Invasive Fungal Infections Associated with COVID-19.

The COVID-19 pandemic caused >6 million deaths worldwide, often from respiratory failure. Complications frequently occurred in hospitalized patients, particularly in the intensive care unit. Among these, fungal infections were a cause of high morbidity and mortality. Invasive aspergillosis, candidiasis and mucormycosis were the most serious of these infections. Risk factors included alterations in immune defense mechanisms by COVID-19 itself, as well as immunosuppression due to various therapies utilized in severely ill patients. Diagnosis was often challenging due to lack of sensitivity of current testing. Outcomes were generally poor, due to significant co-morbidities and delayed diagnosis, with mortality rates >50% in some studies. High index of clinical suspicion is needed to facilitate early diagnosis and initiation of appropriate antifungal therapy.

Intensive care unit presentation of central corneal descemetocele secondary to Methicillin-Resistant staphylococcal infection superimposed by a hypopyon: a case report.

A descemetocele is a rare type of keratopathy that occurs when an intact descemet's membrane of the eye undergoes a herniation through an overlying stroma. Previous literature has documented corneal damage via bacterial enzymes, especially, Pseudomonas and Neisseria species. Most recent prospective interventional studies showed treatment of these infections. Case presentation: This report presents the first instance of a methicillin-resistant Staphylococcus aureus descemetocele presentation in a 51-year-old African American male, with co-presenting hypopyon sequelae successfully managed conservatively in an intensive care unit setting. Clinical discussion: An instance of a methicillin-resistant Staphylococcus aureus has not yet been documented in the literature. Likewise, a co-presentation with a hypopyon, which is known as a formation of inflammatory debris rich in white blood cells has not been studied. Conclusion: The presence of a hypopyon in the instances of bacterial descemetocele herniation should be further evaluated to see if there are associations with conservative, nonsurgical intervention outcomes.

Oculomotor Nerve Palsy as a Manifestation of Immune Thrombocytopenic Purpura: A Case Report.

Immune thrombocytopenic purpura (ITP) is caused by alterations in the immune system resulting in platelet destruction. It often manifests clinically with bleeding or on routine lab work revealing thrombocytopenia in asymptomatic individuals. Neurologic manifestations of this condition are sparsely documented in the literature. Among the symptoms reported were case reports of ischemic strokes, transient ischemic attacks, mononeuropathy multiplex, and polyneuropathy as neurological complications from immune thrombocytopenic purpura. Isolated cranial nerve palsies are uncommon. The following case describes a patient with immune thrombocytopenic purpura who presented with an isolated cranial nerve III palsy. A 55-year-old presented with pain in the right eye that was found in a downward and lateral gaze paralysis. There was no evidence of central or peripheral neurovascular etiology on imaging. However, workup revealed isolated thrombocytopenia with platelets <2000/ml3. Other possible etiologies, such as human immunodeficiency virus (HIV) and infectious etiologies, were evaluated and excluded. Thrombotic thrombocytopenia purpura was excluded with the results from ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. The patient was appropriately transfused with platelets and was treated with methylprednisolone, which improved his platelets. At the time of discharge, the patient continued to have cranial nerve III palsy and was referred to follow up with hematology on an outpatient basis. In prior case reports where ITP presented as neurological deficits, there was evidence of intraneural microhemorrhage. Our case is unique in that the primary neurologic presentation without central nervous system pathology eventually led to the diagnosis of ITP. The symptoms were attributed to microhemorrhages that were not detected in imaging studies. Further studies are warranted to explore any correlation or causative association between ITP and neurological symptoms. This case report highlights the need to consider uncommon but possible manifestations of conditions that may initially appear seemingly irrelevant to the patient's chief complaint.

A Case of Collet-Sicard Syndrome Caused by Otitis Externa.

Collet-Sicard syndrome is a unilateral palsy of the lower cranial nerves IX, X, XI, and XII, resulting from lesions at the skull base that affect the jugular foramen and hypoglossal canal. Common causes of the lesions include basilar skull fractures, carotid artery dissections, and malignancy. Infectious and inflammatory etiologies have also been reported. A 63-year-old male with a history of uncontrolled diabetes was admitted for dysphagia, right ear pain, drainage, and right-sided facial droop after recent local trauma and surgical instrumentation of the right ear. Culture of the external auditory canal grew Pseudomonas aeruginosa. Triple phase bone scan demonstrated osteomyelitis at the skull base due to complications from otitis externa. The patient's presentation was consistent with Collet-Sicard syndrome, and he was subsequently treated with a six-week course of ciprofloxacin. This patient demonstrates a unique case since his malignant otitis externa spread locally and led to skull base osteomyelitis and subsequently developed Collet-Sicard syndrome. His uncontrolled diabetes likely played a role in his disease progression.

Influence of rotational speed on torque/force generation and shaping ability during root canal instrumentation of extracted teeth with continuous rotation and optimum torque reverse motion.

AIM: To evaluate how different rotational speeds affect the torque/force generation and shaping ability of rotary root canal instrumentation using JIZAI (MANI, Utsunomiya, Japan) nickel-titanium instruments in continuous rotation and optimum torque reverse (OTR) motion. METHODOLOGY: Mesial root canals of extracted mandibular molars were instrumented up to size 25, 0.04 taper using JIZAI instruments, and anatomically matched canals were selected based on geometric features of the canal [canal volume (mm3 ), surface area (mm2 ), length, 15°-20° curvature and radius of curvature (4-8 mm)] after micro-computed tomographic scanning. An automated root canal instrumentation and torque/force analysing device was programmed to permit a simulated pecking motion (2 s downward and 1 s upward at 50 mm min-1 ). The selected canals were prepared with size 25, 0.06 taper JIZAI instruments using continuous rotation or OTR motion and further subdivided according to the rotational speed (300 or 500 rpm, n = 10 each). Real-time clockwise/counterclockwise torque and downward/upward force were recorded using a custom-made torque/force analysing device. Then, the registered pre- and post-operative micro-computed tomographic datasets were examined to evaluate the canal volume changes and centring ratios at 1, 3, 5 and 7 mm from the apical foramen. Data were analysed using two-way analysis of variance or the Kruskal-Wallis test and Mann-Whitney U test with Bonferroni correction (α = 5%). RESULTS: Maximum upward force and clockwise torque were significantly smaller in 500 rpm groups than in 300 rpm groups (P < .05); however, no significant difference was found between continuous rotation and OTR motion (P > .05). OTR motion developed higher maximum counterclockwise torque than continuous rotation (P < .05). Maximum downward force, canal volume changes and centring ratios were not significantly different among all groups (P > .05). There was no file fracture in any of the groups. CONCLUSIONS: Under laboratory conditions using JIZAI instruments, a rotational speed of 500 rpm generated significantly lower maximum screw-in forces and torque values than rotational speed of 300 rpm. Continuous rotation and OTR motion performed similarly in shaping the canals.

Who Watches the "Watchman" and How Often?

Atrial fibrillation (AF) is a common cardiac arrhythmia that is encountered during the hospitalization. Sometimes, many patients cannot be anticoagulated to prevent AF-related cardiovascular accidents because of the risk of bleeding. In these cases, we recommend putting left atrial appendage (LAA) to prevent thrombus formation in the left atrium due to AF. There is no clear time frame of how long we need to follow up with echocardiogram to monitor device-related blood clot formation and continue anticoagulation therapy if there is recurrent thrombus formation after LAA placement. We would like to present a case with AF in which the patient had epistaxis, which required to hold anticoagulation and arterial embolization. The patient agreed to the placement of the Watchman device and subsequently it was complicated by device-related thrombosis (DRT). The patient required prolonged anticoagulation treatment and follow-up echocardiogram to prevent DRT in the future.

Impending Cardiac Tamponade as the Initial Manifestation of BCR-ABL Positive Chronic Myeloid Leukemia.

Leukemia involves all organs and tissues of the body. Leukemic infiltration of the pericardium has been documented frequently at post-mortem examinations. Clinically, however, pericardial effusion with cardiac tamponade is rare, and only isolated case reports have been described. In all the reported cases, therapeutic pericardiocentesis was required for the relief of cardiac tamponade with the risk of bleeding since these patients often had deranged hemostasis. We are reporting a rare case of hemorrhagic pericardial effusion in chronic myeloid leukemia before starting the tyrosine kinase inhibitors. The patient required therapeutic pericardiocentesis and hydroxyurea treatment.

A Rare Case of Subacute Painful Thyroiditis Causing Thyroid Storm and a Successful Trial of Propylthiouracil.

Thyroid storm is a rare, life-threatening condition characterized by severe or exaggerated clinical manifestations of thyrotoxicosis, commonly occurring in patients with longstanding, untreated hyperthyroidism such as Graves' disease and toxic nodular goiter. Subacute painful thyroiditis, also known as de Quervain thyroiditis, is a self-limited inflammatory disease of the thyroid gland that is characterized by neck pain, a tender diffuse thyroid goiter, elevated inflammatory markers, and a predictable course of thyroid function evolution. Rarely, it can cause thyroid storm. Herein, we report a rare case of a 25-year-old woman who was admitted for sepsis and acute painful thyroiditis who then developed thyroid storm. The patient was treated in the intensive care unit (ICU) and responded very well to steroids, propranolol, a seven-day trial of propylthiouracil, and ultimately achieved a euthyroid state on discharge.

Acute Unilateral Oculomotor Nerve Palsy as the Initial Presenting Sign of Nonfunctioning Apoplectic Gonadotroph Adenoma.

Pituitary macroadenoma usually presents with visual field defects. Oculomotor nerve palsy is a rare presentation, and usually a sign of para-sellar growth and cavernous sinus extension. The oculomotor nerve is more susceptible to laterally transmitted pressure by pituitary mass expansion because of its anatomical location. A slow onset oculomotor nerve palsy results from either gradual compression of the nerve in the sinus wall or direct infiltration of the nerve by the pituitary tumor. We are reporting a unique case of a 68-year-old African American patient who presented to an ophthalmology clinic with left eye complete ptosis, blurry vision, and a progressive headache for a few weeks. He was found to have a nonfunctioning pituitary adenoma (NFPA) that required urgent transnasal transsphenoidal tumor resection. The patient's ocular movements significantly improved a few days postoperatively, and repeated computed tomography (CT) of the head showed complete resection of the pituitary adenoma. The postoperative morning cortisol level was significantly low, confirming the diagnosis of secondary adrenal insufficiency. The patient was treated with corticosteroid replacement therapy.

A Rare Case of Serratia marcescens Causing Mycotic Aneurysm and Septic Emboli in Intravenous Drug User.

There are few literatures highlighting the presence of a mycotic aneurysm in the setting of bloodstream infection by Serratia. A 33-year-old male with a history of Marfan syndrome, mitral valve prolapse, and intravenous drug use (IVDU) presented to the ED with fever, nausea, and non-bloody emesis, and vague abdominal pain with concern for sepsis. With the strong association between IVDU and infective endocarditis, transthoracic and transesophageal echocardiograms were performed and were negative for vegetations. Abdominal CT and positron emission tomography (PET) scan were performed and revealed thrombosis at the first jejunal branch of the superior mesenteric artery (SMA), left renal pole infarct, and superior splenic pole infarct. Following CT angiography for potential thrombolysis, aneurysmal formation was discovered proximal to the filling defect within mid-SMA. Blood cultures drawn at presentation grew Serratia marcescens. The patient was treated with appropriate antibiotic, and recommended indefinite anticoagulation. The patient was then recommended to follow up with vascular surgery within two weeks for repeat abdominal CT angiogram.

Epidemiological characteristics of SARS-COV-2 in Myanmar

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In Myanmar, first COVID-19 reported cases were identified on 23rd March 2020. There were 336 reported confirmed cases, 261 recovered and 6 deaths through 13th July 2020. The study was a retrospective case series and all COVID-19 confirmed cases from 23rd March to 13th July 2020 were included. The data series of COVID-19 cases were extracted from the daily official reports of the Ministry of Health and Sports (MOHS), Myanmar and Centers for Disease Control and Prevention (CDC), Myanmar. Among 336 confirmed cases, there were 169 cases with reported transmission events. The median serial interval was 4 days (IQR 3, 2-5) with the range of 0 - 26 days. The mean of the reproduction number was 1.44 with (95% CI = 1.30-1.60) by exponential growth method and 1.32 with (95% CI = 0.98-1.73) confident interval by maximum likelihood method. This study outlined the epidemiological characteristics and epidemic parameters of COVID-19 in Myanmar. The estimation parameters in this study can be comparable with other studies and variability of these parameters can be considered when implementing disease control strategy in Myanmar.

Eosinophilic Gastroenteritis Presenting As Unexplained Chronic Abdominal Pain.

A 27-year-old Caucasian female was hospitalized three times over a four-month period for recurrent, intermittent abdominal pain associated with nausea and diarrhea. No signs or symptoms of gastrointestinal (GI) bleeding were present. A stool occult blood test and stool enteric pathogen tests were negative. A complete blood count (CBC) revealed a peripheral blood eosinophil count of 1080 cells /µL without any inflammatory reaction. An upper endoscopy showed grossly normal-appearing esophageal and duodenal mucosa; however, a gastric mucosal biopsy showed an eosinophil infiltration of ≥20 eosinophils/high power field (HPF). Based on these findings, she was diagnosed with eosinophilic gastroenteritis (EGE). A definitive diagnosis of EGE should be confirmed with both an analysis of gastrointestinal mucosal biopsy and an elevated peripheral blood eosinophil count. Specifically, histological evaluation of the mucosal tissue must show an eosinophilic infiltration rate of 20 eosinophils/HPF. The diagnosis should be followed by an extensive review of the patient's allergic disease history.

Non-Ketotic Hyperglycemia Causing a Transient Unilateral Homonymous Hemianopia: A Manifestation of Occipital Lobe Seizure.

Focal seizures related to non-ketotic hyperglycemia (NKH) are rare in clinical practice. Plasma glucose levels are usually above 16.6 mmol/L and with normal or slightly elevated serum osmolality. The occurrence of focal seizures may be augmented by the absence of ketoacidosis. Electroencephalogram (EEG) during seizures usually confirms the diagnosis, however, the absence of epileptiform discharges does not rule out seizures. A non-ketotic hyperglycemia-associated occipital lobe seizure can manifest itself as color flashes, blurry vision with periodic confusion, and usually resolves with insulin treatment and rehydration. We are reporting a 65-year-old male patient who presented with intermittent confusion and left-sided visual disturbances, found to have a blood glucose of 33.7 mmol/L with a normal anion gap of 10 and calculated serum osmolality of 303 mOsm/L. The patient's visual disturbances responded very well to rehydration and insulin treatment.

Rare Etiology of Renal Failure in a 25-Year-Old Caucasian Man: Fabry Disease With a Novel Mutation of GLA Gene.

Fabry disease (FD) is an X-linked recessive lysosomal storage disease caused by a mutation of the galactosidase alpha (GLA) gene, leading to deficiency of α-galactosidase A (alpha-Gal A). This deficiency results in a progressive, multiorgan accumulation of glycolipids, most notably globotriaosylceramide (Gb3), leading to multiorgan failure and subsequently premature death. Gb3 accumulation in the podocytes, epithelial, and mesangial cells of the glomeruli results in progressive renal disease and eventually renal failure and hemodialysis (HD). There are two types of FD: early-onset classical type 1 and late-onset type 2. Although nearly a thousand mutations of the GLA gene have been identified, the majority of them are of unknown significance. Herein we report the case of a 25-year-old Caucasian male with no significant medical history who presented with peripheral neuropathy and end-stage renal failure, requiring HD. He was diagnosed with FD based on the electron microscopy findings of renal biopsy and severely reduced alpha-Gal A activity (<0.4 nmol/mL/hour). A novel mutation of c.281G>T; p.Cys94Phe was identified. On discharge from our facility, he was referred to a renal transplant center and genetic counseling.

COVID-19 Fears May Be Worse Than the Virus: A Case of Cardiogenic Shock Secondary to Post-Myocardial Infarction Ventricular Septum Rupture.

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been a growing and justifiable fear of catching the virus from the emergency rooms, thus decreasing the hospital visits. With Virginia State slowly reopening and HCA local hospitals resuming elective procedures, the number of emergency room visits, are recovering and increasing. We report a sad and unfortunate case of an 87-year-old female who was experiencing pressure-like chest pain but presented to the emergency room five days later out of fear of catching COVID-19 from the hospital. On presentation to the ED, she was found to have an non-ST-elevation myocardial infarction, which required urgent stenting of the left anterior descending artery. Unfortunately, several hours later, she developed fatal cardiogenic shock due to ventricular septal rupture. We are reporting this case to highlight one of the many potential bad outcomes as a result of a delay in seeking necessary medical attention due to the fear of contracting the virus.

A Rare Case of Immune-Mediated Primary Adrenal Insufficiency With Cytotoxic T-Lymphocyte Antigen-4 Inhibitor Ipilimumab in Metastatic Melanoma of Lung and Neck of Unknown Primary.

Immunotherapy with checkpoint inhibitors such as ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) inhibitor, and nivolumab, a programmed death-1 (PD-1) inhibitor, has significantly improved the survival of patients with metastatic melanoma. The immune-related endocrinopathies of these treatments have been well documented, such as hypothyroidism, hyperthyroidism, primary adrenal insufficiency (PAI), insulin-dependent diabetes, and hypophysitis. We report the onset of PAI in a patient with metastatic melanoma to the lung and neck of unknown primary origin who was treated with ipilimumab. The patient's symptoms resolved with steroid replacement. After the completion of 16 cycles of another checkpoint inhibitor, nivolumab, full remission was achieved.

Choked Vein: Unusual Etiology of Extensive Deep Vein Thrombosis.

Deep venous thrombosis (DVT) is a commonly encountered diagnosis in clinical practice with a variety of established risk factors. Inferior vena cava atresia (IVCA) is a rare vascular anomaly, but an established risk factor, associated with DVT, found in approximately 5% of cases of unprovoked lower extremity DVT in young adults. Patients who develop DVT are at high risk of long-term complications, including DVT recurrence and post-thrombotic syndrome. Thirty percent of inferior vena cava (IVC) anomalies are associated with hypercoagulable conditions in the younger population, Therefore, a hypercoagulable workup is beneficial in this population. We report a rare case of a 31-year-old male who presented with an extensive DVT of bilateral lower extremities secondary to IVC atresia. The treatment of choice for IVC atresia associated with extensive DVT is catheter-directed thrombolysis (CDT), endovascular IVC reconstruction with nitinol stent, and long-term anticoagulation.

Assessment of Noise Exposure and Hearing Loss Among Workers in Textile Mill (Thamine), Myanmar: A Cross-Sectional Study.

BACKGROUND: In a wide range of industries, noise-induced hearing loss remains one of the most prevalent occupational problems. This study aimed to assess the noise exposure level and associated factors of hearing loss among textile workers in Yangon Region, Myanmar. METHODS: A cross-sectional study was conducted at a Textile mill (Thamine), Yangon Region, from April to December 2018. In total, 226 workers who were randomly selected from 3 weaving sections participated in face-to-face interviews using a structured questionnaire. A digital sound level meter and pure-tone audiometer were used for the assessment of noise exposure level and hearing loss, respectively. Logistic regression analysis was performed to assess the associated factors of hearing loss. RESULTS: In total workers, 66.4% were exposed to ≥85 dB(A) of noise exposure, and the prevalence of hearing loss was 25.7%. Age ≥35 years, below high school education, hearing difficulty, tinnitus, hypertension, > 9 years of service duration in a textile mill were positively associated with hearing loss. After adjusting confounding factors, age ≥35 years (adjusted odds ratio = 6.90, 95% confidence interval = 3.45-13.82) and tinnitus (adjusted odds ratio = 2.88, 95% confidence interval = 1.13-7.37) were persistently associated with hearing loss. CONCLUSION: Providing occupational hazard education and enforcement of occupational safety regulations should be taken to decrease the noise exposure level. The regular audiometry test should be conducted for assessment of hearing threshold shift. The employer needs to implement a hearing conservation program in workplace when noise exposure reaches or exceeds 85 dB(A) for 8 hours.

Up-regulation of transient receptor potential vanilloid (TRPV) and down-regulation of brain-derived neurotrophic factor (BDNF) expression in patients with functional dyspepsia (FD).

BACKGROUND: The role of immune activation in Functional Dyspepsia (FD) patients without previous infection is unclear. We compare the gastric and circulating brain-derived neurotropic factor (BDNF), receptor potential vanilloid type (TRPV) families and various cytokines in FD patients. METHODS: Consecutive adult FD patients (Rome III) with no recent history of gastroenteritis and asymptomatic healthy controls were recruited for upper endoscopy. Subjects with GERD and IBS as predominant symptoms, diabetes mellitus, current or previous Helicobacter pylori infection, psychiatric illness and recent use of NSAID or PPI were excluded. Corpus biopsies and serum samples were collected. KEY RESULTS: Forty three [M:F=8:35, mean age: 35.0 (9.3)] FD patients were compared with 23 healthy controls [M:F=8:15, mean age: 36.6 (10.2)]. FD patients had postprandial distress syndrome (PDS) as predominant sub-type (PDS: 36, EPS: 2). There was no significant difference in the median inflammation score (FD:0 (0-1) vs Control:0 (0-1), P=.79). However, FD patients had significantly higher mRNA expression of TRPV1 (FD:0.014±0.007, Control:0.003±0.001, 4.6 fold, P=.02) and TRPV2 (FD:0.012±0.006, Control:0.003±0.001, 4 fold, P=.02) compared to controls. The serum (FD:258.0±12.3 ng ml-1 , Control:319.7±18.1 ng ml-1 , P<.01) and gastric BDNF mRNA (FD:0.06±0.008, Control:0.092±0.01, 0.65 fold, P=.02)levels significantly lower in FD patients. Secretion of cytokines (IL-4, IL-5, IL-6, IL-8, IL-10, G-CSF, TGF-ß2, MCP-1)was also highly correlated with dyspeptic symptoms in patients with FD. CONCLUSIONS & INFERENCES: Despite lacking gastric mucosal inflammation, up-regulation of TRPV1 and TRPV2, down-regulation of BDNF were observed in FD patients. These suggest that immune alteration may contribute to the pathogenesis of FD without any previous infection.

The spread of artemisinin-resistant Plasmodium falciparum in the Greater Mekong subregion: a molecular epidemiology observational study.

BACKGROUND: Evidence suggests that the PfKelch13 mutations that confer artemisinin resistance in falciparum malaria have multiple independent origins across the Greater Mekong subregion, which has motivated a regional malaria elimination agenda. We aimed to use molecular genotyping to assess antimalarial drug resistance selection and spread in the Greater Mekong subregion. METHODS: In this observational study, we tested Plasmodium falciparum isolates from Myanmar, northeastern Thailand, southern Laos, and western Cambodia for PfKelch13 mutations and for Pfplasmepsin2 gene amplification (indicating piperaquine resistance). We collected blood spots from patients with microscopy or rapid test confirmed uncomplicated falciparum malaria. We used microsatellite genotyping to assess genetic relatedness. FINDINGS: As part of studies on the epidemiology of artemisinin-resistant malaria between Jan 1, 2008, and Dec 31, 2015, we collected 434 isolates. In 2014-15, a single long PfKelch13 C580Y haplotype (-50 to +31·5 kb) lineage, which emerged in western Cambodia in 2008, was detected in 65 of 88 isolates from northeastern Thailand, 86 of 111 isolates from southern Laos, and 14 of 14 isolates from western Cambodia, signifying a hard transnational selective sweep. Pfplasmepsin2 amplification occurred only within this lineage, and by 2015 these closely related parasites were found in ten of the 14 isolates from Cambodia and 15 of 15 isolates from northeastern Thailand. C580Y mutated parasites from Myanmar had a different genetic origin. INTERPRETATION: Our results suggest that the dominant artemisinin-resistant P falciparum C580Y lineage probably arose in western Cambodia and then spread to Thailand and Laos, outcompeting other parasites and acquiring piperaquine resistance. The emergence and spread of fit artemisinin-resistant P falciparum parasite lineages, which then acquire partner drug resistance across the Greater Mekong subregion, threatens regional malaria control and elimination goals. Elimination of falciparum malaria from this region should be accelerated while available antimalarial drugs still remain effective. FUNDING: The Wellcome Trust and the Bill and Melinda Gates Foundation.