Interstitial lung disease is one of the most common and severe extra-articular manifestations associated with rheumatoid arthritis. Previous to the biologic treatment era, methotrexate was the medication known to cause acute lung disease mostly in patients with preexisting rheumatoid lung disease. However, recent case reports of patients treated with biologic therapies show an increased incidence of acute lung disease caused by tumor necrosis factor alpha inhibitors. This case will illustrate acute lung disease caused by adalimumab, a recombinant IgG1 monoclonal antibody. The rheumatology community must be aware of this adverse effect described so far with all 3 major tumor necrosis factor alpha inhibitors, before starting but also during maintenance therapy.

We report a case of symptomatic hypomagnesaemia in medical intensive care unit that is strongly related to proton pump inhibitors (PPIs) and provide literature review. A 65-year-old male with severe gastroesophageal reflux on omeprazole 20 mg orally twice a day, who presented to the hospital with abdominal pain, nausea, diarrhea, and new onset seizures. On admission, his serum magnesium level was undetectable. Electrocardiogram showed a new right bundle branch block with a prolonged QT interval. The hypomagnesemia was corrected with aggressive magnesium supplementation and hypomagnesemia resolved only after the PPI was stopped. Neurologic and cardiac abnormalities were corrected. This is a life-threatening case of an undetectable magnesium level strongly associated with PPI use. In critically, ill patients with refractory hypomagnesemia, we advocate considering changing gastrointestinal prophylaxis from a PPI to a histamine-receptor blocker.

Objective:To report a case of seizure-induced takotsubo cardiomyopathy with rare etiology and rarer complications.Methods:A 50-year-old woman had multiple epileptic seizures and later developed acute heart failure complicated by ventricular fibrillation and shock. A two-dimensional echocardiogram revealed apical ballooning of the left ventricle resembling a takotsubo (a Japanese fisherman's pot used to trap octopi). The apex was also hypokinetic.Results:The hemodynamic abnormalities normalized with defibrillation, assisted ventilation, inotropic support, and pressor agents. More importantly, the apical ballooning deformity and systolic dysfunction reversed. The echocardiogram normalized three months later. A nuclear treadmill stress test was negative for ischemia.Conclusions:Apical ballooning of the left ventricle and hypokinesis are typical echocardiographic features in takotsubo cardiomyopathy, a stress-induced heart disease. It may follow severe emotional, physical, and neurologic stressors, in our rare case, grand mal seizures (0.2 % of all takotsubo disease patients). Also rare are life-threatening complications. Based on these observations, in a case with severe stress followed by acute heart failure, takotsubo cardiomyopathy should be a major diagnostic consideration. The dramatic initial triggering event, in our case an epileptic seizure, should not mask the possibility of coexisting takotsubo cardiomyopathy. Awareness of this disease, anticipation of complications, and two-dimensional echocardiography will help channel the management in the right direction.