Addison's disease presents a unique challenge when it occurs during pregnancy due to its potential for maternal and fetal complications if left untreated. This review synthesizes present information about the pathophysiology and clinical aspects of Addison's disease during pregnancy using information from case reports. Pregnancy-induced physiological changes can complicate the diagnosis of adrenal insufficiency as clinical symptoms of the disease overlap with typical pregnancy symptoms; a high index of suspicion is therefore necessary. Diagnostic tests include short synacthen tests and measurement of serum electrolytes, adrenocorticotropic hormone levels, and cortisol levels. Adequate hormone supplementation is crucial for ensuring maternal and fetal well-being. Pregnancy and Addison's disease can have favorable outcomes with proper management, highlighting the importance of early diagnosis and treatment.
Duplication cysts are rare congenital cystic lesions that form along the gastrointestinal tract at various locations. They may be asymptomatic, present with ambiguous symptoms, or mimic other clinical presentations, such as acute appendicitis. We present a unique case of an 11- year-old boy with a preliminary diagnosis of acute perforated appendicitis and abdominal abscess; however, the patient’s appendix was unremarkable during surgery, and he was later found to have an intraluminal duplication cyst within the distal ilium extending into the ileocecal valve. Follow-up imaging with abdominal ultrasound helped guide the diagnosis, and an ileocecal resection proved to be curative. Keywords: Enteric duplication cyst, intraluminal duplication cyst, appendicitis, ultrasound, case report
Coccidioidomycosis is a fungal infection caused by the inhalation of Coccidioides immitis and Coccidioides posadasii spores. After inhalation, the infection can spread hematogenously or through lymphatics to any organ, so the clinical presentation of coccidioidomycosis can vary greatly. A 38-year-old man with obesity was referred to an infectious disease clinic due to a cutaneous coccidioidomycosis infection of his face. The patient initially presented to his primary care physician with symptoms of fatigue, knee pain, and a facial rash that had persisted for a couple of months. Initial treatment involved a course of oral antibiotics, yielding no improvement. Subsequently, the patient sought evaluation at a dermatologist's office for multiple lesions on his face and scalp. Another round of oral antibiotics and topical mupirocin ointment was prescribed. The lesions were biopsied, and a culture tested positive for Coccidioides immitis. He was then referred to infectious disease for management. The physical examination revealed a scaling, erythematous rash located on the right cheek, forehead, and scalp. Vital signs were normal. A chest computed tomography was positive for multiple pulmonary nodules consistent with a history of coccidioidomycosis infection. Laboratory results revealed a cocci IgM titer of 1.2, IgG titer of 8.8, and an antibody by complement fixation titer of 1:128. The patient was started on oral fluconazole 200 mg daily, which was later increased to 400 mg twice daily. The patient began to show improvement in his skin lesions. We report an unusual presentation of cutaneous coccidioidomycosis as a facial rash. Clinicians, especially in endemic areas, should be aware of the differing presentations of Coccidioides infections. Keywords: cutaneous coccidioidomycosis; Coccidioides immitis, fluconazole
A man in his early 40’s with Klippel-Trenaunay-Weber syndrome (KTWS) was referred to the surgical team for treatment of massive upper gastrointestinal bleeding. This syndrome is a rare congenital condition that leads to abnormal development of blood vessels, bones, and soft tissues. Although venous malformations are common in KTWS, gastrointestinal involvement is rare but can cause life-threatening bleeding. In this case, a series of diagnostic tests, including endoscopic and angiographic examinations, failed to identify the etiology of the bleeding. Surgical intervention was required after conservative and interventional radiologic therapies proved unsuccessful. A Dieulafoy’s lesion was identified in the proximal stomach and later confirmed histologically. The patient required a multidisciplinary care involving gastroenterology, interventional radiology, and general surgery for successful management. The pathogenesis of Dieulafoy’s lesion is not well understood, and interventions vary from endoscopic to surgical management. The treatment of Dieulafoy’s lesion is not well- described in patients with KTWS, especially in cases in which endoscopic treatments have failed. Keywords: Klippel-Trenaunay Syndrome; Dieulafoy’s lesion; gastrointestinal bleeding; radiology, interventional; endoscopy; surgical treatment
The management of patients with congestive heart failure requires an accurate working diagnosis and frequent assessment of responses to treatment. In addition, the prediction of short-term and long-term outcomes is important to both the clinician and the patient. The development of pulmonary edema usually represents an acute deterioration of cardiac status and requires immediate attention. The development of peripheral edema usually represents chronic heart failure and warrants evaluation and possibly therapeutic adjustments. Noninvasive tests to identify sites of extravascular fluid formation can help the clinician manage his or her patients. Lung ultrasound can identify B-lines that usually represent pulmonary edema. Ultrasound studies of the inferior vena cava and its dimensions can help determine volume status and make decisions regarding fluid management. This review outlines the use of ultrasound to determine sites of edema formation in patients with heart failure. Key words: ultrasound, inferior vena cava, pulmonary edema, congestive heart failure
Coarctation of the aorta (CoA) is a congenital condition causing narrowing of the aorta, typically just after the left subclavian artery. Most patients with CoA are diagnosed at birth or during infancy. However, they can also be undiagnosed later in adulthood with minimal symptoms to show or treatment-resistant hypertension. However, some patients may also present with life-threatening medical emergencies that may lead to an undiagnosed CoA. This case is a 40-year-old man with hypertension who presented with a late diagnosis of CoA on computed tomography imaging six months after ascending aorta dissection repair. The patient's CoA was repaired via an endovascular approach with stent placement and post-dilatory balloon angioplasty. His CoA segmental blood pressure gradient was 25 mmHg and decreased to 3 mmHg post-procedure. The patient has done well post-procedure, and his blood pressure had been within normal limits. Key words: Aortic coarctation, aortic dissection, hypertension, congenital heart defect
Chest infections and ischemic heart disease are the most common causes of shortness of breath and cyanosis in old age. However, the hemoglobinopathies should be considered if the cardiac cause is ruled out, cyanosis that is not responding to oxygen therapy and antibiotic treatment. A 75-year-old retired soldier was admitted to the inpatient department of a tertiary care hospital with symptoms of cyanosis, shortness of breath and fever. Cyanosis was acrocyanosis in nature and not relieved on oxygen therapy. An initial diagnosis of Lower respiratory tract infection was initiated. However, the cyanosis showed no signs of improvement. Alternate diagnosis was considered, and the patient was started on treatment of ischemic heart disease that included nitrates which further led to worsening of his condition. Blood methemoglobin levels were raised which established the diagnosis of methemoglobinemia. The fast-moving dark brown color band of Hb M on gel electrophoresis confirmed the diagnosis of Hb M. The patient was started on IV ascorbic acid with the patient showing clinical improvement within 36 hours. The patients presenting with unexplained acrocyanosis should not be treated with oxidizing agents like nitrates, irrespective of age and management of another disease, unless the cause of cyanosis has been established.
Addison's disease presents a unique challenge when it occurs during pregnancy due to its potential for maternal and fetal complications if left untreated. This review synthesizes present information about the pathophysiology and clinical aspects of Addison's disease during pregnancy using information from case reports. Pregnancy-induced physiological changes can complicate the diagnosis of adrenal insufficiency as clinical symptoms of the disease overlap with typical pregnancy symptoms; a high index of suspicion is therefore necessary. Diagnostic tests include short synacthen tests and measurement of serum electrolytes, adrenocorticotropic hormone levels, and cortisol levels. Adequate hormone supplementation is crucial for ensuring maternal and fetal well-being. Pregnancy and Addison's disease can have favorable outcomes with proper management, highlighting the importance of early diagnosis and treatment.
Background and Objectives: As part of enhanced recovery after surgery protocols, there has been an increased interest in improving analgesic techniques. This study compares the efficacy of liposomal bupivacaine transverse abdominis plane blocks on outcomes in colorectal surgery patients. Methods: This retrospective study compared patients who had minimally invasive colorectal surgery and perioperative liposomal bupivacaine blocks with patients who did not receive this block on post-operative outcomes, including lengths of stay, opioid consumption, and postoperative pain scores. Results: The mean length of stay in the control group was 4.79 days; in the liposomal bupivacaine group, it was 4.14 days (p = 0.011). There were no differences in opioid use, acetaminophen use, or pain scores in these 2 cohorts. There was a decrease in NSAID use in the liposomal bupivacaine group.Conclusion: This study shows that liposomal bupivacaine blocks can improve some post-operative outcomes in minimally invasive colorectal surgery patients, especially by decreasing length of stay and possibly by decreasing use of other analgesics. Keywords: Minimally invasive surgical procedures; analgesics, nerve block; post-operative pain management; bupivacaine
Herpes zoster dermatitis is a vesicular eruption occurring in a dermatomal distribution secondary to the reactivation of varicella zoster virus. Prodromal symptoms of paresthesia, hyperesthesia, and pruritus normally occur in the regions where the vesicular eruptions develop, typically preceding the cutaneous eruptions. However, this reactivation can present atypically with few to no cutaneous lesions, referred to as zoster sine herpete.This case report describes a middle aged, immunocompetent man with zoster sine herpete, who initially presented with a four-day history of severe migratory prodromal pain and hyperesthesia situated in dermatomal distributions. Physical exam revealed two groups of 2–4 mm erythematous papules of the skin on the left posterior neck and left flank. However, the patient’s sensory symptoms did not align with the dermatomes of his asymptomatic non-vesicular skin lesions.Herpes zoster dermatitis may present atypically, with prodromal neuralgia occurring in differing dermatomes from where cutaneous findings occur, if any eruption occurs at all. In such cases, it is important to rely on the patient’s history, timeline, and description of symptoms in conjunction with a thorough skin examination to diagnose zoster sine herpete. In addition, if no skin findings are present, serologic testing can be used to make the diagnosis.Keywords: Herpes zoster, zoster sine herpete, varicella zoster virus, herpetic neuralgia
Background: Coronavirus disease 2019 (COVID-19) is most frequently associated with a mild presentation of fever, cough, and shortness of breath. Typical radiographic findings in severe COVID-19 infection are bilateral ground-glass opacities on computed tomography (CT) scans. Bilateral pneumothorax is a rare complication of COVID-19. Among observational studies, the incidence of pneumothorax is low at 0.3% in hospitalized COVID-19 patients. However, the incidence of pneumothorax increases to 12.8-23.8% in patients requiring invasive mechanical ventilation. Case: This case report describes a previously healthy 52-year-old man who had recurrent pneumothoraces. He had five separate episodes of bilateral pneumothoraces during a two-month infection with SARS-CoV-2 during which he required mechanical ventilation. Chest x-rays revealed pneumothoraces, and bilateral chest tubes were inserted into the intrathoracic space for drainage five times. This case highlights the potential atypical clinical course in a COVID-19 infection and is the first reported case, to our knowledge, that features five bilateral spontaneous recurring pneumothoraces. Conclusion: COVID-19-related pneumothorax is likely a sequela of COVID-19 disease progression due to the inflammatory insult from COVID-19 infection and the increased respiratory effort needed to maintain gas exchange. COVID-19- related pneumothoraces are associated with mechanical ventilation and resolved in prolonged hospitalization. The treatment of COVID-19 and its long-term consequences represents a relatively new challenge for clinicians and health care providers. A multidisciplinary approach during the posthospitalization management of COVID-19 survivors is strongly advised. Keywords: SARS-CoV-2 infection, COVID-19 lung complications, pneumothorax
Patients on long-term immunosuppression, including corticosteroids or immunomodulatory drugs, are susceptible to opportunistic infections, such as like Pneumocystis jirovecii pneumonia (PJP). Corticosteroid use can increase the frequency of fungal infection, mask symptoms, and delay the diagnosis, and thus warrant preventive measures. Maintaining a high index of suspicion is important, and prophylactic antibiotics, particularly trimethoprim-sulfamethoxazole, should be considered for high-risk patients. This case underscores the diagnosis of PJP in a patient with interstitial lung disease receiving prolonged steroid therapy, despite lacking HIV and conventional risk factors for this infection. Notably, PJP can present as a more severe infection in non-HIV patients, leading to higher mortality rates and stressing the need for swift and effective diagnosis and treatment by healthcare providers. Keywords: Pneumocystis jirovecii; pneumonia; chronic corticosteroid treatment use; fungal pneumonia; interstitial lung disease
Drug-induced thrombocytopenia is a challenging clinical dilemma that is often overlooked. Nafcillin is a beta-lactam anti-staphylococcal penicillin antibiotic used as a first-line treatment for methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia and severe infections. Nafcillin has been associated with a higher rate of premature antibiotic discontinuation than cefazolin. Here we report a 58-year-old woman with multiple comorbid conditions who presented with a prosthetic right hip joint infection due to MSSA and was treated with nafcillin but developed profound thrombocytopenia due to a possible nafcillin side effect on the 14th day of therapy. Thrombocytopenia resolved after discontinuation of nafcillin, and the patient was treated successfully with cefazolin. Keywords: Nafcillin-induced thrombocytopenia, drug-induced thrombocytopenia, thrombocytopenia
Abstract Patients with prior COVID-19 infection can have residual symptoms and significant disability. In particular, some patients have abnormal lung function with reduced volumes and diffusion capacities. However, some patients have relatively normal lung function and chest x-rays but have significant dyspnea. These patients have been evaluated using cardiopulmonary exercise testing (CPET) to determine their peak O2 consumption and their cardiac and respiratory responses during standardized testing. In general, these studies demonstrate that the level of impairment correlates with the severity of the initial infection. In addition, some patients have little or no improvement in their VO2 over time. This test can provide some insight as to exact system limitations resulting in impairment. Six-minute walk tests provide alternative approaches for evaluating patients when CPET testing is not available. Most patients who have had prior COVID infection improve with standard pulmonary rehabilitation. Keywords: COVID-19 infection, dyspnea, cardiopulmonary exercise testing, rehabilitation
Diabetes is a chronic, metabolic disease characterized by hyperglycemia which eventually can cause serious organ damage. The prevalence of diabetes has steadily increased over the past few decades, and approximately 1.4 million Americans are diagnosed with diabetes every year. Diabetes was the seventh leading cause of death in the United States in 2019. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. It occurs more frequently in the patients with type 1 diabetes but can also develop in people with type 2 diabetes. It was determined that the average cost per DKA episode was $6,444, and that the annual cost of medical treatment in a diabetic patient with a prior episode of DKA was 2.67 times higher than a diabetic patient with no history of DKA. The criteria for DKA resolution at University Medical Center (UMC) in Lubbock, Texas, are different from current American Diabetes Association (ADA) guidelines. At UMC, a plasma bicarbonate ≥18 mEq/L, a venous pH > 7.3, and anion gap ≤12 mEq/L must be recorded twice (4 hours apart) before bridging to subcutaneous long-acting insulin administration. This time requirement could contribute to a longer time for DKA resolution and longer intensive care unit and hospital stays.Keywords: Diabetic ketoacidosis, DKA resolution
CaseA 53-year-old woman with hypertension and COPD arrived at the emergency department (ED) by EMS after she had developed respiratory distress.She was intubated in route to the hospital and deteriorated into asystole requiring CPR for 20 minutes.Return of spontaneous circulation was achieved in the ED, and the patient was admitted to the medical intensive care unit (MICU) for further management.There was a purpuric discoloration on the patient's right upper arm, extending proximally from the fingers to the dorsum of the right forearm (Figure 1); pulses were palpable.The patient was afebrile, hemodynamically stable, and on mechanical ventilation.Labs revealed a WBC of 29 K/µL, sodium 149 mmol/L, Cr 2.8 mg/dL, elevated liver enzymes, and creatinine kinase 3000 U/L.Lactic acid was 8.8 mmol/L;
