Group B Streptococcus Persistently Colonizing the Adenosquamous Carcinoma of the Lung: A Blessing in Disguise?

Group B Streptococcus (GBS), also known as Streptococcus agalactiae, is a gram-negative, beta-hemolytic facultative anaerobe that causes neonatal pneumonia and sepsis. The neoplastic epithelial cells in adults, especially those of squamous origin, can show special adhesive properties toward GBS, which tends to reside within these tumors. There are some animal and human studies proving this association. Here, we present a 64-year-old female patient who had lung carcinoma of mixed adeno and squamous origin found to have persistent GBS every time the bronchoscopy was done for tumor ablation or cryotherapy. Subsequently, after starting her on chemo-radiotherapy, she also presented with multiple episodes of pneumonia caused by GBS and Pseudomonas aeruginosa. Moreover, many animal studies have shown the anti-tumor properties of GBS toxin that can prevent its metastasis and stop vascular growth surrounding the tumor. This property of GBS toxin can prove a blessing in disguise.

A Rare Case of Colon Cancer in a Young Patient With HIV Infection: Is it Time for New Colon Cancer Screening Guidelines for HIV Patients?

Patients with human immunodeficiency virus (HIV) infection have a higher prevalence of colonic neoplasms than the general population. In these patients, tumors develop at an earlier age, are diagnosed at more advanced stages, and have a dismal prognosis. Current guidelines recommend initiating colon cancer screening in HIV patients at the age of 45 which is consistent with screening age in the general population. We present a rare case of colon cancer diagnosed in an HIV-infected patient at a young age of only 34 years. Therefore, we recommend early screening for colon cancer in HIV patients than the general population.

Misdiagnosed Progressive Multifocal Leukoencephalopathy (PML) in an HIV-Negative Patient With Discoid Lupus: A Case Report.

Progressive multifocal leukoencephalopathy (PML) is a rare fetal disease that has been uprising since the 1980s. Accurate diagnosis can be challenging and requires a thorough clinical suspicion, particularly among individuals who do not have HIV infection. Further diagnostics studies including cerebrospinal fluid analysis are required for DNA polymerase chain reaction (PCR) and if negative, more invasive tests like Brain biopsy are required. Herein, we describe a rare case of a 64-year-old female with a history of discoid lupus for 30 years who was not on any medications and presented to the hospital multiple times with different neurological deficits. The initial diagnosis consistently pointed toward a stroke until a critical turning point when a cerebrospinal fluid sample tested positive for John Cunningham (JC) virus DNA. Unfortunately, by the time the disease was identified, it had already progressed significantly, resulting in the unfortunate demise of the patient. To our knowledge, this represents the second reported case of PML in a patient with discoid lupus who lacks other commonly observed risk factors for the disease. This finding underscores the significance of maintaining clinical attentiveness within this specific patient population.

Wernicke Encephalopathy in a Patient With Bipolar Disorder: A Case Report.

Wernicke encephalopathy (WE) is a combination of neurological findings including confusion, ataxia, and ophthalmoplegia. It is most commonly associated with patients who have a history of alcohol abuse. This aspect leads to the majority of cases going undiagnosed in non-alcoholic patients who have other potential thiamine deficiency-causing conditions such as malignancy, chronic kidney disease (CKD) on hemodialysis, hyperemesis gravidarum, and psychiatric disorders leading to starvation and malnourishment. Here we present the case of a 59-year-old female patient with decompensated bipolar disorder who came in with altered mental status and multiple syncopal episodes. On examination, she was completely confused and had a fixed gaze. She was worked up for broad differential diagnoses including stroke, arrhythmias, seizures, drug intoxication, and infections. But due to her severely malnourished appearance, Wernicke's encephalopathy was suspected early on, and she was started on thiamine therapy, to which she responded well. It was also confirmed by an MRI of the brain showing flair in the bilateral medial thalamic region. Therefore, to suspect the presence of WE in non-alcoholic patients with psychiatric disorders and to differentiate behavioral symptoms from delirium and encephalopathy is difficult and requires a high degree of clinical suspicion.

Prosthetic Aortic Valve Obstruction With Pannus Formation, an Approach for Diagnosis and Management: A Case Report.

Mechanical valve obstructions are critical medical and surgical emergencies that require immediate attention when patients present with new complaints and exhibit signs such as the onset of murmurs or the disappearance of mechanical valve clicks. Obstructions can arise from various causes, including pannus formation, thrombus, vegetations, or subvalvular tissue growth. While pannus formations have been previously reported for the mitral valve, they are less commonly observed in the aortic valve, and several hypotheses have been proposed to understand pannus formation. Accurate diagnosis relies on imaging techniques such as echocardiography and fluoroscopy, and surgical intervention is considered the optimal treatment approach. Here, we present the case of a 69-year-old female who had previously undergone aortic valve replacement and subsequently developed progressive dyspnea, fatigue, and a new onset murmur. Imaging modalities revealed a closed leaflet and a high transvalvular gradient over the valve. The patient underwent a prosthetic redo valve replacement, and post-surgery, she was discharged home without complications.

Cefiderocol as a Treatment Option for Stenotrophomonas maltophilia Causing Hospital-Acquired/Ventilator-Associated Pneumonia.

Multidrug-resistant (MDR) gram-negative bacteria have been causing havoc for the healthcare system because of the rarity of the treatment options available. Stenotrophomonas maltophilia is a non-fermenting gram-negative bacterium that causes different infections, particularly respiratory tract infections. It displays resistance to many antibiotics (e.g., carbapenems, fluoroquinolones, and trimethoprim-sulfamethoxazole). Cefiderocol is a novel antibiotic which still in the preclinical stages of Food and Drug Administration (FDA) approval for S. maltophilia. We present the case of a 76-year-old male with end-stage renal disease (ESRD), intubated for acute hypoxemic respiratory failure due to volume overload and worsening oxygenation, who subsequently developed ventilator-associated pneumonia, found to be due to MDR Stenotrophomonas maltophilia. The patient ultimately showed clinical improvement with a 7-day course with a renally adjusted dose of cefiderocol. This shows that cefiderocol can prove to be a potential treatment option against serious infections caused by difficult-to-treat S. maltophilia.

Chronic Cocaine Abuse as a Cause of Sinus Bradycardia.

Cocaine abuse has an overwhelming effect on the healthcare system due to its multiple complications. Cardiovascular complications carry the highest burden. Common cardiovascular manifestations of cocaine are related to its adrenergic effects due to the inhibition of dopamine and norepinephrine uptake at the postsynaptic terminal. However, chronic abuse can lead to desensitization of adrenergic receptors, which can lead to bradycardia. Sinus bradycardia can be one of the markers of chronic cocaine abuse, as exemplified in this case report. Therefore clinicians should be aware of this association.

Littré's Hernia: A Rare Intraoperative Finding.

Littré's hernia (LH) is a rare clinical entity defined by the presence of Meckel's diverticulum (MD) within a hernial sac. Although MD is the most common congenital abnormality of the intestinal tract, most of its cases remain asymptomatic. It may, however, manifest itself in the form of multiple complications. One of its rare complications is LH, which is reported occurring in a mere 1% of all MD cases. The anamneses of LH are like any other hernia containing the gut, making its preoperative diagnosis unlikely. We present herein a case of a 16-year-old boy with an incarcerated LH at the inguinal region, which was successfully treated by wedge resection of the diverticulum followed by hernia repair.

A Case of Premature Triple Vessel Coronary Artery Disease and Valvular Degeneration: A Rare Presentation of Familial Hypercholesterolemia.

Familial hypercholesterolemia (FH) is one of the inherited causes of coronary artery disease (CAD) and causes calcific valvular degeneration in rare cases. A 13-year-old boy with multiple xanthomas presented with severe chest pain, shortness of breath, and sweating. He was diagnosed with premature CAD leading to non-ST-elevation myocardial infarction, secondary to early-onset FH [severely raised low-density lipoprotein (LDL) and triglycerides (TG) on lipid profile]. CT angiogram showed triple vessel disease, and echocardiogram revealed tight aortic stenosis. Percutaneous coronary angioplasty was done, and valvuloplasty was planned on the follow-up assessment. Early diagnosis and prompt management could have prevented these complications.

Prevalence of Acute Coronary Syndrome and Various Risk Factors in Acute Stroke Patients.

Background Stroke is the second leading cause of death worldwide after acute coronary syndrome (ACS). Both diseases share many risk factors such as hypertension, diabetes, dyslipidemia, and smoking. Patients who experience acute coronary syndrome are at heightened risk of recurrent ischemic events such as ischemic strokes, one of the most feared cardiovascular events because of the risk of long-term disability. We tried to estimate the prevalence of underlying ACS among patients with acute stroke. Methods This cross-sectional study was done at the CPE Institute of Cardiology, Pakistan, and Nishtar Medical University and Hospital, Pakistan. A total of 160 acute stroke cases were selected by consecutive sampling technique and questionnaire forms were filled. Detailed history, investigations, and physical examinations were done. The primary outcome was the prevalence of ACS and secondary outcomes were the prevalence of hypertension, smoking, dyslipidemia, diabetes mellitus, and previous history of stroke in stroke patients. Results Most of the patients that presented to us were above 50 years of age with the mean age of 62 years (SD = 9.23 years). Male predominance was seen with a total of 115 (72%) cases. Out of 160 patients, 91 (57%, p < 0.05) had underlying ACS, with 45 cases (49%) with unstable angina, 20 (22%) with non-ST-elevation myocardial infarction (NSTEMI), and 26 (29%) with ST-elevation myocardial infarction (STEMI). Prevalence of risk factors in 160 cases were, hypertension (101, 63%), lack of exercise (91, 57%), smoking (70, 44%), diabetes mellitus (61, 38%), dyslipidemia (50, 31%). All these results were statistically significant (p < 0.05). Prevalence of obesity (35, 22%) and previous stroke history (19, 12%) was statistically insignificant (p > 0.05). Conclusion Acute coronary syndrome is still frequently present in patients with acute stroke. The need of the hour is to manage ACS efficiently so that its deadly complications such as stroke can be prevented.

Review Analysis on Thymectomy vs Conservative Medical Management in Myasthenia Gravis.

Myasthenia gravis (MG) is an acquired, rare autoimmune disease that occurs due to autoantibodies blocking neuromuscular transmission. Its pathophysiology involves production of antibodies against the nicotinic acetylcholine receptors. Patients with negative anti-acetylcholine receptors (AChR) antibodies results are recognized as seronegative myasthenia gravis. In this review we tried to compare surgical and medical management of MG with each other to find out which is more effective. Different clinical trials and retrospective cohorts comparing these two parameters statistically were searched and studied. Remission rates in both medical and surgical management were compared. We found out that rates of remission were better in post thymectomy patients than patients on various medical treatment options including corticosteroids, immunosuppressants, intravenous immunoglobulins and acetylcholinesterase inhibitors alone. Hence thymectomy is studied to be the superior treatment option than other conservative medical management options alone.

Atypical Descending Paralysis in Miller Fisher Syndrome: A Rare Variant of Guillain-Barre Syndrome.

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome (GBS) which usually presents with descending paralysis. Common symptoms are ophthalmoplegia, ataxia, and areflexia. Our case presented with an atypical presentation. A 52-year old lady presented to the neurology outpatient department with frequent falls, blurring and doubling of vision and difficulty swallowing. These symptoms followed mild non-bloody diarrhea for two weeks ago. She had bilateral ptosis, lateral gaze palsy in both eyes, absent gag and cough reflex; she was unable to walk in a straight line and had right-hand grip weakness. Other motor and sensory examination were normal. She was admitted, kept under observation and investigated accordingly. Cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation. Nerve conduction studies showed slowed conduction in abducent, glossopharyngeal, vagus, and the right ulnar nerve. Blood analysis showed antiganglioside GQ1b antibodies; hence, the diagnosis of MFS, a variant of GBS, was made. Empirically plasmapheresis and then after confirmation intravenous immunoglobulins (IVIG) were used as treatment options. She recovered gradually within four weeks.

Role of Prophylactic Antibiotics in Critical Care of Stroke Patients - A Preventive Approach to Post-stroke Infections?

Post-stroke complications are very common worldwide and the most common complication is infection. This contributes the most to the mortality rate in stroke patients. Among the infections, pneumonia and urinary tract infections are most common. Hyperthermia following stroke is associated with neuronal damage and worse outcomes. Post-stroke immunosuppression and activation of inflammatory mediators also cause infections. Based on the high mortality caused by post-stroke infections, various trials were done to seek the advantage that prophylactic antibiotics can give in the critical care of stroke patients. Antibiotics, including ceftriaxone (cephalosporin), levofloxacin (fluoroquinolone), penicillin, and minocycline (tetracycline), were used and the stroke patients were followed up to analyze the primary and secondary outcomes. It was concluded that early antibiotic therapy (mostly within 24 hours) leads to a reduced rate of post-stroke infections and reduced fever spikes, whereas follow-up for a longer period of time showed no better functional outcome. Furthermore, mortality and morbidity benefits were also not seen with prophylactic antibiotic therapy. This review helped us to put a nail in the coffin to the earlier thoughts that prophylactic antibiotics are necessary for the critical care of stroke patients.

The Neuroprotective Effects of Exercise on Cognitive Decline: A Preventive Approach to Alzheimer Disease.

Alzheimer's disease (AD) is a progressive disorder that causes brain cells to slowly degenerate and die. This leads to a continuous decline in thinking, behavioral and social skills that disrupts a person's ability to function independently. AD is the most common cause of dementia globally. Neuroinflammation caused by intracellular neurofibrillary tangles and extracellular amyloid deposits leads to atrophy of brain cells especially the hippocampus, which is associated with memory formation. This atrophy leads to dementia and cognitive decline. Among the many preventive factors being studied, exercise is thought to play a vital role in not only preventing the pre-clinical stage of AD but also slowing the clinical progression of AD. It is also deployed as a treatment option for late-stage AD along with pharmacological treatment options. Various studies and clinical trials in both human and animal models are of the opinion that exercise slows the onset and progression of cognitive decline in AD patients. Some studies suggest that this effect is due to a decrease in neurofibrillary tangles and amyloid deposits in brain parenchyma. Others suggest that exercise causes an increase in angiogenesis, neurogenesis, and synaptogenesis mainly due to an increase in blood flow, brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), hormones, and second messengers.