Severe Metabolic Derangements Research Articles

Severe Metabolic Derangements in a Patient with Hypertension and COVID-19.

Severe Metabolic Derangements in a Patient with Hypertension and COVID-19.

Commentary on Severe Metabolic Derangements in a Patient with Hypertension and COVID-19.

Commentary on Severe Metabolic Derangements in a Patient with Hypertension and COVID-19.

Case report: Successful extracorporeal cardiopulmonary resuscitation despite severe metabolic acidosis after refractory out-of-hospital cardiac arrest

Current guidelines suggest considering extracorporeal cardiopulmonary resuscitation (ECPR) in refractory cardiac arrest and provide some guidance for favorable prognostic factors. However, inclusion and exclusion criteria are not strictly defined. We describe a 60-year-old male who underwent extracorporeal life support (ECLS) following refractory out-of-hospital cardiac arrest and made a full neurological recovery despite severe metabolic derangements, including a pH of 6.6 and lactate of 29 mmol/l. The aim is to present a favorable neurological outcome after ECPR despite severe significant physiologic derangements and put relative contraindications for ECPR into perspective.

Diffusely Invasive Mucormycosis of the Small Bowel in a Patient with Microbiologic Cultures and Tissue Biopsies Negative for Fungal Organisms

Abstract Introduction/Objective Invasive mucormycosis can be a swiftly fatal medical emergency occurring in patients with uncontrolled diabetes. This angioinvasive fungus causes tissue necrosis, hemorrhage, and thrombosis and often develops in the sinonasal cavities where it can extend directly to the CNS or spread systemically to visceral sites like the GI tract. Here, we describe a patient whose small bowel resection shortly before death, revealed diffusely invasive mucormycosis despite that blood and body fluid cultures and tissue biopsies were negative for fungal organisms. Methods/Case Report Our patient is a 39 year old male with a history of uncontrolled diabetes, brought to our hospital in cardiac arrest and found to have fentanyl in his system. His labs showed severe metabolic and electrolyte derangements including diabetic ketoacidosis. His blood cultures revealed bacteremia but no fungal growth, and he was placed on antibiotics for sepsis. The patient developed compartment syndrome of his bilateral forearms, which were amputated and showed necrotic skeletal muscle but no fungal infection. The patient also developed facial necrosis concerning for mucormycosis, but nasal endoscopic and facial skin biopsies were negative for mucor. However, his abdominal CT showed diffuse mural thickening of his small bowel concerning for bowel ischemia, which prompted an exploratory laparotomy that revealed large segments of necrotic jejunum and ileum. While peritoneal fluids collected during the surgery yielded no fungal growth on culture, resected segments of necrotic small bowel showed massive presence of mucor with broad, pauci-septate, ribbon-like hyphae branching at right angles. Small bowel and mesenteric vessels showed angioinvasion by mucor with vasculitis and fibrin thrombi causing ischemic enteritis. Mucor was also noted diffusely invading small bowel muscularis propria, adventitia, and mesenteric fat, and small bowel also showed ulceration, hemorrhage, and transmural and mesenteric fat necrosis. Unfortunately, a few days after his surgery, the patient expired from multi-organ failure and septic shock before he could receive anti-fungal therapy for mucormycosis. Results (if a Case Study enter NA) NA Conclusion Mucormycosis is a rapidly growing, angioinvasive, and potentially lethal fungal infection that must be promptly recognized. This report documents an unusual case of invasive mucormycosis of the small bowel that went undetected in a severely ill patient whose blood and peritoneal cultures and tissue biopsies were all negative for fungal organisms.

Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study.

Rhabdomyolysis is a serious condition that can cause acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Total plasma exchange (TPE) has been used as a treatment modality to clear myoglobin, but the evidence is limited. In this study, we aim to investigate the use of TPE in critically ill rhabdomyolysis patients. We retrospectively chart reviewed adult patients admitted to the intensive care unit (ICU) with a diagnosis of rhabdomyolysis between 2012 and 2021. We dichotomized patients into two groups based on whether TPE was used or not in addition to standard care. PRISMA machines with TPE2000 filters and either 5% albumin or fresh frozen plasma were used in the TPE group. The patients' age ranged from 23 years to 87 years (mean 49.4, SD 18.1), and 51% were male.Initial creatinine ranged from 0.6 to 16mg/dL (mean 3.4, SD 2.7), creatinine phosphokinase (CPK) from 403-93,232 U/L, and myoglobin from 934 to >20,000. The Sequential Organ Failure Assessment (SOFA)scores on admission ranged from 6 to 17 (mean 7.23, SD 3.40). Overall, 28.78% (N=19) of the patients received therapeutic plasma exchange. The overall mortality in our study was 31.9%, with the length of ICU stay ranging from 1-25 days (mean 7.10, SD 5.91) among survivors. Older age and the presence of shock were predictive of mortality in univariate and multivariate analyses. There was no statistically significant association in mortality between the TPE and non-TPE groups (36.84% in TPE vs. 36.17% in the non-TPE group, OR 0.7209, p=0.959). Only two patients in the non-TPE group developed CKD/ESRD on long-term follow-up. Our study showed that TPE administration in critically ill patients with rhabdomyolysis did not improve mortality or length of ICU stay. Further studies are required to elucidate its indication and effect on long-term renal outcomes.

ST-segment elevation in aVR following return of spontaneous circulation is associated with worse outcomes in cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Boston Medical Center Background ST-segment elevation in lead aVR (STE-aVR) is suggestive of global myocardial ischemia, typically in the setting of left main disease, triple vessel disease, or severe metabolic derangements, and is associated with increased mortality in acute coronary syndrome. The prevalence and prognostic significance of STE-aVR in patients presenting with cardiac arrest has not been previously described. Purpose We sought to describe the prevalence of STE-aVR among comatose survivors of cardiac arrest and evaluate the association of STE-aVR with in-hospital mortality and favorable neurologic outcome at hospital discharge. Methods We conducted a retrospective analysis of patients enrolled in the Multimodal Outcome CHAracterization in cardiac arrest patients (MOCHA) study at a single academic center. Participants were comatose survivors of cardiac arrest aged 18-89 years who had an initial electrocardiogram (ECG) obtained after ROSC between 2011-2020. STE-aVR was defined as ST elevation at the J point of ≥1 mm as measured by two trained assessors. Outcomes included in-hospital mortality and favorable neurologic outcome at hospital discharge (Cerebral Performance Category 1-2). Multivariable logistic regression, adjusted for age, medical comorbidities (diabetes, chronic kidney disease, heart failure, malignancy) and arrest characteristics (location, initial rhythm, witnessed status, bystander CPR) was used to test the association between outcomes and STE-aVR on ECG. Results 471 (89.0%) patients met inclusion criteria and were included in this analysis; 58 (11.0%) were excluded due to missing post-ROSC ECG. The median age was 62 years (Interquartile range: 51-73 years), and 284 (60.4%) were male. 297 (63.2%) presented with out-of-hospital cardiac arrest and 138 (29.4%) presented with a shockable rhythm. STE-aVR was present in 87 patients (18.5%). STE-aVR was more common in patients presenting with out-of-hospital cardiac arrest (22.9% vs 11.0%, P<0.01) but did not differ by initial rhythm (21.8% vs 31.1%, P=0.09). Patients with STE-aVR had higher mortality (83.9% vs 66.1%, P<0.01), which persisted after adjustment for confounding variables (Odds ratio (OR) 2.36; 95% Confidence Interval (CI): 1.23-4.52, P<0.01). Patients with STE-aVR had lower incidence of favorable neurologic outcome (13.8% vs 26.1%, P=0.01), however this association was not significant after adjusting for covariates (OR 0.52; 95% CI:0.26-1.05, P=0.07). Conclusion STE-aVR was present in nearly 1 in 5 comatose survivors of cardiac arrest. STE-aVR was independently associated with in-hospital mortality. Further research is needed to clarify the clinical significance and mechanism of STE-aVR in patients presenting with cardiac arrest.

Diabetic Striatopathy; A Differential Worth Considering in Diabetic Patients with Acute Onset Hyperkinetic Movements or Basal Ganglia (Striatal) Abnormalities on Imaging. (P8-4.007)

<h3>Objective:</h3> To describe a rare but interesting neurologic complication of uncontrolled diabetes; diabetic striatopathy, and to discuss its presentation as an uncommon etiology of acute hyperkinetic movement disorders. <h3>Background:</h3> Diabetic striatopathy is described as a hyperglycemic state in conjunction with striatal abnormalities on imaging and or the presence of hyperkinetic movements such as chorea. Imaging abnormalities described include hyperdense appearance of the striatum on CT and hyperintensity of the striatum on T1 MRI sequence. Associated hyperkinetic movements are thought to be reversible with correction of hyperglycemia. Given its rarity and ease of being misdiagnosed, we present a case of a 74-year-old woman with imaging findings consistent with Diabetic striatopathy. She presented in-extremis from an outside hospital for neurosurgical evaluation of a left basal ganglia hemorrhage. Her past medical history included uncontrolled type 2 diabetes and hypertension. <h3>Design/Methods:</h3> Not Applicable <h3>Results:</h3> Physical examination revealed an intubated, comatose, hypotensive patient with an irregular pulse. Her Laboratory values suggested uncontrolled diabetes with a hemoglobin A1C of “&gt; 17.0%” (beyond the laboratory’s upper limit) and serum glucose of 611. She had profound diabetic ketoacidosis. A non-contrasted head CT revealed what was initially thought to be a left basal ganglia hemorrhage; same interpretation as the outside hospital but was later favored to likely represent “nonketotic hyperglycemic chorea” and less likely a basal ganglia hemorrhage by the attending radiologist. MRI confirmed this with T1 hyperintensity in the left striatum. <h3>Conclusions:</h3> Our patient passed away from her severe metabolic derangements and no hyperkinetic movements were observed. However, her presentation highlighted to us an important and underrecognized differential of basal ganglia hemorrhage on imaging especially in the setting of uncontrolled diabetes. The paucity of information surrounding its pathophysiology, poses an area of potential research. Often cited as associated with hyperglycemic nonketotic state, it was enlightening to see it in diabetic ketoacidosis. <b>Disclosure:</b> Dr. Durojaye has nothing to disclose. Dr. Sammond has nothing to disclose. Dr. Moosavi has nothing to disclose.

Catastrophic ACTH-secreting pheochromocytoma: an uncommon and challenging entity with multifaceted presentation.

Cushing's syndrome due to ectopic adrenocorticotropic hormone (ACTH) secretion (EAS) by a pheochromocytoma is a challenging condition. A woman with hypertension and an anamnestic report of a 'non-secreting' left adrenal mass developed uncontrolled blood pressure (BP), hyperglycaemia and severe hypokalaemia. ACTH-dependent severe hypercortisolism was ascertained in the absence of Cushingoid features, and a psycho-organic syndrome developed. Brain imaging revealed a splenial lesion of the corpus callosum and a pituitary microadenoma. The adrenal mass displayed high uptake on both 18F-FDG PET/CT and 68Ga-DOTATOC PET/CT; urinary metanephrine levels were greatly increased. The combination of antihypertensive drugs, high-dose potassium infusion, insulin and steroidogenesis inhibitor normalized BP, metabolic parameters and cortisol levels; laparoscopic left adrenalectomy under intravenous hydrocortisone infusion was performed. On combined histology and immunohistochemistry, an ACTH-secreting pheochromocytoma was diagnosed. The patient's clinical condition improved and remission of both hypercortisolism and catecholamine hypersecretion ensued. Brain magnetic resonance imaging showed a reduction of the splenial lesion. Off-therapy BP and metabolic parameters remained normal. The patient was discharged on cortisone replacement therapy for post-surgical hypocortisolism. EAS due to pheochromocytoma displays multifaceted clinical features and requires prompt diagnosis and multidisciplinary management in order to overcome the related severe clinical derangements. A small but significant number of cases of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome are caused by ectopic ACTH secretion by neuroendocrine tumours, which is usually associated with severe hypercortisolism causing severe clinical and metabolic derangements. Ectopic ACTH secretion by a pheochromocytoma is exceedingly rare but can be life-threatening, owing to the simultaneous excess of both cortisol and catecholamines. The combination of biochemical and hormonal testing and imaging procedures is mandatory for the diagnosis of ectopic ACTH secretion, and in the presence of an adrenal mass, the possibility of an ACTH-secreting pheochromocytoma should be taken into account. Immediate-acting steroidogenesis inhibitors are required for the treatment of hypercortisolism, and catecholamine excess should also be appropriately managed before surgical removal of the tumour. A multidisciplinary approach is required for the treatment of this challenging entity.

Abstract #1307599: Successful Treatment of a Case of Congenital Lipodystrophy With 1 mg Subcutaneous Semaglutide

Lipodystrophy is a group of rare metabolic disorders characterized by generalized or partial lack of adipose tissue that leads to severe metabolic derangements including insulin resistance, severe hypertriglyceridemia, ectopic fat deposition, and hyperandrogenism. The available treatment is replacement of metroleptin which is costly and not available in my country. We review a case of generalized lipodystrophy presented with severely uncontrolled diabetes, severe hypertriglyceridemia, and severe hyperandrogenism treated successfully by insulin sensitizers and semaglutide 1 mg.

Long-term neurological intact survival and quality of life after refractory out-of-hospital cardiac arrest treated with rescue mechanical circulatory support

Abstract Background Mechanical circulatory support (MCS) with either veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella has emerged as a rescue therapy for refractory out-of-hospital cardiac arrest (OHCA). However, only short-term outcome is specified and most studies do not report follow-up beyond six months. Long-term survival and quality of life in this high-risk population remains unknown. Purpose To determine long-term neurological intact survival and quality of life in patients with refractory OHCA treated with MCS. Methods This was an observational, single-centre study of OHCA-patients from January 2015 to December 2019. Patients treated with MCS for OHCA were compared with patients receiving conventional cardiopulmonary resuscitation (CPR). A follow-up of long-term survivors in the MCS group was conducted (&amp;gt;1 year after arrest). This included health related quality of life questionaries (Short Form-36 [SF-36]) and assessment of neurological function with Cerebral Performance Category (CPC). Good neurological outcome was defined as CPC 1 and CPC 2. Results A total of 1015 with OHCA were included; 101 received MCS for refractory cardiac arrest. Among these V-A ECMO was deployed in 97 patients and Impella in 4 patients. The MCS group had significantly longer low-flow times compared to the conventional group (105 [IQR, 94–123] minutes versus 18 [IQR 10–39] minutes) and were more metabolically deranged upon arrival at hospital (Table 1). In patients receiving MCS, the hospital discharge rate was 27% and good neurological outcome was seen in 93% among patients discharged. At follow-up, 15 out of 21 long-term survivors participated. Median follow-up time was 4.8±1.6 (range 2.8–6.1 years). Mean age at follow-up was 61±7.3 years, 11 (73%) were men. Neurological outcome with CPC 1 was found in 12 patients (80%), with CPC 2 in 2 patients (13%), and with CPC 3 in 1 patient (7%). Two had improved neurological status from CPC 2 to CPC 1 since discharge. Mean scores of the SF-36 revealed an overall high level of psychical and mental health in long-term survivors (Figure 1). Conclusion Long-term survival with good neurological outcome was high in patients with refractory OHCA treated with MCS despite prolonged resuscitation and severe metabolic derangement. These patients may expect a reasonable quality of life after discharge. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University HospitalSnedkermester Sophus Jacobsen og hustru Astrid Jacobsens Fond

Selection of patients for mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) is a potential salvage therapy for selected patients with refractory out-of-hospital cardiac arrest (OHCA). Purpose The objective of this study was to describe the characteristics of potential ECPR patients. Methods This retrospective, observational cohort study included 579 patients admitted with refractory OHCA for possible ECPR at all tertiary cardiac arrest centers in Denmark between 2015 and 2020. Presenting characteristics, reasons for refraining from ECPR, and survival to hospital discharge were recorded. Results After initial evaluation, 221 patients (38%) proceeded to ECPR, and 358 (62%) were considered futile. Median prehospital low-flow time was 70 minutes [interquartile range 56–85] in ECPR patients and 62 minutes [48–81] in no-ECPR patients, p&amp;lt;0.001. Intra arrest transport was more than 50 km in 92 (42%) ECPR patients and 135 in no-ECPR patients (38%), p=0.25. Treatment decision was taken by a team of three specialists in 513 cases (97%). The leading cause for not initiating ECPR was duration of low flow time (39%). Severe metabolic derangement and low end-tidal CO2 (ETCO2) were contributing factors in 35% and 31%, respectively, Figure 1. 83% of the patients had two or more contributing factors recorded as reasons for not initiating ECPR, Figure 2. The most prevailing combination of contributing factors were non-shockable rhythm, low ETCO2, and metabolic derangement or duration of prehospital low flow time combined with low ETCO2. Survival to discharge was achieved in six patients (1.7%) in the no-ECPR group and 50 (23%) in the ECPR group. Conclusions In this large nationwide study of patients admitted for possible ECPR, 62% were not treated with ECPR. The most frequent reasons to abstain from ECPR were duration of prehospital low flow time, metabolic derangement, and low ETCO2. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Selection of patients for mechanical circulatory support for refractory out-of-hospital cardiac arrest

ObjectiveTo describe characteristics of patients admitted with refractory cardiac arrest for possible extracorporeal cardiopulmonary resuscitation (ECPR) and gain insight into the reasons for refraining from treatment in some.MethodsNationwide retrospective cohort...

Abstract #1180301: A case of multiple acyl-coenzyme A dehydrogenase deficiency (MADD) in a young adult

Multiple acyl-coenzyme A dehydrogenase deficiency (MADD), also known as glutaric acidemia type II, is a rare, clinically heterogenous disorder often characterized by non-specific symptoms such as fatigue and muscle weakness but if undiagnosed may lead to severe metabolic derangements.

Post-acute cardiac complications following SARS-CoV-2 infection in partial lipodystrophy due to LMNA gene p.R349W mutation

PurposeSARS-CoV-2 infection may cause varying degrees of cardiac injury and the presence of underlying cardiovascular morbidities contributes to the frequency and severity of occurrence of this complication.Lipodystrophy syndromes are frequently characterized by severe metabolic derangements that represent relevant cardiovascular risk factors. Besides causing lipodystrophy, mutations in the lamin A/C (LMNA) gene can lead to a wide spectrum of tissue-specific disorders including cardiac involvement.Methods and resultsWe herein examine the case of two patients affected by atypical progeroid syndrome and partial lipodystrophy due to a heterozygous missense LMNA mutation c.1045 C > T (p.R349W) who presented initially with mild COVID-19 and developed severe cardiovascular complications within few weeks of SARS-CoV-2 infection. Before being infected with SARS-CoV-2, our patients had cardiovascular morbidities (mild mitral regurgitation in one patient, ischemic heart disease with bifascicular block in the other patient) in adjunct to cardiovascular risk factors, but the SARS-CoV-2 infection contributed to quickly and significantly decompensate their balance.ConclusionThese findings warn that patients affected by LMNA p.R349W mutation and likely other LMNA mutations associated with cardiovascular morbidity should be considered at extremely elevated risk of post-acute cardiological manifestations and should therefore undergo a vigilant follow-up after SARS-CoV-2 infection. Both patients developed COVID-19 before the specific vaccination was available to them and this unfortunate situation should remark the importance of vaccination coverage against SARS-CoV-2 infection for all patients affected by lipodystrophy, especially those with underlying comorbidities.

Increased Frequency of Diabetic Ketoacidosis: The Link With COVID-19 Pandemic.

Diabetic ketoacidosis is the most severe metabolic derangement due to prolonged insulin deficiency as in type 1 diabetes. Diabetic ketoacidosis, a life-threatening condition, is often diagnosed late. A timely diagnosis is mandatory to prevent its consequences, mainly neurological. The COVID-19 pandemic and lockdown have reduced the availability of medical care and access to hospitals. The aim of our retrospective study was to compare the frequency of ketoacidosis at the diagnosis of type 1 diabetes between the lockdown-post lockdown period and the previous two calendar years, in order to evaluate the impact of the COVID-19 pandemic. We retrospectively assessed the clinical and metabolic data atthe diagnosis of type 1 diabetes in children in the Liguria Region during 3 different timeperiods: calendar year 2018 (Period A), calendar year 2019 until February 23,2020 (Period B) and from February 24, 2020 onwards to March 31, 2021 (Period C). We analyzed 99 patients with newly-diagnosed T1DM from 01/01/2018 to 31/03/2021. Briefly, a younger age at diagnosis of T1DM was observed in Period 2 compared to Period 1 (p = 0.03). The frequency of DKA at clinical onset of T1DM was similar in Period A (32.3%) and Period B (37.5%), while it significantly increased in Period C (61.1%) compared to Period B (37.5%) (p = 0.03). PH values were similar in Period A (7.29 ± 0.14) and Period B (7.27 ± 0.17), while they were significantly lower in Period C (7.21 ± 0.17) compared to Period B (p = 0.04). An increase in the frequency of diabetic ketoacidosis has been documented in newly diagnosed pediatric patients in the Liguria Region during and after the lockdown period compared to previous calendar years. This increase could have been caused by the delay in diagnosis following the restrictions imposed by the lockdown with consequently reduced access to health care facilities. More information on the risks of ketoacidosis is desirable by means of social and medical awareness campaigns.

English

Celiac disease is also called as non-tropical sprue, celiac sprue, adult celiac disease and gluten sensitive enteropathy. Environmental, immunologic and genetic factors play an important role in the aetiology.1 Symptoms of celiac disease can manifest at any age throughout adulthood. Symptoms range from significant malabsorption of multiple nutrients with diarrhoea, steatorrhea, weight loss and consequences of nutrient depletion (like anaemia and metabolic bone disease). Atypical celiac disease can present with symptoms not related to intestinal malabsorption like neurologic symptoms. Large number of patients with celiac disease can even be asymptomatic. The gold standard in diagnosis of celiac disease is an abnormal small intestinal biopsy and the response of the condition to the elimination of gluten from the diet. Classic changes seen on duodenal /jejunal biopsy 1. An increase in number of intraepithelial lymphocytes 2. Absence or a reduced height of villi 3. A cuboidal appearance and nuclei that are no longer oriented basally in surface epithelial cells 4. Increased numbers of lymphocytes and plasma cells in lamina propria Serology tests for celiac disease: IgA antiendomysial antibody and tissue transglutaminase TG antibodies which when positive is supportive in diagnosis. Acute presentation of celiac disease with severe metabolic derangement in adults is rare and called as “celiac crisis.” 2 In crisis the patient may present with profuse diarrhoea, severe dehydration and metabolic abnormalities, hypokalaemia, hypoalbuminemia, neurologic symptoms and azotaemia. We describe one such case in an elderly female patient.

UHPLC-ESI-QTOF-MS2 analysis of Acacia pennata extract and its effects on glycemic indices, lipid profile, pancreatic and hepatorenal alterations in nicotinamide/streptozotocin-induced diabetic rats.

Diabetes mellitus (DM) is a chronic disorder associated with severe metabolic derangement and comorbidities. The constant increase in the global population of diabetic patients coupled with some prevailing side effects associated with synthetic antidiabetic drugs has necessitated the urgent need for the search for alternative antidiabetic regimens. This study investigated the antidiabetic, antioxidant, and pancreatic protective effects of the Acacia pennata extract (APE) against nicotinamide/streptozotocin induced DM in rats. The antidiabetic activity of APE was evaluated and investigated at doses of 100 and 400 mg/kg body weight, while metformin (150 mg/kg bw) was used as a standard drug. APE markedly decreased blood glucose level, homeostatic model assessment for insulin resistance, serum total cholesterol, triglycerides, low‐density lipoprotein, blood urea nitrogen, creatinine, alanine transaminase, aspartate transaminase, and alanine phosphatase levels. Additionally, treatment with APE increased the body weight, serum insulin concentration, and high‐density lipoprotein. Moreover, activities of pancreatic superoxide dismutase, catalase, and glutathione peroxidase were increased, while the altered pancreatic architecture in the histopathological examination was notably restored in the treated rats. Ultra‐high performance liquid chromatography combined with electrospray ionization quadrupole time‐of‐flight mass spectrometry (UHPLC‐ESI‐QTOF‐MS) analysis of APE showcases the prevailing presence of polyphenolic compounds. Conclusively, this study showed the beneficial effects of the Acacia pennata in controlling metabolic derangement, pancreatic and hepatorenal dysfunction in diabetic rats.

Lithium-induced bilateral flapping tremors (asterixis) in geriatric mania

Asterixis (flapping tremors) is a movement disorder due to cortical or subcortical pathology that usually indicates serious underlying disease processes such as encephalopathy secondary to severe hepatic dysfunction, metabolic derangements, toxic agents, or serious adverse drug events. Mood stabilizers such as valproate and carbamazepine with or without concomitant administration of antipsychotics such as clozapine and risperidone have been implicated to induce asterixis. Lithium, a first-line mood stabilizer drug for geriatric mania, with its unique profile of side-effects due to narrow therapeutic window, is very rarely implicated to induce asterixis, especially when used as a monotherapy. We report a case of lithium-induced asterixis, ataxia, acute cognitive impairment, and altered sensorium in an elderly male with first-episode of mania, both during toxic and therapeutic serum levels of lithium. This case highlights the association between asterixis, ataxia, delirium, and lithium, substantiating the dictum “start low and go slow” in geriatric psychopharmacology.

A rare complication of hyperosmolar hyperglycaemic state in the intensive care unit

Diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS) are common presentations to the Intensive Care Unit (ICU) and represent a spectrum of pathology which encompasses well understood biochemistry. There are well established management processes and guidelines for DKA and HHS. This clinical pearl discusses these pathologies in the context of a patient with severe metabolic derangement who developed a rare complication.

TPE OR NOT TPE: USING THERAPEUTIC PLASMA EXCHANGE IN SEVERE RHABDOMYOLYSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Rhabdomyolysis is a syndrome caused by damage to skeletal muscle and the release of its breakdown products into the circulation. It can be asymptomatic or progress to acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Therapeutic plasma exchange (TPE) also known as plasmapheresis has been reported as a treatment option but data is limited to a handful of case reports. [1,2] We report our institutional experience using TPE for rhabdomyolysis in 10 critically ill patients admitted to our ICU during 2012-2020. CASE PRESENTATION: The patient age range was from 23 - 63 years (mean 41.4 years) and predominantly male (n=8). The most common etiologies were traumatic (n=4), amphetamine-induced (n=2), and acute limb ischemia, heat-stroke, electrocution, sepsis, and cardiogenic shock. Six patients had no major medical comorbidities, while others had concomitant COPD, heart failure, atrial fibrillation with mesenteric ischemia, and traumatic subdural hemorrhage. Initial creatinine (Cr) ranged from 1.9 to 8 mg/dl (mean 4.0), creatinine phosphokinase (CPK) from 6,000-100,000 U/L, and myoglobin from 5000 to >20,000 ng/ml. All patients had acute renal failure and eight of them had at least one other organ dysfunction such as respiratory failure (n=7), shock (n=6), liver injury (n=1), or encephalopathy (n=2). SOFA scores ranged from 3-18 (mean 7.85). All patients required continuous veno-venous hemofiltration due to renal impairment. TPE was started within 48 hours of diagnosis. PRISMAX machines with TPE2000 filters were used to perform TPE via membrane plasma separation. Either 5% albumin or fresh frozen plasma were exchanged at a filtration fraction of 25%. Patients underwent 1-3 TPE sessions (mean 1.4). A decrease in myoglobin, CPK, and Cr was seen post-TPE. Six patients had resolution of condition with successful discharge from ICU. Two patients deceased secondary to multi-organ failure and two were transitioned to comfort care due to concomitant neurotrauma and poor prognosis. Length of ICU stay ranged from 3-14 days (mean 7.5). Among survivors, only one patient required renal replacement therapy (RRT) upon hospital discharge. All patients had complete resolution of kidney dysfunction at a 3-month follow-up. No complications due to TPE were seen. DISCUSSION: There are no RCTs evaluating optimal treatments for rhabdomyolysis, however, case series using TPE in severe rhabdomyolysis have reported favorable outcomes. Our case series shows similar findings and suggests that TPE was effective in clearing circulating myoglobin as well as potentially other cytokines which are thought to propagate the disease process [3]. CONCLUSIONS: TPE can be safely and effectively used to treat severe rhabdomyolysis with multiorgan dysfunction. Further studies are required to elucidate its exact role in preventing long-term kidney dysfunction REFERENCE #1: Swaroop R, Zabaneh R, Parimoo N. Plasmapheresis in a patient with rhabdomyolysis: a case report. Cases J. 2009;2:8138. Published 2009 Aug 12. doi:10.4076/1757-1626-2-8138 REFERENCE #2: Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care. 2014;18(3):224. Published 2014 May 28. doi:10.1186/cc13897 REFERENCE #3: Ronco C. Extracorporeal therapies in acute rhabdomyolysis and myoglobin clearance. Crit Care. 2005;9(2):141-142. doi:10.1186/cc3055 DISCLOSURES: No relevant relationships by Paul Bhamrah, source=Web Response No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Cesar Davila-Chapa, source=Web Response No relevant relationships by Rajkamal Hansra, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response