Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms.

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

Syncope Secondary to Concomitant Ingestion of Tizanidine and Alcohol in a Patient With Alcohol Use Disorder.

Syncope is the transient loss of consciousness due to cerebral hypoperfusion. A significant number of individuals experience a syncopal attack at one stage of their lives. The common causes of syncope include vasovagal syncope, orthostatic hypotension, and cardiac causes. Drugs are also associated with causing syncope. The drugs involved are mostly those that depress the central nervous system, and concomitant use of more than one of such drugs increases the risk of syncope even further. Tizanidine and alcohol individually can cause hypotension and combining both drugs is not advised due to heightened central nervous system depression and profound hypotension. We present a case of a 53-year-old female with alcohol use disorder who presented with a first-time syncopal attack due to postural hypotension after ingesting both tizanidine and alcohol concurrently. Co-administration of tizanidine and alcohol is not advised, however, cases of syncope have been rarely reported with concomitant use. This case will enlighten physicians to counsel patients about the need to abstain from alcohol consumption when taking tizanidine.

Bilateral Empyema With Beta Hemolytic Group C Streptococcus and Streptococcus constellatus Co-infection Resulting From an Esophageal Perforation and Associated With Septic Shock, Diffuse ST Elevation, and New-Onset Atrial Fibrillation.

Empyema is the collection of pus in the pleural cavity and most times, it occurs unilaterally. It is often associated with underlying pneumonia, but other causes have been identified as well. When it occurs after an esophageal perforation, which in itself is also rare, morbidity and mortality are even higher. Esophageal perforation can cause life-threatening complications due to its close proximity to the vital organs of the mediastinum, necessitating its timely diagnosis and aggressive management. Bacteria forming part of the normal esophageal and oral flora are the most common causative pathogens for empyema from an esophageal perforation. Streptococcus constellatus and group C Streptococci, though both rare and often not taken seriously, have been identified as individual causes of empyema. We present a case of a 58-year-old male who presented with a worsening cough, chest pain, and shortness of breath after choking on a fish bone. He was diagnosed with bilateral loculated empyema resulting from esophageal perforation with the pleural fluid culture isolating both group C streptococcus and Streptococcus constellatus. He also developed respiratory failure, mediastinitis, and septic shock. This case will enable physicians to take empyema caused by these bacteria seriously and also to include esophageal perforation as a differential diagnosis when a patient presents with bilateral empyema associated with chest pain and electrocardiographic changes.

Methylphenidate-Induced Non-ischemic Heart Failure With Reduced Ejection Fraction and Mild Pulmonary Hypertension.

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is commonly diagnosed during childhood. Patients present with hyperactive-impulsive behavior and/or inappropriate inattention which may persist through adulthood. Central nervous system stimulants have been used to manage patients with ADHD. Methylphenidate which is used as a first-line therapy has been shown to have adverse cardiovascular effects in these patients. This is a case of a young male with a history of ADHD since childhood on methylphenidate who was diagnosed with acute non-ischemic heart failure with an ejection fraction of 15-20%. Methylphenidate-induced heart failure is the rare adverse effect seen in ADHD patients who are on this medication. Our patient was started on goal-directed medical therapy for heart failure and was discharged with an implantable cardioverter defibrillator (LifeVest®, ZOLL, Pittsburgh, PA) because of his persistently low left ventricular ejection fraction. It is important for physicians to always consider heart failure as a possible cardiovascular adverse effect when starting patients on methylphenidate for the management of ADHD.

Severe Sepsis Associated With Multiorgan Failure and Precipitating Nonhepatic Hyperammonemia Crisis in Late-Onset Ornithine Transcarbamylase Deficiency: A Case Report and Literature Review.

Sepsis is characterized by a dysregulated immune response to an infection. It is a major public health problem owing to its high mortality and morbidity. Sepsis is a medical emergency and requires aggressive and timely management. It can cause multiorgan failure, unmask an existing but undiagnosed disease such as ornithine transcarbamylase deficiency (OTCD), or make a known well-controlled disease worse. We present the case of a 52-year-old male who was brought to the emergency department unresponsive. He was diagnosed with severe sepsis which was associated with multiorgan failure and hyperammonemia crisis. Hyperammonemia was due to a newly diagnosed, late-onset OTCD which was unmasked by severe sepsis. This case will enable physicians to be aware and consider OTCD in a patient presenting with severe sepsis, altered mentation, and seizures, with no obvious cause of hyperammonemia.

An Atypical Case of Polycystic Ovarian Syndrome and Possible Newly Diagnosed Systemic Lupus Erythematosus Complicated With a Cerebrovascular Accident in a Young Female: A Case Report.

Polycystic ovary syndrome (PCOS) is the leading cause of endocrine disorders among females of reproductive age and is linked with autoimmune disorders. PCOS has been associated with autoantibodies such as antinuclear antibody (ANA), anti-thyroid, and anti-Smith (anti-SM). Young patients with PCOS and systemic lupus erythematosus (SLE) have up to a 10-fold increase in stroke. We present a case of a patient with a history of PCOS (on metformin), hypothyroidism, and pulmonary embolism who presented to the emergency room with acute left-sided weakness. She was extensively investigated for risk factors and was eventually diagnosed with a cerebrovascular accident secondary to possible SLE with positive ANA (1:160, nuclear homogenous pattern). The diagnosis of PCOS, coupled with autoantibodies and recurring episodes of thromboembolic events, rendered her case management complex. She received tenecteplase and had thrombectomy done twice because of recurrent thrombotic events during her hospital stay. She passed away on the fifth day post-thrombectomy from a possible massive pulmonary embolism with hemodynamic compromise. There is a need for more research to comprehend the underlying mechanisms of SLE and PCOS to guide the proper management of patients in this situation.

An Atypical Presentation of Burkitt Lymphoma Presenting As Large Intra-abdominal Masses Compressing Multiple Organs With Peri-Pericardial Involvement in an HIV Patient: A Case Report and Literature Review.

Many types of malignancies have been associated with immunodeficiency states, especially patients who are HIV positive. Burkitt lymphoma (BL) is one of those malignancies associated with HIV and it presents in three varieties. The endemic form is primarily seen in children, and it is associated with the Epstein-Barr virus (EBV). In this form, patients with Burkitt's present with a large jaw mass. The second variety is seen in older adults. These patients usually present with abdominal and pelvic masses. This subtype is more prominent in the United States. The third variety of BL is seen in patients who are HIV positive. In this case report, we present an atypical presentation of BL secondary to undiagnosed HIV/AIDS with a very large tumor burden causing compressive symptoms. This case will further guide healthcare professionals in diagnosing BL, which presents uniquely in high-risk populations. This report will also serve as a review of the diagnosis and treatment options of BL.

Lupus-Induced Accelerated Heart Failure in a Young African American Female: Cardiovascular and Systemic Complications of Noncompliance to Maintenance Therapy and the Social Determinants of Cardiovascular Disease.

Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disorder characterized by dysregulations of the immune system with intermittent and remitting symptoms. SLE affects multiple organs and systems, including the cardiovascular system. This condition is associated with an increased risk of cardiovascular disease, particularly in younger patients. Our case report describes a patient who rapidly developed structural, functional, and electrophysiological cardiac abnormalities due to lupus-induced cardiomyopathy. The accelerating cardiac events were the result of medication noncompliance. Myocarditis and other potentially fatal cardiac complications associated with SLE have been the subject of numerous studies. This presentation appears to be the first to emphasize the rarity of lupus-induced cardiomyopathy, the importance of treatment adherence, the adverse cardiac effects of targeted therapeutic interventions, and the influence of social determinants of cardiovascular health on a patient's prognosis.

Diffuse Alveolar Hemorrhage Occurring Suddenly in a Diabetic Patient With Asthma Exacerbation.

Diffuse alveolar hemorrhage (DAH) is a rare but potentially life-threatening condition characterized by bleeding into the alveolar spaces of the lungs. DAH can occur due to a wide range of etiologies including autoimmune diseases, infections, drugs, and malignancies. The clinical presentation is variable and may include cough, dyspnea, fever, and hemoptysis. Diagnosis is often challenging due to the nonspecific symptoms and a lack of definitive diagnostic criteria. Treatment is primarily aimed at addressing the underlying cause and providing supportive care.

Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review.

Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.

Therapeutic Potential of Vitamin D in Management of Asthma: A Literature Review.

Asthma, a prevalent chronic respiratory illness, affects a substantial number of individuals worldwide, with an estimated occurrence of 358 million cases. Evidence for the benefits of vitamin D in treating asthma is ambiguous and contradictory. The goal of this review article is to emphasize the value of vitamin D supplementation for people with asthma. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on vitamin D supplementation in asthma patients. We selected a comprehensive range of academic writing examples published in English, encompassing various types of texts. The study included a total of 37 papers, of which 18 were randomized controlled trials (RCTs) and five were meta-analyses. The use of a corticosteroid, with or without the inclusion of an adrenergic receptor agonist, improves the disease's symptoms, but it is unable to halt the long-term decline in lung function. Over the past 20 years, vitamin D has developed into a potent immunomodulator, influencing both immunological and structural cells, most notably airway smooth muscle cells. Among adults with low 25-hydroxyvitamin D levels, the administration of vitamin D supplements was found to have positive effects in a reduction in the likelihood of asthma exacerbations requiring systemic corticosteroids. The provision of vitamin D supplements during pregnancy significantly reduces the risk of asthma in babies. Both children and adults with inadequate vitamin D levels who have been given vitamin D supplements have shown evident preventive effects against asthma. Therefore, we conclude there should be a lower threshold for prescribing vitamin D to patients with asthma who are vitamin D deficient.

The Associations of Auto-Brewery Syndrome and Diabetes Mellitus: A Literature Review and Clinical Perspective.

Endogenous production of alcohol without the external intake of alcohol is called auto-brewery syndrome (ABS), and to get its levels to rise to a level that it has physical symptoms of alcohol intake is rare. The most common cause of ABS is the metabolism of ingested carbohydrates by intestinal microflora. This occurrence does not happen in all normal individuals but only in some high-risk individuals. Patients with diabetes mellitus (DM) have been hypothesized to be at high risk for ABS. We searched databases, such as PubMed, Medline, and PubMed Central, to search for existing literature with relevant keywords. In the finalized review, we have included 30 relevant articles. Alcohol formed in the gut gets absorbed in the bloodstream and immediately gets metabolized, so usually it does not achieve a level in blood high enough to cause symptoms. In high-risk patients, there is an increase in the level of bloodstream alcohol above a certain level, so it shows symptoms. Because there is higher blood glucose in DM, the patients have been shown to be at increased risk for developing ABS. Similarly, obesity is also a risk factor for DM, making it a high-risk condition for ABS. The most involved pathogens are Candida and Saccharomyces.

Cerebral Salt Wasting Syndrome Following Right Occipital Craniotomy in a Patient With Metastatic Lung Adenocarcinoma.

Cerebral salt wasting syndrome (CSW) is characterized by excessive natriuresis leading to hyponatremia and hypovolemia. It is commonly encountered among patients who have undergone brain trauma or subarachnoid hemorrhage. The occurrence of CSW after neurosurgical procedures has been frequently reported in the pediatric age group; however, it is a rare phenomenon in adults. We describe the case of a 59-year-old female who developed symptoms of polyuria and polydipsia after a right occipital craniotomy.

Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome.

Propofol has revolutionized anesthesia and intensive care medicine owing to its favorable pharmacokinetic characteristics, fast onset, and short duration of action. This drug has been shown to be remarkably effective in numerous clinical scenarios. In addition, propofol has maintained an overwhelmingly favorable safety profile; however, it has been associated with both antiarrhythmic and proarrhythmic effects. This review concisely summarizes the dual arrhythmic cardiovascular effects of propofol and a rare but serious complication, propofol infusion syndrome (PRIS). We also discuss the need for careful patient evaluation, compliance with recommended infusion rates, and vigilant monitoring.

Severe soft tissue infection: A complication of mpox in an individual with HIV coinfection requiring vaccinia intravenous immunoglobulin and intravenous tecovirimat.

We highlight a case of a 38-year-old immunocompromised man with untreated human immunodeficiency virus and Hepatitis C who presented with progressive soft tissue infection of the right foot despite appropriate antibiotic therapy. While he was admitted, the patient disclosed a recent diagnosis of mpox treated with oral tecovirimat. He subsequently developed worsening lesions over his entire body. In addition, a polymerase chain reaction of the wound on the right foot was positive for mpox virus, and the patient improved on treatment with intravenous tecovirimat and vaccinia immunoglobulin.

Rectal ulcers: a complication from stool management system use.

Fecal management System (FMS) is widely used across medical facilities in United States. These devices have helped in preventing problems associated with fecal incontinence. Although highly efficient, these devices can also lead to certain complications including rectal ulcer and lower Gastrointestinal (GI) bleed. Here, we report a case of a 56-year-old male being treated for pneumonia and atrial fibrillation, who had significant lower GI bleed while being on FMS for stool incontinence. A colonoscopy was performed, which showed multiple rectal ulcers with one large ulcer having a visible pulsating vessel. This case highlights a rarely reported complication of rectal ulcers and GI bleed associated with use of FMS.

Spontaneous Cholesterol Embolism Leading to Small Bowel Obstruction and Perforation.

A spontaneous occurrence of cholesterol embolization syndrome causing small bowel obstruction and perforation is a highly scarce event. In this article, we report a case of spontaneous cholesterol embolism resulting in small bowel obstruction and perforation in a 52-year-old male with multiple cardiovascular and medical comorbidities. In our patient, the source was an eccentric left lateral atherosclerotic plaque from the abdominal aorta that was identified using computed tomography. A distal occlusion in numerous small intestinal arteries due to cholesterol embolism was confirmed on biopsy after surgical resection. (Level of Difficulty: Intermediate.).

Understanding Auto-Brewery Syndrome in 2023: A Clinical and Comprehensive Review of a Rare Medical Condition.

Auto-brewery syndrome (ABS) occurs when the gastrointestinal tract produces excessive endogenous ethanol. This article examines various aspects of ABS such as its epidemiology, underlying etiology, diagnostic difficulties, management strategies, and social implications. By synthesizing the existing medical literature, we hope to identify understanding gaps, pave the way for further research, and ultimately improve detection, treatment, and awareness. The databases we used are PubMed, PubMed Central, and Google Scholar. We carefully screened all published articles from inception till date and narrowed down 24 relevant articles. We at Richmond University Medical Center and Mount Sinai are one of the leading medical centers for diagnosing and treating this rare condition in the United States.

Exploring the Potential of Broadly Neutralizing Antibodies for Treating SARS-CoV-2 Variants of Global Concern in 2023: A Comprehensive Clinical Review.

In the aftermath of the coronavirus disease 2019 (COVID-19) pandemic, the world is still seeing outbreaks of COVID-19 infections as of 2023, especially in populations that have been adequately vaccinated. This situation across the globe gives rise to important questions regarding the efficacy of current treatments and the real rate of mutations in the COVID-19 virus itself which can make the currently available treatments and vaccines obsolete. We have tried to answer a few of those questions and put forth some new questions of our own. Our efforts in this paper were directed towards understanding the utilization of broadly neutralizing antibodies as a treatment for COVID-19 infection with a particular focus on the Omicron variant and other newer variants. We gathered our data from three major databases: PubMed, Google Scholar, and Cochrane Central Register of Controlled Trials (CENTRAL). We have screened 7070 studies from inception till March 5, 2023, and gathered 63 articles that were relevant to the topic of interest. Based on the existing medical literature regarding the topic of interest and also based on our own personal and clinical experience treating COVID-19 patients across the multiple waves in the United States and India since the beginning of the pandemic, we have concluded that broad neutralizing antibodies could be an effective option for treatment and prophylaxis for current and future outbreaks of COVID-19 including the Omicron variant and newer variants. Further research, including clinical trials, is required to tailor optimal dosages, prevent adverse reactions/side effects, and develop treatment strategies.

Inhaled Sargramostim (Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor) for COVID-19-Associated Acute Hypoxemia: Results of the Phase 2, Randomized, Open-Label Trial (iLeukPulm).

INTRODUCTION: Granulocyte-macrophage colony-stimulating factor (GM-CSF), a protein produced in the lung, is essential for pulmonary host defense and alveolar integrity. Prior studies suggest potential benefits in several pulmonary conditions, including acute respiratory distress syndrome and viral infections. This trial evaluated the effect of the addition of inhaled sargramostim (yeast-derived, glycosylated recombinant human GM-CSF) to standard of care (SOC) on oxygenation and clinical outcomes in patients with COVID-19-associated acute hypoxemia. MATERIALS AND METHODS: A randomized, controlled, open-label trial of hospitalized adults with COVID-19-associated hypoxemia (oxygen saturation <93% on ≥2 L/min oxygen supplementation and/or PaO2/FiO2 <350) randomized 2:1 to inhaled sargramostim (125 mcg twice daily for 5 days) plus SOC versus SOC alone. Institutional SOC before and during the study was not limited. Primary outcomes were change in the alveolar-arterial oxygen gradient (P(A-a)O2) by day 6 and the percentage of patients intubated within 14 days. Safety evaluations included treatment-emergent adverse events. Efficacy analyses were based on the modified intent-to-treat population, the subset of the intent-to-treat population that received ≥1 dose of any study treatment (sargramostim and/or SOC). An analysis of covariance approach was used to analyze changes in oxygenation measures. The intubation rate was analyzed using the chi-squared test. All analyses are considered descriptive. The study was institutional review board approved. RESULTS: In total, 122 patients were treated (sargramostim, n = 78; SOC, n = 44). The sargramostim arm experienced greater improvement in P(A-a)O2 by day 6 compared to SOC alone (least squares [LS] mean change from baseline [SE]: -102.3 [19.4] versus -30.5 [26.9] mmHg; LS mean difference: -71.7 [SE 33.2, 95% CI -137.7 to -5.8]; P = .033; n = 96). By day 14, 11.5% (9/78) of sargramostim and 15.9% (7/44) of SOC arms required intubation (P = .49). The 28-day mortality was 11.5% (9/78) and 13.6% (6/44) in the sargramostim and SOC arms, respectively (hazard ratio 0.85; P = .76). Treatment-emergent adverse events occurred in 67.9% (53/78) and 70.5% (31/44) on the sargramostim and SOC arms, respectively. CONCLUSIONS: The addition of inhaled sargramostim to SOC improved P(A-a)O2, a measure of oxygenation, by day 6 in hospitalized patients with COVID-19-associated acute hypoxemia and was well tolerated. Inhaled sargramostim is delivered directly to the lung, minimizing systemic effects, and is simple to administer making it a feasible treatment option in patients in settings where other therapy routes may be difficult. Although proportionally lower rates of intubation and mortality were observed in sargramostim-treated patients, this study was insufficiently powered to demonstrate significant changes in these outcomes. However, the significant improvement in gas exchange with sargramostim shows this inhalational treatment enhances pulmonary efficiency in this severe respiratory illness. These data provide strong support for further evaluation of sargramostim in high-risk patients with COVID-19.