A Successful Treatment of COVID-Induced Acute Idiopathic Pancreatitis with an RNA-Polymerase Inhibitor Agent.

Acute idiopathic pancreatitis (AIP) has been rarely linked to SARS-CoV-2 and its mechanism is not completely understood. As a result, its management, due to the heterogeneity of the literature, may pose a challenge. This case report describes a 59-year-old female who presented to the emergency department with severe epigastric pain, fever, and a positive SARS-CoV-2 polymerase chain reaction (PCR) test. Imaging confirmed acute interstitial pancreatitis, which was successfully managed using the viral RNA polymerase inhibitor, remdesivir. Pancreatitis-associated complications, such as sepsis and shock, are recognized as significant factors contributing to extended hospitalization and increased mortality rates. The management of autoimmune pancreatitis poses a challenge due to the diverse existing literature, resulting in a lack of standardized approaches. Although the impact on inpatient mortality of remdesivir remains uncertain, early administration of RNA polymerase inhibitors could alleviate complications and positively impact the duration of hospitalization. Further research is important to create optimal management strategies for complications related to COVID-19-related pancreatitis.

Crochetage, the Forgotten Electrocardiographic Sign.

Acquired complete heart block is a rare but severe arrhythmia caused by various factors such as infections, medications, and autoimmune conditions. Atrial septal defect (ASD) is a common congenital heart defect, with larger ASDs possibly causing symptoms such as fatigue, shortness of breath, and frequent respiratory infections. In some cases, high-grade atrioventricular block with ASD can occur; however, the exact incidence is not well established. We report a rare case of a 15-year-old male presenting with acute dizziness. Initial electrocardiogram (EKG) showed a complete heart block with a Crochetage sign. Patent foramen ovale (PFO) was confirmed by transthoracic and transesophageal echocardiograms. Closure of PFO and permanent pacemaker resulted in complete resolutions of symptoms and disappearance of Crochetage sign.

Severe Liver Injury Secondary to COVID-19-Induced Rhabdomyolysis in McArdle Disease.

Severe liver injury is an uncommon condition caused by non-traumatic rhabdomyolysis. This rare correlation is more commonly seen in the aspartate aminotransferase (AST) than in the alanine transaminase (ALT) level elevation. We report a case of a 27-year-old male with a history of McArdle disease who presented with generalized muscle aches associated with dark urine. His workup showed SARS-CoV-2 positive, severe rhabdomyolysis (creatinine kinase [CK] > 40000 U/L) and acute kidney injury (AKI) followed by severe liver injury (AST/ALT: 2122/383 U/L). He was started on aggressive intravenous hydration. After multiple boluses, he became overloaded, fluids were re-adjusted and continued, his renal function, CK, and liver enzymes improved, and the patient was discharged; during his visit at the post-discharge, the patient was asymptomatic and no clinical or laboratory abnormalities were found. The glycogen storage diseases are challenging, but prompt and accurate assessment is determinant in recognizing potential life-threatening complications of SARS-CoV-2. The failure to identify complicated rhabdomyolysis could lead to the patient's rapid deterioration, ending in multiorgan failure.

Pre-workout Induced Demand Ischemia.

Pre-workout supplement use has increased in recent years. Multiple side effects and off-labeled substances have been reported. We report a case of a 35-year-old patient who recently started a pre-workout and was found to have sinus tachycardia, elevated troponin, and subclinical hyperthyroidism. The echocardiogram showed normal ejection fraction and no wall motion abnormality. Beta-blockade therapy with propranolol was offered, but she refused, and her symptoms and troponin levels improved after proper hydration within 36 hours. A cautious and accurate assessment of young, fitness-enthusiastic patients experiencing unusual chest pain is essential to identify a reversible cardiac injury and possible off-label substances in over-the-counter supplements.

A Successfully Treated COVID-19 Vaccine Induced Immune Thrombocytopenic Purpura.

Immune Thrombocytopenic Purpura (ITP) is a life-threatening condition where an accurate initial assessment is essential to be able to offer the proper therapy in a timely matter to improve the outcome of the patient. Here, we present a case of ITP secondary to the coronavirus disease 2019 (COVID-19) vaccine (BioNTech, Pfizer vaccine). A 61-year-old obese African American female presented to the emergency room (ER) from a clinic with a platelet count of 11k/ul 21 days after she received the second dose of the BioNTech, Pfizer vaccine. The patient was immediately started on intravenous immunoglobulin (IVIG) 1g/kg twice daily (bid) and dexamethasone 20 mg IV every 12 hrs (q12h). The next day, the platelet count increased to 63 k/ul, and after the second dose of IVIG, the platelet count improved to 122 k/ul and trended up. The early detection of ITP induced by the mRNA COVID-19 vaccine is determinant to guide the early and proper therapy with immunoglobulins and steroids to improve the outcome of our patients.

Anomalous Origin of the Right Coronary Artery: An Uncommon Presentation.

The anomalous origin of the coronary artery is a relatively uncommon condition with a variant incidence depending on the modality of the imaging techniques such as transesophageal echocardiography (TEE), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or invasive coronary angiography (ICA). The importance of diagnosing ectopic coronary artery origin comes from its possible relation to sudden cardiac death (SCD) cases in young populations. The anomalous origin of the coronary artery could cause myocardial ischemia and fibrosis; this would, in turn, increase the chances of fatal ventricular arrhythmias. In this report, we present a 40-year-old male, incidentally found to have persistent tachycardia and a gradually decreasing left ventricular ejection fraction (LVEF). He denied any symptoms or changes in his baseline, unlimited, functional capacity. However, his records were remarkable for persistent tachycardia over more than six months, raising concerns about tachyarrhythmia-induced cardiomyopathy related to his anatomical variations. We also discussed the guideline-directed therapeutic option for the abnormal origin of the coronary artery as per current guidelines.

Left Main Coronary Artery Fusiform Aneurysm.

Aneurysm of the coronary artery is an uncommon condition that is usually found incidentally. The left coronary aneurysm is the least common. We report the case of a young patient with a history of vasculitis who was found to have a left fusiform coronary aneurysm. This is a 20-year-old female who has a history of polyarteritis nodosa and who came due to shortness of breath associated with chest discomfort. The physical exam was only relevant for multiple joint pains and tenderness. An echocardiogram showed a possible coronary aneurysm that was confirmed on the angio-tomography. The patient was discharged without complications. The left main coronary artery aneurysm is a rare condition and the least common of the coronary aneurysms. There is no established guideline for screening and therapy of these aneurysms, but invasive methods are not a preferred method for follow-up on this condition.

Reversible Autoimmune Cardiomyopathy Secondary to a Vaccine-Induced Multisystem Inflammatory Syndrome.

The Dominican government started an early booster protocol, including a heterogeneous vaccination sequence needed based on availability. We report a case of a 25-year-old male who presented with jaundice, and vomiting for 6 days, associated with maculopapular rash (Mucocutaneous features), elevated pro-B-type natriuretic peptide (pro-BNP), erythrocyte sedimentation rate (ESR), transaminitis (> 1000 U/L), thrombocytopenia, echocardiogram evidenced stigmata of heart failure after his third dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. He was started on steroids and immunoglobulin therapy for multisystemic organ failure syndrome. A significant improvement was noticed, then was discharge; in the post-discharge clinic, he was asymptomatic, inflammatory markers improved, and the echocardiogram showed a recovered ejection fraction. An accurate anamnesis, including a proper chronologic gathering of the events, is essential to recognize a vaccine-multisystem inflammatory syndrome; its prompt assessment and therapy would directly improve the outcome.

Acute Hydronephrosis Secondary to Methadone-Induced Constipation.

Opioid-induced constipation is a significant medical problem accounting for over 40% to 60% of patients without cancer receiving opioids. We report a unique case of a 71-year-old male with a history of opioid use disorder now on methadone maintenance presenting with severe opioid-induced constipation and fecal impaction causing extrinsic compression on the right-sided ureter resulting in right hydronephrosis and hydroureter that improved with aggressive bowel regime with the stool softener, laxatives and enemas. Methadone alone can predispose to hydroureter with hydronephrosis due to external compression from the severe intestinal dilation secondary to opioid-induced constipation.