From Silent to Severe: Gastric Perforation Causing Spontaneous Hydropneumothorax Secondary to a Large Hiatal Hernia.

Hiatal hernias, characterized by the protrusion of internal organs through the diaphragmatic hiatus, are commonly seen in the elderly age group. While surgical management remains debatable for asymptomatic cases, emergent complications necessitate prompt intervention. Here, we present a case of a 69-year-old female with a history of diaphragmatic hernia, who developed acute hypoxic respiratory failure secondary to acute pleural effusion caused by paraesophageal hernia rupture. Despite initial inconclusive imaging, a CT scan revealed the severity, prompting emergent management. The patient underwent esophageal stent placement, video-assisted thoracoscopic surgery-assisted total lung decortication, and three chest tubes placement, followed by antimicrobial therapy. Favorable outcomes were achieved with multidisciplinary intervention, highlighting the importance of timely recognition and comprehensive diagnostic approaches. This case underscores the potential severity of hiatal hernias, particularly paraesophageal types, necessitating vigilance among clinicians for timely intervention. It also emphasizes the effectiveness of combined surgical and medical multidisciplinary approaches in such emergent situations for optimal patient outcomes.

Colonic Varices as an Unsettling Cause of Lower Gastrointestinal Bleeding.

Colonic varicose veins are very rare and are usually discovered incidentally during colonoscopy or when complications occur, such as lower gastrointestinal (GI) bleeding. The primary cause of colonic varices is usually portal hypertension secondary to liver disease or very rarely due to pancreatic disease (e.g., pancreatic adenocarcinoma). Varicose veins secondary to cirrhosis are often seen in the upper GI tract but rarely in the lower GI tract. Here, we report a 54-year-old woman who presented with colonic varices due to decompensated alcoholic cirrhosis. The main intention of this case report was to raise awareness of the possibility of developing colonic varices from liver cirrhosis and to promptly identify and manage its side effects due to the major complication which is lower GI bleeding.

Primary Diffuse Large B-cell Lymphoma of the Colon Presenting as Idiopathic Thrombocytopenia: A Case Report.

Introduction: Primary lymphoma of the colon and rectum is an uncommon form of cancer comprising less than 0.5% of all colorectal tumors combined. Typically, extra nodal lymphomas manifest in the gastrointestinal tract, with non - Hodgkin lymphoma being the most frequent subtype and the stomach being the most common location. Case presentation: 70 year old female with medical history of osteoarthritis and osteoporosis was evaluated for bilateral leg rash and thrombocytopenia. Eventual work up revealed cecal mass but inconclusive findings on colonoscopy. She underwent hemicolectomy due to persistent thrombocytopenia with histopathology positive for primary Diffuse Large B-cell Lymphoma (DLBCL). She underwent chemotherapy with complete resolution of her mass and lymphadenopathy. Conclusion: We are presenting a rare case of Non - Hodgkin lymphoma in the colon. This disease can show up with unclear symptoms, so it's important to use different types of imaging and pathology tests to identify the specific type of lymphoma. The main treatment for this type of cancer involves using chemotherapy and radiation therapy.

Cardioembolic Stroke Secondary to Massive Stress-Induced Apical Thrombosis: A Clinical Conundrum Relating to Anticoagulation Initiation.

Takotsubo cardiomyopathy or stress cardiomyopathy is a condition characterized by acute and transient left ventricular systolic dysfunction in the absence of coronary heart disease, occurring after an acute emotional or physical stressful event. Cardiac dysfunction in these patients is suspected to be secondary to catecholamine induced cardiac myocyte injury via cyclic AMP-mediated calcium overload or due to endothelial dysfunction. Even though left ventricular dysfunction in takotsubo cardiomyopathy is transient, it can lead to acute complications. Left ventricular thrombus formation is a widely reported complication and has an incidence of around 5-14% in Takotsubo cardiomyopathy patients and can lead to thromboembolic events like stroke. We report a case of takotsubo cardiomyopathy with an apical LV thrombus, complicated by a large cardioembolic stroke. This case constitutes a clinical conundrum, as LV thrombus would warrant prompt initiation of anticoagulation, while the severe ischemic stroke would be a contraindication for immediate anticoagulation.

Infective Endocarditis Complicated by Iatrogenic Intracranial Hemorrhage Secondary to Cefazolin-Induced Coagulopathy.

Infective endocarditis can be acute or subacute. It can be caused by viral, bacterial, fungal, and sometimes nonbacterial etiologies. It is an important cause of mortality and morbidity in children as well as adolescents, despite advances in management. A 59-year-old male with a past medical history of aortic valve (AV) replacement on warfarin presented to the Emergency Department with dull right flank pain and poor dentition on examination. Computerized tomography (CT) scans of the abdomen revealed the presence of splenic and renal infarcts. Warfarin was held after the international normalized ratio (INR) was noted to be elevated at 11. Following the activation of the sepsis bundle in the ER, he received intravenous fluids (30 cc/kg) and was started on vancomycin and ceftriaxone. On further evaluation, the transesophageal echocardiogram revealed mobile densities on the aortic surface concerning vegetation. Antibiotics were transitioned to cefazolin, gentamycin, and rifampin for the management of prosthetic valve endocarditis. The patient's INR improved to 3.5 on the third day of hospitalization, and heparin was initiated to maintain anticoagulation for the prosthetic valve. However, on the eighth day of hospitalization, the patient developed left-sided weakness and slurred speech. The CT head showed acute frontoparietal intracranial hemorrhage (ICH), with an INR noted to be 5. Heparin was reversed with protamine sulfate, and vitamin K was administered, following which the INR improved to 2.3. The patient was transferred to intensive care, but on the second day of the ICU stay, the INR again shot up to 6 with normal LFTS. The patient received vitamin K, but the INR only improved to 5. Subsequently, antibiotics were changed from cefazolin to nafcillin. INR thus fell to 1.6 in two days after changing the antibiotics. The patient was soon transferred to a higher center for aortic valve replacement. While few case reports have described severe coagulopathy induced by cefazolin, it is particularly seen with impaired renal function; however, our patient's renal function was completely normal. Coagulopathy is due to the drug's effect on intestinal flora and its structural methyl-thiadiazole side chain, which has similar effects as epoxide reductase inhibitors and results in INR elevation. Patients on cefazolin need to be closely monitored for INR levels every day, as there is a high likelihood of developing complications like ICH, as noted in this patient. While the monitoring of cefazolin levels is not necessarily indicated, it is necessary to place patients on fall precautions and monitor INR levels every day, as mentioned above.

Hereditary Hemorrhagic Telangiectasia in a Young Adult: Gastrointestinal Arteriovenous Malformations as a Presenting Feature.

Hereditary hemorrhagic telangiectasia (HHT) is characterized by the presence of multiple arteriovenous malformations (AVM) in which arteries and venules are connected directly without intervening capillaries. The primary clinical presentation is spontaneous and recurrent nosebleeds (epistaxis), typically starting around 12. Telangiectases, which are small arteriovenous malformations, are commonly found in mucocutaneous areas and gastrointestinal (GI) mucosa. The presentation of epistaxis precedes the occurrence of telangiectases. Larger AVMs most commonly affect the lungs, liver, or brain, and complications from bleeding or shunting can be potentially life-threatening. Here, we discuss the case of a 44-year-old man who presented to the emergency department with a chief complaint of fatigue for three weeks associated with shortness of breath. His eventual labs revealed severe anemia with a hemoglobin of 4.4 g/dL. He denied any history of symptoms of GI bleeding. Computed tomography of the abdomen was done which did not reveal any intra-abdominal bleeding, hematoma, or abnormality. Further history revealed a recent diagnosis of HHT in his mother through genetic testing. During the stay, he also developed spontaneous epistaxis which was treated with topical vasoconstrictors by the ear, nose, and throat (ENT) physician. Given the high likelihood of HHT, he underwent luminal evaluation. Upper and lower endoscopies of the gut revealed multiple AVMs. A diagnosis of HHT was established as he fulfilled the criteria required for the diagnosis of HHT. It is rare for individuals with HHT to experience GI bleeding before the age of 50, making this case unique.

Pericardial Tamponade and Berger's Disease: An Unusual Association.

Cardiac tamponade is considered a medical emergency because a patient can deteriorate easily and die of cardiac arrest if the fluid is not drained immediately. The most common etiologies are the same as pericarditis as fluid accumulates due to pericardial inflammation, including infection, malignancy, trauma, iatrogenic, autoimmune, post-myocardial infarction, radiation, and renal failure. Although the treatment is pericardiocentesis or pericardial window, finding the etiology responsible for the development of pericardial effusion is important. Here, we describe the case of a 40-year-old female who presented to the emergency department with a chief complaint of severe epigastric pain of a two-day duration that was associated with multiple episodes of nausea, vomiting, dysphagia, and severe shortness of breath (New York Heart Association III). The patient was eventually diagnosed with cardiac tamponade as a cause of her dyspnea, as a two-dimensional cardiac echocardiogram detected a large pericardial effusion (>2 cm) with echocardiographic indications for cardiac tamponade with severe pulmonary hypertension. The patient underwent a therapeutic pericardial window with drainage of 250 mL of pericardial fluid. Ultrasound of the abdomen focusing on the kidneys showed an atrophic and echogenic right kidney with a bidirectional flow in the hepatic veins, suggestive of right heart failure. Subsequently, she underwent a kidney biopsy that showed diffuse mesangial proliferative glomerulonephritis with segmental sclerosing features consistent with IgA nephropathy, associated with tubular atrophy, interstitial fibrosis, interstitial inflammation, and moderate arteriosclerosis. The patient was diagnosed with stage V chronic kidney disease secondary to IgA nephropathy. IgA nephropathy is usually common in Caucasian or Asian males in their teens and late 30s, with hematuria as a usual presentation. This case is unique as cardiac tamponade with renal failure is rarely the presenting symptom of IgA nephropathy.

Fulminant Presentation of Budd-Chiari Syndrome Secondary to COVID-19 Infection.

Budd-Chiari syndrome (BCS) is a rare condition characterized by the obstruction of hepatic venous outflow. It is estimated to affect 1 in 100,000 people worldwide. In cases of new BCS, inherited and acquired hypercoagulability states must be evaluated. Coronavirus disease 2019 (COVID-19) can induce a hypercoagulable state because of its extensive inflammatory response, and while it has been reported to cause portal vein thrombosis, it rarely causes BCS. This article presents a case of a 22-year-old man who developed fulminant symptoms and was subsequently diagnosed with BCS and portal vein thrombosis secondary to COVID-19 infection, after ruling out other inherited and acquired causes of BCS. In addition, a literature review is provided to understand the presentation and management of such patients. Although most patients improve with medical management, this article emphasizes the consideration of liver transplant for patients who do not improve.

A Rare Case of COVID-19 Vaccination-Induced Cholangiopathic Liver Injury.

Drug-induced liver injury is a serious adverse drug reaction that can result in acute liver injury or cholestatic injury affecting the bile ducts, known as cholangiopathic liver injury (CLI). Although CLI is not as familiar as the hepatocellular pattern, emerging evidence suggests that it may occur after coronavirus disease 2019 (COVID-19) vaccination. This case report focuses on an 89-year-old woman who developed CLI after receiving the tozinameran COVID-19 vaccine. The main aim of this report was to raise awareness of the possibility of developing CLI after COVID-19 vaccination and to underscore the critical significance of promptly identifying and managing this infrequent but severe side effect.