3 articles
Metformin is the most widely used oral antidiabetic agent, belonging to the biguanide pharmacological group. Lactic acidosis associated with metformin is a rare event with an incidence of 19 cases per 100,000 patient-years. The risk of developing lactic acidosis when taking this drug is increased by several factors, such as age > 65 years; concomitant diseases that have the ability to induce hypoxemia (chronic kidney disease, congestive heart failure, cardiogenic shock, acute respiratory distress, sepsis, advanced liver disease, history of lactic acidosis); excessive alcohol consumption; and administration of iodinated contrast media.
A 46-year-old man self-administered 50 metformin tablets at a dose of 500 mg each. Twelve hours after ingestion, he requested emergency medical assistance, presenting with the following symptoms: drowsiness, repeated vomiting, lethargy, and dizziness. The patient’s condition was assessed as serious, so he was admitted to the intensive care unit. The patient’s personal pathological history revealed the presence of comorbidities: type 2 diabetes mellitus, toxic liver cirrhosis, hypertension and chronic kidney disease. Paraclinical investigations revealed the presence of metabolic acidosis, but with lactate <5 mmol/l; progressive renal dysfunction with creatinine values in the first 24 hours up to 1184 µmol/l, urea – 34.5 mmol/l; severe hypoglycemia - 1.68 mmol/l; moderate cytolytic, cholestatic, inflammatory; hepatocellular insufficiency syndrome; coagulation disorders; and pancreatic dysfunction.
Since metformin is easily dialyzable, it was decided to promptly initiate intermittent hemodialysis. Fourteen hemodialysis sessions were performed, with a gradual reduction of creatinine to 112.1 µmol/l. Recurrent episodes of hypoglycemia were corrected with 40% glucose solution. Subsequently, hyperglycemia was resolved with insulin.
Metformin should be used with caution in patients with concomitant pathologies. Metformin-induced lactic acidosis is potentially fatal. Early identification of metformin intoxication, with prompt initiation of renal replacement measures and dynamic monitoring of biochemical parameters, is essential.
Carney complex (CNC) is a rare genetic disorder with multisystem involvement. Endocrine manifestations include primary pigmented nodular adrenocortical disease with Cushing’s syndrome, pituitary tumors secreting GH and/or prolactin, thyroid and gonadal tumors. Non-endocrine tumors associated with CNC include myxomas of the heart, breast, and skin; ductal adenomas of the breast, cutaneous lentigines, psammomatous melanocytic schwannomas, osteochondromyxomas, and an increased predisposition to various malignancies.
Patient X.Y, a 54-year -old woman, was diagnosed in 2013 with GH-secreting pituitary microadenoma and underwent surgery via a transfrontal approach. In 2022, the patient presented with dyspnea on moderate exertion, hypertensive episodes, retrosternal discomfort, vertigo, headache. Echocardiography revealed a 20 × 30 mm mass, attached to the interatrial septum, suggestive of a left atrial myxoma. IGF 1 was 218 ng/ml (reference range 67.3-201), while the other hormonal axes were normal. The patient underwent minimally invasive cardiac surgery for myxoma resection, without postoperative complications. At 6 months after intervention, echocardiography showed no residual mass, interatrial septal defect or valvular regurgitation. As IGF-1 had remained slightly elevated for over 10 years and repeated MRI scans during this period showed no recurrence, pituitary somatotroph cell hyperplasia was assumed. The patient reported adverse reactions to dopamine agonists, and therefore octreotide 10 mg, intramuscular monthly was initiated.
Cardiac myxomas are the leading cause of mortality in CNC, early diagnosis is imperative to reduce cardiovascular mortality and improve quality of life.
Community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality, particularly in patients with chronic heart failure (CHF), who are at increased risk of adverse outcomes. Identifying reliable predictors of disease severity in this population is essential for timely risk stratification and optimization of therapeutic strategies.
Assessment of clinical and disease-course characteristics, oxidative stress, and predictors of CAP severity in patients with CHF.
A total of 210 patients were enrolled in the study and divided into two groups: group 1 (n = 105) – patients with community-acquired pneumonia associated with chronic heart failure and group 2 (n = 105) – patients with community-acquired pneumonia without chronic heart failure. The research was conducted based on clinical examination of patients, daily monitoring of the inflammatory process, assessment of comorbidities, and paraclinical investigations. Statistical analysis of the collected data was performed using a wide range of methods, including descriptive statistics, correlational analysis, and regression models.
The age of patients in the study group ranged from 50 to 92 years, with a mean of 70.6 ± 8.89 years (95% CI [68.8–72.3]), (F = 18.109; p = 0.205). In Group 1, the proportion of women was 57 (54.3%; 95% CI [44.8-64.1]), and that of men was 48 (45.7%; 95% CI [35.9-55.2]). In Group 2, the proportion of men was higher than that of women: 54 (51.4%; 95% CI [42.3-61.0]) men and 51 (48.6%; 95% CI [39.0-57.7]) women, respectively (χ2 = 0.686; df = 1; p = 0.407). Ischemia-modified albumin values were higher in patients in Group 1 compared to Group 2: 236.60 ± 57.23 µM/L and 229.77 ± 64.35 µM/L, respectively, (F = 0.660; p = 0.045). The IMA threshold value of 218.98 µM/L was determined for patients with CHF and severe CAP. The mean NT-proBNP values in Group 1 patients were 1371.88 ± 498.91 pg/ml, compared to Group 2: 58.19 ± 48.22 pg/ml, (F = 721.54; p < 0.0001). The NT-proBNP threshold value of 1665.73 pg/ml was identified for severe CAP in CHF patients. A method which allows early detection in 87.0% of cases of patients with CHF at high risk of severe community-acquired pneumonia was developed.
Our hypothesis that community-acquired pneumonia in patients with chronic heart failure is more frequently associated with a severe clinical course was confirmed. The proposed NT-proBNP and ischemia-modified albumin threshold values, together with our risk estimation formula, may improve early therapeutic intervention to prevent severe complications.