Euphoric Presentation in Creutzfeldt-Jakob Disease and Its Diagnostic Implications: A Case Report.

Creutzfeldt-Jakob disease (CJD) constitutes an aggressively advancing, terminal neurodegenerative condition classified within the spectrum of transmissible spongiform encephalopathies. The difficulty in establishing a diagnosis before death arises from the condition's rarity and the resulting limited level of suspicion attributed to it. The polymorphic nature of CJD symptoms contributes to the challenge of early diagnostic recognition. Emotional and behavioral changes have been well documented, but the initial presentation of euphoria has not been documented. Here, we present the case of a female patient who was experiencing an unusual state of euphoria followed by intermittently altered mental status. She was ultimately diagnosed with sporadic CJD, discharged home on hospice, and died within six months of discharge.

Hemophagocytic Lymphohistiocytosis Secondary to Obstructive Uropathy and Escherichia coli Bacteremia.

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome in which widespread activation of the immune system causes multi-organ tissue damage. HLH is a serious and potentially fatal disorder characterized by excessive immune system activation. It is characterized by a dysregulation in natural killer (NK) T-cell function, causing activation of lymphocytes and histiocytes. These cells secrete a large number of inflammatory cytokines and infiltrate various tissues causing multi-organ system failure. The spectrum consists of hereditary or "primary" HLH that comprises genetically heterogeneous conditions, occurring during childhood. The secondary form presents later in life and is associated with several conditions mainly malignancy, autoimmune diseases, viral or bacterial infections, and hematological diseases. Here we present an interesting case in which a 39-year-old patient presented with a complaint of shortness of breath. He was diagnosed with obstructive uropathy in the emergency department and subsequently developed acute liver injury, acute kidney injury, Escherichia coli bacteremia, and was diagnosed with HLH with comorbid bacteremia.

Unusual Fungal Endocarditis Causing Disseminated Infection After Renal Transplant.

Fungal endocarditis is a relatively uncommon disease; it mostly affects those with intracardiac devices and those with compromised immune systems. Scedosporium apiospermum (S. apiospermum), the asexual state of Pseudoallescheria boydii, has become increasingly reported as an opportunistic pathogen. These filamentous fungi present in soil, sewage, and polluted waters, and was previously recognized to cause human infection after their inhalation or traumatic subcutaneous implantation. In immunocompetent individuals, it usually causes localized diseases depending on the site of entry such as skin mycetoma. However, in immunocompromised hosts, the fungus species appear to disseminate and cause invasive infections, frequently reported to be life-threatening with poor response to antifungal medications. S. apiospermum invasive endocarditis remains a rare complication, mostly cited in immunocompetent hosts with prosthetic cardiac valves or other intracardiac devices and severely immunocompromised patients with hematologic neoplasia. Herein, we describe the case of a renal transplant patient on immunosuppressive medications who presented with S. apiospermum fungal septic infection that invaded the left ventricular outflow tract (LVOT) causing endocarditis with disseminated infection and resulted in poor clinical outcome.

Fungal Endocarditis Secondary to Transdermal Fentanyl Patch.

Fungal endocarditis is an uncommon and dangerous disorder of the heart. The two most frequent etiologic fungi discovered to be responsible for fungal endocarditis are Aspergillus and Candida species. It is difficult to make a diagnosis of fungal endocarditis; a comprehensive assessment must be carried out, and specific diagnostic requirements must be completed. One of the main causes of endocarditis that physicians deal with in the hospital is intravenous drug abuse, but we never hear about transdermal drug abuse causing endocarditis. Here we present an interesting case of a 33-year-old male patient that presents to the hospital with non-specific complaints, and he was found to have fungemia. It was found out that the patient was using a kitchen appliance to cause dermal abrasion on his skin to increase the absorption rate of his fentanyl patch. Patient also suffers from trypanophobia, so he declined any surgical intervention and wanted lifelong oral medication therapy.

Ranolazine Toxicity Secondary to Paxlovid.

An Emergency Use Authorization (EUA) was issued by the FDA on December 22, 2021 for the investigational antiviral drug nirmatrelvir copackaged with the HIV-1 protease inhibitor ritonavir (Paxlovid - Pfizer) for outpatient treatment of mild to moderate COVID-19 in children 12 years and old that are high risk of severe disease. Due to the effects, Paxlovid has on liver metabolism it has a copious amount of drug-to-drug interactions. Here we present a rare case of a patient that was given Paxlovid and continued to take her Ranolazine at home. She presented to the emergency department obtunded and after an initial workup, it was determined to be secondary to ranolazine toxicity. She eventually recovered over 54 hours and returned to her baseline.

Blood Culture-Negative Endocarditis Secondary to Skin Popping.

Infectious endocarditis (IE) is a diagnosis in which thorough evaluation must be performed and certain diagnostic criteria must be met. Thorough history and detailed physical examination can affect and guide the management of a patient from the very beginning. One of the main causes of endocarditis that physicians deal with in the hospital is intravenous drug abuse. This case report is of a 29-year-old male presenting to a rural emergency department with a two-week history of altered mental status after being struck on the head with a metal pipe. The patient also endorsed using intravenous drugs along with subcutaneous injections (skin popping). The patient was initially treated as a traumatic intracranial hemorrhage, but it was later found to be secondary to septic emboli from blood culture-negative endocarditis. Throughout this case report, we will approach the difficulties of diagnosing IE in a patient who represented many of the less common findings including dermatologic manifestations of diseases such as Osler nodes and Janeway lesions.

Biventricular Takotsubo Cardiomyopathy Secondary to COVID-19.

Takotsubo cardiomyopathy (TCM) is a heart failure syndrome characterized by acute and transient dysfunction of the apical segment of the left ventricle. Since the emergence of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the diagnosis of TCM has increased in prevalence. Here we present an intriguing case of a patient who initially presented to the hospital with respiratory failure and received a diagnosis of COVID-19. During the patient's hospital course, he was also diagnosed with biventricular TCM and subsequently experienced complete resolution of TCM before discharge. Providers should be cognizant of the potential cardiovascular complications of COVID-19 and consider those heart failure syndromes, including TCM, could be causing some of the respiratory dysfunction in these patients.

Cardiac Metastasis From Renal Cell Carcinoma.

While metastasis is common, it is unusual for renal cell carcinoma (RCC) to spread to the heart and even more so without involving the inferior vena cava (IVC). In fact, only a few cases have been reported where RCC has metastasized to the heart without IVC invasion. There have been only a few cases published that show RCC metastasis to the heart without invasion through the IVC. Here, we present an interesting case of a patient that was found to have RCC metastasis to the lungs that had a direct invasion to the left atrium.

Atrioventricular Nodal Dysfunction Secondary to Chronic Alcohol Abuse.

Atrioventricular (AV) nodal conduction disorders occur when the AV conduction pathway is refractory due to functional or organic reasons, resulting in a delay or complete blockage of atrial impulses to the ventricles. One of the causes of nodal dysfunction includes chronic alcohol abuse and excessive binge drinking. We are presenting a case where a chronic alcoholic was binge drinking due to a loss of a close friend, which resulted in nodal dysfunction and multiple cardiac rhythms, including supraventricular bigeminy, sinus bradycardia, significant sinus pauses, and complete heart block. He eventually got a single-chamber permanent pacemaker and endorsed that he quit drinking alcohol when he was discharged. He followed up with cardiology after discharge, and his pacemaker interrogation showed that he has been without any type of cardiac arrhythmias.

Unusual Presentation of an Inguinal Bladder Hernia.

Cases of an inguinal bladder hernia (IBH) are rare as the diagnosis may be challenging because patients are often asymptomatic or have nonspecific symptoms. When patients are symptomatic, normally they complain of urinary symptoms. Our patient initially presented to the hospital because he had a ground-level fall after having chest pain while transitioning from a bed to a wheelchair. Incidentally in the emergency department, he was found to have scrotal edema, which was later diagnosed as inguinal bladder herniation. The patient did not have any further episodes of chest pain or abdominal pain once he was given medicinal therapy for his IBH. Surgery is usually the definitive treatment for inguinal bladder herniation, but our patient wished to try medicinal therapy and follow-up outpatient.

Hypokalemia-Induced Cardiac Arrest.

Renal tubular acidosis (RTA) refers to a group of disorders in which the elimination of hydrogen ions from the kidney or the reabsorption of filtered bicarbonate is impaired, resulting in metabolic acidosis. Hypokalemia is also prominent in different types of RTA. We are presenting an interesting case about a chronic alcoholic patient who presented to the emergency department and was found to be severely hypokalemic. During her hospital stay, she had multiple cardiac arrests likely secondary to her hypokalemia despite adequate treatment with potassium supplementation. We came to the conclusion of distal RTA in our patient based on hyperchloremic metabolic acidosis, sodium bicarbonate of 10 mmol/L, low potassium, blood urea nitrogen, and creatinine within normal limits, alkaline urine, and a positive urinary anion gap. It is likely that the cause of our patient's underlying type 1 RTA was secondary to her chronic alcohol abuse. Her potassium eventually returned to baseline, and she was discharged.

A Case of Symptomatic Paroxysmal Complete Atrioventricular Block.

Paroxysmal complete atrioventricular block (PCAB) is clinically characterized by a sudden change from 1:1 atrioventricular (AV) conduction leading to complete heart block. Patients may have a vast array of symptoms, but commonly, PCAB will lead to syncope and possible sudden cardiac death. The literature currently consists of three different types of PCAB: intrinsic paroxysmal atrioventricular block, extensive vagal paroxysmal atrioventricular block, and extrinsic idiopathic paroxysmal atrioventricular block. Currently, there is no single symptom or sign that is specific to a single type of AV block. PCAB is often missed or overlooked because of its unpredictability and no evidence of conduction disease with a normal 1:1 conduction on routine electrocardiograms. Here, we present a case of a 65-year-old female who has been intermittently symptomatic for four years and was found to have PCAB.

Management of Massive Rivaroxaban Overdose With Acetaminophen and Isosorbide Mononitrate Overdose.

Direct oral anticoagulants (DOACs) have been used more frequently for the prevention and management of thromboembolic disease in comparison to their predecessors. DOACs provide greater ease of administration, shorter half-lives, less monitoring, and fewer drug-drug interactions. With the rise of DOACs such as rivaroxaban, the opportunity for abuse also increases. Therefore, standardization of care based on rivaroxaban misuse must also be explored, an area in which there is not ample information. We present a case where a patient consumed a stockpile of her home medications in hopes to commit suicide. A 64-year-old female presented to the emergency department due to the ingestion of rivaroxaban 5,000 mg along with ingestion of acetaminophen 30,000 mg and isosorbide mononitrate 1000 mg in the setting of intentional self-harm with multiple declarations of being classified as Do Not Resuscitate. There have been documented cases of rivaroxaban overdose, however, there are no documented cases with levels of ingestion reaching 5,000 mg along with signs of severe bleeding. Our case study reviews the previously documented management of rivaroxaban abuse and the treatment that was given to our patient in the setting of extreme anticoagulant ingestion.

Mitral Valve Endocarditis Secondary to Nasal Irrigation Use in Chronic Allergic Rhinitis.

Streptococcus mitis (S. mitis) is a common colonizer of the teeth, nasopharynx, and oropharynx. S. mitis has been reported in several cases of streptococcal infective endocarditis (IE). Streptococcal IE is most associated with dental procedures and diseases of the mouth. There are fewer reports of diseases of the nasopharynx leading to endocarditis secondary to nasal irrigation systems, and that is why we present a unique case of mitral valve IE secondary to nasal irrigation. We report a case of a 49-year-old African American woman with a history of chronic allergic rhinitis who presented with chest pain and subjective fevers. Transthoracic echocardiogram (TTE) failed to show valvular vegetation, but high clinical suspicion led to transesophageal echocardiogram (TEE) imaging that demonstrated a mobile echo density with a size of 5mm by 3mm attached to the atrial side of the anterior mitral valve leaflet with thickening of the anterior mitral leaflet tip as well as moderate mitral valve regurgitation. Findings on TTE were consistent with IE. The patient still has organized/nodular vegetation after three months of appropriate antibiotic therapy. We highlight how poor nasal hygiene is low on the differential for a cause of valvular endocarditis. This case will help clinicians in determining appropriate therapy for chronic allergic rhinitis. This will also help clinicians to inform patients to stop using nasal irrigation systems if epistaxis is present.

A Rare Case of Blood Culture-Negative Isolated Pulmonic Valve Endocarditis Causing Empyema.

Right-sided native valve infective endocarditis (IE) refers to IE involving the tricuspid or pulmonic valve. The most common factors causing right-sided IE include intravenous drug use, intracardiac device, and central venous catheters. Isolated pulmonic valve IE has only been reported in less than 2% of all IE cases. We present a unique case of a patient with a history of poor oral hygiene found to have isolated blood culture-negative pulmonic valve IE, who subsequently developed empyema positive for Streptococcus constellatus.

Stress-Induced Cardiomyopathy Raising Concern for Myocardial Ischemia.

Stress-induced cardiomyopathy (SIC), or Takotsubo syndrome, is considered a reversible dysfunction of the left ventricle that may mimic an acute coronary syndrome (ACS). Patients may present with chest pain, dyspnea, syncope, or other serious complications including cardiogenic shock, ventricular arrhythmias, and thrombus formation. Diagnostic criteria for SIC include several factors, including electrocardiogram changes, cardiac biomarker elevations, ventricular regional wall abnormalities on echocardiogram, and absence of occlusive coronary disease on coronary angiography. There is no standardized protocol for the treatment of SIC, although the current consensus is that patients should be risk-stratified, managed for complications, and treated with supportive therapy accordingly. In this case study, we present an 85-year-old female who presented with one month of fatigue, lower extremity weakness, and exertional dyspnea with chest pressure. She received a cardiac workup which revealed lab and imaging findings consistent with SIC. She received treatment for SIC, pericarditis, and Clostridium difficile colitis.