A near-miss diagnosis of necrotizing breast fasciitis complicated by atrial fibrillation secondary to septic focus: a case report and brief review of literature.

Necrotizing fasciitis of the breast is a rare, life-threatening entity characterized by a rapidly aggressive infection of the soft tissue. There are few literature reports on necrotizing fasciitis at the level of the breast tissue as the most common locations are within the abdominal wall or extremities, but this entity can lead to sepsis and systemic multiorgan failure if not adequately managed. Here, we report a case that highlights the course of a 68-year-old African American female with a past medical history of hypertension, hyperlipidemia, and poorly controlled diabetes mellitus, who presented with the complaint of a painful right breast abscess with intermittent, purulent drainage. An initial point-of-care ultrasound displayed an area of induration of the right breast as well as soft tissue edema with no identifiable fluid collection. A subsequent CT abdomen and pelvis was obtained given new onset abdominal pain, which demonstrated incidental findings of inflammatory changes and subcutaneous emphysema along with colonic diverticulosis. Surgical intervention was immediately sought for which she underwent debridement and exploration of the right breast with findings that were consistent with necrotizing transformation. The patient was sent back to the OR for an additional surgical debridement the next day. Of note, the patient had post-op atrial fibrillation with rapid ventricular response and had to be admitted to the ICU for conversion to sinus rhythm. She returned to sinus rhythm and was transferred back to medicine before application of a negative pressure wound dressing on discharge. The patient was transitioned from Enoxaparin to Apixaban for anticoagulation control in the setting of atrial fibrillation before being discharged to a Skilled Nursing Facility with long-term antibiotics. This case highlights the difficulty and significance in establishing a prompt diagnosis for necrotizing fasciitis.

MDCT Findings of Splenic Pathology.

The delineation and characterization of splenic lesions and other abnormalities can be challenging on computed tomography. Many splenic lesions are incidentally found, imaging features tend to overlap, and without the appropriate clinical context, differentials can range from benign to malignant. Radiologists should be familiar with the wide variety of pathologies seen on computed tomography as it is often the first imaging modality a splenic lesion is seen. The purpose of this MDCT-focused review is to understand normal splenic anatomy and its variants, to illustrate and describe typical and atypical imaging patters of inflammatory, infectious, vascular, traumatic, benign, and malignant tumors of the spleen and provide clues in reaching the appropriate differential diagnosis and management.

An unusual case of infective endocarditis with acute limb ischemia and cardiac embolism.

Infective endocarditis (IE) is a persistent health issue, particularly among intravenous drug users. We discussed a case of infective endocarditis in a patient who uses IV drugs, which had some unusual features such as unusual presentation, polymicrobial infection, left-sided valve involvement, coronary embolism, and an uncommon pathogen for IE.

Perforated Gangrenous Gallbladder in an Asymptomatic Patient.

Acute cholecystitis or inflammation of the gallbladder is a common cause of hospitalizations. A percentage of those patients will progress to gangrenous cholecystitis and perforation. This medical emergency can lead to peritonitis, which has increased morbidity and mortality. The first-line modality for the diagnosis of acute cholecystitis is an ultrasound, but if it is inconclusive, then a computed tomography (CT) scan may be beneficial. Gangrenous cholecystitis and perforation have been reported in asymptomatic diabetic patients secondary to diabetic neuropathy and/or gallbladder ischemia leading to nerve denervation. Yet, here we present the case of an asymptomatic non-diabetic patient with gangrenous gallbladder perforation that was treated with antibiotics and drain placements. Diagnosis and treatment involve the collaboration between primary care, interventional, and diagnostic services to appropriately manage these patients. This case demonstrates that clinicians should have a low threshold to conduct CT scan of the abdomen, especially when there is a sudden resolution of pain.

MDM2 Antagonists Counteract Drug-Induced DNA Damage.

Antagonists of MDM2-p53 interaction are emerging anti-cancer drugs utilized in clinical trials for malignancies that rarely mutate p53, including melanoma. We discovered that MDM2-p53 antagonists protect DNA from drug-induced damage in melanoma cells and patient-derived xenografts. Among the tested DNA damaging drugs were various inhibitors of Aurora and Polo-like mitotic kinases, as well as traditional chemotherapy. Mitotic kinase inhibition causes mitotic slippage, DNA re-replication, and polyploidy. Here we show that re-replication of the polyploid genome generates replicative stress which leads to DNA damage. MDM2-p53 antagonists relieve replicative stress via the p53-dependent activation of p21 which inhibits DNA replication. Loss of p21 promoted drug-induced DNA damage in melanoma cells and enhanced anti-tumor activity of therapy combining MDM2 antagonist with mitotic kinase inhibitor in mice. In summary, MDM2 antagonists may reduce DNA damaging effects of anti-cancer drugs if they are administered together, while targeting p21 can improve the efficacy of such combinations.