A Case of Trauma-Related Angioedema of the Airway in a Patient on an Angiotensin Receptor Blocker

BACKGROUND Angioedema is non-pitting edema that occurs in the deep layers of the skin and subcutaneous tissue due to vascular leakage of plasma resulting from 1 of 2 major pathophysiological processes: mast cell-mediated angioedema and bradykinin-mediated angioedema. While it is a well-recognized adverse reaction of angiotensin-converting enzyme inhibitors, the association of angioedema with angiotensin receptor blockers is relatively less studied. Direct local trauma, although rarely, has been suggested to induce angioedema under certain conditions. We present a unique case of direct, local, trauma-related angioedema in a patient on an angiotensin receptor blocker. CASE REPORT The patient, an 83-year-old woman on telmisartan for hypertension, hit her neck against the edge of a chair during a fall. Shortly thereafter, she developed progressive airway compromise due to airway angioedema, as noted on direct laryngoscopy. A contrast CT scan of the neck also noted edema of the periglottic and supraglottic regions. She required intravenous corticosteroid administration and intubation in the emergency room and was successfully extubated 3 days after admission. She had no prior history of angioedema or allergy. We hypothesize that increased levels of circulatory bradykinin in the setting of telmisartan, combined with a local release of bradykinin from trauma, was the main pathophysiologic cause of the angioedema. CONCLUSIONS This case report highlights the rare and often forgotten adverse reaction of angioedema with use of angiotensin receptor blockers and confirms the finding of local trauma as a possible trigger.

The impact of comorbidities and sociodemographic predictors on pneumococcal vaccination coverage in adults with coronary heart disease

Aim: Coronary heart disease (CHD) increases the risk of adverse outcomes from invasive pneumococcal disease. Methods: Using the 2020 and 2021 data from the national health interview survey, we identified adults with CHD. Chi-square analysis and logistic regression were used to examine factors that influence vaccination status. Results: There were 2675 participants aged 41 and above with CHD. Participants were predominantly white people (82.5%) and males (60.1%). The odds of receiving the pneumococcal vaccine increased with stepwise increase in comorbidities from 1 to 2 and from 2 to 3. Among individuals with ≥2 comorbidities, black people were less likely to be vaccinated compared with white people. Conclusion: Pneumococcal vaccine uptake among adults with CHD is determined by cumulative comorbidities and ethnicity.

The Deadly Contaminant: A Case of Staphylococcus lugdunensis Endocarditis

The incidence of infective endocarditis (IE) has been on the rise since it was first reported a century ago, and the associated mortality remains unchanged despite advances in medical and surgical management. To diagnose IE, the modified Duke criteria are used, which rely on isolating the causative organism. However, this can be challenging if the micro-organism is considered a contaminant. Staphylococcus lugdunensis (SL) is one such organism. In this case, an elderly female presented with intermittent chest pain, palpitation, and diaphoresis, for which she underwent left heart catheterization. Her hospital course was complicated by persistent fever and night sweats, leading to blood cultures isolating methicillin sensitivity. It was initially reported as a contaminant. However, an extensive workup was unremarkable, and a transthoracic echocardiogram was done, which revealed tricuspid vegetations with moderate regurgitation. The patient was treated with cefazolin, repeat cardiac imaging at the end of treatment revealed no vegetation, and the patient remained asymptomatic. Despite being associated with fulminant IE with higher mortality than Staphylococcus aureus (S. aureus), which requires surgical management in most cases, SL is still often reported as a contaminant. Isolation of SL should warrant further investigation beyond mere contaminants, and prompt treatment should be initiated in the appropriate clinical scenario to avoid poor outcomes.

Delayed Diagnosis of an Invisible Seizure: Cefepime-Induced Non-convulsive Status Epilepticus

Cefepime-induced non-convulsive status epilepticus (NCSE) is a recognized adverse event of cefepime. Risk factors for this adverse event include older age, underlying renal dysfunction, previous brain injury, diabetes, and severe infection. We present a case of a 79-year-old woman with no prior seizure history, who was admitted for Pseudomonas aeruginosa surgical wound infection for which she was on cefepime. She developed acute encephalopathy with associated, occasional, right-sided myoclonic facial twitches 11 days into her admission. Electroencephalogram (EEG) confirmed NCSE as evident by epileptiform activity described as generalized periodic discharges with predominantly triphasic morphology. Cefepime was substituted with piperacillin-tazobactam> 24 hours after symptom onset. NCSE completely resolved two days after the discontinuation of cefepime. This case highlights the fact that NCSE can occur even when precautions such as renal dosing of cefepime are observed. Clinicians need to have a high index of suspicion for the condition when taking care of at-risk patients on cefepime, as delayed diagnosis correlates with potentially fatal outcomes.

The Decimating Army: Hemophagocytic Lymphohistiocytosis as the Initial Presentation of Adult-Onset Still's Disease

Hemophagocytic lymphohistiocytosis (HLH) is a rare and often missed presentation in the hospital setting. It is a hyperinflammatory syndrome of immune activation and dysregulation characterized by fever, cytopenias, elevated serum ferritin levels, and hepatosplenomegaly. It has a multifactorial etiology occurring primarily secondary to infection, malignancy, immune checkpoint inhibitors, or autoimmune disease. HLH that occurs in autoimmune diseases such as adult-onset Still's disease and systemic lupus erythematosus is referred to as macrophage activation syndrome. However, it may rarely be a primary disorder from a genetic defect. The pathophysiology of HLH is poorly understood and often results in multiorgan dysfunction. We present an older adult male patient with several hospital stays due to his symptoms, who presented with lethargy, low-grade fever, cough, dyspnea, and recurrent pleural effusions. He had bicytopenia, elevated ferritin, and hypertriglyceridemia. The diagnosis of HLH may be delayed, especially in older adult patients with an insidious course, and requires a high index of suspicion.