An Atypical Initial Presentation of Systemic Lupus Erythematous With Bilateral Lower Extremity Edema and Unilateral Pleural Effusion.

Systemic lupus erythematosus (SLE) is an autoimmune condition more commonly observed in women of childbearing age. The most commonly reported initial presentations were fatigue, arthritis, and skin manifestations. However, due to the involvement of a variety of organs, diagnosis remains a challenge for physicians. Our patient is a 48-year-old lady who presented with severe bilateral lower extremity edema with non-resolving right lower lobe pneumonia and ipsilateral exudative pleural effusion. Her leg swelling was not responding to diuretics, and her pneumonia was not improving following a course of antibiotics. This unusual presentation prompted an autoimmune workup, which later revealed a diagnosis of SLE with class 5 lupus nephritis. Pleuritis, exudative pleural effusion, and lupus nephritis have been associated with autoimmune disorders in the literature, but this is an uncommon initial presentation in SLE without other clinical manifestations. Our case report highlights the challenges in the diagnosis of an atypical case of SLE and the need to maintain high clinical suspicion for SLE, especially in female patients with multiorgan involvement.

Small Cell/Neuroendocrine Prostate Cancer: A Rare Treatment-Resistant Variant Presenting as Acute Onset Severe Back Pain.

Adenocarcinoma of the prostate is the most frequent subtype of prostate cancer. Being an androgen-driven disease, androgen deprivation therapy (ADT) is one of the mainstay treatments for prostatic adenocarcinoma. ADT however can induce androgen resistance and can cause neuroendocrine differentiation of the cells and subsequently can lead to the emergence of neuroendocrine prostate cancer (NEPC). NEPC, despite being rare, is very aggressive with a very low survival period. The majority of the NEPC cases are treatment-emergent. There is no definite guideline on screening for the development of NEPC for patients who are on ADT. Our case highlights the lethality and aggressiveness of NEPC and the relationship between ADT and NEPC. More research is needed to compare different imaging techniques for early detection and identification of NEPC and to establish screening protocols for patients at risk of developing NEPC while on ADT.

A Case of Acute Extensive Viral Sinusitis Secondary to Acute Epstein Barr Virus.

Infectious mononucleosis (IM), the most common presentation of acute Epstein Barr virus (EBV) infection, typically presents with fever, pharyngitis and lymphadenopathy. We describe an unusual case of IM presenting as acute sinusitis. A 25 year-old male presented to the emergency department with worsening right frontal sinus pain along with fever, chills, and greenish nasal discharge for 3 weeks. Laboratory workup showed leukocytosis with high lymphocyte counts as well as transaminitis. Facial computerized tomography (CT) showed extensive right frontal, ethmoidal and maxillary sinusitis and antrochoanal polyp. The patient underwent endoscopy with drainage of purulent material and polyp removal. Unfortunately, cultures of the sample were not sent and bacterial infection could not be ruled out. Broad spectrum antibiotics were continued. Pathology of redundant tissue revealed large atypical lymphocytes with positive EBV-encoded RNA and lack of evidence of extranodal natural killer/T-cell (NK/T-cell) type lymphoma (ENKTCL). Tests for serum EBV IgM antibodies and EBV early Antigen antibodies were positive, indicating acute EBV infection. Lymphocytosis resolved along with significant clinical improvement at the 10-day follow up visit. Even though patient did receive antibiotics, multiple factors including isolated lymphocytosis, pathology positive for EBV with no neutrophilia were more suggestive of sinusitis caused by viral infection, EBV in this case. Lymphocytosis with fever and sore throat should prompt physicians to consider IM. There are no known reports in the literature of EBV as a causal organism for acute viral sinusitis. There are some studies relating EBV with ENKTCL. It is unknown whether this particular patient with a history of EBV sinusitis will be at high risk for nasal type lymphoma in the future. Further studies should be conducted to understand the pathogenesis and relationship between EBV and ENKTCL. LEARNING POINTS: Infectious mononucleosis (IM) can present with various atypical presentations. Consideration of IM should not be limited to people presenting with a triad of fever, lymphadenopathy and sore throat. Lymphocytosis with atypical symptoms should raise suspicion of infectious mononucleosis.No case has been reported of EBV as a causal organism for acute sinusitis. Association with EBV infection and chronic sinusitis or nasal polyp or extranodal NK/T cell lymphoma has been demonstrated but pathogenesis is poorly understood.Studies should be done on whether acute sinusitis secondary to EBV poses a risk for nasal type lymphoma.

A Case of Severe Cardiomyopathy Due to Covid-Induced Myocarditis, Completely Resolved after Colchicine and Immunoglobulin Therapy.

Coronavirus 19 (COVID-19) is well known for causing acute respiratory distress syndrome. Among other systemic complications, myocarditis is a frequently reported presentation as well as complication. One systematic review reported a 14% mortality rate in patients with COVID-19 myocarditis. Endomyocardial biopsy is a definitive diagnostic test but has been a challenge to perform in most cases of COVID myocarditis due to the contagious nature of the disease. Patients presenting with new cardiomyopathy with troponin leak and arrhythmias, supported by recent COVID-19 diagnosis should be suspected for COVID-induced myocarditis. Supportive treatment has been the mainstay of treatment with limited data on immunotherapy and colchicine. Our case is about a male in his 50s who had a cardiac arrest due to ventricular fibrillations, with a positive COVID-19 test. Further workup showed severe non-ischaemic cardiomyopathy with an EF of 15-20%. He was treated with intravenous immunotherapy and colchicine. A repeat echocardiogram 3 days later showed resolution of cardiomyopathy. Our case report highlights the possible beneficial effects of immunotherapy and colchicine in viral myocarditis. LEARNING POINTS: Myocarditis should be suspected in patients with acute onset cardiomyopathy with troponin leak and no evidence of ischaemia. COVID-19 myocarditis can present with arrhythmia, which could be fatal in some cases.Even though supportive management is the mainstay of treatment for COVID-19 myocarditis, there have been reports of benefits of intravenous immunotherapy (IVIG) and colchicine.More studies are warranted to explore the beneficial effects of IVIG and colchicine not just in COVID-19 myocarditis, but also in other viral causes of myocarditis he aim of this study is also to raise awareness among healthcare professionals about the Bentall procedure in patients with type A aortic dissection involving the aortic valve.

Secukinumab-Induced Crohn's Disease in a Patient Treated for Juvenile Idiopathic Arthritis.

Juvenile idiopathic arthritis (JIA) is a common form of arthritis that occurs in children, typically with an onset before the age of 16 years. It can affect joints in any part of the body. As per the International League of Rheumatology, JIA is classified into systemic arthritis, oligoarthritis, extended oligoarthritis, polyarthritis (rheumatoid factor positive), polyarthritis (rheumatoid factor negative), enthesitis-related arthritis (ERA), juvenile psoriatic arthritis (JPsA), and other arthritis. JIA is treated with disease-modifying antirheumatic medications (DMARDs), which include both nonbiologic agents like methotrexate (MTX) and biologic agents like inhibitors of tumor necrosis factor-alpha, interleukin-1 (IL-1), IL-6, and T-cell co-stimulation modulators. As per recent studies, in December 2021, Secukinumab, an IL-17A inhibitor, is one of the most recent biologic agents approved for active ERA and JPsA. A few reports have suggested Secukinumab is related to new-onset inflammatory bowel diseases (IBDs). We present a case of a 20-year-old female who was being treated with Secukinumab for JIA, and six months into therapy, she developed symptoms suggestive of Crohn's disease (CD). The diagnosis was confirmed with colonoscopy, histopathology, and radiology results. Her symptoms completely resolved four weeks after discontinuing Secukinumab and oral steroid therapy. The efficacy and side effects of Secukinumab have been studied mainly on middle-aged populations who were being treated for psoriasis and ankylosing spondylitis (AS); however, there is limited literature on younger populations. With this case report, we would like to highlight the possible relationship between the development of IBD and Secukinumab therapy in the adolescent population and emphasize the importance of regular screening for IBD in this population.

Retroperitoneal Hematoma: A Sequela of Acute Hemorrhagic Pancreatitis Post Endoscopic Retrograde Cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic tool for pancreaticobiliary diseases. Like every other procedure, ERCP can lead to complications that include pancreatitis, cholecystitis, perforation, and rarely, retroperitoneal hematoma. We present a case of post-ERCP acute hemorrhagic pancreatitis resulting in retroperitoneal hematoma and sequelae of unilateral hydronephrosis and ileus. The patient was treated supportively and had good clinical improvement with resolution of hydronephrosis, ileus and more importantly tolerating oral diet without further episodes of abdominal pain. LEARNING POINTS: The most common complications of endoscopic retrograde cholangiography are acute pancreatitis and hemorrhage. In high-risk patients, acute pancreatis can be prevented with rectal non-steroidal anti-inflammatory suppository before the procedure.Occurrence of Grey-Turner or Cullen sign should prompt immediate search for retroperitoneal hematoma especially in the setting of acute hemorrhagic pancreatitis.Apart from hemodynamic instability or compressive symptoms, retroperitoneal hematoma can also cause complications due to inflammatory reactions resulting in hydronephrosis or ileus.

Enterobacter cloacae as sole organism responsible for vertebral osteomyelitis/discitis and vertebral collapse in a patient with intravenous drug abuse.

Staphylococcus aureus is the most commonly isolated organism in osteomyelitis, while gram-negative bacteria (GNB) comprises only a minor portion. GNB osteomyelitis is usually seen in patients with bacteraemia, recent genitourinary infection, open fractures or trauma and is rarely seen in the spines. Our case is a man in his 30s with no significant risk factors except an extended history of intravenous drug use (IVDU), who presented with back pain and subsequently developed vertebral collapse. Bone culture grew Enterobacter cloacae, yet blood cultures were negative. To date, there are limited data on the prevalence of GNB osteomyelitis in IVDU and its association. Due to rising rates of IVDU, further research must be done into associated medical complications to provide comprehensive care. Moreover, the emergence of multidrug-resistant GNB strains limits the number of effective antibiotics and is expected to pose more serious public concerns in the future.

Why behaviours do not change: structural constraints that influence household decisions to control pig diseases in Myanmar.

This article problematises the ways in which behavioural change by poor individuals dominates the global discussions on means to tackle issues caused by systemic problems. We do so by focusing on the case of animal diseases, a symptom of many systematic failures. While livestock farming has long been praised as a mitigating factor against poverty, livestock diseases threaten the lives and livelihoods of poor and marginalised people who depend on animals. Aiming at controlling animal diseases, policy makers tend to focus on behavioural change by individual farmers by enhancing their knowledge. We conducted an in-depth qualitative research among pig farmers in Myanmar, a country that is rapidly increasing livestock production, to document contextual and systematic constraints that influence farmers' understandings and perceptions of disease-related risks and household-level decisions to invest in animal disease control. We conducted in-depth interviews, focus group discussions and participant observation in three townships in the Yangon region. Structural constraints such as weak veterinary health system and limited access to low-interest credit prevent farmers from gaining necessary knowledge about disease prevention and make them economically vulnerable. These systematic constraints drive behaviours considered 'risky' for disease emergence and spread. As a result, many small- and medium-scale farmers in low- and middle-income countries remain trapped in a vicious cycle of poverty and ill health for both animals and humans. We conclude that, instead of focusing on individual behavioural change, interventions need to combine enhancing knowledge by individual farmers and tackling economic and structural constraints that limit their agency and ability to address practices that are considered risky.

Novel plasma phospholipid biomarkers of autism: mitochondrial dysfunction as a putative causative mechanism.

Autism is a neurological disorder that manifests as noticeable behavioral and developmental abnormalities predominantly in males between the ages of 2 and 10. Although the genetics, biochemistry and neuropathology of this disease have been extensively studied, underlying causal factors to this disease have remained elusive. Using a longitudinal trial design in which three plasma samples were collected from 15 autistic and 12 non-autistic age-matched controls over the course of 1 year, universal and unambiguous alterations in lipid metabolism were observed. Biomarkers of fatty acid elongation and desaturation (poly-unsaturated long chain fatty acids (PUFA) and/or saturated very long chain fatty acids (VLCFA)-containing ethanolamine phospholipids) were statistically elevated in all autistic subjects. In all 8 of the affected/non-affected sibling pairs, the affected sibling had higher levels of these biomarkers than the unaffected sibling. Exposure of neurons, astrocytes and hepatocytes in vitro to elevated extracellular glutamate levels resulted in lipid biomarker changes indistinguishable from those observed in autistic subjects. Glutamate stress also resulted in in vitro decreased levels of reduced glutathione (GSH), methionine and cysteine, in a similar way to the decreases we observed in autism plasma. Impaired mitochondrial fatty acid oxidation, elevated plasma VLCFAs, and glutamate toxicity as putative causal factors in the biochemistry, neuropathology, and gender bias in autism are discussed.