Persistent Norovirus infection in a young patient with renal transplant: The challenging cost of immunosuppression and the negative impact on patient's quality of life.

Norovirus (NoV) is one of the most common causes of acute infectious gastroenteritis in the United States (US). The infection is typically short-lasting and self-limiting in immunocompetent hosts. Renal transplant recipients on immunosuppressive therapy are more prone to infectious gastroenteritis that can be caused by various common and opportunistic organisms. NoV infection in renal transplant patients presents as an acute diarrheal illness that may progress to a chronic infection with frequent relapses leading to adverse short-term complications (acute renal injury (AKI) and acute graft rejection from the reduction of the dose of immunosuppressive medications) and possibly long-term morbidities (malabsorption syndrome, and a decline in graft survival). The management of chronic NoV infections in renal transplant patients may be quite challenging, as no specific antiviral treatment is presently approved, and frequent adjustments of immunosuppressive therapy may be required in the setting of reduced renal clearance and the attempts to decrease immunosuppressive effects to enhance the viral clearance.Herein, the authors present a case of persistent NoV in a young female patient with a renal transplant that was associated with recurrent admissions with AKI, gross electrolyte disturbances, and significant weight loss. The relapsing NoV infection has negatively impacted the patient's quality of life and socioeconomic performance.

A Rare Pathogen of Bones and Joints: A Systematic Review of Osteoarticular Infections Caused by Gemella morbillorum.

Osteoarticular infections (OAIs) caused by Gemella morbillorum (G. morbillorum) are a rare clinical entity. This study aimed to review all published cases of OAI due to G. morbillorum. A systematic review of PubMed, Scopus, and Cochrane Library was conducted to report the demographic and clinical characteristics, microbiological data, management, and outcome of OAIs caused by G. morbillorum in the adult population. A total of 16 studies reporting on 16 patients were included in this review. Eight patients had arthritis and eight patients had osteomyelitis/discitis. The most reported risk factors were immunosuppression, poor dental hygiene/dental infections, and recent gastrointestinal (GI) endoscopy. Five cases of arthritis occurred in a native joint while three patients had prostheses. The potential source of G. morbillorum infection was documented in more than half of the cases (56%) (most commonly odontogenic and GI sources (25% and 18%, respectively). The knee and hip joints were the most frequently affected joints in patients with arthritis, while the thoracic vertebrae were the most common sites for osteomyelitis/discitis. The blood cultures were positive in three patients with arthritis (37.5%) and five patients with osteomyelitis/discitis (62.5%). Associated endovascular infection was found in five patients with bacteremia. Contiguous spread (adjacent mediastinitis) was documented in two patients with sternal osteomyelitis and thoracic vertebral osteomyelitis. Surgical interventions were performed for 12 patients (75%). Most strains of G. morbillorum were susceptible to penicillin and cephalosporins. All patients with reported outcomes had achieved complete recovery. G. morbillorum is an emerging pathogen for OAIs in certain susceptible populations with specific risk factors. This review reported the demographic, clinical, and microbiological features of OAIs caused by G. morbillorum. A careful evaluation of an underlying infectious focus is warranted to control the source. When G. morbillorum bacteremia is present, it is also necessary to have a high index of suspicion to rule out an associated endovascular infection.

A Case Series of Non-Tuberculous Mycobacterial Pulmonary Disease Masquerading as Malignancy From a Community-Based Hospital.

Non-tuberculous mycobacteria (NTM) are ubiquitous organisms in the environment that can potentially cause a range of pulmonary and extrapulmonary infections in humans. Epidemiological risk factors and the host's immune status determine the susceptibility to various clinical syndromes caused by different NTM species. Non-tuberculous mycobacteria pulmonary disease (NTM-PD) is primarily reported in patients with underlying lung disease. These infections often pose a significant disease burden on affected patients as they are often chronic, difficult to treat, and necessitate long-term multi-drug therapy. Mycobacterium avium complex (MAC) is the most common causative pathogen of NTM-PD in the USA, followed by Mycobacterium kansasii (M. kansasii). Less common species in the USA include Mycobacterium xenopi (M. xenopi), Mycobacterium abscessus, and others, largely depending upon the geographic location and exposure to species-specific predisposing risks. In this case series, the authors report on three elderly patients with chronic lung diseases who had pulmonary NTM disease caused by M. xenopi and MAC. The patients were encountered in both inpatient and outpatient settings from a community-based hospital in the midwestern USA. The clinical and radiological features of NTM-PD masqueraded as malignancy and posed a diagnostic dilemma. The epidemiology, clinical and radiological features, diagnosis, and management of NTM-PD are reviewed in this report.

Metastatic Squamous Cell Carcinoma From Primary Hypopharynx Source to Gastric Mucosa Presenting as Massive Gastrointestinal Bleeding.

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure that represents an important supportive adjunctive component for patients with primary head and neck squamous cell carcinoma (HNSCC). The HNSCC population is considered a high-risk group for developing critical nutritional deficiency due to a multitude of factors. Nevertheless, as the use of PEG in modern practice is gaining more popularity due to various indications, unusual complications have been increasingly reported. PEG site metastasis from primary HNSCC has emerged as a rare, yet serious oncological phenomenon that warrants careful consideration. The authors report an unusual case of squamous cell carcinoma (SCC) of the hypopharynx that metastasized to the gastric body mucosa through a PEG site. The metastatic SCC presented as massive gastrointestinal bleeding, and esophagogastroscopy revealed an ulcerated mass in the gastric body masquerading as a primary gastric adenocarcinoma. Histopathology and immunohistochemistry examination confirmed metastatic SCC which concurred with the patient's primary hypopharyngeal SCC. The review of the updated literature revealed that a total of 121 cases of this rare oncological entity have been reported to date. Physicians need to be vigilant of the symptoms of PEG site metastasis to accurately diagnose and manage the care of this rare occurrence as it is associated with poor prognosis.

Subarachnoid Hemorrhage From Cavernous Malformation Masquerading as Myocardial Infarction.

Intracranial hemorrhage, including subarachnoid hemorrhage (SAH), is associated with many cardiac effects, including cardiac rhythm abnormalities, ischemic electrocardiographic (ECG) changes, elevated cardiac troponin levels, and regional wall motion abnormalities on echocardiogram. About 40% of patients with SAH demonstrate increased serum markers for myocardial necrosis. Approximately 10% of patients with SAH demonstrate left ventricular (LV) wall motion abnormalities; a subset of these patients will have irreversible myocardial damage, but most regain LV function in several weeks. Cardiac effects of SAH are thought to be a result of an imbalance of the autonomic nervous system with resultant increased catecholamine effect on the myocardial cells rather than due to preexisting coronary artery disease. These cardiovascular complications carry a prognostic significance in patients with SAH and can also be misdiagnosed as primary cardiac problems and delay the diagnosis of SAH. Herein, we present a case of a 68-year-old female who presented to the emergency department with acute onset of upper back and neck pain. She was initially misdiagnosed with myocardial infarction in view of the ischemic changes in the ECG and elevated cardiac troponins. She was started on antiplatelets and anticoagulation but was later found to have a negative coronary angiography and was diagnosed with SAH via a computed tomography (CT) scan. Intracranial hemorrhage can be associated with elevated cardiac enzymes and ECG changes and can sometimes masquerade as an acute coronary syndrome (ACS). A careful history and examination and a high index of clinical suspicion are pivotal in such cases since early diagnosis significantly impacts prognosis and prevents the inadvertent use of antiplatelets and anticoagulation, which can be detrimental if used in such cases.

Statin-Induced Immune-Mediated Necrotizing Myopathy Resulting in Proximal Muscle Weakness.

Statin-induced immune-mediated necrotizing myopathy (IMNM) is a subtype of IMNM linked to exposure to statins and is characterized by positive anti-hydroxymethylglutaryl (HMG) coenzyme A reductase (HMGCR) antibodies. Although rare, this entity has become increasingly recognized as a cause of proximal muscle weakness, especially with the widespread use of statin therapy. Unlike typical statin-associated muscle symptoms, IMNM myopathy often causes severe muscle injury, and muscle weakness persists or sometimes worsens following the withdrawal of statin therapy. Medical practitioners need to keep a high index of clinical suspicion for statin-induced IMNM in patients taking statins who present with muscle weakness. The disease can be debilitating, and treatment strategies are not well established despite the advances that have been made in the diagnosis. Here we present the clinical characteristics and disease course of two cases of statin-induced IMNM. Both patients presented with progressive proximal muscle weakness and myalgias while on long-term statin therapy without significant improvement in their symptoms following the withdrawal of statin therapy. IMNM was suspected, and both patients were found to have high titers of anti-HMG coenzyme A reductase antibodies and demonstrated microscopic features consistent with a diagnosis of IMNM on muscle biopsy. The patients experienced significant disability due to muscle weakness and required a protracted course of escalated immunosuppressive therapy. Although rare, IMNM should be suspected in patients taking statins who present with muscle weakness that fails to improve or worsens when statins were stopped. Early diagnosis and institution of immunosuppressive therapy are important to prevent the progression of the disease.

A Rare Case of Granulomatous Mastitis Associated With Positive Systemic Lupus Erythematosus Serology in a Young Female Patient: A Case Report and Literature Review.

Granulomatous mastitis (GM) is a rare benign breast disease that affects women of childbearing age, usually within five years of pregnancy. The hallmark diagnostic feature of GM is the presence of lobular granulomatous inflammation. The occurrence of this clinicopathological entity is usually idiopathic. Nevertheless, GM has often been associated with systemic inflammatory conditions of either infectious (such as tuberculosis) or autoimmune etiology (particularly sarcoidosis, vasculitis, and less likely systemic lupus erythematosus [SLE]). In this report, the authors described an unusual case of GM that was associated with features of SLE in a young female patient who presented with a painful breast lump. Histopathological examination of the lump's biopsy showed GM. Further laboratory workup revealed evidence of some immunological criteria of SLE. Steroid therapy led to the resolution of the patient's breast swelling. The breast mass remained in remission with hydroxychloroquine treatment. Only a handful of similar cases in the current literature demonstrated a plausible association between SLE and GM. Our case provides a reference to consider SLE as a possible differential diagnosis when GM is encountered in young-aged female patients.

Nephrogenic Ascites: An Unusual Culprit of Refractory Ascites in a Hemodialysis Patient-A Case Report and Review of Literature.

Nephrogenic ascites or dialysis-associated ascites is a rare condition that develops in patients with end-stage renal disease (ESRD) who have been on long-term hemodialysis. It is characterized by rapidly accumulating ascites that is often recurrent and resistant to standard treatment. The diagnosis typically requires the exclusion of common causes of ascites including possible hepatic, cardiac, malignant, and infectious etiologies. Nephrogenic ascites generally has a poor prognosis. Renal transplantation is the sole definitive cure for this difficult-to-treat clinical entity, however, majority of the affected patients are usually deemed unsuitable candidates for transplantation. In this communication, the authors presented a rare case of nephrogenic ascites that posed a therapeutic challenge in an ESRD patient on regular hemodialysis along with a brief review of the literature regarding the pathogenesis, clinical features, and outcome of nephrogenic ascites.

The outcome of rituximab in treating steroid dependent nephrotic syndrome.: Histopathology and immunosuppressive drugs as predicting factors.

OBJECTIVES: To present our experience of treating steroid-dependent nephrotic syndrome (SDNS) in children with repeated doses of rituximab (RTX) with a relatively long follow-up, and to discuss the role of the histopathology type and previous immune-suppressor (IS) drugs on the outcome of these patients. METHODS: The patients included in this prospective study were children with SDNS who were in remission on a high-dose steroid or with additional IS drugs. All patients underwent renal biopsy before RTX treatment. Intravenous RTX was administered monthly at 375 mg/m2 for 4 doses. Response to treatment was defined as maintaining remission with no steroid-sparing agents or prednisone for one year. RESULTS: Seventeen (14 males) patients were enrolled. Approximately 76% had minimal change disease (MCD) and 3 (18%) patients had immunoglobulin M (IgM) nephropathy. Approximately 85% of MCD and 33% of IgM nephropathy showed complete response to RTX. CONCLUSION: Compared to other IS used to treat SDNS, RTX showed a significant decrease in relapse rate with fewer side effects. The dose and interval should be modified according to the patient's characteristics, such as medical history, pathology type, and previous IS agents.

Rare Occurrence of Apical Hypertrophic Cardiomyopathy Among Hispanics.

Apical hypertrophic cardiomyopathy (ApHCM), also known as Yamaguchi syndrome represents an uncommon morphologic variant of hypertrophic cardiomyopathy (HCM) in which the myocardial hypertrophy predominantly involves the apex of the left ventricle (LV). It is exemplified by "giant" negative precordial T-waves on electrocardiography and a peculiar "spade-like" configuration of LV cavity on ventriculography historically, and more recently, on echocardiography with use of image enhancing agents. The disease entity was first described in 1976. Available literature reveals that it is prevalent largely among the East-Asian population but is rare among non-Asians. Here, we report a case of a 66-year-old Hispanic male with multiple cardiac histories including persistent atrial fibrillation, non-ST-elevation myocardial infarction (NSTEMI), and ventricular fibrillation cardiac arrest with multiple inconclusive evaluations, who later in life was found to have ApHCM. This case highlights the rare incidence of the disease among the Hispanic population and underlines the challenging diagnosis that requires a high index of suspicion in patients with cardiac symptoms, as ApHCM can masquerade as ischemic coronary heart disease. Our case also describes an unusual clinical course for ApHCM presenting with extreme clinical features, including ventricular arrhythmias and cardiac arrest, unlike the usual benign natural history of this disease.

Comparison of Renal Stones and Nephrocalcinosis in Children: Findings From Two Tertiary Centers in Saudi Arabia.

Background: Renal stones (nephrolithiasis and urolithiasis) and nephrocalcinosis are uncommon in children; however, their incidences in pediatric populations have been increasing. Patients and Methods: This multicenter retrospective study compared the clinical presentation, etiology, and outcomes of childhood nephrolithiasis or urolithiasis with those of nephrocalcinosis. Results: The study included 144 children: 93 with renal stones and 51 with nephrocalcinosis. The mean age at presentation was 72 months and 54 months for children with renal stones and nephrocalcinosis, respectively. A history of consanguinity was found in 65% and 76% of the cases of renal stones and nephrocalcinosis, respectively. Congenital anomalies of the kidneys and urinary tract (CAKUT) were present in 28 and 9.8% of the patients with renal stones and nephrocalcinosis, respectively. The most common symptoms of renal stones were flank pain (29%), hematuria (15%), and dysuria (11%). Urinary tract infection was the primary presentation in the nephrocalcinosis group (18%), followed by failure to thrive (16%), polyuria (12%), and dehydration (12%). The majority of renal stone cases were caused by metabolic disorders, including hyperoxaluria (18%), cystinuria (18%), hypercalciuria (12%), and hyperuricosuria (2%). In contrast, the most common underlying disorders in cases of nephrocalcinosis were familial hypomagnesemia, hypercalciuria, nephrocalcinosis (35%), distal renal tubular acidosis (23%), and Bartter syndrome (6%). Clinical outcomes were significantly better in children with nephrolithiasis/urolithiasis than in those with nephrocalcinosis, who showed radiological evidence of worsening/persistent calcinosis and progressed more frequently to chronic kidney disease (stage II-IV) and end-stage kidney disease. Conclusion: The average age at presentation for children with renal stones was greater than that for those presenting with nephrocalcinosis. More than 25% of the children with renal stones were found to have CAKUT. Nephrocalcinosis was associated with worse clinical outcomes related to kidney function and disease resolution than nephrolithiasis.