scholarly journals Strongyloides Hyperinfection Associated with Enterococcus faecalis Bacteremia, Meningitis, Ventriculitis and Gas-Forming Spondylodiscitis: A Case Report

2020 ◽  
Vol 5 (1) ◽  
pp. 44 ◽  
Author(s):  
Liang En Wee ◽  
Su Wai Khin Hnin ◽  
Zheyu Xu ◽  
Lawrence Soon-U Lee
Keyword(s):  
Enterococcus Faecalis ◽  
Strongyloides Stercoralis ◽  
Altered Mental Status ◽  
Early Morning ◽  
Peripheral Eosinophilia ◽  
Imaging Evaluation ◽  
Steroid Use ◽  
Travel History ◽  
History Of ◽  
Stool Specimens

An elderly Singaporean male with no travel history was hospitalized for fever and altered mental status. Blood cultures grew Enterococcus faecalis, and given a preceding history of steroid use and peripheral eosinophilia, Strongyloides hyperinfection was suspected. Stool specimens were positive for Strongyloides stercoralis larvae over four days, and larvae were also isolated in an early morning nasogastric aspirate specimen prior to initiation of ivermectin. A cerebrospinal fluid examination was consistent with partially treated bacterial meningitis and ventriculitis was demonstrated on neuroimaging. In view of a persistent fever, a further imaging evaluation was performed, which demonstrated bilateral pneumonia as well as the unusual finding of gas-forming emphysematous spondylodiscitis and left psoas abscesses. Despite the early suspicion of Strongyloides hyperinfection, commencement of appropriate antibiotics and anti-helminthics, microbiological clearance of bacteremia as well as clearance of S. stercoralis from the stool, the patient still succumbed to infection and passed away 11 days after admission.

scholarly journals Gram negative rod meningitis due to Strongyloides stercoralis

2017 ◽  
Vol 4 (2) ◽  
pp. 28
Author(s):  
Nicholas S. Hendren ◽  
Shahzad Chindhy ◽  
Kaylee Shepard
Keyword(s):  
Strongyloides Stercoralis ◽  
Altered Mental Status ◽  
Chronic Infections ◽  
Travel History ◽  
Gram Negative ◽  
Immunosuppressive Medications ◽  
Dexamethasone Therapy ◽  
Immunosuppressed Patients ◽  
High Doses ◽  
One Year

A 57-year-old male Mexican immigrant living in Dallas presented with altered mental status, progressive confusion, mild headache and fevers. He was diagnosed with embryonal liver sarcoma one year prior to admission and had recently started dexamethasone therapy for metastatic spinal lesions. Blood and cerebrospinal fluid cultures from a lumbar puncture were both positive for Escherichia coli. He was diagnosed with spontaneous gram negative rod (GNR) meningitis. Given his travel history, immunosuppression and GNR meningitis, a stool ova and parasite sample was obtained to screen for Strongyloides stercoralis. His stool was markedly positive for Strongyloides stercoralis larvae and he was further diagnosed with Strongyloides hyperinfection syndrome. Strongyloides is capable of chronically re-infecting human hosts without an external life cycle via autoinfection. In chronic infections, hyperinfection can be triggered with immunosuppressive medications, especially steroids. Disseminated Strongyloides should be considered as the source for unexplained GNR bacteremia or meningitis especially in immunosuppressed patients. Our patient likely had a chronic asymptomatic Strongyloides infection acquired in Mexico that became a hyperinfection resulting in GNR meningitis after starting high doses of dexamethasone.

Loperamide Induced Recurrent Torsades de Pointes: A Case Report

2021 ◽  
pp. 089719002110048
Author(s):  
Gregory G. Jackson ◽  
Christine R. Lopez ◽  
Elizabeth S. Bermudez ◽  
Nina E. Hill ◽  
Dan M. Roden ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Torsades De Pointes ◽  
Altered Mental Status ◽  
Spontaneous Circulation ◽  
Prior History ◽  
Common Phenomenon ◽  
Medical Providers ◽  
Return Of Spontaneous Circulation ◽  
History Of ◽  
Overdrive Pacing

Purpose: A case of loperamide-induced recurrent torsades de pointes is reported to raise awareness of an increasingly common phenomenon that could be encountered by medical providers during the current opioid epidemic. Summary: A 40 year-old-man with a prior history of opioid abuse who presented to the emergency department after taking up to 100 tablets of loperamide 2 mg daily for 5 years to blunt opioid withdrawal symptoms and was subsequently admitted to the intensive care unit for altered mental status and hyperthermia. The patient had prolonged QTc and 2 episodes of torsades de pointes (TdP) that resulted in cardiac arrest with return of spontaneous circulation. He was managed with isoproterenol, overdrive pacing, and methylnatrexone with no other events of TdP or cardiac arrest. Conclusion: A 40-year-old male who developed torsades de pointes from loperamide overdose effectively treated with overdrive pacing, isoproterenol, and methylnatrexone.

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.

861 Vascular dementia presenting as rapidly progressive dementia secondary to zolpidem

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A335-A335
Author(s):  
Cameron Barber ◽  
Dylan Carroll ◽  
Bhavani Suryadevara
Keyword(s):  
Vascular Dementia ◽  
Microvascular Disease ◽  
Altered Mental Status ◽  
Progressive Dementia ◽  
Personality Changes ◽  
The Us ◽  
History Of ◽  
Gait Abnormalities ◽  
Scheduled Time ◽  
Chronic Use

Abstract Introduction Rapidly progressive dementia is a condition with a wide differential which remains difficult to accurately diagnose. The potential pathologies responsible include thyroid, vitamin, and electrolytes abnormalities, infectious, and malignant causes. Vascular dementia, however, typically has a slow and insidious presentation. Zolpidem (Ambien) is among the top 50 prescribed medications in the US. Report of case(s) An 84-year-old Caucasian male with a past medical history of insomnia, and sleep apnea who is noncompliant with CPAP presented after a fall associated with altered mental status. He has taken zolpidem 10 mg nightly for over six years. The patient and wife reported notable personality changes beginning six months prior, as well as four months of progressively worsening auditory and visual hallucinations. Additionally, the patient noted developing urinary incontinence, and worsening gait steadiness with recurrent falls. The patient then developed sleep-wake inversion during the three weeks prior to his fall, and an outpatient referral to neurology was subsequently sent for dementia evaluation. On the night prior to his presentation, the patient took his usual nighttime zolpidem at 22:00 and later fell and was unable to get up. Subsequent testing was negative for reversible causes of dementia and MRI Brain revealed only chronic microvascular disease. His zolpidem dose was decreased to 5 mg and scheduled earlier which resulted in the resolution of his hallucinations, gait abnormalities, and acute encephalopathy. Conclusion One month later, the patient presented to the hospital after a repeat fall secondary to taking his zolpidem at his previously scheduled time. Once more, his dosage was further decreased to 2.5 mg and scheduling earlier, resulting again, in the complete resolution of his symptoms. Zolpidem, has an increased potential for delirium in elderly patients and especially those with dementia. Chronic use of zolpidem with insidiously progressive vascular dementia led to a worsening delirium which resolved after adjustment of timing and reduction of zolpidem dosing. Support (if any):

scholarly journals P045 Nothing is too 'cagey' for the rheumatologist

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Muhammad F Kazmi
Keyword(s):  
Weight Loss ◽  
Inflammatory Markers ◽  
Low Grade ◽  
Careful Monitoring ◽  
Chronic Infections ◽  
Asian Origin ◽  
Travel History ◽  
Chest Clinic ◽  
History Of ◽  
Inflammatory Changes

Abstract Background/Aims  Rheumatological conditions can present with a number of non-specific features like arthralgia, fever, fatigue, weight loss along with raised inflammatory markers and positive antibodies. Due to this, when similar symptoms are referred for input it is very important to consider other ‘mimics’. We report a case of Pigeon fancier’s lung presenting with these symptoms which was referred as likely connective tissue disease. Methods  A 52-year-old lady of South Asian origin was referred by her GP with six month history of 3kg weight loss, arthralgia, fatigue, low grade fever and persistently raised inflammatory markers (ESR ranging from 50-64 mm/hr, CRP 10-14 mg/L, normal BMI). On further questioning there was history of mouth ulcers, non-specific rash, occasional cough but no Raynaud’s or joint swelling. Blood investigations showed weakly positive ANA and RF but negative ENA, DNA, antiCCP , CK, C3,C4. C-ANCA was positive but PR3 negative. CXR was clear and tests for chronic infections including TB were negative. Due to lack of objective CTD signs, plan was to take a careful monitoring approach to see if clinical features evolved. A month later due to worsening cough, a CT chest/abdomen arranged by GP showed ground-glass changes consistent with pneumonitis and hence her rheumatology appointment was expedited to see if there was an autoimmune unifying diagnosis. She was also referred by her GP to the chest clinic in view of CT report and mild shortness of breath. Results  On further review, again there were no objective CTD signs. On direct questioning there was history of travelling before worsening chest symptoms to South Asia. Also around a year before her symptoms started she was given an African grey parrot. Based on this, serology for Avian precipitin was checked which showed strongly positive IgG antibodies to avian antigens (Budgerigar droppings and feathers, Pigeon feathers IgG Abs) confirming the diagnosis of pigeon fanciers lung. She fulfilled the diagnostic criteria and was asked to avoid the trigger. Urgent respiratory input was arranged where diagnosis was agreed with and disease was deemed sub-acute in presentation. Due to PFTs showing low transfer factor of 38%, Prednisolone was started with significant improvement within few days. Review of CT chest only showed inflammatory changes and no established fibrosis predicting excellent prognosis as delay in treatment can cause irreversible pulmonary fibrosis. Conclusion  A number of conditions can mimic rheumatological conditions which usually turn out to be either infectious or malignant in origin. This case highlights the importance of considering other differentials and along with taking a travel history also asking for other possible triggers like pets. In similar scenarios the diagnosis may be ‘cagey’ but as rheumatologists we are expected to answers questions which others can’t. Disclosure  M.F. Kazmi: None.

scholarly journals Osteoporosis-Related Simultaneous Four Joints Fractures and Dislocation after a Seizure: A Case Report

2010 ◽  
Vol 2010 ◽  
pp. 1-4
Author(s):  
Abdullah S. AlOmran
Keyword(s):  
Vitamin D ◽  
Case Report ◽  
Clinical Examination ◽  
Epileptic Seizures ◽  
Antiresorptive Therapy ◽  
Multiple Fractures ◽  
Steroid Use ◽  
Skeletal Injury ◽  
History Of ◽  
Rule Out

A case of steroid-induced osteoporosis-related multiple fractures and dislocations are described after a seizure is reported. Patient had two years history of steroid use with no supplement or antiresorptive therapy. There was a delay in the diagnosis which affected an otherwise good outcome in such situations. It is recommended that patients on steroid should be given calcium, vitamin D, and an antiresorptive. Furthermore, a meticulous clinical examination is required in patients who are on steroids and suffer epileptic seizures to rule out skeletal injury.

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.

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