Splenic artery pseudoaneurysm; a cause or consequence: a case report.

BACKGROUND: Splenic artery pseudoaneurysm is a rare complication of recurrent pancreatitis usually presenting as an incidental finding on abdominal computed tomography. CASE PRESENTATION: We present the case of a 66-year-old north African male with a known history of previous pancreatitis who presented with upper gastrointestinal bleeding along with recurrent epigastric pain for 3 days. Investigations did not reveal any particular pancreatitis etiology. Computed tomography of the abdomen with contrast showed splenic artery pseudoaneurysm along with findings suggestive of acute pancreatitis. Upper and lower endoscopies failed to identify gastrointestinal the bleed source. The patient underwent intervention radiology embolization of the aneurysm sac with multiple coils via right retrograde common femoral artery-celiac access. The patient was discharged with a plan for capsule endoscopy in outpatient setting. CONCLUSION: Splenic artery pseudoaneurysm is a life-threatening complication and carries a high mortality rate if left untreated. Prompt identification through various imaging modalities, followed by urgent intervention, is crucial to avoid adverse outcomes.

Man-in-the-Barrel Syndrome Secondary to Idiopathic Acute Anterior Spinal Artery Infarction.

A 52-year-old female presented to our hospital with an acute history of isolated bilateral arm weakness. An MRI of the cervical spine confirmed an acute anterior spinal artery infarction. Further investigations to determine a specific etiology were unremarkable, leading to a diagnosis of idiopathic anterior spinal artery infarction consistent with Man-in-the-Barrel syndrome.

Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates.

BACKGROUND: Hospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates. METHODS: We established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted. RESULTS: The average LOS reduced from 10 to 5 days (95% CI [4.14-6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25-290.75], p < 0.001). There was no increase in 30-day readmission rates. CONCLUSION: Restructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

Thrombotic Microangiopathy Secondary to Disseminated Varicella Zoster Virus Infection in an Adult Patient.

BACKGROUND Thrombotic microangiopathy (TMA) is a life-threatening condition caused by small-vessel platelet microthrombi. While various disease triggering factors, including infections, have been well described, there have been few reports of an association between TMA and varicella zoster virus (VZV) infection. VZV infection is rare among people age 20 and older, and infection-induced TMA is mostly reported in the pediatric age group. We report a case of TMA induced by a disseminated VZV infection in an adult. CASE REPORT A 43-year-old man presented with a 3-day duration of fever, headache, vomiting, and bloody diarrhea. He also reported body rash after a recent contact with a few roommates with chickenpox. On presentation, the patient developed convulsive seizures. His laboratory test results were significant for acute kidney injury (AKI) and thrombocytopenia. Atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP) were suspected but further diagnostic testing was negative. The treatment plan included acyclovir, therapeutic plasma exchange, and high-dose oral prednisolone (1.5 mg/kg). The clinical and biochemical profile significantly improved, and the patient was discharged home. CONCLUSIONS TMA is a life-threatening hematological emergency with a high mortality rate. Compared to the pediatric population, VZV infection tends to be more severe in the adult age group. This case demonstrates that a high index of suspicion for TMA in adult patients with VZV who present with thrombocytopenia, even when there is no definitive diagnosis, can result in early management with favorable outcome.

Adrenal Gland Function and Dysfunction During COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic is currently one of the major health concerns worldwide accounting for many deaths and posing a great social and economic burden. Early activation of adrenal hormone secretion is pivotal to surviving systemic microbial infections. In addition, clinical studies demonstrated that glucocorticoids might also be beneficial in reducing disease progression and life deterioration in certain patients with COVID-19. Recent studies demonstrated that SARS-CoV-2 might target the adrenal glands, raising the possibility that at least some COVID-19 complications may be associated with adrenal dysfunction. Whether SARS-CoV-2 infection might cause adrenal dysfunction remains unknown. Histopathological examinations provided evidence that SARS-CoV-2 infection might indeed cause certain structural damage to the adrenal glands, especially concerning its vascular system. However, since no widespread cellular damage to cortical cells was observed, it is less likely that those changes could lead to an immediate adrenal crisis. This assumption is supported by the limited number of studies reporting rather adequate cortisol levels in patients with acute COVID-19. Those studies, however, could not exclude a potential late-onset or milder form of adrenal insufficiency. Although structural damage to adrenal glands is a rarely reported complication of COVID-19, some patients might develop a critical illness-related corticosteroid insufficiency (CIRCI), or iatrogenic adrenal insufficiency resulting from prolonged treatment with synthetic glucocorticoids. In this mini-review article, we aimed at describing and discussing factors involved in the adrenal gland function and possible dysfunction during COVID-19.

Risen Alive: The Lazarus Phenomenon.

The Lazarus phenomenon described as delayed return of spontaneous circulation (ROSC) after cessation of CPR is rare, though underreported. We present the case of a 25-year-old woman who visited our hospital for persistent vomiting and weight loss for the last six months following bariatric surgery. On the 16th day of admission, the patient experienced cardiac arrest (code blue). The patient underwent 73 min of continuous cardiopulmonary resuscitation (CPR); however, no responses were observed, which led to an announcement of death. Fifty minutes later, the family members noticed subtle eye movements that necessitated resumption of the advanced cardiac life support protocol and resuscitation. The patient survived; however, she developed significant neurological deficits secondary to prolonged anoxic brain injury. She was discharged after a ten-week stay in the hospital but did not achieve full neurologic, cognitive, and motor recovery. Patients should be observed and monitored after the cessation of CPR before confirming death.

COVID-Related Leukoencephalopathy: Unusual MRI Features and Comparability to Delayed Post Hypoxic Ischemic Encephalopathy.

COVID-19 related leukoencephalopathy can be multifactorial given the systemic effects of the viral disease. We present couple of cases with typical clinico-imaging stigmata of COVID-19 resulting in severe respiratory insufficiency. MR brain imaging revealed confluent diffuse supratentorial white matter T2 hyperintensity with restricted diffusion during the sub-acute course of the disease. The MR imaging pattern of leukoencephalopathy was non-specific but more comparable to delayed post-hypoxic leukoencephalopathy (DPHL) as also previously reported in COVID-19. Interestingly, T2 imaging showed unusual but peculiar finding of "accentuated medullary veins" in the superficial zones. No dural venous sinus thrombosis or micro-hemorrhages were present to explain "dots and stripes" due to dilated medullary veins. The patho-mechanism of this findings is not clear but may possibly be related to demyelination as DPHL has shown to be a demyelinating process. We present a review of COVID-related leukoencephalopathy with discussion on hypoxia-induced demyelinating process with accentuated medullary veins as possible associated marker.

Neuro-imaging manifestations of COVID-19: Predilection for PICA infarcts.

COVID-19 has been an ever-evolving viral pandemic which can cause systemic disturbance especially in some of the critically ill patients. Neurologic or Neuro-imaging manifestations of COVID-19 are being increasingly reported in these patients and mainly consist of ischemic strokes, hypoxic ischemic injury and non-specific encephalopathy. Ischemic strokes as expected more commonly afflict major vascular territories, likely due to accentuated hypercoagulability in these patients. Certain vascular territories may be more susceptible to ischemic infarcts. We observed higher predilection for infarcts in posterior inferior cerebellar artery (PICA). This may represent another peculiarity of this pandemic.

Correlation between Chest CT Severity Scores and the Clinical Parameters of Adult Patients with COVID-19 Pneumonia.

PURPOSE: Our aim is to correlate the clinical condition of patients with COVID-19 infection with the 25-point CT severity score by Chang et al. (devised for assessment of ARDS in patients with SARS in 2005). MATERIALS AND METHODS: Data of consecutive symptomatic patients who were suspected to have COVID-19 infection and presented to our hospital were collected from March to April 2020. All patients underwent two consecutive RT-PCR tests and had a noncontrast HRCT scan done at presentation. From the original cohort of 1062 patients, 160 patients were excluded leaving a total number of 902 patients. RESULTS: The mean age was 44.2 ± 11.9 years (85.3% males, 14.7% females). CT severity score was found to be positively correlated with lymphopenia, increased serum CRP, d-dimer, and ferritin levels (p < 0.0001). The oxygen requirements and length of hospital stay were increasing with the increase in scan severity. CONCLUSION: The 25-point CT severity score correlates well with the COVID-19 clinical severity. Our data suggest that chest CT scoring system can aid in predicting COVID-19 disease outcome and significantly correlates with lab tests and oxygen requirements.

New onset adrenal insufficiency in a patient with COVID-19.

SARS-CoV-2 is the cause of COVID-19. Since the outbreak and rapid spread of COVID-19, it has been apparent that the disease is having multi-organ system involvement. Still its effect in the endocrine system is not fully clear and data on cortisol dynamics in patients with COVID-19 are not yet available. SARS-CoV-2 can knock down the host's cortisol stress response. Here we present a case of a 51-year-old man vomiting for 10 days after having confirmed COVID-19 infection. He had hypotension and significant hyponatraemia. Work-up was done including adrenocorticotropic hormone stimulation test. He was diagnosed as suffering from adrenal insufficiency and started on steroids with subsequent improvement in both blood pressure and sodium level. COVID-19 can cause adrenal insufficiency. Clinicians must be vigilant about the possibility of an underlying relative cortisol deficiency in patients with COVID-19.

Bilateral Central Retinal Vein Occlusion in a 40-Year-Old Man with Severe Coronavirus Disease 2019 (COVID-19) Pneumonia.

BACKGROUND COVID-19 is the disease caused by the novel virus, severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). The spectrum of disease seen in patients with COVID-19 infection ranges from asymptomatic or mild symptoms to severe pneumonia and even acute respiratory distress syndrome, which often requires invasive ventilation and intensive care. COVID-19-associated infection can be catastrophic, leading to both arterial and venous occlusion, microinfarcts, and multiorgan failure, although retinal vein occlusion has not yet been reported. CASE REPORT We present the case of a 40-year-old man who presented with a 3-day history of shortness of breath, cough, and fever. He also reported right calf pain and blurring of vision in both eyes. His medical history included hypertension and morbid obesity. The patient was found to have severe COVID-19 pneumonia on high-resolution computed tomography of the chest, right leg deep venous thrombosis on Doppler ultrasonography, and bilateral central retinal vein occlusion (RVO) on fundal examination. He was started on full-dose anticoagulation and discharged on rivaroxaban for 3 months. After 2 weeks of therapy, he had fully recovered from his COVID-19 symptoms and had near-normal vision. CONCLUSIONS COVID-19 infection can cause RVO. Early full-dose anticoagulation should be considered in high-risk patients with severe COVID-19 infection. Ophthalmologists and other clinicians should have a high index of suspicion for RVO in patients with COVID-19 infection who presenting with blurred vision and severe pneumonia.

Covid-19 pandemic research opportunity: Is the Middle East & North Africa (MENA) missing out?

BACKGROUND: The Covid-19 pandemic has caused fear and panic worldwide, forcing healthcare systems to disregard conventional practices and adopt innovation to contain the infection and death. Globally, there has been a rapid proliferation of research studies and clinical trials assessing risks, infectivity and treatment. METHODS: This review assesses the opportunities and challenges in the Middle East North Africa (MENA) region to engage in the conduct of high quality clinical trials during the Covid-19 pandemic. RESULTS: Opportunities are abundant for conducting clinical trials in MENA countries, including substantial cost savings, academic health centers, integrated health information systems, international accreditation, and international collaborations. Yet, the MENA region has missed out on opportunities to advance patient research during prior infectious disease outbreaks caused by the Severe Acute Respiratory Syndrome, Ebola, and the Middle East Respiratory Syndrome, as evidenced by the lack of concerted research and clinical trials from the region. A large vulnerable population, especially the poor expatriate work force, the current isolation of the health centers, and the lack of an expert network or field trained task force, all contribute to challenges preventing the formation of a pan Arab research enterprise for epidemics. CONCLUSION: Quality clinical research is critical during public health emergencies to identify treatments and solutions. The efficient conduct of clinical trials requires innovative strategies in research design, approval, and dissemination. Many countries in the MENA region have an opportunity to quickly ramp up research capacity and contribute significantly to the fight against the Covid-19 global threat.