Dysphagia as an Initial Presentation of Acute Myeloid Leukemia: A Rare Presentation of Myeloid Sarcoma.

Myeloid sarcoma (MS) represents a unique clinical presentation of acute myeloid leukemia (AML). This report describes a case of MS in a 66-year-old man who presented with dysphagia, nausea, vomiting, anorexia, and fatigue. Generalized lymphadenopathy was noted on physical exam and confirmed by CT scans which also showed diffuse esophageal wall thickening. Axillary lymph node biopsy was positive for MS. Bone marrow biopsy confirmed AML with 88% blasts. The patient received induction chemotherapy with decitabine and venetoclax and was planned for four cycles of treatment over three months while monitoring the response.

Parvimonas micra: A Rare Cause of Pleural Empyema With COVID-19 Co-infection.

Parvimonas micra, an oral anaerobe and a known gastrointestinal microbiota, has also been found to be enriched in mucosal tissues of the colon. Our patient presented with chest pain, productive cough, and hypoxia. He was diagnosed with COVID-19 pneumonia with a suspected superimposed bacterial infection. After the initiation of treatment, the patient developed a right hydropneumothorax/loculated pleural effusion on X-ray. Bedside drainage was done, and cross-sectional imaging showed findings of pleural empyema. Cultures obtained after bedside drainage grew P. micra. The patient underwent right posterolateral open thoracotomy, total lung decortication, wedge resection, pneumonolysis, and mechanical pleurodesis. Antimicrobial therapy was adjusted based on culture sensitivities and infectious disease evaluation. Adequate drainage and source control were achieved, COVID-19 infection was resolved, and the patient was discharged on oral antibiotics. This case report highlights a rare and interesting case of pleural empyema caused by a superimposed bacterial infection with P. micra in a patient with COVID-19 pneumonia.

Rare Ring Chromosome [r(15)]: Cytogenetic Abnormality in TP53-Mutated De Novo AML-M4 Masked as Gastrointestinal Bleed With Rapidly Progressing Hyperleukocytosis and Leukostasis.

TP53-mutated (TP53m) acute myeloid leukemia (AML) comprises only 5-15% of de novo AML, associated with poor survival outcomes due to its resistance to conventional therapy. Ring chromosomes, an even more rare subset of genetic anomalies, occur in only 2% of cases. We report a unique case of de novo AML with both TP53 and ring chromosome anomalies leading to a catastrophic outcome in a 72-year-old male who initially presented with gastrointestinal bleeding (GIB) and urethral stone status post-cystoscopy with J-stent placement. He had no history of chemotherapy use, radiation, benzene exposure, or any other risk factors except for his age. He was noted to have pancytopenia, for which bone marrow biopsy, flow cytometry, and cytogenetic studies were done. Biopsy reported an interesting next-generation sequenced TP53-mutated AML, which correlates with a low rate of response to standard chemotherapy except for bone marrow transplants. Notably, with a complex aberration of 45 XY with multiple translocations (t), deletions (del), inversions (inv), derivative (der) breakpoints, aneuploidy, and rare ring and maker chromosomes, his case was complicated with rapid-onset and very severe hyperleucostasis, reflecting the prognostic value of this rare cytogenetic configuration. The patient expired within 48 hours of diagnosis, despite the urgent initiation of cytoreductive therapy and the mitigation of tumor lysis syndrome with Rasburicase. To the best of our knowledge, this is one of the first AML-M4 patients with rapid-onset leucostasis and the demise of next-generation sequences (NGS) in a de Novo AML patient with this rare complex combination.

Positive Outcome in Catastrophic Momordica charantia-Associated Herb-Induced Liver Injury: A Tale of Two Cities - From Gonaives, Haiti to New York City.

Herb-induced liver injury (HILI) is a global concern due to the uptrend in Complementary and Alternative Medicine (CAM). The authors add to the current literature by reporting a case of a 61-year-old man with recent travel to Haiti. His past medical history include hepatitis C virus treated in 2021 with a sustained virologic response (SVR). He presented with profound weakness and abnormal liver transaminases in the thousands. It was initially unclear what the etiology of the patient's hepatocellular necrosis was, however, the level of abnormality was most consistent with either toxic metabolic injury or vascular ischemic injury. We initiated N-acetylcysteine and vitamin K and had a positive outcome. Upon further questioning, he admitted to consuming an herbal product cleansing tea called "asowosi" in large quantities. We searched the botanical name of the extract and found the active ingredient was Momordica charantia. The team utilized the updated Roussel Uclaf Causality Assessment Method (RUCAM), and the results demonstrated a highly probable relationship with M. charantia.

A Peculiar Presentation of Syphilis as a Mysterious Rash: A Dermatological Dilemma.

A renowned poet in the ancient city of Verona by the name of Girolamo Fracastoro coined the term syphilis in 1530. The stigma and shame that embodied this affliction has been time immemorial and disabling for patients. The hypothesis of the spread from the warm tropics of west and central Africa to the Iberian Peninsula accompanied by the slave trade has been a tale for centuries. Malignant syphilis is a rare skin manifestation of Treponema pallidum infection and a variant of secondary syphilis. The rash is frequently associated with HIV-infected patients, often with low cluster differentiation 4 (CD4) cell count. The authors reported a unique case involving a 46-year-old woman who presented with a one-week history of skin eruptions at various stages. Subsequent laboratory tests revealed a strong positive result for Treponema pallidum and a positive Rapid Plasma Reagin (RPR) test with a titer of 1:16. She received doxycycline because she had a history of penicillin anaphylaxis in the past. She did well, with a remarkable improvement in symptoms - a positive outcome for this catastrophic stigmatizing, rare diagnosis.

Look Beyond Syncope: A Positive Outcome in the Management of Multiple Bladder Diverticuli-Associated Enterococcus faecium Urinary Tract Infection.

Enterococcus faecium is a Gram-positive flora bacterium home to the gastrointestinal tracts of humans. A true ubiquitous pathogen and a member of the intestinal microbiome, formerly known as group D streptococci, this pathogen has been around for over 10 centuries. Enterococcus faecium thrives in the presence of stool and sewage. The ability to cause endocarditis and urinary tract infections (UTIs) has led to morbidity and mortality in the adult population. We report a case of an elderly woman who presented with multiple falls to our trauma bay area. She was initially managed as trauma during multiple visits with superficial scalp lacerations. However, with multiple falls, she was subsequently transferred to medicine to rule out cardiogenic versus neurogenic syncope. She was admitted to the telemetry unit, and a cardiologist was consulted. Orthostatic vitals were negative, and she had no fever or leukocytosis. Abdominal computed tomography (CT) done as part of the standard trauma workup revealed an interesting finding of multiple bladder diverticula.

An Unusual Cause of Acute Right-Sided Heart Failure Presenting With Refractory Hypoxia.

Atrial septal aneurysm (ASA) formation is due to a deformity at the fossa ovalis. While previously considered a rare cardiac anomaly found postmortem, it can now be diagnosed at the bedside with ultrasound. Unrepaired ASA can lead to right-sided heart failure and pulmonary hypertension. The case we describe is complicated by the patient's code status, limiting our ability to perform potential life-sustaining interventions. We also encountered a complication of rebound pulmonary hypertension with the use of inhaled nitric oxide. We detail the critical course of profound hemodynamic and respiratory instability responsive to salvage therapy.

Right Hepatic Artery Pseudoaneurysm Presenting As Upper Gastrointestinal Bleed: A Deadly Hit and Run Following Blunt Trauma.

Hepatic artery pseudoaneurysm (HAA) is a rare complication of blunt trauma, occurring in only 1% of patients. It is life-threatening with abysmal and atrocious outcomes if not recognized early and managed promptly. Other etiologies include transjugular-intrahepatic portosystemic shunt (TIPS), pancreatitis, cholecystectomy, and liver transplantation. We report a near-miss case in a 38-year-old woman following a motor vehicle accident. She sustained Grade III/IV liver laceration (>50% subcapsular hematoma), presenting with upper gastrointestinal bleeding (UGIB). Our patient was managed emergently intra-operatively, with hemostasis promptly achieved; however, she continued to bleed postoperatively, becoming hemodynamically unstable and unresponsive to both massive blood transfusions and high-dose proton pump inhibitors. Further imaging demonstrated HAA for which coil embolization was carried out by interventional radiology (IR).

Cocaine-Induced Kidney, Liver, Lung, and Muscle Injury (C-KLM), Presenting With Foot Drop: A Case Report.

Cocaine-associated organ injury is a well-known phenomenon that may lead to multi-organ failure. Cocaine-induced kidney, liver, lung, and muscle (C-KLM) involvement is an entity with alarmingly high creatinine phosphokinase (CPK) levels exceeding 100,000 U/L. This may have fatal outcomes. Rhabdomyolysis is one of the many mechanisms of kidney injury induced by cocaine intoxication. Sympathomimetic effects of cocaine contribute to muscle Injury in addition to vasoconstriction resulting in muscle ischemia, as well as liver ischemia (shock liver). Furthermore, increased muscular activity from hyperpyrexia, seizures, and agitation due to cocaine use disorder may contribute to muscle breakdown and worsening nephrotoxicity.  The authors detail a case of a 34-year-old male intravenous drug user who presented with an inability to bear weight or move his left lower extremity due to pain, associated with severe edema of his lower extremities of acute onset. He was subsequently noted with foot drop, oliguria, and high blood pressure following cocaine intoxication. The patient began crashing rather quickly and the intensive care unit was recommended. Labs were noted with overwhelming CPK levels over 100,000 U/L and rising for which urgent hemodialysis was initiated. We detail a catastrophic cocaine-induced multi-organ failure with a positive outcome following a multidisciplinary approach.