United States

Introduction 
Propofol infusion syndrome (PRIS) is a rare and fatal complication of high dose administration of propofol. We introduce a case report of a critically-ill patient who received high-dose intravenous (IV) pushes of propofol that resulted in rhabdomyolysis, metabolic acidosis, shock, multi-organ failure, and death. 

Patient Course 
A 48-year-old male diagnosed with acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia was intubated and sedated with propofol and fentanyl. He initially improved on the ventilator, but began to suffer emesis. Ileus was suspected. Imaging was not consistent with aspiration. Patient began to require large propofol boluses for adequate sedation and ventilation, greater than 4mg/kg/hr for several hours. The patient declined with progressive renal failure and increasing creatine kinase (CK). Due to elevation of CK and concern for PRIS, sedative medication was changed to midazolam. Patient soon required continuous renal replacement therapy (CRRT) due to oliguria/hyperkalemia. Evidence of shock liver became apparent. Patient required progressive amounts of vasopressors. Family decided to pursue comfort measures due to poor prognosis. 

Discussion 
PRIS is related to impaired free fatty acid metabolism and mitochondrial activity disruption causing an imbalance between energy production and utilization leading to peripheral and cardiac muscle necrosis. Typically, doses greater than 4-5mg/kg/hr are used in PRIS cases. Other hallmarks of PRIS include metabolic acidosis, kidney and cardiac failure, and hypertriglyceridemia. Treatment is generally supportive. Immediate withdrawal of propofol is recommended on suspicion. Other risk factors for PRIS include mitochondrial disease, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake, or critical illness. 

Our patient’s history fits with PRIS, due to his treatment with steroids and vasopressors, along with large doses of propofol. Carbohydrate rich diet may slow the progression of PRIS. Our patient worsened after cessation of tube feeds, potentially contributing to this patient’s syndrome. After our presented patient’s clinical picture became more evident for PRIS, sedation was transitioned to a non-propofol regimen, utilizing midazolam. In retrospect, a cardiac workup may have benefited diagnosis, as the literature seems to demonstrate that cardiac involvement is common. Triglyceride surveillance may aid in detection of impending complications of propofol, due to correlation with iatrogenic pancreatitis. 

Conclusion 
PRIS is a rare, lethal syndrome that has the best prognosis with early detection; our case demonstrates need for high index of suspicion for PRIS, and utilization of early interventions such as recognition of laboratory excursions, withdrawal of propofol, utilization of fluids, and a carbohydrate rich diet.

AMA Research Challenge 2022

A Rare Case of Propofol Related Infusion Syndrome

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poster

Background
Nontuberculous mycobacteria (NTM) are found ubiquitously in water supplies, dust and soil. Rarely they can cause pulmonary infections, although the true incidence is difficult to establish due to limitations in diagnosing the disease. Newer estimates project a higher incidence than previously thought, likely due to increased awareness of the pathogen and increased numbers of immunocompromised patients. NTM are difficult to diagnose because they do not grow in standard bacterial culture media. We present a case of a patient who required several encounters with the healthcare system before a pulmonary NTM could be established. 

Case Presentation
A patient with a history of COPD on home oxygen presented with acute hypoxic respiratory failure and unintentional 20% loss of body weight over 6 months. A cavitary lung lesion was discovered 6 months prior to this presentation. Biopsies at that time were inconclusive. The patient underwent sputum testing on this admission due to her failure to thrive and history of cavitary lesion. She had two positive acid fast bacilli sputum cultures, which further speciated to non-tuberculosis mycobacteria, Mycobacteria chimaera and Mycobacteria peregrinum. Susceptibilities were obtained and the patient was started on a multidrug regimen with good maintenance of her functional status. 

Discussion
NTM exist naturally in the environment and can be found anywhere from home shower heads to hospital dialysis machines. Diagnosis should not be considered until other causes have been ruled out. There are stringent guidelines for diagnosis, which pose an additional barrier to identifying and treating these patients. 
Guidelines for NTM pulmonary disease have the following criteria: both pulmonary and systemic symptoms must be present, there must be radiologic findings, and there must be appropriate exclusion of other diagnoses. There are microbiological criteria as well which requires at least two separate cultures. This further strains limited resources and jeopardizes the chance of making an appropriate diagnosis. NTM are difficult to diagnose because they do not grow in standard bacterial culture; few labs are capable of culturing these evasive bacteria. Despite this, clinicians should consider NTM in any patient who presents with signs of lung disease without a known cause.

Challenges in diagnosing non-tuberculosis mycobacterium lung infections

Diagnostic Challenge in a Rare Case of Pulmonary Veno-Occlusive Disease: Case Report

Balloon tamponade of bleeding varices is a temporizing measure as a bridge to treatment. The Minnesota tube has an esophageal and gastric balloon, with suction ports. No literature to date has explored the use of the suction ports as an alternative form of enteral access for medication and feeding administration in critically ill patients. We report a case of the novel use of a Minnesota Tube for enteral feeds in a critically ill patient awaiting liver transplantation after massive upper gastrointestinal bleed.

Novel Use of Minnesota Tube for Enteral Feeding In a Critically Ill Patient with Gastro-esophageal Bleeding

Propanol Ingestion Presenting as Severe Anion Gap Metabolic Acidosis and Osmolar Gap

Introduction:

Unilateral diaphragmatic paralysis is a condition in which either side of the diaphragm loses the ability to contract resulting in inadequate ventilation eventually leading to respiratory failure. Even though hypothermia-induced hemi diaphragmatic paralysis is a well-established complication of cardiac surgery, a unilateral diaphragmatic paralysis can also occur after automatic implantable cardioverter defibrillator placement.

CASE:

A 61-year-old female with a past medical history of hypertension, left bundle-branch block, Mobitz type 2 block, and chronic systolic heart failure presented to the emergency department with shortness of breath, fatigue, and orthopnea. A Multigated Acquisition (MUGA) scan at the time showed a left ventricle ejection fraction of 28% and a biventricular implantable cardioverter defibrillator placement was recommended. The left ventricular lead was unable to be placed percutaneously and the patient was referred for surgical implantation. The patient underwent left mini thoracotomy with epicardial left ventricle lead placement; the procedure was tolerated well.

Over the course of the next few months, the patient had repeated presentations of shortness of breath and was started on a beta adrenergic-glucocorticoid combination inhaler. This was followed by spirometry which failed to show a reactive airway and hence the inhaler was stopped. Interestingly however, the spirometry did show an extra thoracic restrictive volume flow loop. A chest Xray was obtained that showed left sided hemidiaphragm elevation which was progressively worsening. Since the surgery had been performed recently, this appeared to be a complication that was expected to resolve in around 6-8 months. A follow up Xray in 9 months post-surgery did not show resolution of the paralysis a thus a formal diagnosis of hemidiaphragm paralysis secondary to AICD placement was established. The patient was referred for a sniff test for confirmation.

Discussion:

This case illustrates that post procedure complications may present in unlikely ways even months after the intervention. The emphasis of having an all-rounded approach to presenting complaints cannot be underemphasized. Surgical history should be obtained at every instance as an anatomical cause of an apparent medical symptom can sometimes be the answer.

Unilateral diaphragmatic paralysis after Automatic Implantable Cardioverter Defibrillator placement

Background
Posterior fossa anomalies with prominent cerebrospinal fluid (CSF) spaces include entities such as Dandy-Walker spectrum, arachnoid cyst, mega cisterna magna, and Joubert Syndrome and Related Disorders (JSRD). Many of these have overlapping radiological findings. Several of the differentiating clinical markers only arise with development, making diagnosis difficult at a single point in time. Proper diagnosis requires longitudinal evaluation, careful consideration of diagnostic studies, at times genetic analysis. Continual re-assessment of the primary diagnosis is necessary to ensure proper diagnosis and treatment.

Case Presentation
A 15-year-old male was brought by his father to establish primary care. Father reported history of spastic quadriplegia and DWM and expressed concern about the patient’s episodic abnormal breathing patterns. Physical exam showed the patient was alert and interactive although speech was limited to “mom” and “dad”. The head was of normal circumference. There was bilateral exotropia, occasional nystagmus, and spastic muscle tone in all limbs. The lungs were clear to auscultation bilaterally. Referral was made to neurosurgery, who disputed the diagnosis of DWM given the clinical picture and prior imaging. A brain MRI showed severe vermis dysplasia with enlargement of the fourth ventricle, prominence of the posterior fossa CSF-spaces, diffusely abnormal foliation and fissuring of bilateral cerebellar hemispheres, and molar tooth sign (MTS) with deepening of the interpeduncular fissure and extension of the superior cerebellar peduncles. The patient received correction of diagnosis to JSRD.

Discussion
JSRD is a ciliopathy with autosomal and X-linked genetic variants. The primary diagnostic criteria are delayed developmental milestones, hypotonia evolving into truncal ataxia, and characteristic imaging. Secondary criteria include oculomotor apraxia and alternating episodes of tachypnea with apnea. “Pure” Joubert Syndrome expresses only primary and secondary criteria, while JSRD is considered when there are accompanying renal, hepatic, ophthalmic, and phalangeal abnormalities.

JSRD and DWM share several radiological criteria, including vermis hypoplasia and prominence of the posterior fossa CSF-space, leading to some diagnostic ambiguity. At a young age, patients with underlying JSRD or DWM may have similar clinical presentation. To ensure early differentiation clinicians should be aware of MTS as a pathognomonic radiologic finding for JSRD.


Joubert Syndrome and Related Disorders

Cranial empyema is a neurosurgical emergency. The body’s response attempts to wall off infection, resulting in a characteristic capsule that can be visualized through imaging. Organisms often correlate with patient age, medical history, and source of infection. In the setting of meningitis Streptococci, Staphylococci, Haemophilus, and other gram-negative bacilli predominate. In contrast, Escherichia and Salmonella species are often responsible for infections of existing subdural hematomas. According to prior studies, empyema of this etiology are typically less aggressive, in contrast to the refractory case seen in our patient. Neurologic prognosis is contingent on early diagnosis and management. We hope to discuss the importance of early radiologic follow-up and differentiating features between empyema and subacute subdural hematomas.


Refractory Empyema Secondary to Escherichia coli Infection of an Infantile Subdural Hematoma

Background
Nipple discharge presents in approximately 3 to 10% of women and is classified as either physiological (green, white, or yellow) or pathological (bloody). Unilateral, spontaneous bloody nipple discharge (BND) presents due to an underlying malignancy in 5-21% of cases. The American College of Radiology does not recommend imaging for physiological discharge but recommends a mammogram (MMG) and ultrasound (US) as first-line imaging modalities for BND dependent upon age. Ductography and magnetic resonance imaging (MRI) are used to further rule out benign, premalignant lesions, such as intraductal papillomas. Studies show MRI has a 93-100% sensitivity for detecting invasive breast cancer, but is not generally used unless suspicion for malignancy remains high after MMG and US are inconclusive. 

Case Presentation
A 53 year-old female presents for diagnostic MMG for complaints of focal right breast pain and BND. Digital breast tomosynthesis (DBT) in January 2021 showed stable calcifications, seen as early as 2019, and no abnormalities. US of the right breast showed a 5x3x3mm subareolar irregular mass, therefore, 6-month follow-up with MMG was recommended. A high-risk MRI 1 month later demonstrated non-mass enhancement extending 2-11 cm from the nipple in the right breast, and a retroareolar hyperintense T2 material extending into the area of non-enhancement. Stereotactic biopsy pathology results confirmed ductal carcinoma in situ, atypical ductal hyperplasia, and intraductal papilloma, with estrogen receptor and progesterone receptor positivity. 

The patient underwent a total mastectomy of the right breast, as breast conserving treatment was not considered due to MRI findings of 9x11x5 cm enhancement, comprising the entire lateral breast. Surgical pathology confirmed DCIS with microinvasion and tumor staged T1N0M0. 

Discussion
Standard treatment of BND typically includes invasive measures such as ductoscopy and major duct excision. However, the case demonstrates the ability for MRI to detect abnormalities not seen on DBT and display the total extent not fully appreciated by US. The use of MRI earlier in the diagnostic process allows for the use of breast conserving measures and, moreover, decreases chances of invasive and even metastatic lesions. This would result in less of a need for more aggressive treatments and also decreases mortality rates. 


The Use of MRI to Detect Malignancy in a Patient Presenting With Unilateral Bloody Nipple Discharge and Unremarkable Diagnostic Mammogram

Adalimumab Induced Lupus: A Review of Case Reports

Abstract Title:
Case Report: Patient with an ANCA negative and treatment-resistant Granulomatosis Polyangitis with CNS involvement.

Background:
Granulomatosis polyangiitis (GPA) is a rare autoimmune disorder affecting the small and medium-sized vessels, most seen in people around 40-60 years of age. Anti-neutrophil cytoplasmic autoantibodies (ANCAs) directed to proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA) are strongly associated with ANCA-associated vasculitis. However, about 10-20% of patients are ANCA negative making it harder to diagnose patients with non-specific symptoms.

Case Presentation:
A 55-year-old female was diagnosed with ANCA negative GPA with CNS involvement. The patient was initially treated with a 3-month course of prednisolone; however, upon recurrence, she was then started on pulse methylprednisolone treatment with cyclophosphamide and rituximab. Despite treatment, the patient developed ischemic stroke and osteomyelitis at the base of the skull. She continued to deteriorate and was subsequently started on high-dose steroids, immunosuppressants, vasopressors, and broad-spectrum antibiotics, including colistin, ciprofloxacin, and teicoplanin. The patient had notable clinical improvement after an array of medical management, transferred out to long term rehabilitation care and subsequently discharged.

Discussion:
GPA is a systemic inflammatory disease characterized by necrotizing granulomatous inflammation and pauci-immune small vessel vasculitis of the upper and lower respiratory tract and kidneys. Most individuals are ANCA positive, and just 10% are ANCA negative. Most ANCA-negative patients have restricted disease or disease that only affects the upper and lower respiratory tracts, and the involvement of the CNS is infrequent.
Patients with ANCA-associated vasculitis have historically reacted successfully to large doses of prednisone combined with immunosuppressants, with a response rate as high as 87.7%. In our patient, the absence of ANCA may have altered the clinical response of GPA to such medications.
Advances in its management include targeted therapy which has emerged as a promising means of treating cyclophosphamide-resistant patients with GPA. Rituximab and infliximab have shown their role in handling GPA patients resistant to cyclophosphamide.
Our case demonstrates the value of prompt rheumatology team intervention when GPA is suspected, even when c-ANCA results are negative. Early detection can prevent the disease from spreading, which would otherwise have severe local and systemic effects.


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