Spontaneous pneumomediastinum, pneumoretroperitoneum, and cervicofacial subcutaneous emphysema after repeatedly and forcefully blowing into a bottle

Spontaneous pneumomediastinum (SPM) is an uncommon, self-limiting condition associated with increased intra-thoracic pressure resulting in alveolar rupture. Search of the literature revealed no detailed case report about a 26-year-old psychiatric patient who repeatedly and forcefully blew air into a bottle for 5 days resulting in a combined condition of spontaneous pneumoretroperitoneum, pneumomediastinum, and cervicofacial subcutaneous emphysema. It is crucial to find a primary source and treat appropriately. Psychiatric patients may have psychotic behaviors mimicking Valsalva's maneuver that increases intra-thoracic pressure and causing SPM. Optimal medications should be given to control psychotic behaviors. Family members and caregivers should be explained about this unusual behavior so that they can prevent this rare condition.

Relationship of symptoms with sleep-stage abnormalities in obstructive sleep apnea-hypopnea syndrome

BACKGROUND

Patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) present with a variety of sleep-related symptoms. In polysomnography, sleep architecture is almost always abnormal, but it is not known which of the sleep-stage abnormalities are related to symptoms. Finding key sleep-stage abnormality that cause symptoms may be of therapeutic importance to alleviate symptoms. So far the mainstay of treatment is continuous positive airway pressure (CPAP)/bi-level positive airway pressure (BIPAP) therapy, but many patients are non-compliant to it. Correcting the sleep-stage abnormality that cause symptoms by pharmacotherapy may become an important adjunct to CPAP/BIPAP therapy.

METHODS

A cross-sectional study. Adult subjects who attended a sleep laboratory for diagnostic polysomnography for a period of 1 month were recruited consecutively. OSAHS was diagnosed using American Academy of Sleep Medicine criteria. Subjects filled a questionnaire for symptoms prior to polysomnography.

RESULTS

Thirty subjects, of whom 83.3% were obese, met diagnostic criteria, with males constituting 46.7% and females constituting 53%. Mean age was 53.40±11.60 years. Sleep architecture comprised N1 19.50±19.00%, N2 53.93±13.39%, N3 3.90±19.50%, and rapid eye movement 8.92±6.21%. Excessive fatigue or sleepiness, waking up tired, falling asleep during the day, trouble paying attention, snoring and insomnia were significantly related to decreased N3 sleep.

CONCLUSIONS

Most of the symptoms in OSAHS in adults are related to decreased stage N3 sleep. If confirmed by larger controlled studies, correcting N3 sleep deficiency by pharmacotherapy may become an important adjunct to CPAP/BIPAP therapy to alleviate symptoms.

Pharmacokinetic profile of methotrexate in psoriatic skin via the oral or subcutaneous route using dermal microdialysis showing higher methotrexate bioavailability in psoriasis plaques than in non-lesional skin

AIMS

The aim of this pilot study was to use microdialysis to evaluate levels of Methotrexate (MTX) directly in psoriatic skin following oral or subcutaneous administration of MTX to elaborate a complete pharmacokinetic profile within the dermal skin.

METHODS

Six patients with chronic plaque psoriasis on the arm undergoing treatment with MTX were included in a mono-centre clinical trial. Patients were under treatment with p.o. or s.c. MTX (7.5 and 15 mg) for at least 3 months. Interstitial fluid was collected ex vivo via dermal microdialysis from lesional or non-lesional skin and via intravenous microdialysis as well as blood serum every hour up to 10 h after methotrexate administration every hour. MTX was analysed via liquid chromatography.

RESULTS

The area under the curve (AUC) of methotrexate from peripheral blood was up to four times higher than from microdiaylsis, which detection of free unbound MTX. The AUC from dialysates in psoriatic lesional skin was higher than in non-lesional psoriatic skin, and the AUC levels from i.v. microdialysis were non-significantly higher than those from lesional psoriatic skin. Pharmacokinetic profiles were individually quite different and did not primarily depend on the dose or the means (p.o. vs. s.c.) in which it was administered.

CONCLUSION

Dermal microdialysis is a valid tool to evaluate levels of methotrexate in the skin of psoriasis patients. Drug levels and bioavailability of methotrexate were higher in lesional than non-lesional psoriatic skin. The individual AUC of MTX was not primarily dependent on the route or dose of administration.

Right Gaze Palsy and Hoarseness: A Rare Presentation of Mediastinal Tuberculosis with an Isolated Prepontine Cistern Tuberculoma

We describe a previously healthy young man who presented with headaches, diplopia with right lateral gaze palsy, dysphagia, and hoarseness over a 2-month period. Magnetic resonance imaging of the brain revealed a small enhancing mass at the prepontine cistern and chest CT showed a left mediastinal mass. Mediastinoscopy and lymph node biopsy were performed. DNA probe and culture of the biopsy specimen were confirmed to be Mycobacterium tuberculosis complex. Resolution of neurologic symptoms was noted after 6 weeks, in addition to regression of brain stem and mediastinal lesions after 12 weeks of antituberculous therapy.

Use of flexible bronchoscopy in an adult for removal of an aspirated foreign body at a community hospital

Foreign body aspiration (FBA) is more common in children than adults with about 80% occurring in children aged less than 15 years. FBA in adults is often overlooked as a potential cause of airway obstruction especially if there is no asphyxiation. We present a case of a 45-year-old male with alcohol abuse who presented with post-obstructive pneumonia secondary to aspiration of tooth of unknown duration. The tooth was removed via flexible bronchoscopy (FBr) and we will discuss the use of FBr for foreign body (FB) removal, which FB can be easily removed by FBr, and the different techniques and devices used for FB removal via FBr.

Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis - a case report

Clozapine is the preferred antipsychotic used for the treatment of resistant schizophrenia with suicidal ideation. The drug is started at a low dose and gradually increased to a target dose of 300–450 mg/day. It is well known to cause agranulocytosis and neutropenia. Several cases of fatal sepsis have been reported in neutropenic patients and emphasis is placed on monitoring for agranulocytosis; however, clozapine also causes intestinal hypomotility and constipation, which if unrecognized can lead to intestinal obstruction, bowel necrosis, and intra-abdominal sepsis. Reduced behavioral pain reactivity in schizophrenics may alter the ability to express pain, potentially leading to a delay in the presentation for medical attention. We report a case of fatal intra-abdominal sepsis secondary to an unrecognized case of clozapine-related constipation.

A case of chylothorax in a patient with sarcoidosis: a rare and potentially fatal complication

Obstruction of the thoracic duct may lead to accumulation of a lymphatic fluid rich in triglycerides named chyle. When chyle accumulates in the pleural cavity, it becomes a chylothorax. Malignancy, particularly lymphoma, is the most common cause of chylothorax; however, any pathology leading to obstruction or destruction of the thoracic duct can lead to a chylothorax. This particular case investigates an incidence of chylothorax in sarcoidosis. A 54-year-old African American woman with a medical history of sarcoidosis, congestive heart failure, and smoking presented to the emergency department with complaints of bilateral foot swelling and exertional shortness of breath 3 days in duration. Physical examination was positive for bilateral crepitations with decreased air entry, abdominal ascites, and bilateral 2+ pitting edema. Both chest X-ray and chest CT were positive for stable bilateral pleural effusions (when compared to imaging done 3 years previously), and thoracocentesis and paracentesis were positive for chylous fluid accumulation. Chylothorax was diagnosed, and based on the previous medical history, the lymphadenopathy of sarcoidosis was determined to cause the occlusion of the thoracic duct. Lymphoscintigraphy and surgical intervention were advised; however, the family decided on conservative management and the patient expired intubated in the ICU. Chylothorax is a rare manifestation of sarcoidosis and high index of suspicion should be there to diagnose this, as there is high morbidity and mortality associated with it.