An Unseen Challenge: Mycotic Pseudoaneurysm Emerges in the Wake of Everolimus-Eluting Stent Deployment.

This case report presents a unique instance of mycotic pseudoaneurysm in the proximal right coronary artery (RCA) following percutaneous coronary intervention (PCI) in a 75-year-old male with a complex medical history. Despite successful initial intervention and resolution of bacteremia, the patient presented three months later with recurrent anginal symptoms. The diagnostic evaluation revealed a mycotic pseudoaneurysm in the RCA, leading to surgical clipping and graft implantation. The successful surgical outcome underscores the critical role of early recognition and intervention in enhancing patient survival. This case contributes valuable insights into the diagnostic intricacies and therapeutic nuances of mycotic pseudoaneurysm, reinforcing the importance of maintaining a heightened index of suspicion, particularly in patients with a history of coronary interventions.

A Rare Presentation of Synchronous Colorectal Adenocarcinoma.

Synchronous carcinoma is defined as multiple malignant lesions presented in a single patient at initial diagnosis. Synchronous colorectal adenocarcinoma is a rare entity that has been increasingly recognized, likely due to the significant improvement in imaging and diagnostic tools. Making the appropriate diagnosis of synchronous colorectal cancer has a major role in the management's determination and treatment plans. Herein, we are reporting a case of a 73-year-old gentleman who was diagnosed with synchronous colorectal adenocarcinoma with two masses in the left colon and was treated initially surgically followed by chemotherapy.

Beyond the Expectation: Pembrolizumab-Associated Tumor Lysis Syndrome in Metastatic Gastric Adenocarcinoma.

Tumor lysis syndrome (TLS) emerges as a critical oncological emergency, a consequence of the body's struggle to manage the intense cellular turnover and release of cytotoxins induced by treatments such as chemotherapy, radiation, targeted immune therapy, or hormonal therapy. While commonly associated with hematological malignancies, the heightened risk also extends to advanced-stage solid tumors and instances of liver metastasis. Although TLS is a rare occurrence in gastric adenocarcinoma, reported cases are usually linked to the initiation of chemotherapy. Remarkably, the incidence of TLS following the commencement of pembrolizumab in gastric adenocarcinoma remains undocumented in the existing literature. In this context, we present a compelling case involving a 73-year-old gentleman diagnosed with advanced-stage metastatic gastric adenocarcinoma. Strikingly, the patient developed TLS subsequent to the initiation of pembrolizumab (Keytruda®). This unique scenario not only accentuates the atypical manifestation of TLS in the context of gastric adenocarcinoma but also underscores the need for heightened awareness and exploration of potential complications associated with immunotherapeutic agents in solid tumor settings. The detailed analysis of this case contributes valuable insights that may prove instrumental in refining our understanding of the intricate interplay between immunotherapy and tumor lysis syndrome in the specific landscape of gastric adenocarcinoma.

Transient Ischemic Attack, the Initial Presentation of Azygos to Pulmonary Vein Fistula.

There are different sources of cerebral emboli, including cardiac embolism, extracranial arterial embolism, paradoxical embolism, trauma, and iatrogenic embolism. In rare cases, atypical sources should be ruled out. We are reporting a lady who presented with transient ischemic attack and had a fistula between the azygos to the pulmonary vein. (Level of Difficulty: Advanced.).

Massive Atrial Thrombosis: A Serious Complication of the Maze Procedure Triggered by Heparin-Induced Thrombocytopenia (HIT).

Atrial fibrillation is one of the most common cardiac arrhythmias, classically presenting with an "irregularly irregular" rhythm with or without chest pain, palpitations, shortness of breath, lightheadedness, or fatigue. The maze procedure is an open-heart operation that creates a carefully designed maze of incisions and ablations in the atrial myocardium. Although it is a common procedure, serious complications may happen. Herein, we report on a 76-year-old man who presented with chest pain and atrial fibrillation and was found to have multi-vessel disease on a coronary angiogram. He underwent coronary artery bypass and the COX-maze procedure, which was complicated by a massive thrombosis in the atria and the superior vena cava following the ablation line, secondary to heparin-induced thrombocytopenia, which is extremely rare. The central focus of this paper is to present this rare complication to stress the importance of rigorous follow-up and anticoagulation therapy in patients undergoing the maze procedure. To our knowledge, we are the first to report such a rare case of diffuse large atrial thrombi triggered by heparin-induced thrombocytopenia (HIT) type II after a COX-maze procedure.

A Unique Case of the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT) Presenting With Multiple Neurological Sequelae.

Lithium can have toxic effects on the central nervous system (CNS) that can be both acute and chronic. The syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) was suggested in the 1980s to describe lithium intoxication-induced persistent neurological sequelae. In this article, we report a 61-year-old patient with bipolar disorder who had developed expressive aphasia, ataxia, cogwheel rigidity, and fine tremors after acute on chronic lithium toxicity. These neurological symptoms remained for four months after discontinuation of lithium, confirming the persistence of CNS signs and symptoms, which makes this case meets the SILENT syndrome criteria. Although rare, our report - which shows a severe and disabling form of SILENT syndrome - highlights the need for additional caution when treating patients with lithium and the need to perform strict control of the putative risk factors argued to be associated with the development of this syndrome.

Urinothorax, a rare complication of rupture renal calyx.

Urinothorax is one of the rare causes of pleural effusion of extra-vascular origin, commonly presents with a transudative pleural effusion due to obstruction, injury or trauma to the genitourinary tract. It is not a common cause which increases the likelihood of underdiagnosis or misdiagnosis. Herein, we are presenting a 65-year-old gentleman who presented with urinary symptoms found to have urinothorax secondary to urinary tract obstruction by benign prostatic hypertrophy. This case was further complicated by urinoma and pyelonephritis. We are reporting this case to highlight the importance of including this entity in the differential diagnosis in patients who have pleural effusion especially if they presented with obstructive urinary symptoms.

Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula.

Periampullary diverticula are outpouches in the mucosa in the duodenum surrounding the ampulla of Vater. Most cases of periampullary diverticuli are asymptomatic, but complications can arise, increasing a patient's mortality. Diagnosis of periampullary diverticuli is often incidental during endoscopy or imaging studies for abdominal pain. When a patient with periampullary diverticuli is symptomatic, imaging modalities such as CT scan and MRI can help make the diagnosis, but a side-viewing endoscope provides direct visualization of the diverticuli and also allows for the potential treatment of the disease. Lemmel's syndrome is a complication of periampullary diverticuli where the diverticuli causes mechanical obstruction of the bile duct leading to obstructive jaundice without choledocholithiasis. These patients are at risk for further complications such as sepsis and perforation. Early diagnosis and treatment of these patients can help to prevent further complications from arising. We are presenting a case of Lemmel's syndrome with obstructive jaundice from a periampullary diverticuli, further complicated by cholangitis without dilation of the biliary tree.

A rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both duodenum and ascending colon.

Lymphoma in the gastrointestinal tract most commonly occurs in the stomach, small intestine and around the ileocecal region. Usually gastrointestinal lymphoma occurs secondary to widespread nodal disease and is rarely found to be the primary site. Of the different types of lymphoma, diffuse large B-cell non-Hodgkin's lymphoma makes up the majority of lymphomas in the gastrointestinal tract. Primary colorectal lymphoma is even less common and accounts for 3% of all gastrointestinal lymphomas and to our knowledge, gastrointestinal lymphoma involving 2 different regions in the GI tract has not been discussed in the literature. Herein, we are presenting a rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both the duodenum and ascending colon.

Schizencephaly as an Unusual Cause of Adult-Onset Epilepsy: A Case Report.

Schizencephaly is a very rare anatomical malformation of the cerebrum characterized by a cleft extending from the cortex to the ventricles. Usually, this disease is diagnosed at a very young age or in early adulthood. Symptoms may vary depending on the site and the size of the malformation. Here, we are describing the unique case of a 21-year-old female, with a past medical history of migraine-type headaches, who presented after the first-onset seizure and was found to have open-lip schizencephaly. She was started on levetiracetam with no complications. In this report, we are trying to describe the proposed etiology and discuss the typical clinical presentation of schizencephaly and compare it to our adult patient who survived childhood without significant cognitive or neurological impairment.

A rare case of marijuana associated with ascending aorta thrombosis complicated with stroke and bilateral renal infarcts.

Ascending aortic is an uncommon site for arterial thrombosis and ascending aortic thrombosis is a very rare phenomenon with a high fatality rate. Marijuana is the most commonly used psychoactive drug in the United States and a few cases have been reported on the association of marijuana with vascular thromboembolism. However, the pathophysiology and exact mechanism are still not well studied. Herein, we present a case of a 44-year-old female with active marijuana use presented with ascending aortic thrombus associated with acute arterial occlusion of the right vertebral artery and bilateral renal artery. The unique part of this case is that the patient did not have the classical risk factors for vascular thromboembolic disease. The only risk factor was marijuana smoking. To our best knowledge, this is one of the unique cases of marijuana-associated with ascending aorta thrombosis.

Cardiac Tamponade Associated with Human Immunodeficiency Virus-Associated Immune Complex Kidney Disease.

Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.

Unusual Presentation of Post-coital Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a grave medical condition that is defined as a separation of the coronary artery wall layer. This presentation is rare in males and can be triggered by cardio-circulatory stress, such as exercise and emotional stress. Sexual intercourse is considered potent cardiovascular stress that can be strenuous and cause rapid and significant changes in the heart rate and blood pressure which can predispose SCAD. Herein, we are reporting a very rare case of a 41-year-old male gentleman who presented with SCAD after vigorous sexual intercourse. We are reporting this case to encourage physicians to educate their patients on the topic.

Hiccups as a Rare Presentation of Thyrotoxicosis Triaged by an Epidural Steroid Injection.

Thyrotoxicosis manifests when excess levels of thyroid hormone act on different tissues throughout the body. Excess hormone levels can be related to endogenous production or exogenous ingestion and can present differently in patients. It has been theorized that high levels of thyroxine can irritate the neuroanatomical hiccup center leading to persistent hiccups. Although extremely rare, physicians should be aware of this entity to allow for proper diagnosis and management. Here, we discuss a rare case of thyrotoxicosis after an epidural steroid injection presenting with intractable hiccups.

Cerebral Air Embolism After Gastrointestinal Procedure: A Case Report and Literature Review.

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity.

A rare presentation of transient hypothermia in HIV infection: A case report and systematic review of cases.

Hypothermia defined as a core body temperature less than 35°C causes hundreds of deaths annually in the United States. It can occur in a variety of clinical settings, including environmental exposure, shock, infection, metabolic disorders, alcohol, or drug toxicity, and malnutrition. This condition can affect many different organ systems and may lead to serious complications including cardiac arrhythmia. Hypothermia is extremely rare in people living with HIV but can be seen in severely malnourished patients or those who are not receiving antiretroviral therapy (ART). It is a life-threatening situation that should be treated aggressively. To the best of our knowledge, there are only a few cases that have been reported for people living with HIV presenting with hypothermia and sinus bradycardia. Herein, we are reporting a very rare case of people living with AIDS who presented with hypothermia complicated by sinus bradycardia. In addition, we also performed a systematic review of cases based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, to investigate the clinical characteristics and outcomes associated with this rare complication. This systematic review of cases hopefully can increase the awareness of this rare entity and help improve its outcome.

A Case of Bordetella bronchiseptica Bacteremia in a Patient With Decompensated Liver Cirrhosis.

Bordetella bronchiseptica is a rare cause of respiratory tract infection in humans, most commonly found in immunocompromised individuals exposed to infected animals. It colonizes the respiratory tract and can lead to infection in dogs, cats, rabbits, and others. In immunocompromised patients, it has been reported to result in life-threatening infections but rarely affects immunocompetent individuals. Here, we are the first to report a case B. bronchiseptica bacteremia in a patient with decompensated liver cirrhosis without known animal exposure.

A Unique Case of Co-Occurrence of Bilateral Pulmonary Artery Embolism and Right Atrium Thrombus.

Pulmonary embolism (PE) is considered a major cause of morbidity and mortality in both inpatient and outpatient settings. PE can be presented in different clinical pictures. However, the association between PE and right atrial thrombus is not frequently reported. PE is categorized based on size, location and clinical presentation. Although management changes between different PE sub-types, optimal medical therapy is not well established for coexisting PE with right atrial thrombus. Herein, we present a unique case of a 58-year-old male with bilateral PE and atrial thrombus, with no known underlying risk factors.

Sensory Axonopathy Associated With Vitamin E Deficiency.

Vitamin E deficiency can be observed in patients with malabsorption syndromes or inherited diseases such as ataxia. It is unusual for it to be a result of dietary insufficiency due to its presence in a wide variety of foods. Patients with vitamin E deficiency can present with neuromuscular disorders such as ataxia, hyporeflexia, spinocerebellar syndrome, as well as loss of vibration and proprioceptive sensation. Herein, we are presenting a case in which a previously healthy adult with no family history of genetic defects and malabsorption syndrome presented with a characteristic sensory axonopathy associated with vitamin E deficiency without any evidence of fat malabsorption. Patient reported a markedly improvement of symptoms after three-month supplementation of vitamin E. The unique part of this case was that the patient presented with neuropathic pain associated with vitamin E deficiency without any family history of inherited deficiency or any malabsorption syndrome.