Spinal Solitary Plasmacytoma With Minimal Marrow Involvement Presenting With Epidural Spinal Cord Compression.

Solitary plasmacytoma (SPC) is a rare type of plasma cell dyscrasia characterized by the proliferation of neoplastic monoclonal plasma cells. It can involve bone or soft tissue without signs of systemic disease. The solitary bone plasmacytoma typically involves the axial skeleton, most commonly the vertebrae. This article presents a 58-year-old male with a history of Parkinson's disease, hypertension, and cervical spine degenerative joint disease. He arrived at the emergency department with severe thoracic and lumbar back pain, accompanied by numbness and weakness in both legs, which worsened with movement and deep breathing. Magnetic resonance imaging (MRI) findings revealed a sizable mass in the T11 vertebra, leading to thoracic spinal cord compression. Treatment included high-dose dexamethasone, and surgical intervention was undertaken. Subsequent pathology confirmed plasma cell dyscrasia. Radiotherapy and chemotherapy (lenalidomide and dexamethasone) were administered, resulting in no recurrence or new masses after two years. Solitary plasmacytoma is a rare disease with limited clinical trials due to the inability to accrue larger cohorts. Prompt diagnosis and staging of plasmacytomas, involving robust histopathological and radiographic methods, are needed to prevent further complications and possible progression to multiple myeloma. Radiation therapy is the primary treatment, with some studies showing the benefits of lenalidomide and dexamethasone. Further studies are needed to improve treatment options for these patients. This case report adds to the current literature the importance of a multidisciplinary approach to the treatment of SPC.

Incidental Finding of Riedel's Lobe of the Liver and Intrahepatic Cholangiocarcinoma.

Riedel's lobe is a rare anatomical variant of the liver morphology with a downward tongue-like projection of the anterior edge of the right lobe. It is usually detected incidentally with abdominal imaging performed for other indications. We present a case where we found Riedel's lobe incidentally, with invasive adenocarcinoma arising from close proximity. A 64-year-old female came in with encephalopathy and was found to have a distended abdomen with tenderness. Imaging revealed a complex lobular mass in the right hepatic lobe with an elongated extension of the right lobe inferiorly consistent with Riedel's lobe. The differential considered was malignancy versus abscess. CT-guided biopsy revealed invasive adenocarcinoma consistent with intrahepatic cholangiocarcinoma, which was further supported by the presence of portocaval lymph nodes. Various studies have tried to establish an association between Riedel's lobe and the occurrence of cancer arising from the surrounding structures, primarily from liver or metastasis. This case report adds to the current literature when such an association is being studied.

Management of Wolff-Parkinson-White Syndrome in a Patient with Post-partum Cardiomyopathy.

Wolf-Parkinson-White (WPW) syndrome is a congenital heart condition in which the atrioventricular (AV) node is bypassed by an accessory pathway that connects the atria and ventricle directly. WPW syndrome in patients with a history of peripartum cardiomyopathy (pregnancy-related cardiomyopathy) is associated with a high risk of morbidity and mortality secondary to failure of the pump and the conduction system of the heart. Management of these cases deals with arrhythmia and systolic heart failure, which becomes more challenging in pregnant patients as it requires treatment methods that minimize risks to the fetus. We report a case of a young female patient with WPW syndrome and postpartum cardiomyopathy presenting with symptomatic arrhythmias (tachycardia).

Multiple Myeloma with CNS Involvement in the Form of Leptomeningeal Carcinomatosis Presenting as Vitamin B12 Deficiency.

A 75-year-old male presented with lower back pain, bilateral lower extremity weakness, decreased sensation to vibration and proprioception in lower extremities, anemia, and vitamin B12 deficiency. The MRI of the lumbar spine revealed extensive leptomeningeal carcinomatosis. Subsequently, the patient was diagnosed with multiple myeloma (MM) and B12 deficiency with negative intrinsic factor antibodies. MM can present as extramedullary hematopoiesis (EM) to involve the central nervous system (CNS). CNS involvement is rare and develops in only around 1% of MM patients. It carries a poor prognosis with less than 6 months survival. MM is thought to be associated with both B12 deficiency and pernicious anemia. Some studies have even suggested B12 deficiency as a possible marker for worsening disease and a prognostic factor. In our patient's case, he had extensive CNS involvement at diagnosis of MM with very low B12 levels. The extent of his disease with extensive CNS involvement, which carries a poor prognosis, could possibly explain the very low levels of B12. This is the first reported case of a patient presenting with B12 deficiency found to have MM with leptomeningeal carcinomatosis at diagnosis. To the author's knowledge, there is no literature investigating association between B12 deficiency at the time of diagnosis of MM with CNS complications. Furthermore, there are no established guidelines on treatment for leptomeningeal myelomatosis. We present this case with the effort to learn more about this disease in terms of response and overall survival.

Where is the Thrombus ? Mural Ascending Aortic Thrombus with Embolic Events in a Patient with Recent COVID 19 Infection.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has triggered a global health pandemic that led to substantial morbidity and mortality worldwide. The virus has been known to predominantly cause severe hypoxemic respiratory failure but there have been multiple reports of extra-pulmonary manifestations. Additionally, there has been increasing evidence of COVID-19 hyper-coagulability. Herein, we present a case of a 49-year-old male with a past medical history of diet controlled type II diabetes mellitus and recently diagnosed COVID-19 who presented to the emergency department with a chief complaint of nausea and vomiting. Our patient was found to have a thrombus-like appearing 1.9 cm × 1.2 cm well-circumscribed mass, attached to the greater curvature of the ascending aorta, superior to the right coronary cusp of the aortic valve almost three weeks after his initial diagnosis of COVID-19 virus.

Fever and Hyponatremia Unmasking Brugada Pattern Electrocardiogram in a Patient With SARS-CoV-2 Infection.

Brugada syndrome is an autosomal dominant genetic disorder that primarily affects myocardial sodium channels and has been associated with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. Here, we report a case of a 58-year-old Hispanic male with a history significant for prior pulmonary tuberculosis infection who presented with pleuritic left-sided chest pain associated with body aches, productive cough, fevers, and chills and was found to be positive for SARS-CoV-2 by real-time reverse-transcription-polymerase chain reaction (rRT-PCR). Electrocardiogram (ECG, EKG) on presentation demonstrated a coved ST-segment elevation in V1-V2, suggesting Brugada pattern type 1 without evidence of ischemic changes. EKG changes normalized once fever and hyponatremia improved.

Management of Wolff-Parkinson-White syndrome in a patient with peripartum cardiomyopathy.

Wolf-Parkinson-White (WPW) syndrome is a congenital heart condition in which the atrioventricular (AV) node is bypassed by an accessory pathway that connects the atria and ventricle directly along with symptoms of syncope or palpitations. WPW syndrome in patients with a history of peripartum cardiomyopathy (pregnancy-related cardiomyopathy) is associated with a high risk of morbidity and mortality secondary to failure of the pump and the conduction system of the heart. Management of these cases deals with arrhythmia and systolic heart failure, which becomes more challenging in pregnant patients as it requires treatment methods that minimize risks to the fetus. We report a case of a young female patient with WPW syndrome and peripartum cardiomyopathy presenting with symptomatic arrhythmias (tachycardia).

An Unusual Presentation of Cholesterol Embolization Syndrome.

Cholesterol embolization syndrome (CES) is a rare presentation of systemic atherosclerosis, which commonly presents in patients with risk factors of coronary artery disease and usually occurs after cardiac or vascular procedures. Laboratory tests are nonspecific, and imaging studies may visualize the plaque. Management includes supportive care directed to relieve the end-organ damage. The prognosis of CES is poor, with high mortality of up to 29% if the CES resulted in atheroembolic renal disease (AERD). In our report, we present a 90-year-old Caucasian female who was diagnosed with CES and complicated with AERD. The patient did not undergo any cardiac or vascular procedures. This case highlights the importance of considering CES and AERD as a potential cause of renal failure, especially in high-risk patients, even if the patients did not have any history of cardiac or vascular intervention.

Azithromycin-Induced Bradycardia.

Azithromycin is a broad-spectrum antibiotic of the macrolide class and has multiple effects on the cardiovascular system, including prolonged corrected QT (QTc) interval. However, there is limited literature on the association between azithromycin and bradyarrhythmias. Monitoring the patient via telemetry can detect bradycardia. The diagnosis of azithromycin-induced bradycardia is usually made by the exclusion of other causes of bradycardia. We report a case of a 44-year-old female with past medical history of obstructive sleep apnea who presented to our hospital due to polysubstance drug overdose with possible aspiration pneumonia. The patient received azithromycin and subsequently developed symptomatic bradycardia two days post-onset of antibiotic treatment. This case raises awareness amongst physicians about the possibility of azithromycin-induced bradycardia and explains the different mechanisms that can cause it.

Serratia marcescens Endocarditis.

Infective endocarditis (IE) secondary to Staphylococcus aureus and streptococcus species comprises the majority of cases in literature with Gram negative bacterial insults occurring infrequently. Serratia marcescens is a Gram negative bacillus which is classified as motile, non-lactose fermenting, and a facultative anerobe. The presumed risk factor for the development of S. marcescens IE is intravenous drug use (IVDU). We report two cases of IE causes by S. marcescens: first case describes IE of tricuspid and aortic valve requiring surgical intervention further complicated by epidural abscess. The second case was associated with renal and splenic infarct. These cases highlight the severity and complicated nature of S. marcescens IE. Given S. marcescens IE has been infrequently described in the literature, we believe that our cases are worth reporting to contribute to the present incidence and management of S. marcescens IE.

5q Deletion Myelodysplastic Syndrome in a Young Male Patient.

Myelodysplastic syndromes (MDS) are a diverse group of hematopoietic stem cell malignancies with various phenotypic variability that are categorized by abnormal differentiation of one or multiple cell lines of the bone marrow. A large part of the phenotypic heterogeneity is in part due to the wide set of genetic defects related to MDS. Though clinically, MDS is centered on diagnostic measures that do not incorporate molecular genetic data, an isolated deletion of the long arm of chromosome 5 (del(5q)) is the only subset of MDS to be identified by genetic defects. This distinctive phenotype is termed 5q-syndrome. We report a case of a 25-year-old with a past medical history of polydactyly, severe anemia, and thrombocytopenia who presented to the emergency department with a chief complaint of weakness and fatigue. Bone marrow biopsy showed myeloid neoplasm with complex genetic abnormalities, nearly 100% hyperplastic marrow with marked trilineage dysplasia, relative myeloid hyperplasia with increased abnormal eosinophilic precursors, erythroid left shift, and atypical megakaryocytes. Fluorescence in situ hybridization (FISH) panel showed deletion of 5q-. Herein, we address the clinical course and morphological characteristics as well as possible therapeutic options for 5q syndrome.

Vasopressor-Induced Digital Ischemia.

In patients who are critically ill and in circulatory shock, substantial dosages of vasopressors including norepinephrine and Neosynephrine are often required to sustain blood pressure. While these medications are necessary and can be lifesaving, they are often associated with several complications related to severe vasoconstrictions. One of these known but underreported side effects is digital ischemia (DI). DI refers to a decrease in digital perfusion. It is a rare and uncommon phenomenon that can lead to significant consequences and unfortunately can result in amputation of the digits. Herein, we report an unfortunate female with septic shock secondary to acute bowel ischemia who developed bilateral digital necrosis while on norepinephrine.

A Case of New Onset Diabetes and Severe Diabetes Ketoacidosis in a Patient With COVID-19.

Diabetic ketoacidosis (DKA) is a significant complication of poorly controlled diabetes. In diabetics, it typically occurs due to insulin deficiency resulting in lipolysis and subsequent ketone body formation and acidosis. The emergence of the COVID-19 infection has been associated with several complications, with the most prominent being pulmonary and cardiovascular-related. However, in some cases, patients with COVID-19 infection present with diabetic ketoacidosis. The pathophysiology of DKA in COVID-19 infection is different and currently not completely understood. The manifestation of DKA in COVID-19 patients is associated with increased severity of mortality and length of stay in these patients. Here, we describe a patient with no past medical history who presented with COVID-19 symptoms and was found to be in DKA. This case report highlights the possible underlying pathophysiology associated with this complication.

A Case Report of Brown Recluse Spider Bite.

Brown recluse spider is a spider of the genus Loxosceles and also known as violin spider or fiddle-back spider. Brown recluse spider is characterized by having six eyes, with a pair in front, a pair on both sides, and a gap between the pairs. The other spiders have eight eyes in two rows of four. Brown recluse spider bites are challenging to verify but may be clinically diagnosed with consideration of geographic location, seasonality, and clinical characteristics. We present a case that involves a brown recluse spider bite in a 59-year-old female with malnutrition and polysubstance use who developed systemic symptoms and a dermonecrotic wound. Local wound care and intravenous (IV) antibiotics lead to clinical improvement by hospital day three, at which time the patient left against medical advice. The case highlights the challenges of diagnosing a brown recluse spider bites, particularly in a patient with multiple risk factors for necrotizing soft tissue infection. Furthermore, the present case represents one of the few case reports of a brown recluse spider bite in Michigan.

Magnetic Resonance Features of a Recent Catheter Ablation of Left Posterior Fascicular Ventricular Tachycardia.

A 71-year-old male patient with a past medical history of hypertension, hyperlipidemia, and chronic kidney disease stage II presented with a complaint of intermittent palpitations for three months and was found to have wide complex tachycardia on the electrocardiogram (ECG). The patient was given adenosine and amiodarone, following which he underwent synchronized cardioversion at 150 Joules followed by 200 Joules without successful conversion. He was subsequently initiated on lidocaine drip at the rate of 1 to 4 mg/minute to maintain adequate rhythm control, which converted him to sinus rhythm and relieved his symptoms. An eventual assessment with an electrophysiology study identified the presence of incessant left ventricular tachycardia (VT). The mechanism was confirmed to be left posterior fascicular ventricular tachycardia (LPF-VT). Successful mapping and ablation for the LPF-VT were achieved. Post-procedure cardiac MRI showed two small areas of near-transmural delayed enhancement. These areas are associated with nulled areas in the inferolateral wall at the left posterior His-Purkinje fascicle. This case highlights fascicular VT as a separate clinical entity, with its characteristic ECG features and acute MRI features after ablation.

Hepatosplenic Abscess From Klebsiella pneumoniae in Poorly Controlled Diabetic.

Invasive Klebsiella pneumoniae infection and pyogenic liver abscess in patients with underlying diabetes mellitus has been well described over the past 3 decades, predominantly in the Southeast Asian population, especially in Taiwan and Korea. K pneumoniae has now become the most common causative pathogen of pyogenic liver abscess in Asian countries. This shift from Escherichia coli to K pneumoniae may also be increasingly occurring in the United States of America and European countries. Compared with the >80% incidence described in Taiwan, the incidence in the United States is still reported to be lower, around 30% to 40%. However, as more evidence and reports come to light, it has become of prime importance to recognize Klebsiella as a significant emerging cause of metastatic infections in patients with uncontrolled diabetes in the United States and not just Southeast Asia, given the significant morbidity and mortality associated with the condition. In this article, we discuss the case of a 53-year-old African American female who presented with diabetic ketoacidosis and was subsequently found to have K pneumoniae pyogenic liver abscess primarily in the left hepatic lobe, bacteremia, and septic metastases to the spleen. She required extensive percutaneous drainage of abscesses and a prolonged course of multiple antibiotics. This case illustrates the growing incidence of invasive K pneumoniae infection in the diabetic population in the United States, and better patient outcomes from prompt recognition and treatment.

Reactive Thrombocytosis after Splenectomy in Hereditary Spherocytosis: Case Report and Literature Review.

Reactive thrombocytosis after splenectomy is a feared cause of thrombosis throughout the arterial and venous system. There are many causes of splenomegaly, ranging from cirrhosis to lymphoma to hereditary spherocytosis. In this report, we will discuss a case of reactive thrombocytosis after splenectomy in a patient with hereditary spherocytosis. Splenomegaly is a relatively common finding in HD patients, causing extravascular haemolysis and thus leading to haemolytic anaemia. Splenectomy is usually considered when patients start to manifest severe symptoms such as abdominal pain, jaundice or worsening liver function tests. Our patient was a good surgical candidate and successfully underwent splenectomy but afterwards developed arterial and venous thrombosis due to reactive thrombocytosis. An extensive hypercoagulable work-up was unremarkable. The patient was started on hydroxyurea and anticoagulation with eventual improvement of platelet levels. LEARNING POINTS: Reactive thrombocytosis can be a significant complication after splenectomy and can range from mild (500,000-700,000/mm3), to moderate (700,000-900,000/mm3), severe (>900,000/mm3) and very severe thrombocytosis (>1,000,000/mm3).The use of low-dose hydroxyurea in patients with very severe thrombocytosis can reduce the platelet count to safe levels, and thus, the risk of developing thrombosis.

Loculated Empyema and SARS-CoV-2 Infection: A Report of Two Cases and Review of the Literature.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clinical manifestations are diverse and can vary from mild respiratory symptoms to severe hypoxic respiratory failure. In severe cases, infection can cause gastrointestinal, renal, cardiac, neurological and haematological complications and result in multi-organ failure. There are very few reports of parapneumonic effusion in patients with COVID-19. We describe two patients with COVID-19 who had loculated empyema and discuss the clinical course and therapeutic options. LEARNING POINTS: The clinical manifestations of COVID-19 vary from mild to severe disease and can result in multi-organ failure.Pleural empyema is usually treated with a combination of antibiotics and surgical drainage of the pleural cavity.

A Rare Yet Morbid Complication of Endotracheal Intubation: Tracheal Rupture.

Tracheal tears are an uncommon phenomenon that can occur due to infection, blunt or penetrating trauma or iatrogenic causes secondary to endotracheal intubation or procedures such as bronchoscopy. Post-intubation tracheal laceration is a very rare yet serious complication with high morbidity and mortality rates. Here, we report the case of a 53-year-old woman with a medical history of hypertension who presented with complaints of facial swelling after undergoing arthroscopic debridement of the coracoacromial ligament as well as partial resection of the acromion for impingement of the right shoulder under general anaesthesia. The patient was found to have extensive pneumomediastinum, subcutaneous emphysema, and a large tracheal tear. We aim to highlight this rare complication of endotracheal intubation, discuss the presenting signs and symptoms, and explore the various management options. LEARNING POINTS: Iatrogenic tracheal laceration after intubation is a rare but life-threatening complication.Prompt recognition and treatment is required to reduce morbidity and mortality.

Cocaine induced heart failure: report and literature review.

Heart failure is a complex clinical syndrome associated with high mortality and morbidity, creating a major public healthcare problem. It has a variety of etiologies, including substance abuse. Cocaine-induced cardiotoxicity is caused by direct effects of inhibition of sodium channels and indirect effects by inhibiting catecholamine uptake leading to increased sympathetic activity. Management is through the cessation of cocaine use and implantation of guideline-directed medical therapy for heart failure with the exception of beta-blockers as their safe usage is still controversial due to the risk of the unopposed alpha-adrenergic activity. Dexmedetomidine (Precedex) and Benzodiazepines (i.e., midazolam) are options for patients that demonstrate signs and symptoms of acute cocaine intoxication. If the actions of benzodiazepines fail to achieve hemodynamic stability, nitroglycerin may be used (especially in patients with cocaine-associated chest pain and hypertension). Cardiac transplantation is recommended for those who have demonstrated severe cardiovascular disease from cocaine. We present a 43-year-old male with a long-standing history of cocaine use who developed cardiomyopathy and severe acute decompensated heart failure found to have an ejection fraction of <20% admitted to the intensive care unit. He required inotropic support with milrinone and mechanical ventilation. He was later extubated and then discharged with an outpatient evaluation for a cardiac transplant.