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Clinical Reasoning: A young woman with respiratory failure, hearing loss, and paraplegia
Abstract
A 35-year-old woman with bipolar disorder presented to the emergency room (ER) obtunded with hypercapnic respiratory failure. Neurology was consulted because the patient had acute hearing loss and paraparesis. She was last seen normal the prior night by her ex-husband. Paramedics found her on the couch, obtunded, bradypneic, and hypoxic to 82% SpO2, blood pressure 116/79 mm Hg, heart rate 98 beats per minute, and normothermic. She awakened after 0.4 mg of naloxone administration. Home medications included oxycodone/acetaminophen for chronic pain and venlafaxine, alprazolam, and lamotrigine for bipolar disorder. Of note, 34 pills were missing from the oxycodone/acetaminophen bottle.
... 4 The hypoxic consequences on the cochlea have been ascribed to the metabolic disturbances of different electrochemical potentials in the ear which are formed by the metabolic activity of Na/K ion potentials, and it is recognized that such process is offended by the deficient oxygenation. 5 Hypoxia and smoking both disturb the antioxidants production pathways. The production of the antioxidant substances continuously guards against the oxidative stress and the reactive oxygen species. ...
Background
Chronic obstructive pulmonary disease is a multisystem disease with multiple comorbidities. Hearing is dependent on the cochlear functions that may be affected by oxygenation. Affection of hearing is problematic and represents a major concern that should be seriously investigated as an important comorbidity in chronic obstructive pulmonary disease patients.
Objective
To assess auditory status among chronic obstructive pulmonary disease patients.
Methodology
The current study was carried out at Al-Azhar University Hospitals, Cairo, from 1 August 2021 to 2022, including 120 participants. In addition to the control group (60 healthy participants), there were two study groups: chronic obstructive pulmonary disease patients with respiratory failure group (30 patients) and non-respiratory failure group (30 patients). Hearing functions were studied using pure tone audiometry, and auditory brain stem response.
Results
There was statistically significant hearing impairment in chronic obstructive pulmonary disease patients in comparison to control group. The hearing impairment was more significant in chronic obstructive pulmonary disease with respiratory failure group in comparison to chronic obstructive pulmonary disease without respiratory failure group. The auditory impairment shows a negative interrelationship with oxygen tension (PaO2) and a positive interrelationship with the smoking index.
Conclusion
Hearing affection was meaningfully higher among chronic obstructive pulmonary disease patients and more prominent in patients with respiratory failure. Hypoxia results in deterioration of pure tone audiometry and increased absolute and interpeak latencies in auditory brain stem response. At every frequency, the mean pure tone audiometry thresholds were higher for chronic obstructive pulmonary disease groups than control group albeit remaining in the mild to moderate area of hearing loss. Retro-cochlear affection was suggested among patients with chronic obstructive pulmonary disease as evidenced with the prolongation of auditory brain stem response waves latencies.
Ischemia of the spinal cord is a rare entity with a poor prognosis. Brain ischemia is no longer a diagnostic challenge; on the contrary, ischemia of the spinal cord remains difficult, particularly in children. In this article, we illustrate the principal causes in children and adults, clinical presentation, different techniques for the diagnosis by MR imaging (diffusion, spinal MR angiography, and 1.5 versus 3T), pathophysiology, and differential diagnosis. We will discuss current knowledge, perspectives, and pitfalls.
To describe a case of cervical flexion myelopathy resulting from a drug overdose.
A 56-year-old male presented to the emergency department unable to move his extremities following drug overdose. Neurological examination revealed him to be at C6 ASIA A spinal cord injury. The CT of his cervical spine revealed no fracture; however, an MRI revealed cord edema extending from C3 to C6 as well as posterior paraspinal signal abnormalities suggestive of ligamentous injury.
The patient underwent a posterior cervical laminectomy and fusion from C3 to C7. Neurologically he regained 3/5 bilateral tricep function and 2/5 grip; otherwise, he remained at ASIA A spinal cord injury at 6 months.
Our patient suffered a spinal cord injury likely due to existing cervical stenosis, and in addition to an overdose of sedating medications, he likely sat in flexed neck position for prolonged period of time with the inability to modify his position. This likely resulted in cervical spine vascular and/or neurological compromise producing an irreversible spinal cord injury. Spinal cord injury is a rare finding in patients presenting with drug overdose. The lack of physical exam findings suggestive of trauma may delay prompt diagnosis and treatment, and thus clinicians must have a high index of suspicion when evaluating patients in this setting.
In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990-2000.
Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990-2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression.
Overall, among decedents ages 15-64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62-0.82), Black (OR = 4.73, 95% CI 4.08-5.49) or Hispanic (OR = 1.51, 95% CI 1.29-1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06-1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44-0.56) and older age (55-64) (OR = 2.53 95% CI 1.70-3.75)).
As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.
Heroin overdose can cause various rare neurological complications like spongiform leukoencephalopathy, seizures, stroke, toxic amblyopia, transverse myelopathy, mononeuropathy, plexopathy, acute inflammatory demyelinating polyradiculoneuropathy, rhabdomyolysis, compartment syndrome, fibrosing myopathy, and acute bacterial myopathy. We report here the simultaneous presentation of multiple complications of heroin toxicity.
A young heroin addict was found unarousable lying in the lotus posture. Examination showed quadriplegia and left leg gangrene. He subsequently developed heroin-induced transverse myelitis, rhabdomyolysis, left leg compartment syndrome, and myoglobin-induced acute renal failure.
This case leads us to consider a common linked or systemic mechanism of injury rather than a local mechanism when multiple simultaneous organ failure occurs complicating heroin abuse.
Vascular myelopathies include several diagnoses that are often misdiagnosed or undertreated. Some represent neurologic emergencies, such as spinal cord infarction, and others can be disabling if they remain unrecognized, such as spinal dural arteriovenous fistulas. This review describes the clinical characteristics and current therapeutic strategies for the most common vascular myelopathies and emphasizes practical concepts for the clinician.
Although none of the vascular myelopathies have been studied in large prospective studies and their treatments have not been tested in randomized controlled trials, recent years have brought advances in diagnostic imaging and treatment alternatives as well as useful information regarding prognosis. Refinement in MRI technique now allows precise, noninvasive diagnoses of most vascular myelopathies and is crucial for the exclusion of differential diagnoses. Surgical and endovascular therapies are highly effective in treating spinal vascular malformations. Longitudinal studies have shown that the prognosis of spinal cord infarction is more favorable than previously conceived, and even patients with severe deficits can achieve meaningful recovery.
Clinicians should be keenly aware of the clinical and radiologic features of the various vascular causes for acute or progressive myelopathy. Optimal management of patients with vascular myelopathies requires close collaboration with neuroradiologists, neurointerventionalists, and vascular neurosurgeons. Prognosis should be estimated with caution because functional outcomes over time may be better than initially expected. Vascular myelopathies are infrequent, but their consequences to the patient's functional capacity can be devastating. Because of their relative rarity, these disorders are often initially misdiagnosed, and, in some cases, this delay in arriving at the correct diagnosis can prove very detrimental. This article reviews the essential concepts of diagnosis and management of vascular diseases of the spinal cord, both ischemic and hemorrhagic, beginning with a basic summary of the vascular anatomy of the cord, as this knowledge is crucial for an understanding of the pathologies.
To investigate the long-term outcome of patients with spinal cord infarct (SCI) and identify prognostic predictors.
We reviewed 115 patients with SCI treated between 1990 and 2007. Severity of impairment was defined using the American Spinal Injury Association (ASIA) scoring. Functional outcome endpoints were ambulatory status, need for bladder catheterization, and pain.
Mean age was 64 years; 72 (62.6%) patients were men. A total of 45% of infarcts were perioperative (69% aortic surgeries). A total of 68% reached maximal deficit within 1 hour (mean = 5 hours). Impairment at nadir was ASIA A 23%, B 26%, C 14%, and D 37%. A total of 75/93 (81%) patients studied with MRI had cord signal abnormality. At nadir, 81% required wheelchair, 86% required catheterization, and 32% had pain. At last follow-up (mean = 3 years), 23% had died. Among survivors, 42% required a wheelchair, 54% required catheterization, and 29% had pain upon last follow-up. Of 74 patients using a wheelchair at hospital dismissal, 41% were walking by final follow-up. Of 83 patients catheterized at dismissal, 33% were catheter-free at last follow-up. Older age (p < 0.0001), increased severity of impairment at nadir (p = 0.02), and peripheral vascular disease (p = 0.003) were independent risk factors for mortality. Severe impairment (ASIA A/B) at nadir predicted wheelchair use (p < 0.0001) and bladder catheterization (p < 0.0001) at last follow-up.
Gradual improvement in not uncommon after spinal cord infarction and it may continue long after hospital dismissal. While severe impairment at nadir is the strongest predictor of poor functional outcome, meaningful recovery is also possible in a substantial minority of these patients.
Cervical and thoracic flexion myelopathy are uncommon causes of spinal cord injury that can lead to irreversible paralysis, autonomic dysfunction, and death. To the authors' knowledge, this report is the first to describe the natural history of flexion myelopathy and the simultaneous occurrence of cervical and thoracic flexion myelopathy in the setting of drug overdose.
To report the association of cervical and thoracic flexion myelopathy and drug overdose; to describe the subacute natural history of flexion myelopathy in the setting of drug overdose; to emphasize the need for first responders to document positioning of unresponsive individuals; and to suggest careful neurological examination and early spinal cord imaging in appropriately identified patients at risk of flexion myelopathy.
We describe the case of a 34-year-old woman who developed flexion myelopathy resulting in severe quadriparesis after overdose of quetiapine fumarate, oxycodone/acetaminophen, and chloral hydrate.
Flexion myelopathy in the setting of drug overdose is a subacute injury. Early intervention may limit neurological disability. However, the clinical diagnosis of flexion myelopathy is inevitably delayed by the patient's altered level of consciousness or mental status at presentation, and concurrent multiple organ failure.
The spinal cord has significant thoracic arterial watershed areas rendering it vulnerable to intraoperative ischemic damage, clearly mandating a need for postoperative neurologic monitoring. Mechanisms of hypoperfusion include aortic cross-clamping, rib retraction, intercostal artery interruption, and costovertebral junction bleeding. We report cases of primary lung cancer resection, resection of pulmonary metastasis adherent to the thoracic aorta, resection of cartilaginous tumor with chest wall invasion, and esophagomyotomy for achalasia-all complicated by postoperative paraplegia. We review spinal cord circulation, describe mechanisms and patterns of neurologic dysfunction of susceptible watershed areas, and outline roles of preoperative spinal angiography and intraoperative evoked potentials.
What is your localization and differential diagnosis? 2. How does the pattern of sensory involvement narrow the differential? REFERENCES 1 Cocaine-and opiate-related fatal overdose in
- Kt Bernstein
- A Bucciarelli
- Tm Piper
- C Gross
- K Tardiff
- S Galea
What is your localization and differential diagnosis?
2. How does the pattern of sensory involvement narrow the differential?
REFERENCES
1. Bernstein KT, Bucciarelli A, Piper TM, Gross C, Tardiff
K, Galea S. Cocaine-and opiate-related fatal overdose in
New York City, 1990-2000. BMC Public Health 2007;
7:31.
- Aa Rabinstein
- Vascular Myelopathies
Rabinstein AA. Vascular myelopathies. Continuum 2015;
21:67–83.