scholarly journals Profound Hypoglycemia with Ecstasy Intoxication

2015 ◽  
Vol 2015 ◽  
pp. 1-2 ◽  
Author(s):  
Perliveh Carrera ◽  
Vivek N. Iyer
Keyword(s):  
Early Recognition ◽  
Serum Insulin ◽  
Severe Hypoglycemia ◽  
Altered Mental Status ◽  
High Dose ◽  
Psychomotor Agitation ◽  
Hemodynamic Compromise ◽  
Frequent Monitoring ◽  
Ecstasy Intoxication ◽  
Synthetic Drug

Background.3,4-Methylenedioxymethamphetamine (MDMA) or ecstasy is a synthetic drug that is commonly abused for its stimulant and euphoric effects. Adverse MDMA effects include hyperthermia, psychomotor agitation, hemodynamic compromise, renal failure, hyponatremia, and coma. However, endogenous hyperinsulinemia with severe persistent hypoglycemia has not been reported with MDMA use.Case Report.We report the case of a 29-year-old woman who remained severely hypoglycemic requiring continuous intravenous infusion of high-dose dextrose solutions for more than 24 hours after MDMA intoxication. Serum insulin and C-peptide levels confirmed marked endogenous hyperinsulinemia as the cause of the severe hypoglycemia.Why Should an Emergency Physician Be Aware of This?Immediate and frequent monitoring of blood glucose should be instituted in patients presenting with MDMA ingestion particularly if found to be initially hypoglycemic. Early recognition can help prevent the deleterious effects of untreated hypoglycemia that can add to the morbidity from MDMA use. Clinicians need to be aware of this side effect of MDMA so they can carefully monitor and treat it, especially in patients presenting with altered mental status.

scholarly journals The pathophysiology of “happy” hypoglycemia

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Thomas Loeb ◽  
Anna Ozguler ◽  
Geraldine Baer ◽  
Michel Baer
Keyword(s):  
Critical Care ◽  
Hemorrhagic Shock ◽  
Lactate Production ◽  
Severe Hypoglycemia ◽  
Altered Mental Status ◽  
Case Presentation ◽  
Energy Substrate ◽  
Tissue Hypoperfusion ◽  
The Brain ◽  
Critical Care Patients

Abstract Background Hypoglycemia usually includes various neurological symptoms, which are the consequence of neuroglycopenia. When it is severe, it is associated with altered mental status, even coma. Case presentation We report the case of a patient with severe hypoglycemia, completely asymptomatic, due to the increase of lactate production in response to tissue hypoperfusion following a hemorrhagic shock. This illustrates that lactate can substitute glucose as an energy substrate for the brain. It is also a reminder that this metabolite, despite its bad reputation maintained by its role as a marker of severity in critical care patients, has a fundamental role in our metabolism. Conclusions Following the example of the “happy hypoxemia” recently reported in the literature describing asymptomatic hypoxemia in COVID-19 patients, we describe a case of “happy hypoglycemia.”

Early Recognition of Renal Toxicity of High-dose Methotrexate Therapy

2008 ◽  
Vol 30 (12) ◽  
pp. 950-952 ◽  
Author(s):  
Theodore Scott Nowicki ◽  
Kari Bjornard ◽  
David Kudlowitz ◽  
Claudio Sandoval ◽  
Somasundaram Jayabose
Keyword(s):  
Renal Toxicity ◽  
Early Recognition ◽  
Methotrexate Therapy ◽  
High Dose ◽  
High Dose Methotrexate ◽  
Dose Methotrexate

scholarly journals 079 Glial fibrillary acidic protein (GFAP) astrocytopathy associated with cerebral micro-infarction and poor therapeutic response

2019 ◽  
Vol 90 (e7) ◽  
pp. A25.2-A25 ◽  
Author(s):  
Allycia MacDonald ◽  
James Triplett ◽  
Srimathy Vijayan ◽  
Michael Bynevelt ◽  
Rahul Lakshmanan ◽  
...  
Keyword(s):  
White Matter ◽  
Glial Fibrillary Acidic Protein ◽  
Early Recognition ◽  
Oral Intake ◽  
Brain Biopsy ◽  
Acidic Protein ◽  
Gait Disturbance ◽  
High Dose ◽  
Elevated Protein ◽  
Upper Thoracic

IntroductionGlial fibrillary acidic protein (GFAP) astrocytopathy is a lesser recognised immune-mediated meningo-encephalomyelitis, which is steroid responsive in the majority of cases. Neuroimaging is unique with a distinctive symmetric white matter perivascular linear and punctate enhancement pattern. We present a case with classical phenotype but delayed clinical response, and highlight the importance of early recognition and treatment.CaseA 59-year-old Caucasian female presented with a two month history of headache, gait disturbance, insomnia, agitation, disorientation and reduced oral intake. Examination revealed a high frequency upper limb tremor, hypertonicity and pathologically brisk reflexes with impaired cognitive function. MRI brain and spinal cord demonstrated high T2 signal and striking perivascular and punctate enhancement in supratentorial white matter, cervical and upper thoracic cord. CSF examination revealed lymphocytic pleocytosis and elevated protein. Brain biopsy demonstrated reduced GFAP expression, perivascular T-lymphocytic infiltrate, and recent white matter microinfarction. CSF and serum GFAP antibodies were positive.Motor deterioration accompanied progression to a stuporous state. High dose corticosteroids were commenced, followed by intravenous immunoglobulin and mycophenolate. While there was marked improvement of perivascular contrast enhancement on imaging, the patient continued to demonstrate prominent tremor, gait disturbance and behavioural issues 9 months following symptom onset.ConclusionsThe persistence of disability in this case is likely the result of axonal loss from the initial insult, reflected by the biopsy evidence of microinfarction. Awareness of the unique pattern on MRI and the clinical phenotype will aid in early recognition and prompt treatment of this condition, thus preventing the potential long term morbidity.

POEMS Syndrome

Hematology ◽  
2005 ◽  
Vol 2005 (1) ◽  
pp. 360-367 ◽  
Author(s):  
Angela Dispenzieri
Keyword(s):  
Peripheral Neuropathy ◽  
Chronic Inflammatory Demyelinating Polyneuropathy ◽  
Early Recognition ◽  
Correct Diagnosis ◽  
Bone Lesion ◽  
High Dose Chemotherapy ◽  
Poems Syndrome ◽  
Bone Lesions ◽  
High Dose ◽  
Sclerotic Bone

Abstract POEMS syndrome is defined by the presence of a peripheral neuropathy (P), a monoclonal plasma cell disorder (M), and other paraneoplastic features, the most common of which include organomegaly (O), endocrinopathy (E), skin changes (S), papilledema, edema, effusions, ascites, and thrombocytosis. Virtually all patients will have either sclerotic bone lesion(s) or co-existent Castleman’s disease. Not all features of the disease are required to make the diagnosis, and early recognition is important to reduce morbidity. Other names for the syndrome include osteosclerotic myeloma, Crow-Fukase syndrome, or Takatsuki syndrome. Because the peripheral neuropathy is frequently the overriding symptom and because the characteristics of the neuropathy are similar to that chronic inflammatory demyelinating polyneuropathy (CIDP), patients are frequently misdiagnosed with CIDP or monoclonal gammopathy of underdetermined significance (MGUS)-associated peripheral neuropathy. Not until additional features of the POEMS syndrome are recognized is the correct diagnosis made and effective therapies initiated. Clues to an early diagnosis include thrombocytosis and sclerotic bone lesions on plain skeletal radiographs. Therapies that may be effective in patients with CIDP and MGUS-associated peripheral neuropathy (intravenous gammaglobulin and plasmapheresis) are not effective in patients with POEMS. Instead, the mainstays of therapy for patients with POEMS include irradiation, corticosteroids, and alkylator-based therapy, including high-dose chemotherapy with peripheral blood stem cell transplantation.

scholarly journals A Retrospective Review of Patients with Necrotizing Fasciitis Presenting to an Emergency Department in Hong Kong

2002 ◽  
Vol 9 (1) ◽  
pp. 10-17 ◽  
Author(s):  
Fp Sin ◽  
Mc Yuen ◽  
Kw Lam ◽  
Cw Wu ◽  
Wk Tung
Keyword(s):  
Emergency Department ◽  
Necrotizing Fasciitis ◽  
Early Recognition ◽  
High Dose ◽  
Accident And Emergency ◽  
Patients With Diabetes ◽  
Wrong Diagnosis ◽  
Radical Debridement ◽  
Accident And Emergency Department ◽  
Clinical Records

Background Necrotizing fasciitis is a soft tissue gangrenous infection that require early diagnosis, radical debridement and broad-spectrum antibiotics. Aim To review the clinical spectrum and outcome of necrotizing fasciitis in Kwong Wah Hospital during a period of 18 months. Method Cases of necrotizing fasciitis were identified from discharge statistics for the period January 1999 to June 2000. Accident and Emergency Department (AED) notes and clinical records after admission were reviewed for clinical features, predisposing factors, microbiology, histology, treatment and outcome. Results Fifteen cases of necrotizing fasciitis were found but two of them had wrong diagnosis made. Of the thirteen cases, ten were male and three were female. The average age was 61.7 years old. Most of them presented with different combinations of swelling, pain, erythema and fever. They attended the emergency department with an interval of 3.5 days from the onset of symptoms. Risk factors were identified in 64% of patients, with diabetes mellitis (DM) and hypertension (HT) being the most common. Monomicrobial and polymicrobial infections were equally common in our study. Streptococcus pyogene was the most common pathogen. Only two NF (18%) were diagnosed in AED. Six patients were admitted to either surgical or orthopaedic wards and all of them underwent operations within 24 hours although two of them died. Other five patients were managed in medical ward and four of these patients underwent delayed operations but survived whilst one of them died despite of early surgical intervention. Overall mortality was 23%. Conclusions This condition affects a wide age group and have associated morbidities. It is often a fatal disease. Early recognition, high dose antibiotics and surgical debridement are important in its management.

scholarly journals Profile of Blood Glucose and Insulin after Vitamin C and Vitamin E Supplementation on Active Teenagers

2018 ◽  
Vol 7 (4.26) ◽  
pp. 136
Author(s):  
Irfiansyah Irwadi ◽  
Hayuris Kinandita ◽  
Jamaluddin Mahmud ◽  
Lilik Herawati
Keyword(s):  
Blood Glucose ◽  
Vitamin E ◽  
Vitamin C ◽  
Serum Insulin ◽  
Fasting Blood Glucose ◽  
Combination Group ◽  
Control Group ◽  
High Dose ◽  
Moderate Dose ◽  
Significant Difference

Aim: Antioxidants, such as vitamin C and vitamin E, is widely used as supplements. The aim of this study is to analyze the profile of blood glucose, serum insulin, and  HOMA in active teenagers after vitamin C and vitamin E supplementation.Methods: Subjects (14-16 y.o) consisted of 12 boys and 5 girls, divided into 3 groups: control (4 boys, 2 girls), ‘moderate dose’ of vitamin C and vitamin E combination group (5 boys, 1 girls), and ‘high dose’ of vitamin C and vitamin E combination group (3 boys, 2 girls). The treatment was given for 5 days. Vitamin C and vitamin E for ‘moderate dose’ was 500mg;  200IU, and for ‘high dose’ was 1000mg; 400IU. Fasting Blood Glucose (FGB) and 1 hour BG (1hr_BG), fasting serum insulin (FSI) and 1 hour SI (1hr_SI) was collected after treatment. We also calculated the HOMA-IR and HOMA-β.Result: There was no significant difference on FBG, 1hr_BG, FSI, 1hr_SI, HOMA-IR, and HOMA-β (p≥ 0.05). However, mean FBG and 1hr_BG tended to be higher on the treatment groups. The control group had the lowest HOMA-IR and the highest HOMA-β.Conclusions: We suggest that the supplementation of vitamin C and vitamin E in active teenagers is not essential on glucose homeostasis.  

Meningiomas: genetics, malignancy, and the role of radiation in induction and treatment

1994 ◽  
Vol 81 (5) ◽  
pp. 666-675 ◽  
Author(s):  
Charles B. Wilson
Keyword(s):  
San Francisco ◽  
Early Recognition ◽  
Neurological Injury ◽  
High Dose ◽  
Content Type ◽  
Parasellar Region ◽  
Patients At Risk ◽  
Radiation Induced ◽  
Malignant Lesions ◽  
The University

✓ The author reviews the molecular genetics, pathology, and cell kinetics of meningiomas and the role that regional multiplicity in the dura mater may play in their recurrence. Malignant and radiation-induced meningiomas are discussed, with summaries of series of 60 patients with frankly malignant lesions treated over a period of 22 years at the University of California, San Francisco, and of 10 patients with meningiomas induced by high-dose radiation therapy. Reviewing a 23-year series of 140 patients with subtotally removed meningiomas who were treated postoperatively with radiation, the author recommends that, with meticulous technique, irradiation is effective in preventing the regrowth of subtotally removed benign meningiomas and of all malignant meningiomas. Adoption of both the microscopical cytological grading system proposed by Jääskeläinen's group in Helsinki and the classification of operations proposed by Donald Simpson is also recommended. Wide removal of dura adjacent to meningioma reduces the risk of recurrence, and determination of the bromodeoxyuridine labeling index provides a valid basis for planning treatment and follow-up evaluations. Increased awareness is necessary for early recognition of radiation-induced meningiomas in patients at risk for developing such tumors. For meningiomas in such sites as the parasellar region and the posterior fossa, conservative removal of tumor followed by irradiation is advocated in preference to a radical operation that may cause neurological injury without being curative.

Chemotherapy-Induced T-MDS/AML-Associated Genetic Aberrations.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 2021-2021
Author(s):  
Joerg Baesecke ◽  
Martina Podleschny ◽  
Julia Goldstein ◽  
Claudia Riechel ◽  
Detlef Haase ◽  
...  
Keyword(s):  
Cord Blood ◽  
Peripheral Blood ◽  
Early Recognition ◽  
Genotoxic Stress ◽  
High Dose Chemotherapy ◽  
Ongoing Study ◽  
Control Group ◽  
High Dose ◽  
Fish Analysis ◽  
Genetic Aberrations

Abstract Therapy-related solid and hematological neoplasias occur according to the treatment regimen and intensity. The cumulative incidence of therapy related myelodysplastic syndromes and acute myeloid leukemias(t-MDS/AML) ranges between 5 and 15% in non-myeloablative and myeloablative treatment protocols respectively. t-MDS/AML share characteristic genetic aberrations which include translocations (e.g. involving 11q23, MLL and t(9;22), inv 16, t(8;21), t(3;21), t(15;17) and cytogenetic aberrations (e.g. 5q-, 7q-). We have investigated if these genetic aberrations are present in patients who underwent chemotherapy. Since we and others have detected aberrations in aleukemic hematopoiesis (Baesecke et al. Blood. 2002;100:2267–2268) we also wanted to determine if t-MDS/AML early recognition can be performed by this screening. We enrolled patients with Non Hodgkin Lymphoma, either treated by conventional or high dose chemotherapy, included in the MegaChoep protocoll of the German high grade lymphoma study group. Samples were taken as fresh peripheral blood stem cells (PBSCT), bone marrow aspirates (BM) or peripheral blood (PB) after informed consent according to the convention of Helsinki. PBSC of healthy adult donors and cord blood of healthy newborn were used as control. Blood samples were submitted to RT- or Real-Time PCR (sensitivity 10–4 to 10–5) of t(9;22), inv 16, t(8;21), t(15;17) and MLL-partial tandem duplications (MLL-PTD). RNA preparation, reverse transcription, and PCR were performed in separate laboratories. Cytogenetic analysis was performed by FISH (probes EGR1-del5, p53, cep7-del 7, MLL and cep8-tris 8). The results of the ongoing study are as follows. In the cord blood control group, positive samples were t(15;17) 1.7% (1/60 samples), inv 16 5.6% (3/54), t(8;21) 2.8% (1/36), t(9;22) 3.4% (2/59), MLL-PTD primary PCR 0% (0/34). No positive results were observed in PBSC samples of healthy donors (22 samples). 53 samples of patients of which 21 were PBSC and 32 were BM or PB have been investigated so far. 34/53 patients (64.2%) underwent a high dose chemotherapy. In 9.4% (5/53) the translocation t(15;17) was detected. All five samples were PBSC. No amplification of inv 16, t(8;21) and t(9;22) was observed. In FISH analysis two of 18 patient PBSC samples (11%) exhibited aberrations in the p53 locus, which were classified as abnormal but still non-clonal. Our results confirm the existence of AML-associated translocations in cord blood at frequencies, which by far exceed the incidence of AML in healthy individuals. Compared to these findings the incidence of t-AML- associated aberrations in patients who underwent chemotherapy-induced genotoxic stress is lower than expected. Positive PCR-results of this group may thus be more informative concerning the detection of a leukemic clone and the risk of attracting a t-MDS/AML. Positive patients are currently under observation and the number of samples and aberrations in the ongoing study is increased.

Diagnosis and Treatment of Neuromyelitis Optica

US Neurology ◽  
2009 ◽  
Vol 05 (01) ◽  
pp. 56
Author(s):  
Marcelo Matiello ◽  
Brian G Weinshenker ◽  
◽  
Keyword(s):  
Neuromyelitis Optica ◽  
Early Recognition ◽  
Water Channel ◽  
Basic Research ◽  
Immunosuppressive Drugs ◽  
High Dose ◽  
Autoimmune Inflammatory Disease ◽  
The Central Nervous System ◽  
New Treatments

Neuromyelitis optica (NMO), an autoimmune inflammatory disease of the central nervous system (CNS), is characterized by severe attacks of optic neuritis and myelitis. A specific immunoglobulin G1 (IgG1) autoantibody, NMO-IgG, is present in NMO patients. Its discovery facilitates the early recognition of NMO, differentiation of NMO from multiple sclerosis (MS), and recognition of a broader spectrum of manifestations of NMO. Following an attack of NMO, high-dose intravenous methylprednisolone is the treatment of choice. Plasmapheresis is recommended for attacks that do not respond to first-line treatment. For long-term relapse prevention, immunosuppressive drugs such as azathioprine, mycophenolate mofetil, rituximab, and mitoxantrone are recommended rather than the immunomodulatory agents used for MS. The study of NMO has rapidly progressed due to the successful translation of the discovery of a specific biomarker into clinical practice and basic research. The discovery of the antigenic target of NMO-IgG, the water channel aquaporin-4, improved understanding of the physiopathology of NMO and may lead to the development of new treatments.

032 Neurological sequelae of immune checkpoint inhibitors: a case series

2018 ◽  
Vol 89 (6) ◽  
pp. A13.3-A14 ◽  
Author(s):  
Matthew Silsby ◽  
Stephen R Duma ◽  
Neil Mahant ◽  
Steve Vucic ◽  
Andrew Henderson
Keyword(s):  
T Cells ◽  
Checkpoint Inhibitors ◽  
Early Recognition ◽  
Case Series ◽  
Tumour Response ◽  
Stage Iv ◽  
High Dose ◽  
Solid Organ ◽  
Fisher Syndrome ◽  
Neurological Sequelae

IntroductionMonoclonal antibodies directed against co-stimulatory molecules on T cells (checkpoint inhibitors, CIs) are used to treat solid organ malignancies. Neurological complications are an increasingly recognised consequence of their use. We present three patients referred to the Neurology service at Westmead Hospital in 2017 with new neurological complaints following CI therapy.CasesPatient 1, a 54 year old woman with stage IV non-small cell lung cancer treated with pembrolizumab (anti-PD-1), presented with cerebral vasculitis causing bilateral ACA territory cerebral infarction. Patient 2, a 59 year old woman with metastatic melanoma treated with ipilimumab (anti-CTLA4) and nivolumab (anti-PD-1), presented with ataxia, diplopia and ptosis consistent with Miller Fisher syndrome. Patient 3, a 77 year old woman with metastatic colorectal adenocarcinoma treated with nivolumab (anti-PD-1), presented with ocular myasthenia manifesting as fatigable ptosis and complex ophthalmoplegia.The diagnoses were made by clinical assessment with imaging and neurophysiological investigations where possible. Antibodies relevant to the neurological condition were negative, in keeping with previous reports. CIs were discontinued in all patients. Treatment included intravenous pulsed methylprednisolone followed by high dose oral taper in all patients. Additionally, Patient 1 was treated with infliximab and rituximab; Patients 2 and 3 received intravenous immunoglobulin followed by monthly maintenance therapy; Patient 2 underwent plasma exchange. Patients 1 and 2 recovered independent ambulation. Patient 3 died two months after presentation due to underlying malignancy.ConclusionCheckpoint inhibitors block co-stimulatory molecules on T-cells, allowing the immune system to mount an anti-tumour response. The resulting immune dysregulation can also lead to organ-specific inflammatory and immune complications, of which neurological sequelae are increasingly recognised. The three reported patients highlight the spectrum of disease that can arise. Their occurrence within one year suggests an increasing incidence, and a need for increased vigilance. Early recognition is paramount as treatment with high dose corticosteroids, even in conditions that would not normally respond, is recommended.

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