Hepatic Vein Pylephlebitis as a Cause of Bilateral Pyopneumothorax.

Pylephlebitis is a rare complication of intra-abdominal infections and has a significant mortality rate, necessitating early recognition for optimal treatment. Here, we present the case of a 36-year-old male with fever, shortness of breath, cough, and epigastric pain. He was ultimately diagnosed with hepatic vein pylephlebitis along with multiple pulmonary and hepatic lesions believed to be septic emboli and hepatic abscess. He developed recurrent bilateral pyopneumothorax which required drainage by interventional radiology multiple times. The patient improved and was discharged on intravenous antibiotics for four weeks. While hepatic abscesses are a known complication of pylephlebitis, pyopneumothorax is a rare, unreported complication. Recognition of this potential complication is important for clinicians when treating patients with hepatic vein pylephlebitis.

The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum.

Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.

Mild Pancreatitis Induced by Linagliptin Revealed by a Medication Review.

As dipeptidyl peptidase-4 inhibitors are becoming more utilized in the treatment of diabetes, it is important to recognize their side effects and become more familiar with them. As these side effects arise, physicians are more prepared to recognize and discontinue these medications. This case report describes a 34-year-old male who initially presented with a hemoglobin A1c greater than 16%. After titration of his diabetic medications, he presented with pancreatitis diagnosed by symptoms and imaging. Common causes of pancreatitis were ruled out, including biliary pathology, alcohol use, tobacco use, elevated calcium levels, and hypertriglyceridemia. The patient followed up in the clinic with persistent symptoms. A review of his medication list revealed pancreatitis as a side effect of linagliptin. After holding this medication, his symptoms improved over the course of a month.

Acute Viral Pericarditis Complicated by Cardiac Tamponade as a Result of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) and coronavirus disease 2019 (COVID-19) predominantly cause respiratory symptoms but cardiovascular complications from COVID-19 have been documented in the literature. Acute pericarditis has been known to be caused by COVID-19 but severe cardiac complications, such as cardiac tamponade, have rarely been reported. Early diagnosis and treatment with pericardiocentesis are imperative, as this can improve patient outcomes. A 56-year-old female presented with chest pain and recurrent episodes of presyncope. The patient tested positive for SARS-Cov-2 through a polymerase chain reaction (PCR) test. The patient was hypotensive on arrival and the initial workup with electrocardiogram was significant for sinus tachycardia with low voltage QRS complexes in the precordial and limb leads. A transthoracic echocardiogram was also done and showed a large circumferential pericardial effusion with chamber collapse of the right atrium and right ventricle during diastole indicative of tamponade physiology. The patient's clinical course was complicated by pulseless electrical activity cardiac arrest during which a pericardiocentesis was done. One hundred (100) mL of serous pericardial fluid was drained and a return of spontaneous circulation was obtained after roughly 10 minutes of cardiopulmonary resuscitation. Further infectious and noninfectious workups, including malignant and rheumatologic etiologies for acute pericarditis, were negative. The patient was subsequently treated with high-dose non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine for viral pericarditis. The patient's clinical course improved, and the patient was subsequently discharged after a prolonged hospital course to a subacute rehabilitation facility to undergo physical therapy.

Dilated Cardiomyopathy as a Result of Coxsackie B Virus Myocarditis.

Dilated cardiomyopathy (DCM) is a myocardial disease that is characterized by left ventricular or biventricular dilation and impairment of systolic function. The etiology is often unknown although it has been thought that DCM may be a consequence of viral myocarditis. The most commonly implicated viruses in the development of myocarditis include coxsackie B virus, hepatitis, parvovirus, cytomegalovirus, influenza virus, and adenovirus. DCM carries a poor prognosis and high rates of mortality, therefore early diagnosis and treatment are imperative. A 47-year-old male presented with atypical chest pain, along with progressive dyspnea. The patient also endorsed symptoms consistent with acute viral syndrome roughly one week prior to presenting to the hospital. The patient initially presented in cardiogenic shock. An initial workup including an echocardiogram was done and showed an ejection fraction of 10-15% with severe left ventricular and left atrial dilation. Left-sided cardiac catheterization revealed nonobstructive coronary artery disease. The patient was placed on mechanical circulatory and inotropic support and was transferred to the cardiovascular intensive care unit. Cardiac MRI was done and showed a moderately sized pericardial effusion along with signs indicative of myocarditis. Serologic testing was positive for coxsackie B virus type IV antibodies. The patient's clinical picture improved as circulatory and inotropic support was removed and the patient was discharged with close outpatient follow-up and evaluation for cardiac transplant.

Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Complication From a Commonly Used Medication.

Leukocytoclastic vasculitis (LCV) is a cutaneous small vessel vasculitis that is characterized by the development of a non-blanching palpable purpura. Diagnosis is made by skin biopsy and histopathology which shows subepidermal acantholysis with dense neutrophilic infiltrate leading to fibrinoid necrosis of the dermal blood vessels. Etiology is generally idiopathic in most cases but secondary causes include chronic infections, malignancies, systemic autoimmune conditions, and medication use. Treatment involves supportive measures in the case of idiopathic LCV, and treatment of the offending condition or agent in LCV due to a secondary cause. A 59-year-old male presented with purulent ulcers on the plantar surface of the right foot. Radiograph of the right foot showed soft tissue swelling without evidence of osteomyelitis. Empiric antibiotic treatment with vancomycin was initiated. A wound culture was obtained from the purulent drainage which grew positive for methicillin-resistant Staphylococcus aureus (MRSA). On the fourth day of treatment with vancomycin, multiple symmetric, purpuric lesions arose on the patient's trunk and extremities. Skin biopsy with histopathology showed subepidermal acantholysis with neutrophil-predominant inflammatory infiltrate consistent with leukocytoclastic vasculitis. Vancomycin was discontinued and the patient's exanthem began to regress, with full resolution after 30 days post withdrawal of the antibiotic.

The Impact of Granulocyte Colony-Stimulating Factor Administration in a Neutropenic Cancer Patient With COVID-19-Related Acute Respiratory Distress Syndrome.

Chemotherapy-induced neutropenia is a serious adverse effect found in cancer patients treated with chemotherapy. As these patients are at risk of infections, granulocyte colony-stimulating factors (G-CSF) are commonly used in these patients to increase neutrophil counts. This report describes a case of a 73-year-old female with metastatic breast cancer treated with letrozole and palbociclib who presented to the hospital with flu-like symptoms and a positive SARS-CoV-2 test. She was saturating well on room air without the need for supplemental oxygen initially, however, she was febrile and lab work revealed neutropenia. Subsequently, she was given two doses of Tbo-filgrastim. Her respiratory status deteriorated shortly afterward and she required supplemental oxygen. The chest X-ray obtained at that time revealed increased atelectasis or infiltration in the middle and lower lung fields, and computed tomography angiography of the chest revealed bilateral patchy airspace and ground glass opacities. The timeline from symptom onset along with her imaging findings suggested COVID-19-related acute respiratory distress syndrome (ARDS) as a possible explanation for her respiratory status decline. Interestingly, her neutrophil-to-lymphocyte ratio (NLR) had consistently increased, along with her respiratory status deterioration, after the completion of the two doses of G-CSF. The patient was treated with dexamethasone. Her respiratory status eventually improved prior to discharge.

A Case of Left Ventricular Thrombus and Herpetic Esophagitis in an Immunocompetent Patient With COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with thrombosis, both venous and arterial, but the mechanism behind this coagulation is not fully understood. Several cases involving coronavirus disease 2019 (COVID-19)-positive patients with left ventricular thrombus (LVT), particularly in those with low ejection fraction, have been reported. This report describes a case of a 57-year-old male patient who presented to the hospital with altered mental status and a positive SARS-CoV-2 polymerase chain reaction (PCR) test. CT of the chest revealed the presence of an LVT, and transthoracic echocardiography showed a reduced ejection fraction and confirmed the presence of the thrombus. The patient also reported epigastric chest pain and several bloody bowel movements. A colonoscopy revealed internal hemorrhoids. An esophagogastroduodenoscopy revealed the presence of multiple esophageal ulcers, and biopsy results confirmed herpes simplex virus (HSV) infection. The patient had no history of organ or bone marrow transplant, long-term immunosuppressive therapy, or HIV infection. He was eventually discharged on apixaban for his LVT and acyclovir for his HSV esophagitis.

An Unusual Bacterial Etiology of Fournier's Gangrene in an Immunocompetent Patient.

Fournier's gangrene (FG) is necrotizing fasciitis that affects the penis, scrotum, or perineum. Males are more likely to get affected by this disease. The most common predisposing risk factors are diabetes, alcoholism, hypertension, smoking, and immunosuppressive disorders. FG is a polymicrobial infection caused by both aerobic and anaerobic bacteria. The most common aerobic organisms are Escherichia coli, Klebsiella, Proteus, Staphylococcus, and Streptococcus. The most common anaerobic organisms are Bacteroides, Clostridium, and Peptostreptococcus. The disease carries high mortality and morbidity, so timely diagnosis and treatment are of utmost importance. Here, we report a case of a 61-year-old male with a medical history significant for benign prostatic hyperplasia (BPH), who presented to our hospital with fever, watery diarrhea, and painful swelling of the scrotum and penis. The patient was started on piperacillin-tazobactam, vancomycin, and clindamycin. A computed tomography scan of the pelvis showed prostatic enlargement, edema of the penis and scrotum, and air collection within the corpus cavernosum. The patient underwent multiple surgical debridements of the glans penis. Patient wound cultures were positive for Streptococcus anginosus, Actinomyces turicensis, and Peptoniphilus harei. As mentioned earlier, FG is common in diabetic and immunocompromised patients, and infection is usually polymicrobial. Our patient was immunocompetent and his cultures grew atypical organisms.