Asymptomatic, Incidental Quadricuspid Aortic Valve: A Case Report and Discussion of Management.

With its exceeding rarity, there is little research on the quadricuspid aortic valve (QAV) inherently to drive guideline-based management. This leaves physicians without evidence-based guidance on the management of such patients should they come across this finding on imaging or should they care for a symptomatic patient. This article describes the case of an incidentally identified QAV in a patient undergoing treatment for tuberculosis, which seemingly had bicuspid-appearing valve hemodynamics. Additionally, current literature is reviewed to describe classification, presentation, complications, and intervention, with additional exploration and commentary on the lack of guideline-based care.

The Rapid Growth of Burkitt Lymphoma Causing Partial Small Bowel Obstruction.

Burkitt lymphoma (BL) is a neoplasm of the lymphoid tissue and one of the most prevalent malignancies worldwide. Classically, these patients present with unregulated B-cell differentiation causing fever, chills, night sweats, and weight loss. Although more common in children, in sporadic Burkitt lymphoma, symptoms often can be present in the abdomen. These patients also additionally report nausea, vomiting, and abdominal distention, which in rare instances can cause small bowel obstruction (SBO). Early detection and the initiation of chemotherapy remain highly effective in providing adequate care. This provides better outcomes and prevents surgical management.

Fibrosing mediastinitis resulting in unilateral pulmonary artery hypertension.

Fibrosing mediastinitis (FM), a rare disorder that is further classified as excessive fibrous tissue that occurs within the mediastinum. Classically, presenting with manifestations dependent on where the fibrous tissue is located. In rare instances, compression of pulmonary vasculature can lead to Pulmonary Hypertension. Pulmonary Hypertension- Fibrosing Mediastinitis (PH-FM) represents a rare complication with minimal available data on incidence. In regards to all-cause mortality, no specific data regarding the prognosis of PH-FM exist. With the scarcity of data, this case aids in the advancement of literature due to unique unilateral obstruction and the need for further analysis on our current treatment.

Sarcoid-like reaction in malignant melanoma exacerbated with pembrolizumab therapy case report.

Sarcoid Like Reaction (SLR) is a localized non-caseating epithelioid granulomatous reaction seen secondary to certain immunotherapies and malignancies. Invasive melanoma, while being associated with onset of sarcoidosis, has not shown to directly induce SLR in the literature. We present the case of a 68-year-old male with malignant melanoma, who was found to have SLR prior to starting immunotherapy, which worsened while on pembrolizumab. This case highlights the challenge of distinguishing between drug-induced SLR and melanoma-induced SLR, and the implications in terms of management.

The Challenges of Diagnosing Tuberculous Meningitis and Importance of Early Intervention.

Background: Reported is a patient found to have miliary TB seeding the lungs and brain with CNS involvement resulting in tuberculous meningitis (TBM). False security in laboratory studies that lack adequate sensitivity resulted in delay of therapy which may have negatively impacted the patient's outcome. This case report aims to emphasize the importance of early initiation of therapy when clinical suspicion remains high despite initially negative diagnostic studies. Case presentation: 52 year old female originally from Guatemala presented headache, neck pain, vomiting and photophobia. CT of the chest showed numerous submillimeter sized bilateral lung nodules, with scattered calcifications. IGRA of the serum, sputum Acid Fast Bacillus (AFB) stain and culture and CSF AFB stain and culture were obtained and were all initially negative. Clinical suspicion for tuberculous meningitis remained high and RIPE therapy and methylprednisolone were started. CSF AFB culture was found positive for MTB. Despite therapy, patient continued to clinically decline with poor overall prognosis. Conclusion: Early diagnosis and initiation of therapy is paramount in improving outcomes in TBM. Unfortunately, the available diagnostic tests lack adequate sensitivity to confidently rule out disease. False negative results can delay therapy and worsen clinical outcomes. Early identification often relies on history, evaluation of risk factors, in conjunction with corresponding labs and imaging findings. If clinical suspicion is high, empiric therapy should be initiated early. Infectious disease consultation is often indicated to further assist with diagnosis and management.

Spontaneous Hemorrhage of Thoracic Cavernous Malformation Leading to Bilateral Lower Extremity Paralysis.

Cavernous malformations (CMs) are abnormal clusters of thin-walled blood vessels located in the central nervous system. An 87-year-old male with a history of heart failure with reduced ejection fraction, coronary artery disease, and atrial fibrillation on rivaroxaban was admitted for acute onset, bilateral lower extremity weakness. He was found to have hemorrhagic transformation of a pre-existing spinal cord cavernous malformation located at the level of T9 of the thoracic column worsened by his use of anticoagulation. Surgical resection remains the only definitive management. Patients at high risk for surgical intervention are managed with supportive care and physical therapy.

Symmetric Ascending Paralysis Secondary to West Nile Virus.

West Nile virus (WNV) is classified as a Flavivirus, belonging to a Japanese encephalitis subgroup often transmitted via mosquitoes. The classic presentation of a WNV infection usually displays high fevers, myalgias, and headache which can progress to neck stiffness, stupor, and coma (Case Rep Infect Dis. 2020;2020:6501658). Our case study presented with a rare manifestation of ascending paralysis, encompassing the feared neuroinvasive disease pattern that is seldom exhibited. This case had an unusual presentation as certain manifestations experienced by our patient closely resembled that of Guillain-Barré syndrome, although others were more indicative of poliomyelitis-like syndrome. Overall, the mainstay of therapy in both conditions is supportive care, although the prognosis varies substantially depending on the underlying diagnosis.

Concomitant Treatment of Tuberculosis and Hepatitis C Virus in Coinfected Patients Using Serum Drug Concentration Monitoring.

Background: Concern for drug-drug interactions leading to treatment failure and drug-resistant strains have discouraged clinicians from attempting concomitant treatment of hepatitis C virus (HCV) and tuberculosis (TB). Increased metabolism of direct-acting antivirals (DAAs) by rifamycins has hindered concurrent use. Development of an assay for ledipasvir and sofosbuvir (LDV/SOF) serum concentrations for therapeutic drug monitoring (TDM) can ensure adequate therapy. We present the first cases of concomitant therapy of active TB and HCV with rifamycin-containing regimens and DAAs using TDM. Methods: Using TDM, we aim to determine whether concomitant therapy with rifamycin-containing regimens and DAAs is safe and effective for patients coinfected with TB and HCV. Five individuals with TB and HCV who experienced transaminitis before or during TB therapy were concomitantly treated with rifamycin-containing regimens and LDV/SOF. Therapeutic drug monitoring was performed for LDV, SOF, and rifabutin during therapy. Baseline laboratory tests and serial liver enzymes were performed. Hepatitis C virus viral load and mycobacterial sputum cultures were obtained upon completion of therapy to determine efficacy of therapy. Results: All patients were found to have nondetectable HCV viral loads and negative mycobacterial sputum cultures upon completion of therapy. No clinically significant adverse effects were reported. Conclusions: These cases illustrate concomitant use of LDV/SOF and rifabutin in patients with HCV/TB coinfection. Utilizing serum drug concentration monitoring to guide dosing, correction of transaminitis were achieved, which allowed the use rifamycin-containing TB therapy. These findings suggest that concomitant therapy of TB/HCV is possible, safe, and effective.

Subdural hematoma expansion in relation to measured mean and peak systolic blood pressure: A retrospective analysis.

Objective: Subdural hematomas (SDH) account for an estimated 5 to 25% of intracranial hemorrhages. Acute SDH occur secondary to rupture of the bridging veins leading to blood collecting within the dural space. Risk factors associated with SDH expansion are well documented, however, there are no established guidelines regarding blood pressure goals in the management of acute SDH. This study aims to retrospectively evaluate if uncontrolled blood pressure within the first 24 h of hospitalization in patients with acute SDH is linked to hematoma expansion as determined by serial CT imaging. Methods: A single center, retrospective study looked at 1,083 patients with acute SDH, predominantly above age 65. Of these, 469 patients met the inclusion criteria. Blood pressure was measured during the first 24 h of admission along with PT, INR, platelets, blood alcohol level, anticoagulation use and antiplatelet use. Follow-up CT performed within the first 24 h was compared to the initial CT to determine the presence of hematoma expansion. Mean systolic blood pressure (SBP), peak SBP, discharge disposition, length of stay and in hospital mortality were evaluated. Results: We found that patients with mean SBP <140 in the first 24 h of admission had a lower rate of hematoma expansion than those with SBP > 140. Patients with peak SBP > 200 had an increased frequency of hematoma expansion with the largest effect seen in patients with SBP > 220. Other risk factors did not contribute to hematoma expansion. Conclusions: These results suggest that blood pressure is an important factor to consider when treating patients with SDH with medical management. Blood pressure management should be considered in addition to serial neurological exams, repeat radiological imaging, seizure prophylaxis and reversal of anticoagulation.