A case of Meningitis induced by amoxicillin



Severe anemia in a kidney transplant patient

24 y/o F with ESRD due to Henoch-Schönlein Purpura undergoes kidney transplant. The donor is her mother. Induced with ATG followed by Tacrolimus, Mycophenolate mofetil and prednisone.

Uneventful recovery with discharge creatinine of 0.7 mg/dL. TAC trough levels between 8-11 ng/ml . Discharge Hb of 12.1 g/dL. 2 months after surgery she notices mild fatigue and pallor, otherwise fairly asymptomatic.

On PE nothing stands out except for pallor. Lab only notable for Hb of 7.2 g/dL , normo, normo ,with normal WBC and platelet count. Anemia workup is extensive and turns up only remarkable for reticulocyte 0.29%, Haptoglobin of 89 mg/dL and a normal LDH. Subsequently, a bone marrow aspirate is done that reveals hypoplastic erythroid series and a few giant pronormoblast with nuclear inclusions as shown in fig below consistent with parvovirus B19 infection.

Blood B19 PCR comes back at 895000 copies. She is treated with 2 doses of IVIG 1 gr/kg/day on alternate days, transient discontinuation of MMF, with resolution of anemia.

Fortunately, no side effects of IVIG or other B19 manifestations occurred.

A case of Acquired Hemophilia induced by Levofloxacin


Atypical skin manifestations of dengue fever in a child


54 yo with Severe Leg Pain/Weakness

A 54-year-old otherwise healthy female presented to her primary care physician with acute severe left thigh pain, which was treated with steroid taper, pain medications, muscle relaxants without improvement. She is unable to ambulate due to pain and requires use of wheelchair due to pain and weakness. She denies any bowel or bladder changes and has no right leg symptoms and no night sweats, fevers, chills, or red flags.
She was sent for advanced imaging by PCP and referred to spine for evaluation.
Past medical and social history
The patient had a past medical history of hyperlipidemia and reflux, a bilateral total knee arthroplasty in 2017, and carpal tunnel release.
She reports no alcohol, tobacco or illicit drug use. She is engaged to be married and employed in computer work.
Physical exam
  • Well-developed, well-nourished female in a moderate-to-significant degree of discomfort
  • Found sitting in wheelchair
  • Right lower extremity strength 5/5 throughout; reflex patella and Achilles 2/4
  • Left lower extremity plantar flexion and dorsiflexion 5/5; quadriceps and hip flexors are markedly weaker on left 3+/5; Achilles reflex 2/4; patella reflex 1/4
  • Marked paresthesia over the left anterior thigh to knee.
  • Bilateral total knee arthroplasty scars noted; no warmth; full range of motion bilateral knee 0-110 flexion
  • No pain with range of motion of the hip
  • The patient had a CT of the lumbar spine disk space ordered by her primary care physician
  • The CT revealed the patient has degenerative disk disease at L5-S1, but this does not explain her dermatomal complaint or, more importantly, her physical exam as above
  • The patient believed that her knee replacement was a contraindication for MRI, which in this scenario it is not. Total joint replacement is generally completed with Titanium or Cobalt Chrome, neither of which is contraindicated for MRI imaging. Testing of these materials to 3 tesla magnets have been found to be safe.
  • She was sent for an MRI of the lumbar spine

The patient took pain medication and an oral sedative, but her discomfort precluded her from completing all sequences of the above MRI. Significant motion artifact was consequently noted, particularly on axial imaging. Her symptoms remained unexplained, necessitating further workup.
On reexamination, the patient demonstrated ongoing reflex changes, motor weakness, and dermatomal-specific complaints. After increased sedation and pain control measures, the area of concern (L3-5 nerve roots) was imaged.
Repeat MRI imaging with light oral sedation 24 hours later.
The blue arrow represents marked foraminal narrowing on the symptomatic side.
The green arrow represents a normal finding.
The green arrows demonstrate normal nerve roots at the L4-5 disk space. Notice the nice perineural fat signal (white) around the nerve root.
The blue arrow demonstrates a large foraminal herniated disk impaling the left exiting L3 nerve root (which correlates with her subjective and objective findings).
Extraforaminal disc herniations are uncommon causes of lumbar radiculopathy and occur less frequently than posterior or posterolateral disc herniation at the lumbar level. Extraforaminal disk herniation accounts for less than 10% of most lumbar disk herniations. The extraforaminal zone is generally not focused on in daily practice with spine MRI, particularly in the condition of large extrusion or protrusion causing descending nerve root compression.
The CT features of extraforaminal disc herniation are nonspecific. Recently, a detailed evaluation of disc herniation using only CT imaging was determined to be unsuitable. MR is preferred because it is noninvasive and has high soft-tissue resolution and multiplanar imaging capabilities. It may be a more favorable method for evaluating a symptomatic patient with both central and lateral spine canal pathology.
Lastly, this case study underscores the need to use the most appropriate imaging tool at our disposal and to treat the patient rather than the radiograph.

Coca-Cola considering ‘healthy’ cannabis-infused drinks

Coca-Cola says it is “closely watching” the use of CBD (Cannabidiol) as an ingredient in “wellness beverages” as a growing number of companies develop cannabis-infused drinks.

Coca-Cola Cannabis Deep Mind image

CBD is a cannabinoid that can be extracted from both marijuana and hemp varieties of cannabis. CBD doesn’t produce the high associated with marijuana, however, it is believed by many to have calming, anti-inflammatory and pain-relieving properties.

While Coca-Cola said it has “no interest in marijuana or cannabis,” they have stated: “Along with many others in the beverage industry, we are closely watching the growth of non-psychoactive CBD as an ingredient in functional wellness beverages around the world,” the company added. “The space is evolving quickly. No decisions have been made at this time.”

Coca-Cola released their statement after a report from Canada’s BNN Bloomberg reported that they were in “serious talks” with Aurora Cannabis, a medical marijuana producer and distributor, to develop drinks infused with CBD.

Enjoy Cannabis coca-cola image

Following the BNN report, stocks for Aurora Cannabis spiked 17% and Coca-Cola’s shares rose slightly.

Aurora spokeswoman Heather MacGregor said her company “has expressed specific interest in the infused-beverage space and we intend to enter that market”.

CBD oil has boomed in popularity as a number of states and countries legalize the use of CBD, hemp and marijuana products. The CBD market is forecast to grow $2.1 billion by 2020 according to Hemp Business Journal.

Canadians can legally buy and consume cannabis starting October 17th. South Africa’s highest court has recently legalized the use of cannabis by adults in private places, although it remains illegal to sell, supply and use in public. The statement has been seen as a prelude to further legalization in the united states.

Coca-Cola has been diversifying their product portfolio with recent investments in sparkling water and coffee beverages. Demand for sugary sodas has declined each year over the last decade as consumers become more health conscious.

Beer giant Molson Coors announced on August 1st that they were teaming up with The Hydropothecary Corporation, a Canadian medical marijuana grower, to develop cannabis-infused non-alcoholic beverages. Although it likely that these beverages will not only contain CBD, but also THC, the cannabinoid that causes the high or buzz effect of marijuana.

Two weeks later, spirits company Constellation Brands announced a new $4 billion in investment in Canada’s Canopy Growth, a Canadian medical marijuana producer, in exchange for a 38% stake in the company.

68 yo Male with “Sciatica”

Patient history:
  • A 68 yo male presents with slowly progressing right anterior thigh and knee pain
  • Pain never goes past the knee
  • Saw primary care physician who treated with anti-inflammatory medications with minimal improvement
  • Was sent for x-ray of the lumbar spine and diagnosed with degenerative disk disease
  • Eventually sent for MRI of lumbar spine and referred to spine surgery for evaluation
  • Difficulty putting on right shoe and sock
  • Pain getting into the driver’s side of the car
Past medical history:
  • Hypertension
  • Hypercholesterolemia
  • Coronary artery disease
  • Nonsmoker, no drug or alcohol use
Physical exam:
  • Motor and neurological function in the lower extremities are normal for age
  • Reflexes 2/4 at the patella and Achilles
  • Dorsalis and posterior tibialis pulses +2; calf soft; no skin lesions
  • Internal/external rotation of the left hip is normal with no pain
  • Internal/external rotation of the right hip reproduces significant concordant pain and markedly diminished range of motion
  • Full range of motion of the knee, no pain, no crepitus, no gross instability
  • Negative Patrick’s test
Based on the history, physical exam, and images, what is the reason for his right thigh and knee pain?

The correct answer is end-stage right hip osteoarthritis. It is true that the patient has multilevel degenerative disk pathology, but his complaints and physical exam does not support the diagnosis of end-stage degenerative disk disease. Degenerative change is a common finding in adult patients over the age 30. Anterior groin and thigh pain is generally associated with intra-articular hip pathology such as osteoarthritis or labral tear. Meralgia paresthetica should be considered when there is no real pain with range of motion but abnormal sensation in the anterior thigh. Posterior hip pain is associated with piriformis syndrome, sacroiliac dysfunction, and lumbar radiculopathy.

3-Day Headache: What’s the Cause?

Patient presentation
A 21-year-old Asian female presents with a 3-day history of acute-onset headache. Acetaminophen is not providing any relief. The patient is an otherwise healthy college student and does not have underlying disease or a significant family history. She reports that she experienced fatigue and low-grade fevers for 2 months prior to headache onset. She has no history of arm or leg claudication and denies weakness, numbness, blurry vision, nausea, stiff neck, or other associated symptoms. She does not use tobacco, alcohol, or illicit drugs.
Examination and imaging:

  • Blood pressure 190/105 in right arm and 110/65 in left arm
  • Left brachial and radial pulses barely palpable
  • Normal neurological examination
  • Labs remarkable for high ESR (65 mm/hr)
  • CT angiography of the aorta ordered

Takayasu arteritis is a large-vessel vasculitis that primarily affects the aorta and its major branches. It occurs most commonly in young females, especially those of Asian descent. Patients typically present with constitutional symptoms associated with inflammation, e.g., low-grade fever, fatigue, arthralgia, and weight loss. Obstruction of the aortic branches may lead to other signs/symptoms, including limb claudication, decreased peripheral pulses or unequal blood pressure between arms, abdominal pain (due to an obstructed mesenteric artery), and hypertension (due to an obstructed renal artery). Glucocorticoids are the cornerstone of treatment.
Takayasu arteritis has a classic radiographic appearance on computed tomography angiography (CTA) and magnetic resonance angiography (MRA), showing long-segment stenosis or occlusion of the aorta and its major branches at the aortic origins. These radiographic characteristics can confirm the diagnosis. Biopsy is rarely needed.
In this case, there is occlusion of the left common carotid artery and left subclavian artery at their aortic origin, as well as stenosis of the left renal artery.

Severe Stomach Pain after Camping .Medical case.

Patient Case

A 56-year-old male presents to the emergency department (ED) with a 4-day history of worsening left upper quadrant (LUQ) abdominal pain. He went camping about 2 weeks ago and noticed progressive weakness, chills, joint pain, night sweats, and worsening LUQ pain about 3-4 days ago. He denies abdominal trauma or bleeding from any site. His past medical history is significant for smoking tobacco.
The patient was hypotensive in the ED, but his blood pressure improved after 2 liters of a normal saline bolus.

  • Hemoglobin 11 g/dL
  • Platelet count 95,000/mm3
  • Creatinine 1.2 mg/dL
  • Total bilirubin 1.1 mg/dL
Imaging: Abdominal CT.
Case discussion: Babesiosis
Babesiosis is an infection caused by B. microti and transmitted by ticks. Infections typically occur in the Northeastern and Midwestern U.S. in the spring/summer, with an estimated incidence of 1,000 cases annually. B. microti can cause a wide spectrum of symptoms, ranging from mild anemia to more severe illness (e.g., acute respiratory distress syndrome and organ failure).
Spontaneous splenic rupture in babesiosis is a rare complication that is not widely reported in the literature. It is typically associated with low parasitemia and can occur in immunocompetent, nonelderly individuals. The underlying pathophysiology is not well understood.
This patient was monitored in the intensive care unit with serial hematocrit measurements, managed conservatively, and treated with atovaquone and azithromycin. He was discharged home after 5 days.

Hydralazine-Induced Hepatotoxicity Described in Case Report