Louisiana Research Day Program Book 2025

Case Studies: Section 2

Case Studies: Section 2

111 MESALAMINE-INDUCED PERICARDIAL EFFUSION: A RARE COMPLICATION IN MANAGEMENT

112 A CAUTIONARY TALE: EXPLORING KRATOM ASSOCIATED ENCEPHALOPATHY IN A CLINICAL CASE

Mizba Basheer Patel, MD 1 ; Luz Mariana Ramirez Hernandez, MD 2 ; Amanda Schorr, MD 3 ; Harikrishna Bandla, MD 4 ; Richard C Kamm, Jr., MD 5 1,2,3 IM Resident Physician, St. Francis Medical Center, Monroe, Louisiana; 4 Hospitalist, St. Francis Medical Center, Monroe, Louisiana; 5 Critical Care Medicine & Pulmonology, St. Francis Medical Center, Monroe, Louisiana

Niku Thapa, MD 1 ; Aaphtaab Dheendsa, MD 1 ; Dipesh Upreti, MD 1 ; Navin Ramlal, MD 1 ; Richard C Kamm, Jr., MD 2 1 St Francis Medical Center; Department of Internal Medicine, Monroe, Louisiana; 2 St Francis Medical Center; Department of Pulmonary & Critical Care, Monroe, Louisiana

Background: Mesalamine, or 5-aminosalicylic acid, has been a key treatment for inflammatory bowel disease since the 1980s, recognized for its anti-inflammatory properties and safety. However, it can cause rare but serious cardiotoxic side effects, including myocarditis, pericarditis, and pericardial effusion. A review of 52 cases found that myocarditis occurred in 40.4% of instances, pericarditis in 32.7%, and myopericarditis in 26.9%. Pericardial effusion is even rarer, with only three published case reports. Case Presentation: We report the case of a 74-year-old male with a significant medical history, including non-ischemic chronic heart failure, severe left ventricular hypertrophy, paroxysmal ventricular tachycardia, and IBD managed with mesalamine. The patient presented with progressive dyspnea, scrotal swelling, abdominal discomfort, and lower extremity edema. Imaging revealed a large pericardial effusion without tamponade. Because of the size of the effusion, a pericardial window was performed with a pericardial biopsy. Pericardial biopsy showed findings of pericarditis. Fluid analysis ruled out infectious

or malignant causes. Autoimmune workup was negative. Hence, mesalamine-induced pericarditis complicated with pericardial effusion was thought to be the diagnosis. The patient was started on prednisone, colchicine, and mesalamine was discontinued. The patient had significant improvement in his dyspnea and edema. Repeat ECHO showed no recurrence of pericardial effusion, suggesting mesalamine as the culprit. Discussion: This case highlights the rare but significant risk of pericardial effusion induced by mesalamine, which can lead to potentially serious outcomes. The chronic nature of the effusion in this patient illustrates the gradual onset of mesalamine-related cardiotoxicity. While the precise mechanism remains unclear, possible explanations include direct cardiotoxic effects, hypersensitivity reactions, or immune-mediated responses. Diagnosing mesalamine-induced pericardial effusion requires careful consideration to rule out other causes and an understanding of the timing between drug exposure and the onset of symptoms. Prompt discontinuation of mesalamine is essential for resolving the issue, and in severe cases, procedural interventions may be necessary.

Conclusion: This case highlights the need to maintain a high level of suspicion for rare cardiac complications induced by mesalamine, particularly in patients who present with progressive pericardial effusion after long term use of the drug. Increasing awareness and reporting of such cases is essential for understanding and addressing this uncommon adverse effect.

Introduction: Mitragyna speciosa Korth, also known as Kratom, is a plant native to Southeast Asia historically used by laborers to enhance energy and alertness. Its active compounds, mitragynine and 7-OH-mitragynine, have notable side effects, such as irritability and psychosis. Despite the long history of Kratom use in Asia, toxicity and fatalities are less documented compared to the USA. Here, we present a case of encephalopathy linked to Kratom use. Case Presentation: A 48-year-old male with a history of polysubstance abuse and on Suboxone for opioid dependence was brought to the ER by his mother with concerns of him being sleepy, tremulous, and clumsy for the last month. On arrival, his vitals were stable. Initial labs revealed mild non-anion gap metabolic acidosis with hyperglycemia consistent with a hyperosmolar hyperglycemic state (HHS). CT head was unremarkable. His urine drug screen was negative. Over the course of admission, his mental status continued to deteriorate. He became restless, irritable, diaphoretic and ultimately combative, requiring sedation and intubation for airway protection. On further inquiry, his mother reported frequent

use of Kratom and said she saw multiple bottles of it in his room. His repeat labs were unremarkable. He remained intubated for six days due to persistent agitation and aggression, necessitating the use of continuous sedation. He gradually improved with supportive management and was successfully extubated before discharge to a rehabilitation center. Discussion: This case report emphasizes the importance of recognizing Kratom as a potential cause of encephalopathy in patients with substance abuse histories. Kratom, an increasingly popular yet unregulated substance, can produce serious adverse effects, including encephalopathy, seizures, and psychosis. Routine drug screenings do not detect Kratom, making diagnosis challenging. While treatments for Kratom withdrawal are being explored, further research is needed to optimize the management of Kratom intoxication.

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127 2025 Research Recognition Day