Acute Colonic Pseudo-Obstruction in an Elderly Female Patient With Chronic Constipation.

Acute colonic pseudo-obstruction (ACPO), or Ogilvie's syndrome, is an acute colonic dilatation without mechanical obstruction; it is most commonly seen in severely ill or postoperative patients. While this syndrome has no clear pathophysiology, it is diagnosed when the cecum and right colon expand without physical obstruction. This condition can lead to perforation and intestinal ischemia. Ogilvie's syndrome is associated with a relatively high morbidity and mortality rate. The diagnosis of ACPO can be often missed due to its vague symptoms such as bloating, abdominal distention, abdominal pain, nausea and vomiting, and severe constipation. We report the case of an 82-year-old female patient who had a unique diagnosis of ACPO, or Ogilvie's syndrome, overshadowed by the diagnosis of severe constipation. This case highlights the importance of maintaining a high index of suspicion and early diagnosis of symptoms that can rapidly become dangerous.

Amoxicillin-Clavulanate Induced Liver Injury in a Young Female.

Amoxicillin-clavulanate (AC) is an antibiotic widely used for various infections. It has rarely been associated with drug-induced liver injury (DILI), mainly in males 55 or older with associated alcohol consumption or medications causing liver injury. Here we present an atypical case of a 22-year-old female with a past medical history of celiac disease and alopecia areata who was prescribed AC in urgent care for bilateral cervical lymphadenopathy, nausea, and chills. Her nausea and vomiting worsened after taking AC for three days, and she developed jaundice. On workup, she was found to have deranged liver functions, and pan-lobular hepatitis was confirmed on liver biopsy. She started to improve symptomatically after withdrawing AC, and her transaminases started showing a decreasing trend.

Lemierre's Syndrome: A Comeback Story.

Lemierre's syndrome is a very rare and life-threatening complication of bacterial pharyngitis and tonsillitis. Often referred to as a 'forgotten disease', Lemierre's syndrome has seen a rise in cases over the years secondary to increased antibiotic resistance. With the potential for multiple organ failure secondary to widespread septic emboli, Lemierre's syndrome can no longer be forgotten. Prompt initiation of treatment is needed for better patient outcomes. We describe an unusual case of a young female without any significant past medical history who presented with left-sided pleuritic chest pain several days after experiencing a sore throat.

An Unusual Etiology of Hypothyroidism and New-Onset Insulin-Dependent Diabetes: A Rare Side Effect of Nivolumab.

Nivolumab, a monoclonal antibody targeting programmed cell death 1 receptor, is prescribed for many advanced cancers like malignant melanoma, non-small cell lung cancer, renal cell cancer, etc. With the increase in the use of nivolumab like immunotherapy, the incidences of immune-related side effects are also on the rise. Immune-related endocrinopathies like hypothyroidism and new-onset type 2 diabetes mellitus associated with nivolumab use, although rare, are already documented in the literature. Here we present a case of hypothyroidism and new-onset type 2 diabetes mellitus in a renal cell cancer patient receiving nivolumab for the past six months. The patient was managed successfully with discontinuation of nivolumab, intravenous insulin, and thyroid hormone replacement therapy. These types of endocrinopathies can be fatal; hence, prompt diagnosis and management are required. Thus, not only physicians' awareness of such endocrinopathies among nivolumab-treated patients but also patients' awareness regarding warning signs and symptoms are essential.

Modifying Beauty Is Not Priceless: A Rare Case of Silicone-Induced Hypercalcemia With Renal Failure.

Silicone implant-induced hypercalcemia is a rather rare pathological entity. There are only a few published reports on the topic. Here, we have reported a case of acute kidney injury in the background of hypercalcemia and elevated vitamin D level in a transgender patient with a history of silicone injections in the breast and buttocks for cosmetic purposes.

A Case of Angioimmunoblastic T-cell Lymphoma Hidden in Plain Sight: A Delay in Diagnosis and Management.

Angioimmunoblastic T-cell lymphoma (AITL) is an uncommon type of cluster of differentiation (CD)4 T-cell peripheral lymphoma. The varied clinical presentations of AITL present a challenge for accurate diagnosis. We present a case of a 57-year-old female with a history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in May 2020, who presented to the hospital in the summer of 2021 with shortness of breath for 3 months. She underwent an extensive workup for lymphadenopathy while in Canada involving multiple core lymph node biopsies, which were inconclusive. Here in our institution, several tests for infectious diseases were unremarkable. Imaging tests revealed bilateral pleural effusion, lymphadenopathies, and rectal thickening. Results from rectal biopsy and excisional cervical lymph node biopsy revealed findings typical of AITL. Due to worsening hypoxia with pleural fluid accumulation, bilateral chest tubes (PleurX catheter) were placed. Steroids and chemotherapy were started. She was discharged in stable condition to follow-up care. An integrated and persistent approach comprising clinical, morphologic, excisional biopsy, immunophenotyping, and molecular tests is essential in reaching a correct diagnosis of AITL. Through our consistent effort to obtain further imaging and tissue biopsies, we came to the diagnosis which allowed her to begin appropriate life-saving treatments.

Iatrogenic Infective Endocarditis With Septic Emboli: An Unusual Complication of Intracardiac Manipulation.

Radiofrequency catheter ablation (RFA) is an effective treatment for recurrent symptomatic atrial fibrillation (AF) despite medical therapy. Complications include cardiac tamponade, pulmonary vein stenosis, and rarely atrial-esophageal fistula (AEF). We present a case of a 77-year-old male patient with a history of persistent AF status post posterior left atrial isolation 50 days prior, who presented to the emergency department with bilateral lower extremity weakness ongoing for an hour. In addition, he reported a non-productive cough, chest discomfort, and dysphagia. He was hypertensive, febrile, tachycardic, and with tachypnea on initial assessment. Initial labs revealed leukocytosis with elevated troponin level. Brain imaging confirmed subacute infarcts suggestive of embolic disease. Tissue plasminogen activator was contraindicated. He was admitted for management of altered mental status and sepsis of an unknown origin. Due to associated chest discomfort and dysphagia, computed tomography (CT) scan of the chest with contrast obtained revealed a small focus of air between the posterior wall of the left atrium and the esophagus. A few hours later, he deteriorated with worsened hypoxic respiratory failure, altered mental status, requiring intubation and mechanical ventilation. Cardiothoracic surgery was consulted, and he was taken to the operating room for open-heart surgery due to concern for AEF. Peri-operatively, a left atrial fistula measuring 0.5 cm was identified and closed. Also, a fibrinous material (3 × 4 cm) was identified and removed in the left inferior pulmonary vein. On post-operative day 1, he underwent an upper endoscopy, and a 1 cm esophageal defect was closed. Biopsy from fibrinous material was positive for polymicrobial organisms (lactobacillus, candida, and prevotella), while blood cultures grew Streptococcus anginosus. Despite treatment with aggressive intravenous antibiotics, the patient deteriorated with poor neurological function and ventilator dependency. A multidisciplinary team reached a consensus agreement for palliative measures. To our knowledge, this case represents one of the few cases documenting life-threatening infective endocarditis with septic emboli as a complication of AEF from RFA. Therefore, clinicians should have a high index of suspicion due to associated grave prognosis.