Tainted Love: A Case of Gonococcal Endocarditis.

Gonococcal endocarditis (GE) is a rare complication of disseminated gonococcal infection with significant morbidity and increasing mortality despite early diagnosis and surgical intervention. The discovery and use of antibiotics in the treatment of gonococcal infections has made this once relatively common entity a rarity. Notably, over the recent years, GE has shown an alarming resurgence for unclear reasons. The upward trend in the incidence of gonococcal infections coupled with observed antibiotic resistance may in part explain the rise in cases. GE mostly affects sexually active young people without a history of valvular heart disease. Prompt diagnosis and surgical intervention are important in the bid to mitigate poor outcomes. Management is therefore multidisciplinary; primary care clinicians who usually are the first to see this patient population should be able to make an early diagnosis and facilitate early referral for surgical intervention as indicated. Despite appropriate and timely therapy, devastating consequences of this condition are not uncommon.

Management of Acquired Factor VIII Inhibitors With NovoSeven and Obizur.

Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by the production of autoantibodies against coagulation factor VIII (FVIII). AHA is associated with significant morbidity and mortality primarily as a result of bleeding. Although many disorders are associated with the development of these inhibitors, up to 50% of cases remain idiopathic. The approach to therapy involves an initial strategy often to control acute bleeding episodes followed by definitive treatment to eradicate the inhibitor with immunosuppressive agents. We present the case of a 63-year-old Caucasian male hospitalized for severe Covid-19 who developed bleeding due to an acquired FVIII inhibitor that had never been treated definitively. Our case presentation focuses on in-hospital management of this patient's acute bleeding episodes with by-passing agents and recombinant porcine factor VIII.

Salivary Duct Carcinoma: Case Reports and Brief Review of the Literature.

Salivary duct carcinoma (SDC) is an uncommon and highly aggressive tumor associated with high morbidity and mortality. According to the World Health Organization, it is an extremely rare malignancy with an estimated incidence of 1-1.2 in 1,000,000 patients. Standard treatment for SDC is wide surgical resection along with lymph node dissection followed by adjuvant radiation therapy. The role of adjuvant chemotherapy is not known. In this report, we present three cases of SDC. A 71-year-old female with T1N0M0 disease was treated with total parotidectomy, ipsilateral neck dissection, and adjuvant radiotherapy without evidence of disease recurrence at 5 months. The second is a 59-year-old female with TXN1M0 disease who was treated with total parotidectomy with ipsilateral level I-IV neck dissection and adjuvant radiotherapy without evidence of disease occurrence at 21 months. The third case is a 79-year-old male with widely metastatic disease, including brain metastases, treated with cranial irradiation, leuprolide, and lapatinib who remains under home hospice care.

Retrospective Analysis of Inflammatory Markers and Patient Characteristics in Hospitalized Covid-19 Patients: An Early Experience in Louisiana.

Background The community transmission of coronavirus disease 2019 (Covid-19) was detected in Baton Rouge, Louisiana, in March 2020. Several previous studies have reported elevations of inflammatory markers in Covid-19 positive patients and suggested a possible correlation to disease severity. Methods We identified 69 patients from Baton Rouge General (BRG) Hospital who were admitted with acute hypoxic respiratory failure and laboratory confirmed positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) between March 13 and April 5, 2020. Demographic and laboratory data were obtained through a review of medical records. Statistical analysis was performed on several inflammatory markers in association with clinical disease severity. Results We identified 69 patients with confirmed Covid-19 infection. The mean (±SD) age of the patients was 65±14 years, 68% were male and 32% were female. A total of 13 patients (19%) were considered to have mild disease, 25 (36%) had moderate disease, and 31 (45%) were considered to have severe disease. A total of nine patients died (13%), 25 (36%) have been discharged from the hospital, 20 (29%) remain in the ICU, and 15 (22%) remain admitted to the hospital at the time of writing. Lymphopenia was common among hospitalized patients (39%) and was found to be statistically more pronounced in patients with severe disease (p<0.05). Inflammatory marker elevations were also seen in several patients, with statistically significant elevations in C-reactive protein (CRP) and lactate dehydrogenase (LDH) (p <0.05). We found no statistically significant associations between ferritin, D-dimer, troponin I, body mass index (BMI), or creatine kinase (CK) with disease severity. Conclusions During the first three weeks of the Covid-19 outbreak in Baton Rouge, Louisiana, the most common reason for admission amongst Covid-19 positive patients was acute hypoxic respiratory failure. Previously, several studies have suggested a correlation between elevated inflammatory markers and disease severity. The presence of lymphopenia and elevations of CRP and LDH may be helpful in the risk stratification of these patients. In an effort to guide clinical decision making and provide insight into disease severity, further characterization of Covid-19 infection in hospitalized patients is urgently needed.

A case series of coinfection with SARS-CoV-2 and influenza virus in Louisiana.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the novel coronavirus initially detected in Wuhan, China, and is responsible for the worldwide pandemic coronavirus disease 2019 (Covid-19). Influenza is a common endemic respiratory virus that causes seasonal outbreaks of respiratory illness. There are currently few reports in the literature describing patients with coexisting infections. This case series of 4 patients identified at our single institution in Louisiana highlights the patient characteristics, laboratory findings, and outcomes in patients with both Covid-19 and influenza infection.

Ibrutinib-Associated Cardiac Tamponade with Concurrent Antiplatelet Therapy.

Ibrutinib is approved for the first-line treatment of chronic lymphocytic leukemia (CLL). A well-known side effect of ibrutinib therapy is increased bleeding risk, which ranges from mild mucocutaneous bleeding to rarely life-threatening hemorrhage. The increased bleeding tendency associated with ibrutinib is thought to be related to its effect on several platelet signaling pathways, which can be exacerbated in the setting of concurrent antiplatelet or anticoagulant therapy. We present an 82-year-old male with CLL on ibrutinib and concurrent antiplatelet therapy who developed cardiac tamponade due to a hemorrhagic pericardial effusion requiring emergent placement of a pericardial window. This case further highlights the risk of major bleeding in patients treated with ibrutinib and concurrent antiplatelet therapy.

TAFRO Syndrome: A Case of Significant Endocrinopathy in a Caucasian Patient.

Idiopathic multicentric Castleman disease (iMCD) is a lymphoproliferative disorder that manifests as multiorgan dysfunction secondary to widespread inflammation. The underlying pathogenesis is driven by an excessive and inappropriate cytokine storm. TAFRO syndrome is a rare subtype of iMCD, characterized by thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly. Multiorgan dysfunction is a known consequence of this syndrome, although endocrine involvement has yet to be reported. We present a case of TAFRO in a previously healthy Caucasian male who presented with abdominal pain, dysuria, diffuse anasarca, and ascites. On presentation, the patient was found to have acute kidney injury, thrombocytopenia, elevated inflammatory markers, elevated interleukin-6 (IL-6), and endocrinopathy. Following an extensive infectious and autoimmune workup, lymph node biopsy confirmed the diagnosis of TAFRO. The patient was started on prednisone, rituximab, and anti-IL-6 therapy with siltuximab. He achieved clinical remission after 4 months of treatment, with normalization of renal function, thrombocytopenia, inflammatory markers, and endocrinopathy. He has continued on siltuximab for maintenance therapy. It is our hope that this unique case of TAFRO syndrome with significant endocrinopathy will add to the growing literature surrounding iMCD, and help clinicians better understand the pathogenesis and treatment of this rare disease.