The SARS-CoV-2 pandemic has grown into a major global concern with huge efforts to combat the spread. Exaggerated inflammatory response plays a major role in which was the rationale to use corticosteroids to treat patients. However, multiple studies showed an association between opportunistic and bacterial infections with corticosteroid therapy. We report a case of a 76 year old patient diagnosed with COVID-19 treated with 10 days Dexamethasone and Remdesivir who presented with abdominal symptoms with eosinophilia. Biopsy and stool studies revealed Strongyloides stercoralis larvae. The patient was treated with 2 doses of Ivermectin with significant clinical resolution. Clinician should have high clinical suspicion for Strongloydiasis in patients who have lived or visited endemic areas and for patients with unexplained eosinophilia. Prompt treatment with Ivermectin is crucial for confirmed cases and high risk cases where obtaining a diagnosis is unfeasible.
Antihistamine usage is commonplace for alleviating allergy symptoms, though they are not without side-effects. We present a case of antihistamine use precipitating upper and lower extremity ballismus in a patient. We also discuss other case reports which outline similar dopaminergic dysregulation secondary to antihistamine usage, as well as our recommendations for prevention of these symptoms.
We describe a case of infectious spondylodiscitis of the lumbar spine complicated by epidural and bilateral psoas abscesses which started with subtle symptoms and a non-specific clinical picture. Diagnosis is based on clinical, laboratory and radiological features. It can be difficult and often delayed due to the rarity of the disease and the high frequency of low back pain in the general population. Our aim is to raise awareness for the possibility of specific low back pain which requires quick and indispensable action from the physician.
The surgical resection timing of left atrial (LA) myxoma is still controversial in concern for the risk of further embolic phenomena if delayed surgery versus hemorrhagic transformation during early surgery. We describe a case of 60-year-old man without significant past medical history admitted with two-day of double vision and found to have LA myxoma. Multiple factors including clinical aspects and comorbidities should be evaluated to decide the favorable management.
A 29-year-old woman with known sickle cell disease (SCD) and iatrogenic iron overload presented to the emergency department with a recurrent pain crisis and fever. Blood cultures obtained at a recent prior admission for the same complaints grew M avium. Bone marrow biopsy revealed non-caseating granulomas, but stains for mycobacteria and fungi were negative. Disseminated non-tuberculous mycobacterial infections (NTMIs) occur almost exclusively in immunosuppressed patients. SCD is not considered a risk factor for the development of disseminated NTMIs, making diagnosis challenging in this population. However, a number of case reports describing disseminated NTMIs in patients with SCD have been published. This case adds to the current literature, suggesting SCD with iatrogenic iron overload is a possible risk factor for disseminated NTMIs. Potential mechanisms for this increased risk include 1) functional asplenia, 2) iatrogenic iron overload, 3) chronic indwelling central venous catheters, and 4) hydroxyurea use. Further investigation is required to describe the strength and mechanism of the relationship between SCD and disseminated NTMIs.
Treatments for COVID-19 infection have varied widely within the past year. Remdesivir is the only direct-acting antiviral approved by the Food and Drug Administration with demonstrated efficacy in the management of patients with COVID-19.[1] Commonly reported adverse effects include hepatotoxicity and gastrointestinal symptoms such as nausea and diarrhea. Less common adverse effects include respiratory toxicity, cardiovascular toxicity and nephrotoxicity.[2] We report a case of international normalized ratio (INR) prolongation in a COVID-19 patient receiving concomitant warfarin and remdesivir therapy.
Hyperoeosinophilic syndrome (HES) is rare, and clinicians may not recognize its potential association with malignancy. Red flag signs of HES include steroid resistance, older age, and significant lymphadenopathy that can be indicative of malignancy. In this case, an elderly male presenting with right chest wall erythema and axillary lymphadenopathy was initially diagnosed with and treated for cellulitis. Labs were significant for hypereosinophilia. Evidence of end organ damage raised concern for HES. Over the course of three hospitalizations, he was found to have a rising eosinophil count despite high-dose corticosteroid treatment. Further investigation eventually revealed a diagnosis of Hodgkin’s Lymphoma. This case highlights steroid-resistant HES as a presenting sign of malignancy and allows for discussion of potential investigative approaches for HES therapy. Though corticosteroids are first-line treatment for hypereosinophilia and HES, they are well known to have many adverse effects. Biologics, such as mepolizumab and benralizumab, have more acceptable side effect profiles and are effective in treating non-myeloid HES. The use of biologics as first-line treatment for HES has yet to be investigated.
Adenosquamous carcinoma (ASC) of the esophagus is a rare malignancy of the esophagus with histopathologic features of both adenocarcinoma and squamous cell carcinoma. Given the rarity of this disease, there is scant literature on ASC. We report a unique case of a 29-year-old African American female with advanced ASC manifesting as a pathologic fracture. Magnetic resonance imaging (MRI) confirmed femoral fracture, and femoral biopsy demonstrated metastatic ASC. Upper endoscopy revealed a distal esophageal stricture, and histopathology confirmed ASC. To our knowledge this is the youngest case of ASC to be reported. We discuss ASC epidemiology, clinical findings, diagnosis, and current treatments.
Cardiovascular manifestations of COVID-19 infection remain an ongoing study. We present a case of significant bradycardia in the patient with COVID-19 sepsis. We discuss about the possible mechanism, pathophysiology, and management in this pathology.
Hepatosplenic T cell lymphoma (HSTCL) is an exceedingly uncommon, aggressive peripheral T cell lymphoma comprising < 1% non-Hodgkin’s lymphomas (NHL). Despite treatments including allogeneic stem cell transplantation, median survival is < 2 years. In the majority of patients, the etiology of HSTCL is undetermined; although it has been associated with chronic immunosuppression which accounts for 20% of cases. HSTCL presents as a systemic illness, and sometimes in association with hemophagocytic lymphohistiocytosis syndrome (HLH). Our patient is a young male with a long-standing history of Crohn’s disease on immunosuppressive medications, who presented with progressive bicytopenia. He was diagnosed with HSTCL on a bone marrow biopsy and met clinical diagnostic criteria for HLH. He was started on chemotherapy and dexamethasone per HLH treatment protocol and underwent allogeneic hematopoietic stem cell transplantation (HSCT).
Objective: To report a case of leukocytosis (LCT) and hyperleukocytosis (HLCT) episodes post Pegfilgrastim (Neulasta) administration.Case Summary: A 74-year-old female presented with several episodes of LCT and HLCT following administration of Pegfilgrastim while undergoing adjunct dose dependent chemotherapy for adenocarcinoma of the gallbladder. The patient had completed cycle 6, day 8 of chemotherapy and subsequently received Neulasta 48 hours later. Two days later, she presented to the ER with white blood cell (WBC) count of 110K. Prior to Neulasta administration, her WBC counts were within normal range and after each episode of leukocytosis, the patient’s WBC count trended downward. Upon consultation, hematology considered Pegfilgrastim as a likely cause for this patient’s WBC cycling and HLCT.Discussion: Pegfilgrastim-induced HLCT occurs in less than 1% of patient cases. Dose-dependent chemotherapy combined with Pegfilgrastim treatment is an optimal treatment option to reduce the length of chemotherapy schedules and risk of febrile neutropenia. Following the dosing of Pegfilgrastim, the drug clearance is mediated by neutrophil receptors which results in a reduction of ANC values.Conclusions: Further studies are needed to determine the optimum timing and dosage of Pegfilgrastim to offer maximum myeloprotective benefit while also minimizing the risks of adverse events such as leukocytosis and hyperleukocytosis experienced by our patient.
An occlusion of the artery of Percheron (AOP) is a rare clinical condition that remains a diagnostic challenge for physicians given its variable presentation. This infarction is a result of an anatomical variant of a single vessel arising from the posterior cerebral artery. Occlusion of the AOP results in variable levels of alteration of consciousness, vertical gaze palsy, and memory impairment. Unfortunately, due to this variable presentation these strokes are often missed. We report a case of a 71 year-old-female who presented with sudden onset of unresponsiveness who was subsequently diagnosed with bilateral thalamic infarction with midbrain involvement secondary to AOP occlusion. Delayed diagnosis can result in poor neurologic outcomes as demonstrated in this case making it imperative to bring further awareness to this clinical syndrome.
A 67-year-old patient visited the hospital for the evaluation of pulmonary nodular lesions detected in his chest radiograph duringan annual screening. He was asymptomatic and transbronchial tumor biopsy of the nodule in the right upper lobe revealed features of pulmonary sarcoma, which did not resemble any of the histolopathological categories of primary lung cancer. A positive immunological staining for both HMB-45 and Melan-A resulted in the final diagnosis of melanoma. It is important for a respiratory clinician to remind the possibility of a melanoma, when tumors cannot be histopathologically classified under any of the categories of primary lung cancer.
Amiodarone is one of the most frequently used antiarrhythmic drugs on the market, treating both life-threatening ventricular arrhythmias as well as supraventricular tachyarrhythmias. Some of its most commonly known side effects include corneal deposits, cardiac toxicity, pneumonitis, thyroid hormone fluctuation, and dermatological reactions. Despite the frequency of occurrence of neurological complications secondary to Amiodarone they remain to be under-recognized by healthcare professionals. This casereport aims to increase awareness of the neurological complications of Amiodarone.
Capnocytophaga canimorsus is a commensal in the normal gingival flora of canine and feline species and is reported to cause infections in humans following bites by these species with potentially serious consequences, especially in the immunocompromised. Here we report a case of a 58-year-old healthy woman presenting with uncomplicated meningitis following a seemingly minor bite by her pet dog. With early detection and appropriate antibiotic therapy she had an uneventful recovery. Our case reports the possibility of this organism infecting an otherwise healthy, immunocompetent adult and the importance of being vigilant of such rare presentations by clinicians which will help to deliver appropriate therapy early to avoid any serious complications.
External compression of the celiac artery by the median arcuate ligament is referred to as Dunbar syndrome, which is an eponym for celiac axis syndrome or median arcuate ligament syndrome. It is correlated with the archetypal triad of postprandial abdominal pain, weight loss of greater than 20 pounds, and an abdominal bruit on auscultation. This is often accompanied by epigastric tenderness, vomiting, and nausea. Given its lack of symptomatic specificity, Dunbar syndrome is a diagnosis of exclusion for unexplained episodic abdominal discomfort. Here, we present a unique case of a 24-year-old woman who experienced several months of chronic abdominal distress and an extensive workup prior to being diagnosed with Dunbar syndrome. The diagnosis was made via cross-sectional abdominal imaging and duplex ultrasound with respiratory maneuvers, which showed downward displacement of the celiac trunk, post-stenotic dilatation, and increased flow velocity on expiration. She underwent successful laparoscopic division of the median arcuate ligament which greatly alleviated her pain.
Cryptococcosis is an opportunistic fungal infection responsible for high morbidity and mortality in patients in immunosuppressive clinical conditions. The sites most affected by the hematogenous spread after the lungs are the central nervous system and the skin. The early diagnostic associated with a standard fungal therapy is important for decrease the clinical sequelae derived. We describe an unusual situation of disseminated cryptococcosis without pulmonary involvement in a patient with newly diagnosed human immunodeficiency syndrome with cutaneous lesions as initial markers of severity and precursory of cryptococcal meningitis. In this case, the authors describe a systemic approach to how an initial skin lesion is key to reach the diagnosis and perform an early treatment avoiding irreversible sequelae.
Amlodipine is a calcium channel blocker that is well known to be vasoselective, thereby having minimal effects in cardiac tissue. However, recent literature have reported cases of symptomatic bradycardia associated with amlodipine use. We present a case of an otherwise healthy 71-year-old male who was found to have symptomatic bradycardia while taking amlodipine. He underwent comprehensive evaluation including an exercise stress echocardiogram during which he demonstrated chronotropic competence. Amlodipine was discontinued with return of his heart rate to baseline levels after 24 hours. There is a very low reported incidence of amlodipine-induced bradycardia (0.89% of cases). Despite its infrequency, it is important to recognize amlodipine-induced bradycardia as simply discontinuing the drug will lead to complete resolution of symptoms. Failure to recognize this side effect may lead to unnecessary healthcare costs and negatively impact patient outcomes.
Primary sclerosing cholangitis (PSC) is a rare autoimmune disorder of the biliary system. PSC is fulminant in its course and leads to jaundice and biliary cirrhosis with specific radiological findings of the beading of larger ducts and pruning of smaller ducts. Though cholangiogram is the gold standard for PSC diagnosis, it may be inconclusive in patients with an early disease or small duct PSC or overlap with autoimmune hepatitis. These conditions may require a liver biopsy for confirmation of the underlying pathology. In this case report, we discuss one of these rare instances when a 24-year-old male was admitted with jaundice. During hospitalization, extensive workup, including cholangiograms, remained inconclusive, but based on a high suspicion of PSC, the patient underwent a liver biopsy, which confirmed our diagnoses
Introduction: Eosinophilic Gastritis (EG), one of the less common amongst Eosinophilic Gastrointestinal Disorders (EGID), with a prevalence of 6.3 cases/100,000, is an uncommon cause of unspecific abdominal symptoms, including epigastric pain. Case: A 23-year-old female, was admitted with recurrent episodes of nausea, vomiting, abdominal pain and weight loss. She was discharged one week previously after being treated for similar symptoms. The patient had failed an outpatient treatment with a Proton Pump Inhibitor (PPI). During her re-admission, Esophagogastroduodenoscopy (EGD) was performed, and results were significant for gastritis without ulcers or esophagitis. While awaiting biopsy results, the patient experienced a minimal improvement in her symptoms with intravenous fluids and PPI. Extensive workup remained negative except of eosinophilia in peripheral blood. Gastric mucosal biopsy revealed eosinophilic infiltrates in Lamina Propria, confirming the diagnosis of Eosinophilic Gastritis. Helicobacter pylori on immunohistochemistry was negative. The patient was counseled regarding the Six Food Elimination Diet for the management of this condition. Her symptoms began to improve under dietary restrictions. Repeated EGD with biopsy at 12 weeks showed resolved eosinophilic infiltrates. Discussion: EG remains a rare diagnosis, and it should be included as a differential diagnosis in every patient with refractory symptoms of nausea, vomiting, abdominal pain, and failure to thrive. Diagnosis of EGID is established after the exclusion of other causes of eosinophilia in the gastrointestinal tract.
