Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review.

Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.

A Rare Case of Colon Cancer in a Young Patient With HIV Infection: Is it Time for New Colon Cancer Screening Guidelines for HIV Patients?

Patients with human immunodeficiency virus (HIV) infection have a higher prevalence of colonic neoplasms than the general population. In these patients, tumors develop at an earlier age, are diagnosed at more advanced stages, and have a dismal prognosis. Current guidelines recommend initiating colon cancer screening in HIV patients at the age of 45 which is consistent with screening age in the general population. We present a rare case of colon cancer diagnosed in an HIV-infected patient at a young age of only 34 years. Therefore, we recommend early screening for colon cancer in HIV patients than the general population.

A Rare Case of Malignant Syndrome in Parkinson's Disease Caused by Severe Dehydration and Complicated by Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH).

Malignant syndrome (MS) in Parkinson's disease (PD) is a rare complication that occurs in patients who have a history of PD and are taking dopaminergic drugs. The syndrome is quite similar to neuroleptic malignant syndrome (NMS) in presentation and is a potentially fatal syndrome. Awareness of symptoms, early diagnosis, and the ability to differentiate it from NMS is important to prevent mortality. Clinical manifestations of MS are similar to NMS and include altered mentation, rigidity, fever, leukocytosis, and elevated serum creatine kinase (CK). However, MS is differentiated from NMS by the precipitating factors; of which, the commonest precipitating factor for MS is dopaminergic drug withdrawal or dose reduction while other less common causes include infection, dehydration, and hot weather. We present a rare case of MS in a patient with a history of PD precipitated by severe dehydration and hot weather in the absence of dopaminergic drug withdrawal. He presented with fever, severe rigidity, altered mentation, dehydration, leukocytosis, and elevated CK. He was correctly diagnosed with MS and promptly treated, preventing mortality. The triad of fever, severe rigidity, and altered sensorium in a patient with a history of PD should prompt evaluation for MS in addition to NMS to initiate appropriate treatment and prevent mortality.

Evaluation of Monkeypox as an Unrecognized Sexually Transmitted Disease: A Rare Case of Monkeypox Infection with HIV and Syphilis Coinfection.

Monkeypox (MPX) virus is endemic in Africa. However, since May 2022, many cases have been reported worldwide in many non-endemic regions as well. The virus usually spreads from animals to humans or from humans to humans through respiratory droplets or after contact with infected lesions. In the recent outbreak of MPX, many cases did not have any travel history to endemic areas and were reported in men who have sex with men (MSM) along with the diagnosis of other sexually transmitted diseases (STDs). However, MPX is not yet considered a sexually transmitted infection (STI), even though a relationship between MPX and other STIs may exist with a possible facilitating action on their spreading. We present a similar case of MPX infection in an MSM patient with concomitant HIV and syphilis infections and no travel history to an endemic area.

Cefiderocol as a Treatment Option for Stenotrophomonas maltophilia Causing Hospital-Acquired/Ventilator-Associated Pneumonia.

Multidrug-resistant (MDR) gram-negative bacteria have been causing havoc for the healthcare system because of the rarity of the treatment options available. Stenotrophomonas maltophilia is a non-fermenting gram-negative bacterium that causes different infections, particularly respiratory tract infections. It displays resistance to many antibiotics (e.g., carbapenems, fluoroquinolones, and trimethoprim-sulfamethoxazole). Cefiderocol is a novel antibiotic which still in the preclinical stages of Food and Drug Administration (FDA) approval for S. maltophilia. We present the case of a 76-year-old male with end-stage renal disease (ESRD), intubated for acute hypoxemic respiratory failure due to volume overload and worsening oxygenation, who subsequently developed ventilator-associated pneumonia, found to be due to MDR Stenotrophomonas maltophilia. The patient ultimately showed clinical improvement with a 7-day course with a renally adjusted dose of cefiderocol. This shows that cefiderocol can prove to be a potential treatment option against serious infections caused by difficult-to-treat S. maltophilia.

A Meta-analysis of the Severity of Acute Pancreatitis (AP) in COVID-19 Infection.

Many studies have reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affecting the gastrointestinal tract and causing gastritis, colitis, duodenitis and acute pancreatitis (AP). We conducted a meta-analysis to evaluate if SARS-CoV-2 infection (COVID-19 infection) affects the outcomes and severity of AP. We searched for articles in PubMed (MEDLINE), Cochrane Library, and clinicaltrials.gov databases and included studies comparing the outcomes of AP in patients with and without COVID-19. Our outcomes were the mean age of occurrence of AP, Charlson Comorbidity Index, incidence of idiopathic etiology of AP, severity of AP, incidence of necrotizing pancreatitis, need for intensive care unit (ICU) admission, and mortality between the two cohorts. We included five observational studies with a total population of 2,446 patients. Our results showed that in COVID-19 patients; AP had higher odds of having an idiopathic etiology (odds ratio, OR 3.14, 95% confidence interval, CI 1.36-7.27), be more severe (OR 3.26, 95% CI 1.47-7.49), had higher risk for pancreatic necrosis (OR 2.40, 95% CI 1.62-3.55), require ICU admission (OR 4.28, 95% CI 2.88-6.37) and had higher mortality (OR 5.75, 95% CI 3.62-9.14) than in patients without COVID-19 infection. Our study concluded that SARS-CoV-2 infection does increase the morbidity and mortality associated with AP and further large-scale multi-center studies are needed to confirm these results.

The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis.

Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients.  An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords "Aortic stenosis", "SAVR", "TAVR", and "Asymptomatic". A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.

Acute Pancreatitis Related to COVID-19 Infection: A Systematic Review and Analysis of Data.

There is increasing literature mentioning severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19 infection) causing acute pancreatitis (AP). It is hypothesized that SARS-Cov-2 causes pancreatic injury either by direct cytotoxic effect of the virus on pancreatic cells through the angiotensin-converting enzyme 2 (ACE2) receptors - the main receptors for the virus located on pancreatic cells - or by the cytokine storm that results from COVID-19 infection or a component of both. Many viruses are related to AP including mumps, coxsackievirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and as data evolves SARS-CoV-2 virus may be one of them as well. We conducted a systematic literature review to explore the current literature and provide an overview of the evidence of AP in COVID-19 infection. We studied the presence of AP in patients with SARS-CoV-2 infection and calculated the time of diagnosis of SARS-CoV-2 infection with respect to the time of diagnosis of AP. We also studied the age, gender, clinical manifestations, time of onset of symptoms, laboratory values, imaging findings, mortality, length of stay, comorbidities, need for Intensive Care Unit (ICU) care, and excluded any other common causes of AP. We included 40 articles comprising 46 patients. All patients had a positive SARS-CoV-2 polymerase chain reaction (PCR) test and all patients had AP as per Atlanta's criteria. The most common clinical presentation was abdominal pain in 29 (63.0%). Edematous pancreas was the most common Computed Tomography Abdomen Pelvis (CTAP) scan finding in these patients (35 patients). Seventeen (37%) patients required ICU admission and six (13%) patients died. Our study provides an important overview of the available data on AP in COVID-19 patients and concludes that AP is an important complication in COVID-19 infection and should be considered as an important differential in patients with COVID-19 infection who complain of abdominal pain.

Acute Mesenteric Ischemia in a Chronically Anticoagulated Patient With Atrial Fibrillation: Anticoagulation Reversal, Management and Preventing Recurrence.

Acute mesenteric ischemia (AMI) is caused by an interruption of the blood supply to the small intestine. Atrial fibrillation is a common cause of thromboembolic AMI. Patients taking direct oral anticoagulants (DOACs) for anticoagulation in atrial fibrillation are prone to anticoagulation failure and can present with thromboembolism. We present an interesting case of a 69-year-old female with a past medical history of chronic atrial fibrillation treated with a DOAC (apixaban) who was diagnosed with AMI despite being compliant with her anticoagulant. Her anticoagulation was promptly reversed and she was taken for urgent surgical intervention yielding a good outcome. Later, due to the failure of anticoagulation on apixaban her anticoagulant was changed to warfarin to prevent the recurrence of thromboembolism and follow-up showed she was doing well.

Management of Chronic Portal Vein Thrombosis in a Cirrhotic Patient With Pancytopenia and Grade II Esophageal Varices.

Chronic portal vein thrombosis (PVT) is a major vascular complication of liver cirrhosis. Patients may be asymptomatic and chronic PVT might be detected incidentally on imaging. PVT is associated with worsening liver disease, poorer clinical outcomes, and might proceed to life-threatening intestinal ischemia. Management of chronic PVT with anticoagulation has been shown to be successful in promoting recanalization and reducing thrombus extension in patients with cirrhosis. However, optimal anticoagulation for PVT in cirrhosis has not yet been addressed in any large-scale trial, and the decision to anti-coagulate varies on a case by case presentation. We report the case of a 62-year-old male patient with a history of liver cirrhosis, pancytopenia, and grade II esophageal varices presenting with abdominal pain who was incidentally found to have chronic thrombosis of the portal vein on imaging and was managed appropriately with a good outcome.