Recurrent Generalized Seizures with Postictal Todd’s Paralysis Caused by Medication-Associated Severe Hypomagnesemia: A Case Report

Hypomagnesemia is one of the electrolyte disturbances that can cause seizures. It is common in the hospitalized patients and can be induced by long-term usage of many medications. A 68-year-old male known to have hypertension and gastroesophageal reflux presented to the Emergency Department with an unprovoked first seizure at home followed by a temporary right-sided hemiparesis, dysphasia, and facial asymmetry. The hemiparesis, dysphasia, and facial asymmetry resolved within less than an hour after the seizure. His serum potassium was low with prolonged QT interval in the electrocardiogram (serum magnesium was not checked in the Emergency Department). He received intravenous IV potassium chloride infusion, and his serum potassium level was corrected, but he had a recurrent seizure after 10 h. At that time, his serum magnesium was found to be very low, he received IV magnesium sulfate infusion, and his indapamide, omeprazole, and metformin medications were stopped. He had no further seizures, the rest of his blood tests were normal, and his CT brain was unremarkable. He was treated for aspiration pneumonia, and his outpatient MRI brain and EEG came to be normal too.

Bell’s Palsy Caused by SARS-CoV-2

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has led to major healthcare and everyday life challenges. Every day, new disease associations and systemic manifestations are being explored and reported. Peripheral facial nerve paralysis or Bell’s palsy has been reported to be caused mainly by viral infections. This case represents a COVID-19-positive patient with Bell’s palsy making SARS-CoV-2 as the most likely culprit of his condition.

Traumatic Refractory Ventricular Fibrillation Successfully Treated with Intra-Arrest Esmolol

Here, we describe a case of refractory ventricular fibrillation (RVF) in an undifferentiated trauma patient that responded to intra-arrest esmolol. To our knowledge, this is the first case of RVF in an undifferentiated trauma patient that responded to intra-arrest esmolol. This case continues to support the growing evidence for use of esmolol as a treatment of refractory fibrillation and should be considered even in undifferentiated traumatic arrest patients prior to the cessation of resuscitation efforts.

Veno-Arterial Extracorporeal Membrane Oxygenation for Severe Heatstroke with Refractory Hemodynamic Failure

A 68-year-old male was found unconscious in a hot bathtub on a cold winter’s day and was brought to our hospital. On arrival, the patient’s systolic blood pressure was 65 mm hg, heart rate was 134 beats per min, and rectal temperature was 40.5°C. A large volume infusion of acetated Ringer’s solution and vasopressors were administered as an immediate treatment for circulatory failure due to heatstroke. Although the circulatory failure temporarily improved, the blood pressure dropped almost to the point of cardiac arrest. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was implemented and the hemodynamics were soon stabilized. Subsequently, VA-ECMO was withdrawn on the third hospital day. The patient recovered enough to feed normally on the 40th hospital day and was transferred to another hospital on the 116th hospital day. Based on this case study, we consider that VA-ECMO implementation before cardiac arrest might be a suitable strategy.

Administration of Tranexamic Acid as Treatment for Angiotensin Converting Enzyme Inhibitor-Induced Angioedema: A Case Report

<b>Background</b> Angiotensin converting enzyme inhibitor-induced angioedema is a major cause of angioedema-related hospitalizations each year. Common swelling predilection sites include the face, periorbital skin, lips, pharynx, larynx, and tongue. Involvement of airway structures could lead to airway obstruction and ultimately death if not treated promptly. A 62-year-old man presented to a rural clinic with a massively swollen tongue that obscured visualization of the retropharynx and mildly swollen lips. The patient stated that he had been taking lisinopril for many years and never had a swelling episode similar to this. The patient was initially administered epinephrine, antihistamine, steroids, and Tranexamic acid. A second dose of Tranexamic acid was administered 30 min later followed by close monitoring. Seven hours after the first administration, the patient had near-complete resolution of tongue swelling and was later discharged. Angioedema treatment is still variable and hospitals in different settings may be able to take advantage of available resources for treatment. Tranexamic acid is a cheap and widely available antifibrinolytic that may be used to treat angiotensin converting enzyme inhibitor-induced angioedema, especially if more specific therapeutics are unavailable.

Case Report: De Quervain’s Thyroiditis as a Long-Term Sequelae Complication to SARS-CoV-2 Infection

A 44-year-old man presented with an enlarged painful lower anterior neck lump with elevated serum concentrations of free thyroxine (T4) and tri-iodothyronine (T3), alongside the presence of antithyroid peroxidase antibodies. Prior to presentation, the patient was demonstrating recovery from a SARS-CoV-2 infection that required sedation, intubation, and invasive ventilation in the intensive care unit (ICU) for 11 days. Ultrasound examination of the thyroid demonstrated features of De Quervain’s (subacute) thyroiditis. This corresponded to the clinical picture, and continuous thyroid function tests were arranged. Emerging evidence throughout the SARS-CoV-2 pandemic describes the long-term sequelae of the infection, including developing atypical effects on the thyroid gland. This case report emphasises the association of painful subacute thyroiditis with post-viral infection and its manifestation during recovery from severe SARS-CoV-2, suggesting that follow-up thyroid function testing should be considered in patients discharged from the ICU who develop neck discomfort.

Fatal lymphocytic myocarditis masquerading as thoracic aortic dissection

Acute myocarditis usually presents with a broad spectrum of symptoms and has variable clinical outcomes. A proportion of acute myocarditides may develop into fulminant myocarditis resulting in significant mortality if left untreated. This case report describes an unusual presentation of fatal lymphocytic myocarditis mimicking a thoracic aortic dissection in a previously healthy 45-year-old male. Fulminant myocarditis should be considered as part of the differential diagnosis in an acutely unwell young adult presenting to the Emergency Department with non-specific symptoms.

Could the Use of Antihistamines Have Triggered Reversible Cerebral Vasoconstriction Syndrome? A Case Report

A 38-year-old woman presented to the emergency department with recurrent severe headaches. Although initial computer tomography (CT) brain imaging was unremarkable, a later CT venogram demonstrated a small subarachnoid haemorrhage. Magnetic resonance angiogram (MRA) brain imaging subsequently confirmed reversible cerebral vasoconstriction syndrome (RCVS). In the acute setting, RCVS rarely falls into a differential diagnosis for headache presentations, as in this case. The radiological variability can make diagnosis of RCVS challenging. However, there are clinical consistencies that can aid physicians into accurately diagnosing RCVS. A thorough history, including a medication history, can help identify potential triggers of RCVS. As in this case, the combination of commonly used drugs, including antihistamines, provides a plausible trigger for RCVS. The direct vasoactive role of antihistamines is unclear, yet there is suggestion for its ability to potentiate the vasoactive action of other drugs. In this case we propose a causal relationship between the use of antihistamine and the development of RCVS.

Post-Traumatic Meningitis: Case-Based Review of Literature from Internists’ Perspective

Most cases of post-traumatic meningitis (PTM) occur following immediate head trauma or neurosurgical procedures. Hence, internists do not often come across these patients. However, closed-head trauma can be associated with community-acquired meningitis (CAM), and this history can often be missed especially if it is remote or trivial in nature. Therefore, meticulous clinical assessment is necessary to identify cases of community-acquired PTM. Knowledge about pathophysiological, anatomical, and microbiological context of community-acquired PTM is required in order to manage these patients. The role of internist is to provide holistic management in these patients which includes not only antimicrobial treatment but also timely referral to surgical specialties if required as well as vaccination to prevent further episodes. Here, we present a case of CAM with remote history of close head trauma and cerebrospinal fluid rhinorrhea for years who was found to have base of skull (BOS) defect on imaging of skull. He was treated with antibiotics and referred to surgical specialties for repair of BOS defect as well as given pneumococcal vaccine to prevent further episodes of meningitis.