Swarup Sharma Rijal - Academia.edu (original) (raw)
Papers by Swarup Sharma Rijal
Cureus, 2022
Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic si... more Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic side effects, primarily neurological are a concern. Cardiotoxic effects of lithium are rare, reported as non-specific T-wave flattening, prolonged QT interval, sinus node dysfunction, ventricular tachycardia, cardiomyopathy, and myocardial infarction. We report an interesting case of a young female patient with schizoaffective disorder on lithium who developed life-threatening cardiotoxicity secondary to lithium requiring urgent dialysis.
Journal of the Endocrine Society
Case summary A 62-year-old Caucasian female presented to our institute with mechanical fall compl... more Case summary A 62-year-old Caucasian female presented to our institute with mechanical fall complicated by cervical spine fracture. She had known history of essential hypertension and recently diagnosed acute myeloid leukemia with myelodysplasia related changes (AML-MRC). She had undergone induction chemotherapy with combination of daunorubicin and cytarabine, resulting in chemotherapy induced prolonged pancytopenia. She was initially started on primary prophylaxis with fluconazole, but was switched to voriconazole due to persistent neutropenia. Patient then developed bilateral upper and lower extremity erythematous popular rash on voriconazole. Decision at that time was to switch to Posaconazole 300 mg orally daily. Three months after initiating Posaconazole, patient presented with severe hypokalemia (2.1 mmol/L) and hypertension. Previously her blood pressure was under control with amlodipine, lisinopril and nadolol. Hypokalemia persisted despite aggressive oral and intermittent i...
Cureus, May 28, 2022
Munankami et al. This is an open access article distributed under the terms of the Creative Commo... more Munankami et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Cureus, Jun 27, 2022
Aerococcus urinae is a rare cause of urinary tract infection (UTI) seen in elderly males with mul... more Aerococcus urinae is a rare cause of urinary tract infection (UTI) seen in elderly males with multimorbidity. Incidence is estimated between 0.15 and 0.8%. This organism is frequently misidentified for other grampositive species. Missed or delayed diagnosis of A. urinae UTI can lead to systemic infection with high morbidity and potential mortality. We present a classic case of A. urinae UTI in a 91-year-old male with multiple comorbidities, including heart failure, diabetes mellitus, and metastatic prostate carcinoma. Empiric therapy with nitrofurantoin was unsuccessful, but intravenous ceftriaxone and bladder catheterization resulted in rapid symptomatic improvement. Variable antimicrobial sensitivities and resistance have been reported for A. urinae. Therefore, antimicrobial resistance testing should be performed for all patients with A. urinae infections.
Cureus
Paget-Schroetter syndrome (PSS) is a rare form of spontaneous upper extremity deep vein thrombosi... more Paget-Schroetter syndrome (PSS) is a rare form of spontaneous upper extremity deep vein thrombosis associated with vigorous activity of the upper extremities. We present a rare case of a young swimmer who presented with a painful right upper extremity swelling, with compression ultrasound (CUS) revealing extensive venous clots in the basilic, axillary, and subclavian veins. Venous duplex revealed extrinsic compression of the subclavian vein, and catheter-based contrast venography confirmed our diagnosis of PSS. The patient was started on a therapeutic dose of subcutaneous enoxaparin and referred to a higher center for further intervention.
Advances in Clinical Medical Research and Healthcare Delivery
Chronic cough can pose various diagnostic and therapeutic dilemmas to physicians. Airway narrowin... more Chronic cough can pose various diagnostic and therapeutic dilemmas to physicians. Airway narrowing secondary to endoluminal disease or extrinsic compression are known etiologies of chronic cough. We report an extremely rare case of chronic cough due to extrinsic airway compression by a large pericardial lipoma with subsequent resolution of symptoms after the resection of the mass. This case provides insight into the rare etiology of chronic cough that is addressable with surgical intervention.
Cureus
Elevated potassium levels can be a life-threatening emergency. We describe a case of falsely elev... more Elevated potassium levels can be a life-threatening emergency. We describe a case of falsely elevated serum potassium level in a patient with leukemia, which was suspected to be falsely elevated because the patient was asymptomatic with a normal electrocardiogram (EKG). Common reasons behind such a discrepancy in leukemia patients are the use of a tourniquet before collection, use of vacuum/pneumatic tubes for transportation, prolonged periods of incubation, use of heparin for sample collection, and processing of samples via centrifugation. Since the process is related to the method of collection and processing, we recommend using rapid point of care testing in such cases to differentiate between false and true potassium elevation, as it is a well-validated tool. Moreover, there is a good correlation between potassium measured with the blood gas, point of care, and central laboratory analyzers when the concentration of potassium is above 3 mEq/L.
Cureus, 2022
Needle embolization in the heart leading to pericardial effusion with cardiac tamponade is rare. ... more Needle embolization in the heart leading to pericardial effusion with cardiac tamponade is rare. We present an unusual case of an intravenous drug user presenting with severe anginal pain with a history of intravenous needle use one month back, whose bedside echocardiography demonstrated pericardial effusion leading to tamponade. Emergent open sternotomy and exploration revealed an inadvertent tuberculin needle and hemorrhagic pericardial effusion. After removal of the needle, subsequent multiple follow-up echocardiography did not demonstrate reoccurrence of effusion.
Chest, 2017
INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare, frequently fatal disorder chara... more INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare, frequently fatal disorder characterized by exuberant cytokine production, hemophagocytosis, multi-organ failure and death. CASE PRESENTATION: A 31-y/o male with h/o liver transplant for Krill oil-induced liver injury presented with fever (102 F), chills, and bloody diarrhea. He was tachycardic, tachypneic, hypotensive and jaundiced. Initial work-up revealed pancytopenia (Hb 6.7 g/dl; WBC 2.5 x 10 9 /L with ANC 1500 cells/mL; platelets 13000/mL). In the ICU, he had an extensive work-up revealing hepatitis (bilirubin 23.8 mg/dL, ALT 156 U/L, AST 540 U/L and ALP 408 U/L), ferritin 11,600 ng/mL (30-400 ng/mL), D-dimer 3.88 mg/mL (< 0.40 mg/mL), LDH 1162 U/L, triglycerides 223 mg/dL, HHV-6 and HHV-8 viremia and splenomegaly on abdominal CT. Serologic testing was negative for HIV, influenza, para-influenza, adenovirus, RSV, EBV, CMV, Hepatitis B and C virus. The course was complicated by septic shock, acute hypoxemic respiratory failure, pericardial effusion with tamponade requiring pericardial window and renal failure on dialysis. Bone marrow aspiration was negative for malignancy but demonstrated histiocytes with erythrophagocytic and hemophagocytic activity. Inflammatory markers associated with HLH were obtained: IL-2R 32,500 pg/mL (#1033 pg/mL), IL-6 871 pg/mL (#5 pg/mL), and VEGF 317 pg/mL (<86 ng/mL). The clinical presentation confirmed a diagnosis of HLH fulfilling 7 out of 8 HLH-2004 criteria. He was treated with dexamethasone, rituximab, IVIG and ganciclovir but failed to improve. Due to high suspicion of HHV-8 driven disease in the setting of elevated IL-6 and VEGF, he was started on tocilizumab therapy. Despite aggressive treatment, he died of multi-organ failure. DISCUSSION: This patient likely had HHV-8 induced HLH. Some forms of viral induced HLH may be driven by IL-6. There is an IL-6 gene in the HHV-8 genome and viral production of vIL-6 is a primary driver for Castleman's Disease, Kaposi's sarcoma, and primary effusion lymphoma. Thus our patient was treated with cytokine inhibitory therapy using the IL-6 receptor blocker tocilizumab, due to reports of use in HHV-8 driven diseases, especially in refractory HLH. CONCLUSIONS: A strict requirement to fulfill five HLH-2004 diagnostic criteria in the adult patient might delay potentially lifesaving therapy. A low index of suspicion is necessary due to the extremely aggressive nature of HLH.
Journal of the Endocrine Society, 2021
Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading ... more Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading to impaired urinary concentration and manifests with extreme thirst and excessive urination. Patients unable to drink fluids are at risk of severe dehydration and hypernatremia. CDI can be a rare complication of acute myeloid leukemia (AML). The occurrence of AML with CDI is extremely rare with only few case reports published. This combination of AML with CDI has been reported to be associated with monosomy 7 and inversion (3) (q21q26) and portends an overall a very poor treatment response resulting in poor outcomes. Case Presentation: 66-year-old female with hypertension, polycythemia vera diagnosed in 2006 with transformation to AML in 2020. FISH studies revealed monosomy 7. Cytogenetic studies showed inv (3)(q21q26.2). Remission induction chemotherapy was initiated. Subsequently, neutropenic fever and sepsis secondary to Clostridium difficile colitis lead to hospitalization. Her sodiu...
Journal of the Endocrine Society, 2021
Background: Thyrotoxic periodic paralysis (TPP) is a rare but serious thyroid emergency character... more Background: Thyrotoxic periodic paralysis (TPP) is a rare but serious thyroid emergency characterized by hypokalemia, acute onset flaccid paralysis & thyrotoxicosis. Typically, seen in an Asian male with untreated hyperthyroidism symptoms, who awakens at night or in the early morning with flaccid ascending paralysis. This is precipitated by exercise, alcohol or carbohydrate rich meal. TPP is widely reported & studied in Asian population. Its prevalence is about 2 % in Asian hyperthyroid patients. However, incidence is 0.1-0.2% in non-Asian hyperthyroid patients. Clinical Case: 33-year-old Caucasian male with celiac disease and no thyroid disease sought emergency care for complaints of sudden onset severe weakness in all extremities. He reported 20-pound unintentional weight loss, intermittent palpitations and low-grade fever. He noticed leg cramps with numbness and unable to move his extremities. At initial evaluation, he had acute flaccid paralysis and tachycardia. Initial laborato...
Journal of Primary Care & Community Health, 2021
Statin therapy is a widely prescribed medication class for hypercholesterolemia. In statin-induce... more Statin therapy is a widely prescribed medication class for hypercholesterolemia. In statin-induced autoimmune myopathy, genetically predisposed and at-risk patients can develop antibodies against hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the key enzyme in the production of cholesterol. As a result, an autoimmune reaction causing weakness, myalgia, with possible severe rhabdomyolysis, renal failure, and myonecrosis also can occur. A 73-year-old female presented to clinic with myalgia and fatigue. She was on atorvastatin 20 mg/day for over 1 year, which she stopped 1 week prior to her initial presentation. Patient did experience rhabdomyolysis as well as a transaminitis. She underwent an autoimmune workup which was positive for HMG-CoA reductase antibodies. Patient was initially treated on a prednisone taper, starting dose 50 mg/day. Without remission of symptoms, methotrexate 15 mg/week was initiated.
Cureus, 2022
Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic si... more Lithium has been widely used as a mood stabilizer. With its narrow therapeutic index, systemic side effects, primarily neurological are a concern. Cardiotoxic effects of lithium are rare, reported as non-specific T-wave flattening, prolonged QT interval, sinus node dysfunction, ventricular tachycardia, cardiomyopathy, and myocardial infarction. We report an interesting case of a young female patient with schizoaffective disorder on lithium who developed life-threatening cardiotoxicity secondary to lithium requiring urgent dialysis.
Journal of the Endocrine Society
Case summary A 62-year-old Caucasian female presented to our institute with mechanical fall compl... more Case summary A 62-year-old Caucasian female presented to our institute with mechanical fall complicated by cervical spine fracture. She had known history of essential hypertension and recently diagnosed acute myeloid leukemia with myelodysplasia related changes (AML-MRC). She had undergone induction chemotherapy with combination of daunorubicin and cytarabine, resulting in chemotherapy induced prolonged pancytopenia. She was initially started on primary prophylaxis with fluconazole, but was switched to voriconazole due to persistent neutropenia. Patient then developed bilateral upper and lower extremity erythematous popular rash on voriconazole. Decision at that time was to switch to Posaconazole 300 mg orally daily. Three months after initiating Posaconazole, patient presented with severe hypokalemia (2.1 mmol/L) and hypertension. Previously her blood pressure was under control with amlodipine, lisinopril and nadolol. Hypokalemia persisted despite aggressive oral and intermittent i...
Cureus, May 28, 2022
Munankami et al. This is an open access article distributed under the terms of the Creative Commo... more Munankami et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Cureus, Jun 27, 2022
Aerococcus urinae is a rare cause of urinary tract infection (UTI) seen in elderly males with mul... more Aerococcus urinae is a rare cause of urinary tract infection (UTI) seen in elderly males with multimorbidity. Incidence is estimated between 0.15 and 0.8%. This organism is frequently misidentified for other grampositive species. Missed or delayed diagnosis of A. urinae UTI can lead to systemic infection with high morbidity and potential mortality. We present a classic case of A. urinae UTI in a 91-year-old male with multiple comorbidities, including heart failure, diabetes mellitus, and metastatic prostate carcinoma. Empiric therapy with nitrofurantoin was unsuccessful, but intravenous ceftriaxone and bladder catheterization resulted in rapid symptomatic improvement. Variable antimicrobial sensitivities and resistance have been reported for A. urinae. Therefore, antimicrobial resistance testing should be performed for all patients with A. urinae infections.
Cureus
Paget-Schroetter syndrome (PSS) is a rare form of spontaneous upper extremity deep vein thrombosi... more Paget-Schroetter syndrome (PSS) is a rare form of spontaneous upper extremity deep vein thrombosis associated with vigorous activity of the upper extremities. We present a rare case of a young swimmer who presented with a painful right upper extremity swelling, with compression ultrasound (CUS) revealing extensive venous clots in the basilic, axillary, and subclavian veins. Venous duplex revealed extrinsic compression of the subclavian vein, and catheter-based contrast venography confirmed our diagnosis of PSS. The patient was started on a therapeutic dose of subcutaneous enoxaparin and referred to a higher center for further intervention.
Advances in Clinical Medical Research and Healthcare Delivery
Chronic cough can pose various diagnostic and therapeutic dilemmas to physicians. Airway narrowin... more Chronic cough can pose various diagnostic and therapeutic dilemmas to physicians. Airway narrowing secondary to endoluminal disease or extrinsic compression are known etiologies of chronic cough. We report an extremely rare case of chronic cough due to extrinsic airway compression by a large pericardial lipoma with subsequent resolution of symptoms after the resection of the mass. This case provides insight into the rare etiology of chronic cough that is addressable with surgical intervention.
Cureus
Elevated potassium levels can be a life-threatening emergency. We describe a case of falsely elev... more Elevated potassium levels can be a life-threatening emergency. We describe a case of falsely elevated serum potassium level in a patient with leukemia, which was suspected to be falsely elevated because the patient was asymptomatic with a normal electrocardiogram (EKG). Common reasons behind such a discrepancy in leukemia patients are the use of a tourniquet before collection, use of vacuum/pneumatic tubes for transportation, prolonged periods of incubation, use of heparin for sample collection, and processing of samples via centrifugation. Since the process is related to the method of collection and processing, we recommend using rapid point of care testing in such cases to differentiate between false and true potassium elevation, as it is a well-validated tool. Moreover, there is a good correlation between potassium measured with the blood gas, point of care, and central laboratory analyzers when the concentration of potassium is above 3 mEq/L.
Cureus, 2022
Needle embolization in the heart leading to pericardial effusion with cardiac tamponade is rare. ... more Needle embolization in the heart leading to pericardial effusion with cardiac tamponade is rare. We present an unusual case of an intravenous drug user presenting with severe anginal pain with a history of intravenous needle use one month back, whose bedside echocardiography demonstrated pericardial effusion leading to tamponade. Emergent open sternotomy and exploration revealed an inadvertent tuberculin needle and hemorrhagic pericardial effusion. After removal of the needle, subsequent multiple follow-up echocardiography did not demonstrate reoccurrence of effusion.
Chest, 2017
INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare, frequently fatal disorder chara... more INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare, frequently fatal disorder characterized by exuberant cytokine production, hemophagocytosis, multi-organ failure and death. CASE PRESENTATION: A 31-y/o male with h/o liver transplant for Krill oil-induced liver injury presented with fever (102 F), chills, and bloody diarrhea. He was tachycardic, tachypneic, hypotensive and jaundiced. Initial work-up revealed pancytopenia (Hb 6.7 g/dl; WBC 2.5 x 10 9 /L with ANC 1500 cells/mL; platelets 13000/mL). In the ICU, he had an extensive work-up revealing hepatitis (bilirubin 23.8 mg/dL, ALT 156 U/L, AST 540 U/L and ALP 408 U/L), ferritin 11,600 ng/mL (30-400 ng/mL), D-dimer 3.88 mg/mL (< 0.40 mg/mL), LDH 1162 U/L, triglycerides 223 mg/dL, HHV-6 and HHV-8 viremia and splenomegaly on abdominal CT. Serologic testing was negative for HIV, influenza, para-influenza, adenovirus, RSV, EBV, CMV, Hepatitis B and C virus. The course was complicated by septic shock, acute hypoxemic respiratory failure, pericardial effusion with tamponade requiring pericardial window and renal failure on dialysis. Bone marrow aspiration was negative for malignancy but demonstrated histiocytes with erythrophagocytic and hemophagocytic activity. Inflammatory markers associated with HLH were obtained: IL-2R 32,500 pg/mL (#1033 pg/mL), IL-6 871 pg/mL (#5 pg/mL), and VEGF 317 pg/mL (<86 ng/mL). The clinical presentation confirmed a diagnosis of HLH fulfilling 7 out of 8 HLH-2004 criteria. He was treated with dexamethasone, rituximab, IVIG and ganciclovir but failed to improve. Due to high suspicion of HHV-8 driven disease in the setting of elevated IL-6 and VEGF, he was started on tocilizumab therapy. Despite aggressive treatment, he died of multi-organ failure. DISCUSSION: This patient likely had HHV-8 induced HLH. Some forms of viral induced HLH may be driven by IL-6. There is an IL-6 gene in the HHV-8 genome and viral production of vIL-6 is a primary driver for Castleman's Disease, Kaposi's sarcoma, and primary effusion lymphoma. Thus our patient was treated with cytokine inhibitory therapy using the IL-6 receptor blocker tocilizumab, due to reports of use in HHV-8 driven diseases, especially in refractory HLH. CONCLUSIONS: A strict requirement to fulfill five HLH-2004 diagnostic criteria in the adult patient might delay potentially lifesaving therapy. A low index of suspicion is necessary due to the extremely aggressive nature of HLH.
Journal of the Endocrine Society, 2021
Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading ... more Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading to impaired urinary concentration and manifests with extreme thirst and excessive urination. Patients unable to drink fluids are at risk of severe dehydration and hypernatremia. CDI can be a rare complication of acute myeloid leukemia (AML). The occurrence of AML with CDI is extremely rare with only few case reports published. This combination of AML with CDI has been reported to be associated with monosomy 7 and inversion (3) (q21q26) and portends an overall a very poor treatment response resulting in poor outcomes. Case Presentation: 66-year-old female with hypertension, polycythemia vera diagnosed in 2006 with transformation to AML in 2020. FISH studies revealed monosomy 7. Cytogenetic studies showed inv (3)(q21q26.2). Remission induction chemotherapy was initiated. Subsequently, neutropenic fever and sepsis secondary to Clostridium difficile colitis lead to hospitalization. Her sodiu...
Journal of the Endocrine Society, 2021
Background: Thyrotoxic periodic paralysis (TPP) is a rare but serious thyroid emergency character... more Background: Thyrotoxic periodic paralysis (TPP) is a rare but serious thyroid emergency characterized by hypokalemia, acute onset flaccid paralysis & thyrotoxicosis. Typically, seen in an Asian male with untreated hyperthyroidism symptoms, who awakens at night or in the early morning with flaccid ascending paralysis. This is precipitated by exercise, alcohol or carbohydrate rich meal. TPP is widely reported & studied in Asian population. Its prevalence is about 2 % in Asian hyperthyroid patients. However, incidence is 0.1-0.2% in non-Asian hyperthyroid patients. Clinical Case: 33-year-old Caucasian male with celiac disease and no thyroid disease sought emergency care for complaints of sudden onset severe weakness in all extremities. He reported 20-pound unintentional weight loss, intermittent palpitations and low-grade fever. He noticed leg cramps with numbness and unable to move his extremities. At initial evaluation, he had acute flaccid paralysis and tachycardia. Initial laborato...
Journal of Primary Care & Community Health, 2021
Statin therapy is a widely prescribed medication class for hypercholesterolemia. In statin-induce... more Statin therapy is a widely prescribed medication class for hypercholesterolemia. In statin-induced autoimmune myopathy, genetically predisposed and at-risk patients can develop antibodies against hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the key enzyme in the production of cholesterol. As a result, an autoimmune reaction causing weakness, myalgia, with possible severe rhabdomyolysis, renal failure, and myonecrosis also can occur. A 73-year-old female presented to clinic with myalgia and fatigue. She was on atorvastatin 20 mg/day for over 1 year, which she stopped 1 week prior to her initial presentation. Patient did experience rhabdomyolysis as well as a transaminitis. She underwent an autoimmune workup which was positive for HMG-CoA reductase antibodies. Patient was initially treated on a prednisone taper, starting dose 50 mg/day. Without remission of symptoms, methotrexate 15 mg/week was initiated.