Bilateral Symmetric Gastrocnemius Myositis Secondary to COVID-19.

As the coronavirus disease 2019 (COVID-19) pandemic perseverates on, more insight into the multidisciplinary manifestations of COVID-19 is being brought to the forefront. Musculoskeletal presentations range from mild creatinine kinase elevation and myalgias to severe rhabdomyolysis. We present a case of a patient who presented with symmetric myositis of bilateral gastrocnemius muscles secondary group.

Obstructive Sleep Apnea as a Risk Factor for COVID-19 Severity-The Gut Microbiome as a Common Player Mediating Systemic Inflammation via Gut Barrier Dysfunction.

The novel corona virus that is now known as (SARS-CoV-2) has killed more than six million people worldwide. The disease presentation varies from mild respiratory symptoms to acute respiratory distress syndrome and ultimately death. Several risk factors have been shown to worsen the severity of COVID-19 outcomes (such as age, hypertension, diabetes mellitus, and obesity). Since many of these risk factors are known to be influenced by obstructive sleep apnea, this raises the possibility that OSA might be an independent risk factor for COVID-19 severity. A shift in the gut microbiota has been proposed to contribute to outcomes in both COVID-19 and OSA. To further evaluate the potential triangular interrelationships between these three elements, we conducted a thorough literature review attempting to elucidate these interactions. From this review, it is concluded that OSA may be a risk factor for worse COVID-19 clinical outcomes, and the shifts in gut microbiota associated with both COVID-19 and OSA may mediate processes leading to bacterial translocation via a defective gut barrier which can then foster systemic inflammation. Thus, targeting biomarkers of intestinal tight junction dysfunction in conjunction with restoring gut dysbiosis may provide novel avenues for both risk detection and adjuvant therapy.

Non-ST Segment Elevation Myocardial Infarction Secondary to Coronary Multi-Vessel Thrombosis in the Setting of COVID-19.

Coronavirus disease 2019 (COVID-19) has been shown to impact the cardiovascular system by causing congestive heart failure, arrhythmias, myocarditis, acute coronary syndrome (ACS), or nonischemic cardiomyopathy. The infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) triggers the overproduction of proinflammatory cytokines, generating systemic inflammation and a procoagulant state that can lead to cardiovascular morbidity and mortality. Symptomatology may not be discrete with presentation of chest pain, dyspnea, and fatigue, so careful consideration should be applied to cardiovascular complications. Serial troponin dosage as well as EKG changes serve as viable prognosis markers. Prompt dissolution of the thrombi will minimize the extent of the myocardial injury.

Clinical Presentation and Outcomes of Myocarditis Post mRNA Vaccination: A Meta-Analysis and Systematic Review.

BACKGROUND: Myocarditis is being increasingly reported as a potential complication of both Pfizer-BioNTech and Moderna vaccines for COVID-19. One thousand five hundred and twenty-two cases were reported as of September 02, 2021, as per CDC's (Centers for Disease Control) vaccine adverse event reporting system. Most of the published data is available in the form of case reports and series. There is a need to compile the demographic data, clinical features, and outcomes in these patients.  Methods: A systematic search was conducted in PubMed, Embase, Web of science, and google scholar for published literature between January 01, 2020, and July 17, 2021. Individual data of 69 patients were pooled from 25 qualifying case reports and case series. RESULTS: The median age of onset was 21 years. 92.7% of the patients were male. 76.8% of patients received the Pfizer-BioNTech vaccine, and 23.2% received the Moderna vaccine. 88.5% developed symptoms after the second dose. Patients were admitted to the hospital a median of three days post-vaccination. All the patients had chest pain and elevated troponin. The myocarditis was confirmed on cardiac MRI in 87% of the patients. Most of the patients had late gadolinium enhancement on MRI. The median length of stay was four days. All the reported patients recovered and were discharged. CONCLUSION: Post-mRNA vaccination myocarditis is seen predominantly in young males within a few days after their second dose of vaccination. The pathophysiology of myocarditis is not well known. The prognosis is good as all the reported patients recovered. The presence of late gadolinium enhancement on cardiac MRI indicated myocardial necrosis/fibrosis and further studies are needed to establish the long-term prognosis of the condition.

Rare complication of ceftriaxone therapy: drug-induced thrombocytopenia (DITP).

A 62-year-old woman with a history of end-stage renal disease on haemodialysis, essential hypertension and type 2 diabetes mellitus was diagnosed with sepsis and placed on 600 mg oral linezolid every 12 hours and 1 g intravenous ceftriaxone every 24 hours. Blood cultures grew Streptococcus dysgalactiae, and she was switched to intravenous ceftriaxone 2 g daily. Platelet counts slowly trended down after starting ceftriaxone reaching 5 K/µL on day 12 of treatment. Ceftriaxone was discontinued and heparin-induced thrombocytopaenia was ruled out. She was switched to vancomycin and her platelet count improved. Given the temporal relationship between changing platelet counts and starting and discontinuing ceftriaxone, a diagnosis of drug-induced thrombocytopaenia was made.

Lemmel's Syndrome Secondary to Common Bile Duct Compression by an Inflamed Duodenal Diverticulum.

A 50-year-old female presented with acute epigastric abdominal pain, diarrhea, nausea, and vomiting for two days. Laboratory data showed hyperbilirubinemia and leukocytosis. Abdominal imagining was concerning for a pancreatic head/uncinate process lesion concerning a pancreatic neoplasm. Subsequent esophagogastroduodenoscopy with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography found the major papilla adjacent to an inflamed and infected duodenal diverticulum, which was extrinsically compressing the distal common bile duct, causing biliary obstruction and common bile duct dilation. These findings are consistent with a diagnosis of Lemmel's syndrome. A biliary sphincterotomy was performed to relieve the obstruction and one temporary plastic biliary stent was placed into the common bile duct. The duodenal diverticulitis was treated with antibiotics for 10 days and the patient made a good recovery.

Post-mRNA COVID-19 Vaccination Myocarditis.

A new trend of myocarditis among young adults who received mRNA vaccines for COVID-19 is emerging. We present the case of a young adult who presented with chest pain 3 days after the second dose of Pfizer-BioNTech COVID-19 vaccine. He had elevated troponin I and C-reactive protein levels at the time of admission. Electrocardiogram (ECG) and echocardiogram findings were unremarkable. The patient improved with conservative management and was discharged home the next day. LEARNING POINTS: Myocarditis is rare but is increasingly being reported in young adults post vaccination for COVID-19.Patients usually present with chest pain, elevated troponin and/or inflammatory markers.The condition carries a good prognosis and patients usually recover with supportive care.

Iatrogenic Iron Overload Causing Porphyria Cutanea Tarda in a Patient With a Rare Nonsense Heterozygous UROD Gene Mutation.

Porphyria cutanea tarda (PCT) is a rare dermatologic condition characterized by blistering of sun-exposed surfaces and elevated hepatic enzymes. It may infrequently occur as the primary presentation of underlying hemochromatosis. A 61-year-old female with anemia caused by chronic kidney disease and end-stage renal disease on hemodialysis presented with a bullous rash on her hands with associated pruritus. The rash worsened despite conservative treatment. An initial biopsy demonstrated a pauci-inflammatory cell-poor subepidermal cleft. Subsequent workup revealed elevated serum and urine porphyrins, confirming a diagnosis of PCT. Additionally, her skin was darkened and ferritin was elevated. MRI of the liver demonstrated iron overload with genetic testing negative for C282Y or H63D mutations, supporting a diagnosis of secondary hemochromatosis. Further genetic testing revealed that the patient had a rare heterozygous nonsense mutation of the uroporphyrinogen decarboxylase (UROD) gene, for a sequence variant designated c.616C>T, which is predicted to result in premature protein termination (p.Gln206*). PCT occurs due to decreased function of UROD, leading to accumulation of porphyrins causing dermatologic manifestations and liver injury. UROD is inactivated in an iron-dependent process, explaining the mechanistic link between hemochromatosis and PCT.

A Case of Histoplasmosis Mimicking Primary Lung Cancer With Liver Metastasis.

Histoplasmosis is usually self-limiting in healthy individuals but often fatal in immunocompromised patients. It can mimic primary lung malignancy and liver metastasis, causing a delay in appropriate therapy. We report a case of a 58-year-old male, with a 20 pack-year smoking habit, who presented with a three-week history of persistent fevers and productive cough with night sweats. Computed tomography (CT) scan of chest, abdomen and pelvis showed findings suggestive for primary lung malignancy associated with liver metastasis. Liver biopsy showed budding yeast. Bronchoalveolar lavage (BAL) fluid grew fungal organisms. Urine and serology were positive for histoplasmosis. Patient was pancytopenic, hence, we decided to evaluate further with a bone marrow biopsy which revealed underlying hairy cell leukemia. In the case of disseminated histoplasmosis, a high degree of suspicion towards any immunosuppressive condition should be entertained and any signs should be promptly investigated.

A Case of Diagnostic Difficulty: Transient Loss of Consciousness in Artery of Percheron Infarct.

The artery of Percheron (AOP) is a rare anatomical variant of the paramedian thalamic vessels in 7-10% of the general population. An AOP infarct can present with rare clinical manifestations like transient loss of consciousness (LOC) and lethargy, as was seen in the patient whose case is discussed in this report, due to the plethora of regulatory inputs and outputs by the thalamus, which cannot be compensated for because of the absence of anastomotic connections. The AOP supplies the reticular activating system (RAS), which regulates consciousness. Ischemia to this area from an AOP infarct can result in the transient LOC, which our patient experienced. The AOP is a small vessel that is often missed on a CT angiogram (CTA) alone due to low resolution. As a result, it is imperative that clinicians utilize MRI to diagnose AOP infarcts in patients who present with symptoms that raise concerns for decreased bilateral thalamic function and transient LOC.

An Uncommon Incidence of Drug-Induced Immune Hemolytic Anemia Secondary to Ceftriaxone.

A 69-year-old female with a history of psoriatic arthritis was diagnosed with septic arthritis and started on broad-spectrum antibiotics. She underwent left hip excisional debridement of her prosthetic hip joint which grew group B Streptococcus (S. agalactiae). She was switched to IV ceftriaxone 2 g daily and her hemoglobin decreased to 5.4 g/dL on day 11. Peripheral blood smear showed normochromic normocytic anemia and thrombocytopenia without the presence of schistocytes. Increased lactate dehydrogenase (LDH), decreased haptoglobin and hemoglobin, and positive direct Coombs test (DCT) led to a presumptive diagnosis of drug-induced immune hemolytic anemia (DIIHA). As a result, she was switched from ceftriaxone to IV ertapenem 500 mg every 24 hours and oral prednisone 60 mg for four days during the initial phase. Her hemoglobin, LDH, and haptoglobin trended towards normal limits, further supporting the diagnosis of DIIHA secondary to ceftriaxone.

Strongyloides Stercoralis Infection: A Rare Cause of Acute Abdomen.

A 30-year-old female presented to the emergency department with severe recurrent abdominal pain, nausea, vomiting and a 50-pound unintentional weight loss within the past few years. After emigrating from Liberia to the United States in 2005, the patient was evaluated for similar complaints in the past and underwent exploratory laparotomies and partial small bowel resection with no significant improvement in symptoms. Computerized tomography (CT) of the abdomen showed intestinal inflammation and mesenteric edema. Small intestinal enteroscopy was unremarkable. Small intestinal biopsy showed larval round worms in intestinal crypts. Stool ova and parasite exam revealed larval forms of Strongyloides stercoralis. She was treated with ivermectin 200 mcg/kg daily for two days and recommended to return in four weeks to repeat stool exam to ensure complete parasite clearance.

Posterior Fossa Progressive Multifocal Leukoencephalopathy Secondary to Rituximab.

Progressive multifocal leukoencephalopathy (PML) is a rare fatal central nervous system disorder characterized by infection-induced demyelination of white matter due to the opportunistic reactivation of John Cunningham virus in an immunocompromised patient. PML is associated with many immune-mediated diseases, lymphoproliferative conditions, and immunosuppressive agents. In this case report, we present a 79-year-old female patient diagnosed with rheumatoid arthritis who developed posterior fossa PML while on rituximab. She presented with subacute cerebellar ataxia, dysarthria, and nystagmus, and her brain MRI showed right pontine and pontocerebellar lesion with diffusion restriction and heterogenous enhancement highly characteristic of PML. Though many cases of PML with rituximab were reported in the literature, our case describes a rare type of PML affecting the posterior fossa in an HIV-negative patient on rituximab.

A Short Case Report on Ruptured Sinus of Valsalva Aneurysm.

A 35-year-old woman without any history of congenital heart disease presented to our clinic with dyspnea on exertion. Transthoracic echocardiogram (TTE) showed an eccentric tricuspid regurgitant jet and increased right ventricular systolic pressure. Transesophageal echocardiogram (TEE) revealed a sinus of Valsalva aneurysm (SVA) arising from the noncoronary sinus that ruptured into the right atrium, leading to the formation of an aorto-right atrial fistula. Right heart catheterization confirmed left to right shunt. The fistulous tract was resected, and the aneurysm repaired surgically. The patient made a good recovery.

A Rare Case of Erythema Gyratum Repens Associated With Esophageal Carcinoma.

Rash is a common complaint in a primary care setting. Erythema gyratum repens (EGR) is a unique rash strongly associated with malignancy. Sometimes this rash can precede the clinical presentation of malignancy, most commonly lung carcinoma. Even though this is an uncommon rash, physicians need to be aware of this condition for the prompt evaluation of malignancy to start the therapy. In this report we present the case of a 61-year-old gentleman with stage IV squamous cell carcinoma of the esophagus who presented with EGR two months after the diagnosis of his malignancy. The diagnosis was made based on clinical exam and histological findings. The patient was reassured and the rash was managed conservatively. Chemotherapy was continued and the rash was resolved in two months.

Diabetic Myonecrosis: An Uncommon Complication of a Common Condition.

INTRODUCTION: Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes. Its etiology is poorly understood, with many suggesting microvascular occlusion to be a key factor resulting in necrosis of skeletal muscle. CASE PRESENTATION: A 28-year-old male with a history of poorly controlled type I diabetes mellitus and end-stage renal disease requiring dialysis presented to the emergency department with severe pain of the lower extremities bilaterally. RESULTS: Work-up included an x-ray, which demonstrated no acute fractures but extensive vascular calcification of the lower extremities, and Doppler ultrasonography, which showed no DVT. MRI demonstrated severe muscular edema with patchy, geographic areas of sparing, which, in conjunction with the patient's clinical presentation, allowed for a diagnosis of diabetic myonecrosis. He underwent conservative treatment, consisting of rest and pain management, leading to resolution of symptoms. DISCUSSION: Diabetic myonecrosis, although uncommon, can be easily diagnosed with a high degree of clinical suspicion. It typically presents in a patient with poorly controlled diabetes, and will commonly involve the proximal muscles of the lower extremity unilaterally, but may present bilaterally and involve the distal muscles, as demonstrated in this case. Diagnosis is made via MRI, and it is treated conservatively with pain management and rest. Most cases resolve with conservative management but recurrence is common. LEARNING POINTS: Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes presenting with significant unilateral lower extremity pain, although bilateral presentation is also possible.A diagnosis of diabetic myonecrosis can be easily made with MRI, which demonstrates highly characteristic muscular edema with patchy areas of geographic sparing, but a high degree of clinical suspicion is necessary to reach a diagnosis.Recurrence of diabetic myonecrosis is common, and should be suspected in patients who have a history of this condition presenting with recurrent musculoskeletal pain, even if this pain is localized to a different muscle group.

Acute Eosinophilic Pneumonia: A Rare Complication of Daptomycin Therapy.

Daptomycin is a cyclic lipopeptide antibiotic with great efficacy targeting gram-positive cocci, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Acute eosinophilic pneumonia is a rare complication of daptomycin therapy, with a poorly understood etiology thought to involve the accumulation of the drug in pulmonary surfactant inducing inflammation. We present a 56-year-old male with a history of spinal epidural abscess being treated with intravenous daptomycin, who presented to the emergency department with fever, developed worsening shortness of breath, and was subsequently discovered to have eosinophilia of pulmonary secretions via bronchoalveolar lavage. Daptomycin was discontinued, and he underwent treatment with corticosteroids, resulting in full resolution of symptoms. Diagnosis of acute eosinophilic pneumonia requires a high degree of clinical suspicion. Identification may be further complicated by the fact that symptoms can present anywhere from days to weeks after starting the therapy. This complication is very responsive to treatment with corticosteroids and cessation of daptomycin, but recognition is essential. With an increasing use of daptomycin subsequent to continued emergence of antibiotic resistance, it is essential that physicians are aware of this rare complication of daptomycin therapy.

Bilateral chorea/ballismus: detection and management of a rare complication of non-ketotic hyperglycaemia.

Non-ketotic hyperglycaemia (NKH) is the most common metabolic cause of hemichorea-hemiballismus (HC-HB) and an often-reversible condition. A 68-year-old man presented to the emergency department with a severe hyperglycaemic episode and altered mental status. He was treated appropriately and discharged home after his blood glucose levels were normal with an improvement of mental status. Four weeks after the discharge, he returned with flailing movements of bilateral upper and lower limbs. MRI of the brain revealed hyperintensities of the bilateral putamen on T1-weighted imaging. The patient's symptoms improved with a combination of amantadine, clonazepam and tetrabenazine. Several hypotheses involving gemistocytes, calcification and petechial haemorrhage were proposed in support of imaging abnormalities in the striatum. Dopamine-depleting agents and neuroleptics are used in the treatment of chorea. It is recommended to try a dose of tetrabenazine in patients with NKH-induced HC-HB if no improvement is appreciated with initial treatment of glycaemic control.

Acute necrotising pancreatitis: a late and fatal complication of pancreaticoduodenal arterial embolisation.

A 70-year-old man was diagnosed with a massive bleeding duodenal ulcer which was refractory to emergency endoscopic management. Angiogram of the coeliac and superior mesenteric arteries revealed bleeding from the superior and inferior pancreaticoduodenal arteries. Transcatheter arterial embolisation of superior and inferior pancreaticoduodenal arteries along with the gastroduodenal artery was performed. Two weeks later he developed severe necrotising pancreatitis of the pancreatic head probably due to ischaemia, which was managed conservatively. Three months later the patient experienced another episode of pancreatitis which progressed into multiorgan dysfunction and the patient passed away.

Priapism in a patient with sickle cell trait using marijuana.

A 22-year-old man with a history of multiple episodes of priapism presented to the emergency room with an erection lasting more than 48 h after conservative management failed at home. He had no known family history of sickle cell disease or trait. He was haemodynamically stable. Physical examination revealed an enlarged, tender penis. Laboratory data revealed a positive sickle solubility test. Haemoglobin electrophoresis revealed sickle cell trait and urine drug screen was positive for cannabinoids. Initial management was attempted with intracavernosal phenylephrine without any success. The patient underwent a limited El-Ghorab procedure on the right corpora cavernosa but the priapism did not resolve adequately. Two days later, the patient had to undergo a bilateral El-Ghorab procedure and achieved complete resolution of the priapism.