Transient Ischemic Attack Shakes: A Case Report.

Transient ischemic attack (TIA) shakes can present as epilepsy which could lead to misdiagnosis. When a patient present with neurological findings we must ensure our differentials remain broad. As a physician, we must ensure our role in analyzing the full clinical picture of our patients. We present the case of a 75-year-old man with multiple comorbidities who presented with limb shaking and seizure-like symptoms and who was found to have bilateral carotid stenosis. After finding bilateral carotid stenosis, it ultimately led to the diagnosis of "TIA Shakes." Overall, this case re-emphasizes the importance of diagnosis and correctly managing our patients.

COVID-19 associated collapsing glomerulopathy presenting as acute kidney injury on chronic kidney disease: a case report and review of the literature.

Traditionally collapsing glomerulopathy (CG) is associated with medications, autoimmune disease, viral infection and the APOL1 gene variant seen in blacks/African Americans. Most reported cases of acute kidney injury (AKI) in COVID-19 infected individuals have been in individuals without prior CKD. In this report, we present a 49-year-old African American female with a past medical history of chronic kidney disease (CKD) stage 4, hypertension, type 2 diabetes mellitus, recent COVID-19 infection, and a repeat positive blood test for COVID-19 more than 21 days after the initial result, who presented with an AKI on CKD. Renal biopsy revealed a collapsing glomerulopathy. She was started on hemodialysis and did not receive immunosuppressive therapy due to the advanced scaring seen on the renal biopsy. Concerning the pathophysiology of COVID-19-associated CG, researchers have postulated different mechanisms such as a direct cytopathic effect of the virus on podocytes, immune dysregulation, and fluid imbalance. This is one of a few cases of AKI on CKD due to CG related to COVID-19. The mechanism of CG was, however, unclear. Currently, there is no specific interventions to prevent the development of CG in patients with COVID-19 infection. Further studies should investigate measures to prevent the development of CG.

A Case of Massive Lower Gastrointestinal Bleed from a Cystic Artery Pseudoaneurysm Bleeding through a Cholecystocolic Fistula.

BACKGROUND Acute lower gastrointestinal bleeding (GIB) is often associated with favorable outcomes. It is readily diagnosed and managed with colonoscopy, or may resolve spontaneously. Rarely, extra-colonic sources of bleeding may masquerade as lower GIB, posing a diagnostic challenge and potentially lead to harm if there are therapeutic delays. An example is cystic artery pseudoaneurysm, a rare complication of acute cholecystitis and laparoscopic cholecystectomy, which may bleed through a cholecystocolic fistula presenting as lower GIB. CASE REPORT A 66-year-old man with multiple comorbidities including coronary artery disease with multiple stents and peripheral arterial disease presented with massive hematochezia. He was on aspirin 81 mg, clopidogrel 75 mg, and rivaroxaban 20 mg daily. The patient was hemodynamically unstable with BP 77/50 mmHg and heart rate 115 beats/min. Pertinent laboratory investigations showed hemoglobin 10.4 g/dL, WBC 17.2×10³/uL, platelet 437×10³/uL, and INR 1.28. Total bilirubin and liver enzymes were normal. Following prompt volume resuscitation with crystalloids and 2 units of O-negative blood, CT angiogram of the abdomen revealed a ruptured cystic artery pseudoaneurysm bleeding through a cholecystocolic fistula. This developed as a complication of undiagnosed gangrenous cholecystitis. The patient was sent for transcatheter embolization and the bleeding was controlled. The gangrenous cholecystitis was managed conservatively due to the patient's high surgical risk. CONCLUSIONS Although extra-intestinal sources of gastrointestinal bleeding are rare, clinicians should maintain a high index of suspicion, especially in elderly patients presenting concomitantly with right upper-quadrant pain. As delayed diagnosis leads to increased fatality rates, a prompt CT angiogram of the abdomen is pertinent in suspected cases.