Probable Enoxaparin-Induced Liver Injury in a Young Patient: A Case Report of a Diagnostic Challenge.

Low molecular weight heparin (LMWH) is associated with elevated liver enzyme levels in a small percentage of patients. Elevations more than five times the upper limit of normal are uncommon and have been noted to primarily occur in patients receiving higher doses. The literature reports mild, primarily asymptomatic cases, with adverse effects at higher therapeutic doses. We report the case of a 27-year-old woman who developed drug-induced liver injury (DILI) while receiving enoxaparin during admission for a loculated pleural effusion secondary to pulmonary tuberculosis. The Roussel Uclaf Causality Assessment Method (RUCAM) score delineated enoxaparin as the likely cause.

Incidentally Discovered Mucosal Prolapse of the Colon During Colorectal Cancer Screening: A Case Report.

Colonic mucosal prolapse syndrome is a rare type of non-neoplastic non-inflammatory colorectal polyps that can mimic neoplastic lesions. We present a case of a 65-year-old man with mucosal prolapse syndrome, incidentally, discovered during colorectal cancer screening. The patient was asymptomatic, and his physical exam and laboratory test results were unremarkable. During a colonoscopy, the physician removed three small tubular adenomas and two pedunculated polyps suspicious of neoplasms. Retroflexion revealed small internal hemorrhoids. The histology of the larger polyps revealed mucosal prolapse features, while the smaller polyps displayed features consistent with tubular adenomas. Management involves the removal of associated polyps during colonoscopy, followed by surveillance colonoscopy to detect any recurrent polyps or early signs of colorectal cancer. Accurate diagnosis is crucial to avoid unnecessary interventions and ensure appropriate management.

Blepharospasm and Bradyphrenia With Infarction of the Artery of Percheron: A Case Report.

The artery of Percheron (AOP) is a variant of the posterior cerebral circulation where a single branch of either posterior cerebral artery supplies both paramedian territories of the thalami. A stroke of the AOP has become a neurodiagnostic conundrum due to its relative rarity and vague symptoms, and, hence, a missed opportunity for recanalization treatment. The classical presentation of AOP stroke is the triad of altered mental status, vertical gaze palsy, and memory impairment. Here, we describe a retrospective case review of a 59-year-old male presenting with confusion and slurred speech with subsequent symptoms such as blepharospasm and bradyphrenia. The initial computed tomography of the head failed to recognize the bilateral thalamic infarct which was established on day three on brain magnetic resonance imaging. Because the patient was out of the therapeutic window for thrombolysis, dual antiplatelet therapy was started. The patient made a rapid recovery to near-baseline function and was discharged to rehab services. This case is unique with the clinical presentation of both blepharospasm and bradyphrenia being rarely found in the literature. The shared insult to the basal ganglia-thalamocortical circuits may have caused both symptoms. Physician awareness of these subtle findings can increase awareness, earlier diagnosis, and treatment of bilateral thalamic lesions and AOP strokes.

Metastatic rectal neuroendocrine carcinoma presenting with treatment-refractory immune thrombocytopenia: A case report and literature review.

RATIONALE: Colorectal neuroendocrine cancer (CRNEC) accounts for < 1% of all colorectal cancers. It presents in advanced stages and carries a risk of poor survival. CRNEC may be diagnosed incidentally on imaging or routine endoscopy. When symptomatic, it may mimic colorectal adenocarcinoma. Syncope and immune thrombocytopenic purpura (ITP) have not previously been reported as clinical presentations. PATIENT CONCERNS: A 57-year-old man with human immunodeficiency virus infection on treatment, seizure and stroke without residue presented for the evaluation of fall and syncope. DIAGNOSIS: Physical examination revealed tachycardia, swelling, and ecchymosis of his proximal left lower extremity. Laboratory tests showed a new isolated thrombocytopenia of 26,000/mm3. Computed tomography for a trauma survey showed an incidental left posterior rectal wall mass. After hospital admission, his platelet count dropped to 14,000/mm3. A peripheral blood smear revealed low platelet count, no schistocytes or immature cells. ITP at a high risk for bleeding was diagnosed and treated with standard medical therapy but remained refractory. Bone marrow biopsy showed metastatic neuroendocrine carcinoma, likely from the rectum. INTERVENTIONS: Patient received courses of high-dose dexamethasone and intravenous immunoglobulin. He also receive eleven units of platelet transfusion. A course of rituximab was administered. The platelet count response was suboptimal or short lived with drop to a nadir of 4000/mm3. However, after initiation of Eltrombopag, the thrombocytopenia resolved. Patient was started on etoposide, carboplatin, Atezolizumab. His hospital stay was complicated by neutropenia and sepsis, which was successfully treated. OUTCOMES: He was discharged to subacute rehab in stable condition. About 4 months later, he was readmitted for severe thrombocytopenia, septic shock, and acute respiratory failure. Despite appropriate treatment, the patient deteriorated and expired. CONCLUSION: CRNEC is a rare aggressive disease with dismal outcome that lacks standardized treatment. Metastasis to the bone marrow is uncommon and concomitant ITP has not been reported. We report a rare case of rectal neuroendocrine carcinoma metastatic to bone marrow associated with refractory ITP and review the relevant literature.

An Interesting Case of Klebsiella Pneumoniae Pylephlebitis.

Pylephlebitis is defined as suppurative thrombophlebitis of the portal venous system. It is a rare condition that can be fatal if left untreated. It is usually caused by polymicrobial bacteria, most commonly Escherichia coli and Streptococcus genus. Klebsiella pneumoniae have been identified but the literature does not suggest a percentage of cases caused by this organism. The presentation includes abdominal pain, signs of sepsis and even septic shock. We present a case of a middle-aged female with K. pneumoniae bacteremia and pylephlebitis, with portal vein thrombosis visualized on an abdominal ultrasound. Although the patient was treated with broad-spectrum antibiotics and anticoagulation, she succumbed to multiorgan failure and septic shock on day two of intensive care.

Hepatocellular-Cholestatic Pattern of Liver Injury in a Patient With Infectious Mononucleosis.

Hepatic dysfunction in the setting of infectious mononucleosis has been documented in the literature. However, clinically significant jaundice and direct hyperbilirubinemia are rarely associated with this infection. In the instance of undetermined underlying diagnosis and hepatic enzyme derangement, this may pose a diagnostic challenge. Furthermore, several diagnostic tests may be indicated, which could potentially increase resource consumption in any hospital setting. This case report aims to remind physicians that infectious mononucleosis may be a cause of hyperbilirubinemia, which does not usually require further complex testing other than monitoring and supportive therapy.

A Case of Classical Hodgkin's Lymphoma Presenting With Intractable Pruritus.

Hodgkin's Lymphoma presenting with hypereosinophilia and intractable pruritus is a rare entity. Diagnostic and therapeutic decisions remain a challenge in such patients. Here we report a case of a 25-year-old female with a special case of Hodgkin's lymphoma. A 25-year-old was admitted to our hospital for intractable pruritus and was found to have significant leukocytosis with eosinophilic predominance. The patient underwent a bone marrow biopsy and mediastinal lymph node biopsy, which confirmed classical Hodgkin's lymphoma. Furthermore, the patient was given six cycles of adriamycin, bleomycin, vincristine, and doxorubicin (ABVD) chemotherapy and initially showed improvement; however, she relapsed within a short period. Post-treatment positron emission tomography (PET) scan showed interval progression of the disease, and so the patient was referred for a clinical trial with immunotherapy and Brentuximab vedotin.

Compliance and Treatment Outcomes of Various Regimens for Trichomoniasis in Trinidad and Tobago.

Trichomoniasis is the most common non-viral sexually transmitted disease (STD) globally and yet is not a reportable disease. Trichomonas vaginalis is an important source of reproductive morbidity and may increase risk of acquisition and transmission of human immunodeficiency viruses (HIV). The World Health Organization (WHO) and the Control Disease Center (CDC) recommend various regimens of nitroimidazole s for treatment. The common nitroimidazoles used for trichomoniasis are metronidazole and tinidazole, which vary in their cost, efficacy, and side effect profile. It is relevant to study these factors for better management of the patients. This study aimed to compare and study the efficacy, compliance of various treatment regimens, their outcomes, and side-effects for trichomoniasis, among STI clinic attendees in Trinidad. A clinical trial study was designed, and after obtaining the informed consent, a routine clinical examination was conducted and the swabs for trichomoniasis tests were collected for diagnosis from the 692 participants. Out of 692 participants, 82 patients with positive diagnosis of Trichomonas infection were treated according to the patient's choice, using different drug regimens. Compliance to treatment, side effects, and outcome were evaluated. The prevalence of trichomoniasis in the population attending our STI clinic is 11.9% and prevalence of HIV is 9%. Of the total 82 participants for the treatment, 80% were females; nearly 90% of the patients belonged to age group 15-45 years, and over 60% were below 30 years. Among those diagnosed for Trichomonas vaginalis, 14.6% had coexistent HIV infection. The compliance with respect to single dose treatment was significantly better than the long-duration oral regimen and has a significant relation with side effects of the treatment. The outcome is generally better and comparable and shows no significant difference between different treatment regimens used in the study. Metronidazole and tinidazole are commonly used drugs in various regimens. Compliance is better with those treated with tinidazole and metronidazole single dose than with other groups. Outcome is comparable between these regimens, especially when combined with other important factors like abstinence and treatment of the partners. The treatment regimens mainly differed in the compliance side effects profile and duration of therapy, which suggests that to improve the compliance of the drugs with fewer side effects, short course regimen would be a preferred choice.