Post-inflammatory Hyperpigmentation in an African American Female: An Atypical Presentation and Treatment Dilemma.

We present the case of a 32-year-old African American female with a known history of primary Sjogren's syndrome, multiple vitamin deficiencies, and prior facial cellulitis who presented with diffuse facial post-inflammatory hyperpigmentation following a motor vehicle accident. Following glucocorticoid treatment, only select hyperpigmented areas associated with inflammation, infection, or trauma improved, which thereby posed a clinical challenge to improve the patient's appearance and condition. Such results may warrant the consideration of adjunctive topical therapies to lighten the remaining areas of hyperpigmentation.

An Unusual Case of Haemophilus parainfluenzae Endocarditis in a Young Patient With Crohn's Disease.

We present a rare case of infective endocarditis (IE) associated with Haemophilus parainfluenzae in a 40-year-old male patient with a history of Crohn's Disease (CD). A complete workup, including an echocardiogram and blood cultures, revealed mitral valve vegetation colonized by H. parainfluenzae. The patient was started on appropriate antibiotics with follow-up for outpatient surgery. This case discusses the potential for ectopic colonization of heart valves by H. parainfluenzae in patients with CD. The presence of this organism as the offending agent in this patient's case of IE shines a light on the pathogenesis of CD. Although uncommon, CD-associated bacterial seeding should be a differential when assessing young patients with IE.

A Rare Presentation of Congenital Chilaiditi Syndrome: Symptomatic Hepatobowel Entrapment.

The displacement and trapping of the colon between the liver and the right hemidiaphragm are known as the Chilaiditi sign or syndrome. The Chilaiditi sign presents in an asymptomatic patient, while Chilaiditi syndrome presents with symptoms such as abdominal pain, distension, and constipation, in addition to complications such as perforation, volvulus, and bowel obstruction. It is often misdiagnosed as pneumoperitoneum or free air under the diaphragm and liver, often seen on the abdomen and chest radiography. It more commonly presents in males than in females. Here, we present the case of a 37-year-old female who reported abdominal pain and persistent constipation. An abdominal CT scan showed entrapment of a bowel segment, which is referred to as the Chilaiditi sign. The patient's presentation with hepatobowel entrapment and persistent gastrointestinal symptoms was diagnosed as Chilaiditi syndrome. This presentation entails a conservative management approach. The aim of this report is to educate about the rare occurrence of Chilaiditi sign and Chilaiditi syndrome as a differential diagnosis to often misdiagnosed critical conditions such as pneumoperitoneum and intestinal perforation. Correctly identifying these patients will reduce overtreatment and help improve outcomes.

Rare Occurrence of a Symptomatic Persistent Sciatic Artery Aneurysm.

Persistent sciatic artery (PSA) aneurysms are a rare cause of gluteal or lower extremity pain. The persistent sciatic artery is an uncommon congenital vasculature anomaly that presents with variable clinical presentation and is prone to cause an aneurysm, thrombosis, rupture, and possible amputation. Thus, early diagnosis is imperative to prevent further complications. We present the case of a 75-year-old female who was diagnosed with a persistent sciatic artery aneurysm after presenting with gluteal and lower extremity pain initially thought to be sciatica. Our patient underwent a successful hybrid open and endovascular approach with a femoral to below-knee popliteal artery bypass and the placement of coils at the proximal and distal ends of the aneurysmal segment.

Application of Aspiration-Assisted Percutaneous Venous Removal of Right Atrial Thrombus in a Critically Ill Patient: A Case Study and Clinical Management Overview.

We herein present a complex case of a 50-year-old female with catheter-related atrial thrombus (CRAT). This patient with end-stage renal disease on hemodialysis presented with angioedema leading to respiratory failure. She was subsequently intubated, and the pre-procedural course was complicated by a cardio-respiratory arrest, and anoxic brain injury. The patient's hemodialysis catheter placement in the superior vena cava (SVC) potentially correlated with the development of the right atrial thrombus. The patient was treated percutaneously as she presented with complex morbidities. The mass was successfully removed via aspiration-assisted percutaneous right heart bypass, a procedure that utilizes a vacuum system to remove thrombi. Post-procedure, the patient remained stable and continued supervised care.

Case Series of Quadricuspid Aortic Valve.

Three patients presented with different symptoms to the emergency department. Further imaging of their hearts displayed an abnormal variant of their aortic valve called a quadricuspid aortic valve (QAV). There are seven types of QAVs, from type A to G, with varying presenting symptoms. The most common complication is aortic regurgitation. The management of QAV is based on these presenting symptoms and complications. Surgical valve repair or replacement is indicated when a QAV becomes symptomatic or a QAV results in ventricular remodeling, which can lead to ventricular dysfunction. Successful surgical repair of QAVs has been shown with both tricuspidization and bicuspidization methods.

Subacute Stroke in a Young Female: A Case of Moyamoya Syndrome Initially Anchoring with Anxiety.

Moyamoya disease is an arterial disorder causing stroke in a young patient. This is a chronic condition causing progressive cerebrovascular disease due to bilateral stenosis and occlusion of the arteries around the circle of Willis, with prominent arterial collateral circulation. It was first described in Japan and subsequently reported in other Asian countries, but infrequently found in the Western world. Interestingly, there may be racial differences in the presentation and subsequent prognostication of treatment of moyamoya. It is diagnosed with classic angiographic findings of stenosis or occlusion of the circle of Willis vessels. Here, we describe a 28-year-old Caucasian female who was initially diagnosed with anxiety when she presented with symptoms of impaired concentration and fatigue. After the development of remitting slurred speech and facial droop, magnetic resonance imaging and cerebral angiogram yielded the discovery of high-grade stenosis of the origin of the left middle cerebral artery with associated thrombosis in that area. She did well after getting surgery and rehabilitation. This demonstrates a unique presentation of prominent psychiatric symptoms initially thought to be anxiety and culminated in the finding of ischemic stroke in an adult patient with moyamoya.

A Case of Persistent Asthma Resistant to Available Treatment Options: Management Dilemma.

Asthma affects nearly 300 million people worldwide, with 250,000 associated deaths annually. An estimated 5%-10% of patients have severe asthma, while only 1%-2% presented with treatment-resistant or refractory asthma. Currently, the endotype of asthma is divided into T-helper type 2 (Th2) high and Th2-low inflammation endotypes. The Th2-high endotype is characterized by eosinophilic asthma, while the Th2-low endotype is associated with neutrophilia and a pauci-granulocytic profile. The Th2-low endotype carries a high resistance to corticosteroid and bronchodilator therapy, and these patients typically have a severe and acute-onset of symptoms. We present a 57-year-old nonsmoking female with recurrent intensive care unit (ICU) admissions for severe acute asthma exacerbations, resistant to bronchodilator and steroid treatment, requiring mechanical ventilation. Currently, the guidelines for treating neutrophil-predominant Th2-low inflammation asthma have not been established. This creates a management dilemma when encountered with such a patient in clinical practice. We aim to propose targeted treatment options for these severe and potentially fatal asthma patients, with reference to current literature.

Co-existing Gastrointestinal Hemorrhage and Deep Vein Thrombosis in a Patient with Hereditary Hemorrhagic Telangiectasia: Management Dilemma.

Hereditary hemorrhagic telangiectasia (HHT) is described as a vascular defect, causing recurrent visceral and mucocutaneous bleeding. It is an autosomal dominant disease and has variable expressivity. The phenotypic presentation is dependent on the type of gene defect. Recurrent epistaxis is the most common symptom, along with gastrointestinal (GI), pulmonary, and arteriovenous malformations (AVM). The Curacao criteria are used to make the diagnosis of HHT. Genetic sequence testing for endoglin (ENG) or activin receptor-like kinase type 1 (ALK1) can be performed to confirm the diagnosis. However, genetic sequencing is not necessary. Along with recurrent bleeding, patients with HHT also have an increased risk of thromboembolic events. Supportive treatment prevents acute symptoms, but the therapeutic options of HHT are based on multiple factors. We describe the case of a 69-year-old male who presented with GI bleeding and a history of HHT and recurrent deep vein thrombosis (DVT). We discuss the diagnostic guidelines and treatment options for patients with HHT. Furthermore, we also discuss the challenge in treating patients with co-existing GI bleeding and DVT, as in our case.

A Rare Case of 15q11.2 Microdeletion Syndrome with Atypical Features: Diagnostic Dilemma.

Burnside Butler syndrome or 15q11.2 microdeletion syndrome is a relatively rare chromosomal abnormality that is recently being recognized. Current diagnostic techniques like chromosomal microarray analysis (CMA) have profoundly contributed to currently reported cases. The diagnostic dilemma is that prenatal screening and karyotype analysis typically yield unclear results. We would like to emphasize the importance of taking a detailed family history, knowing the classic clinical features, and using CMA to help diagnose this syndrome. We present an eight-year-old Caucasian female with a past medical history of intrauterine growth restriction, microcephaly, a high arched palate, speech delay, and a learning disability with recurrent bleeding from the eyes and oral cavity. The bleeding co-occurs whenever she develops the common cold.