BMJ case reports
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Rivaroxaban is a commonly used anticoagulant agent for treatment and prevention of thromboembolism. There are case reports demonstrating an association between its use and drug-induced liver injury. However, this has not been reported in a patient who previously tolerated apixaban. ⋯ The patient recovered well after cessation of rivaroxaban, suggesting that it was the likely offending agent. The mechanism of rivaroxaban-induced liver injury remains to be investigated. Drug-induced liver injury should be discussed and monitored for as a potential adverse reaction when commencing rivaroxaban, even if a patient has previously tolerated a drug of the same class.
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We present a 75-year-old man who was admitted to our hospital due to 4 months of general deterioration, gait disturbance and cognition impairment which appeared very close to the start of levetiracetam (LEV) as a new antiepileptic drug. Brain CT shows central and less peripheral atrophy of brain, and diagnosis of normal pressure hydrocephalus was raised; however, removal of 30 cc of cerebrospinal fluid (CSF) by lumbar puncture in order to amend walking did not lead to gait improvement. ⋯ Several days after that, there is marked improvement in his general sensation, alertness and cognitive status and there is marked improvement in walking balance to the point of being able to walk without the use of walker or cane or help from other person. Certain cognitive impairment and gait difficulties are not known as side effects of LEV treatment.
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Rabies is an almost always fatal disease that physicians and patients dread due to its dismal prognosis and limited treatment options. Transmission of this disease occurs through the bite of dogs and wild animals (like jackal in our case). ⋯ Few people have described the role of imaging in diagnosis. We hereby report a patient with rabies encephalitis, having a history of jackal bite and classical MRI findings that we can use for early diagnosis in the absence of typical clinical features and specialised diagnostic testing.
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An aortic arch floating thrombus is a rare cause of embolic ischaemic cerebral infarction. Previously, thrombolysis or mechanical thrombectomy has been used to treat acute cerebral infarction in this context; however, combination therapy using both modalities is yet to be published. The optimal management of aortic arch floating thrombi is debated. ⋯ He was successfully treated with acute thrombolysis and subsequent mechanical thrombectomy of the cerebral thrombus resulting in resolution of his neurological symptoms. Repeat imaging demonstrated persistence of the aortic arch floating thrombus despite thrombolysis. The aortic arch floating thrombus was managed successfully with direct oral anticoagulant therapy.
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We demonstrate the utility of risk stratification for postoperative delirium in geriatric patients and show that postoperative delirium can be prevented in high-risk patients when potentially inappropriate medications (PIMs) (medications that are best avoided in older adults) are avoided. In this case, a 65-year-old woman underwent two debridement procedures with similar presurgical risk for postoperative delirium. ⋯ In the second procedure, PIMs were intentionally avoided and postoperative delirium did not occur. This case supports recent recommendations from the European Society of Anaesthesiology, the American Society of Anesthesiologists and the American Geriatrics Society that providers assess a patient's cognitive function and delirium risk profile preoperatively to appropriately guide perioperative management.