A Case of Disseminated Histoplasmosis From California, in the Setting of Secondary Hemophagocytic Lymphohistiocytosis: A Diagnostic Challenge.

Histoplasma capsulatum is a geographically specific dimorphic fungus that can cause a spectrum of diseases. While most cases are asymptomatic pulmonary infections, in severe cases, particularly in immunocompromised patients, disseminated disease can occur. Histoplasmosis in California is limited to only a few case reports. In this article, we describe a rare case of disseminated histoplasmosis in a non-endemic region presenting with diagnostically challenging symptomatology, including altered mental status, status epilepticus, septic shock, and bilateral adrenal masses.

A Rare Hemorrhagic, Orange-Colored Ascites, Challenging Traditional Ascitic Fluid Analysis.

Analysis of ascitic fluid can offer useful information in developing and supporting a differential diagnosis. As one of the most prevalent complications in patients with cirrhosis, ascitic fluid aids in differentiating a benign condition from malignancy. Both the gross appearance of the ascitic fluid, along with fluid analysis, play a major role in diagnosis. Here, we discuss a patient with liver cirrhosis, esophageal varices, hepatitis C, and alcohol abuse, who had a paracentesis performed, which revealed a turbid, viscous, orange-colored ascitic fluid that has not been documented in literature. Ascitic fluid is routinely analyzed based on gross appearance, cell count, and serum ascites albumin gradient (SAAG) score. An appearance of turbidity or cloudiness has commonly suggested an inflammatory process. In our case, fluid analysis revealed a red blood cell count of 24 250/mcL, further suggesting inflammation. However, it also revealed an insignificant number of inflammatory cells, with a total nucleated cell count of 14/mcL. This rich-orange color has posed a challenge in classification and diagnosis of the underlying cause of ascites, with one classification system suggesting inflammation, while another suggesting portal hypertension. Furthermore, we have traditionally relied on the SAAG score to aid in determining portal hypertension as an underlying cause of ascites. With a 96.7% accuracy rate, the SAAG score incorrectly diagnosed portal hypertension in this patient. In this article, we aim to explore how this rare, orange-colored ascitic fluid has challenged the traditional classification system of ascites.

Clonidine Overdose as an Unusual Cause of Heart Failure.

Clonidine is used as an antihypertensive medication due to its effect on decreasing peripheral vascular resistance and therefore lowering blood pressure. Alpha antagonism in the medulla and the posterior hypothalamus causing a reduction in sympathetic activation allows for clonidine to be used as an effective off-label treatment for attention-deficit/hyperactivity disorder (ADHD). This is a case of a 28-year-old female with hypertension, ADHD, and depression who developed acute heart failure with significant troponemia after ingesting 30 pills of clonidine. We illustrate the possible rare diagnosis of systolic heart failure and coronary vasospasm secondary to clonidine overdose.

Erythrodermic Psoriasis and Staph-Infective Endocarditis-A Conundrum in Succession.

Erythrodermic psoriasis is a rare subtype of psoriasis vulgaris that presents with diffuse erythema and desquamation over greater than 75% of the body's surface area. We present a case of a 57-year-old male who was admitted with a diffuse, erythematous scaly rash covering his entire body, with associated subjective fevers. Skin biopsy revealed erythrodermic psoriasis, and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Echocardiogram revealed a mitral valve vegetation. Clinical improvement was achieved with intravenous antibiotic administration and topical corticosteroids without the use of immunomodulators.

HHV-8-Associated Multicentric Castleman Disease, a Diagnostic Challenge in a Patient With Acquired Immunodeficiency Syndrome and Fever.

Patients with acquired immunodeficiency syndrome (AIDS) are at an increased susceptibility to pathogens and associated malignancies which can present with a unique constellation of symptoms. In this article, we describe a case of Castleman disease in a patient with AIDS, nonadherent with antiretroviral therapy (ART), who presented with fevers, constant abdominal pain, nausea, and vomiting. After an extensive work up, a lymph node biopsy confirmed a diagnosis of human herpesvirus-8 (HHV-8)-associated multicentric Castleman disease. Patients presenting with AIDS and fever have broad differential diagnoses; therefore, reaching a diagnosis as rare as Castleman disease can be challenging. HHV-8 has a propensity to CD20 positive B cells, which allows rituximab to be an effect treatment.

A Rare Case of Guillain-Barré Syndrome With Severe Pandysautonomia.

Acute pandysautonomia is a rare disorder characterized by autonomic failure affecting sympathetic, parasympathetic, and enteric functions. We present a case of acute inflammatory demyelinating polyneuropathy (AIDP) with severe pandysautonomia in a young, otherwise healthy, female who presented with gastrointestinal symptoms and sensory demyelinating polyneuropathy, which progressively worsened and subsequently developed bladder dysfunction and orthostatic hypotension. We discuss the challenges with diagnostic workup as well as the challenges we encountered as part of the management.

Severe Restrictive Lung Disease in One of the Oldest Documented Males With Coffin-Lowry Syndrome.

Coffin-Lowry syndrome is expressed as different phenotypes in males and females. In males, it is characterized by facial abnormalities, marked developmental disability, and skeletal changes. Approximately 80% of cases are associated with kyphoscoliosis, which can be quite severe, as seen in our patient, causing paraplegia and restrictive lung disease. In this article, we present the third oldest documented male case of Coffin-Lowry syndrome with severe kyphoscoliosis, paraplegia, and restrictive lung disease.

An Atypical Presentation of Tuberculomas in an Immunocompetent Host.

Tuberculomas are an intracranial form of tuberculosis that account for a third of intracranial lesions in endemic areas. If symptomatic, they usually present as meningitis in an immunocompromised host; however, in patients without signs of meningitis, clinical features are essentially indistinguishable from any other space-occupying lesion. We present a case of central nervous system tuberculosis in an immunocompetent host who presented with new-onset seizures.