An unusual presentation of takotsubo syndrome in an elderly patient.

Takotsubo syndrome occurs predominantly in women and is usually preceded by acute emotional and/or physical stress. Patients commonly present with chest pain and/or dyspnea. Syncope or out-of-hospital cardiac arrest is a rare presentation. We report an unusual case of takotsubo syndrome in an elderly patient who presented with left facial droop, slurred speech, and syncopal episode. Initial presumed diagnosis was an ischemic stroke/transient ischemic attack. However, the patient was then treated for acute myocardial ischemia/infarction based on abnormal electrocardiogram, elevated cardiac troponin, and unremarkable neurological workup. Eventually diagnosed with takotsubo syndrome. Our case illustrates the importance of prompt identification particularly in the context of atypical presentation and further evaluation to rule out serious causes to mitigate related morbidity and mortality while simultaneously avoiding unnecessary investigations.

Jackfruit Anaphylaxis Due to Cross Reactivity with Latex.

Growing evidence has demonstrated that many common plant foods such as mangos, kiwis and jackfruit lead to cross reactivity with the latex antigen in latex allergic patients. Here, we discuss the case of a 68 year old female of Bangladeshi descent who developed shortness of breath in the setting of anaphylaxis following the ingestion of jackfruit (Artocarpus heterophyllus). The patient had a history of latex allergy described as mild rash along with seasonal allergies causing mild rhinorrhea, congestion and sneezing. Given the strong cultural significance of jackfruit consumption in Asian countries and growing popularity in the use of jackfruit as a superfood meat alternative in Western nations, along with growing Asian population, there is a need for extensive education on the cross reactivity between plant foods and latex to prevent deadly cross-reactivity induced anaphylaxis. With this case report, we hope to raise awareness of this rare, yet morbid association.

Proportion of thyroid cancer and other cancers in the democratic republic of Congo.

BACKGROUND: Cancer diagnosis is increasing around the world and in the Democratic Republic of the Congo (DRC). The proportion of thyroid cancer has increased over the past three decades. There are very few studies on cancer epidemiology, and in particular on thyroid cancer in the DRC. AIM: To establish the most recent proportion of thyroid cancer in the DRC compared to other cancers. METHODS: This is a retrospective and descriptive study of 6106 consecutive cancer cases listed in the pathological registers of 4 Laboratories in the city of Kinshasa. This study included all cancer cases recorded in the registers between 2005 and 2019. RESULTS: From a sample of 6106 patients, including all cancer types, 68.3% cases were female and 31.7% were male. Breast and cervical cancer were the most common types of cancer in women and, prostate and skin cancer were the most common types in men. Thyroid cancer was sixth in proportion in women and eleventh in men compared to all cancers. Papillary carcinoma was the most common of thyroid cancers. Rare cancers such as anaplastic and medullary thyroid carcinomas had a proportion of 7% and 2%, respectively. CONCLUSION: Newer diagnostic tools led to a surge in cancer diagnoses in the DRC. Thyroid cancer has more than doubled its proportion over the last several decades in the country.

Ultrasound performance using the EU-TIRADS score in the diagnosis of thyroid cancer in Congolese hospitals.

The thyroid imaging reporting and data systems by the European Thyroid Association (EU-TIRADS) has been widely used in malignancy risk stratification of thyroid nodules. However, there is a paucity of data in developing countries, especially in Africa, to validate the use of this scoring system. The aim of the study was to assess the diagnostic value of the EU-TIRADS score in Congolese hospitals, using pathological examination after surgery as the gold standard in Congolese hospitals. This retrospective and analytical study examined clinical, ultrasound and pathological data of 549 patients aged 45 ± 14 years, including 468 females (85.2%), operated for thyroid nodule between January 2005 and January 2019. In the present study, only the highest graded nodule according to the EU-TIRADS score in each patient was taken into account for the statistical analyses. So 549 nodules were considered. Nodules classified EU-TIRADS 2 and 3 on the one hand, and, on the other hand, 4 and 5, were considered respectively at low and high risk of malignancy. The sensitivity and specificity of the EU-TIRADS score were calculated. The significance level was set at 5%. Of all patients, 21.7% had malignant nodules. They made 48.4% of the nodules in patients younger than and at 20 years old, and 31.1% in those aged 60 or over. Malignant nodules were more frequent in men than in women (30.9% vs. 20.1%; p = 0.024). Papillary carcinoma (67.2%) and follicular carcinoma (21.8%) were the main types. The malignancy rate was 39.7% and 1.5% among nodules rated EU-TIRADS 4 and 5, and those with EU-TIRADS score 2 and 3, respectively (p < 0.001). The EU-TIRADS score had a sensitivity of 96.6% and a specificity of 59.3%. The ROC curve indicated an area under the curve of 0.862. In a low-income country, a well performed thyroid ultrasound, using the EU-TIRADS score, could be an important tool in the selection of thyroid nodules suspected of malignancy and requiring histopathological examination in the Congolese hospital setting.Trial registration: The research protocol had obtained the favorable opinion of the DRC national health ethics committee no. 197/CNES/BN/PMMF/2020. The data was collected and analyzed anonymously.

New Perspectives on Long COVID Syndrome: The Development of Unusually Delayed and Recurring Pericarditis After a Primary SARS-CoV-2 Infection.

Since the start of the COVID-19 pandemic in early 2020, pericarditis has been identified as a COVID-19 complication. We report a case where the development of pericarditis was unusually delayed after the initial COVID infection. The reported onset of pericarditis and pericardial effusion is anywhere from a few days to a few months after infection. Our case surmises that a latent complication of COVID-19 can manifest more than one year after the initial infection. A forty-three-year-old male with a past medical history of SARS-CoV-2 infection in September 2020 presented in September 2021 and January 2022 with recurrent sharp chest pain and shortness of breath. During both admissions, he was diagnosed with acute pericarditis, and his workup was significant for elevations in D-dimer and CRP as well as pericardial and pleural effusions. Recurring pericardial symptoms and persistent elevations in D-dimer and CRP point toward a COVID etiology, particularly in the absence of other factors associated with pericarditis. Our case highlights the importance of recognizing this latent complication one year after the initial infection and how the symptoms can persist beyond the one-year period.

A Case Report of Premalignant Plasma Cell Dyscrasia-Induced Renal Failure in a 31-Year-Old Female.

Monoclonal gammopathy of renal significance (MGRS) is a rare disorder in which monoclonal immunoglobulin secreted by nonmalignant B cell or plasma cell clone causes kidney damage. Although MGRS is a premalignant condition, it can cause severe kidney disease and end-stage renal disease (ESRD) at any age. Herein, we present a 31-year-old female with past medical history of lupus nephritis who presented with signs of volume overload and worsening renal function despite adequate immunosuppressive therapy. Renal biopsy revealed heavy and light chain deposition consistent with MGRS. This case report demonstrates the importance of including MGRS in the differential diagnosis of worsening renal function despite adequate treatment, raising awareness of this premalignant yet morbid condition.

A Case Report of DVT following the Johnson and Johnson Vaccine against the Novel SARS-CoV-2.

Deep vein thrombosis (DVT) is the formation of a blood clot typically in the deep veins of the extremities. The risk factors for venous thrombosis are primarily related to hypercoagulability, which can be genetic, acquired, or due to immobilization and venous stasis. The Johnson and Johnson (J&J) vaccine developed against the novel SARS-CoV-2 has been linked to more specific cases of thrombosis, associated with low platelet levels similar to that seen in heparin-induced thrombocytopenia. In this case report, we present a female who developed a DVT four days after receiving the J&J vaccine. We propose that the administration of this vaccine may further increase the risk of developing DVTs in patients with previous risk factors, and we hope to use this case to support screening all patients for previous risk factors for thrombosis before administration of the J&J vaccine.

An Unusual Cause of Refractory Hypothyroidism.

Refractory hypothyroidism has been increasingly identified worldwide. Primary hypothyroidism is considered refractory when there is a persistent elevation of thyroid-stimulating hormone (TSH) above the upper limit of normal despite escalating doses of levothyroxine with or without the persistence of hypothyroid symptoms. Further escalation of levothyroxine to supratherapeutic doses could be associated with potential complications such as iatrogenic hyperthyroidism, cardiac failure, and other conditions. Therefore, physicians should rule out non-compliance and pursue a further evaluation to identify etiologies for increased requirements or decreased absorption of levothyroxine in patients not achieving therapeutic doses. Here, we present a 40-year-old Indian male with worsening refractory hypothyroidism that resolved following eradication of his Helicobacter pylori (H. pylori) infection. Herein, we highlight a unique and reversible cause of refractory hypothyroidism. With this case report, we hope to encourage physicians to include H. pylori testing in the evaluation of primary hypothyroidism refractory to treatment.

Real-world prevalence of endoscopic findings in patients with gastroesophageal reflux symptoms: a cross-sectional study.

Background and study aims Data regarding endoscopic findings and symptom correlation in patients with gastroesophageal reflux disease (GERD) symptoms are largely limited to single-center experiences. We performed a nationwide study to examine the association between patient-reported GERD symptoms and clinically relevant endoscopic findings. Patients and methods Using the National Endoscopic Database, we retrospectively identified all esophagogastroduodenoscopies (EGDs) performed for GERD symptoms from 2000 to 2014. Patients were categorized into three symptom groups: 1) typical reflux only (R); 2) airway only (A); and 3) both R and A (R + A). Outcomes were the point prevalence of endoscopic findings in relation to patient-reported GERD symptom groups. Statistical analyses were performed using R. Results A total of 167,459 EGDs were included: 96.8 % for R symptoms, 1.4 % for A symptoms, and 1.8 % for R + A symptoms. Of the patients, 13.4 % had reflux esophagitis (RE), 9.0 % Barrett's esophagus (BE), and 45.4 % hiatal hernia (HH). The R + A group had a significantly higher point prevalence of RE (21.6 % vs. 13.3 % and 12 %; P  < 0.005) and HH (56.9 % vs. 45.3 % and 38.3 %; P  < 0.005) compared to the R or A groups, respectively. The R group had a significantly higher point prevalence of BE compared to the A or R + A groups, respectively (9.1 % vs. 6.1 % and 6.1 %, P  < 0.005). Conclusions On a national level, patients experiencing R + A GERD symptoms appear more likely to have RE and HH, while those with only R symptoms appear more likely to have BE. These real-world data may help guide how providers and institutions approach acid-suppression therapy, set thresholds for recommending EGD, and develop management algorithms.

A Rare Case of Systemic Sarcoidosis in a Middle-Aged Female with a Solitary Thyroid Nodule.

Sarcoidosis is a multisystem inflammatory disease characterized by the presence of noncaseating granulomas. Sarcoidosis can affect any organ of the body, the lung being the most affected. Sarcoidosis rarely affects the thyroid gland, and only a few cases of thyroid-related sarcoidosis have been reported in the literature. Herein, we report a case of systemic sarcoidosis with multiple organ involvement in a patient with a solitary left thyroid nodule and benign Fine Needle Aspiration (FNA) findings. The patient was eventually diagnosed with thyroid sarcoidosis using a core needle biopsy of the thyroid nodule. With this case report, we highlight the limitations of the FNA. This case report has the objective to encourage clinicians to include thyroid sarcoidosis in the differential diagnosis of thyroid nodules in patients with systemic sarcoidosis even with unremarkable FNA findings.

Prevalence of Fabry Disease in Patients With Cryptogenic Strokes: A Systematic Review.

Fabry disease (FD) is an X-linked disorder involving multiple organs. Stroke is a serious and frequent complication of FD. Cryptogenic stroke is a common presentation of FD, especially in the young population. The etiology of cryptogenic stroke is highly variable and difficult to assess, frequently leaving patients without a primary diagnosis. We conducted a systematic review to investigate the pooled prevalence of FD among patients with cryptogenic stroke, or patients with FD in whom a stroke was the presenting condition. English-language studies involving humans published in the last 20 years were included in this systematic review. FD was more common in male patients and tended to present at an earlier age. The frequency of hemorrhagic and ischemic strokes in this population was similar to that in the general population. There was a high rate of stroke recurrence in the study sample, even among patients undergoing enzyme replacement therapy. We conclude that screening for FD in patients with cryptogenic stroke is low yield and not cost-effective. However, it may be worthwhile to screen for FD among patients with recurrent strokes.

New-onset depression after colorectal cancer diagnosis: a population-based longitudinal study.

INTRODUCTION: To date, no large studies examining the temporal relationship between colorectal cancer (CRC) and the subsequent development of depressive disorders exist. We aimed to assess the incidence of depression post-colorectal cancer (CRC) diagnosis. METHODS: To conduct this longitudinal study, we searched the large US population-based database, Explorys (IBM), from January 1, 1999, to January 1, 2021. We investigated new-onset depression and its associated mortality as well as the role of the mental health provider post-CRC diagnosis. Confidence intervals were calculated for all outcomes and multivariate regression analysis was performed. RESULTS: Incident depression post-CRC diagnosis was 20.8 vs 8.9 per 100 person-years [OR 3.46, p < 0.0001] in the general population and conferred a 123% increased risk of all-cause mortality [P < 0.0001]. Male patients (OR: 1.89) were more likely to become depressed post-CRC diagnosis as compared to females. Moreover, the absolute number of male patients with post-CRC depression was significantly higher than that of females (68% vs 32%; P < 0.0001). In addition, depression after CRC was more common among Whites (OR: 1.68) and patients aged > 65 years (OR: 5.17). Referral to a mental health provider resulted in significantly lower all-cause mortality (3.6% vs 26.9%; p < 0.0001). DISCUSSION: Our findings advocate for initiating depression screening for high-risk patients post-CRC diagnosis and prompt mental health provider referral.

IgG4-Related Disease Retroperitoneal Fibrosis: An Unusual Cause of Low Back Pain.

IgG4-related disease (IgG4-RD) is a cluster of rare fibroinflammatory diseases that more commonly affect organs such as major salivary glands, biliary tree, periorbital tissues, kidneys, lungs, lymph nodes, retroperitoneum, and less frequently, meninges, aorta, prostate, thyroid gland, pericardium, and the skin. The clinical picture mainly depends on the affected organ and the effects on the surrounding organs, however, the histopathologic findings are very similar regardless of the organ affected. Most patients have a subclinical presentation of the disease and the only clinical manifestation is related to the anatomic location of the disease, whereas some patients may have constitutional symptoms such as weight loss and are often misdiagnosed as having other pathologies (i.e., malignancies, other inflammatory conditions, etc.). Up to 40 percent of patients can have symptoms of allergy or asthma. Patients often have diseases confined to one organ but multiorgan involvement is not uncommon. Patients with multiple organs involvement can have an elevation of up to 30-40 upper limit of normal serum IgG4 concentration; patients with fewer organ involvement can have normal serum IgG4 concentration despite histopathologic findings of the disease.  Idiopathic retroperitoneal fibrosis (RPF) is a commonly encountered subtype of IgG4-RD. Idiopathic retroperitoneal fibrosis accounts for approximately 70 percent of cases and can be divided into IgG4-RD and non-IgG4-RD. Most cases of RPF are incidental findings on radiology studies but should be suspected in any patients complaining of back pain and flank pain, with new-onset kidney dysfunction.

A rare cause of acute compartment syndrome after gluteal cyst rupture.

Acute Compartment Syndrome (ACS) is a serious medical condition that often results in high morbidity. ACS more commonly presents after substantial trauma in the extremities where compartment pressures can be measured. Here, we present an unusual case of a healthy man who presented with ACS of the thigh secondary to rupture of the gluteal cyst which was formed after multiple unsupervised testosterone injections. Our goal is to encourage a broad differential diagnosis while keeping limb threatening conditions and emergencies on top in patients complaining of leg pain and also to educate the patient population on safety concerns of unsupervised intramuscular injections.

Management of West Nile Encephalitis: An Uncommon Complication of West Nile Virus.

West Nile virus disease (WNVD) is a mosquito-borne disease that affects the meninges and central nervous system, causing West Nile virus (WNV) encephalitis, a debilitating, life-threatening condition, especially in the elderly. While there is a lot of research discussing different aspects of the disease, the treatment is mainly unknown. We conducted a literature review to explore the wide variety of treatment options that consolidate the knowledge about the most recent management of WNV encephalitis. We did a combined advanced search and Medical Subject Headings (MeSH) search on PubMed. Inclusion criteria included papers written in the English language and human subjects research for the past 25 years. We initially gather 110 papers, and after applying the inclusion/exclusion criteria, we end up with 30 articles for the paper's discussion. This review aims to provide clinicians with an overview of the latest approach in treating and managing hospitalized WNVD patients. It discusses case reports and the outcome of different treatment regimens done in vitro and in vivo. The study discusses all the advancements in treatment and prophylaxis and compares their effectiveness. However, more research is warranted to gain further insight to develop a single guideline for the management of this disease. This review discusses the following treatment modalities: ribavirin, interferon-alpha, intravenous immunoglobulin (IVIG), and other less-used drugs. More studies about ribavirin are needed to know if the drug is useful for WNV encephalitis. Interferon-alpha has been shown to have both protective and disease limiting properties. At the moment, there are no guidelines for the treatment of WNV encephalitis, nor is there a single Food and Drug Administration (FDA)-approved drug. For the time being, IVIG offers the best results in treating WNV encephalitis.

Calcium-Alkali Syndrome: Historical Review, Pathophysiology and Post-Modern Update.

Milk-alkali syndrome or calcium-alkali syndrome (CAS) is the triad of hypercalcemia, metabolic alkalosis and renal impairment. It is often related to ingestion of high amounts of calcium carbonate, which was used historically for the treatment of peptic ulcer disease. The incidence of the syndrome decreased dramatically after the introduction of newer peptic ulcer medications such as proton pump inhibitors and histamine blocking agents. However, a resurgence was seen in the late 1980s with the wide use of over-the-counter calcium supplements, mainly by females for osteoporosis prophylaxis. The modern version of the syndrome continues to evolve along with medical management. This review focuses on the historical context of CAS, pathogenesis, resurgence of the condition with variable presentations, and contemporary management.

Impact of inflammatory bowel disease on hospital outcomes in acute ischemic stroke: a nationwide cohort study.

PURPOSE: Patients with inflammatory bowel disease (IBD) have an increased risk of venous thrombotic events. The impact IBD has on arterial thrombosis is not well characterized. We aimed to identify the impact of IBD on hospital outcomes in patients admitted for acute ischemic stroke (AIS). METHODS: This is a retrospective cohort study utilizing the 2017 National Inpatient Sample. We identified all adult patients with a principal diagnosis of AIS and compared those with a concurrent diagnosis of IBD to those without-subgrouped by ulcerative colitis (UC) and Crohn's disease (CD). Outcomes were mortality and healthcare usage among IBD patients with AIS. Multivariate analysis was used to control for confounders. Analyses were performed using STATA. RESULTS: Five hundred twenty-four thousand and forty-five patients were admitted for AIS in 2017; of them 2200 (0.41%) had a concurrent diagnosis of IBD. The presence of IBD did not significantly affect in-hospital mortality (4.09% vs. 4.01%) among patients admitted for AIS [OR 1.07 95% CI: 0.65-1.76], with similar findings upon subgroup analysis of UC [OR 0.91, 95% CI: 0.39-2.09] and CD [OR 1.17, 95% CI: 0.62-2.19]. Mean hospital length of stay and charges/costs in AIS were similar irrespective of IBD. CONCLUSIONS: UC and CD do not appear to be associated with a higher risk of mortality or increased healthcare usage in AIS. AIS risk assessment in patients with IBD is important but should be done in a similar fashion to the general population.

Chlamydia trachomatis Mimicking COVID-19 Chronic Follicular Conjunctivitis.

PURPOSE: To characterize the clinical presentation and report lab findings of Chlamydia trachomatis follicular conjunctivitis in two patients with a positive history of active COVID-19 infection. Participants. Two patients with follicular conjunctivitis with a recent history of COVID-19 infection. DESIGN: Retrospective, noncomparative, case report. METHODS: Demographic data including age, gender, and place of residence were recorded. A full exam with an emphasis on inflammatory characteristics and systematic workup. Sample follicles were surgically excised in selected cases, and molecular and histopathological analyses were performed. RESULTS: Both patients were initially treated for viral conjunctivitis. After symptoms failed to resolve, biopsy results indicated that both patients were positive for chlamydia conjunctivitis and treated accordingly. CONCLUSIONS: These cases illustrate the role of biopsy as an investigative tool in chronic conjunctivitis and the importance of having a broad differential when treating patients with acute conjunctivitis.

Chronic Pain Secondary to a Cervical Intramedullary Ependymoma: A Case Report.

Intramedullary spinal cord tumors (IMSCT) are a rare subset of neoplasms classified based on anatomical location. The most common presenting symptom is pain; however, the high prevalence of back pain in the general public secondary to common causes including degenerative disc disease or osteoarthritis, makes diagnosing spinal cord tumors a challenge. We present a case of a 43-year-old male with a cervical intramedullary ependymoma to discuss the clinical presentation, diagnosis, and treatment of these spinal tumors.