Assessment of total aflatoxin and ochratoxin A in poultry feed ingredients by thin-layer chromatography and enzyme-linked immunosorbent assay.

Objective: This study was conducted to evaluate the prevalence of total aflatoxin (AF) and ochratoxin A (OTA) in poultry feed ingredients under different environmental conditions during the summer and winter seasons, while the hygiene quality of the feed ingredient was assessed through viable fungal count (VFC). Materials and Methods: A total of 288 poultry feed ingredients (n = 96 each) samples were collected from different poultry shops, which were initially analyzed for the presence of AF and OTA through thin layer chromatography (TLC) and then confirmed the contamination concentration through the enzyme-linked immunosorbent assay method. Results: The results of the current study confirmed the incidence of contamination with AF and OTA by TLC and ELISA methods. The contamination level of AF ranged from 26.09 to 50.56 (mean = 41.22 ± 9.45) µg/kg, whereas the contamination level of OTA ranged from 50.13 to 6.21 (mean 42.60 ± 6.21) µg/kg. The contamination level of AF was found to be above the permissible level set by the Food and Drug Administration (20 µg/kg), whereas the contamination level of OTA was below the permissible limits. Moreover, the VFC values were also below the recommended level. The results showed that the association between AF, OTA, and moisture content was significant (p < 0.05). Conclusion: Mycotoxin contamination was significantly (p < 0.05) highest in the winter season. These findings suggested that continuous monitoring regimes might prevent mycotoxin contamination in poultry feed ingredients.

Post-inflammatory Hyperpigmentation in an African American Female: An Atypical Presentation and Treatment Dilemma.

We present the case of a 32-year-old African American female with a known history of primary Sjogren's syndrome, multiple vitamin deficiencies, and prior facial cellulitis who presented with diffuse facial post-inflammatory hyperpigmentation following a motor vehicle accident. Following glucocorticoid treatment, only select hyperpigmented areas associated with inflammation, infection, or trauma improved, which thereby posed a clinical challenge to improve the patient's appearance and condition. Such results may warrant the consideration of adjunctive topical therapies to lighten the remaining areas of hyperpigmentation.

An Unusual Case of Haemophilus parainfluenzae Endocarditis in a Young Patient With Crohn's Disease.

We present a rare case of infective endocarditis (IE) associated with Haemophilus parainfluenzae in a 40-year-old male patient with a history of Crohn's Disease (CD). A complete workup, including an echocardiogram and blood cultures, revealed mitral valve vegetation colonized by H. parainfluenzae. The patient was started on appropriate antibiotics with follow-up for outpatient surgery. This case discusses the potential for ectopic colonization of heart valves by H. parainfluenzae in patients with CD. The presence of this organism as the offending agent in this patient's case of IE shines a light on the pathogenesis of CD. Although uncommon, CD-associated bacterial seeding should be a differential when assessing young patients with IE.

A Rare Presentation of Congenital Chilaiditi Syndrome: Symptomatic Hepatobowel Entrapment.

The displacement and trapping of the colon between the liver and the right hemidiaphragm are known as the Chilaiditi sign or syndrome. The Chilaiditi sign presents in an asymptomatic patient, while Chilaiditi syndrome presents with symptoms such as abdominal pain, distension, and constipation, in addition to complications such as perforation, volvulus, and bowel obstruction. It is often misdiagnosed as pneumoperitoneum or free air under the diaphragm and liver, often seen on the abdomen and chest radiography. It more commonly presents in males than in females. Here, we present the case of a 37-year-old female who reported abdominal pain and persistent constipation. An abdominal CT scan showed entrapment of a bowel segment, which is referred to as the Chilaiditi sign. The patient's presentation with hepatobowel entrapment and persistent gastrointestinal symptoms was diagnosed as Chilaiditi syndrome. This presentation entails a conservative management approach. The aim of this report is to educate about the rare occurrence of Chilaiditi sign and Chilaiditi syndrome as a differential diagnosis to often misdiagnosed critical conditions such as pneumoperitoneum and intestinal perforation. Correctly identifying these patients will reduce overtreatment and help improve outcomes.

Rare Occurrence of a Symptomatic Persistent Sciatic Artery Aneurysm.

Persistent sciatic artery (PSA) aneurysms are a rare cause of gluteal or lower extremity pain. The persistent sciatic artery is an uncommon congenital vasculature anomaly that presents with variable clinical presentation and is prone to cause an aneurysm, thrombosis, rupture, and possible amputation. Thus, early diagnosis is imperative to prevent further complications. We present the case of a 75-year-old female who was diagnosed with a persistent sciatic artery aneurysm after presenting with gluteal and lower extremity pain initially thought to be sciatica. Our patient underwent a successful hybrid open and endovascular approach with a femoral to below-knee popliteal artery bypass and the placement of coils at the proximal and distal ends of the aneurysmal segment.

Case Series of Quadricuspid Aortic Valve.

Three patients presented with different symptoms to the emergency department. Further imaging of their hearts displayed an abnormal variant of their aortic valve called a quadricuspid aortic valve (QAV). There are seven types of QAVs, from type A to G, with varying presenting symptoms. The most common complication is aortic regurgitation. The management of QAV is based on these presenting symptoms and complications. Surgical valve repair or replacement is indicated when a QAV becomes symptomatic or a QAV results in ventricular remodeling, which can lead to ventricular dysfunction. Successful surgical repair of QAVs has been shown with both tricuspidization and bicuspidization methods.

Recurrent Urinary Tract Infection in a Patient With Asymptomatic Crohn's Disease.

Recurrent urinary tract infection (UTI) is uncommon in males, but it is a common complication of Crohn's disease (CD). Patients with CD often present with abdominal pain, diarrhea, and systemic symptoms, such as weight loss, low-grade fever, and fatigue, and rarely it can cause serious complications, such as fistulas or abscesses. Some patients with CD remain asymptomatic, which can progress to severe complications and delayed treatment. We are presenting a 22-year-old male with recurrent UTIs and no established past medical history of CD. However, on subsequent investigations, an anatomical abnormality was discovered that helped us make the diagnosis of CD. The aim of this report is to emphasize the early detection of asymptomatic CD in atypical patients, to not only decrease the risk of complications such as UTIs but also allow for early treatment intervention and better outcomes.

Percutaneous Mitral Valve Repair versus Optimal Medical Therapy in Patients with Functional Mitral Regurgitation: A Systematic Review and Meta-Analysis.

OBJECTIVES: To compare percutaneous mitral valve repair (PMVR) with optimal medical therapy (OMT) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). BACKGROUND: Many patients with HF and FMR are not suitable for surgical valve replacement and remain symptomatic despite maximal OMT. PMVR has recently emerged as an alternative solution. METHODS: We performed a systematic review and a meta-analysis to address this question. Cochrane CENTRAL, MEDLINE, and Scopus were searched for randomized (RCT) and nonrandomized studies comparing PMVR with OMT in patients with HF and FMR. Primary endpoint was all-cause midterm mortality (at 1 and 2 years). Secondary endpoints were 30-day mortality and cardiovascular mortality and HF hospitalizations, at maximum follow-up. Studies including mixed cohort of degenerative and functional MR were allowed initially but were excluded in a secondary sensitivity analysis for each of the study's end points. This meta-analysis was performed following the publication of two RCTs (MITRA-FR and COAPT). RESULTS: Eight studies (six observational, two RCTs) comprising 3,009 patients were included in the meta-analysis. In comparison with OMT, PMVR significantly reduced 1-year mortality (RR: 0.70 [0.56, 0.87]; p=0.002; I2=47.6%), 2-year mortality (RR: 0.63 [0.55, 0.73]; p<0.001; I2=0%), and cardiovascular mortality (RR: 0.32 [0.23, 0.44]; p<0.001; I2=0%). No significant difference between PMVR+OMT and OMT was noted in HF hospitalization (HR: 0.69 [0.40, 1.20]; p=0.19; I2=85%) and 30-day mortality (RR: 1.13 [0.68, 1.87]; p=0.16; I2=0%). CONCLUSIONS: In comparison with OMT, PMVR significantly reduces 1-year mortality, 2-year mortality, and cardiovascular mortality in patients with HF and severe MR.

A Case of Persistent Asthma Resistant to Available Treatment Options: Management Dilemma.

Asthma affects nearly 300 million people worldwide, with 250,000 associated deaths annually. An estimated 5%-10% of patients have severe asthma, while only 1%-2% presented with treatment-resistant or refractory asthma. Currently, the endotype of asthma is divided into T-helper type 2 (Th2) high and Th2-low inflammation endotypes. The Th2-high endotype is characterized by eosinophilic asthma, while the Th2-low endotype is associated with neutrophilia and a pauci-granulocytic profile. The Th2-low endotype carries a high resistance to corticosteroid and bronchodilator therapy, and these patients typically have a severe and acute-onset of symptoms. We present a 57-year-old nonsmoking female with recurrent intensive care unit (ICU) admissions for severe acute asthma exacerbations, resistant to bronchodilator and steroid treatment, requiring mechanical ventilation. Currently, the guidelines for treating neutrophil-predominant Th2-low inflammation asthma have not been established. This creates a management dilemma when encountered with such a patient in clinical practice. We aim to propose targeted treatment options for these severe and potentially fatal asthma patients, with reference to current literature.

Management of Persistent Hyponatremia Induced by Long-acting Injectable Risperidone Therapy.

We present the case of a 55-year-old Caucasian male with a history of schizophrenia presenting with severe hyponatremia attributed to long-acting injectable risperidone treatment. Antipsychotic-induced hyponatremia is an uncommon but serious side effect that should be considered when assessing individuals on chronic psychiatric regimens. In this report, we will discuss our treatment plan for the patient when water deprivation and hypertonic saline failed to correct his serum sodium levels. The goal of this case report is to raise awareness of severe hyponatremia as a side effect of long-acting risperidone, and to encourage further studies to create guidelines for its management when current protocols fail to correct sodium levels.

Hyperpigmentation with Capecitabine: Part of Hand-Foot Syndrome or a Separate Entity?

Capecitabine has several side effects, most common of which is Hand-Foot syndrome (HFS); however, less frequently reported is capecitabine-associated hyperpigmentation. The hyperpigmentation associated with this drug has been documented to involve the hands and feet and, less commonly, the mucous membranes of the mouth. To our knowledge, it has never been documented to involve the face. We report a case of a patient with capecitabine-induced Hand-Foot Syndrome (HFS), who also presented with hyperpigmentation of the hands, feet, oral mucosa, and face.

Fibrillary Glomerulonephritis in a Patient with Sjogren's Syndrome.

Fibrillary glomerulonephritis (FGN) is an uncommon cause of primary glomerular disease. FGN is usually idiopathic; however, it has been associated with underlying malignancy or autoimmune diseases in some patients as well. The most commonly found autoimmune diseases in FGN patients include Graves' disease, systemic lupus nephritis, Chron's disease, and idiopathic thrombocytopenia purpura. FGN in a patient with underlying asymptomatic Sjogren's syndrome is very rare in the literature, with only two previously reported cases of this association. We present the case of a 75-year-old female with a past medical history of asymptomatic primary Sjogren's syndrome and fibromyalgia, who presented to emergency department with a new episode of hypertension. The electron microscopy (EM) showed randomly arranged nonamyloid fibrillar deposits in the mesangium and glomerular capillary walls, confirming FGN. In this case-based review, we describe in detail the diagnostic work-up, clinical course, and complications in management. We also discuss some of the other nonamyloid fibrillary glomerular diseases.

High-grade Non-small Cell Neuroendocrine Carcinoma of the Esophagus.

High-grade neuroendocrine carcinoma (NEC) of the esophagus is an extremely aggressive and rare disease, which is still not well understood. In this case report, we discuss a 73-year-old male patient that presented with the sole complaint of dysphagia to solid foods. During our evaluation of the patient, a six-centimeter esophageal mass was found on esophagogastroduodenoscopy (EGD). A diagnosis of poorly differentiated (high-grade) non-small cell neuroendocrine carcinoma was made after a histological analysis and immunostaining. We attempted to highlight the diagnosis, evaluation process, and treatment options related to this entity. Our review of the literature revealed that further research is needed, focusing on neuroendocrine carcinomas of the esophagus and how this entity differs from some of the more well-known neuroendocrine neoplasms in terms of management.

Mature Testicular Teratoma with a Focus of Embryonal Carcinoma: A Case Report and Review of Literature.

We present a 37-year-old male patient with a mature teratoma of the right testicle with a focus of embryonal carcinoma. This patient's tumor metastasized radically to the retroperitoneum, right adrenal gland, bilateral lungs, and liver. A metastatic teratoma with embryonal carcinoma in males is a very rare case. We will describe our patient's case, diagnostic workup, and management in detail, in addition to reviewing the related literature.

Celiac Disease and Concomitant Conditions: A Case-based Review.

Celiac disease is a chronic autoimmune disease with genetic predisposition, triggered by the ingestion of gluten. It has a wide range of clinical manifestations ranging from asymptomatic forms to classic presentation of malabsorption with diarrhea and abdominal cramps. Celiac disease can also present with several other concomitant disorders (at the time of diagnosis or during the course of celiac disease) such as: type 1 diabetes, inflammatory bowel disease, rheumatoid arthritis, thyroid disorders, nutritional deficiencies, and gram-negative sepsis. We present a 57-year-old female with past medical history of rheumatoid arthritis, who presented to the emergency department with a complaint of chronic diarrhea, complicated by gram-negative sepsis. The family history of the patient was significant for celiac disease, type 1 diabetes, and rheumatoid arthritis. The patient was closely monitored and treated appropriately. In this case-based review, we explore different associated conditions of celiac disease in the literature, as well as the patient's risk of developing malignancy.

Persistent Bradycardia with the Long-term Use of Phenytoin and Oxycodone: First Case Report.

Phenytoin is a medication that is used primarily in the treatment of epilepsy as well as generalized tonic-clonic seizures and status epilepticus. Phenytoin is also considered a class IB antiarrhythmic medication by shortening the duration of the action potential and increasing myocardial conduction. The neurologic adverse effects of phenytoin are well-documented and include altered mental status, ataxia, and nystagmus. Some adverse cardiac manifestations have also been reported, including arrhythmias, hypotension, and respiratory arrest. Oxycodone is an opioid that exerts its effects by binding to Mu opioid receptors located in the central nervous system. This selective binding results in the opening of potassium (k+) channels and the closing of calcium channels, decreasing synaptic transmission. Oxycodone, unlike phenytoin, has not been observed to elicit cardiotoxicity independent of other medications. However, in combination with other medications, bradycardia and hypotension have been observed. We report the case of a 62-year-old male who developed persistent bradycardia following treatment with phenytoin and oxycodone for seizure disorder and pain, respectively. To our knowledge, this is the first case report where bradycardia was induced by a combination of these medications.

Metformin-Induced Lactic Acidosis: A Case Study.

Metformin is the first line management for patients with Type 2 diabetes mellitus. Metformin-induced lactic acidosis (MALA) is a severe side effect of metformin in high doses. However, there have not been many reported cases of MALA. The threshold metformin concentration needed to induce lactic acidosis is still not fully understood. It is important for physicians to measure metformin levels upon admission in Type 2 diabetes patients who take metformin and present with suspected lactic acidosis. We present a case of a 40-year-old Caucasian male who presented with severe lactic acidosis shortly after overdosing on metformin.

Catheter-Related Candida Endocarditis on the Right Atrial Septum - A Case Report.

The use of subcutaneous catheter devices has increased over the past two decades along with its associated infections. One of the complications is infective endocarditis (IE), which usually occurs on the valves of the heart. However, IE can rarely occur on the atrial septal wall. The most common pathogens associated with catheter-related IE are staphylococcus bacteria, and it is rarely caused by fungi. We present a case of a 75-year-old Caucasian female with infective endocarditis located on the right side of the atrial septum, caused by Candida albicans due to the use of a subcutaneous catheter port. We will discuss the diagnostic criteria and treatment plan for this patient and other treatment options available for these cases. To our knowledge, a similar case was reported in Brazil, but this is the first reported case in the United States of catheter-related infective endocarditis of the right atrial septal wall due to Candida albicans.

Adult-onset Minimal Change Disease with IgA Nephropathy and Hepatitis C.

Minimal change disease (MCD) is one of the most common causes of nephrotic syndrome in children, leading to heavy proteinuria and edema. However, it is not as common in adults. Adult-onset minimal change disease with IgA nephropathy is rare. The initial presentation of heavy proteinuria and edema with effacement of podocytes on electron microscopy (EM) should lead the physician to suspect minimal change disease regardless of age. We present a 44-year-old male patient with a history of hepatitis C virus (HCV) who presented with sudden onset of lower extremity edema and 6.6 grams (g) of proteinuria per day.

Cutaneous, Intranasal Blastomycosis Infection in Two Patients from Southern West Virginia: Diagnostic Dilemma.

Blastomycosis is a dimorphic fungus caused by the species of Blastomyces dermatitidisand Blastomyces gilchristii, which are endemic to the Ohio River and Mississippi River Valleys. It is commonly found in soil or decomposing wood. It is capable of infecting both immunocompromised and immunocompetent patients via the respiratory tract by inhaling conidia, where it may remain asymptomatic for a prolonged period of time. Extrapulmonary complications can occur in disseminated disease due to haematogenous spread from the lungs to other organ systems. Haematogenous dissemination from the lungs occurs most commonly to the skin. Although rare, primary cutaneous blastomycosis can also occur with direct inoculation through the trauma of the skin. Patients presenting with cutaneous blastomycosis are often misdiagnosed with malignant neoplasms and may not be appropriately managed until further testing and tissue biopsy. Currently, there are only four previous case reports of blastomycosis presenting in the intranasal region. We report two cases of cutaneous blastomycosis of the nasal passages and upper lip with pulmonary manifestations in Southern West Virginia. These patients first presented with cutaneous symptoms, which were originally treated for melanoma and squamous cell carcinoma and were later diagnosed with systemic blastomycosis.