A Rare Case of Benign Metastasizing Leiomyoma Causing T11 Spinal Cord Compression: A Report and Literature Review.

Diagnosis of uterine smooth muscle tumors depends upon histologic characteristics as both benign and malignant share clinical features such as metastases. A benign metastasizing leiomyoma is a rare benign smooth muscle tumor that metastasizes to extrauterine sites with simultaneous uterine leiomyoma or previously biopsy-proven leiomyoma during myomectomy or hysterectomy. Benign metastasizing leiomyoma metastasizes outside the uterus, predominantly to the lungs and lymph nodes. However, the involvement of other organs, such as the heart, liver, spine, and soft tissue, is also reported. Here, we present a case of a 42-year-old woman with a history of uterine leiomyoma with prior myomectomy and hysterectomy, who presented with worsening back pain and lower extremity weakness and was found to have an acute cord compression, a serious complication caused by mass effect and a medical emergency that requires prompt attention to prevent permanent spinal cord damage. Sacral soft tissue biopsy and T11 spinal bone biopsy both demonstrated leiomyoma with immunostains positive for desmin, smooth muscle actin, and positive estrogen and progesterone receptors. No atypia, necrosis, and mitosis were identified. The patient had hepatic and pulmonary metastasis on imaging. The final diagnosis was benign metastasizing leiomyoma. There is no standard treatment for benign metastasizing leiomyoma. Both surgical and pharmacological approaches are employed. Although most cases are benign, there is a possibility for life-threatening complications. Benign metastasizing leiomyomas can be considered when multiple soft tissue tumors are found in premenopausal women with a history of uterine leiomyomas. Multidisciplinary discussion between oncologists, gynecologists, and relevant specialists is crucial in the optimal evaluation and treatment of benign metastasizing leiomyoma.

Multiple Massive Bullae Formation Within Lung of SARS-CoV-2-Infected Patient.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has altered the world for more than two years and continues to impact the globe in numerous ways. This disease has a wide spectrum of presentations that can range from no symptoms at all to rapid decline and death. Complications of SARS-CoV-2 include acute respiratory failure, pneumonia, acute respiratory distress syndrome (ARDS), acute liver injury, acute cardiac injury, septic shock, blood clots, multisystem inflammatory syndrome in children, and chronic fatigue. Although many complications such as these and others exist, we are still seeing novel developments related to the virus. In this case report, we present a patient with SARS-CoV-2 who concurrently had a massive left lung bulla of unknown etiology. Due to the size and scale of this bulla, we suspect it to be a complication of his SARS-CoV-2 infection. A few cases have been described in the literature beforeand here we would like to contribute another one. Our goal is to help expand the body of evidence demonstrating the far-reaching and atypical nature that SARS-CoV-2 can present with today.

Assessment of Bleeding Risk in Hospitalized COVID-19 Patients: A Tertiary Hospital Experience during the Pandemic in a Predominant Minority Population-Bleeding Risk Factors in COVID-19 Patients.

Introduction: In the wake of the SARS-CoV-2 (COVID-19) pandemic, our world has faced multiple challenges. Infection with this virus has commonly been associated with thrombotic events. However, little is known about bleeding risk and anticoagulation therapy. This study aims to determine factors that are associated with increased risk of bleeding in COVID-19 patients. Methods: A retrospective cohort study was conducted using the records of COVID-19 patients admitted during the COVID-19 pandemic from March 2020 through May 2020. Using patient charts, investigators manually collected data regarding patient characteristics and bleeding. Patients were included in the analysis if they had a confirmed COVID-19 PCR test, were older than 18 years of age and were admitted to the hospital. Patients who were pregnant or had incomplete charts were excluded from the study. ANOVA and logistic regression were used to determine the statistical significance of the data using SPSS version 27. Results: A total of 651 patients were included in the analysis out of 685 patients located in the database of COVID-19 infected patients during that time frame. The general characteristics of the patients were as follows: 54.2% were males; females 45.8% ages ranged from 28 to 83 years old (median age = 66 years old). There were 31 patients (4.9%) who required more than 1 unit of packed red blood cell (PRBC). A total of 16 (2.85%) patients had a documented gastrointestinal bleed (GIB), of which 8 received a total of 29 units of PRBC transfusions. The HAS-BLED score (without alcohol/drug due to inadequate charting) is calculated for patients who had a documented GI bleed and who received more than one unit of PRBC. It was noted that the higher the HAS-BLED score the greater the likelihood of having a GI bleed (p < 0.001). The HAS-BLED score (not including alcohol/drug) was also predictive for patients who received more than one unit of PRBC during their hospital stay (p < 0.001). Discussion: Using the HAS-BLED score without alcohol/drugs, patients with COVID-19 can be stratified in regard to their risk of GI bleeding and their risk of transfusion while in the hospital. When administering anticoagulation therapy, cautious monitoring should be carried out. Decisions regarding anticoagulant therapy should be based on individual patient characteristics.

Yolk Sac Tumor in the Anterior Mediastinum Presenting as Acute Pericarditis.

BACKGROUND Mediastinal masses can originate from anatomical structures normally located in the mediastinum, or from structures that travel through the mediastinum during embryogenesis. Initial presenting symptoms usually vary from shortness of breath, cough, chest pain, and superior vena cava syndrome to nonspecific constitutional symptoms (eg, fever, weight loss, fatigue). However, the initial presentation of a mediastinal mass with acute pericarditis has not been reported in the literature as far as we know. CASE REPORT A 20-year-old man presented to the Cardiology Clinic with chest pain and new pericardial effusion on echocardiography, both fulfilling the diagnostic criteria of acute pericarditis. The patient also had venous engorgement on the neck, and a chest X-ray followed by computed tomography imaging showed a large mediastinal mass. The serum tumor marker a-fetoprotein (AFP) was markedly elevated. The biopsy and immunohistochemistry revealed a high-grade malignant neoplasm - yolk sac tumor, which is a type of non-seminomatous germ cell tumor. The acute pericarditis resolved after administration of NSAID and colchicine. The patient was then started on chemotherapy. CONCLUSIONS The discussed case shows the rare presentation of an anterior mediastinal mass with acute pericarditis. This emphasizes the importance of a thorough review of systems and critical analysis of every sign and symptom at the time of initial presentation, which helps the physician to obtain appropriate imaging studies early in the course, leading to an early diagnosis and treatment of the disease, such as in this case of an extremely rare germ cell tumor.

Treatment-Refractory, Primary Immune Thrombocytopenic Purpura in a Patient with Celiac Disease.

BACKGROUND Immune thrombocytopenic purpura (ITP) is primarily caused by antibody-mediated destruction of platelets. Alterations in immune homeostasis can induce loss of peripheral tolerance and promote the development of self-reactive antibodies. Primary ITP is the diagnosis of exclusion made after the extensive work-up rules out other possible causes of thrombocytopenia. The association between the ITP and other autoimmune disorders is well-established. In recent years, increasing attention has been directed toward the association between celiac disease (CD) and ITP. CASE REPORT A 27-year-old man with a history of primary ITP presented with an occasional nosebleed, 1 episode of rectal bleeding, and easy bruising. The patient was later found to have high titers of TTG-IGA and endomysial IGA levels consistent with CD. Our patient not only failed to improve with the gluten-free diet, but also failed multiple lines of treatment including steroids, IVIG, rituximab, eltrombopag, and even a non-traditional treatment for ITP (azathioprine and plasma exchange). The patient's CD-related antibody titers remained elevated. CONCLUSIONS It is possible that in certain cases the alteration of immune response caused by CD with a concurrent elevation of CD-related antibodies can make ITP refractory to all medical management. Whether or not this refractoriness to treatment is related to the persistently elevated antibody titers of CD or unknown genetic relationship between ITP and CD remains not entirely clear and warrants further molecular, immunologic, and genetic analysis.

High Incidence of Thrombotic Thrombocytopenic Purpura Exacerbation Rate Among Patients With Morbid Obesity and Drug Abuse.

This study aims to identify the baseline patient characteristics, clinical presentation, and response to treatment of 11 patients who were diagnosed with thrombotic thrombocytopenic purpura (TTP) between 2014 and 2020 at Brookdale University Hospital Medical Center, Brooklyn, NY. Laboratory and clinical parameters were recorded for 29 patients who received plasmapheresis in this time period. Of 29 patients, 11 had confirmed TTP and one was diagnosed with hereditary TTP. Young, black, and female patients made up the majority of our patient population. A high prevalence of obesity and drug abuse were seen among our patients. Five out of 11 were obese and four of them were morbidly obese; six out of 11 patients were positive for the drug screen including cannabinoids (3), opiates (2), benzodiazepines (1), PCP (1), and methadone (1). Four patients with a positive drug screen had acute kidney injury (AKI), and plasmapheresis helped them enhance their kidney function. We observed a high incidence of AKI and high TTP exacerbation rates in patients who were drug abusers and those who were morbidly obese. There is a paucity of data on the relationship of TTP with obesityor drug abuse and this needs further study.

Hematological manifestations and complications of COVID-19.

The virus SARS-CoV-2 commonly causes self-resolving, flu-like illnesses in the majority of patients, but a critical illness can be seen in 5% of cases - especially in the elderly population or in patients with multiple comorbidities. When COVID-19 is severe, it can cause pneumonia and hypoxemic respiratory failure, and can progress to viremia involving multiple organ systems. It causes significant cytopenia, mainly severe lymphopenia, and excessive exhaustion of CD8+ T cells, resulting in an immunocompromised state and cytokine storm. Furthermore, COVID-19 can commonly be complicated with acute thrombotic events, including venous thromboembolism, acute stroke, acute myocardial infarction, clotting of hemodialysis and extracorporeal membrane oxygenation (ECMO) catheters, and acute limb ischemia. This makes SARS-COV-2 a unique virus with an undiscovered pathophysiology. Therefore, patients with COVID-19 need close monitoring of their symptoms and laboratory parameters, and early hospitalization and treatment in severe cases. Early identification of severe cases and the abovementioned complications of COVID-19 could decrease the morbidity and mortality caused by the disease. In the study, we summarize what is currently known about the hematological manifestations and complications of COVID-19.

The Association Between Anemia of Chronic Inflammation and Alzheimer's Disease and Related Dementias.

BACKGROUND: Dementia is a spectrum of neurological diseases characterized by memory impairment and cognitive decline with the pathogenesis and effective management remaining elusive. Several studies have identified a correlation between anemia and Alzheimer's disease and related dementias (ADRD); however, anemia subtypes and association with ADRD have yet to be studied conclusively. OBJECTIVE: To study an association between ADRD and anemia of chronic inflammation. METHODS: We conducted a retrospective case-control study of the patients, diagnosed with ADRD at Brookdale Hospital. Pair-wise comparisons between means of controls and cases in terms of iron studies and laboratory results were performed using a Mann-Whitney U test. Pair-wise comparisons between anemia subgroups (moderate and severe) were performed using a Two Sample proportion Z-Test, where for each couple of normally distributed population. RESULTS: There was a total of 4,517 (1,274 ADRD group; 3,243 Control group) patients. There was significant difference in hemoglobin 10.15 versus 11.04 [p-value <0.001]. Iron studies showed a significant difference in ferritin 395±488.18 versus 263±1023.4 [p < 0.001], total iron binding capacity 225±84.08 versus 266±82.30 [p < 0.001] and serum iron level 64±39.34 versus 53±41.83 [p < 0.001]. Folic acid and vitamin B12 levels were normal in both groups. Severe and moderate anemia in the ADRD group were respectively 6.2% [95% CI: 4.2-8.4] and 13% [95% CI: 9.8-16.2] higher. Overall, incidence of moderate-to-severe anemia was found to be 19% higher in ADRD group [95% CI: 15.8-22.1]. CONCLUSION: We demonstrated an association between ADRD and anemia of chronic inflammation independent of age, renal function, and HgbA1C levels.

Ivermectin: A Closer Look at a Potential Remedy.

Amid the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the search for effective treatment and vaccines has been exponentially on the rise. Finding effective treatment has been the core of attention of many scientific reports and antivirals are in the center of those treatments. Numerous antivirals are being studied for the management of the coronavirus disease 2019 (COVID-19) pneumonia caused by the SARS-CoV-2. Remdesivir was the first drug to gain emergency FDA approval to be used in COVID-19. Similarly, favipiravir, an anti-influenza drug, is being studied as a potential agent against COVID-19. Contrastingly, hydroxychloroquine has been a controversial drug in the management of COVID-19. Nevertheless, the National Institute of Health (NIH), along with the World Health Organization (WHO), have discontinued clinical trials for hydroxychloroquine as the drug showed little or no survival benefit. Ivermectin, an antihelminthic drug, has shown antiviral properties previously. Additionally, it was described to be effective in vivo against the SARS-CoV-2. However, its survival benefit in patients with COVID-19 has not been documented. We herein propose the theory of inhaled ivermectin which can attain the desired lung concentration that will render it effective against SARS-CoV-2.

Spontaneous Retroperitoneal Bleed Coincided With Massive Acute Deep Vein Thrombosis as Initial Presentation of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has caused a global pandemic and unfortunately has caused a health crisis. When severe, coronavirus disease 2019 (COVID-19) can manifest with bilateral pneumonia and hypoxemic respiratory failure but also can affect different organ systems. SARS-CoV-2 infection is known to cause a hypercoagulable state resulting in acute thrombotic events, including venous thromboembolism, acute myocardial infarction, acute stroke, acute limb ischemia, and clotting of ECMO (extracorporeal membrane oxygenation) and CRRT (continuous renal replacement therapy) catheters. Even though it commonly causes thrombotic complications, bleeding complications of COVID-19 due to coagulopathy and use of anticoagulation are less commonly reported. We herein present a case of a patient with COVID-19 complicated by spontaneous retroperitoneal bleeding and massive deep vein thrombosis (DVT), which was later complicated by compartment syndrome. To the best of our knowledge, coexistence of spontaneous bleeding with massive DVT has not been reported in the current literature. This case emphasizes that COVID-19 induced hypercoagulable state can cause massive thrombosis, and patients might need anticoagulation therapy. However, clinicians should also consider the risk of hemorrhagic complications of the disease and be cautious when administering anticoagulant therapy in selected cases.

Multiple Lacunar Cerebral Infarcts as the Initial Presentation of COVID-19.

Coronavirus Disease-19 (COVID-19) is a novel corona virus that started as an outbreak in the Hubei province of China in December 2019 and later became a pandemic affecting every continent on the planet. Patients with severe COVID-19 tend to develop acute thrombotic complications including myocardial infarction, pulmonary embolism, and ischemic stroke. We describe a case of a 75-year-old-female who presented with acute onset slurred speech and right sided facial droop. She was diagnosed with COVID-19 with acute ischemic stroke as the initial presentation. Stroke as the initial presentation of COVID-19 is rare and has not been described in the literature frequently. The purpose of this report is to raise awareness about this potential complication of COVID-19 as an initial presentation.

Acute Kidney Injury Caused by Levetiracetam in a Patient With Status Epilepticus.

Levetiracetam is a widely used, effective and usually well-tolerated anti-epileptic medicine. It is mostly excreted by kidneys and requires dose adjustment according to the glomerular filtration rate. Very few case reports have been published in the literature about levetiracetam causing acute kidney injury (AKI). We present a case of a 26-year-old male with a seizure disorder on levetiracetam, presented with status epilepticus requiring intubation for airway protection. He received 4 g of intravenous levetiracetam as a loading dose and continued with a maintenance dose of 750 mg intravenous every 12 hours. He had signs of AKI on day two and creatinine eventually reached a maximum level of 12.2 mg/dL. His kidney function improved to his new baseline in a period of 30 days without requiring renal replacement therapy. He did not have significant rhabdomyolysis and his kidney function started improving right after his anti-epileptic therapy was switched to valproic acid pointing towards levetiracetam as the primary cause of kidney injury. Clinicians should be aware that levetiracetam can cause AKI on patients with a seizure disorder, especially when administered in high doses. Kidney function should be monitored closely and patients should be treated aggressively with intravenous fluids when they have any signs of rhabdomyolysis to prevent further kidney damage.

Disseminated Varicella-Zoster Virus Infection Complicated by Encephalitis and Ramsay Hunt Syndrome in an HIV Patient.

Varicella-zoster virus (VZV) is a human α-herpesvirus which cause primary varicella infection (chicken pox) or herpes zoster infection (shingles) after reactivation of the dormant virus. VZV infection is usually self-limited but disseminated infection can be seen in immunocompromised individuals. It can also get complicated by central nervous system (CNS) involvement. We describe a case of a 51-year-old male with human immunodeficiency virus (HIV) who presented with altered mental status and deficits in his right-sided cranial nerves of VI, VII, and VIII. The patient also had disseminated vesicular-pustular rash all over his body at different stages of healing. A diagnosis of disseminated VZV infection complicated by encephalitis and Ramsay Hunt syndrome was made and the patient was treated with intravenous acyclovir and oral prednisone with a rapid improvement. The coexistence of these conditions is rare. The purpose of this report is to increase awareness of the coexistence of these two conditions in HIV infected patients.

Polycythemia Vera Presenting With Normal Hemoglobin and Hematocrit: A Rare Variant.

Polycythemia vera (PV) is a myeloproliferative neoplasm, and its diagnosis requires elevated hemoglobin level (>16.5 mg/dL in men and >16 mg/dL in women), bone marrow characteristics of PV (hypercellularity for age with trilineage growth), and presence of JAK2 (Janus kinase 2) mutations or subnormal erythropoietin level if JAK2 mutation is not present. There exists a subset of patients with normal hemoglobin and hematocrit due to either from dilution of the blood or from coincidental blood loss anemia but these patients still might have underlying PV. These patients have masked PV, which is a variant of overt PV. We present a case of masked PV presenting with venous thrombosis as a first presentation and with normal blood counts. A 42-year-old male with past medical history of portal vein thrombosis and portal hypertension presented with nausea and vomiting presumably secondary to viral gastroenteritis. He was not an alcoholic nor a smoker. He was diagnosed with portal vein thrombosis six years ago which was treated with warfarin but was never investigated for a cause. His physical exam was within normal limits except he had splenomegaly. His laboratory values on admission showed hemoglobin of 14.1 g/dL, white blood count of 7.4 x109/L, and platelet count of 164 x109/L. His liver function test and renal function tests were within normal limits. His viral gastroenteritis improved within 48 hours. Extensive workup to rule out myeloproliferative neoplasm, thrombophilia, antiphospholipid syndrome, and paroxysmal nocturnal hemoglobinuria was arranged. Final results revealed JAK2V617F genetic mutation with a subsequent bone marrow analysis revealing a hypercellular marrow with increased trilineage hematopoiesis, consistent with primary PV. It is rare for myeloproliferative neoplasms to present with normal blood counts. There is a subgroup of patients with JAK2-positive PV presenting with normal hemoglobin and hematocrit. The prognosis of these subgroups seems to be poor especially when present in the older age group and with associated leukocytosis. Our case emphasizes two important points: first, need for extensive workup in a patient with unusual site thrombosis including JAK2 analysis and second, investigating for myeloproliferative neoplasm if presented with thrombosis even with normal blood counts.

Unexplained chronic cytopenia: is it idiopathic cytopenia of undetermined significance or myelodysplastic syndrome.

Idiopathic cytopenia is a condition where there is a decrease in peripheral blood counts causing either anaemia, leucopoenia and thrombocytopaenia. Most cases of cytopenia reveal a cause on further workup. But very rarely, in some cases, a definitive cause could not be identified. Unexplained cytopenia becomes challenging and poses difficulty in diagnosis and management. Discriminating these groups of bone marrow failure disorders from myelodysplastic syndrome (MDS) becomes an important clinical question. We describe a case of a middle-aged Hispanic woman who presented with pancytopenia and on extensive workup did not reveal any specific cause. Her bone marrow examination revealed severely reduced megakaryocytes but with normal haemopoiesis of other lineages. Cytogenetics, flow cytometry, comprehensive next-generation whole genomic analysis did not reveal any abnormalities. She fit the criteria for idiopathic cytopenia of undetermined significance rather than MDS. She remained asymptomatic and her counts never improved with immunosuppressives or thrombopoietin mimetics.

An Unusual Presentation of Merkel Cell Carcinoma in a HIV Patient: A Case Report and Literature Review.

Merkel cell carcinoma (MCC) is a rare, rapidly growing, aggressive neuroendocrine skin cancer that generally arises on sun-exposed areas of body such as head, neck, upper limbs, and shoulders of people with light complexity. Typically, MCC presents as shiny, flesh-colored or bluish-red, intracutaneous nodule, possibly with ulceration or crusting. In most of the cases, there is an association with Merkel cell polyomavirus. Even though these are very aggressive tumors, early detection and treatment has always given favorable outcome. There seems to be no consensus in definite prognostic markers, and advanced stages have the worst outcome even with treatment. There has been a recent trend in using PD-I/PD-L1 target therapy rather than chemotherapy in these cancers and have shown to improve survival by many months. In this article, we report a very unusual presentation of MCC first found on left frontoparietal skull as an 8-cm diameter fixed, subcutaneous mass without any typical features of MCC and was found to have metastatic spread to lung and liver. The patient was treated with palliative radiotherapy to brain and chemotherapy with cisplatin/etoposide with addition of immunotherapy later.

Cholangiocarcinoma Presenting as Humoral Hypercalcemia of Malignancy: A Case Report and Literature Review.

Humoral hypercalcemia of malignancy (HHM) is most commonly encountered in squamous cell carcinoma (SCC) of different organs, and It is characterized by elevated parathyroid hormone-related peptide (PTHrP) levels. It may be seen as a manifestation of cholangiocarcinoma (CCC) at presentation and later in the course of the disease. However, HHM due to intrahepatic cholangiocarcinoma is a rare association and is associated with a poor prognosis. We herein report a case of hypercalcemia presenting as the first manifestation of an underlying rare variant of intrahepatic cholangiocarcinoma. Our patient is a 57-year-old male who presented to the emergency room with severe symptoms of constipation and polyuria and was admitted to the hospital for symptomatic hypercalcemia. He was found to have a hypermetabolic 15 cm liver mass, abdominal lymph nodes on imaging, which was subsequently diagnosed as adenosquamous cholangiocarcinoma by liver biopsy. This necessitated an urgent inpatient treatment with gemcitabine/cisplatin combination chemotherapy to control the aggressive nature of the malignancy. However, he deteriorated and expired after three months of his diagnosis. Adenosquamous cholangiocarcinoma is a very rare variant of a liver tumor. It develops due to squamous metaplasia of an underlying cholangiocarcinoma and usually has aggressive clinicopathological features. HMM is a life-threatening, yet unrecognized, phenomenon of cholangiocarcinoma, which represents a poor prognostic marker. Prompt recognition of this complication is important for preventing serious complications associated with hypercalcemia and to improve the quality of life of these patients.

Novel antifoam for fermentation processes: fluorocarbon-hydrocarbon hybrid unsymmetrical bolaform surfactant.

As foaming appears as a problem in chemical and fermentation processes that inhibits reactor performance, the eminence of a novel fluorocarbon-hydrocarbon unsymmetrical bolaform (FHUB: OH(CH2)11N+(C2H4)2(CH2)2(CF2)5CF3 I-) surfactant as an antifoaming agent as well as a foam-reducing agent was investigated and compared with other surfactants and a commercial antifoaming agent. The surface elasticity of FHUB was determined as 4 mN/m, indicating its high potential on thinning of the foam film. The interactions between FHUB and the microoganism were investigated in a model fermentation process related with an enzyme production by recombinant Escherichia coli, in V = 3.0 dm3 bioreactor systems with V(R) = 1.65 dm3 working volume at air inlet rate of Q(o)/V(R) = 0.5 dm3 dm(-3) min(-1) and agitation rate of N = 500 min(-1) oxygen transfer conditions, at T = 37 degrees C, pH(o) = 7.2, and C(FHUB) = 0 and 0.1 mM, in a glucose-based defined medium. As FHUB did not influence the metabolism, specific enzyme activity values obtained with and without FHUB were close to each other; however, because of the slight decrease in oxygen transfer coefficient, slightly lower volumetric enzyme activity and cell concentrations were obtained. However, when FHUB is compared with widely used silicon oil based Antifoam A, with the use of the FHUB, higher physical oxygen transfer coefficient (K(L)a) values are obtained. Moreover, as the amount required for the foam control is very low, minute changes in the working volume of the bioreactor were obtained indicating the high potential of the use of FHUB as an antifoaming agent as well as a foam-reducing agent.