Journal of Clinical Case Reports

Purpose: Falls, a common cause of injuries and hospitalizations, are observed more commonly as age increases. Several factors may potentiate a fall including vision impairment, muscle weakness, and medications. Among those, medication use is a modifiable risk factor that pharmacists can address to lower the risk for falls and falls-related injuries. Fall-risk-increasing drugs are associated with adverse drug events such as sedation, dizziness, impaired coordination, and orthostatic hypotension. The purpose of this case report is to present mitigation strategies a clinical pharmacist provided after a medication review that identified a fall-risk-increasing drug and multi-drug interactions, to which its resultant intervention reduced the risk for falls and improved patient safety.

Case: A 63-year-old male who suffered a recent fall in his home received a targeted fall assessment medication review by a clinical pharmacist. Upon review, the clinical pharmacist identified hydroxyzine as a fall-risk-increasing drug and identified drug-drug interactions with simvastatin and fluoxetine that could increase the risk for hydroxyzine-related adverse drug events. Additionally, other fall-risk-increasing drugs (e.g., clonazepam, meclizine, fluoxetine) were present, each involved in one or more drug-drug interactions. As a first step, the clinical pharmacist recommended to discontinue the hydroxyzine to lower his risk for a future fall and fall-related injury.

Conclusion: This case demonstrates an example of a clinical pharmacist’s interventions that resulted in a reduction of falls risk, along with the improvement of patient safety.

Langerhans Cell Histiocytosis (LCH), also known as Histiocytosis X (HX), is a group of hyperplastic cellular diseases of unknown causes. LCH could affect bones, lungs, central nervous system, liver, thymus, skin, and also lymph nodes. The diagnosis of LCH is difficult to enforce and rarely found in adults, with just about 5 cases per million per year. The present study reports the case of a young woman with LCH with multisystem involvement, including that of the bone, orbit, pulmonary system and central nervous system. The patient received chemotherapy for 6 months and exhibited rapid improvement in the involved systems. The last PET/CT showed metabolic activity in the right iliac bone. One year after completion of the therapy, the patient returned to the hospital showing deteriorating health. The clinical case is interesting not only because of the registered clinical, morphological, and imaging data of histiocytosis but also because of the unclear prognostic and diagnostic importance of this phenomenon.

Group A Streptococcus (GAS) puerperal sepsis is still one of the significant causes of morbidity and mortality, despite the dramatic advancements in knowledge, prevention, and sepsis treatment since the days of Zimmerman. The incidence of GAS infections is variable. However, it is around 3-4 cases per 100,000 population every year in developed countries. It would be higher in developing countries. GAS Puerperal sepsis is the infection of the genital tract between membranes' rupture and the 42^nd day postpartum, according to the WHO. We present the case of a 36-yearold Para 2, who came with fever and severe abdominal pain three days after vaginal delivery and progressed to septic shock. Differential diagnosis of complex appendicitis or Right Ovarian vessel thrombosis made. A Laparotomy confirmed Right Ovarian Vein Thrombosis, for which a Right Salpingo-Oophorectomy performed. Blood cultures established GAS infection. The woman made an uneventful recovery following aggressive antibiotic therapy and care in the Intensive Care Unit. The baby received antibiotics. She was discharged home on day 11, in good condition. One of the rarest complications of GAS Puerperal Sepsis is Ovarian Vein Thrombosis. Aggressive IV fluids and antibiotics therapy, as well as surgical intervention, is the mainstay of treatment. Multidisciplinary input is important.

Miller Fisher Syndrome (MFS) is a rare inflammatory peripheral neuropathy where the diagnosis is made based on the clinical triad of ophthalmoplegia, ataxia, and areflexia. It is considered a variant of Guillain-Barré Syndrome (GBS) and associated with antiGQ1b IgG positive serology. Reports on cerebellar ataxia and supranuclear gaze palsy in MFS suggested an additional involvement of the central nervous system, encompassing Bickerstaff's Brainstem Encephalitis (BBE) spectrum.

Background: Appendicular Endometriosis represents less than 1% of all pelvic endometriosis cases. It manifests with pain in right iliac fossa and bear resemblance to acute appendicitis. Definitive diagnosis is possible only after histopathological examination of excised appendix.

Case presentation: We report a rare case of Appendicular Endometriosis (AE) in a 38 years old non-married female, otherwise healthy, came to emergency room with less than 24 hours lower abdominal pain associated with nausea but no vomiting. All other systemic review was unremarkable. Patient has no positive medical or surgical history. Blood investigations were normal and abdominal ultrasound US showed edematous wall thickening of the appendix with 12 mm distended lumen. Laparoscopic appendicectomy was performed with incidental finding of blood-tinged fluid in the pelvis and multiple prominent fibroids of the uterus, the appendix was inflamed, and appendectomy done. Postoperative recovery course was uneventful. The final histopathological examination confirmed endometriosis of appendix.

Conclusion: AE is a rare entity and almost always diagnosed after histopathological examination. it should be included in the differential diagnosis of acute abdominal pain, especially when women of childbearing age present with clinical symptoms of acute appendicitis.

Individuals that have undergone cardiac surgery or heart valve replacement are at increased risk for developing Infective Endocarditis (IE). IE has numerous signs and symptoms as well as complications. However, an interesting and unique presentation of IE can be in an individual showing a complete heart block on EKG. A heart block from an IE will typically present with a cardiac abscess on Transesophageal Echocardiogram (TEE) and coronary Computed Tomography Angiography (CTA). This individual, with a past medical history of transcatheter aortic valve replacement in 2011, was found to have Enterococcus faecalis bacteremia and endocarditis. Soon after discovery of the infection, CTA of the coronaries showed a 7.6 × 4.6 × 2.5 cm loculated pericardial collection consistent of a cardiac abscess. Despite the initiation of antibiotic therapy, this gentleman with bacterial endocarditis had an increased risk of immediate mortality, due to the complete heart block and additional complications. High clinical suspicion and early intervention are warranted for cases of infective endocarditis.