BMJ case reports
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Case Reports
Intermittent swelling in the chest; a case of spontaneous intermittent lung herniation.
Herniation of the lung is uncommon and occurs due to protrusion of the lung beyond the confines of the thoracic cavity through an abnormal opening in the chest wall. Any condition associated with raised intrathoracic pressure or that which weakens the thoracic wall may result in lung herniation. We present a case of spontaneous lung herniation which was managed successfully by minimally invasive thoracic surgery.
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Case Reports
Methylene blue reverses recalcitrant shock in β-blocker and calcium channel blocker overdose.
β-blocker and calcium channel blocker toxicity generally present with bradycardia and hypotension. A 69-year-old woman presented after a suicide attempt with a β-blocker and calcium channel blocker overdose. Her blood pressure was 69/35 mm Hg and her HR was in the 40s. ⋯ She suffered two cardiac arrests and required a transvenous pacemaker. When all interventions failed, she was started on a methylene blue infusion for refractory vasodilatory shock which resulted in a dramatic improvement in her blood pressure. The patient was successfully weaned off all vasopressors and from mechanical ventilation without any end-organ damage.
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A teenage boy with vertically acquired-HIV presented with bone pain of 6 months duration. His antiretroviral therapy (ART) consisted of tenofovir disoproxil fumarate (TDF), emtricitabine and ritonavir-boosted lopinavir. Plain X-rays showed stress fractures of metatarsals bilaterally. ⋯ This case uniquely features renal and skeletal toxicities with resultant metatarsal stress fractures. Children and adolescents on combined ART which include tenofovir should be screened for the early detection of proximal tubulopathy, with the measurement of renal function, phosphate, vitamin D and urinary phosphate excretion. Although uncommon and mostly reversible, recognition of tenofovir-related effects is paramount as prolonged exposure may lead to persistent renal tubular damage and osteomalacia.
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Fetal supraventricular tachycardia (SVT) is the most common form of fetal tachycardia. If started early in pregnancy, it can cause non-immune fetal hydrops. Echocardiography is the preferred method for the diagnosis with simultaneous pulsed Doppler recording from the superior vena cava and ascending aorta. ⋯ We present a case of fetal SVT detected at 26 weeks of pregnancy. Digoxin therapy restored the rhythm initially, but later paroxysms of fetal SVT persisted necessitating the addition of second antiarrhythmic medication which was discussed with the parents. The couple chose to proceed for premature delivery at 32 weeks.
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Agranulocytosis is a rare yet life-threatening complication of methimazole therapy for hyperthyroidism. We present the case of a 37-year-old female recently started on methimazole for hyperthyroidism who presented to our facility for evaluation of suspected thyroid storm. In addition to having abnormal thyroid indices, she was noted to have an odontogenic abscess, and was septic with profound neutropenia. ⋯ Her neutrophil count improved significantly following cessation of methimazole and administration of granulocyte colony-stimulating factor. Diagnosis was initially confounded by the similarity between symptoms of early sepsis and those of thyroid storm. This case report discusses the factors leading to diagnostic delay and highlights the dangerous manifestations of neutropenia in patients on methimazole therapy.