Ogilvie's Syndrome in a Young Female With Chronic Constipation.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is often encountered in post-surgical patients or those with serious comorbidities requiring intensive care. For this reason, it has rarely been reported in patients younger than 50 years without any predisposing risk factors. Our case report highlights a unique case of Ogilvie's syndrome in a young female with no recent trauma or surgical history. To that extent, we discuss risk factors that predisposed her to this condition, including her history of chronic constipation. We also emphasize the need for outpatient workups for such patients to prevent the worsening of their symptoms.

Increasing Trends of Clostridium difficile Infection in Hospitalized Young Patients: A Study of the National Inpatient Sample From 2007 to 2017.

Background Clostridium difficile infection (CDI) is one of the rising public health threats in the United States. It has imposed significant morbidity and mortality in the elderly population. However, the burden of the disease in the young population is unclear. This study aimed to identify hospitalization trends and outcomes of CDI in the young population. Methodology We obtained data from the National (Nationwide) Inpatient Sample (NIS) for hospitalizations with CDI between 2007 and 2017. We used the International Classification of Diseases Ninth Edition-Clinical Modification (ICD-9-CM) and ICD-10-CM to identify CDI and other diagnoses of interest. The primary outcome of our study was to identify the temporal trends and demographic characteristics of patients aged less than 50 years old hospitalized with CDI. The secondary outcomes were in-hospital mortality, length of hospital stay (LOS), and discharge dispositions. We utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze the trends and outcomes. Results From 2007 to 2017, CDI was present among 1,158,047 hospitalized patients. The majority (84.04%) of the patients were ≥50 years old versus 15.95% of patients <50 years old. From 2007 to 2017, there was a significant increase in CDI among <50-year-old hospitalized patients (12.6% from 2007 to 18.1% in 2017; p < 0.001). In trend analysis by ethnicities, among patients <50 years old, there was an increasing trend in Caucasians (63.9% versus 67.9%; p < 0.001) and Asian females (58.4% versus 62.6%; p < 0.001). We observed an increased trend of discharge to home (91.3% vs 95.8%; p < 0.001) in association with a decrease in discharge to facility (8.3% vs 4%; p < 0.001). The average LOS from 2007 to 2017 was 5 ± 0.03 days, which remained stable during the study period. Conclusions The proportion of young (<50 years old) hospitalized patients with CDI has been steadily increasing over the past decade. Our findings might represent new epidemiological trends related to non-traditional risk factors. Future CDI surveillance should extend to the young population to confirm our findings, and the study of emerging risk factors is required to better understand the increasing CDI hospitalization in the young population.

Trends and Factors Associated With Ventilator-Associated Pneumonia: A National Perspective.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs more than 48 hours after mechanical ventilation. Studies showing temporal trends, predictors, and outcomes of VAP are very limited. OBJECTIVE: We used the National database to delineate the trends and predictors of VAP from 2009 to 2017. METHODS: We analyzed data from the Nationwide Inpatient Sample (NIS) for adult hospitalizations who received mechanical ventilation (MV) by using ICD-9/10-CM procedures codes. We excluded hospitalizations with length of stay (LOS) less than two days. VAP and other diagnoses of interest were identified by ICD-9/10-CM diagnosis codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze the data. RESULTS: Out of a total of 5,155,068 hospitalizations who received mechanical ventilation, 93,432 (1.81%) developed VAP. Incidence of VAP decreased from 20/1000 in 2008 to 17/1000 in 2017 with a 5% decrease. Patients who developed VAP had lower mean age (59 vs 61; p<0.001) and higher LOS (25 days vs. 12 days; p<0.001). In multivariable regression analysis, we identified that males, African Americans, teaching hospitals and co-morbidities like neurological disorders, pulmonary circulation disorders and electrolyte disorders are associated with the increased odds of developing VAP. VAP was also associated with higher rates of discharge to facilities and increased LOS. CONCLUSION: Our study identified the trends along with the risk predictors of VAP in MV patients. Our goal is to lay the foundation for further in-depth analysis of this trend for better risk stratification and development of preventive strategies to reduce the incidence of VAP among MV patients.

Acute Pancreatitis After the Use of Belimumab in a Patient With Systemic Lupus Erythematosus: Case Report and Review of Literature.

Belimumab is a B-cell depletion therapy that has emerged as an effective and safe treatment option for Systemic Lupus Erythematosus (SLE), but ongoing phase IV trials continue to report its common and rare adverse effects. Our case report seeks to add data to the existing literature on the safety profile of belimumab. We report an interesting and complicated case of a 30-year-old female with a 12-year history of SLE and multiple treatment failures who developed acute pancreatitis in the context of the initiation of belimumab. The temporal link between the two events made us undertake a review of literature on the efficacy and safety of belimumab. We used PubMed and Medline to shortlist eight studies that included phase III parent and extension clinical trials of belimumab that had been conducted in the past 10 years and illustrated the results in a tabulated form.  The United States Food and Drug Administration has approved belimumab as a safe and effective treatment option for SLE. The BLISS-52, BLISS-76, and BLISS-SC trials along with their extension trials showed that SRI (SLE Responder Index) was higher in the patient cohorts that were treated with IV (intravenous) or SC (subcutaneous) belimumab. According to the website "eHealthMe.com", which tracks the incidence of adverse events from drugs by allowing people to report events, 14100 people reported side effects when taking belimumab and among them, 29 people (0.21%) reported acute pancreatitis. Time on belimumab when patients had acute pancreatitis was 1-2 years for 52% of the patients and 1-6 months for 40% of the patients; 96% of the patients were females. The age group at which it was most reported was 40-49 years. Additional data is needed to enable a better characterization of the pathophysiology and nature of acute pancreatitis as a possible side effect of belimumab.

The Impact of Door to Diuretic Time in Acute Heart Failure on Hospital Length of Stay and In-Patient Mortality.

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further.

A Rare Case of Hypereosinophilic Syndrome-Induced Shower Thrombus Responsive to Nilotinib.

Hypereosinophilic syndrome (HES) is a rare clinical disease that affects 0.036/100,000 patients, with a minority of patients having associated genetic markers which can encompass PDGFRA/B or FGFR1 mutations. The prognosis is dependent on the timing of diagnosis and early treatment, with a mortality rate ranging from 48% to 75% if there is a delayed diagnosis. Eosinophilic myocarditis is characterized by invasion of the myocardium with eosinophils. Myeloid neoplasms are a rare, but known cause of HES induced myocarditis. Signs and symptoms can range from being asymptomatic to retrosternal pain, arrhythmias, and even sudden death. HES myocarditis is a diagnosis of exclusion that is made via endomyocardial biopsy. Peripheral eosinophilia is the only specific sign to suggest eosinophilic myocarditis with traditional biomarkers, electrocardiogram, and echocardiogram. Treatment modalities include systemic corticosteroids and symptomatic management. Complications from HES myocarditis may include embolic events, eosinophilic vegetations, and dysrhythmias, or conduction disturbances. We present a case of a 62-year-old male who initially presented with epigastric pain, and then suffered a myocardial infarction. After testing, the probable diagnosis of eosinophilic myocarditis was made. His clinical course was complicated by the development of shower thrombus associated with acute encephalopathy. Although HES has classically been treated with imatinib, in this case, an alternative biologic agent was used, resulting in a good prognosis and ultimate patient survival. This case details the importance of early clinical suspicion, diagnosing the condition, and early initiation of treatment to prevent worsening clinical status.

Acute saddle pulmonary embolism: A rare complication of mycoplasma pneumonia.

BACKGROUND/INTRODUCTION: Mycoplasma pneumonia affects 1% of the population in the United States. The majority of patients infected with Mycoplasma experience upper respiratory tract infection symptoms, and about 10% of patients infected with Mycoplasma develop pneumonia. A rare complication is a pulmonary embolism (PE), which may be life-threatening if not diagnosed early and treated promptly. Our case explores the presentation of Mycoplasma pneumonia complicated by acute saddle PE, an association only reported in the form of case reports globally. CASE PRESENTATION: A 75-year-old previously healthy female presented to the emergency department with shortness of breath. The patient was found to be in acute hypoxic respiratory failure secondary to community acquired pneumonia and antibiotics were started. During hospitalization, her respiratory failure worsened and had to be escalated to a non-rebreather mask. Repeat chest X-ray showed a possible developing infiltrate on the left side. Antibiotic coverage was escalated and broadened. Serology was positive for mycoplasma pneumoniae. Telemetry monitoring showed non-sustained episodes of Atrial Fibrillation and Electrocardiogram showed the presence of new-onset SIQIIITIII. Computer Tomography Angiography of the chest showed acute saddle PE. The patient was subsequently upgraded to the ICU, where she was intubated and started on catheter-directed thrombolysis to decrease clot burden. CONCLUSION: To our knowledge, this is the first case of acute saddle PE in a live patient with mycoplasma pneumonia. This entity is important in order to ensure early diagnosis of PE in association with mycoplasma pneumonia and the initiation of early treatment to improve patient outcomes.

A Rare Case of Non-Small Cell Lung Cancer with BRAF V600E Gene: Case Report and Literature Review.

Non-small cell lung cancer is one of the leading causes of mortality in the United States. The BRAF mutation, which has been associated with malignant melanoma, has been documented in only 3.5-5% of the non-small cell lung cancer (NSCLC) patient population.The involvement of the BRAF mutation in NSCLC and the treatment for tumors with such mutations is still an evolving topic of interest, which is why more in depth information is warranted. We present a rare case of stage IV non-small cell lung adenocarcinoma, who presented first with a complicated pericardial effusion with evidence of malignant effusion. He had genetic testing done, revealing he had a positive BRAF V600E mutation. He was put on multiple chemotherapy regimens, but was most responsive to Vemurafenib. This case will shed light into the importance of the BRAF V600E gene and its importance in NSCLC for better prognosis value.

Severe Sepsis and Wet Gangrene Requiring Foot Amputation Caused by an Emerging Human Pathogen - Shewanella algae.

A 69-year-old woman with type 2 diabetes mellitus, peripheral vascular disease, and other comorbidities presented with recurrent syncopal episodes. Cellulitic skin changes in her right lower extremity were noted, as well as a large hemorrhagic bulla on the dorsum of her right foot. Severe sepsis was determined to be the reason for her syncopal episodes. Blood cultures and the bulla aspirate culture were positive for Shewanella algae that was pan-sensitive to antibiotics. Her clinical status was stabilized with a regimen of intravenous fluids and broad-spectrum antibiotics. However, due to the development of right foot gangrene, she underwent debridement and eventually required transmetatarsal open amputation.

Rivaroxaban-Induced Acute Interstitial Nephritis: A Case Report.

BACKGROUND Direct oral anticoagulant agents (DOACs) have become increasingly more popular in recent years and have largely replaced warfarin in the treatment of certain conditions, such as atrial fibrillation, and in the prevention of thromboembolic events. Rivaroxaban is one of the most commonly used direct anticoagulant drugs for conditions such as atrial fibrillation and thromboprophylaxis. CASE REPORT We present a case of a 70-year-old male who developed acute interstitial nephritis after starting rivaroxaban, and who responded to medical treatment, which included corticosteroid therapy. A renal biopsy was not performed because the patient was on essential anticoagulation therapy secondary to a high CHADS2VASc score. CONCLUSIONS Dose adjustments when using rivaroxaban are necessary in patients with underlying renal failure. Acute interstitial nephritis is a rare condition associated with direct anticoagulant drugs. The treatment of acute interstitial nephritis is usually to remove the offending agent and treat the underlying cause.

Iatrogenic Hepatic Portal Venous Gas in a Patient With Crohn's Disease After Colonoscopy.

Hepatic portal venous gas is a radiologic sign and is associated with several abdominal disorders. The prognosis and survival of the patient depends on the underlying etiology. Most cases respond to broad-spectrum antibiotics, but some may need surgical intervention. We report a case of hepatic portal venous gas after colonoscopy in a patient with Crohn's disease.

Actinomyces turicensis: An unusual cause of cervicofacial actinomycosis presenting as ludwig angina in an immunocompromised host - Case report and literature review.

Actinomyces is an anaerobic, gram-positive bacillus that is known to cause chronic granulomatous infections. Common risk factors predisposing patients to this life-threatening infection are recent dental procedures, immunosuppression from malignancy, or history of smoking and alcohol use. Actinomyces, commonly found in the normal flora of the oral cavity, is one of the pathogens that can cause Ludwig's angina. Ludwig's angina is diffuse cellulitis and edema of the soft tissues of the neck and floor of the mouth. Cervicofacial actinomyces is an invasive infection that can form life-threatening abscesses through its rapid spread. Actinomyces turicensis is an isolate that has emerged recently to cause infections in humans. There are few reported cases of this species causing abdominal and genital infections; however, there is no report of it invading the cervicofacial space. A feared complication of Ludwig's angina and cervicofacial actinomyces is airway compromise. Therefore, prompt initiation of intravenous antibiotics is required for the treatment and prevention of deadly complications. We present a patient with left-sided neck swelling after a recent oral surgical procedure and was found to grow Actinomyces turicensis on wound culture. The patient was treated with intravenous ampicillin-sulbactam, which not only decreased the swelling but improved the necrotic appearance of his abscess wound.

Spontaneous Fungal Peritonitis as a Rare Complication of Ascites Secondary to Cardiac Cirrhosis: A Case Report.

BACKGROUND Spontaneous fungal peritonitis (SFP) is a life-threatening infection which occurs more commonly in patients with liver failure. SFP is not as common as spontaneous bacterial peritonitis (SBP) and has higher mortality rates due to late recognition and difficulty in differentiation between SFP and SBP. Spontaneous fungal peritonitis is extremely uncommon in patients with cardiac ascites due to a high protein content, which predisposes to a low risk of infections. CASE REPORT This report presents a rare case of spontaneous fungal peritonitis in a patient with cardiogenic ascites. To the best of our knowledge, this is the second known case of SFP occurring in a patient with cardiac cirrhosis. The patient did not respond to initiation of SBP treatment and after ascitic fluid grew Candida glabrata, the diagnosis of SFP was made. The patient's clinical status improved after initiation of intravenous caspofungin. CONCLUSIONS SFP should be a differential diagnosis in patients who have cardiac or liver cirrhosis, who are not improving with empirical antibiotic therapy for spontaneous bacterial peritonitis.

Complete Eye Ophthalmoplegia: the unusual initial presentation of Leptomeningeal Carcinomatosis.

Ophthalmoplegia is a paralysis or weakness of extraocular muscles that have a variety of different etiologies including and not limited to Leptomeningeal Carcinomatosis (LC). LC is caused mainly by metastatic cancers and can cause a wide variety of symptoms. We present a case of LC with no preexisting condition who presented with a unilateral ophthalmoplegia as initial presentation who was found to have LC secondary to large B-cell lymphoma.

Atypical Hemolytic Uremic Syndrome: A Case Report.

Hemoytic uremic syndrome (HUS) is a rare type of thrombotic microangiopathies. Manifestations include thrombocytopenia, microangiopathic hemolytic anemia, and thrombi in small blood vessels. The prognosis is poor. Herein, we present a case of atypical HUS, which is very rare.

Marijuana Induced Sick Sinus Syndrome: A Case Report.

BACKGROUND Marijuana is a commonly abused illicit drug in the United States (US). Regular marijuana usage has been linked to many adverse cardiovascular effects. Our case describes the association of abusing marijuana and the development of sick sinus syndrome. CASE REPORT A 27-year-old male carpenter was admitted to the hospital for recurrent syncopal episodes. He reported 2 episodes of syncope every month for the last 5 years. He denied alcohol or nicotine intake but reports using marijuana daily. He also reported cervical injuries due to syncope in the past. Physical examination was unremarkable. Orthostatic vitals were negative. Electrocardiogram (ECG) showed sinus bradycardia. A series of investigations, including a stress test and tilt table testing, were negative. The drug screen was positive for marijuana. A loop recorder was implanted to evaluate the cause of syncope and was positive for a long sinus pause of more than 3 second, indicative of sick sinus syndrome. The patient was successfully treated with a permanent pacemaker with no further events on follow-up after 6 months. CONCLUSIONS The case we report here adds to the literature that several reversible etiologies are shown to be associated with the development of sick sinus syndrome, in which marijuana abuse can be one of them. We strongly suspect that marijuana was the cause of this patient's sick sinus syndrome after ruling out all the possible etiologies. The relation between marijuana use and sick sinus syndrome needs to be further investigated in the future.

Atheroma of the Innominate Artery Presenting as a Transient Ischemic Attack.

Supra-aortic atherosclerotic lesions, including innominate artery atheromas, are an uncommon but established cause of transient ischemic attacks, stroke, upper extremity ischemia, and vertebrobasilar insufficiency. We present a patient with a transient ischemic attack admitted with right hemispheric symptoms who was found to have a severe ulcerated innominate artery atheroma. The patient underwent an aortic arch angiogram with stenting of the innominate artery. The proper diagnosis, treatment, and management of innominate artery atheromas are imperative to prevent further cardiovascular morbidity and mortality in patients. Currently, both endovascular and surgical options are available for revascularization, and there have been no randomized controlled trials comparing endovascular versus open repair to standardize one as the standard of care over the other. No randomized controlled trials are examining the benefit of dual versus single antiplatelet therapy post-stenting in supra-aortic atherosclerotic lesions. We believe that this topic warrants further research and needs evidence-based guidelines to help direct physicians about treatment and management.

Isolated Starvation Ketoacidosis: A Rare Cause of Severe Metabolic Acidosis Presenting with a pH Less than 7.

Anion gap metabolic acidosis (AGMA) occurs when an anion gap exists along with metabolic acidosis, most commonly due to diabetic ketoacidosis (DKA) and lactic acidosis (LA). Isolated starvation ketoacidosis (ISK) is one of the rare causes of AGMA; however, it usually presents with a mild disturbance in pH. We report a rare case of a 45-year-old female with previously diagnosed squamous cell cancer (SCC) of the larynx. She presented to the emergency department complaining of difficulty in breathing following laryngectomy and tracheostomy for SCC. Her laboratory results on admission were consistent for isolated starvation ketoacidosis and the patient responded quickly to the appropriate treatment.

Pulmonary arterial hypertension: A rare yet fatal complication of Neurofibromatosis Type 1.

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder with an incidence of approximately 1 in 4,000 live births [1]. Pulmonary arterial hypertension (PAH) is a rare but extremely life-threatening complication associated with NF1. Timely recognition of this unusual and severe association between NF1 and PAH is imperative in prolonging the survival in this specific patient population. We present the clinical outcomes of a 47-year old female previously diagnosed with NF1, who presented with progressively worsening dyspnea.

Delftia acidovorans: A rare cause of septic pulmonary embolism from catheter-related infection: Case report and literature review.

Septic pulmonary emboli is a rare condition due to the dislodgement of an infected thrombus traveling to the pulmonary vasculature via the venous system. Staphylococcus spp. and Candida spp. are the most common causative agents. The most common risk factor is intravenous drug abuse, but there has been an association with intravenous catheters. Delftia acidovorans (DA) is a rare organism causing catheter-related infection, which has a tendency to embolize and clog up major vessels. It is highly resistant to all available aminoglycoside agents. There are only a few cases reported in children showing DA as a cause of septic emboli with none of the cases reported in a young patient. We report a similar case but in a young adult who developed septic emboli due to DA that was caused by an infected peripherally inserted central catheter (PICC) line. Since the organism is highly susceptible to recurrent embolization, the PICC line was removed and the patient was treated successfully with an appropriate antibiotic regime.