Metronidazole induced cerebellar toxicity after prolonged treatment of large multiloculated pyogenic liver abscess; A case report and literature review.

Metronidazole is a common antibiotic agent for hepatic abscesses, which require both gram-negative and anaerobic coverage. Rarely, this antibiotic has been found to induce encephalopathy. Here, we describe a 65-year-old male who was treated with metronidazole for his hepatic abscess, who presented with syncope and questionable seizure and was found to have magnetic resonance imaging (MRI) brain findings consistent with metronidazole toxicity. Our patient demonstrated striking brain MRI findings which can be used to further understand the process behind this medication-induced toxicity. Hypotheses of this mechanism include swelling of axons secondary to increased water or vasospasm leading to reversible ischemia that is localized in the brain. In terms of MRI findings, brain lesions tend to populate bilaterally with focus at the dorsal pons, midbrain, cerebellar dentate nuclei (as with our patient), dorsal medulla, or splenium of corpus callosum. Additional research is warranted regarding this rare manifestation and timely removal of the offending agent is crucial for reversal of symptoms.

How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts.

Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.

Pulmonary Carcinosarcoma: A Rare Disease With Challenging Diagnosis and Treatment.

Pulmonary carcinosarcoma (PCS) is a rare type of non-small cell cancer. Overall, middle-aged and older smokers are the most affected age and sex groups. The diagnosis of PCS is difficult due to the absence of characteristic imaging findings. Additionally, preoperative biopsies do not usually reflect the heterologous nature of this tumor. Given the rarity of such tumors and the challenging diagnosis, the prognostic factors have not been established, and the overall prognosis remains poor. The valid therapeutic options are still limited. Here, we report a rare case of metastatic PCS that was accidentally discovered by imaging and properly diagnosed after surgical resection. The clinicopathological features, diagnostic tools, genetic theories, prognosis, and therapeutic options of this rare cancer are also discussed.

Hemosuccus Pancreaticus: Challenging Diagnosis and Treatment.

Hemosuccus pancreaticus (HP) is defined as bleeding from the ampulla of Vater through the pancreatic duct. It is a rare complication associated with acute or chronic pancreatitis. The source of bleeding can be from the pancreas itself or surrounding vessels, with the splenic artery most commonly involved. Diagnosing HP is challenging and computed tomography angiography remains the gold standard for diagnosis. We present the case of a 62-year-old male with recurrent pancreatitis complicated with HP. Imaging and endoscopy were consistent with bleeding from the section portion of the duodenum, which resolved without intervention. LEARNING POINTS: Hemosuccus pancreaticus is a rare complication associated with acute or chronic pancreatitis.CT angiography is the gold standard for diagnosing hemosuccus pancreaticus.Arterial embolization is the first-line treatment of hemosuccus pancreaticus.

The Racial Divide: A Follow Up Study on Racial Disparity Amongst COVID-19 Survivors in an Urban Community.

Background: Studies have shown that COVID-19 has had a disproportionate effect on minority groups in both the clinical and social settings in America. We conducted a follow up study on patients previously diagnosed with COVID-19 one year ago in an urban community in New Jersey. The purpose of the study was to evaluate the socioeconomic impact of COVID-19 as well as assess for receptiveness towards COVID-19 vaccination amongst various ethnic groups. Methods: This was a prospective cohort study consisting of patients who had recovered from COVID-19 one year prior. The patients included in the study had a confirmed COVID-19 diagnosis in the months of March and April of 2020. This was a single institutional study conducted at St. Joseph's University Medical Center in Paterson, NJ from the months of March to April of 2021. Patients included in the study were either male or female aged 18 years or older. Patients who met criteria for inclusion were contacted by telephone to participate in a telephone survey. After informed consent was obtained, the patients completed a survey which obtained sociodemographic information pertaining to their diagnosis with COVID-19. Statistical analysis was performed using chi-square testing and multivariable logistic regression analysis. Results: Of the 170 patients enrolled in the study, the most common ethnicity was Hispanic (79/170 [46.47%]), followed by African American (46/170 [27.05%]). The gender distribution was 83 male (83/170 [48.82%]) and 87 female (87/170 [51.18%]) with a mean age of 51.5. Caucasians were the most willing to receive a COVID-19 vaccine (28/30 [93.3%]), followed by Asians (13/14 [92.8%]), Hispanics (63/78 [80.7%]) and African Americans (29/46 [63.0%]). Hispanics had the highest rate of job loss (31/79 [39.24%]), followed by of African Americans (16/46 [34.7%]). Hispanics were found to be in the most financial distress (31/79 [39.2%]), followed by African Americans (17/46 [36.9%]). Chi square analysis revealed Hispanics and African Americans were more likely to lose their jobs after being diagnosed with COVID-19 (p: 0.04). Hispanics and African Americans were also more likely to refuse vaccination with any of the available COVID-19 vaccines (p: 0.02). Multivariable Logistic regression analysis was then performed comparing both Hispanics and African Americans to Caucasians. Hispanics were more likely to lose their jobs compared to Caucasians (odds ratio, 4.456; 95% CI, 1.387 to 14.312; p: 0.0121). African Americans were also more likely to lose their jobs when compared to Caucasians (odds ratio, 4.465; 95% CI, 1.266 to 15.747; p: 0.0200). Discussion: Overall Hispanics reported the highest rates of financial distress after their diagnosis with COVID-19. Nearly 40% of the Hispanic lost their jobs following their diagnosis with COVID-19 which was the highest in our study group. African Americans were similarly affected with about 37% of all patients experiencing job loss and financial distress following diagnosis with COVID-19. Hispanics and african americans were the two ethnic groups who were least willing to receive COVID-19 vaccination. Only 63% of African Americans were willing to receive the vaccine, with 80.7% of Hispanics willing to become vaccinated. The most common reason for not receiving any of the COVID-19 vaccines was due to lack of trust in the vaccine. Both Hispanics and African Americans were more statistically likely to lose their jobs as well as refuse COVID-19 vaccination following diagnosis with COVID-19.

Use of Systemic Anticoagulation in COVID-19: Delving Beyond Theoretical Hypothesis.

Background Studies suggest that COVID-19 infection may induce increased hypercoagulability, leading to thrombotic complications. The high rates of thrombotic complications among patients receiving standard-dose deep venous thrombosis (DVT) prophylaxis have prompted some clinicians to support the empiric increase of anticoagulation (AC) doses used for prophylaxis in patients with COVID-19. At present, the optimal anticoagulant agents, dosages, and duration have not been designated. We conducted a retrospective study to assess for outcomes in patients who received treatment for COVID-19 based on various dosings of AC. Methods This was a single-institution, retrospective cross-sectional study including patients with a positive COVID-19 test who were admitted within the St. Joseph's Health Network from September to November of 2020. The inclusion criteria were men and women aged 18 years or older who had confirmed COVID-19 by polymerase chain reaction (PCR). Medical charts of patients who met the inclusion criteria were audited to obtain information. The patients were separated into three cohorts: those who received DVT prophylactic dose of AC, those who received an intermediate dose of AC, and those who received therapeutic AC. Results A total of 440 patients were included in the study, of whom 236 were Hispanic (50.3%), 131 were Caucasian (27.1%), 47 were African American (10.7%), and 26 were Asian (5.9%). The most common comorbidities were hypertension (273/440 [62.2%]), diabetes 189/440 [43.1%]), and coronary artery disease (60/440 [13.7%]). In the DVT prophylactic dose of AC cohort, there were 215 patients, and the average length of stay was 10.3 days. Eleven patients experienced bleeding events, five patients experienced thrombotic events, 16 patients required mechanical ventilation, and 20 patients died. In the intermediate dose of AC cohort, there were 63 patients, and the average length of stay was 10.3 days. Three patients experienced bleeding events, two patients experienced thrombotic events, seven patients required mechanical invasive ventilation, and 11 patients died. In the therapeutic dose of AC cohort, there were 162 patients, and the average length of stay was 14 days. In this cohort, 19 patients experienced bleeding events, 12 patients experienced thrombotic events, 26 patients required invasive mechanical ventilation, and 29 patients died. Patients who received intermediate dosing of AC also had the lowest risk of thrombotic events (0.05). Patients who received intermediate dosing of AC had the lowest rates of requiring both high-flow nasal cannula (p = 0.0001) and invasive mechanical ventilation (p = 0.031). Patients who received intermediate dosing of AC had a lower rate of bleeding compared to those who received the DVT prophylaxis dose and systemic AC dose (p = 0.037). The DVT prophylactic and intermediate dosing of AC groups had a shorter length of stay in comparison to the systemic AC group (p = 0.0002). Conclusion In comparison to the venous thromboembolism prophylaxis dose and systemic AC dose groups, intermediate dosing of AC had the lowest rates of hemorrhage, mortality, length of stay, and requirement of high-flow nasal cannula or mechanical invasive ventilation. In the systemic dose AC group, there were worse clinical outcomes in terms of length of stay, incidence of bleeding events, requirement of mechanical ventilator use, and rate of mortality.

Endovascular Embolization of Pulmonary Sequestration Presenting With Hemoptysis: A Promising Alternative to Surgery.

Pulmonary sequestration is abnormal lung parenchyma separated from the normal tracheobronchial system and supplied by an aberrant systemic artery. It is usually asymptomatic; however, it can present with hemoptysis and recurrent pulmonary infections. Although surgery is the classical treatment, arterial embolization is recently established as an alternative treatment to avoid surgical complications. We present a case of left lower lobe intralobar pulmonary sequestration presented with hemoptysis and was successfully treated with coil embolization.

Crazy vaping and crazy-paving, a case of E-Cigarette/Vaping-Associated Lung Injury (EVALI) with chest CT showing crazy-paving pattern.

E-cigarettes are devices that generate an aerosol by heating a fluid containing multiple chemicals, such as nicotine, additives, and flavorings. They were developed to aid in smoking cessation and were promoted as socially acceptable, healthier, cheaper than conventional cigarettes. Multiple lung disorders related to e-cigarette use are reported, and they range from mild cases of pneumonitis to life-threatening lung disorders that may require intubation and mechanical ventilation. Most of the complications are due to the generation of various unknown and potentially harmful chemicals within the aerosol generated in the e-cigarette. These disorders are known collectively as e-cigarette/Vaping-associated lung injury (EVALI). E-cigarettes are marketed as safer alternatives to traditional cigarettes, with the highest rates of use are noted in young smokers. Given the significant prevalence of e-cigarettes use and their pulmonary complications, EVALI should be considered a potential etiology in the broad differential diagnosis of patients with pulmonary disease and a history of vaping. Herein, we present a case of cryptogenic organizing pneumonia with a chest C.T. showing a crazy-paving pattern in a patient with a history of vaping.

Acute Pancreatitis in the Transgender Population.

Hypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality. Hormone replacement therapy in the transgender population is an underrecognized cause of elevated triglyceride (TG) levels and may put this group at a higher risk for severe pancreatitis. We present a case of AP in a genetically male patient receiving hormone therapy for female gender transformation.A 51-year-old with a past medical history of type 2 diabetes mellitus presented with severe epigastric abdominal pain associated with nonbilious, nonbloody vomiting and anorexia for two days. The patient was diagnosed with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) in the setting of elevated lipase levels of 2,083 u/L and TGs of >5,000 mg/dL. In addition, a computerized tomography scan of the abdomen showed pancreatitis without evidence of necrosis. The patient was admitted to the medical intensive care unit for the management of AP in the setting of elevated TG levels. She was treated with intravenous fluids and an insulin drip. Her home medications including estradiol and Aldactone were held. Once the TG levels were reduced to <500 mg/dL, she was taken off the Insulin drip and transitioned to a subcutaneous insulin regimen along with gemfibrozil and omega-3 fatty acid over the next three days, and then discharged to home. HTG accounts for only about 7% of pancreatitis cases and increases in severity as TG levels increase. The clinical presentation of patients suffering from HTG-AP is similar to patients with AP from other etiologies and presents in a relatively younger population compared to AP from other causes. Treatment options for HTG-AP usually utilize insulin and heparin; however, plasma exchange and venovenous filtration may be used for severe cases of HTG-AP. The goal of treatment is to lower the TG levels. Physicians should be aware of such complications and should counsel patients while utilizing hormone replacement therapy, especially in patients with a prior family history of dyslipidemia.

Massive Mixed Adenoneuroendocrine Carcinoma: A Case Report.

Mixed adenoneuroendocrine carcinoma (MANEC) of the gastrointestinal (GI) tract is a rare subtype of mixed tumors, and it is scarcely described in the literature. MANEC tumors are composed of adenocarcinoma and neuroendocrine carcinoma components, each of which comprises at least 30% of the lesion. Diagnosing MANEC requires specific histological and immunohistochemistry (IHC) analysis. Typically, MANEC tumors carry a poor prognosis due to their very aggressive nature. We report the case of a 70-year-old female patient with no past medical history who presented with a three-week history of abdominal pain and one episode of hematemesis one week prior to presentation. Initial CT of the abdomen showed a large, 8 x 6 x 6-cm mass arising from the stomach and extending to the lesser sac as well as the central crus of the diaphragm with bilateral retroperitoneal lymphadenopathy. Upper endoscopy revealed an excavated, ulcerated, and partially necrotic mass on the lesser curvature of the proximal gastric body. Tissue biopsy of the lesion showed infiltrating mixed poorly differentiated adenocarcinoma and neuroendocrine carcinoma. On IHC, the adenocarcinoma component stained positively for CDX2 and pancytokeratin, and the neuroendocrine component stained positively for synaptophysin and chromogranin. Further workup included CT of the chest, which demonstrated extensive bilateral pulmonary emboli and new liver lesions with moderate ascites not seen on the initial abdominal CT. The latter was repeated and showed remarkable enlargement of the gastric mass (up to 12 cm) with extensive retroperitoneal adenopathy and mesenteric implants. Given the rapid clinical deterioration and progression of tumor burden, comfort measures were offered and the patient passed away soon after. MANEC tumors are highly aggressive subtypes of "collision" tumors, which are not well described in the medical literature due to their rarity. The etiology is poorly understood with various theories proposing different pathophysiological mechanisms. Standard therapy is not well developed at present; however, a few reports have demonstrated successful outcomes with surgery or combined chemotherapy (cisplatin with irinotecan or etoposide) if diagnosed at an early stage.