Splenic Laceration: A Rare Complication of Colonoscopy.

Splenic injury is usually seen with penetrating or blunt abdominal trauma. It is also one of the rare complications of colonoscopy. Various patient and procedural factors have been reported to increase the risk of this dreaded complication. We present a case of splenic injury after outpatient colonoscopy where intra-abdominal adhesions from previous abdominal surgeries were presumed to be the cause of splenic injury. Our patient had improved outcomes with timely diagnosis and intervention.

Turning walking pneumonia into recurrent abscesses: a curious case of CVID and review of the literature.

BACKGROUND: Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder associated with a broad symptom presentation that is still being characterized. We report a rare case of recurrent mycoplasma skin abscesses in a patient with a history of autoimmune disorders and prolonged mycoplasma pneumonia who was diagnosed with CVID. CASE PRESENTATION: A 34-year-old woman presented with a history of recurrent abscesses previously confirmed positive for Mycoplasma pneumoniae. Her past medical history of recurrent mycoplasma abscesses, prolonged mycoplasma pneumonia, and autoimmune disorders (mixed connective tissue disease and immune thrombocytopenia) raised suspicion of CVID. Workup included negative anti-mycoplasma antibody titers, hypogammaglobulinemia, and negative anti-pneumococcal antibody titers despite prior vaccination, solidifying the diagnosis of CVID. The patient was discharged on antibiotic and intravenous immunoglobulin therapy and now follows allergy and immunology long-term for treatment. CONCLUSIONS: Her diagnostic history underscores the importance of considering the various criteria of CVID for diagnosis, and her unique presentation of M. pneumoniae skin abscesses highlights the broad sequelae patients with CVID can manifest.

Eculizumab for refractory thrombosis in antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis with antiphospholipid antibodies. Dysregulation of the complement pathway has been implicated in APS pathophysiology. We report the successful use of eculizumab, an anti-C5 monoclonal antibody, in controlling and preventing recurrent thrombosis in a refractory case of APS. An 18-year-old female was diagnosed with APS after developing extensive, unprovoked deep vein thrombosis (DVT) of axillary, inferior vena cava, and brachiocephalic veins. Thrombophilia evaluation revealed triple-positive lupus anticoagulant, ß-2 glycoprotein IgM, IgA, and anticardiolipin antibodies (each >40 U/mL) with persistently positive titers after 12 weeks. She was refractory to multiple anticoagulants alone (enoxaparin, fondaparinux, apixaban, rivaroxaban, and warfarin) with antiplatelet (aspirin and clopidogrel) and adjunctive therapies (hydroxychloroquine, immunosuppression with steroids and rituximab, and plasmapheresis). Despite these, she continued to develop recurrent thrombosis and additionally developed hepatic infarction and pulmonary embolism with failure to decrease titers after 6 weeks of plasma exchange. Following this event, eculizumab (600 mg weekly × 4 weeks followed by 900 mg every 2 weeks) was initiated in combination with fondaparinux, aspirin, clopidogrel, and hydroxychloroquine. She has remained on this regimen without recurrence of thrombosis. Our case suggests that eculizumab may have a role as a therapeutic option in refractory thrombosis in APS.

Is Increased BMI a Risk Factor for Developing Severe Clostridioides Difficile Infection? A Retrospective Study.

Background: Obesity is associated with a relative increase in bacterial phyla like firmicutes, which helps in the colonization of Clostridioides Difficile. Hypothesis: Individuals with increased BMI (greater than 25) are more susceptible to severe Clostridioides Difficile infection (CDI). Methods: Data was collected by retrospective chart query. Severe CDI was defined as a white blood cell count of more than 15,000 (x 109 cells/L) or serum creatinine levels greater than 1.5 mg/dL. To examine the association between the primary outcome (severe CDI) and BMI, the factors of age, gender, albumin level, ICU admission, antibiotic use within 3 months of admission, diabetes, and hypertension were also considered. Patients with chronic kidney disease, end-stage liver disease, pregnancy, inflammatory bowel disease, previous gastrointestinal surgeries, active malignancy, and immunosuppressed were excluded. Results: 219 patients were included in the final study. Of these 52.8% of patients had severe CDI, and 47.2% had non-severe CDI. Compared to normal-weight patients, risk of severe CDI was not influenced by being obese (OR = 1.26, p = 0.5119), overweight (OR = 1.65, p = 0.21), or underweight (OR = 1.05, p = 0.9383). Males had higher odds of having severe CDI when compared with females (OR = 1.76, 95% CI = 1.03 to 3.01, p = 0.0395). Albumin levels greater than 3.0 mg/dL were associated with lower odds of having severe CDI (OR = 0.41, 95% CI = 0.27 to 0.62, p< 0.0001). Conclusion: BMI of an individual does not appear to be associated with the severity of CDI.

Efficacy of subcutaneous interferon-beta in COVID-19: a meta-analysis and systematic review.

Type 1 interferons, especially interferon-beta, has been reported to be effective in COVID-19 patients in multiple randomized controlled trials. The aim of our meta-analysis and systematic review is to assess efficacy of subcutaneous IFN-beta in regards to mortality and discharge rate. Prospective, retrospective and randomized controlled trials were included. Primary outcomes measured were 28-day mortality and discharge rate. Secondary outcomes measured were mean hospital stay and post-intervention intubation rate. A thorough literature search was conducted in Medline, PubMed, Ovid journals, Google Scholar, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews from 1 April 2020 to 28 February 2021. Relative risk was calculated using both the Mantel-Haenszel method (fixed-effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test, based upon inverse variance weights. 7 studies were included in the meta-analysis and systematic review. The IFN-beta group did not improve the 28-day mortality (RR = 1.276; 95% CI: 1.106-1.472, p = 0.001) or the discharge rate (RR = 0.906; 95% CI = 0.85-0.95, p = < 0.001). The mean hospital stay was 11.95± 2.5 days in the interferon-beta group and 11.43 ± 3.74 days in the traditional treatment group. Likewise, interferon-beta did not add any advantage to post-intervention intubation rate (RR = 0.92; 95% CI = 0.7841-1.0816, p = 0.3154). Our findings revealed that use of subcutaneous interferon-beta is futile in COVID-19.

Deep Venous Thrombosis after Ad26.COV2.S Vaccination in Adult Male.

With extensive loss of life and well-being seen since the beginning of the SARS-CoV-2 pandemic, the initiation of vaccinations has come with enormous hope towards the end of this pandemic. Detailed discussions regarding the safety and efficacy of these vaccines led to their approval. With such success, there have also been reports of vaccine-associated adverse events-allergic reactions, anaphylaxis, immune thrombocytopenia, and thrombosis. We discuss and report the first case of a healthy young adult male developing extensive thrombosis, after receiving the Ad26.COV2.S (Johnson & Johnson/Janssen) vaccine.

Pericardial Angiosarcoma: A Diagnostic Challenge.

Cardiac angiosarcomas are the most common malignant primary cardiac tumors accounting for 31% of all primary cardiac tumors. However, primary pericardial angiosarcomas are extremely rare and are associated with high mortality. A 41-year-old male with a past medical history of end-stage renal disease (ESRD) on hemodialysis, follicular thyroid carcinoma, hypertension, and asthma presented with recurrent pericardial effusions. Previously, different imaging modalities had shown small hemodynamically stable pericardial effusions with pericardial thickening. His pericardial effusion was attributed to his ESRD until this presentation. However, during the current admission, chest X-ray showed cardiomegaly with lobulated left heart border. Computed tomography (CT) and transthoracic echocardiogram showed an increased posterior complex pericardial effusion when compared to previous imaging. A pericardial window was created and the space was evacuated. Pericardial fluid cytology reported rare atypical cells, which were indeterminate for malignancy. Histopathology from the pericardial biopsy revealed fibrous tissue with cellular proliferation, consistent with an angiosarcoma. A positron emission tomography revealed findings of angiosarcoma (hypermetabolic pericardial soft tissue nodularity and complex pericardial fluid) limited only to the pericardium. Unfortunately, the angiosarcoma was deemed unresectable, and the patient underwent one cycle of chemotherapy with paclitaxel. The patient's hospital course was further complicated by myelosuppression from chemotherapy and disseminated intravascular coagulation. Therefore, no further chemotherapy was pursued. A repeat echocardiogram showed constriction of both ventricles with loculated pericardial effusion. The patient eventually transitioned to comfort care and passed away. Through this case report, we would like to highlight that multiple confounders can be present when considering the etiology of persistent pericardial effusions. We suggest contemplating alternate diagnosis, such as malignancy, and initiate aggressive work-up especially in young individuals with recurrent, unexplained pericarditis.

COVID-19-Associated Coagulopathy: A Case Report of Thrombosis despite Therapeutic Anticoagulation.

The Coronavirus disease (COVID-19) pandemic, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has led to tremendous morbidity and mortality. Various inflammatory markers have been monitored and considered to be associated with disease prognosis. One of the major sources of comorbidity involved has been development of thrombosis alongside the infection. This prothrombotic phenomenon considered, COVID-19-associated coagulopathy (CAC), has been the center of discussion in dealing with this infection. There still remains ambiguity regarding management guidelines for thromboprophylaxis dosing and therapeutic anticoagulation. We present a case of severe SARS-CoV-2 infection complicated by thrombosis despite therapeutic anticoagulation contributing to prolonged intensive care unit and hospital stay.

Hemotympanum post-bronchoscopy: An unusual complication!

Diagnostic bronchoscopy with endobronchial ultrasound (EBUS) guided biopsy is the procedure of choice for visualization of bronchial airway and sampling of pulmonary lesions. While complications are relatively uncommon, they typically include hemorrhage, pneumothorax and/or infections. We report an unusual and unique complication, Hemotympanum following endobronchial ultrasound with biopsies. Occasional one or two reported cases of such a complication exist in literature. However, due to rare evidence, minimal awareness exist for its possibility, pathophysiology and measures of prevention.

Extraordinary Creatinine Level: A Case Report.

Creatinine, an amino acid derived from creatine, has been traditionally used to assess kidney function. However, its levels are significantly affected by nutritional status, muscle mass, age, and sex of an individual. The effect of creatinine levels on human physiology is not completely understood, and no correlation has been established between high creatinine levels and physiological equilibrium. We describe a case of a 27-year-old Hispanic male who presented with extremely elevated serum creatinine level (>37 mg/dL) with minimal symptoms of uremia and relatively fair functional status, eventually requiring hemodialysis. To our knowledge, based on a thorough review of the literature using PubMed, Medline, and Google Scholar, only four other cases have been reported with a creatinine level higher than that of our patient. A brief discussion on the utility of serum creatinine levels to assess mortality is provided using examples from similar case reports.

Multifactorial Pulmonary Hypertension in Systemic Sclerosis.

Pulmonary hypertension is a progressive disease often associated with multifactorial etiology. The impact of multiple causes contributing to rapid progression of the disease, to our knowledge has not been thoroughly reviewed in literature. The cause of pulmonary hypertension is often implied from pre-existing comorbidities. A diagnostic and management challenge exists when simultaneous presence of multiple plausible causes exist. Studies evaluating the rapid progression of symptoms in multifactorial pulmonary hypertension to this effect are lacking. We present a case of pulmonary arterial hypertension (PAH) in a patient with rapidly progressing symptoms to highlight the need for an early and thorough diagnostic workup.

Eosinophilic lung disease with plastic bronchitis and bronchiectasis in an adolescent male.

Any case of unresolving chronic pneumonia with expectoration of thick mucoid plugs should have high index of suspicion for plastic/cast bronchitis, requiring early flexible bronchoscopy with lavage and histopathologic evaluation. Associated presence of idiopathic chronic eosinophilic pneumonia is unusual and could be considered as a cause for atypical plastic bronchitis complicated by bronchiectasis.