Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

BACKGROUND AND OBJECTIVES: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. METHODS: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. RESULTS: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DISCUSSION: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Right atrial thrombus leading to pulmonary embolism in a patient with dermatomyositis and COVID-19 managed with FlowTriever device thrombectomy.

A woman in her late 40s presented with complaints of shortness of breath, right-sided pleuritic chest pain and diffuse myalgias. She was diagnosed with deep vein thrombosis (DVT) 3 weeks earlier and had been compliant with her oral anticoagulation therapy. Investigations revealed a pulmonary embolism (PE) involving the right distal pulmonary artery on a CT angiogram of the chest. She was also found to have an incidental SARS-CoV-2 (COVID-19) infection and an elevated creatine kinase value. Anticoagulation with intravenous heparin was initiated according to the DVT/PE protocol. The following morning, a medium-sized mobile mass was identified in her right atrium on performing a transthoracic echocardiogram. Due to concerns of embolisation of the mass which could result in obstruction, right ventricular strain and ultimately haemodynamic instability, a thrombectomy was performed using the FlowTriever device under transthoracic echocardiography guidance. The right atrial mass was successfully removed and the patient was transitioned to another oral anticoagulant agent. On discharge, a muscle biopsy was performed and aided in the diagnosis of dermatomyositis and the patient received intravenous Ig, steroids and methotrexate.

Subcutaneous Implantable Cardioverter-Defibrillator Lead Dislodgement Masquerading as Left Shoulder Pain.

Implantable cardioverter-defibrillators (ICDs) have demonstrated efficacy in the prevention of sudden cardiac death secondary to cardiac arrhythmias in eligible patients. Complications with the subcutaneous ICD (S-ICD) are rarer than with the transvenous ICD but do still exist. Our patient presented four weeks after the insertion of S-ICD with complaints of left shoulder pain radiating to the chest wall and swelling over the S-ICD site. He was initially treated for rotator cuff injury and subacromial impingement syndrome but upon obtaining chest radiography was found to have a lead displacement traversing the splenic flexure of the colon. The patient was managed by a treatment team involving cardiology, surgery, and infectious disease and underwent S-ICD removal, exploratory laparotomy with splenic flexure mobilization, and completion of a four-week antibiotic course ultimately leading to reimplantation of S-ICD.

A Case of Severe Cardiomyopathy Due to Covid-Induced Myocarditis, Completely Resolved after Colchicine and Immunoglobulin Therapy.

Coronavirus 19 (COVID-19) is well known for causing acute respiratory distress syndrome. Among other systemic complications, myocarditis is a frequently reported presentation as well as complication. One systematic review reported a 14% mortality rate in patients with COVID-19 myocarditis. Endomyocardial biopsy is a definitive diagnostic test but has been a challenge to perform in most cases of COVID myocarditis due to the contagious nature of the disease. Patients presenting with new cardiomyopathy with troponin leak and arrhythmias, supported by recent COVID-19 diagnosis should be suspected for COVID-induced myocarditis. Supportive treatment has been the mainstay of treatment with limited data on immunotherapy and colchicine. Our case is about a male in his 50s who had a cardiac arrest due to ventricular fibrillations, with a positive COVID-19 test. Further workup showed severe non-ischaemic cardiomyopathy with an EF of 15-20%. He was treated with intravenous immunotherapy and colchicine. A repeat echocardiogram 3 days later showed resolution of cardiomyopathy. Our case report highlights the possible beneficial effects of immunotherapy and colchicine in viral myocarditis. LEARNING POINTS: Myocarditis should be suspected in patients with acute onset cardiomyopathy with troponin leak and no evidence of ischaemia. COVID-19 myocarditis can present with arrhythmia, which could be fatal in some cases.Even though supportive management is the mainstay of treatment for COVID-19 myocarditis, there have been reports of benefits of intravenous immunotherapy (IVIG) and colchicine.More studies are warranted to explore the beneficial effects of IVIG and colchicine not just in COVID-19 myocarditis, but also in other viral causes of myocarditis he aim of this study is also to raise awareness among healthcare professionals about the Bentall procedure in patients with type A aortic dissection involving the aortic valve.

Enterobacter cloacae as sole organism responsible for vertebral osteomyelitis/discitis and vertebral collapse in a patient with intravenous drug abuse.

Staphylococcus aureus is the most commonly isolated organism in osteomyelitis, while gram-negative bacteria (GNB) comprises only a minor portion. GNB osteomyelitis is usually seen in patients with bacteraemia, recent genitourinary infection, open fractures or trauma and is rarely seen in the spines. Our case is a man in his 30s with no significant risk factors except an extended history of intravenous drug use (IVDU), who presented with back pain and subsequently developed vertebral collapse. Bone culture grew Enterobacter cloacae, yet blood cultures were negative. To date, there are limited data on the prevalence of GNB osteomyelitis in IVDU and its association. Due to rising rates of IVDU, further research must be done into associated medical complications to provide comprehensive care. Moreover, the emergence of multidrug-resistant GNB strains limits the number of effective antibiotics and is expected to pose more serious public concerns in the future.

Retroperitoneal Hematoma: A Sequela of Acute Hemorrhagic Pancreatitis Post Endoscopic Retrograde Cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic tool for pancreaticobiliary diseases. Like every other procedure, ERCP can lead to complications that include pancreatitis, cholecystitis, perforation, and rarely, retroperitoneal hematoma. We present a case of post-ERCP acute hemorrhagic pancreatitis resulting in retroperitoneal hematoma and sequelae of unilateral hydronephrosis and ileus. The patient was treated supportively and had good clinical improvement with resolution of hydronephrosis, ileus and more importantly tolerating oral diet without further episodes of abdominal pain. LEARNING POINTS: The most common complications of endoscopic retrograde cholangiography are acute pancreatitis and hemorrhage. In high-risk patients, acute pancreatis can be prevented with rectal non-steroidal anti-inflammatory suppository before the procedure.Occurrence of Grey-Turner or Cullen sign should prompt immediate search for retroperitoneal hematoma especially in the setting of acute hemorrhagic pancreatitis.Apart from hemodynamic instability or compressive symptoms, retroperitoneal hematoma can also cause complications due to inflammatory reactions resulting in hydronephrosis or ileus.

Protein S Deficiency and COVID-19: A Brutal Combination Leading to Acute Submassive Bilateral Pulmonary Embolism.

Protein S deficiency is a form of inherited thrombophilia that occurs due to low levels of or improper function of protein S. The role of protein S is to inactivate procoagulant factors, and a deficiency results in an increased risk of thrombotic events. The coronavirus disease 2019 (COVID-19) infection has also been studied to increase the risk of venous thromboembolism (VTE) due to an interplay of several mechanisms. However, the risk of VTE in patients affected by both of these disease processes simultaneously has not been thoroughly studied, and so recommendations regarding routine screening and prophylaxis of VTE have also not been established. We discuss the case of a 46-year-old woman with a past history of protein S deficiency and a recent COVID-19 infection who presented with complaints of shortness of breath. Upon examination, she was found to be hypoxic and tachycardic. A computed tomography angiography of the chest was done and revealed acute submassive bilateral pulmonary embolism with right heart strain and pulmonary infarcts. She was initially treated with intravenous heparin and later transitioned to oral anticoagulation for a minimum of six months.

Methotrexate-Induced Lymphoproliferative Disorder Complicating Into Spontaneous Tumor Lysis Syndrome and Disseminated Intravascular Coagulation.

Lymphoproliferative disorder (LPD) is a severe adverse outcome of methotrexate (MTX) administration in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). The immunosuppression caused is attributed to pathogenesis. Hence, discontinuation is the treatment. Reports on spontaneous tumor lysis with cessation of MTX are rare. We report a case of a female in her 50s with methotrexate-associated lymphoproliferative disease (MTX-LPD) following treatment for rheumatoid arthritis. Methotrexate was discontinued immediately. She presented two months later with severe disseminated intravascular coagulation (DIC) and spontaneous tumor lysis syndrome (STLS). Although tumor lysis syndrome responded well to rasburicase therapy, DIC was a challenge. MTX-LPD has various complications and highly variable presentation. RA/SLE patients receiving MTX should be regularly monitored, and MTX should be immediately stopped in suspicion of MTX-LPD. Although many patients respond to MTX cessation, some patients head to remission and relapse. At the same time, some worsen with complications such as DIC and tumor lysis syndrome, as described above. This case reiterates the need for regular monitoring following MTX therapy cessation for early identification and treatment of these complications to improve prognosis.

Varicella Zoster Meningitis in a Young, Immunocompetent Patient Despite Initiation of Antiviral Therapy.

Varicella zoster virus (VZV) reactivation, also known as herpes zoster is common in older adults and immunocompromised individuals and often causes a painful, vesicular rash limited to a dermatomal distribution. On occasion, it can lead to various neurological complications as well. Here we present the case of a young, immunocompetent male in his 20's with a history of primary varicella infection who presented with complaints of a painful rash in the S3-S4 dermatomal distribution. Despite being initiated on the standard oral antiviral dose for two days, he developed a headache and neck stiffness. He was diagnosed with VZV meningitis through the lumbar puncture and cerebrospinal fluid polymerase chain reaction (PCR) assay analysis. The patient reported significant improvement in symptoms following intravenous acyclovir and was discharged with additional oral valacyclovir at a higher-than-standard dosage. Our case highlights that even in relatively low-risk patients, physicians must maintain a high level of clinical suspicion for the complications of VZV reactivation even after beginning the oral antiviral medication.

Unveiling of Type B Lactic Acidosis From Systemic Lupus Erythematosus-Associated B-cell Lymphoma: A Fatal Oncology Emergency.

Type B lactic acidosis is a rare oncological emergency usually associated with leukemia and lymphoma but also with solid malignancies. It can often go unrecognized as a possible source of lactic acidosis, leading to a delay in treatment. We review a 56-year-old woman with systemic lupus erythematosus and generalized lymphadenopathy being evaluated for underlying malignancy who presented with dyspnea, fatigue, and hematemesis. The patient was hemodynamically unstable and had severe lactic acidosis, leukocytosis, electrolyte derangements, multiple organ damage, and worsening diffuse lymphadenopathy. She was initially treated for septic shock due to acalculous cholecystitis on imaging with antibiotics and a cholecystostomy. The latter was complicated by a liver laceration requiring explorative laparotomy and open cholecystectomy, during which an excisional biopsy of the omental lymph node was done and confirmed B-cell lymphoma with marked plasmacytic differentiation. Her lactic acidosis never fully cleared despite surgery, and the refractory nature of it despite appropriate treatment of septic shock confirmed the diagnosis of type B lactic acidosis from underlying B-cell lymphoma. Chemotherapy was deferred due to the acuity of the condition. She continued to deteriorate despite aggressive management and was transitioned to comfort measures only per family request, following which she passed away. Type B lactic acidosis should be suspected in oncology patients without clinical evidence of ischemia who are not responding to fluid resuscitation and appropriate treatment of septic shock. Prompt recognition and early initiation of antineoplastic agents should be considered, when possible, to prevent adverse outcomes.

A Fatal Case of Systemic Calciphylaxis in the Gastrointestinal Tract: A Case Report and Literature Review.

Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation.

Antimitochondrial Antibody-Negative Primary Biliary Cholangitis: A Retrospective Diagnosis.

Primary biliary cholangitis (PBC) is an inflammatory cholestatic disease that tends to worsen, leading to hepatic cirrhosis and portal hypertension. We present a case of a middle-aged female who presented with progressively worsening generalized itch; the examination was significant only for urticarial rash and facial swelling. Investigation revealed direct hyperbilirubinemia, mildly elevated transaminase, and significant elevation of alkaline phosphatase. A differential was performed with labs including antimitochondrial antibodies (AMA) for PBC, hepatitis panel, anti-smooth muscle antibodies for autoimmune hepatitis, and tissue transglutaminase IgA for celiac disease, all of which were unremarkable. The patient was empirically treated with ursodeoxycholic acid (UDCA). Given the excellent clinical response at the three-week follow-up to treatment despite negative AMA, further testing with anti-sp100 and anti-gp210 was pursued, which returned positive for anti-sp100, confirming the diagnosis of PBC.

Constipation in transverse myelitis.

Transverse myelitis is an extremely rare neuroinflammatory disorder. About half of the affected patients develop paraplegia associated with urinary and bowel dysfunction. The bowel dysfunction is thought to be benign and is usually managed with dietary management and laxatives. We report a case of a man in his 60s presenting with transverse myelitis and the acute disease course complicated with treatment refractory intestinal dysfunction resulting in intestinal perforation, eventually leading to his death. Thus, this case helps us weigh the fact that intestinal dysfunction in the case of transverse myelitis is not always benign but can lead to deadly outcomes as well.

Extraintestinal Clostridioides difficile Infection (CDI): A Recurrent Battle with Resilient Abdominal Wall Abscess.

Clostridioides (formerly Clostridium) difficile infection is a common and costly healthcare-associated infection. Extraintestinal C. difficile infection is rarely encountered, especially in isolation. We present a unique case of abdominal wall abscess presenting six months following gastrointestinal (GI) surgery. The patient was managed with computed tomography (CT) guided drainage of the abscess, placement of a drainage catheter, and aggressive broad-spectrum antibiotic treatment for a prolonged duration over multiple admissions. LEARNING POINTS: Risk factors for extraintestinal CDI include prior hospital stay, prolonged antibiotic therapy, proton pump inhibitor (PPI) use, relative state of immunodeficiency such as malnutrition and diabetes mellitus, previous abdominal surgery especially following perforation and leak of intestinal content.Presentation can be late following surgery with mesh repair (foreign body implantation) for intestinal perforation as they have high risk of colonisation, which later leads to infection.For extraintestinal CDI in the presence of a foreign body, removal is the desired course of action. But it is not always possible given the presence of comorbidities in this population, thus resulting in a prolonged course of antibiotics.

Pain Management Options in a Patient with Livedoid Vasculopathy and Peripheral Neuropathy.

Livedoid vasculopathy (LV) is a rare clinical condition presenting as painful lesions mostly on the lower extremities. We present a case of LV with peripheral neuropathy in a young man initially misdiagnosed and treated for cellulitis. He was started on aspirin, pentoxifylline and apixaban immediately after the diagnosis of LV. However, pain management was a real challenge for the clinicians. Hence, he was later treated with epoprostenol and amlodipine for vasodilation, steroids for any possible inflammation, and antibiotics to treat superimposed infection. Irrespective of all the above, his pain was uncontrollable, and he finally received ketamine infusions along with narcotics, achieving better pain control. Various studies support the use of intravenous immunoglobulin and anti-TNF agents for pain relief in idiopathic and secondary LV. Intermittent low-dose dabigatran has also been found to be effective in the maintenance of remission in LV. However, no large studies have yet been conducted to confirm the efficacy of these medications. LEARNING POINTS: Early initiation of treatment with antiplatelets and anticoagulants is recommended to prevent the progression of livedoid vasculopathy (LV).Anti-TNF agents can be tried in refractory LV for rapid relief of pain.Intravenous immunoglobulin has been shown to be effective for the resolution of pain and improvement of neuropathic symptoms especially in LV refractory to immunosuppressive agents.

Post-EMR for colorectal polyps, thermal ablation of defects reduces adenoma recurrence: A meta-analysis.

Background and study aims Adenoma recurrence is one of the key limitations of endoscopic mucosal resection (EMR), which occurs in 15 % to 30 % of cases during first surveillance colonoscopy. The main hypothesis behind adenoma recurrence is leftover micro-adenomas at the margins of post-EMR defects. In this systematic review and meta-analysis, we evaluated the efficacy of snare tip soft coagulation (STSC) at the margins of mucosal defects to reduce adenoma recurrence and bleeding complications. Methods Electronic databases such as PubMed and the Cochrane library were used for systematic literature search. Studies with polyps only resected by piecemeal EMR and active treatment: with STSC, comparator: non-STSC were included. A random effects model was used to calculate the summary of risk ratio and 95 % confidence intervals. The main outcome of the study was to compare the effect of STSC versus non-STSC with respect to adenoma recurrence at first surveillance colonoscopy after thermal ablation of post-EMR defects. Results Five studies were included in the systematic review and meta-analysis. The total number patients who completed first surveillance colonoscopy (SC1) in the STSC group was 534 and in the non-STSC group was 514. The pooled adenoma recurrence rate was 6 % (37 of 534 cases) in the STSC arm and 22 % (115 of 514 cases) in the non-STSC arm, (odds ratio [OR] 0.26, 95 % confidence interval [CI], 0.16-0.41, P  = 0.001). The pooled delayed post-EMR bleeding rate 19 % (67 of 343) in the STSC arm and 22 % (78 of 341) in the non-STSC arm (OR 0.82, 95 %CI, 0.57-1.18). Conclusions Thermal ablation of post-EMR defects significantly reduces adenoma recurrence at first surveillance colonoscopy.

COVID-19 Vaccine Survey among Healthcare Workers. A Community Experience.

INTRODUCTION: In December 2019, the coronavirus (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) made its first appearance in Wuhan, China with a pandemic declared by March 2020. As the death toll continued to rise, the Centers for Diseases Control and Prevention (CDC) recommended healthcare workers to strongly encourage the general population to receive COVID-19 vaccinations. For this to be effective, it is important to understand the general perceptions of the health care workers and persons associated with the healthcare industry towards their acceptance of the vaccine. METHODS: The authors of this 2021 cross-sectional study administered a 28-item survey to a convenience sample of 1,257 (43.1%) healthcare system workers out of a total of 2,915. The survey assessed respondents' demographic information, COVID-19 vaccine status, work-related exposures to COVID-19, reasons for receiving or refusing the vaccine, and primary sources of vaccine related information. Respondents were classified as vaccine status/intention positive or negative. RESULTS: Those in the youngest 18 - 35 years age group were significantly less likely to receive the vaccine (p < 0.01) and male healthcare workers were significantly more likely to receive the vaccine (p = 0.01). White respondents, 759 (77.9%) were also more likely to receive the vaccine than African-American, 127 (13%). It was more likely for persons to be vaccinated when encouraged/provided (p = 0.01) information by their respective employers. A subgroup of 277 (22.0%) respondents reported their employer as the primary source of vaccine information, causing the authors to conclude that employer information was the most influential informational factor impacting COVID-19 vaccination. CONCLUSION: Vaccine hesitancy continues to be a major obstacle hampering the success of COVID-19 vaccination promotion programs. Results indicate that a combination of a prior COVID-19 diagnosis, information dispensed by a person's employer, persons' home living situations, and contact with persons who had an uneventful post vaccination experience increased the likelihood of vaccination.

A Rare Presentation of Sarcoidosis: Dysphagia, Pancytopenia, and Acute Renal Failure.

Sarcoidosis is a multisystem inflammatory chronic disorder that can virtually affect any organ system in the body. Most commonly affected organs are the intrathoracic structures with 90% of the reported cases involving the lungs. Esophageal involvement in sarcoidosis is extremely rare. Involvement of the esophagus and kidney along with hematological involvement is extremely uncommon in the same patient. Here, we present a case of a 58-year-old gentleman with a similar rare presentation. The patient presented with shortness of breath, productive cough, fatigue, and difficulty in swallowing, along with a weight loss of 20-30 pounds over three months. Laboratory workup was significant for leukopenia (2900 K/UL), serum creatinine level of 2.7 mg/dL (baseline: 1.2-1.7), and raised angiotensin-converting enzyme level at 187 nmol/ml/min. Chest X-ray showed bilateral widespread fine reticulonodular opacities, chest CT showed extensive bilateral reticulonodular opacities throughout the lung parenchyma, and fine-needle aspiration cytology of the right lung showed noncaseating granulomas. No fungal or acid-fast organisms were identified, and no evidence of malignancy was seen. Special stains for fungal (Grocott's methenamine silver and periodic acid-Schiff) and acid-fast organisms (acid-fast bacilli (AFB) and fluorescent AFB) were negative. Esophagogastroduodenoscopy (EGD) with gastric biopsy showed acute and chronic inflammation and no intestinal metaplasia, dysplasia, or malignancy was identified. Bronchoalveolar lavage was done, which showed macrophages (74%), neutrophils (6%), eosinophils (3%), and lymphocytes (17%), and was negative for malignant cells. QuantiFERON and AFB sputum/Mycobacterium tuberculosis polymerase chain reaction were negative. The patient was initially started on intravenous fluids and calcitonin, which significantly improved renal function and the calcium status of the body. Then prednisone 40 mg daily was started, which improved swallowing and breathing. After a week, prednisone was changed to 20 mg daily and was continued at the time of discharge.

Cryptococcus neoformans var. grubii septic arthritis in an immunocompromised patient on haemodialysis with history of splenectomy and sarcoidosis.

A male adult in his mid-40s with end-stage renal disease (ESRD) on haemodialysis, with history of splenectomy and sarcoidosis, developed septic arthritis of the knee. Excision and drainage was performed and empiric antibiotics were initiated. Cultures were initially negative without clinical improvement. Eventually, the aerobic synovial fluid culture grew Cryptococcus neoformans (formerly Cryptococcus neoformans var. grubii). The patient was treated with liposomal amphotericin B and then switched to fluconazole until the infection resolved. This case highlights the less well-recognised association between cryptococcal arthritis and immunodeficiency states like ESRD, splenectomy and sarcoidosis.