Journal of Clinical Case Reports

Introduction: Valproic acid (VPA) toxicity causes a wide range of neurological manifestations, spanning from mild lethargy to life-threatening cerebral edema. Extracorporeal elimination, mainly hemodialysis enhances plasma clearance of VPA. Meanwhile, Carbapenems interact with VPA leading to reduction in its plasma concentration. Previous cases reported utilizing either one of these two modalities in VPA toxicity. In this case, we combined the use of both hemodialysis and carbapenem antibiotic in treating a patient with severe VPA poisoning.

Case Report: A 41-year-old male brought to the emergency department after being found unresponsive in his room. He was in deep coma with Glasgow Coma Scale (GCS) 3/15. He was intubated and placed on mechanical ventilator. Physical examination revealed loss of all brainstem reflexes. He was shifted to the medical intensive care unit. Blood test showed unquantifiable high serum VPA concentration >4000 umol/L (Therapeutic Range: 350 - 690 umol/L). Hemodialysis was done and 1-gram ertapenem was administered. Later on, day 1, patient started to breathe over the ventilator. On day 2, patient underwent another session of hemodialysis and another dose of ertapenem was given. He became fully awake, with GCS 15/15 and valproate level came down to 1760 umol/L then later day 2 to 800 umol/L. The patient was successfully extubated, and history was taken which revealed that he took 300 tablets of 500 mg valproic acid (total 150 g) for suicidal attempt.

Conclusion: Carbapenems may add additional benefit to extracorporeal elimination in patients with life threatening valproic acid toxicity. Further studies are needed to establish the role of carbapenem in VPA poisoning.

Objectives: The aim of this study is two-fold: to present an atypical Erb’s palsy presentation in a premature newborn and to report his recovery through conservative care after three months without spontaneous resolution.

Case presentation: A 3-month-old male presented at the clinic with right side Erb’s palsy following a cesarean delivery at 33 weeks of gestation from a mother with a bicornuate uterus. The mother and the baby had no other risk factors commonly associated with this condition.

Intervention and outcome: Treatment consisting of light mobilization and soft tissue techniques was performed twice a week for 9 weeks for a total of 18 visits along with postural advice. After 18 visits, there was no mobility restriction of the neck, and bilateral abduction and flexion of arms was possible. Biceps and grabbing reflexes were improved. The baby was able to lie in the prone position with the head upright and arms at 90° flexion.

Conclusion: We are reporting a rare case of Erb’s palsy in a premature baby, which is not documented in the scientific literature as a common risk factor. Before surgery is considered, chiropractic care should be considered as a conservative and non-invasive approach for clinical management of Erb’s palsy in cases without spontaneous recovery.

NMS is an iatrogenically caused medical emergency, by D2 receptor blocking drugs. Atypical NMS is a presentation of three of the four signs-hyperthermia, rigidity or other extrapyramidal syndromes, autonomic disturbances and mental status changes. We report a case of a 41-year-old male with multiple drug abuse, dysthymia with moderate depressive episode and hypertension who developed Atypical NMS when on treatment with quetiapine. Atypical NMS resolved within a week of discontinuation of quetiapine and with supportive care. Atypical NMS is an impending state of NMS, which needs to be identified at the earliest to avert further complications.

Primary hyperoxaluria (PH) is a rare disorder that can cause renal failure due to accumulation of oxalate crystals. This study reports an eight-year-old female, product of consanguineous marriage, with strong family history of renal calculi, who presented with acute on chronic renal failure. Imaging revealed bilateral staghorn calculi and renal cortical nephrocalcinosis. Molecular studies confirmed primary hyperoxaluria type 1 in the patient, and carrier status in her parents. Patient ultimately required renal replacement therapy with hemodialysis. Organ transplantation has not yet been explored.

Aim: Etoposide is an anti-neoplastic drug used in the management of testicular malignancies. In this report, we describe an unexpected adverse reaction experienced by a 27-year-old male patient undergoing first line treatment for metastatic testicular cancer with bleomycin, etoposide, and cisplatin (BEP) protocol.

Case Report: The patient, on separate days, experienced two episodes of severe muscle cramps associated with excruciating pain shortly after the administration of etoposide therapy. With no other drugs administered at the time of the etoposide infusions, and a Naranjo probability score of seven, the association between etoposide and the muscle cramps experienced by the patient is probable. To maintain the patient on first-line therapy, diazepam was administered prior to each infusion of etoposide with a favorable response. The patient continued to receive therapy with etoposide without the occurrence of muscle cramps.

Conclusion: To the extent of our knowledge, this is the first case report describing such an adverse reaction, also highlighting a possible means of management.