Depressed Mental Status Research Articles

8278 Myxedema Coma With COVID-19 Infection

Abstract Disclosure: R. Kalas: None. V. Manohar: None. N.S. Bapat: None. Y. Kim: None. Myxedema coma is a rare medical emergency that occurs in severe hypothyroidism with a mortality rate reaching 60%. The hallmarks include depressed mental status and hypothermia, but hypotension, hyponatremia, bradycardia, and hypoventilation can also occur. This complication can occur in patients with a longstanding history of severe hypothyroidism especially when precipitated by an acute event such as infection, myocardial infarction, or surgery. Prompt recognition and treatment of the condition is important to prevent fatal outcomes. We present a case of myxedema coma in the setting of COVID-19 infection and nonadherence to medication. A 91-year-old woman with history of hypothyroidism, hypertension, coronary artery disease, cardiomyopathy, and chronic obstructive pulmonary disease presented with dyspnea. Her home medications included levothyroxine 75 mcg daily, which she reported not taking for at least 3 weeks. Vital signs revealed a normal heart rate and blood pressure of 84 beats/min and 137/78 mmHg, but the patient was hypothermic to 35.7 °C. On exam, she was somnolent. Labs were notable for markedly elevated TSH level of 111 (0.380 - 4.700 uIU/mL), low free T4 level of 0.57 (0.93 - 1.70 ng/dL), random cortisol level of 25.5 (6.2-18.4 ug/dL), and positive SARS-COV-2 PCR test. Chest x-ray revealed bilateral lower lung parenchymal consolidations and arterial blood gas revealed a pH of 7.29 and pCO2 of 52.5 (35-45 mm Hg), indicating hypercapnia. She was treated for COVID pneumonia and given concern for COVID induced myxedema coma she was given IV levothyroxine 100 mcg for 2 days, after which the patient’s hypothermia and somnolence improved, with an improved repeat free T4 level 0.87 ng/dL. She was subsequently transitioned to oral levothyroxine 112 mcg daily and discharged after improvement of her COVID symptoms. Myxedema coma is a rare complication of decompensated hypothyroidism, frequently triggered by an infection. Thyroid hormone plays an important role in regulating both the innate and adaptive immune systems. As a result, individuals with hypothyroidism are at increased risk of acquiring infections, which can further lead to myxedema coma. COVID-19 infection has been associated with thyrotoxicosis, thyroiditis and hypothyroidism. Given the associated high mortality rate, regardless of the underlying precipitant, prompt diagnosis and early administration of thyroid hormone replacement therapy is crucial to improve outcomes. Presentation: 6/3/2024

The prevalence and distribution of risk factors for depression and emotional mental disorders in the elderly in Indonesia.

Depression is a mental health disorder. The prevalence of mental health disorders in the elderly is high. This study was to determine the mental status depression and emotional of the elderly based on their characteristics. This study was a further analysis of Basic Health Research 2018 data. The population was all households from all districts/cities in 33 provinces in Indonesia with a cross-sectional design. The sample was all elderly, with a total sample of 82,304,000 people. The respondents included young elderly (60-69 years), middle elderly (70-79 years), and old elderly (>80 years). Depression is experienced by most of elderly aged 60 to 69 years as many as 3,756,384 respondents (59.72%), females as many as 3,885,191 respondents (61.77%), living in urban areas, as many as 3,147,131 respondents (50.03%), graduated from elementary school as many as 2,052,22 respondents (32.63%), not working as many as 3,535,241 respondents (56.21%), and quintile one expenditure level as many as 1,532,358 respondents (24.36%). Emotional disorders of depression in elderly are due to the adaptation process to physical and psychosocial changes. Family support is a must to improve elderly's quality of life on mental health aspects, especially depression. Furthermore, better treatment by medical personnel is required.

Amantadine as an Aid to Extubation in Severe Acute Brain Injury: A Case Series.

For a subset of patients with severe acute brain injury (SABI) undergoing invasive mechanical ventilation, the primary barrier to successful extubation is depressed mental status. Amantadine is a neurostimulant that has been demonstrated to increase arousal and improve functional outcomes in patients with SABI. In this case series, we describe 5 patients with SABI and invasive mechanical ventilation who received amantadine as an agent to improve mental status to allow extubation. The primary barrier to extubation for all patients was depressed mental status. Median age was 77 (range 32 to 82). Primary diagnoses were ischemic stroke (n = 1), subdural hemorrhage (n = 2), intracerebral hemorrhage (n = 1), and traumatic brain injury (n = 1). Median Glasgow Coma Score was 7T prior to administration of amantadine and 10T on the day after amantadine was initiated, with improvements in eye-opening and motor response. Four patients displayed improvement in arousal and attention and were successfully extubated 1 to 4days after initiation of amantadine (median 2days). The fifth patient only displayed marginal improvement in mental status after starting amantadine, but was ultimately able to be extubated 7days later. Amantadine may improve the likelihood of or reduce the time to successful extubation in patients with SABI.

PEDIATRIC ANAPHYLAXIS TO PIPERACILLIN-TAZOBACTAM REQUIRES FURTHER ALLERGY TESTING TO OTHER PENICILLINS DUE TO SELECTIVE SENSITIZATION.

<h3>Introduction</h3> Individuals with type-I IgE-mediated reactions to Piperacillin-Tazobactam often avoid other penicillins. Previous studies reveal 70% of those individuals were selectively sensitized to only Piperacillin-Tazobactam and tolerated other penicillins. <h3>Case Description</h3> The patient is a 20-month-old, full term female with a past medical history of maple syrup urine disease s/p liver transplant that presents with anaphylaxis to Piperacillin-Tazobactam. She was treated with Intravenous Piperacillin-Tazobactam and immediately after administration was noted to have vital sign instability and depressed mental status. She was treated with epinephrine, steroids, and supportive care. Her Tryptase level was 49.2. She later followed up in allergy clinic and tolerated an oral amoxicillin challenge. She had negative skin prick testing, but positive intradermal testing to Piperacillin-Tazobactam, confirming her type-1 IgE-mediated reaction. <h3>Discussion</h3> This case demonstrates an additional example of the lack of cross reactivity between Piperacillin and other penicillins. Previous studies have demonstrated that the immune response is directed at the unique side chain of the Piperacillin. Only 33% of individuals were found to have a cross sensitivity to other penicillins after a Type-1 IgE-mediated reaction to Piperacillin-Tazobactam. Individuals with penicillin allergies are often exposed to broad-spectrum antibiotics. This can lead to an increased risk of infection with resistant organisms, further leading to higher death rates and increased hospital costs. After having an allergic reaction to Piperacillin-Tazobactam, it is important that patients are tested for a type-1 IgE-mediated reaction to other penicillins, potentially allowing patients to use other penicillin-class antibiotics.

Methanol induced intracranial hemorrhage: A rare case report

Intracranial hemorrhage is a rare but fatal complication in methanol poisoning. We report a case of large bilateral basal ganglia hematoma in a 29-years old man with methanol poisoning. He drank alcohol, and was admitted to a tertiary level hospital 6 hours post-ingestion for depressed mental status, lower blood pressure, and high anion gap metabolic acidosis. After fourteen days of methanol exposure, he suddenly developed left sided weakness with one episode of seizure attack. MRI of brain was carried out and showed large intracerebral bleed basal ganglia, specially putaminal and brain edema with midline shift. The uncommon presentation of methanol poisoning is highlighted in this case report. Bangladesh J Medicine 2022; 33: 300-303

P.035 Impressive MRI findings in the case of iatrogenic osmotic demyelination syndrome: case report

Background: Osmotic demyelination syndrome (ODS) is a known complication of rapid sodium correction. While the pons is classically the most vulnerable region to osmotic shifts, other structures may also be affected. Prognosis varies from death to full recovery, yet we cannot accurately predict a patient’s outcome in the acute phase. Methods: Patient chart, medical imaging, and laboratory findings were reviewed. Results: Here we present the case of a 57-year-old woman seen at our center, who was transferred from a community hospital in the context of ODS after having her serum sodium corrected from 106 mmol/L to 122 mmol/L within 24 hours. She showed depressed mental status, bulbar symptoms, ataxia and respiratory compromise, eventually requiring transfer to the intensive care unit for intubation. MRI of the brain showed striking demyelinating injury at the level of the pons. The patient was discharged to a rehabilitation facility, eventually achieving independence in activities of daily living. Conclusions: This case illustrates canonical neuroimaging findings associated with ODS. Despite extensive initial damage, long-term disability can be mitigated with appropriate care. Future studies seeking to identify specific markers imaging and clinical markers would be of interest to predict functional outcome.

A Chemist with a Strange Etiology of Rhabdomyolysis: A Case Report of a Rare Toxicological Emergency.

IntroductionChloroform, a halogenated hydrocarbon, causes central nervous depression, hepatotoxicity, nephrotoxicity, and rhabdomyolysis. Historically, chloroform had been used as a general anaesthetic and today is still used in chemical industries. Lack of proper personal protective equipment and adequate knowledge about its toxic effects can lead to serious harm.Case reportA 33-year-old gentleman presented to the emergency department (ED) with altered mental status. Given his depressed mental status, the decision was made to intubate shortly after arrival for airway protection. Further history raised suspicion of occupational chloroform exposure. Brown-colored urine further strengthened suspicion of chloroform poisoning with resultant rhabdomyolysis. Forced alkaline diuresis and N-acetylcysteine were started in the ED. His mental status and respiratory efforts improved on hospital day two, and he was ultimately extubated. Creatine phosphokinase and myoglobin levels were initially high but gradually came down by hospital day six. On hospital day 10, the patient was deemed stable and safely discharged.ConclusionA patient with chloroform inhalation who suffered resultant rhabdomyolysis and hepatotoxicity was successfully treated with early initiation of forced alkaline diuresis, N-acetylysteine, and hemodialysis.

Delayed traumatic pneumocephalus and cervical pneumorrhachis in a dog

AbstractA 7‐year‐old female spayed Labrador Retriever was referred for generalised seizures which initiated 48 hours prior to presentation. Physical examination revealed facial asymmetry and enucleation of the right eye due to head trauma 6 years earlier. Neurological examination showed depressed mental status, absent menace response of the left eye, non‐ambulatory tetraparesis, absent postural reactions in all four limbs and normal spinal reflexes. Neuroanatomical localisation was prosencephalic (forebrain). MRI study of the brain allowed a diagnosis of pneumocephalus and pneumorrhachis as the cause of neurological signs. The dog was hospitalised and treated conservatively with anticonvulsants, antimicrobials and oxygen therapy. During hospitalisation, no further seizures were observed, the neurological condition improved progressively, and the dog was discharged with oral anticonvulsant treatment 4 days after admission. Eight months later, the dog was still seizure‐free, and the follow‐up MRI showed no lesions consistent with the previously diagnosed pneumocephalus and pneumorrhachis.

Otitis Media and Internal with Brainstem Extension in a French Bulldog

Background: Otitis is a frequent condition in dogs, with a multifactorial etiology covering primary causes, predisposing and perpetuating factors. It is characterized by an inflammatory process of structures that make up the auditory system, with prevalence data ranging from 15 to 20%, which can occur in any age group and without sex predisposition. According to the location, it can be classified as uni or bilateral, affecting the outer, middle and / or inner ear, the latter two being associated with neurological changes such as vestibulopathy, facial nerve paresis and Horner's syndrome. The morbidity and mortality of otitis media and internal may increase with delay in diagnosis, resulting in delay in the correct treatment, and the extension to brainstem is described in felines and considered rare in dogs. The present study aims to report an atypical case of otitis media and internal, with extension to the brain parenchyma in a brachycephalic dog.Case: A 3-year-old bitch French Bulldog canine was seen, weighing 12 kg, with a history of vomiting, apathy, nystagmus, ataxia and acute evolution hemiparesis. As a result of adoption, it was not known about the animal's morbid past. On special physical and clinical examination, depressed mental status, changes in postural reactions, nostril stenosis with unilateral mucopurulent nasal discharge, corneal ulcer, palpebral and labial ptosis, absence of eyelid reflex and spontaneous strabismus were observed, all of these findings observed on the left side of the face. No signs of otitis external to otoscopy were found. The clinical signs found characterize left facial nerve paresis and peripheral and central vestibulopathy. Otitis media / internal and meningoencephalitis were suspected. Hemogram, serum biochemistry (glucose, urea, creatinine, alanine aminotransferase, total proteins, albumin, globulin, alkaline phosphatase, gamma glutamyltransferase, phosphorus, total bilirubin, cholesterol and total calcium), urinalysis, rapid tests for erlichiosis, anaplasms , borreliosis, heartworm, distemper and leishmaniasis, CSF analysis, neurological panel performed by PCR (Polymerase Chain Reaction) that tested the animal for Bartonellosis, Lyme Disease (Borrelia burgdorferi), Blastomyces dermatitidis, Cryptococcus sp., Virus West Nile, Distemper, Toxoplasmosis, Neosporose and Coccidioides sp. using conjunctival swab, whole blood, urine and CSF samples. The samples were negative for all of these tests. As an image exam, brain magnetic resonance was performed. In the latter, otitis media and left internal was observed with extension of the lesion to the brain parenchyma. CSF analysis showed cytological changes compatible with a non-suppurative inflammatory process, mild pleocytosis with predominantly mononuclear leukocyte infiltrate. As a form of treatment, antibiotic therapy and total ablation of the auditory canal with lateral bulectomy were performed, showing good results with reduced clinical symptoms.Discussion: It is concluded that although the diagnosis of otitis media and internal with extension to brainstem is more common in cats, it should be included as a differential for central vestibular disorders in dogs, and that the diagnosis together with early and effective treatment are important, since that the evolution of the infection to the central nervous system represents a risk to the patient.Keywords: vestibulopathy, meningoencephalitis, brachycephalic.Descritores: vestibulopatia, meningoencefalite, braquicefálico.Título: Otite média e interna com extensão para tronco encefálico em cão buldogue francês

Effects of Adjunctive Therapeutic Hypothermia Combined With Hyperbaric Oxygen Therapy in Acute Severe Carbon Monoxide Poisoning.

To determine the effects of adjunctive therapeutic hypothermia, by comparing hyperbaric oxygen therapy versus hyperbaric oxygen therapy combined with therapeutic hypothermia in acute severe carbon monoxide poisoning. Retrospective analysis of data from our prospectively collected carbon monoxide poisoning registry. A single academic medical center in Wonju, Republic of Korea. Patients with acute severe carbon monoxide poisoning older than 18 years. Acute severe carbon monoxide poisoning was defined as mental status showing response to painful stimulus or unresponsive at the emergency department, and a continuation of this depressed mental status even after the first hyperbaric oxygen therapy. Patients were classified into the no-therapeutic hypothermia and therapeutic hypothermia groups. Hyperbaric oxygen therapy was performed up to twice within 24 hours after emergency department arrival, whereas therapeutic hypothermia was performed at a body temperature goal of 33°C for 24 hours using an endovascular cooling device after the first hyperbaric oxygen therapy. Hyperbaric oxygen therapy versus hyperbaric oxygen therapy combined with therapeutic hypothermia. We investigated the difference in the Global Deterioration Scale score at 1 and 6 months after carbon monoxide exposure, between the no-therapeutic hypothermia and therapeutic hypothermia groups. Global Deterioration Scale scores were classified as follows: 1-3 points (favorable neurocognitive outcome) and 4-7 points (poor neurocognitive outcome). During the study period, 37 patients were treated for acute severe carbon monoxide poisoning, with 16 and 21 patients in the no-therapeutic hypothermia and therapeutic hypothermia groups, respectively. The therapeutic hypothermia group demonstrated significantly higher number of patients with favorable outcomes (p = 0.008) at 6 months after carbon monoxide exposure and better improvement of the 6-month Global Deterioration Scale score than the 1-month score (p = 0.006). Our data suggest that in acute severe carbon monoxide poisoning, patients who were treated using therapeutic hypothermia combined with hyperbaric oxygen therapy had significantly more favorable neurocognitive outcomes at 6 months after carbon monoxide exposure than those treated with hyperbaric oxygen therapy alone.

SAT-480 Myxedema Madness: A Rare Case of Severe Hypothyroidism Presenting as Psychosis

IntroductionMyxedema coma is a rare, life-threatening medical emergency resulting from uncontrolled hypothyroidism. Myxedema coma refers to the neurological sequelae of severe hypothyroidism, which classically manifests as depressed mental status. Rarely, myxedema coma can present with a hyperactive mental state and psychosis. We present an unusual case of a drug overdose secondary to myxedema coma-induced psychosis.Clinical CaseA 48 year old woman with a history of seizure disorder and hypothyroidism presented to the hospital after lamotrigine overdose. The patient’s spouse witnessed her ingest forty-five tablets of lamotrigine after an argument. The patient had no previous psychiatric diagnoses or suicide attempts. On examination, the patient was hemodynamically stable but was agitated, disoriented, and uncooperative. She had a normal neurologic exam and no peripheral edema. Her lamotrigine level was 25.4 ug/ml (2.5-15.0 ug/ml). The patient’s mental status did not improve with lamotrigine cessation. Psychiatry determined that the patient’s psychosis was not consistent with lamotrigine overdose. Given these recommendations, alternative causes of psychosis were considered. The patient’s husband stated she had not taken levothyroxine for over one year. Thyroid function tests revealed a thyroid stimulating hormone (TSH) of 299 mcIU/ml (0.35-5.50 mcIU/ml) with a free thyroxine (T4) level of 0.27 ng/dl (0.89-1.76 ng/gl). The patient was started on levothyroxine intravenously. After five doses of intravenous levothyroxine, her mental status improved to baseline and she was transitioned to oral levothyroxine. She denied that the lamotrigine ingestion was a suicide attempt. Based on the patient’s presentation and clinical course, we concluded that her overdose was due to severe hypothyroidism leading to myxedema madness.ConclusionSevere hypothyroidism with myxedema coma often presents with depressed mental status, which can manifest as progressive confusion, lethargy, and eventually coma. However, in the case of our patient, severe hypothyroidism presented as psychosis, a rare manifestation. Remarkably, the patient had no other obvious physical manifestations of severe hypothyroidism. Psychosis, though rare, has been seen in cases typically after thyroidectomy or in patients with previously undiagnosed Hashimoto’s thyroiditis. In this patient’s case, it is likely that her myxedema madness was precipitated by long-term nonadherence with her thyroid replacement therapy, as the patient had no prior psychiatric history. Additionally, her rapid reversal of symptoms after the administration of levothyroxine supports the diagnosis of hypothyroid-induced myxedema madness.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Toxicity of agents used for opioid withdrawal: a case-based approach.

Oral Ingestion of Cannabis in a 19 Months Old Infant

According to the World Health Organization (WHO), 2.5 percent of the world population, use cannabis, making it the world's most widely cultivated, trafficked, and abused illicit substance. In children, acute marijuana intoxication mainly occurs after exploratory ingestion of marijuana intended for adult use. Intentional exposure of children to cannabis depends on the child age either by caretakers Intentionally exposing them to its smoke by inhalation, or direct cannabis inhalation and use by the kids themselves especially adolescent population. After exposures, children may display simple sleepiness to depressed mental status and In large overdoses even respiratory depression can happen making the patients in need of invasive ventilation support. We are reporting a case of a 19 months old boy presenting with acute decrease level of consciousness, and slow improvement of his mental depression over 24 hours following oral cannabis intoxication.

Outcomes of Casualties Without Airway Trauma Undergoing Prehospital Airway Interventions: A Department of Defense Trauma Registry Study.

Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. However, casualties may require airway interventions for other indications (e.g., depressed mental status). We describe casualties undergoing airway intervention in the prehospital, combat setting without apparent upper airway trauma. We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subgroup analysis of those patients with a documented prehospital airway intervention and no apparent airway trauma as defined by abbreviated injury scale of 0 for body regions 1 (head/neck) and 2 (face). Our predefined search codes captured 28222 DODTR subjects of whom 409 (1.4%) met criteria for study inclusion. Subjects included members of host nation forces (34%) and civilians (30%). Most subjects sustained injuries in Afghanistan (82%). Explosive (57%) and gunshot wounds (36%) were the most frequent mechanisms of injury. Median injury severity scores were 17. The most common anatomical locations of injuries for included subjects included extremities (53%) and thorax (29%). A majority of subjects underwent intubation (89%); comparatively few casualties underwent placement of a nasopharyngeal airway (2%) or supraglottic airway (2%). The proportion of subjects surviving to hospital discharge was 80% and was highest among subjects undergoing intubation (82%). In this subgroup analysis of casualties without apparent upper airway trauma, survival rates were lower when compared to our previous report. Higher quality data are necessary to better understand the resuscitation needs of this critically ill subset of combat casualties.

Attention to Detail.

Attention to Detail.

Hyperbaric oxygen therapy and mortality from carbon monoxide poisoning: A nationwide observational study

BackgroundThe effects of hyperbaric oxygen therapy (HBOT) on mortality or morbidity in patients with carbon monoxide (CO) poisoning remain unknown. We examined the effects of HBOT on CO poisoning and further strived to delineate its inherent effects on specific subgroups of patients using a nationwide inpatient database. MethodsWe identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2016. Propensity score-matching was performed to compare patients who received HBOT within 1 day of admission (HBOT group) with those who did not receive HBOT (control group). The primary outcome was in-hospital mortality. The secondary outcomes were a depressed mental status and reduced activities of daily living (ADL) at discharge. We also performed subgroup analyses divided according to severity of CO poisoning. ResultsEligible patients were categorized into the HBOT group (n = 2034) or the control group (n = 4701). One-to-one propensity score-matching created 2034 pairs. In-hospital mortality was not significantly different between the HBOT and control groups (0.8% vs. 1.2%, risk difference: −0.4%, 95% confidence interval: −1.0 to 0.2). Patients in the HBOT group had significantly lower proportions of a depressed mental status and reduced ADL at discharge than did those in the control group. Similar associations were shown in the non-severe poisoning subgroup. ConclusionsAlthough HBOT was not significantly associated with reduced mortality, it was significantly associated with a favorable consciousness level and ADL in patients with CO poisoning. HBOT may be beneficial even for patients with non-severe CO poisoning.

Coma, Seizures, Atrioventricular Block, and Hypoglycemia in an ADB-FUBINACA Body-Packer

BackgroundSynthetic cannabinoid intoxication has become difficult to diagnose and manage in the United States, in part due to varying clinical effects within this heterogeneous group of compounds. Case ReportA 38-year-old man was admitted with altered mental status and bradycardia. He demonstrated progressive encephalopathy, seizure activity, second-degree atrioventricular block type I, respiratory failure, hypotension, hypothermia, and hypoglycemia. A computed tomography scan of the abdomen and pelvis revealed multiple packages in the patient's stomach and rectum. Multiple attempts at gastrointestinal decontamination were unsuccessful. On hospital day 8 the patient developed hypertensive emergency and was taken to the operating room for exploratory laparotomy. Twenty-two poorly wrapped packages were removed from the bowel. Postoperatively the patient demonstrated both generalized and focal seizure activity. His mental status slowly returned to baseline over the period of about 1 week and he was ultimately discharged without neurological sequelae after 1 month. Analysis of patient serum, urine, and plant matter from the packages identified cannabis and 2.N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-carboxamide (ADB-FUBINACA). Why Should an Emergency Physician Be Aware of This?The case presented demonstrates the suspected toxidrome associated with severe ADB-FUBINACA intoxication, including mental status depression, bradycardia, autonomic instability, seizure, hypoglycemia, and hypothermia. Although the patient had simultaneous exposure to cannabis, his constellation of symptoms is not consistent with cannabis intoxication. A previous animal model supports the potential of this specific synthetic cannabinoid to cause the reported toxidrome.

Wilson Disease: Acute Liver Failure in a 72-Year-Old Patient

Introduction Wilson disease (WD) is a disorder of abnormal copper metabolism prevalent in young populations. Though there has been mention of WD in older patients, such cases are extremely rare. Herein we describe an unusual presentation of acute liver failure in a 72-year-old female. Case Report A 72-year-old woman with history significant for lupus on chronic Methotrexate presented to our institution for acute liver failure. Family and social history were unremarkable. Admission labs were AST 125, ALT 94, ALP 468, T-bilirubin 0.7, D-bilirubin 0.3, INR 1.3. Progressive decline in patient's liver function prompted liver biopsy revealing steatohepatitis, minimal fibrosis 1a/4, cholestasis, and anisonucleosis consistent with methotrexate induced hepatotoxicity versus WD (Figure 1). Patient was initially managed conservatively with working diagnosis of presumed methotrexate induced hepatotoxicity. However, suspicion for WD increased when patient developed hemolytic anemia, acute renal failure, depressed mental status and worsening jaundice. Patient underwent slit lamp examination with equivocal findings of Kaiser-Fleischer rings. Notable laboratory values included serum copper of 79 mcg/dL, 24-hour urinary copper excretion of 31 mcg/24 hr (GFR 34 at time of collection), and ceruloplasmin of 14 mg/dL. Non-ceruloplasmin bound copper was 37 μg/dL. Quantitative hepatic copper returned elevated at 298 mcg cu/g. Labs progressed to AST 124, ALT 38, ALP 475, T-bilirubin 34 .7, D-bilirubin 30.8, INR 2.58. Genetic testing with whole gene sequencing revealed heterozygosity for a single copy of a point mutation in the ATP7B gene (A to G substitution at position 226). Unfortunately, patient ultimately passed away.2410 Figure 1. Liver biopsy of our patient revealing steatohepatitis with moderate activity (6/8), minimal increase in fibrosis (1a/4), cholestasis, and anisonucleosis.Discussion Wilson Disease is diagnosed on the basis of several clinical and biochemical tests. In our case, symptoms consistent with WD included cirrhosis, neuro-psychiatric depression, equivocal Kaiser-Fleischer rings, hemolytic anemia and acute renal failure. Convincing laboratory values included low ceruloplasmin, elevated quantitative hepatic copper, elevated non-ceruloplasmin bound copper and anisonucleosis on biopsy. Genetic testing revealed a variant of unclear significance in the ATP7B gene, and recent literature has cited high alleleic heterogeneity patients with WD. This case illustrates the atypical presentation of WD in an elderly 72-year-old patient, highlighting the importance of maintaining clinical suspicion for WD even in older patients.

Investigation of PD-1H in DEN-induced mouse liver cancer model.

Immune therapy has recently become a novel strategy for treating liver cancer, making it of critical importance to identify novel targets for treatment. Programmed death-1 homology (PD-1H) is one newly discovered negative co-stimulating molecule, and plays important regulatory roles in suppressing T cell activation. However, the expression or function of PD-1H in liver tumors has not been reported. Liver cancer tissues were collected from The Cancer Genome Atlas (TCGA) (http://tcga-data.nci-nih.gov). This study then utilized diethylnitrosamine (DEN) induced liver cancer mice, on which PD-1H monoclonal antibody and PD-1H extra-cellular Fc domain fusion protein were injected intraperitoneal. General status, gross morphology of liver tissues was examined, followed by hematoxylin-eosin (HE) staining and plotting survival curve. Among TCGA samples, PD-1H expression was significantly elevated. Induced liver cancer mice showed depressed mental status, early onset of hepatitis and liver cirrhosis. Five mice dead in model group (mortality=33.33%). No natural death occurred in control group. Injection of PD-1H-Fc-Ig fusion and PD-1H monoclonal antibody improved the condition to certain extents, with morality at about 20%. Comparing to DEN group, combined treatment group showed significantly fewer tumor lesion on liver surface, with increased body weight and lower liver-body weight ratio. HE staining showed significantly elevated ratio of normal cells in combined treatment group, although large amounts of cancer cells still existed. Blocking of PD-1H signal pathway could suppress liver cancer cell growth, decrease mouse mortality, indicating promising application of PD-1H in tumor immune therapy.

Status Epilepticus due to Baclofen Intoxication

Background. Baclofen is a muscle relaxant agent that in toxic doses exhibits symptoms such as depressed mental status, hypotonia, hyporeflexia, and respiratory depression. Seizure is a less common presentation of Baclofen toxicity, especially in pediatric patients. Case Description. The patient was a 4 year-old boy with no previous neurologic disorder who experienced status epilepticus after ingestion of high dose of Baclofen orally. He was treated conservatively and after 8 hours, he became awake in good condition without any abnormal finding in imaging or laboratory tests. Discussion. This case describes some rare clinical presentations of Baclofen toxicity that were seizure and bradycardia in an otherwise-normal pediatric patient which could be managed conservatively.