Rare Case of Refractory Hypokalemia in a Patient with Acute Monocytic Leukemia.

BACKGROUND Refractory hypokalemia has been rarely demonstrated in patients with acute monocytic leukemia (AMoL). Hypokalemia develops in these patients owing to renal tubular dysfunction, secondary to lysozyme enzymes that are released by monocytes in AMoL. Additionally, renin-like substances are produced from monocytes and can lead to hypokalemia and metabolic alkalosis. There is also an entity called spurious hypokalemia, in which high numbers of metabolically active cells in blood samples increase sodium-potassium ATPase activity, resulting in influx of potassium. Additional research is warranted regarding this specific demographic to create standardized treatment approaches to electrolyte repletion. CASE REPORT In this case report, we demonstrate a rare case of an 82-year-old woman with AMoL, complicated by refractory hypokalemia, who presented with concerns of fatigue. The patient's initial laboratory results were significant for leukocytosis with monocytosis and severe hypokalemia. Refractory hypokalemia was noted, despite administration of aggressive repletions. During her hospitalization, AMoL was diagnosed and an extensive workup was performed to evaluate the underlying cause of hypokalemia. Ultimately, the patient died on day 4 of hospitalization. We describe the correlation between severe refractory hypokalemia and leukocytosis and provide a literature review of multiple etiologies of refractory hypokalemia in patients with AMoL. CONCLUSIONS We evaluated the numerous pathophysiologic mechanisms responsible for refractory hypokalemia in patients with AMoL. Our therapeutic outcomes were limited owing to the patient's early death. It is of high importance to evaluate the underlying cause of hypokalemia in these patients and to treat accordingly with caution.

COVID-19 Viral Infection Presenting With Diabetic Ketoacidosis, Hyperosmolar Hyperglycemic Syndrome, or Mixed Hyperglycemic Crisis: A Case Series.

Cardiovascular disease, COPD, and diabetes (DM) are associated with increased complications with COVID-19. A correlation between COVID-19 and diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic Syndrome (HHS) has been suggested; however, the precise mechanism remains unclear. We present a case series of six patients with COVID-19 infections who were found to have DKA, HHS, or mixed picture. Wedescribe an association between COVID-19 and hyperglycemic emergencies. Six patients (50% male, 50% female, mean age 47.667 ± 18.747) were identified from November 2021 to February 2022. Comorbidities included DM (83.3%), HTN (50%), as well as ESRD, A-Fib, ISLD, HIV, and dementia (each 16.7%). Common review of systems included nausea and vomiting (50%), abdominal pain (33.3%), dyspnea (33.3%), and decreased appetite (33.3%). Additional findings were dysarthria, facial droop, generalized weakness, productive cough, myalgias, and increased urinary frequency (16.7%). Patients were diagnosed with DKA (50%), mixed process (33.3%), andHHS(16.7%). In terms of COVID-19 symptoms, most patients were asymptomatic (83.3%), with one patient developing hypoxia. The survival rate was 100%. Infections can incite DKA/HHS; yet, COVID-19 may have factors that amplify this process, in the setting of pancreatic beta-cell dysfunction from the virus itself. This may contribute to why diabetic patients have a ten times higher risk of death if they develop COVID-19. This virus binds to ACE2 receptors in the pancreas and damages the islets, ultimately decreasing insulin release. Here, we introduce cases of DKA/HHS in the setting of COVID-19, to understand the relationship between how COVID-19 infections may exacerbate diabetic complications.

Priming effects of nZVI on carbon sequestration and iron uptake are positively mediated by AM fungus in semiarid agricultural soils.

We investigated the priming effect of nanoscale zero-valent iron (nZVI) on carbon sink and iron uptake, and the possible mediation by AMF (arbuscular mycorrhizal fungi, Funneliformis mosseae) in semiarid agricultural soils. Maize seed dressings comprised of three nZVI concentrations of 0, 1, 2 g·kg-1 and was tested with and without AMF inoculation under high and low soil moistures, respectively. The ICP-OES observations indicated that both low dose of nZVI (1 g·kg-1) and high dose of nZVI (2 g·kg-1) significantly increased the iron concentrations in roots (L: 54.5-109.8 %; H: 119.1-245.4 %) and shoots (L: 40.8-78.9 %; H: 81.1-99.4 %). Importantly, the absorption and translocation rate of iron were substantially improved by AMF inoculation under the low-dose nZVI. Yet, the excess nanoparticles as a stress were efficiently relieved by rhizosphere hyphae, and the iron concentration in leaves and stems can maintain as high as about 300 mg·kg-1 while the iron translocation efficiency was reduced. Moreover, next-generation sequencing confirmed that appropriate amount of nZVI clearly improved the rhizosphere colonization of Funneliformis mosseae (p < 0.001) and the development of soil fungal community. Soil observations further showed that the hyphae development and GRSP (glomalin-related soil protein) secretion were significantly promoted (p < 0.05), with the increased R0.25 (< 0.25 mm) by 35.97-41.16 %. As a return, AMF and host plant turned to input more organic matter into soils for microbial growth and Fe uptake, and such interactions became more pronounced under drought stress. In contrast, high dose of nZVI (2 g·kg-1) tended to agglomerate on the surface of hyphae and spores, causing severe deformation and inactivation of AMF symbionts. Therefore, the priming effects of nZVI on carbon sequestration and Fe uptake in agricultural soils were positively mediated by AMF via the feedback loop of the plant-soil-microbe system for enhanced adaptation to global climate change.

Esophageal Stab Wounds Repaired Endoscopically: A Case Report and Comprehensive Literature Review.

Esophageal injuries are typically iatrogenic after endoscopic/surgical procedures, but they are rarely caused by penetrative or blunt trauma. We present a case of patient who suffered multiple stab wounds to the neck and underwent surgical repair for hemorrhagic shock but was ultimately diagnosed and treated successfully via endoscopy for a thoracic esophageal injury. Early detection is imperative and usually diagnosed via contrast studies but less commonly via direct visualization endoscopically. Moreover, endoscopic treatment is also less commonly utilized, even if diagnosed from that modality. Cervical injuries also confer a lower mortality than thoracic injuries.

A Rare Presentation of Gastrointestinal Stromal Tumor Causing Gastroduodenal Intussusception.

Adult intussusception is exceedingly rare and most commonly occurs in the stomach or ileum. It is less common for adult intussusception to be classified as gastroduodenal, which also carries a higher mortality rate. Adult intussusception usually warrants surgical intervention as the underlying cause is often malignancy. However, rarely, the etiology is a gastrointestinal stromal tumor (GIST). Here, we present the case of a patient who presented with abdominal pain, vomiting, and hemorrhagic shock and was diagnosed with gastroduodenal intussusception secondary to a gastric GIST.

Aleukemic Acute Promyelocytic Leukemia: How Concomitant HIV, Hepatitis C, and Chronic Alcohol Use Disorder May Have Hidden an Underlying Malignancy.

BACKGROUND Acute promyelocytic leukemia (APL) is a rare subtype of acute myeloid leukemia (AML) and is characterized by a genetic translocation affecting the retinoic acid receptor-alpha gene, leading to blockage in the differentiation of granulocytic cells. The accumulation of promyelocytes in bone marrow leads to cytopenias and life-threatening coagulopathies. Definitive diagnosis is made with bone marrow biopsy. Differentiation of APL from other leukemias is important to appropriately treat with all-trans retinoic acid (ATRA) and arsenic trioxide. Patients with HIV are at a higher risk to develop AML. This article identifies how multiple comorbidities and social factors can contribute to difficulties in diagnosing AML. CASE REPORT We present a 67-year-old man with a past medical history of hypertension and substance use disorder who presented with progressive exertional dyspnea and was found to have HIV, chronic hepatitis C, and APL with pancytopenia. His bone marrow biopsy confirmed AML. This was a case of co-existing HIV and aleukemic leukemia. CONCLUSIONS APL can present with pancytopenia, weakness, failure to thrive, or bleeding complications, which can be similar to presentations of those diagnosed with HIV. Diagnosis of APL can be differentiated between hypergranular and hypogranular; our patient demonstrated APL with only 52% blasts, which can make for a challenging diagnosis. Given increased mortality of APL, immediate ATRA therapy is warranted. Aleukemic leukemia is a rare presentation typically accompanied by skin manifestations. Our case highlights the importance of having high clinical suspicion for malignancy in patients with comorbidities that can interfere with the classic presentation of leukemia.

Rhizosphere effect of nanoscale zero-valent iron on mycorrhiza-dependent maize assimilation.

Rhizosphere effect of nanoscale zero-valent iron (nZVI) is crucial but little reported. Maize seeds were dressed with four nZVI concentrations (0, 1.0, 1.5, 2 g kg-1 ) and inoculated with arbuscular mycorrhizal fungus (AMF) (Funneliformis mosseae). The SEM images illuminated that excessive nZVI particles (2 g kg-1 ) were agglomerated on the surface of hyphae and spore, causing severe deformation and inactivation of AMF symbionts and thereafter inhibiting water uptake in maize seedlings. This restrained the scavenging effects of enzymatic (superoxide dismutase, peroxidase) and non-enzymatic compounds (proline & malondialdehyde) on ROS, and leaf photoreduction activity and gas exchange ability (p < 0.05). Interestingly, the inoculation with AMF effectively alleviated above negative effects. In contrast, appropriate dose of nZVI, that is, ≤1.5 g kg-1 , can be evenly distributed on the hyphae surface and form the ordered symbionts with AMF. This help massively to enhance hyphae growth and water and nutrient uptake. The enhanced mycorrhizal infection turned to promote rhizosphere symbiont activity and leaf Rubisco and Rubisco activase activity. Light compensation point was massively lowered, which increased photosynthetic carbon supply for AMF symbionts. Particularly, such priming effects were evidently enhanced by drought stress. Our findings provided a novel insight into functional role of nZVI in agriculture and AMF-led green production.

A Rare Case of Intravenously Managed Hypertensive Emergency Arising from a Perirenal Hematoma Subsequent to a Native Kidney Biopsy.

Page kidney is a pathologic and rare occurrence caused by a compression of renal parenchyma leading to hypertension. When infiltrated or engulfed by extrinsic matter, the subcapsular region surrounding the renal tissue may cause blanket compression, leading to the activation of the renin-angiotensin-aldosterone system secondary to renal hypoperfusion. While most cases of Page kidney are secondary to blunt trauma to the costovertebral angle, herein we present a case of Page kidney due to renal parenchymal core needle biopsy. The rarity of our case is not due to the cause of such an incidence but because our case resulted in a hypertensive emergency treated with dual intravenous infusions.

Dual effects of nZVI on maize growth and water use are positively mediated by arbuscular mycorrhizal fungi via rhizosphere interactions.

Nanoscale zero-valent iron (nZVI) might generate positive and negative effects on plant growth, since it acts as either hazardous or growth-promotion role. It is still unclear whether such dual roles can be mediated by arbuscular mycorrhizal fungi (AMF) in plant-AMF symbiosis. We first identified that in 1.5 g kg-1 nZVI (≤1.5 g kg-1 positively), maize biomass was increased by 15.83%; yet in 2.0 g kg-1 nZVI, it turned to be declined by 6.83%, relative to non-nZVI condition (CK, p < 0.05), showing a negative effect. Interestingly, the inoculation of AMF massively improved biomass by 45.18% in 1.5 g kg-1 nZVI, and relieved the growth inhibition by 2.0 g kg-1 nZVI. The event of water use efficiency followed similar trend as that of biomass. We found that proper concentration of nZVI can positively interact with rhizosphere AMF carrier, enabling more plant photosynthetic carbon to be remobilized to mycorrhiza. The scanning of transmission electron microscopy showed that excessive nZVI can infiltrate into root cortical cells and disrupt cellular homeostasis mechanism, significantly increasing iron content in roots by 76.01% (p < 0.05). Simultaneously, the images of scanning electron microscopy showed that nZVI were attached on root surface to form an insoluble iron ion (Fe3+) layer, hindering water absorption. However, they were efficiently immobilized and in situ intercepted by extraradical hyphae in mycorrhizal-nZVI symbiosis, lowering iron translocation efficiency by 6.07% (p < 0.05). Herein, the optimized structure remarkably diminished aperture blockage at root surface and improved root activities by 30.06% (p < 0.05). Particularly, next-generation sequencing demonstrated that appropriate amount of nZVI promoted the colonization and development of Funneliformis mosseae as dominant species in rhizosphere, confirming the positive interaction between AMF and nZVI, and its regulatory mechanism. Therefore, dual effects of nZVI can be actively mediated by AMF via rhizosphere interactions. The findings provided new insights into the safe and efficient application of nanomaterials in agriculture.

Nano-enabled improvements of growth and colonization rate in wheat inoculated with arbuscular mycorrhizal fungi.

Arbuscular mycorrhizal fungi display desired potential to boost crop productivity and drought acclimation. Yet, whether nanoparticles can be incorporated into arbuscular mycorrhizal fungi for better improvement and its relevant morphologic and anatomical evidences are little documented. Pot culture experiment on wheat (Triticum aestivum L.) was conducted under drought stress (30% FWC) as well as well watered conditions (80% FWC) that involved priming of wheat seeds with iron nanoparticles at different concentrations (5mg L-1, 10 mg L-1 and 15 mg L-1) with and without the inoculation of Glomus intraradices. The effects of treatments were observed on morphological and physiological parameters across jointing, anthesis and maturity stage. Root colonization and nanoparticle uptake trend by seeds and roots was also recorded. We observed strikingly high enhancement in biomass up to 109% under drought and 71% under well-watered conditions, and grain yield increased to 163% under drought and 60% under well-watered conditions. Iron nanoparticles at 10 mg L-1 when combined with Glomus intraradices resulted in maximum wheat growth and yield, which mechanically resulted from higher rhizosphere colonization level, water use efficiency and photosynthetic rate under drought stress (P < 0.01). Across growth stages, optical micrograph observations affirmed higher root infection rate when combined with nanoparticles. Transmission electron microscopy indicated the penetration of nanoparticles into the seeds and translocation across roots whereas energy dispersive X-ray analyses further confirmed the presence of Fe in these organs. Iron nanoparticles significantly enhanced the growth-promoting and drought-tolerant effects of Glomus intraradices on wheat.

Density- and moisture-dependent effects of arbuscular mycorrhizal fungus on drought acclimation in wheat.

Arbuscular mycorrhizal fungus (AMF) is widely viewed as an ecosystem engineer to help plants adapt to adverse environments. However, a majority of the previous studies regarding AMF's eco-physiological effects are mutually inconsistent. To clarify this fundamental issue, we conducted an experiment focused on wheat (Triticum aestivum L.) plants with or without AMF (Funneliformis mosseae) inoculation. Two water regimes (80% and 40% field water capacity, FWC80 (CK) and FWC40 (drought stress) and four planting densities (6 or 12 plants per pot as low densities, 24 or 48 plants per pot as high densities) were designed. AMF inoculation did not show significant effects on shoot biomass, grain yield, and water use efficiency (WUE) under the low densities, regardless of water regimes. However, under the high densities, AMF inoculation significantly decreased shoot biomass, grain yield and WUE in FWC80, while it significantly increased these parameters in FWC40, showing density and/or moisture-dependent effects of AMF on wheat performance. In FWC40, the relationships between reproductive biomass (y-axis) vs. vegetative biomass (x-axis) (R-V), and between grain biomass (y-axis, sink) vs. leaf biomass (x-axis, source) fell into a typical allometric pattern (α > 1, P < 0.001), and the AMF inoculation significantly increased the values of α. Yet in FWC80, they were in an isometric pattern (α ≈ 1, P < 0.001) and AMF addition had no significant effects on α. Similarly, AMF did not significantly change the isometric relationship between leaf biomass (i.e., metabolic rate) and shoot biomass (body size) in FWC80, while it significantly decreased the α of allometric relationship between both of them in FWC40 (α > 1, P < 0.001). We therefore, sketched a generalized model of R-V and sink-source relationships as affected by AMF, in which AMF inoculation might enhance the capabilities of sink acquisition and utilization under drought stress, while having no significant effect under the well watered conditions. Our findings demonstrate dual density- and moisture-dependent effects of AMF on plant development and provide new insights into current ecological applications of AMF as an ecosystem engineer.

Green route to synthesize Zinc Oxide Nanoparticles using leaf extracts of Cassia fistula and Melia azadarach and their antibacterial potential.

Development of plant based nanoparticles has many advantages over conventional physico-chemical methods and has various applications in medicine and biology. In present study, zinc oxide (ZnO) nanoparticles (NPs) were synthesized using leaf extracts of two medicinal plants Cassia fistula and Melia azadarach. 0.01 M zinc acetate dihydrate was used as a precursor in leaf extracts of respective plants for NPs synthesis. The structural and optical properties of NPs were investigated by X-ray diffraction (XRD), Fourier transform infrared (FTIR) spectroscopy, scanning electron microscope (SEM), ultraviolet-visible spectrophotometer (UV-Vis) and dynamic light scattering (DLS). The antibacterial potential of ZnO NPs was examined by paper disc diffusion method against two clinical strains of Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) based on the zone of inhibition and minimal inhibitory indices (MIC). Change in color of the reaction mixture from brown to white indicated the formation of ZnO NPs. UV peaks at 320 nm and 324 nm, and XRD pattern matching that of JCPDS card for ZnO confirmed the presence of pure ZnO NPs. FTIR further confirmed the presence of bioactive functional groups involved in the reduction of bulk zinc acetate to ZnO NPs. SEM analysis displayed the shape of NPs to be spherical whereas DLS showed their size range from 3 to 68 nm. The C. fistula and M. azadarach mediated ZnO NPs showed strong antimicrobial activity against clinical pathogens compared to standard drugs, suggesting that plant based synthesis of NPs can be an excellent strategy to develop versatile and eco-friendly biomedical products.