Summary: We present 4 hospitalized patients with chronic illness without social history of alcoholism. These patients suddenly developed altered mental status and drowsiness. Clinical examination was inconclusive and patients were diagnosed as Wernicke’s encephalopathy on typical Magnetic Resonance Imaging (MRI) features.
Background: Wernicke’s encephalopathy (WE) is acute encephalopathy primarily caused by acute thiamine deficiency. It’s a neurological emergency; thiamine replacement can prevent permanent neurological damage and even death. Chronic alcoholism is most common cause; others include prolonged starvation, malignancy, prolonged parenteral nutrition and bowel surgeries. Despite over a century of reports, diagnosis is not uncommonly delayed, if overlooked altogether. In Pakistan, alcohol is prohibited and majority population is non-alcoholic, clinical suspicion of WE is usually low leading to delay in diagnosis. The real challenge comes when patient has multiple comorbidities and admitted in intensive care receiving total parenteral nutrition or chemotherapy secondary to bowel surgeries or treatment of malignancy. We present 4 cases after obtaining informed and written consent. All were nonalcoholic; presented with multiple comorbidities. During hospital stay, in addition to primary complaints, these patients developed altered mental status and drowsiness. These patients were administered thiamine replacement on basis of Magnetic Resonance Imaging findings and rapid clinical response was documented. Unfortunately 1 out of 4 patients succumbed to death due to other co-morbidities; remaining recovered.
Conclusion: Non-alcoholic WE has relatively high mortality because of delayed diagnosis and lack of clinical suspicion. Mortality and morbidity decreases with an earlier diagnosis based on MRI and simultaneous prompt treatment with thiamine administration.
Neuroendocrine tumour of the appendix is a rare neoplasm discovered only incidentally. We hereby report an occurrence of this tumour in the appendix of a 27 years old female. There was an initial diagnosis of acute appendicitis based on a few days history of right abdominal quadrant pain, anorexia, vomiting and low-grade fever. The vermiform appendix obtained after an emergency appendectomy was large and had a firm yellowish mass, 1.6 cm in diameter. Histology revealed an appendiceal neuroendocrine tumour that had involved the mucosa, submucosa and part of the muscularis propria.
A 70 year old Caucasian female had been prescribed alendronate for osteopenia 4 years earlier. While on an overseas vacation, the day after enjoying an ocean swim, she experienced a sudden displaced fracture of her right femur while walking across a room. This fracture was treated locally with a femoral nail but failed to heal and remained a source of pain. Ten months after the initial fracture, the rod was replaced. Teriparatide subcutaneous injections were begun and resolution of the pain and healing followed. At the end of her 24 month course of teriparatide, she was started on denosumab twice yearly injections for a total of 5 injections. About 6 weeks before the 5th injection, she experience a fall from a standing height, but her X-ray evaluation revealed no fracture. Three months after the injection, the pain increased and additional studies were done, eventually demonstrating an insufficiency fracture of the left femoral shaft. Six weeks later, another plain film still showed an “undisplaced insufficiency fracture” and a femoral nail was placed the next day. Subsequently, she started on a second course of teriparatide which is still ongoing. She has not had any subsequent fractures.
Cutaneous metastases from various malignancies have been reported in literature but skin as a site of recurrence in cancer ovary has been seldom reported. We hereby report one such case of a 47 year old, follow up case of ovarian cancer, which progressed after two lines of chemotherapy and presented with abdominal skin nodule as site of metastatic recurrence, nearly 32 months after diagnosis of ovarian cancer.
Blastomycosis is a fungal infection that mostly involves the skin and lung with only a 5-10% incidence of Central nervous system involvement [1]. It occurs worldwide but it is endemic to areas like the Midwestern United States, Manitoba and Ontario provinces of Canada and equally affects both immunocompetent and immunocomprimised individuals with the likelihood of being more aggressive in the latter [1]. We present a 51 year old hypertensive factory machine operator from a Blastomyces non- endemic area of Cape Town, South Africa with no immunosuppressive condition who presented with worsening protracted headaches and cerebellar signs. Brain Computed Tomography and Magnetic Resonance imaging appearances of a heterogeneously enhancing left cerebellar hemisphere lesion posed an initial diagnostic dilemma which led to worsening of the patient’s clinical condition from hydrocephalus as a result of increased perilesional oedema and compression of the fourth ventricle. Eventual biopsy and culture after craniectomy yielded a diagnosis of primary cerebellar blastomycosis which necessitated a 6 week intravenous treatment with amphotericin B followed by oral itraconazole for 12 months leading to complete radiological resolution of the cerebellar lesion and clinical resolution of the headaches and ataxia.
