All modern vaccines share the risk of neurological adverse effects. Only a few cases of Parsonage-Turner syndrome (PTS), an uncommon peripheral nerve condition associated with coronavirus disease 2019 (COVID-19) immunization, have been reported to date. We describe a case of COVID-19 vaccine-induced PTS and provide a brief literature review. A 78-year-old male non-smoker with a medical history of coronary artery disease presented with non-exertional, constant chest pain for one hour and new onset of bilateral hand weakness for three days. He had no neurological disease or allergies and denied any recent trauma or infection. Three weeks before the onset of the symptoms, the patient received a second dose of the BNT162b2 COVID-19 vaccine, which was administered 21 days after the first dose. Physical examination was significant for weakness in right-hand grip and wrist flexion. There were no other motor deficits, upper motor neuron signs, bulbar weakness, or sensory deficits. Diagnostic workup for the underlying diabetes mellitus, infections, or other autoimmune diseases was negative. Imaging workup revealed no demyelination, fracture deformity, traumatic subluxation, or compressive myelopathy. Nerve conduction studies, including needle electromyography, showed decreased motor unit recruitment in the bilateral first dorsal interosseous and right deltoid, biceps, and triceps muscles confirming PTS. The patient was treated with 40 mg/day of oral prednisone and occupational therapy to maintain range of motion and activities of daily living. PTS is also known as neuralgic amyotrophy, brachial plexus neuritis, brachial plexopathy, and shoulder-girdle syndrome. It is characterized by asymmetrical, chronic, resistant upper extremity neuropathic pain and neurological defects such as paralysis and paresthesia. There are two different types of PTS: non-hereditary and inherited. The etiology and pathophysiology of PTS are not fully understood. Various aspects such as genetic, environmental, and immunological predisposition may play a role in developing the syndrome. Infections, vaccines, and injuries are typical causes of non-hereditary forms. After the COVID-19 epidemic and the commencement of a global immunization effort, similar instances happened. Presently there is no available test that unequivocally confirms or excludes PTS itself. Electrodiagnostic study and imaging modalities help to rule out other differential diagnoses. Also, there is no specific treatment available; however, it may resolve independently of treatment with supportive care.
Various factors can cause pleural effusion in multiple myeloma patients. Myelomatous pleural effusion (MPE) is an uncommon but potentially life-threatening complication of multiple myeloma with a poor prognosis. After ruling out all other probable causes, the present case reports MPE in a patient with IgG kappa multiple myeloma.
Purpose Abnormalities in serum magnesium levels have been seen in obesity and its related diseases. Our aim is to determine the mean magnesium levels in overweight and obese children as compared to the levels in normal weight controls to study its relationship with obesity and overweight. The study was done at a tertiary care hospital. Methods A case-control study was conducted at the Department of Pediatrics, Combined Military Hospital, Peshawar, over a 12-month period from August 7, 2015 to August 6, 2016. A total of 140 children between 2-14 years of age were included in the study. They were divided into two equal groups of 70 children each. Both of the groups were matched according to their age and sex. Children with a body mass index (BMI) greater than or equal to 85th centile and 95th centile were placed in the overweight and obese category, respectively, and termed as cases while the other 70 children with a BMI greater than or equal to 5th centile but less than 85th centile were categorized as the normal weight group and termed controls. The serum magnesium levels of both case and control groups were calculated. Results The serum magnesium levels were significantly lower in the overweight and obese group (2.08 ± 0.211 mg/dl) as compared to the normal weight group (2.55 ± 0.155 mg/dl, p<0.001). A significantly strong inverse relationship was seen between serum magnesium levels and body mass index. Conclusion Mean serum magnesium levels in overweight and obese children are lower than those in normal weight children. Further studies are required to see the effect of supplementation of diet with this essential micronutrient on the weight of children.
Introduction: Myocarditis caused by Ehrlichiosis is a rare manifestation. The following case emphasizes the significance of early detection and its treatment. Description: A previously healthy 77-year-old female presented with a two-day history of generalized weakness and altered mental status. On arrival, she had a fever of 101.5°F, a heart rate of 110 beats per minute, a respiratory rate of 26 breaths per minute, a blood pressure of 80/70 mmHg, and an oxygen saturation of 92% on low-flow nasal cannula oxygen therapy. She was disoriented without a focal neurologic deficit, and the remainder of the examination was unremarkable. Laboratory evaluation revealed leukocytosis at 22000 /mm3, thrombocytopenia at 34000 /mm3, troponins at 6300 ng/mL, creatinine of 3.0 mg/dL, and mild transaminitis. Her hepatitis panel, toxicology screen, urine, and blood cultures were negative. A lumbar puncture was not performed because of thrombocytopenia. Her pan-computed tomography (CT) scans were also unremarkable. Echocardiography revealed severe diffuse hypokinesia with a left ventricle ejection fraction of 20%. Cardiac catheterization was deferred due to renal dysfunction. Her empiric antibiotics regimen was de-escalated to doxycycline after peripheral smear, and a PCR test confirmed Ehrlichiosis. Her symptoms improved, and she was discharged to inpatient rehabilitation. An echocardiogram in 6 months showed an improved ejection fraction of 45%. Discussion: Ehrlichiosis usually manifests with symptoms of fever, myalgias, and malaise mimicking influenza-like illness. However, severe sequelae are more traditionally encountered at extreme ages. Myocarditis is a rare and fatal occurrence. The pathogenic mechanism driving cardiac involvement is still partially understood. It may cause cardiac damage or produce immunosuppression and inflammatory cell dysfunction, leading to nonspecific myocyte damage. We believe our patient had ehrlichiosis-related myocarditis, as evidenced by peripheral smear testing, profoundly raised cardiac enzymes, new-onset congestive heart failure, and recovery of cardiac function after treatment. In endemic locations, especially during the summer, it is prudent to keep suspicion of ehrlichiosis-associated myocarditis.
Restless legs syndrome (RLS) is a common neurological disorder in hemodialysis (HD) patients. It is associated with poor sleep and decreased quality of life. The precipitants for the disorder are still poorly understood. The condition has not been studied extensively in Pakistan, which has a vast majority of end-stage renal disease patients on maintenance HD. We aimed to determine the prevalence of this condition in patients attending HD units of the largest renal dialysis center in Northern Pakistan. We also strived to determine any associations with dialysis inadequacy and the total duration of HD. This was an observational study comprising 279 patients. RLS was diagnosed using the International Restless Leg Syndrome Study Group criteria. Dialysis adequacy was determined using the Urea Reduction Ratio and the Kt/V technique. The prevalence of RLS in this large HD population was 24%. Our results show that a longer duration and greater number of HD sessions were significantly associated with the development of RLS (p<0.05). Dialysis inadequacy was not associated with the development of the disorder. These results may indicate that the pro-inflammatory nature of hemodialysis may have a role in the pathophysiology of RLS in HD patients and prolonged exposure to it may make them more prone to developing the disorder.
The urgent requirement for a preventative vaccination became more pressing due to the severe repercussions that the SARS-CoV-2 (COVID-19) virus had on society and the economy. The deployment of the COVID-19 vaccination program had to be expedited. As with all vaccinations, adverse events have been recorded with the COVID-19 vaccine. Some patients may experience cutaneous reactions such as rashes, itching, hives, and swelling after receiving the COVID-19 vaccine, but it is unclear how common these events are or how frequently they recur. This article discusses an unusual case of a young man who got chronic severe dermatographism after receiving a booster shot of the Moderna vaccine (Moderna, Inc., Cambridge, Massachusetts).
Introduction: Drug-induced pancreatitis is generally mild to moderate in intensity, but severe and even fatal cases have been observed and have now been linked with increased morbidity. This case outlines an interesting incidence of mirtazapine-associated hypertriglyceridemia that contributed to the development of acute pancreatitis. Case Description/Methods: We describe a 33-year-old female who presented to us with intractable nausea and acute abdominal pain. Physical examination was unremarkable except for severe epigastric pain on palpation. Laboratory workup was significant for elevated lipase levels (700U/L) and severe hypertriglyceridemia (>1000 mg/dL). CT scan of the abdomen revealed edema around the pancreas, suggesting inflammation, and ruled out any other pathology. Her history was uneventful except for depression and anorexia, for which she was recently started on Mirtazapine. She denied any recent history of alcohol or any other illicit drug use. Mirtazapine was then suspected as the cause of severe hypertriglyceridemia that led to acute pancreatitis. After discontinuing the offending agent, she was started on an insulin infusion and underwent multiple plasmaphereses. Subsequently, her triglyceride levels normalized with the resolution of her acute symptoms. Discussion: Pancreatitis can have multiple etiologies, of which drug-induced pancreatitis accounts for less than 5%, but cases may be higher owing to inconspicuousness. The pathophysiology varies depending on the medication and includes an accumulation of toxic metabolites, direct cytotoxic effects, or hypersensitivity reactions. Mirtazapine is an antidepressant drug usually prescribed for the treatment of major depressive disorder and anorexia. Although it does cause high serum triglyceride levels, the development of acute pancreatitis is a rare entity. As recommended by Mallory and Kern to prove a definitive diagnosis, a medication re-exposure test was not performed due to ethical reasons (1). Physicians must be aware of this association so that patients being given Mirtazapine should be monitored closely. Also, a quick diagnosis based on the association can help prompt cessation of the drug, which paves the way for a favorable outcome that can help avoid morbidity, reduce hospitalization stay and decrease medical expenditures.Figure 1.: Figures (a & b) show diffuse pancreatic parenchymal enlargement, indistinct pancreatic margins, and surrounding retroperitoneal fat stranding owing to inflammation suggestive of acute pancreatitis.
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