Altered mental status (AMS) in advanced chronic kidney disease (CKD) frequently reflects overlapping metabolic, cardiopulmonary, and neurologic contributors rather than a single unifying diagnosis. We present a 59-year-old woman with autosomal dominant polycystic kidney disease (ADPKD) progressing to end-stage renal disease (ESRD), congestive heart failure (CHF) with preserved ejection fraction (HFpEF), and stiff person syndrome (SPS) who developed recurrent encephalopathy accompanied by equivocal pulmonary findings and elevated cardiac troponin without electrocardiographic evidence of acute ischemia. Her hospital course was marked by severe renal dysfunction, metabolic acidosis, anemia, and intermittent electrolyte abnormalities. Management required iterative reassessment rather than reliance on a single explanatory diagnosis, included time-variable use of antibiotics and diuretics, continued chronic cardiometabolic therapies, and preparation for renal replacement therapy. This case highlights three practical teaching points: encephalopathy in ESRD is often multifactorial; troponin elevation in advanced kidney disease requires careful clinical correlation to avoid misclassification as acute coronary syndrome; and distinguishing pneumonia from pulmonary edema in volume-sensitive patients may necessitate repeated reassessment over time.

Acute water intoxication is an uncommon but potentially fatal condition characterized by excessive water consumption over a brief period. It results in dilutional hyponatremia. The condition is frequently associated with psychiatric disorders, endurance athletics, or iatrogenic causes. Early recognition and prompt treatment are crucial for preventing serious complications and ensuring favorable outcomes. A 38-year-old male patient presented to the emergency department exhibiting sudden loss of consciousness followed by altered mental status, confusion, and an episode of seizure. The history revealed ingestion of approximately 8 liters of water within a three-hour period while waiting for uroflowmetry testing. Initial laboratory tests indicated severe hyponatremia with serum sodium of 120 mEq/L. He was diagnosed with acute water intoxication with dilutional hyponatremia. Management involved fluid restriction, electrolyte monitoring, and gradual correction of sodium levels utilizing 3% hypertonic saline. The patient's neurological status improved progressively, and he was discharged after five days. This case highlights the significance of identifying acute water intoxication as a potential etiology of dilutional hyponatremia, particularly in patients presenting with neurological symptoms and a history of excessive fluid intake. Expeditious diagnosis and appropriate management are essential to prevent severe complications such as cerebral edema and permanent neurological damage.

We report the case of a 69-year-old Hispanic female with end-stage renal disease (ESRD) on hemodialysis and a complex medical history who presented with acute altered mental status shortly after initiating valacyclovir at a non-renally adjusted dose. The patient was admitted to inpatient services and treated with a presumptive diagnosis of valacyclovir-associated neurotoxicity (VAN). The patient received hemodialysis for three consecutive days, resulting in neurologic improvement. Additional competing causes of altered mental status and encephalopathy were investigated and ruled out over the course of a five-day hospitalization. The patient was subsequently discharged with a diagnosis of VAN. This case underscores the importance of proper renal dose adjustment and medication safety in patients with ESRD to prevent serious, avoidable adverse drug events.

This operative video report demonstrates two cases of endoscopic fenestration for enlarging symptomatic thalamic cysts causing obstructive hydrocephalus. A literature review of 29 cases (1987-2026)[1-17] reveals hydrocephalus present in the majority of cases. Common presentations include headache, gait disturbance, and cognitive changes. The first case involves a 62-year-old female with progressive proprioceptive deficits and imbalance due to a 2.5 cm right thalamic cyst protruding into the third ventricle. The second case involves a 59-year-old female presenting with altered mental status and headaches from an enlarging right thalamic cyst. In both cases, a frontal transcortical endoscopic approach was utilized to fenestrate the cysts into the lateral and third ventricles in combination with an endoscopic third ventriculostomy. To ensure precise access, two separate trajectories were employed: one providing a straight-line path to the cyst wall and another to the floor of the third ventricle. Fenestration was achieved using blunt dissection and Fogarty balloon dilation, followed by further enlargement with alligator clamps. Postoperatively, both patients experienced complete resolution of symptoms and mass effect. These cases illustrate that while benign thalamic neuroepithelial cysts are rarely symptomatic[10], they can be effectively treated with endoscopic fenestration. While treatment approaches in the literature vary, endoscopic or microsurgical fenestration remains the most common intervention. This technique, utilizing a high-resolution rigid endoscope coupled with stereotactic navigation and preoperative trajectory planning, allows for safe and effective treatment of these deep cystic lesions.

ObjectivesThis study aimed to compare serum leucine-rich repeat and fibronectin type III domain-containing protein-5 (LRFN5) and olfactomedin-4 (OLFM4) levels and aggregate index of systemic inflammation (AISI) values between hospitalized subjects with bipolar disorder (BD) experiencing acute manic episodes with psychotic features and healthy controls (HCs), and to examine their associations with clinical features and symptom severity.MethodsIn this cross-sectional study, participant characteristics and clinical features were assessed by structured clinical interviews. LRFN5 and OLFM4 levels were measured in the BD (n = 37) and HC (n = 35) groups using Enzyme-Linked ImmunoSorbent Assay kit.ResultsSerum LRFN5 (adjusted P = 0.0117) and OLFM4 (adjusted P = 0.0117) levels were significantly lower, whereas AISI (adjusted P = 0.0005) levels were significantly higher in the BD group compared with HCs, after adjusting for age, gender, body mass index, and smoking status. Within the BD group, a strong positive correlation was observed between LRFN5 and OLFM4 levels (r = 0.702, adjusted P = 0.006) and AISI showed a significant positive correlation with manic symptom severity score after controlling for age, gender, body mass index, and smoking status (r = 0.472, adjusted P = 0.030). In binary logistic regression analysis adjusted for age, gender, body mass index, and smoking status, lower OLFM4 levels (odds ratio (OR) = 0.970, P = 0.020, adjusted P = 0.003) and higher AISI values (OR = 1.008, P = 0.002, adjusted P = 0.001) were independently associated with BD status, alongside smoking status (OR = 19.213, P = 0.005, adjusted P = 0.001) (apparent area under the curve (AUC) = 0.914, optimism-corrected AUC = 0.884). After repeated stratified holdout validation, the mean and median test AUCs were 0.868 and 0.876, respectively.ConclusionsSubjects with BD experiencing acute manic episodes with psychotic features exhibited decreased circulating LRFN5 and OLFM4 levels alongside an increased systemic inflammatory burden, as reflected by AISI. AISI showed the strongest association with BD status and symptom severity and OLFM4 remained significant in adjusted analyses. Rather than indicating definitive diagnostic utility, the observed alterations may instead reflect underlying biological processes related to BD.

Childhood maltreatment (CM) is a risk factor for adult psychiatric and substance use disorders (SUD). Retrospectively assessed CM has been linked to increased proinflammatory cytokines, including IL-6. Induced by inflammation, the neurotoxic branch of the kynurenine pathway has been implicated in psychiatric disorders and SUD. This study explored proinflammatory responses and kynurenine metabolites following acute stress in participants with, and without, prospectively recorded CM, with or without, lifetime SUD.

Tuberculosis (TB) presents with fever, night sweats, and cough. The antituberculous therapy (ATT) used to treat TB affects various systems, including the renal system and the hepatobiliary system. ATT-induced acute tubular necrosis (ATN) can have various presentations, such as fever, vomiting, diarrhea, abdominal pain, oliguria, and cola-colored urine. We present a case of a 56-year-old patient using ATT. He presented with the complaint of altered mental status, vomiting, jaundice, and cola-colored urine. Labs revealed elevated liver enzymes, elevated creatinine, anemia, and thrombocytopenia. The autoimmune profile was normal; however, the biopsy revealed ATN. In addition to supportive management, hemodialysis and steroid therapy were initiated. Discontinuation of rifampin along with continuation of modified ATT therapy led to improved renal function tests, platelet counts, and Hb levels.