A 49 y.o. male presents with a pruritic rash on the top of his head and his penis.

What would be in the differential?

novlichenpl.JPG

Our patient had lichen planus. The term lichen planus was derived from the Greek word leichen meaning tree moss and the Latin word planus meaning flat.  It was first used by Wilson in 1869.  This is a skin disease caused by a cell-mediated response of unknown origin. It may be found in diseases of altered immunity , such as ulcerative colitis, vitiligo, dermatomyositis, myasthenia gravis and hepatitis C. It can be caused by medications including diuretics, ACE inhibitors, beta-blockers and NSAIDs.  It is also associated with syphilis which is what our patient had.

Wickham's striae, white lacy lines on the oral mucosa.

Wickham's striae, white lacy lines on the oral mucosa.

Lichen planus affects one percent of the general population .  It causes scaly raised areas that may occur on the genitals, skin or in the mouth where classically it forms Wichkham’s striae.  It can cause ridged nails and is most common  in patients in their 30s to 50s.  The lesions are intensely pruritic. The differential in this case with penile and scalp lesions  would have included lichen planus, psoriasis or lichen sclerosus.  Lichen sclerosus presents with a hypopigmented glans with a cellophane-like texture and phimosis. 

lichen sclerosus

lichen sclerosus

Pathologically, there is degeneration of the basal layer of the epidermis and a bandlike lymphocytic infiltrate obscuring the dermal epidermal junction. There is irregular epidermal hyperplasia with  a saw tooth appearance.  The basal layer of skin shows necrosis with keratinocyte damage.The pathology is what distinguishes it from an ID reaction where fungal infections in the feet can cause a diffuse eczematous rash. 

lichen planus path.JPG

It is treated with topical corticosteroids and may last up to a year. Our patient was treated for syphilis and given steroids for his scalp.  His phone number has changed and he has been lost to follow up.

J Cutan Pathol 1993 apr;20(2):143-7.

Young SK, Kim MH, Kim CW, et al. A case of palmoplantar lichen planus mimicking secondary syphilis. Ann Dermatol 2009 21(4): 429-431.

Singh JP, Priyadarshi V, Goel H, Vijay M, et al.  Penile lichen sclerosus: a n urologist’s nightmare! A singlecenter experience. Urol Ann 2015 7(3): 303-308.

Wilson E. On lichen planus. J Cutan Med Dis Skin.  1869;3:117-132.

A 28 y.o. presents with shortness of breath. What should you do?

this is his cxr

this is his cxr

Our patient had congenital lobar emphysema.   It is a cause of respiratory distress in the neonate, but can also be found in young adults.  The diagnosis is often made on cxr. Key findings include hyperlucency on the affected side with atelectasis of the normal lobes.  The mediastinum may be displaced away from the affected side and may herniate into the contralateral hemithorax.  Lung slide may be absent although there is no pneumothorax. The patient does not need a chest tube. This condition should be distinguished from Swyer- James,  which is acquired hyperlucency after an adenovirus infection where the lung does not grow normally.

In two other conditions a chest tube is not needed although it may look like it on first glance. One condition is a large bleb which can mimic a pneumo.  The danger of putting a chest tube into such a patient is that a persistent air leak can develop.

CXR with a large bleb below

pneumo 4.JPG

Another condition that can mimic a pneumo/hemo  is a collapsed lung. The image below is  from a patient who presented one month ago to the ED.  There was a call from the triage doctor stating, “patient is coming to TCC 2 needing an urgent chest tube. “ The image is below and represents a completely obstructed L mainstem bronchus with L lung collapse.  A chest tube would not be indicated but rather a bronch.

pneumo3, larry stevens.JPG

Our patient underwent a resection of the emphysematous upper lobe and recovered without incident.It was easy to make the diagnosis on history in his case and it was confirmed on CT where lung markings could be seen on the empysematous side..

Stern EJ, Webb WR,  Weinacker A, Muller NL.  Idiopathic giant bullous emphysema (vanishing lung syndrome) imaging findings. In nine patients . AJR , 162(1994) 279-282.

Boushy SF, Kohen R, Billig DM, Heiman MJ.  Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients. Dis Chest, 1968. 54:327-334.

Gelabert, C, Nelson M.  Bleb Point: Mimicker of Pneumothorax in bullous lung disease. 201516(3).447-449.

lung markings seen on the emphysematous side

lung markings seen on the emphysematous side

A 57y.o. presents with a cold pulseless R leg, a CT is done to ro aortic dissection. There is no dissection but the finding below is seen. What does it mean?

There is no PE.

dye is refluxing into the liver and there is a "half-moon" sign in the vena cava.

dye is refluxing into the liver and there is a "half-moon" sign in the vena cava.

Our patient had dependent layering of contrast in the inferior vena cava which is a sign of cardiogenic shock.  This also occurs if a patient arrests during a CT and involves not only the IVC but the major tributaries of the hepatic veins.

Indeed,  our patient had cardiogenic shock along with an acute occlusion of the R common femoral vein.  She had a heart rate of 40 with complete heart block n the ED and a transvenous pacemaker was floated.  The patient was taken to the OR for her ischemic leg  and then to the cath lab where she was noted to have a right coronary occlusion and RV failure.  A right ventricular assist device was placed. Interestingly, the pacemaker placed correctly in the ED became completely entangled in the RV assist device.

half moon pacer.JPG
half moon pacer tangle..JPG

In spite of milrinone, vasopressin , norepinephrine and a right ventricular assist device, the patient could not maintain her BP and expired.

An addendum was made to the original CT done in the ED stating the R coronary was occluded.  Her initial trop had been normal and peaked at 30.

 

Roth,  C, Sneider M, Bogot N, Todd M , Cronin.  Dependent Venous Contrast Pooling and Layering: A sign of Imminent Cardiogenic Shock.  American Journal of Radiology. 2006. 186:1116-19.

Tsai PP, chen JG, Huang JL, Shen WC.  Dependent pooling : a contrast-enhanced sign of cardiac arrest during CT. AJR. 2002;178:1095-99.

Jana M, Gamnagatti SR, Kumar A. Case series: CT scan in cardiac arrest and imminent cardiogenic shock. Indian J Radiol Imaging. 2010;20:150-53.

A 29y.o. woman presents with abdominal pain. What do you notice on the CT?

silicone.JPG

Our patient had silicone buttock injections. Since her pain was upper abdomen and involved the R lower lungfield a silicone embolus was considered. How common is a silicone embolus?

Silicon was discovered in 1824 by Jons Berzelius.  Silicones are synthetic polymers made by combining silicon and oxygen, which at high temperatures and pressures produce polydimethylsiloxone, injectable silicone.

Silicone is used to enhance body shape and contour; often by illegal practitioners. Specific groups are known to use silicone enhancement :exotic dancers, prostitutes and transgender individuals.  Complications of silicone injections are in the range of 1-2% including silicone embolism to the lungs.  In 1983 silicone was detected in cells obtained from bronchoalveolar lavage by use of spectrophotometry in patients presenting with acute pneumonia. Since then, many cases of silicone embolism have been reported.

Transbronchial biopsy of a pt with silicone embolus with intra-alveolar hemorrhage and vaculolated glabular deposits of silicone in the interstitial capillaries.

Transbronchial biopsy of a pt with silicone embolus with intra-alveolar hemorrhage and vaculolated glabular deposits of silicone in the interstitial capillaries.

In the case of illegal silicone injections, the proposed mechanisms  of embolization include excessive local tissue pressure, local massage by the illegal practitioner, or direct intravascular injection.   It is thought that large volumes of silicone result in local tissue damage and the silicone eventually gains access to the bloodstream and this results in pulmonary embolization.  This can occur even weeks after an injection.

On CT scan  this looks like peripherally distributed ground-glass opacities with interlobular septal thickening similar to eosinophilic lung disease and fat embolism.  On plain film, silicone embolus can look like pneumonia and therefore a high index of suspicion is needed to make the diagnosis.

silicone lung.JPG

Steroids are the suggested treatment presumably because the silicone incites an immune response in the lung.

Our patient was an exotic dancer and had NO evidence of silicone embolization on CT.  Her final diagnosis was gastritis and her pain resolved with proton pump inhibitors.

Teaching point:  If you obtain a history of silicone injections and pneumonia; consider embolization. Other complications of silicone injections include renal failure, granulomas and cellultis.

 

 

 

Mendonca D, Leitao D, Friend R, Epelboim J , Eiger G. An unusual case of pulmonary embolism.  Respiratory Care Aug 2012 Vol 57 (8) 1346-47.

2. Restrepo CS, Artunduaga M, Carrillo J, Rivera A, Ojeda P, Martinez-Jimenez S, et al. Silixone pulmonary embolism: report of 10 cases and review of literature. J Comput Assist Tomogr 2009. 33(2):233-237. 

3. Chung KY, Kim SH, Kwon, et al. Clinicopathologic review of pulmonary silicone syndrome embolism with special emphasis on the resultant histologic diversity in the lung: a review of five cases. Yonsei Med J. 2002;43(2):152-159.

4. Zamorea AC, Collard HR, Barrera L, et al. silicone injection causing acute pneumonitis; a case series. Lung 2009;187(4): 241-244.

A 22 y.o. woman presents to the ED with low back pain after a fall in the bathtub. Her cxr and bone scan are shown.

What is wrong?

rickets3.JPG
bone scan

bone scan

Our patient had rickets with the classic “tie” sign ; increased uptake over the sternum on bone scan.

Rickets results from defective mineralization or calcification of bones due to deficiency or impaired metabolism of Vit D, Mg,  phosphorus or calcium.  If this occurs prior to epiphyseal closure in children bony abnormalities result.  These include bowing of the femurs,  scoliosis, and skull bossing.  

Rickets was first described in Ephesus in the first century AD when Soranus described it in infants. In 1645, Whistler  in England defined it as a specific medical condition.  It wasn’t until 1923 thatSteenbock in the US showed that irradiation of food  couldincrease the amount of Vitamin D and reverse the disease.  Rickets was nearly eliminated from the US by 1945 due to the irradiation of milk. 

Bowed legs

Bowed legs

There are several types of rickets.

1.       The most common is Vit D deficient,  which is caused mainly by malnutrition often in the mother who is then unable to provide Vit D in her breast milk.

Vit D responsive rickets persists in the rest of the world.  The Middle East, despite high rates of sun-exposure has the highest rate of rickets worldwide. This is explained by limited sun exposure due to cultural practices and lack of Vit D supplementation in nursing women. 80% of girls in Iran and Saudi Arabia are Vit D deficient.

2.        Our patient had a second type of rickets ; Vit D resistant rickets or X linked hypophosphatemia.  This is a mutation in the X chromosome causing overactivityof fibroblast growth factor and decreased phosphate resorption by the kidneys.

3.       A third type of rickets is caused by fibroblast tumors.  In these individuals a tumor produces fibroblast growth factor and decreased absorption of phosphate in the kidneys.  In these cases removal of the tumor cures the disease.

swollen costchondral junctions; the rachitic rosary

swollen costchondral junctions; the rachitic rosary

Our patient had scoliosis and multiple microfractures on bone scan.  On her current ED visit plain films showed no new fracture in the back and she was given symptomatic treatment.

 Imaging in  all types of rickets shows pseudofractures which light up on bone scan where there is a stress fracture caused by insufficient mineralization.  They tend to occur  bilaterally in the mandible, at costochondral junctions ( causing the rachitic rosary)  andin the epiphyses of the knees.

 

The Middle East & Africa Regional Audit Executive Summary, epidemiology, cost & burden of osteoporosis in 2011.  The International Osteoporosis foundation.   www.iofbonehealth.org.

Magnesium and vitamin D’s co-factors, by John Jacob Canell, MD. Citing The Lancet: The Vitamin D Council. Two cases of Mg dependent Vit D resistant rickets appeared in the Lancet in 1974.

Pettifor JM 2004. Nutritional rickets : deficiency of vit D, calcium, or both?.  The American Journal of Clinical Nutrition (Review) 80(6 suppl): 1725S-9S. 

A 71 y.o. woman presents with nausea and vomiting. Do you see a reason?

hyche.JPG

Our patient had a uterine sarcoma causing a small bowel obstruction.  While fibroids are present in 70% of women by age 50; uterine sarcomas represent only 4% of uterine malignancies. Most tumors occur after menopause and often they occur in the setting of pre existing fibroids. Sarcomas are more likely in women taking tamoxifen and African American women.

Sarcomas by definition have > 10 mitoses per high powered field. They are defined by the extent of their spread. Type 1 is confined to the uterus, Type 2 involves leiomyomatosis involving tumor growth within veins which can spread to the heart and type 3 involves  tumor which has metastasized to distant organs like lung or lymph nodes.  Five year survival for type 1 is 63%, type 2 is 35% and type 3 five year survival is 14%. 

uterine sarcoma

uterine sarcoma

Our patient underwent a hysterectomy and resection of small bowel which was involved with tumor.  She is doing well.

Galducci A, Cosio S, Romamini A, Genazzani AR. The Management of patients with uterine sarcoma: a debated clinical challenge. Crit Rev Oncol Hematol. 2008. 65(2) 129-42.

Zagouri F, Dimopoulos AM,Fotiou S, Kouloulias V, Papadimitriou CA. Treatment of early uterine sarcoma: disentangling adjuvant modalities. World J Surg oncol. 7:381477-7819-7-38.

fibroids1.JPG

A 21 y.o. male presents with a sore throat and a rash on his palms. What does he have?

rash.JPG

Our patient had an enterovirus causing hand/foot/mouth disease.  This was cultured from his throat swab.

This a common viral illness of infants and children less than five years of age but can also occur in adults.  Typical symptoms include fever, mouth sores and a skin rash.  It can be accompanied by viral meningitis.  Rare complications include a polio-like paralysis or encephalitis which can be fatal. Coxsackievirus A 16 is the most common cause of hand,foot and mouth disease in the US.

From Aug 2014 to Jan 2015,  1,153 pople had confirmed enterovirus D68 infection.The virus  was thought to be causing a polio-like paralysis in children. The first facility to report enterovirus D68 was Mercy Children’s Hospital in Kansas City , Missouri.  They reported six children on one shift in the ED with severe respiratory symptoms. Several children in various sites across the country developed limb weakness or transverse myelitis prompting a CDC investigation.

A child with hand/foot/mouth disease

A child with hand/foot/mouth disease

The differential for rashes of the hands and feet includes:

1.       Enterovirus- as in our patient usually benign and gone in 7 days

2.       Syphilis- In secondary syphilis the reddish or brownish spots can occur on palms and soles. The lesions of disseminated GC tend to be pustules occurring on the distal extremities. 

3.       Rocky Mountain Spotted Fever- Rash begins as small macules on the wrists, forearms and ankles

On the sixth day petechiae deveop with a rash on the palms and soles in 80% of patients.

4.       Janeway lesions of endocarditis- These are indications of septic emboli

5.       Kawasaki disease-In Kawasaki erythema of palms and soles often occurs first accompanied by pain . Children often refuse to hold objects in their hands.

6.       Measles-This rash start of the face and then progresses to the palms and soles.

7.       Toxic Shock Syndrome- is more likely to desquamate than cause a papular rash

8.       Reactive arthritis- Causes small hard nodules called keratoderma blennorrhagicum usually on the soles.

9.       Meningococcemia- causes a petechial rash in 50-75% of cases. They do not blanch.

 

Janeway lesions in an IV drug user with endocarditis of the aortic valve.

Janeway lesions in an IV drug user with endocarditis of the aortic valve.

 

Our patient recovered without incident.

https://www.cdc.gov/features/handfootmouthdisease/index.html

Schwartz, R.  Enteroviruses treatment &Management May 2, 2014 http://emedicine. medscape.com/article217146-treatment

United States. Centers for disease Control and Prevention”Severe Respiratory Illness Associated with Enterovirus D68-Missouri and Illinois, 2014.  MMWR 63:36 Sept 12, 2014. 798-99 http//www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0908a1.htm

 

A 40 y.o. male with a history of aortic dissection repair and paraplegia comes to the ED with altered mental status.

an abnormality was noted on cxr.

spinal epicxr.JPG
And confirmed on CT.  What is the problem?

And confirmed on CT.  What is the problem?

Our patient had a spinal epidural abscess which unfortunately had not been treated for some time.

He had a history in the past of an MVC in which he sustained an aortic injury and became paraplegic. He presented from a long term care facility with altered mental status and a widened mediastinum was noted on CXR.  The CT showed the epidural abscess. In spite of antibiotics, he died of sepsis.

Epidural abscess is often not recognized on the first ED presentation.  The “red flags” for the diagnosis include: unexplained fever, focal neurologic deficit , immunosuppression, IV drug use, prolonged steroid use, weight loss, enduring back pain and history of cancer.    In 58% of the cases with errors, the “red flag” was documented but not acted upon.. The route of infection was identified in 52% of caseswith bacteremia as the most common cause (26%) followed by recent surgery(21%), and spinal injection. (6%).  The most common risk factors were steroid use and diabetes.  The most common organism was Staph Aureus, with MRSA in 25%.  . The incidence is 5 cases for every 10,000 admissions in a study by Vakili however, our ED has seen at least three cases in the past month.

epidural abscess meyerf.jpg

The second case (shown above) was a schizophrenic; well known for ingesting foreign objects and stabbing himself in the abdomen. He presented with a fever and paraplegia.  His abscess wrapped around the aorta and esophagus and he was deemed “inoperable” by thoracic surgery.  He remains paralyzed and in the hospital two months after presentation awaiting placement. 

epidural abscess,misseyf.jpg

A third was a woman with diabetes who had previous back surgerywhich became infected one month pta. She presented to an outside hospital with nausea and vomiting and  CT showed a psoas abscess.  She was noted to have acute cholecystitis which was drained percutaneously and was discharged on long term IV antibiotics. Candida tropicalis grew from the gall bladder drain and nothing  grew from the psoas abscess ( she had been previous treated with antibiotics.)

 

Bhise V et al. Errors in diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med 2017 Aug; 130:975.

Vakili M, Crum-Cianflone N.  Spinal Epidural Abscess: A series of 101 Cases. American Journal of Medicine 2017, in press.

Davis DR, Wold RM, Patel RJ et al. The clinical presentation and impact of diagnostic delays on emergency department pateitns with spinal epidural abscess. J Emerg Med 2004;26(#):285-291.

Darouich RO. Spina epidual abscess. N engl J Med. 2006;355:2012-2020.

A 51 y.o. woman comes in with shortness of breath

What do you notice on her PE protocol CT?

lam.JPG

Our patient had tuberous sclerosis with cystic lung disease. There was no PE.

Tuberous sclerosis is a genetic disease that causes benign tumors to grow in the brain, lungs, kidneys, heart , skin, eyes and pancreas.   It is caused by mutations in one of two genes: TSC1 or TSC2.  These genes produce proteins that suppress tumors and when they are absent, tumors occur.

tubers in the brain on MRI

tubers in the brain on MRI

Tuberous sclerosis was first described by Bourneville in 1880 .  He was a French surgeon who founded a day school for children with mental disability and noted a constellation of symptoms including seizures, mental disability and skin tumors which he named tuberous ( tuber from the Latin for swelling) and sclerosis (sklero from the Greek for hard).

The manifestations affect many organs.  In the kidneys angiomyolipomas occur and polycystic kidneys in children may be the first manifestation of the disease.  The disease in the lungs with multiple cysts is thought to be monoclonal metastasis from the renal angiomyolipomas which is why it has been reported after lung transplant.

Angiomyolipomas of the kidneys

Angiomyolipomas of the kidneys

Skin manifestations are found in 96% of individuals with tuberous sclerosis. Hypomelanic macules (ash leaf spots) , adenoma sebaceum( adenomas in a butterfly distribution on the face), Shagreen patches (thick skin patches dimpled like orange peel),  and periungual fibromas are found in these patients.

Many of the findings of tuberous sclerosis are found in patients who do not have the disease.  The lung cysts in isolation are called lymphangioleimyomatosis(LAM) .  Tuberous sclerosis manifests differently in each patient with some patients like our patient with little symptomatology. She has mild obstructive lung disease and multiple kidney angiomyolipomas without renal failure and is followed periodically in clinic. 

 

Henske EP. Metastasis of benign tumor cells in tuberous sclerosis complex.  2003 Genes Chromosomes and Cancer. 38(4):376-81.

Krueger D, Northrup H.  International tuberous sclerosis complex consensus group (2013-10-01) Tuberous sclerosis complex surveillance and management: recommendations of the 2012 International Tuberous SclerosisComplex Consensus conference . (https://www.ncbi.nlm.nig.gov’pmc/articles/PMC4058297) Pediatric Neurology 49(4): 255-265.

Shepherd CW, Gomez MR, Lie JT, Crowson CS. Causes of death in patients with tuberous sclerosis. 1991 Mayo Clin Proc 66(8): 792-6.

Rakowski SK, Winterkorn EB, et al. Renal manifestations of tuberous sclerosis complex: Incidence, prognosis and predictive factors. 2006. Kidney Int 70(10):1777-82.

adenoma sebaceum 

adenoma sebaceum 

A 78 y.o. female with a hx of recurrent arrhythmias sp mitral valve repair presents with diffuse abdominal pain.

pictured below are the CT scan and the delayed image.

urine3.JPG
urine delayed film.JPG

Why is she having pain?

Our patient had a calyceal rupture caused by a 2 mm stone.  Calyceal or forniceal rupture is accompanied by urinary extravasation which can be seen on CT both in intraperitoneal and retroperitoneal areas.  The majority of cases involve ureteral calculi but vascular compression from abdominal aortic aneursyms and malignancy have also been reported. Rarely, pregnancy can significantly obstruct the ureter, as well as a foley catherer balloon in one case. 

calyceal rupturecauses.JPG

75% of the stones causing rupture were distal, below the sacroiliac vessels. Calculi were small with a mean size of 4mm.  Only 5% of patients in theGershman study showed signs of infection.

The physiologic reason for the rupture of the kidney is not known however it is presumed that pressure increases as the kidney increases in size, in accordance with Laplace’s law which states that the pressure tangent to the circumference of an object equals the product of the pressure across the wall and the radius of the object.    It has been suggested that rupture  protects the kidney by decreasing pressure in the collecting system.

Our patient was nauseated and given ondansetron and promptly developed the rhythm below. 

calyceal rupture, tachy.JPG

She was treated with 4 gm of Mg  ( goal of 2.5) and her K was raised to 4.0 . The polymorphic v tach resolved and she went to the OR where the stone was removed and  a stent was placed in the R ureter.

She underwent a Left heart cath showing only 30% lesions so the final diagnosis was v tach secondary to QT prolongation and ondansetron. She had no further episodes of v tach and was discharged.  And kudos to Phil who noticed the pelvic fracture. ( It had occurred earlier)

Gershman B, Kulkarni N, Sahani D, Eisner B.  Causes of renal forniceal rupture,  BJUI 2011. 108: 1909-1912.

Spurlock J, Burke T, Dunn N, et al. Calycealrupture with perirenal urinoma in a patient with cervical carcinoma.

Heffernan E, Skehan. Calyceal rupture secondary to ureteric obstruction by recurrent colorectal ca. Clin Nucl Med 2007;32:199-200.

 Satoh S, Okuma A, Fuita Y, Tamaka M, Nakano H. spontaneous rupture of the renal pelvis during pregnancy: a case report and review of the literature. Am J Perinatology 2002;19:189-95.

A 71 y.o. female sp bilateral lung transplant in 2007 presents with fever, pancytopenia and altered mental status. Her CXR is shown below.

What is the differential?

What is the differential?

Our patient had Ehrlichiosis.

Tick-borne rickettsiae in the genera Ehrlichia (lone star tick)and Anaplasma ( Ixodes tick)  are intracellular bacteria that infect animals and man. They present with a febrile illness. The first case of human granulocytic anaplasmosis (HGA) was recognized in Duluth Minnesota in 1990. Ehrlichia chaffensis was first describe in 1987 at Fort Chaffee Arkansas when it was found among military recruits.  Missouri, Arkansas and Oklahoma account for over 1/3 of the cases of Ehrlichia in the US.  The reservoir of the disease is white tailed deer.

ehrlichia map.JPG

Both Ehrlichia(HME) and Anaplasmosis(HGA) have similar presentations including fever, headache, leukopenia, thrombocytopenia and elevated liver enzymes.  Lung infiltrates, noncardiogenic pulmonary edema and ARDS can be seen on CXR.  CSF pleocytosis is identified in 60% of patients who undergo lumbar puncture.  Symptoms begin a median of 9 days after an infected tick bite. Neurologic manifestations are most frequently reported with Ehrlichia.  

Ehrlichia is also an important veterinary pathogen.  It was first described inAfrica in 1935 and is transmitted by the brown dog tick.

The gram negative  bacteria infects granulocytesand replicates in the membrane bound compartments of granulocytes and monocytes.  They form colonies called morulae derived from the Latin word :”morus” for mulberry.  They can be seen in peripheral blood leukocytes. Up to 17% of patients develop life threatening complications although they are much more likely in immunocompromised patients like ours.  

ehrlichia, morula.JPG

Our patient developed hemophagocytic lymphohistiocytosis (HLH) which is a generalized reaction of the immune system where a  proliferation of morphologically benign lymphocytes and macrophages secrete high amounts of inflammatory cytokines. It is classified as one of the cytokine storm syndromes.  Rbcs can be seen in within macrophages in the marrow.  It is characterized by high ferritin, cytopenia, fever and splenomegaly and  is treated with steroids.  Our patient not only received treatment with doxycycline for Ehrlichia but also received steroids for HLH. She was on hemodialysis for renal failure and was eventually transferred to rehab after being in the hospital for two months.

Howard Ricketts, was a pathologist for whom these organisms were named.  Ricketts was devoted to his research and on several occasions injected himself with pathogens to study their effects.  In 1910 he discoveredthe cause of murine typhus and days after isolating the organism, he himself died of the disease.

 

 

Ismail N, Bloch K, McBride J.  Human Ehrlichiosis and Anaplasmosis. Clin Lab Med. 2010 30(1); 261-292.

Paddock CD, Sumner JW, Shore GM, et al. Isolation and characterization of Ehrlichia chaffeenisis strains from patients with fatal ehrlichiosis. J Clin Microbiol. 1997;35:2496-2502.

Demma LJ, Holman RC, McQuiston JH.  Human monocytic ehrlichiosis and human granulocytic anaplasmosis in the United States, 2001-2. Ann NY Acad Sci 2006;1078:118-9.

A 38y.o. woman arrested after an opiate overdose. Immediate cpr was done by her boyfriend and she was revived.

She had chest pain following cpr and pneumomediastinum was noted.

 

opiodarrowpneumomediastinum and L pleural effusion jpg.jpg

Something else was noted on the barium swallow; what was it?

opiod 1stagnant contrast in lesser sac jpg.jpg

Our patient had a ruptured stomach after CPR.  On the image shown it looks like there is contrast in the stomach which is actually in the lesser sac.  There is also free air over the dome of the stomach. Gastric rupture has been reported following both CPR and the Heimlich procedure.The lesser sac is a space behind the stomach which can be seen below.

lesser sac.JPG
lessersac 2.JPG
free air

free air

CPR has been associated with injuries in between 21 and 65% of cases.  CPR complications are often encountered during the medico-legal postmortem examination and sometimes it is not clear if they contributed to the death.  Rib fractures are common, with liver rupture, gastric rupture and cardiac rupture being less common. More commonly,   hemopericardium, epicardial hematoma, myocardial contusion, and rupture of the vena cava close to its junction with the R atrium are the cardiac injuries  reported.

Presumably, many CPR associated injuries are never discovered since the patients do not have an autopsy. 

Our patient was resuscitated by her boyfriend with CPR and developed severe abdominal pain over the next six hours. After the swallow showed no esophageal injury but free air in the abdomen; the abdomen was opened anda 3 cm rent in the posterior fundus of the stomach was seen. Bile and fibrinous material was irrigated from the abdomen, the defect was excised, and the wound stapled. G and J tubes were placed and the patient was sent home with them in place to be removed in two weeks. 

Case courtesy of Keith Naunheim

 

 

Fearing MN, Harrision PB. Complications of the Heimlich maneuver: case report and literature review. J Trauma 2002; 53(5): 978-9. 

Tattoli L, Maselli E, Romanelli MC et al. Complete cardiac Rupture associated with closed chest cardiac massage: case report and review of the literature.  J Rorensic Sci 2014;59(2):564-567.

Kusunokia S, Tanigawab K, Kondoa T, Kawamotoa M.  Safety of the inter –nipple line hand position landmark for chest compression. Resuscitation. 2009;80:1175-1180. 

Darok M. Insuries resulting from resuscitation procedures.  In: Tsokos M, editor. Forrensic Pathology Reviews, Vol1. Totowa, New Jersey Humana Press; 2004. P. 1175-1180.

Hanganu B, Neagu M, Iorga M, et al. Cardiac rupture during cardio-pulmonary resuscitation case presentation and literature data.  2017Romania Journal of Leg Med (25)44-48.

A 30 y.o. woman with HIV and lupus was treated for a rash on the day pta. She now presents with fevers, myalgias and worsening rash.

What is the differential?

jar.jpg
jar2.jpg

 

Our patient had been treated for syphilis the day before arrival with penicillin.  She was suffering from a Jarisch-Herxheimer reaction.  This is a reaction to the endotoxin released by the death of spirochetes after treatment of syphilis. It occurs in 50% of patients with primary syphilis and 90% of patients with secondary syphilis.

The reaction is a sepsis mimic because it presents with fever,  hypotension, headache, tachycardia, worsening skin rash and tachycardia.

Other diseases caused by spirochetes can cause the same reaction: Lyme disease, relapsing fever, and leptospirosis.  It has also been reported after treatment of Q fever, bartonellosis, brucellosis, trichinellosis and African trypanosomiasis.

 

secondary syphilis of the tongue

secondary syphilis of the tongue

primary syphilis of the tongue

primary syphilis of the tongue

St. Louis as of 2016 still ranks number one with the highest rates of STDs per capita. It is known as a "condom desert" since fewer stores carry condoms than in most cities in a study done by St. Louis University.  Our patient was treated symptomatically with fluids and pain medication with resolution of her symptoms. 

Lukehart, S (2017) Syphilis. In Kasper , DL; Fauci, A. Harrisons’ Infectious Diseases (3rd ed) New York: McGraw-Hill p666.  ISBN 978-1-259-83579-1
 

Butler T (2017) The Jarisch-Herxheimer reaction after antibiotic treatment of spirochetal infections: a review of recent cases and our understanding of pathogenesis. Tropical Medicine and Hygiene. 96(1):46-52.  PMID 28077740

A 30 y.o. woman comes to the ED with hoarseness . She is scoped and you find what is pictured.

What is it?

 

Our patient had juvenile laryngeal papillomatosis.  This is caused by a human papillomavirus infection of the throat (types 6 and 11).   HPV can activate the epidermal growth factor receptor pathway and inactivate tumor-suppressor proteins resulting in ‘cauliflower-like’  growths in the airway.  Without treatment it is potentially fatal and often requires repetitive surgery to prevent airway obstruction. The disease is most commonly found in children and may be caused by an infant contracting HPV from the mother  in the birth canal during vaginal delivery.   It is often misdiagnosed as asthma in children. Since the HPV vaccine includes HPV 6 and 11, it is expected to prevent genital infections among women and thus prevent secondary laryngeal infections to newborns which can lead to laryngeal papillomatosis. A second form of papillomatosis occurs in adults usually in their 30s which appears to be less aggressive.

Papillomatosis has the potential for malignant transformation to squamous lung carcinoma with a dismal prognosis.  HPV11 is associated with greater risk of producing lung ca than HPV 6. These are often manifested by “drop metastases” where the virus drops into the airway and lodges in the lung where it transforms into a carcinoma. Fortunately, only 1% of papillomas undergo this transformation to squamous cell cancer.

The tumors can be treated with  photodynamic therapy where physicians inject a light-sensitive dye that is only absorbed by the tumors and then the physician activates the dye using a bright light which destroys the tumors. Antiangiogenic therapy is also used. Atopical treatment with anti=vascular endothelial growth factor (VEGF) antibody bevacizumab is used to paint the tumors and since many express VEGF-A there is a significant reduction in tumor burden.

 

James, WD, Berger Timothy G, et al . Andrews’Diseases of the Skin: clinical Dermatology. Saunders Elsevier.  ISBN 0-7216-2921-0

Recurrent Respiratory Papillomatosis National Institute on Deafness and Other Communication Disorders 2011.

Mohr, M, Schliemann c, Biermann C, Schmidt L. et al. Rapid response to systemic bevacizumab therapy in recurrent respiratory papillomatosis Oncology Letters 8(5) 1912-1918.  Doi 10.3892/ol.2014.2486.

Ahn J, Best S. 2016 Adjuvant and novel treatment of recurrent respiratory papillomatosis. Current Otorhinolaryngology Reports 4 (2) 67-75.

Katsenos S, Becker H. Recurrent Respiratory Papillomatosis: A rare chronic disease, difficultto treat with potential to lung ca transformation; Case Reports in Oncology. 2011p4:162-171

A 28 y.o. male arrives in the ED with a rash and a finding under his tongue. What problem does this represent?

Our patient had a brown recluse spider bite six days pta.  He developed severe pain over the area of the bite and hemolysis.  He presented with sublingual jaundice and a hct of 16.

Classic "violin" pictured above

The brown recluse venom contains spningomyelinase D, alkaline phosphatase, lipase, hyaluronidase, deoxyribonuclese and ribonuclease. Since Spingomyelinase D is temperature dependent,  application of cool compresses may limit necrosis. There are no other proven treatments other than supportive. The brown recluse is not an aggressive spider but will bite if it feels threatened.  The initial bite is painless but within several hours an intense pruritus and pain occur from local vasospasm.  Systemic symtoms include, fever, hemolysis, DIC, renal failure , seizures and coma.    The two poisonous spiders of North America are the brown recluse and the black widow. 

While the brown recluse  has predominately skin necrosis effects, the black widow possesses a neurotoxin.  Alpha-latrotoxin which stimulates motor endplates causing neurologicand autonomic dysfunction. Antivenom is available however there is a risk for allergic reaction to it with one reported case of death.

black widow with hour glass marking

black widow with hour glass marking

While  the brown recluse and black widow are not aggressive, this is not the case with spiders in much of the world.  The wandering spiders, in the genus Phoneutria, are the most aggressive and venomous spiders in the world. They roam the jungle floorsin Central and South America at night looking for food. Their venom contains a neurotoxin that cases paralysis and asphyxiation, with intense pain and inflammation.  In males, priapism may result.  There is an antivenin. 

Funnel-web spiders ( genera Hadronyche and Atrax) are venomous spiders from Australia .  They create funnel-like burrows in which to trap prey. Their venom is a delta-atracotoxin(robustoxin ) which is neurotoxic. While the most common complication of a bite is pain; they have been know tocause fasciculations, pulmonary edema, and coma.  An antivenin is available.

Another common spider of North America is the yellow sac spider.  They are attracted to the smell of gasoline and weave webs inside the canister vents of Mazda vehicles resulting in blockages which may cause fuel leakage.  Because of these spiders Mazda 6 models built between 2010 and 2012 were recalled to fit them with software that alerts drivers of problems.

 

Our patient was admitted to the ICU and required 7 units of blood for ongoing hemolysis. He was found to have stress ulcers on endoscopy though they were not bleeding. He recovered and was discharged. 

 

Centers for Disease Control and Prevention Workplace safety & health topics;

http://reference.medscape.com/features/slideshow/venomous-spiders#page

Vetter RS, Isbister GK, Bush SP, Boutin LJ 2006 Verified bites by yellow sac spiders in the United States and Australia where is the necrosis?  Am J Trop Med Hyg 74(6) pp 1043-49.

Spider invasion prompts Mazda software fix.  BBC7 April 2014. 

Howell W, Jenkins M, Ronald L. 2004 Spiders of the US: a photographic guide.  ISBN 0-536-75853

 

A 32 y.o. male was smoking meth and complains of shortness of breath.

His CXR is shown below.  What happened?

Our patient had eosinophilic pneumonia from smoking meth. Classically, the pneumonia is peripheral; the opposite of the bat-wing pattern of pulmonary edema, and there is a peripheral eosinophilia. He initially presented with a sat of 72%.  ABG on 15 liters was pH 7.43 PCO2 32 and PO2 59.

Medications, substance abuse and environmental exposure may all cause eosinophilic  pneumonia.   Drugs which frequently cause eosinophilc pneumonia include:  ampicillin, phenytoin (Dilantin), ibuprofen, and daptomycin.  Inhaled substances and cigarette smoke can also cause it.  A firefighter who rescued people during 9/11 in the World Trade Center attack contracted eosinophilic pneumonia.  Eosinophilic granuloma (Langerhans cell histiocytosis) is related to smoke inhalation from cigarettes as well.

Parasites can also cause eosinophilic pneumonia either by living in the lung as part of their life cycle (ascaris, strongyloides and hookworms), migrating to the lungs (paragonimiasis, echinococcus, taenia), or depositing massive numbers of eggs in the lungs through the bloodstream (trichinella, schistosomes, strongyloides, and ascaris) .

Cutaneous larva migrans (hookworm) of the lung: Loeffler's syndrome.

Cutaneous larva migrans (hookworm) of the lung: Loeffler's syndrome.

Peripheral rash associated with hookworms.

Peripheral rash associated with hookworms.

Automimmune diseases like eosinophilic granulomatosis with polyangitis or Churg-Strauss also result in eosinophilic pneumonia.  The early stages of this disease is marked by asthma, followed by eosinophilia and then vasculitis of the lungs and GI tract.

Differential diagnosis of eosinophilic pneumonia

Differential diagnosis of eosinophilic pneumonia

Our patient remained hypoxic and did not tolerate BiPaP, and he was switched to CPAP and remained on this for two days.  His IV solumedrol was changed to prednisone.  He was started on azithromycin, ceftriaxone, and linezolid which was switched to Cipro at discharge. His CXR cleared dramatically and he was discharged on the third hospital day.

 

Bain GA, Flower CD.  Pulmonary eosinophilia Eur J Radiol 1996 23 (1) 3-8.

Rom WN. Weiden M, Garcia R et al Acute eosinophilc pneumonia in a New York City firefighter exposed to World Trade Center dust.  Am J Respir. Crit Care med 2002. 166(60 797-800.

Watanabe K, Shinbo T, Kojima M, et al. B-cell lymphoma associated with eosinophilia. 1989 Cancer 1564(8): 1682-5.

Swartz J, Stoller JK. Acute eosinophilic pneumonia complicating Coccidiodes immitis pneumonia: a case report and literature review. Respiration 2009. 77(1):102-6.

A 65 yo male with a history of juvenile idiopathic arthritis presents with a three month hx of recurrent pericardial effusions.

and something wrong with his bones

Pet scan showing uptake in the distal femurs.

Pet scan showing uptake in the distal femurs.

and infiltration of the retroperitoneum with bilateral hydronephrosis

and infiltration of the retroperitoneum with bilateral hydronephrosis

and something infiltrating his pituitary on MRI; what disease does he have?

and something infiltrating his pituitary on MRI; what disease does he have?

Our patient had Erdheim-Chester disease.  This is a rare form of non Langerhan’s cell histocytosis in which histiocytes( tissue macrophages) proliferate in  the entire body with predilection for :  marrow, pericardium, bones, pituitary and lung. The histiocytes are lipid laden and can form nodules in the tissues with fibrosis surrounding.   It was first described in 1930 by William Chester during his visit to the Austrian pathologist Jakob Erdheim in Vienna.

The disease usually occurs in middle-aged patients and can manifest in a variety of ways.  Manifestations run the gamut between a focal asymptomatic process where patients can present  only with leg pain (from  metaphyseal sclerosis) to a fatal systemic disease that involves all organ systems. About half of the patients diagnosed have multifocal disease:  fever, orbital tumors, lung fibrosis, pericardial infiltration, pituitary involvement or urinary tract obstruction from retroperitoneal fibrosis .

our patient had been treated for chf for many weeks based on this cxr

our patient had been treated for chf for many weeks based on this cxr

A key to the diagnosis can be the infiltration of the pituitary although Inflammatory, infectious, granulomatous and neoplastic diseases of the pituitary can also cause pituitary infiltration. Tuberculosis, sarcoid, lymphoma and lymphocytic hypophysitis  (which has been linked to autoimmune disease) are common causes.

Diseases causing pituitary infiltration

Diseases causing pituitary infiltration

Previous options included steroids or interferon, but half of the patients have point mutations of the BRAF gene at codon 600 substituting glutamine for valine.  Vemurafenib, which has been approved to treat the BRAF mutation for melanoma, also works for Erdheim-Chester disease and is currently the treatment of choice. Our patient is currently undergoing testing to see if he has the BRAF mutation. It is not clear if years of immune suppression led to the mutation. 

 

Haroche J, Cohen-Aubart F, Emile JF, ArnaudL, Maksud P, et al. Dramatic efficacy of vemurafenib in both multisystemiC and refractory Erdheim-Chester disease harboring the BRAF V600E mutation. Blood 121(9))1495-500.

Erdheim-Chester disease at the United States National Library of Medicine http://www.nlm.nig.gov/cgi/mesh/2003/MB-cgi?term=ERDHEIM-CHESTER=DISEASE.

 Verdalles U, Goicoechea M, Garcia de Vinuesa S, et al. Erdheim-Chester disease: a rare cause of renal failure2007 Nephrol Dial Transplant. 22(6):1776-77.

Contemporary Endocrinology Vol 3.  McDermott, M. Diseases of the Pituitary: Diagnosis and Treatment, Edited by ME Wieman Humana Press, Inc., Totowa, NJ. 305

foamy macrophages and fibrosis seen on biopsy

foamy macrophages and fibrosis seen on biopsy

A 58 y.o. woman who works as a park superintendent in Sullivan, MO, comes in with somnolence, fevers and a rash. She reports several tick bites.

What illness could she have?

Our patient had an illness caused by the Bourbon virus.  This is a tick borne illness discovered in 2014 and named after Bourbon County in eastern Kansas where a man developed the index case after being bitten by ticks.  He presented with a flu-like illness and later died.  Our patient removed two ticks from her body several weeks before she was admitted to the hospital with somnolence, fevers, myalgias and a rash.

Rocky Mountain spotted fever map  above. .

Lyme disease map above.

Tick borne diseases in Missouri  also include Rocky Mountain spotted fever , tularemia,,heartland virus,  Ehrlichia, and lyme disease. Where Rocky Mountain spotted fever had been reported most often in the southeast; there were 229 cases reported in Missouri in 2017. The number of cases of Erhlchia is also rising  with 149 reported cases. Tularemia is not only found in ticks but also in rodents and rabbits.  It can be aerosolized with reported illness in a person who ran over a dead rabbit with a lawn mower. ( Francisella tularensis is very infectious with 10-50 organisms causing disease and is a candidate for possible weaponization) If contaminated animals inhabit a site, even a lawn, there have been cases of tularemia reported after mowing the lawn. Of the 200 or so cases reported each year, Arkansas, Missouri, Kansas and Oklahoma claim the most cases.

Heartland virus was discovered in Missouri at Heartland hospital near St. Joseph in 2009 when two farmers were infected and did not respond to doxycycline. Their sera was sent to the CDC and a new virus was confirmed. 

rocky mountain spotted fever rash. 

rocky mountain spotted fever rash. 

 None of the reported  incidence of tick borne disease is likely to be accurate since most people have a mild illness and do not seek medical attention.  It is a good thing that tick borne illness is often mild since ticks are a world wide vector of disease.  Two cases of Crimean- Congo hemorrhagic fever were reported from near Madrid in the July 13, 2017 New England Journal of Medicine.  This is a particularly virulent tick borne illness in which the first patient presented with fever and malaise, developed a coagulopathy and died.  The second case reported was the nurse who assisted with the intubation  and central lines of the first  patient. She developed fever and coagulopathy.  She was treated with ribavirin and developed hemolytic anemia but  eventually recovered after 22 days.

Our patient had a complicated course .  Her past history included follicular lymphoma which had been treated.  She developed encephalopathy, mouth ulcers, acute respiratory failure, hemophagocytic lymphohistiocytosis, pancytopenia and shock.  She died three weeks after admission.

 

 

Feldman KA, Enscore RE, Lathrop SL, et al. an outbreak of primary pneumonic tularemia on Martha’s Vineyard.  N Engl . J Med 2001.  345(22): 1601-6.

http://www.daily camera.com/Lafayette-news/ci-28203252/Lafayette-resident-contracts-tularemia-after-mowing-lawn-dies.

Negredo A, de la Celle-Prieto F, et al. Autochthonous Crimean-Congo Hemorrhagic Fever in Spain. NEJM 2017 377;2: 154-161.

 

A 45 y.o. construction worker states he has an infection in his hand. His hand is pictured.

What is wrong?

What is wrong?

Our patient had Sweet’s disease or acute febrile neutrophilic dermatosis.  It is characterized by tender red, papules and plaques that show dense infiltrates of neutrophils.  It was first described by Robert Sweet in 1964 and four criteria have to be met to diagnose the disease: fever, leukocytosis, tender red plaques, and a dermal infiltrate of neutrophils. Often patients with the disease are treated several times with antibiotics for cellulitis/abscess and they do not improve because the treatment is steroids. In addition to the raised plaques pts present with fever in 50% ofcases,  arthritis in 62% of cases and eye findings in 38% of cases.

skin biopsy of a pt with sweets showing neutrophils

skin biopsy of a pt with sweets showing neutrophils

It is classified by the setting in which it occurs either malignancy associated,  drug induced or idiopathic.

20% of the cases are associated with malignancy. It can also be associated with strep infections, inflammatory bowel disease, rheumatoid arthritis,  and pregnancy. Drugs that cause it include granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor.  It is thought to represent a hyperactive immune response in response to a systemic process.   Steroids dramatically improve the condition in 72 hours presumably suppressing dysregulated cytokines.

The differential of Sweet’s includes:  pyodermagangranosum which appears as purple colored ulcers,  erythema multiforme which appears as red spots on the hands, feet and face( often in rings) and erythema nodosum which appears as raised plaques.

pyoderma gangranosum in the setting of crohns

pyoderma gangranosum in the setting of crohns

The process usually lasts 2-4 weeks and can recur in one third of the patients.  In our patient, treatment with steroids caused resolution of the rash and he has not had a recurrence.

 

Mustafa MN, Lavizzo M. Sweet’s syndrome in a patient with Crohn’s disease: a case report.  J Med Case Reports 2008 2:221.

Cohen PR. Sweet’s syndrome-a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet Journal of Rare Diseases 2(34).

Sweet RD An acute febrile neutrophilic dermatosis. Br J Dermatol. 1964 76:349-56.

A 33 y.o. with a history of depression is found on the basement floor wearing a swim suit and in a pool of urine. Pictured are her urine and vomitus.

She is somnolent; what could she have taken?

She is somnolent; what could she have taken?

Our patient had nephrogenic diabetes insipidus from Lithium.  She had texted her mother and told her she had taken 160 pills.  Her mother found her in the basement in a pool of urine with empty bottles  of Lithium( which she had been prescribed a year earlier) and clonazepam.  The reason she was in a pool of urine is that  Li causes nephrogenic diabetes insipidus.  Her urine was very dilute with a specific gravity of 1.004.  In the ED  she was rousable to painful stimuli and began to vomit so was intubated for airway protection.  She continued to make large volumes of dilute urine after her admission to the ICU.

 

The name insipidus comes from the old practice of tasting urine to determine the cause of illness.  Unlike diabetes mellitus which results in sweet urine, diabetes insipidus creates watery flavorless urine. (tasting urine is no longer recommended).  The word diabetes comes from the Greek diabainein ”to pass through” and refers to the excessive amounts of urine in both conditions. In diabetes insipidus more than 2.5 L of urine is produced per day.  Li is the most common drug implicated in nephrogenic DI with50% ofpeople on Li chronically developing dilute urines.  It is more common in chronic overdose but has been reported with acute overdose.

Nephrogenic DI is caused by conditions affecting aquaporin(porous to water) channels in the tubules which allow water resorption.  Aquaporin 2 (AQP2) in the kidney is usually dormant in the intravesicular membrane. When it is needed, vasopression ( antidiuretic hormone) cases the vesicles containing aquaporin to fuse to the membrane and release aquaporin which happens in water retaining states like pregnancy and chf.  Li, however, decreases the expression of the AQP2 gene preventing the absorption of water.

Persons with nephrogenicDI need to consume amounts of fluid equal to the amount excreted but they excrete more water than sodium so serum osmolarity increases which stimulates thirst.  Thiazide diuretics are often given to allow increased excretion of sodium, decreasing serum osmolarity and therefore decreasing thirst.  This breaks the polydipsia-polyuria cycle.  In the case of our patient she was producing 300 cc of urine per hour for several days and these fluids were replaced.

Our patient remained somnolent/intubated because of the clonazepam overdose and although her initial nasal swab was negative for staph, she developed MSSA pneumonia and remained intubated for 8 days.  She was extubated on the 8th  day and is now alert and oriented agreeing to psychiatric admission.

 

Clinical pearls: serum lithium levels do not correlate well with clinical findings. Our patient’s Li level rose only to 1.5and yet she had profound polyuria.  If sodium rises desmopressin can be given to correct the electrolyte abnormalities. Dialysis is helpful with neurologic toxicity which usually occurs with a Li level of 3 or greater.

Wildin R. What is nephrogenic diabetes insipidus? 2006.  The diabetes Insipidus Foundation http://www.diabetes insipidus.org/4-types-nephrogenic-di.htm

Erden A, Karagoz H, et al. Lithium intoxication and nephrogenic diabetes insipidus: a case report and review of literature. Int J Gen med 2013;6:535-539.

Alexander MP, Farag YMK, et al. Lithium toxicity: a double-edged sword.  Kidney Int. 2008;73:233-7.