Crushing Muscles: A Case Study on Rhabdomyolysis, Renal Failure, and Compartment Syndrome Triggered by Pre-Workout Supplement Abuse

The use of steroids and protein-based dietary supplements for muscle enhancement is prevalent in contemporary society. While these products promise increased muscle mass and strength, they carry significant risks, including severe medical complications. The consumption of these supplements has been linked to adverse symptoms, including dehydration, gastrointestinal distress, dizziness, and alterations in heart rate and blood pressure, primarily due to ingredients like creatine, arginine, and caffeine. Following the proper dosage, ensuring adequate hydration, and consulting a healthcare provider to verify if the supplement's components could affect any pre-existing conditions is recommended. Indiscriminate use of these products, including taurine, can lead to serious side effects. We present a 36-year-old patient with severe rhabdomyolysis, life-threatening acid-base imbalance, renal and liver injury, and peripheral neuropathy associated with the use of performance-enhanced unregulated supplements and exercise. This case highlights the importance of recognizing and managing complications related to exercise-aid supplements, emphasizing early identification and management. Increasing social awareness and research on those products is highly needed to avoid supplement-associated complications and potential long-term disabilities.

Hypermetabolic Pulmonary and Mediastinal Lesions With Elevated Cancer Antigen (CA) 15-3 and CA 27-29 in a Patient With a History of Ovarian and Breast Cancer

Breast cancer affects around 13% of women. Breast cancer gene 1 (BRCA1) carriers are prone to lung and lymph node metastasis, while breast cancer gene 2 (BRCA2) carriers tend to have bone metastasis. Findings of pulmonary nodules, mediastinal lymphadenopathy, and elevated markers such as cancer antigen (CA) 15-3 and CA 27-29 suggest metastatic disease. Here, we present the case of a patient with BRCA1-positive breast cancer in remission and a history of ovarian cancer with mediastinal lymphadenopathy and pulmonary nodules, with avid fluorodeoxyglucose uptake on positron emission tomography (PET) scan and elevated CA 15-3 and CA 27-29. A 70-year-old female with a history of bilateral breast and ovarian cancer and a positive BRCA test presented with pulmonary nodules, mediastinal lymphadenopathy, and elevated CA 15-3 and CA 27-29. Imaging showed mediastinal and hilar lymphadenopathy. A PET scan revealed increased metabolic activity in the lymph nodes and pulmonary lesions. Fiberoptic bronchoscopy and endobronchial ultrasound lymph node sampling demonstrated granulomatous inflammation without malignant cells. The patient underwent a therapeutic trial of steroids with clinical improvement of symptoms and decreased hypermetabolic activity in chest lesions, as well as a decrease in tumor markers. The coexistence of sarcoidosis and breast cancer is rare; sarcoidosis can coexist, precede, or appear after breast cancer. In both conditions, tumor markers and PET avidity are seen, which makes diagnosis and management challenging. In case of ambiguity, biopsy is crucial. This case underscores the importance of integrating clinical, pathological, and imaging data to reach an accurate diagnosis and consider a therapeutic trial of steroids. Furthermore, the early PET response to treatment can be pivotal in differentiating between sarcoidosis and malignancy, especially in complex clinical scenarios. Proper differentiation is paramount to avoid therapeutic missteps and ensure appropriate patient management.

Human T-cell Lymphotropic Virus Type 1 (HTLV-1)-Associated Adult T-cell Leukemia/Lymphoma in a Patient Previously Treated for Strongyloidiasis

Adult T-cell leukemia/lymphoma (ATLL) is a rare form of T-cell lymphoma with poor median survival time and limited response to chemotherapy. We present a 45-year-old female from Ghana with generalized body rash, hypercalcemia, lymphadenopathy, and lytic bone lesions. She had a history of strongyloidiasis, treated two years ago, and her serology was positive for the human T-cell lymphotropic virus type 1 (HTLV-1). Histopathology of cervical lymph node and abdominal rash biopsy revealed T-cell lymphoma. We present a literature review on the topic and the challenges of diagnosis. We emphasize the importance of considering HTLV-1-associated ATLL in patients who have been treated for strongyloidiasis in the past and are presenting with rash or lymphadenopathy.

Comparison of patients admitted to an inner-city intensive care unit across 3 COVID-19 waves

To expand our limited knowledge of COVID-19-related outcomes in patients admitted to inner-city intensive care unit (ICU across multiple infection waves. This retrospective study compared patients admitted to the ICU in Bronx, NY, during 3 COVID-19 waves (March 2020 to February 2022). Outcomes included in hospital mortality, length of stay (LOS), use of mechanical ventilation, and discharge disposition. The study included 716 patients (343, 276, and 97 in the first, second, and third COVID-19 waves, respectively). The number of days on mechanical ventilation and LOS were lower in the first wave. Of the 345 discharged patients, 37% went home directly, whereas 11% were discharged to a skill nursing facility. More patients went home during the second and third waves. Mortality decreased from the first to the third waves (57%-37%; P < .001). Predictors of mortality included age, male gender, COPD, shock, acute kidney injury (AKI), dialysis requirement, and mechanical ventilation. The decreased mortality and better discharge disposition of these inner-city patients during the second and third waves is encouraging, as this population historically had a high COVID-19-related mortality risk.

Conductivity prediction model for ionic liquids using machine learning

Ionic liquids (ILs) are salts, composed of asymmetric cations and anions, typically existing as liquids at ambient temperatures. They have found widespread applications in energy storage devices, dye-sensitized solar cells, and sensors because of their high ionic conductivity and inherent thermal stability. However, measuring the conductivity of ILs by physical methods is time-consuming and expensive, whereas the use of computational screening and testing methods can be rapid and effective. In this study, we used experimentally measured and published data to construct a deep neural network capable of making rapid and accurate predictions of the conductivity of ILs. The neural network is trained on 406 unique and chemically diverse ILs. This model is one of the most chemically diverse conductivity prediction models to date and improves on previous studies that are constrained by the availability of data, the environmental conditions, or the IL base. Feature engineering techniques were employed to identify key chemo-structural characteristics that correlate positively or negatively with the ionic conductivity. These features are capable of being used as guidelines to design and synthesize new highly conductive ILs. This work shows the potential for machine-learning models to accelerate the rate of identification and testing of tailored, high-conductivity ILs.

Outcomes of hospitalized patients with COVID-19 pneumonia, hypoxia, and a normal initial chest roentgenogram

BACKGROUND

Outcomes of patients with coronavirus disease (COVID-19) pneumonia, hypoxia, and an initial normal chest roentgenogram (CXR) are not well defined. This study aimed to analyze the factors associated with poor outcomes in these patients.

METHODS

This retrospective study evaluated patients admitted with COVID-19 pneumonia, a CXR without infiltrates and hypoxemia requiring supplemental oxygen. Outcomes were compared based on D-dimer levels and included in-hospital mortality, need for mechanical ventilation, acute kidney injury, shock, and length of hospital stay.

RESULTS

We identified 115 patients, 31 (27%) had D-dimer levels above 4 times upper limit of normal on admission. Predictors of mortality included elevated D-dimers in hypoxic patients, use of mechanical ventilation, acute kidney injury, shock, and elevated admission serum sodium and lactic dehydrogenase.

CONCLUSIONS

Patients with COVID-19 and hypoxia on initial presentation despite a normal CXR had significant mortality rates, higher in those with elevated inflammatory markers. The use of inflammatory markers, such as D-dimer and serum ferritin levels, may assist in identifying patients with higher morbidity and mortality risks. Additional imaging with chest computed tomogram should be obtained if clinically indicated and avoidance of overreliance of a normal CXR in those patients.

Change in patterns of hospitalization for influenza during COVID-19 surges

Background

Hospitalization due to influenza has been stable in recent years. In March 2020, New York was an epicenter for coronavirus disease 2019 (COVID‐19). Because influenza and COVID‐19 present similarly, there were serious concerns that coinfection of these viruses would burden the healthcare system. We compared incidence and outcomes of patients hospitalized with influenza before and during COVID‐19 (seasons 2017–2021).

Methods

We conducted a retrospective study evaluating hospitalized patients with influenza. Four influenza seasons were evaluated, 2017–2021, pre‐ and during COVID‐19 pandemic. We compared incidence of influenza and clinical outcomes across the seasons.

Results

We found 412 patients hospitalized due to influenza in the study period; 394 had influenza, and 18 had both influenza and COVID‐19 infections. Demographics across the four influenza seasons were comparable; the cohort was predominantly female (61%) and had an average age of 60 years old. Comorbid conditions were common. No outcome differences were found for patients with influenza when comparing influenza seasons prior to and during the COVID‐19 pandemic. The mortality for the entire cohort was 6.5%. During the COVID‐19 pandemic, there were 18 (4.4%) influenza patients coinfected with COVID‐19 and 32 (7.8%) patients with bacterial super infection. Predictors of mortality in patients with influenza included presence of shock, heart failure, bacterial pneumonia, and use of mechanical ventilation. Coinfection with COVID‐19 did not increase mortality.

Conclusion

We observed a significant decrease in the incidence of hospitalization due to influenza during the COVID‐19 pandemic. Clinical presentations and outcomes for patients with influenza remain stable. Being aware of possible increased mortality for patients with both influenza and bacterial pneumonia is important. Although coinfection with COVID‐19 did not increase mortality in influenza patients, identifying the specific virus responsible for infections has major therapeutic implications.

Outcomes of patients with a non-diagnostic initial bronchoscopy for suspected thoracic malignancy

Lung cancer is 1 of the leading causes of cancer-related deaths and bronchoscopy is an essential tool for the diagnosis. The diagnostic yield varies based on the characteristics of the lesion and bronchoscopic techniques employed. There is limited data regarding outcomes of patients suspected of thoracic malignancies with a non-diagnostic initial bronchoscopy. The goal of the study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy for suspected thoracic malignancies and to evaluate variables predictive of a diagnostic bronchoscopy.Retrospective analysis of adult patients at BronxCare Hospital Center who underwent bronchoscopy for suspected thoracic malignancy. The study period was January 2012 to February 2019. Exclusion criteria included patients who underwent only inspection bronchoscopy or bronchoalveolar lavage as the diagnostic yield for malignancy with these techniques is low. All other bronchoscopic procedures were included that is, endobronchial biopsies, transbronchial biopsies, and endobronchial ultrasound guided-transbronchial needle aspiration. Bronchoscopy was considered diagnostic when a specific histopathological diagnosis was established.311 patients underwent bronchoscopy to rule out malignancy. A diagnosis was obtained in 153 (49.2%) patients, 81 (52.9%) had primary lung cancer and 14 (9.15%) other malignancies. 158 (50.8%) patients had initial non-diagnostic bronchoscopy; 86 (54.43%) were lost to follow up. Of the remaining 72 (45.57%) patients, radiological resolution or stability was observed in 51 (70.8%) patients. Primary lung cancer was found in 13 (18.05%) patients and other malignancies in 5 (6.94%). Predictive of a diagnostic bronchoscopy was the performance of endobronchial biopsies and endobronchial ultrasound guided-transbronchial needle aspiration.This study highlights some of the barriers to the timely diagnosis of thoracic malignancies. Following patients with a non-diagnostic procedure as well as all those patients with diagnosed malignancies it of the utmost importance. In patients available for follow up, close to 25% of additional cases with treatable malignancy could be identified and patients diagnosed with cancer could receive timely treatment.

Lung mass with bilateral mediastinal hypermetabolic lymphadenopathy in a chronic smoker indicative of lung cancer?

We present the case of an asymptomatic woman, a chronic heavy smoker, who presented with an incidental lung mass and mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsy and endobronchial ultrasound-guided transbronchial needle aspiration did not show malignancy. A positron emission tomography/computed tomography scan showed increased uptake with a standardized uptake value of 26.4 in the mediastinal lymph node and an additional hypermetabolic right supraclavicular lymph node. Surgical biopsy of the supraclavicular node revealed non-necrotizing granuloma. Discussion of the clinical dilemma is provided.

Outcomes of patients with non-diagnostic bronchoscopy: A clinico-radiological comparison of patients with diagnostic and non-diagnostic bronchoscopy

Bronchoscopy is one of the most common diagnostic procedures in pulmonary practice. Data on the outcome of patients following a non-diagnostic bronchoscopy are sparse. Diagnostic yield depends on indication, the characteristics of patients, and the chest imaging. The aim of this study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy and to compare patients who had a diagnostic with those that had a non-diagnostic bronchoscopy.Retrospective, single-center study of adult patients who underwent bronchoscopy with transbronchial biopsy (TBBX) and/or endobronchial biopsy (EBBX), endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), or brushing. A strict definition for a "diagnostic" bronchoscopy was used. Univariate and multivariate analyses were performed.A total of 684 patients were identified, 350 (51%) had a diagnostic procedure. Of the 334 patients with a non-diagnostic bronchoscopy, 196 (58.6%) were followed, but only 172 (88%) completed 1 year of follow-up. Most of the patients (57.8%) had resolution or stabilization of the condition; in the remaining patients, malignancy was most commonly diagnosed after further investigation followed by diffuse lung diseases and infections. Pulmonary tuberculosis was diagnosed in 8 patients. EBUS-TBNA and EBBX were the procedures associated with a diagnostic bronchoscopy. Presence of bilateral interstitial infiltrates predicted a non-diagnostic bronchoscopy.A significant number of patients with non-diagnostic bronchoscopy may have serious treatable disease that is identified upon further investigation. Close follow up of patients with a non-diagnostic procedure is warranted. Our study found no clear clinical or radiological predictors of diagnostic bronchoscopy.

Mycoplasma Pneumoniae Pneumonia: Walking Pneumonia Can Cripple the Susceptible

Background

Mycoplasma pneumoniae pneumonia (MPP), or “walking pneumonia,” is an atypical mild disease with varied clinical findings. Specifically, diagnosis is often controversial and understanding of disease presentation is limited. The goal of the study was to evaluate presentation, clinical associations and outcomes of MPP patients admitted to an inner-city hospital.

Methods

This was a retrospective analysis of adult patients diagnosed with MPP from January 2010 to January 2017. Primary outcomes were need for intensive care unit (ICU) care, ICU and hospital length of stay (LOS), presence of shock and need for mechanical ventilation (MV). Predictors of mortality were analyzed.

Results

Of the 203 patients analyzed, 16 (8%) died. Relative to survivors, non-survivors were older (65 ± 21 versus 53 ± 18, P = 0.009) and less frequently had obstructive airway disease (OAD; P = 0.003). Non-survivors also had significantly higher serum levels of lactic dehydrogenase (LDH), blood urea nitrogen (BUN), creatinine, transaminases and troponins. Finally, non-survivors more commonly exhibited shock, need for MV and bilateral lung infiltrates. There were no group differences in patient comorbidities, symptoms, antibiotic use or LOS. Predictors of mortality included age, OAD, low CD4⁺ T-cell counts in human immunodeficiency virus-infected patients and elevated serum levels of LDH, creatinine, BUN, leukocytes, transaminases and troponins.

Conclusion

Despite the availability of appropriate antibiotics, MPP incurs significant mortality and morbidity. Our study indicated that the recommended treatment includes prompt serological diagnosis, aggressive supportive care and presumptive antibiotics, especially in patients with poor prognosis.

Mycoplasma pneumoniae: A Potentially Severe Infection

Mycoplasma pneumoniae infections remain one of the most common etiologies of community-acquired pneumonia (CAP). The clinical presentation and manifestations vary widely and can affect all organs of the body. Diagnosis is challenging because there are no constant findings in physical exams or laboratory or radiological assessments that indicate Mycoplasma pneumoniae pneumonia, and specific diagnostic tools are not readily available. Extrapulmonary manifestations and severe pulmonary manifestations can lead to long-term sequelae. The increasing emergence of Mycoplasma pneumoniae that is resistant to macrolides in some areas of the world and increased world travel could add to the difficulty of controlling and treating Mycoplasma pneumoniae infections. We present a concise and up-to-date review of the current knowledge of Mycoplasma pneumoniae pneumonia.

Nebulized heparin and N-acetylcysteine for smoke inhalational injury: A case report

RATIONALE

Every year, ∼40,000 people suffer burn-related injuries in the United States. Despite recent advances, the odds of dying from exposure to fire, flames, or smoke are one in ∼1500. Smoke inhalation causes injury to the airways via a complex physiological process, and the treatment is mainly supportive. Many recent interventions aim to decrease the formation of fibrin casts, the main cause of airway damage in these patients. Among these, treatment with a combination of nebulized heparin and N-acetylcysteine (NAC) has shown benefit.

PATIENT CONCERNS

We describe the case of a 58-year-old man who presented after smoke inhalation during a fire. Soot was found in the nostrils when he was admitted to our hospital, and after he began coughing up carbonaceous material, he was electively intubated and placed on volume assist control ventilation.

DIAGNOSIS

Bronchoscopy on the first day of intensive care confirmed the injury from smoke inhalation and revealed mucosal edema and soot involving the tracheobronchial tree.

INTERVENTIONS AND OUTCOMES

Inhaled unfractionated heparin of 10,000 IU in 3 mL of 0.9% normal saline alternating every 2 hours with 3 mL of 20% NAC was started 48 hours after admission and continued for 7 days. Bronchoscopy on the fifth day of intensive care showed significant improvement in airway edema and a resolution of soot.

LESSONS

On the basis of our experience with this case and limited literature, we posit that nebulized heparin and NAC may be of benefit in patients with inhalational smoke-induced lung injury and mild-to-severe lung injury scores.

Diffuse Alveolar Hemorrhage without Extrapulmonary Manifestations: A Rare Presentation of Lupus

Patient: Female, 31

Final Diagnosis: Lupus DAH

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Pulmonology

Case report: middle-aged woman from Ghana with unsteady gait and enlarging cerebellar mass

RATIONALE

Neurosarcoidosis (NS) is an uncommon manifestation of systemic sarcoidosis, with a propensity for middle-agedwomen. Often discovered only at autopsy, rates of neurologic involvement (5%-10%) reported in the literature underscore a lack of sensitivity and specificity in current diagnostic methods.

PATIENT CONCERNS

Herein, we describe a 53-year-old woman who presented with gait imbalance and distal extremity muscular weakness. She was known to harbor a brain mass (4 years in duration) that was monitored and recently seemed to enlarge.

DIAGNOSIS

A subsequent brain biopsy showed necrotizing granulomatous inflammation suggestive of NS. However, no clinical or radiologic evidence of activity was found in other organs.

INTERVENTIONS AND OUTCOMES

Ultimately, endo and transbronchial biopsies were performed, providing histologic confirmation of systemic sarcoidosis.

LESSONS

This approach is advised in all instances of suspected NS where systemic involvement is in question.

An Unusual Triad of Hemophagocytic Syndrome, Lymphoma and Tuberculosis in a Non-HIV Patient

BACKGROUND Lymphoma complicated with hemophagocytic syndrome and tuberculosis has been rarely reported. The clinical and radiological presentation of these potentially fatal conditions can be easily confused and there is a potential for misdiagnosis. CASE REPORT We present a 58-year-old Hispanic female who was admitted to the hospital with dizziness and fever. Her initial admission diagnosis was severe sepsis secondary to community acquired pneumonia. She was started on intravenous antibiotics. Due to mediastinal lymphadenopathy, lymphoma was considered as a differential diagnosis for which she underwent bronchoscopy and endobronchial ultrasound-guided sampling of her mediastinal lymph nodes. Lymph node aspirate was suggestive of lymphoma. Initial cultures were negative. Her clinical course was complicated with respiratory failure, cytopenia, and rapidly progressive cervical lymphadenopathy. The patient underwent cervical lymph node excision and bone marrow biopsy. The pathology of the lymph nodes confirmed T cell lymphoma, and bone marrow revealed hemophagocytosis. The patient was started on chemotherapy but she continued to deteriorate and died on day 20 of her hospital admission. Post-mortem results of cultures from a cervical lymph node biopsy and PCR were positive for Mycobacterium tuberculosis. CONCLUSIONS We suggest an aggressive tissue diagnosis with staining for acid-fast bacilli for early diagnosis in patients presenting with hemophagocytic syndrome secondary to lymphoma as coexisting tuberculosis is a consideration. Tuberculosis re-activation should be considered in patients from an endemic region who present with lymphoma and a deteriorating clinical condition.

An interesting case of mycoplasma pneumonia associated multisystem involvement and diffuse alveolar hemorrhage

Severe mycoplasma pneumonia is a rare entity with only 0.5–2% of cases having a fulminant course. We present a 74-year-old woman with hypertension, diabetes mellitus and remote history of marginal zone B-cell lymphoma admitted with abdominal pain and diarrhea of 1–2 days associated with body-aches, dyspnea, dry cough and weight loss for 2–3 weeks. On physical exam, she was febrile, tachypneic, tachycardic and hypoxic on room air. Chest examination revealed diffuse crackles and end-expiratory wheezes. Laboratory tests showed anemia, acute-on-chronic kidney injury and hyaline casts and epithelial cells in the urine analysis. Chest roentgenogram and computed tomograhphy scan showed pulmonary infiltrates. Intravenous ceftriaxone and azithromycin with bronchodilators were initiated. Her clinical course was complicated by hypoxic respiratory failure, hemoptysis, and worsening of infiltrates, requiring intubation and mechanical ventilation. Bronchoscopic bronchoalveolar lavage was consistent with diffuse alveolar hemorrhage (DAH). The patient's serum was positive for IgM antibody to Mycoplasma pneumoniae [1134 U/mL] and Anti-I-specific IgM-cold-agglutining [1:40]. A diagnosis of severe mycoplasma infection with DAH was made. The patient was treated with an additional course of doxycycline, pulse dose steroids and plasmapharesis with good clinical response. Surgical lung biopsy showed focal acute lung injury. Bone marrow biopsy and fat pad biopsy were normal. She was liberated from mechanical ventilation and discharged. She returned within 24 hours of discharge with cardiac arrest and new onset right-bundle-branch-block. We hypothesize our patient had severe mycoplasma pneumonia with DAH and multisystem complications of the same including a possible venous thrombo-embolic episode leading to her demise.

Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery

This review describes the perioperative management of patients with suspected or established pulmonary conditions undergoing non-cardiothoracic surgery, with a focus on common pulmonary conditions such as obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions. Considering that postoperative pulmonary complications are common and given the increasing number of surgical procedures and the size of the aging population, familiarity with current guidelines for preoperative risk assessment and intra- and postoperative patient management is recommended to decrease the morbidity and mortality. In particular, smoking cessation and pulmonary rehabilitation are perioperative strategies for improving patients’ short- and long-term outcomes. Understanding the potential risk for pulmonary complications allows the medical team to appropriately plan the intra- and postoperative care of each patient.

A Case Report of an Elderly Woman With Thrombocytopenia and Bilateral Lung Infiltrates: A Rare Association Between Diffuse Alveolar Hemorrhage and Idiopathic Thrombocytopenic Purpura

Etiologies for diffuse alveolar hemorrhage are wide and range from infectious to vasculitis and malignant processes. Idiopathic thrombocytopenic purpura is an autoimmune disorder characterized by persistent thrombocytopenia, with a relatively indolent course in young patients, but a more complicated progression and high associated mortality in the older patients. Diffuse alveolar hemorrhage, complicating idiopathic thrombocytopenic purpura, is a very uncommon association, with only 2 reported cases in the literature. We present a 69-year-old healthy woman presenting with petechial rash, progressive dyspnea, and bilateral alveolar infiltrates. She was found to have idiopathic thrombocytopenic purpura associated with diffuse alveolar hemorrhage. The patient had an excellent response to high doses of pulse steroids and immunoglobulins. A high index of suspicion for noninfectious pulmonary diseases should be considered in patients with autoimmune diseases presenting with pulmonary infiltrates and hypoxia. Flexible bronchoscopy with sequential lavage is a relatively safe procedure in patients with coagulopathy and should be attempted to detect and confirm the diagnosis; absence of hemoptysis should not preclude the diagnosis.

Opioid overdose with gluteal compartment syndrome and acute peripheral neuropathy

PATIENT

Male, 42 FINAL DIAGNOSIS: Gluteal compartment syndrome • acute peripheral nauropathy

SYMPTOMS

-

MEDICATION

- Clinical Procedure: - Specialty: Critical Care Medicine.

OBJECTIVE

Management of emergency care.

BACKGROUND

Heroin addiction is common, with an estimated 3.7 million Americans reporting to have used it at some point in their lives. Complications of opiate overdose include infection, rhabdomyolysis, respiratory depression and central or peripheral nervous system neurological complications.

CONCLUSIONS

We present a 42-year-old male admitted after heroin use with heroin-related peripheral nervous system complication preceded by an acute gluteal compartment syndrome and severe rhabdomyolysis.

CASE REPORT

Early diagnosis and surgical intervention of the compartment syndrome can lead to full recovery while any delay in management can be devastating and can lead to permanent disability. The presence of peripheral nervous system injuries may portend a poor prognosis and can also lead to long term disability. Careful neurological evaluation for signs and symptoms of peripheral nervous system injuries is of paramount importance, as these may be absent at presentation in patients with opioid overdose. There is a potential risk of delaying a necessary treatment like fasciotomy in these patients by falsely attributing clinical symptoms to a preexisting neuropathy. Early EMG and nerve conduction studies should be considered when the etiology of underlying neurological weakness is unclear.

Vitamin D deficiency is associated with mortality in the medical intensive care unit

Introduction

The incidence of vitamin D deficiency in critically ill patients has been reported to range from as low as 17% to as high as 79%. Data regarding the relationship between 25-hydroxyvitamin D levels and outcomes in the medical intensive care unit are sparse. The goal of the study was to evaluate the prevalence of 25-hydroxyvitamin D deficiency in the medical intensive care unit and its relationship with outcomes.

Method

This was a retrospective study in a medical intensive care unit (MICU) at an inner city community hospital. The study period was between October 2009 and February 2010.

Results

Of the 932 patients admitted during the study period, 25-hydroxyvitamin D vitamin D (25(OH)D) levels were available in 523 (53%); 86 of them were excluded from the study due to readmission to the intensive care unit. Deficiency was defined as 0 to 19.9 ng/dL 25(OH)D levels, insufficiency as 20 to 29.9 ng/dL, and normal levels as ≥30 ng/dL. Of the 437 patients studied, 25(OH)D deficiency was identified in 340 (77.8%), insufficiency in 74 (16.9%), and normal levels in 23 (5.3%) patients. Patients with 25(OH)D deficiency/insufficiency were younger (P = 0.015), were male (P = 0.001), and had kidney disease (P = 0.017) and lower total serum calcium levels (P = 0.003). Hospital mortality was higher in patients with 25(OH)D deficiency (P = 0.01). No differences in ventilator days or length of stay in the MICU were evident among the three groups. Analysis by multiple logistic regression demonstrated that acute physiology and chronic health evaluation (APACHE) IV score ((odds ratio (OR) 1.036; 95% confidence interval (CI) 1.024-1.048, P < 0.0001), ventilator requirement (OR 7.7; 95% CI 4.3-13.98, P < 0.0001), 25(OH) D levels(OR 0.942; 95% CI 0.942-0.904, P < 0.0005) and 25(OH) D deficiency (OR 8.7; 95% CI 1.03-72.8, P < 0.0469) showed statistical significance. There was no association between 25(OH)]D insufficiency and hospital mortality. The mean 25(OH)D level of survivors (27.9 ± 9.7 ng/dL) was higher than for non-survivors (9.7 ± 4.7 ng/dL; P < 0.0001).

Conclusions

The study results demonstrate an association between 25(OH)D deficiency and hospital mortality in MICU patients. A randomized prospective study to evaluate the effect of vitamin D replacement therapy on mortality is warranted.

Emphysematous Pyelonephritis Associated With Emphysematous Gastritis and Air in the Portal Vein

Emphysematous gastritis with portal venous air is a rare condition usually caused by gas forming organisms. This may be secondary to local spread of an infection through the mucosa or rarely hematogenous dissemination from a distant focus. We present a young diabetic woman with uncontrolled diabetes mellitus who was admitted with sepsis and severe abdominal symptoms. Investigation revealed emphysematous pyelonephritis due to E. coli infection associated with emphysematous gastritis and air in the portal tract. She improved with broad spectrum antibiotics, fluid resuscitation and electrolyte and diabetic management. To our knowledge this is the first report showing the association between emphysematous pyelonephritis and gastritis with air in the portal system.

Hypomorphic bimA(APC3) alleles cause errors in chromosome metabolism that activate the DNA damage checkpoint blocking cytokinesis in Aspergillus nidulans

The Aspergillus nidulans sepI(+) gene has been implicated in the coordination of septation with nuclear division and cell growth. We find that the temperature-sensitive (ts) sepI1 mutation represents a novel allele of bimA(APC3), which encodes a conserved component of the anaphase-promoting complex/cyclosome (APC/C). We have characterized the septation, nuclear division, cell-cycle checkpoint defects, and DNA sequence alterations of sepI1 (renamed bimA10) and two other ts lethal bimA(APC3) alleles, bimA1 and bimA9. Our observations that bimA9 and bimA10 strains had morphologically abnormal nuclei, chromosome segregation defects, synthetic phenotypes with mutations in the DNA damage checkpoint genes uvsB(MEC1/rad3) or uvsD(+), and enhanced sensitivity to hydroxyurea strongly suggest that these strains accumulate errors in DNA metabolism. We found that the aseptate phenotype of bimA9 and bimA10 strains was substantially relieved by mutations in uvsB(MEC1/rad3) or uvsD(+), suggesting that the presence of a functional DNA damage checkpoint inhibits septation in these bimA(APC3) strains. Our results demonstrate that mutations in bimA(APC3) lead to errors in DNA metabolism that indirectly block septation.