Cocaine-Induced Kidney, Liver, Lung, and Muscle Injury (C-KLM), Presenting With Foot Drop: A Case Report

Cocaine-associated organ injury is a well-known phenomenon that may lead to multi-organ failure. Cocaine-induced kidney, liver, lung, and muscle (C-KLM) involvement is an entity with alarmingly high creatinine phosphokinase (CPK) levels exceeding 100,000 U/L. This may have fatal outcomes. Rhabdomyolysis is one of the many mechanisms of kidney injury induced by cocaine intoxication. Sympathomimetic effects of cocaine contribute to muscle Injury in addition to vasoconstriction resulting in muscle ischemia, as well as liver ischemia (shock liver). Furthermore, increased muscular activity from hyperpyrexia, seizures, and agitation due to cocaine use disorder may contribute to muscle breakdown and worsening nephrotoxicity.  The authors detail a case of a 34-year-old male intravenous drug user who presented with an inability to bear weight or move his left lower extremity due to pain, associated with severe edema of his lower extremities of acute onset. He was subsequently noted with foot drop, oliguria, and high blood pressure following cocaine intoxication. The patient began crashing rather quickly and the intensive care unit was recommended. Labs were noted with overwhelming CPK levels over 100,000 U/L and rising for which urgent hemodialysis was initiated. We detail a catastrophic cocaine-induced multi-organ failure with a positive outcome following a multidisciplinary approach.

Unveiling the Heart of the Matter: Intravascular Ultrasound in Acute Myocardial Infarction

Intravascular ultrasound (IVUS) has become crucial in contemporary percutaneous coronary interventions (PCIs), offering detailed two-dimensional (2D) arterial wall visualization. Current guidelines consider it valuable for guiding coronary stent placement, especially in complex cases like the left main (LM) artery, allowing a comprehensive assessment of vessel characteristics and stent performance. There are some studies that highlight the potential impact of IVUS on acute myocardial infarction (AMI) management, notably improving outcomes. This case involves a 37-year-old man who experienced an AMI, necessitating the use of IVUS to ascertain the underlying cause of his acute coronary syndrome (ACS). This approach was essential for guiding appropriate treatment and ultimately led to successful stent implantation.

Duet of Death: Biventricular Thrombus in a Methamphetamine User

We present the case of a 60-year-old male who developed an ischemic stroke due to left ventricular (LV) thrombus emboli as a complication of methamphetamine-induced cardiomyopathy. The patient had a history of methamphetamine abuse, hypertension, and ischemic stroke with no residual deficits presented with new onset slurred speech, left-sided weakness, and numbness for two hours. Computed tomography (CT) of the head showed no acute changes, and a tissue plasminogen activator was given in the emergency department within 30 minutes of arrival. Urine drug screen (UDS) was positive for methamphetamine, and magnetic resonance imaging (MRI) of the brain showed acute cortical infarcts in the right frontal lobe and parietal lobe and chronic infarct in the left occipital lobe. Transthoracic echocardiography showed bilateral ventricular thrombus and severely reduced ejection fraction of 20-25%. The patient had no evidence of thrombophilia and was started on a heparin drip for thrombus and goal-directed medical therapy for heart failure with reduced ejection fraction (HFrEF). Upon discharge, the patient was prescribed the oral anticoagulant rivaroxaban. The LV thrombus emboli were attributed to causing ischemic stroke. This case highlights the potential risk of ischemic stroke due to LV thrombus emboli in patients with methamphetamine-induced cardiomyopathy.

Mania Induced by Epidural Steroid Injection in an Elderly Female With No Psychiatric History

The psychiatric risks of epidural steroid injections for chronic pain in a geriatric patient with no prior psychiatric history are presented here. A 76-year old Caucasian female presented to the emergency department with her family for an inability to sleep, confusion, and behavioral outbursts. The mood instability and psychosis were reported as having started a week after her third epidural steroid injection for low-back pain associated with a prior fall. After 12 days of mixed treatment outcomes and increasing paranoia without any localized neurological findings, the patient was transferred to the geriatric psychiatry unit. Upon admission to the inpatient unit, she was loud, grandiose, verbally aggressive, unable to sleep, hyper-religious, paranoid, and identified her husband and daughter as demons. The patient was started on risperidone and valproic acid for the management of psychosis and manic symptoms. Hyper-religiosity and paranoia greatly improved within a week, though the patient remained very talkative and tangential, with a disorganized thought process. Valproic acid was titrated to 500 mg twice a day, yielding a level of 56.2 ug/ml, accompanied by improvement to mild talkativeness and circumstantiality. She was able to interact appropriately, with minimal lorazepam requirement, and discharged with a linear thought process and absence of psychosis. On outpatient follow up, there were minimal residual mania and no recurrence of psychosis, allowing her to be weaned off valproic acid and to discontinue risperidone. Two months later, symptoms resolved completely. The persistence of this patient’s psychosis for nearly one month, and mania for about three months, underscores the importance of careful risk-benefit analysis before initiating epidural steroids. This is particularly important in elderly patients who may be more susceptible to psychiatric adverse effects that can outlast any analgesic benefits.

The Risk of Substance Use Among Adolescents and Adults With Eating Disorders

Eating disorders (EDs) are negative eating habits that have harmful mental and physical effects. EDs primarily affect young women. Most cases are diagnosed in adolescence. The most common EDs are bulimia nervosa (BN), anorexia nervosa (AN), and binge eating disorder (BED). There is a strong association between EDs and substance use disorder (SUD) in adolescence. Bulimia nervosa and alcohol use disorder (AUD) are the most common co-occurrence. There is a high behavioral association between EDs and AUD. Alcohol consumption could be a primary trigger for binge eating in women with BN. Alcohol can be used as an appetite suppressor and as a compensatory behavior to avoid food.

The objective of this literature review was to explore the relation between EDs and SUD. The results of the study showed SUD is common with EDs. There are many reasons for this association such as shared neurobiological mechanisms, personality features, environmental and genetic factors.