The Effect of Adding Procalcitonin to the Systemic Inflammatory Response Syndrome (Sirs) and Quick Sepsis-Related Organ Failure Assessment (qSOFA) Scoring System in Predicting Sepsis Mortality.

OBJECTIVE:  The primary objective of this study was to determine if the addition of procalcitonin to the existing systemic inflammatory response syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) scoring systems could improve the predictability of in-hospital sepsis-related mortality. Secondarily, we sought to determine if the addition of procalcitonin could predict the likelihood of ICU admission and discharge home. DESIGN: This is a retrospective, single-center, observational study that looked at data from January 1, 2017 to January 1, 2019. Patients were stratified into four groups: SIRS-positive + procalcitonin >2 ng/mL (pSIRS+), SIRS-positive + procalcitonin ≤2 ng/mL (pSIRS-), qSOFA-positive + procalcitonin >2 ng/mL (pqSOFA+), and qSOFA-positive + procalcitonin ≤2 ng/mL (pqSOFA-). SETTING: The study was conducted at a community hospital in Las Vegas, Nevada. PATIENTS: Patients were included in the study if they were >18 years of age and had hospital admission diagnosis of sepsis with at least one value of procalcitonin level. INTERVENTIONS: After patients which met the inclusion criteria, patients were divided into subgroups of SIRS, SIRS + procalcitonin > 2 ng/mL, qSOFA, qSOFA + procalcitonin >2 ng/mL. Primary outcomes were in-hospital mortality and secondary outcomes were ICU admission, length of stay, and discharge to home. RESULTS:  933 patients were included in the study with an overall mortality rate of 21.22%, an overall ICU admission rate of 56.15%, and an overall discharge home rate of 29.58%. In those identified with a sepsis-related diagnosis code, pSIRS+ predicted an in-hospital mortality rate of 31.89% compared to pSIRS- 16.15% (P < 0.0001). In regards to qSOFA, the addition of procalcitonin added no statistically significant difference in predicting in-hospital mortality. pSIRS+ patients were found to have an ICU admission rate of 76.16% and a discharge home rate of 19.20% compared to pSIRS- who had 47.40% and 34.90%, respectively (P < 0.0001). Like in our primary outcome, our data for qSOFA was not statistically significant. CONCLUSIONS:  Procalcitonin added utility to the SIRS scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home. Procalcitonin did not add statistically significant benefit to the qSOFA scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home.

A Case of Bilateral Cerebral Venous Sinus Thrombosis: More Than Meets the Eye.

Cerebral venous sinus thrombosis (CVST) is a rare etiology of stroke that results from inherited and/or acquired conditions, which can present in a variety of symptoms. CVST in the setting of the 2019 coronavirus disease (COVID-19) has rarely been observed. Herein, we present the case of a 32-year-old female with a recent history of COVID-19 subsequently found to have CVST involving bilateral transverse sinuses. Further workup demonstrated several hypercoagulable conditions, which were likely exacerbated by the viral infection. This case demonstrates an atypical outcome for young, COVID-19-positive patients, which emphasizes the importance of diligence when examining symptomatic patients with a history of COVID-19 infection. The patient was treated with apixaban therapy with radiographic resolution of bilateral CVST and improved vision.

Nonsurgical Approach to Isolated Pancreatic Metastatic Malignant Melanoma: A Case Report and Review of the Literature.

Isolated pancreatic metastases from melanoma are rare with high mortality rate and account for less than 1% of metastatic melanomas. Treatment options are limited with highest overall survival reported in those with complete surgical resection. Of cases reported in the literature with nonsurgical management, highest length of survival was reported to be 10 months. We report a case of malignant melanoma with isolated pancreatic metastasis treated with interferon therapy and immunotherapy, with evidence of progressive tumor shrinkage and survival at 38 months.

Acute Esophageal Necrosis Syndrome (Black Esophagus): A Case Report of Rare Presentation.

Acute esophageal necrosis (AEN) is a rare clinical finding due to multifocal factors consisting of an ischemic insult to the esophagus, corrosive injury from gastric content, and diminished mucosal defense. It is also referred to as "black esophagus" or acute necrotizing esophagitis. The clinical presentation mainly consists of upper gastrointestinal bleed and abdominal pain. Associated symptoms include nausea, vomiting, and dysphagia. AEN can be diagnosed by esophagogastroduodenoscopy (EGD) with findings of diffuse circumferential black pigmentation in the distal esophagus that classically extends to the gastroesophageal junction. A diagnostic biopsy is not required but recommended. Treatment of AEN is conservative management to maintain hemodynamic stability and treat coexisting medical conditions. Herein, we present the case of a 78-year-old male who initially presented with hematemesis and abdominal discomfort of five-day duration and was subsequently found to have AEN.

Portal Vein Thrombosis and Pyogenic Liver Abscess With Concomitant Bacteroides Bacteremia in a Patient With COVID-19 Infection: A Case Report and Brief Review.

The 2019 coronavirus disease (COVID-19) can present with a wide variety of clinical manifestations, including a hypercoagulable state leading to both arterial and venous thrombosis. Portal vein thrombosis (PVT) in the setting of COVID-19 has rarely been reported in the medical literature. Pylephlebitis with concomitant liver abscess is a rare complication of intra-abdominal infection. Here, we present the case of a 49-year-old man who initially presented with intermittent fevers and generalized weakness of 1-month duration and was subsequently found to have COVID-19 infection, PVT, and Bacteroides fragilis bacteremia with associated pyogenic liver abscess. The patient was treated with intravenous antibiotics and oral anticoagulation with plan to follow up outpatient with gastroenterology in 3 months to ensure resolution of PVT and liver abscess.

Metastasis-Induced Acute Pancreatitis Secondary to Small Cell Lung Carcinoma: A Case Report.

Description Metastasis-induced acute pancreatitis (MIAP) is a condition that occurs when patients develop acute pancreatitis secondary to metastatic malignancy. Most pancreatic cancers are adenocarcinomas that are primary malignancies. On the other hand, metastatic pancreatic lesions are rare, especially from primary pulmonary malignancies. Acute pancreatitis caused by metastatic carcinoma of the pancreas is a very rare presentation. Herein, we present the case of a 63-year-old male with a history of small-cell lung carcinoma presenting to the hospital due to recurrent episodes of acute pancreatitis who was found to have metastatic pancreatic carcinoma. The patient was treated conservatively for his recurrent acute pancreatitis, had a stent placed in the common bile duct to relieve an obstruction and planned for outpatient palliative chemotherapy.

A Rare Case of Intraparenchymal Cerebrospinal Fluid Cyst Associated With Ventriculoperitoneal Shunt in an Adult Patient.

Here we are reporting a rare phenomenon associated with ventriculoperitoneal (VP) shunt in the adult patient, namely, the development and finding of intraparenchymal pericatheter cerebrospinal fluid cyst. Our patient had a VP shunt placed for idiopathic intracranial hypertension 16 years ago before presentation to the hospital. The patient was admitted to the hospital for headache for past three weeks with the initial CT scan showing encephalomalacia and vasogenic edema. MRI showed the presence of a 4-cm intraparenchymal cyst in the right frontal lobe with surrounding vasogenic edema. The patient underwent two surgeries with the initial surgery for the drainage of cyst and second surgery for the placement of the cystoperitoneal shunt. Catheter-associated cysts are easily misdiagnosed due to their similarity in appearance to abscesses and other malignancies on imaging, and there are no guidelines yet on their evaluation and management. This is a unique case as the pericatheter cyst developed 16 years after the initial VP shunt placed. Given the rarity of this presentation, we hope that our case report can contribute to the development of guidelines and treatment options in adults with long-standing VP shunts.