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Dialysis disequilibrium syndrome (DDS) is characterized by a spectrum of neurologic symptoms that can affect patients on hemodialysis. Dialysis naive patients are more prone to this condition but it can also occur in patients who have missed several days of dialysis. Early features may be mild, including headache, nausea, and blurred vision, to severe symptoms such as somnolence, confusion, seizures, coma and death. CASE PRESENTATION: A 35 year old female, history of bipolar disorder and depression, presented to a small community hospital ED with confusion and lethargy. She was found to have an elevated creatinine in the setting of lithium toxicity. She was transferred to our facility for a higher level of care and on arrival was somnolent but hemodynamically stable. Initial laboratory studies were as shown below. CT of the brain showed no intracranial hemorrhage. Given the patient's altered level of consciousness, and renal failure in the setting of lithium toxicity, emergent dialysis was recommended by nephrology. During dialysis, the patient became markedly hypotensive and obtunded. She required intubation for airway protection and vasopressor support. MRI of the brain showed diffuse cortical edema and herniation of the cerebellar tonsils. Brain death was declared independently by an intensivist and a neurologist. DISCUSSION: Our patient required emergent dialysis given her severe altered mental status, and renal failure secondary to lithium toxicity. Unfortunately, she went on to develop DDS. DDS usually affects patients who are undergoing their first dialysis session. The exact incidence is unknown but it is thought to be very rare. The broad nature of the symptoms makes it difficult to identify DDS. Risk factors include extremes of age, severe uremia, hypernatremia, hyperglycemia, preexisting neurologic abnormalities, and first dialysis treatment. DDS remains a clinical diagnosis of exclusion. One must rule out stroke, subdural hematoma, intracerebral hemorrhage, infection, and toxic encephalopathy among others. The cornerstone of treatment is prevention. Prevention entails identifying high-risk patients and utilizing intermittent hemodialysis, or CRRT using slow urea removal. The exact mechanism is not well understood, and there are no guidelines on appropriate dialysis settings. If symptoms are mild, one can consider reducing the blood flow rate, but if patients display severe neurologic abnormalities, one should strongly consider stopping the dialysis session. CONCLUSIONS: DDS is a rare but potentially lethal clinical entity. Early recognition, prompt cardiopulmonary resuscitation, and cessation of the dialysis session are of paramount importance in managing patients with severe DDS.

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INTRODUCTION: Bronchobiliary fistula (BBF) is a rare occurrence of altered anatomy of the biliary duct system in which it connects to the lungs. Biliptysis is pathognomonic for this condition. Predisposing factors include malignancy, bile duct obstruction, trauma, and surgery. Our case highlights a patient who presented with several months of non-resolving right middle lobe (RML) pneumonia who was later found to have a BBF. CASE PRESENTATION:Our patient is a 43-year-old male with a history of colon cancer with liver metastasis on palliative chemotherapy who presented after multiple episodes of RML pneumonia. He had endoscopic retrograde cholangiopancreatography (ERCP) with stent placement for malignant biliary obstruction. Three months later, he had fever, cough, and scant yellow sputum with chest x-ray (CXR) findings of RML consolidation. He received appropriate antibiotics for community-acquired pneumonia. His symptoms recurred two weeks later. During that admission, the CT chest showed consolidation of the RML. Sputum culture grew Klebsiella pneumoniae and was treated appropriately. He had two more similar episodes. Bronchoscopy showed erythematous endobronchial mucosa in the RML with carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae on culture. Transbronchial lung biopsy was negative for malignancy. After seven months from the initial ERCP, he presented with copious bilious sputum and right pleuritic chest pain. Repeat CT chest showed persistent RML consolidation and 4 cm fluid collection along the hepatic capsule which grew CRE and Klebsiella pneumoniae. This raised suspicion for bronchobiliary fistula. A hepatobiliary iminodiacetic acid (HIDA) scan done did not demonstrate the presence of a fistula. Magnetic resonance cholangiography (MRC) was done which showed a small sinus tract that represented a BBF. He underwent right anterior sectionectomy of the liver with diaphragm repair and ERCP with replacement of biliary stent. DISCUSSION:The most common cause of acquired BBF is liver malignancy likely through obstruction which produces inflammation in the subdiaphragmatic space with subsequent rupture into the bronchial system. Patients can present with pneumonia, while it is rare, it is the most common comorbidity associated with BBF. Our patient presented with biliptysis and recurrent pneumonia with multidrug-resistant organisms. MRC and HIDA are preferred studies as they are non-invasive. Our patient's HIDA scan was not diagnostic but the MRC showed the BBF. Our patient underwent segmental hepatectomy and ERCP with stent replacement with subsequent symptom resolution.CONCLUSIONS: A high index of suspicion is required to diagnose BBF when the presentation is atypical such as in the case of recurrent RML pneumonia. Early diagnosis is important to prevent progressive antibiotic resistance. Non-invasive modalities like HIDA and MRC are preferred for making the diagnosis.

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