Prevalence and factors associated with inappropriate continuation of stress ulcer prophylaxis at discharge

Stress ulcer prophylaxis is started in the critical care unit to decrease the risk of upper gastrointestinal ulcers in critically ill persons and to decrease mortality caused by stress ulcer complications. Unfortunately, the drugs are often continued after recovery through discharge, paving the way for unnecessary polypharmacy.

STUDY DESIGN

We conducted a retrospective cross-sectional study including patients admitted to the adult critical care unit and started on the stress ulcer prophylaxis with a proton pump inhibitor (PPI) or histamine receptor 2 blocker (H2 blocker) with an aim to determine the prevalence of inappropriate continuation at discharge and associated factors.

RESULT

3200 people were initiated on stress ulcer prophylaxis, and the medication was continued in 1666 patients upon discharge. Indication for long-term use was not found in 744 of 1666, with a 44% prevalence of inappropriate continuation. A statistically significant association was found with the following risk factors: discharge disposition (home vs other medical facilities, p=0.002), overall length of stay (more than 10 days vs less than or equal to 10 days, p<0.0001), mechanical ventilator use (p<0.001), number of days on a mechanical ventilator (more than 2 days vs less than or equal to 2 days, p<0.001) and class of stress ulcer prophylaxis drug used (H2 blocker vs PPI, p<0.001).

CONCLUSION

The prevalence of inappropriate continuation was found to be higher than prior studies. Given the risk of unnecessary medication intake and the associated healthcare cost, a web-based quality improvement initiative is being considered.

Hemophagocytic Lymphohistiocytosis: A Rare Complication of COVID-19 in a Patient With Sickle Cell Anemia

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition that can be fatal due to overwhelming macrophage activation and cytokine production. It can be primary (familial/genetic) or secondary. It is associated with infections, malignancies, and rheumatologic and immunodeficiency disorders. We report a middle-aged female patient with sickle cell anemia who presented with COVID-19 infection that triggered a vaso-occlusive crisis and resulted in HLH. She had preexisting high ferritin levels and cytopenias, making the diagnosis more challenging. A high index of suspicion and timely treatment is essential to prevent adverse outcomes.

Immune Reconstitution Inflammatory Syndrome in Aids Patient After Successful Induction of Virological Suppression with Cabotegravir/Rilpivirine

Long-acting (LA) cabotegravir/rilpivirine (CAB/RPV) is a complete regimen for the management of human immunodeficiency virus type 1 (HIV-1) infection to replace their oral antiretroviral therapy (ART) when they have been virologically suppressed. We present a case of successful achievement of undetectable HIV RNA viral load levels in an acquired immunodeficiency syndrome (AIDS) patient with long-standing virologic failure within two months of CAB/RPV LA initiation. This was later complicated by immune reconstitution inflammatory syndrome (IRIS) due to Mycobacterium avium-intracellulare (MAI) infection and hepatitis B virus (HBV) reactivation.

LEARNING POINTS

This case highlights the efficacy of monthly CAB/RPV LA in rapidly reducing the HIV viral load level in a poorly controlled patient who lacked significant resistance to the two drugs.This is the first case of IRIS reported in the literature while using CAB/RPV LA. IRIS in the setting of occult MAI is well recognised. It would have occurred with good adherence to any regimen which rapidly suppressed the viral load and is unlikely to be due to CAB/RPV. CAB/RPV has no activity against HBV, which may have contributed to its reactivation.The patient had serologic evidence of resolution of prior HBV. However, some patients have covalently closed circular DNA (cccDNA) that may remain long term in hepatocyte nuclei.

Retroperitoneal Hematoma: A Sequela of Acute Hemorrhagic Pancreatitis Post Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic tool for pancreaticobiliary diseases. Like every other procedure, ERCP can lead to complications that include pancreatitis, cholecystitis, perforation, and rarely, retroperitoneal hematoma. We present a case of post-ERCP acute hemorrhagic pancreatitis resulting in retroperitoneal hematoma and sequelae of unilateral hydronephrosis and ileus. The patient was treated supportively and had good clinical improvement with resolution of hydronephrosis, ileus and more importantly tolerating oral diet without further episodes of abdominal pain.

LEARNING POINTS

The most common complications of endoscopic retrograde cholangiography are acute pancreatitis and hemorrhage. In high-risk patients, acute pancreatis can be prevented with rectal non-steroidal anti-inflammatory suppository before the procedure.Occurrence of Grey-Turner or Cullen sign should prompt immediate search for retroperitoneal hematoma especially in the setting of acute hemorrhagic pancreatitis.Apart from hemodynamic instability or compressive symptoms, retroperitoneal hematoma can also cause complications due to inflammatory reactions resulting in hydronephrosis or ileus.

Successful Treatment of Intractable Rectal Varices with Gelfoam Slurry Embolisation and Coiling

A 57-year-old male with heart failure and decompensated alcoholic liver cirrhosis presented with recurrent haematochesia due to rectal varices. After multiple failed therapy with endoscopic band ligation and surgical sclerotherapy, a discussion with an interventional radiologist was arranged. A transjugular intrahepatic portosystemic shunt (TIPS) was deferred due to a history of heart failure. A shared decision to proceed with transhepatic Gelfoam® slurry embolisation with coiling was made. During the procedure, a variant anatomy of the superior rectal vein was identified. The superior rectal vein was found to drain directly into the left portal vein with no connectivity between the inferior mesenteric vein and the rectal varices. As planned, Gelfoam slurry embolisation and coiling was done to the left and right superior rectal vein along with the common trunk it drains. The patient did not develop any further episodes of gastrointestinal bleeding or worsening ascites on follow-up after 6 months. This case represents a successful treatment of bleeding rectal varices when TIPS is contraindicated.

LEARNING POINTS

Rectal varices are an infrequent outcome of portal hypertension formed by portocaval anastomosis between the superior rectal vein with the inferior mesenteric vein of the portal system upstream, and the middle and inferior rectal vein draining into the internal iliac and internal pudendal vein of the systemic circulation, respectively. Portal system variations are extremely rare.Most common modality of recurrent rectal varices bleed is a transhepatic intrajugular portosystemic shunt. The absolute contraindications to this include congestive heart failure among others.In the presence of multiple co-morbidities and contraindication for TIPS, various interventional radiological modalities on a case-by-case basis are available including percutaneous transhepatic rectal varices obliteration.

Methotrexate-Induced Lymphoproliferative Disorder Complicating Into Spontaneous Tumor Lysis Syndrome and Disseminated Intravascular Coagulation

Lymphoproliferative disorder (LPD) is a severe adverse outcome of methotrexate (MTX) administration in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). The immunosuppression caused is attributed to pathogenesis. Hence, discontinuation is the treatment. Reports on spontaneous tumor lysis with cessation of MTX are rare. We report a case of a female in her 50s with methotrexate-associated lymphoproliferative disease (MTX-LPD) following treatment for rheumatoid arthritis. Methotrexate was discontinued immediately. She presented two months later with severe disseminated intravascular coagulation (DIC) and spontaneous tumor lysis syndrome (STLS). Although tumor lysis syndrome responded well to rasburicase therapy, DIC was a challenge. MTX-LPD has various complications and highly variable presentation. RA/SLE patients receiving MTX should be regularly monitored, and MTX should be immediately stopped in suspicion of MTX-LPD. Although many patients respond to MTX cessation, some patients head to remission and relapse. At the same time, some worsen with complications such as DIC and tumor lysis syndrome, as described above. This case reiterates the need for regular monitoring following MTX therapy cessation for early identification and treatment of these complications to improve prognosis.

Incidental Finding of Riedel's Lobe of the Liver and Intrahepatic Cholangiocarcinoma

Riedel's lobe is a rare anatomical variant of the liver morphology with a downward tongue-like projection of the anterior edge of the right lobe. It is usually detected incidentally with abdominal imaging performed for other indications. We present a case where we found Riedel's lobe incidentally, with invasive adenocarcinoma arising from close proximity. A 64-year-old female came in with encephalopathy and was found to have a distended abdomen with tenderness. Imaging revealed a complex lobular mass in the right hepatic lobe with an elongated extension of the right lobe inferiorly consistent with Riedel's lobe. The differential considered was malignancy versus abscess. CT-guided biopsy revealed invasive adenocarcinoma consistent with intrahepatic cholangiocarcinoma, which was further supported by the presence of portocaval lymph nodes. Various studies have tried to establish an association between Riedel's lobe and the occurrence of cancer arising from the surrounding structures, primarily from liver or metastasis. This case report adds to the current literature when such an association is being studied.

Unveiling of Type B Lactic Acidosis From Systemic Lupus Erythematosus-Associated B-cell Lymphoma: A Fatal Oncology Emergency

Type B lactic acidosis is a rare oncological emergency usually associated with leukemia and lymphoma but also with solid malignancies. It can often go unrecognized as a possible source of lactic acidosis, leading to a delay in treatment. We review a 56-year-old woman with systemic lupus erythematosus and generalized lymphadenopathy being evaluated for underlying malignancy who presented with dyspnea, fatigue, and hematemesis. The patient was hemodynamically unstable and had severe lactic acidosis, leukocytosis, electrolyte derangements, multiple organ damage, and worsening diffuse lymphadenopathy. She was initially treated for septic shock due to acalculous cholecystitis on imaging with antibiotics and a cholecystostomy. The latter was complicated by a liver laceration requiring explorative laparotomy and open cholecystectomy, during which an excisional biopsy of the omental lymph node was done and confirmed B-cell lymphoma with marked plasmacytic differentiation. Her lactic acidosis never fully cleared despite surgery, and the refractory nature of it despite appropriate treatment of septic shock confirmed the diagnosis of type B lactic acidosis from underlying B-cell lymphoma. Chemotherapy was deferred due to the acuity of the condition. She continued to deteriorate despite aggressive management and was transitioned to comfort measures only per family request, following which she passed away. Type B lactic acidosis should be suspected in oncology patients without clinical evidence of ischemia who are not responding to fluid resuscitation and appropriate treatment of septic shock. Prompt recognition and early initiation of antineoplastic agents should be considered, when possible, to prevent adverse outcomes.

Kratom-induced acute respiratory distress syndrome (ARDS)

The alkaloid derivatives of Mitragyna speciosa, commonly known as kratom, pose a threat to society due to its potential for abuse, adverse reactions and tendency to be used as self-medication for opioid withdrawal, pain and mood disorders. A number of deaths have been reported along with complications such as respiratory depression, cardiopulmonary arrest, torsade de pointes and seizures. Its various effects and potential are yet to be fully studied. We describe the case of a healthy young male who presented with progressive respiratory failure requiring mechanical ventilation. Imaging revealed multifocal lung infiltrates while extensive infectious and cardiac work-up was negative. Based on the clinical course, a diagnosis of acute respiratory distress syndrome (ARDS) caused by kratom was made. The patient showed gradual clinical improvement and was weaned off supplemental oxygen. This case highlights yet another adverse reaction to kratom and the growing threat posed by its use.

Antimitochondrial Antibody-Negative Primary Biliary Cholangitis: A Retrospective Diagnosis

Primary biliary cholangitis (PBC) is an inflammatory cholestatic disease that tends to worsen, leading to hepatic cirrhosis and portal hypertension. We present a case of a middle-aged female who presented with progressively worsening generalized itch; the examination was significant only for urticarial rash and facial swelling. Investigation revealed direct hyperbilirubinemia, mildly elevated transaminase, and significant elevation of alkaline phosphatase. A differential was performed with labs including antimitochondrial antibodies (AMA) for PBC, hepatitis panel, anti-smooth muscle antibodies for autoimmune hepatitis, and tissue transglutaminase IgA for celiac disease, all of which were unremarkable. The patient was empirically treated with ursodeoxycholic acid (UDCA). Given the excellent clinical response at the three-week follow-up to treatment despite negative AMA, further testing with anti-sp100 and anti-gp210 was pursued, which returned positive for anti-sp100, confirming the diagnosis of PBC.

Constipation in transverse myelitis

Transverse myelitis is an extremely rare neuroinflammatory disorder. About half of the affected patients develop paraplegia associated with urinary and bowel dysfunction. The bowel dysfunction is thought to be benign and is usually managed with dietary management and laxatives. We report a case of a man in his 60s presenting with transverse myelitis and the acute disease course complicated with treatment refractory intestinal dysfunction resulting in intestinal perforation, eventually leading to his death. Thus, this case helps us weigh the fact that intestinal dysfunction in the case of transverse myelitis is not always benign but can lead to deadly outcomes as well.

A Fatal Case of Systemic Calciphylaxis in the Gastrointestinal Tract: A Case Report and Literature Review

Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation.

Pain Management Options in a Patient with Livedoid Vasculopathy and Peripheral Neuropathy

Livedoid vasculopathy (LV) is a rare clinical condition presenting as painful lesions mostly on the lower extremities. We present a case of LV with peripheral neuropathy in a young man initially misdiagnosed and treated for cellulitis. He was started on aspirin, pentoxifylline and apixaban immediately after the diagnosis of LV. However, pain management was a real challenge for the clinicians. Hence, he was later treated with epoprostenol and amlodipine for vasodilation, steroids for any possible inflammation, and antibiotics to treat superimposed infection. Irrespective of all the above, his pain was uncontrollable, and he finally received ketamine infusions along with narcotics, achieving better pain control. Various studies support the use of intravenous immunoglobulin and anti-TNF agents for pain relief in idiopathic and secondary LV. Intermittent low-dose dabigatran has also been found to be effective in the maintenance of remission in LV. However, no large studies have yet been conducted to confirm the efficacy of these medications.

LEARNING POINTS

Early initiation of treatment with antiplatelets and anticoagulants is recommended to prevent the progression of livedoid vasculopathy (LV).Anti-TNF agents can be tried in refractory LV for rapid relief of pain.Intravenous immunoglobulin has been shown to be effective for the resolution of pain and improvement of neuropathic symptoms especially in LV refractory to immunosuppressive agents.

Extraintestinal Clostridioides difficile Infection (CDI): A Recurrent Battle with Resilient Abdominal Wall Abscess

Clostridioides (formerly Clostridium) difficile infection is a common and costly healthcare-associated infection. Extraintestinal C. difficile infection is rarely encountered, especially in isolation. We present a unique case of abdominal wall abscess presenting six months following gastrointestinal (GI) surgery. The patient was managed with computed tomography (CT) guided drainage of the abscess, placement of a drainage catheter, and aggressive broad-spectrum antibiotic treatment for a prolonged duration over multiple admissions.

LEARNING POINTS

Risk factors for extraintestinal CDI include prior hospital stay, prolonged antibiotic therapy, proton pump inhibitor (PPI) use, relative state of immunodeficiency such as malnutrition and diabetes mellitus, previous abdominal surgery especially following perforation and leak of intestinal content.Presentation can be late following surgery with mesh repair (foreign body implantation) for intestinal perforation as they have high risk of colonisation, which later leads to infection.For extraintestinal CDI in the presence of a foreign body, removal is the desired course of action. But it is not always possible given the presence of comorbidities in this population, thus resulting in a prolonged course of antibiotics.

Acute organoaxial gastric volvulus—A dangerous twist

Acute gastric volvulus is a rare yet life‐threatening condition with mortality ranging from 30% to 50% if not treated promptly. The stomach rotates on itself causing strangulation precipitating necrosis, cameron lesions, and perforation. Long‐standing paraesophageal hernia is a common cause of organoaxial gastric volvulus.