pp. 317-319
Author(s):  
Lauren M. Segal ◽  
Angela Walker ◽  
Eric Marmor ◽  
Errol Stern ◽  
Mark Levental ◽  
...  
Keyword(s):  
Eye Movements ◽  
Glasgow Coma Scale ◽  
Emergency Room ◽  
Mental Status ◽  
External Auditory Canal ◽  
Posterior Wall ◽  
Altered Mental Status ◽  
Facial Paresis ◽  
Coma Scale ◽  
History Of

A 29-year-old woman was found lying unconscious in the shower. There was a two-day history of headache and dizziness. In the emergency room, she was initially stuporous (Glasgow Coma Scale 10/15), afebrile, bradycardic and hypertensive. She exhibited roving, conjugate eye movements, left facial paresis (including frontalis), left ptosis, diffuse hypotonia, extensor plantar responses bilaterally and a 1.5 cm warm, fluctuant mass with surrounding erythema behind the left ear (Figure 1). Otoscopy revealed a bulge in the posterior wall of the left external auditory canal.

scholarly journals Non-painful severe variant form of eruptive lingual papillitis: A case report and literature review

2021 ◽  
Vol 13 (2) ◽  
Author(s):  
Manal Ahmed Halwani
Keyword(s):  
Emergency Department ◽  
Case Report ◽  
Literature Review ◽  
Oral Hygiene ◽  
Rare Case ◽  
Dorsal Surface ◽  
Variant Form ◽  
Girl Child ◽  
Rare Case Report ◽  
History Of

Eruptive lingual papillitis is a common benign disorder manifested by inflammation of fungiform papillae on the dorsolateral surface of the tongue. Several variants of lingual papillitis have been reported since 1997, most or all of them with painful erythematous papules. Here we report a case of 6 years old girl child with non-painful severe variant form of eruptive lingual papillitis presented to the emergency department. The entire dorsal surface of the tongue was surfaced by 2-3mm by multiple erythematous papules and some with a white or yellowish colour. The papules were excessively inflamed, pigmented, aggregated, and crusted. The cause was idiopathic which resolved within ten days. The parent and patient were reassured with advice to practice oral hygiene. This is a rare case report describing non-painful lingual papillitis without a history of any prior episodes.

scholarly journals Unusual Presentation of Myxedema Coma in Type 1 Diabetes Mellitus With Hyperglycemia and Polysubstance Abuse

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A971-A972
Author(s):  
Yumna Hamid ◽  
Steven Douedi ◽  
Johnathan Nold ◽  
Raquel Kristin Ong ◽  
Jennifer Cheng ◽  
...  
Keyword(s):  
Type 1 Diabetes ◽  
Mortality Rate ◽  
Mental Status ◽  
White Male ◽  
Altered Mental Status ◽  
Close Monitoring ◽  
Urine Drug Screen ◽  
Metabolic Encephalopathy ◽  
Myxedema Coma

Abstract Background: Myxedema coma is a severe manifestation of hypothyroidism that typicallypresents with altered mental status and requires close monitoring in the intensive care unit dueto 30-60% mortality rate. Clinical Case: A 56 year old white male with type 1 diabetes with recurrent DKA, polysubstanceabuse, Bipolar disorder on lithium and post surgical hypothyroidism presented due to change inmental status after being brought in by sister. Patient was found to be lethargic with confusionthat worsened over the last week. The patient was admitted several times in the past monthsecondary to pneumonia, sepsis, and recurrent DKA. On physical examination, he found to have lethargy, macroglossia, hyporeflexia, and periorbitaledema. Patient had acute respiratory failure with metabolic encephalopathy, bradycardia,tachypnea, severe hyperglycemia, hypotension of 77/51, tachypnea of 31 breaths per minuteand hyponatremia. Laboratory findings showed T4 levels 2.87(n=5.28-9.87ug/dL) withundetectable FT4 and elevated TSH (>50, n=0.300-4.500uIU/mL). Electrolyte panel showedhyponatremia (133, n=136-145mmol/L), hyperglycemia up to 532mg/dL and lithium levels werewithin normal limits (n=0.5-1.5 mmol/L). Urine drug screen was positive for cocaine. A CT scanof the head was negative. His myxedema score was diagnostic (>60). The patient wasdiagnosed with myxedema coma and admitted to the ICU. Patient was treated with IV LT4 400mcg, LT3 10mcg and hydrocortisone 100mg and started onIV LT4 100mcg daily, LT3 2.5mcg daily and hydrocortisone 100mg Q8 hours. There was wideglycemic variation from 46-532 mg/dL on POCT. The patient improved clinically, with resolutionof lethargy, confusion, fatigue, improved appetite, and improved lab work of FT3 2.30 (n=2.28-3.96pg/mL), FT4 at 0.76 (n=0.50-1.26ng/dL) and was downgraded from the ICU. On hospitalday four, he was transitioned to oral levothyroxine and discharged home. Conclusion: It is important to diagnose early and promptly manage decompensatedhypothyroidism in the setting of other comorbidities such as hyperglycemia in diabetes andpolysubstance abuse. The cocaine in the system may cause tachypnea and tachycardia. Manyconditions may have altered mental status, but with a history of hypothyroidism, Myxedemacoma should be on the differential due to its high mortality rate.

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