A Case of Cholecystitis Camouflaging Cholangiocarcinoma.

Cholangiocarcinoma is a malignancy that is hard to detect and resect, due mostly to its location as well as a lack of current screening tests. When found, it is often in the advanced stage as patients are usually asymptomatic during the early course of the disease; the overall prognosis is modest in patients diagnosed at this stage. Here, we discuss the case of a 48-year-old female with no significant past medical history or family history who presented to our hospital with symptoms of acute cholecystitis with a supporting ultrasound. She proceeded to get a laparoscopic cholecystectomy for the same, but an ensuing workup and pathology revealed advanced-stage cholangiocarcinoma. The patient ultimately opted for palliative care given her poor prognosis.

Coronary Artery Bypass Grafting in a Patient With Severe Factor VII Deficiency.

Factor VII deficiency is a rare bleeding disorder. Clinical presentation is highly variable and can range from mild symptoms like mucosal bleeding to life-threatening hemorrhages in early infancy. Some people remain asymptomatic and are only diagnosed incidentally on laboratory tests. Given the low incidence in the population and variable phenotypes, there are no official guidelines on the management of such patients perioperatively to minimize bleeding risk. We present a case of a man with inherited severe factor VII deficiency who underwent successful coronary artery bypass grafting.

Intensified-Dose Chemotherapy in Combination With Gemtuzumab-Ozogamicin for the Treatment of Favorable-Risk Acute Myeloid Leukemia (AML).

Chemotherapy has been the standard of treatment for acute myeloid leukemia (AML). With the emergence of new therapies for AML like gemtuzumab-ozogamicin and FLT3 inhibitors, such as sorafenib, midostaurin, and gilteritinib, the optimal dose of chemotherapy and safety profile in different age groups when combined with these new therapies is yet to be established. There are limited data on the treatment of AML by combining intensified daunorubicin (doses of 90 mg/m2) with gemtuzumab-ozogamicin (GO). We report a young adult with favorable-risk AML treated with daunorubicin at a dose of 90 mg/m2 combined with GO, who had a complete response after induction but had a profound nadir of platelet count after induction and consolidation.

Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views.

Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.

Diagnosis of Stroke on Neuroimaging of COVID-19 Patients in Coma: A Case Series.

Patients with severe coronavirus disease 2019 (COVID-19) disease suffer from many thrombotic complications including deep vein thrombosis, pulmonary embolism, myocardial infarction (MI), and stroke. Large vessel strokes have been reported in young patients with COVID-19 disease. We report four cases of stroke diagnosed based on CT scan in critically ill individuals treated in the medical intensive care unit in a health facility in New York. All patients were receiving supportive treatment and mechanical ventilation at the time of diagnosis. All patients had impaired consciousness and were unable to wake up after sedation had worn off, prompting further workup. The pathogenesis of stroke could be secondary to the embolic phenomenon vs. hypercoagulopathy in our patients. Stroke should be considered in all COVID-19 patients who present with altered mental status. Severe COVID-19 patients with risk factors of stroke may benefit from therapeutic anticoagulation.

Clostridium Difficile and COVID-19: Novel Risk Factors for Acute Portal Vein Thrombosis.

The COVID-19 pandemic has created an unprecedented global health care crisis. COVID-19 patients are found to have increased thrombotic risk. Despite being on prophylactic anticoagulation, many develop serious arterial and venous thromboembolic events. Emerging reports indicate COVID-19 may be considered a novel risk factor for portal vein thrombosis. Although, intra-abdominal infections are identified as risk factors, clostridium difficile colitis has not been typically seen as a risk factor for PVT. We report a case of an elderly female with a recent diagnosis of COVID-19 and no prior history of cirrhosis or malignancy who presented with diarrhea due to clostridium difficile infection. She developed sudden onset severe abdominal pain during the course of hospitalization. Acute portal vein thrombosis was identified on CT imaging of the abdomen, and she improved well with therapeutic anticoagulation. Acute portal vein thrombosis usually results from a combination of local and systemic prothrombotic risk factors. The combination of local infection by clostridium difficile and COVID-19 coagulopathy led to development of portal vein thrombosis in our patient. To the best of our knowledge, this is the first case of portal vein thrombosis reported in a patient with clostridium difficile infection in the setting of COVID-19 coagulopathy. During the current pandemic, clinicians should strongly consider abdominal imaging in patients presenting with abdominal pain due to clostridium difficile infection in the setting of COVID-19 to rule out complications such as portal vein thrombosis. Early diagnosis and treatment of portal vein thrombosis prevent complications of portal hypertension and intestinal infarctions.

Venous Thromboembolism in Hospitalized COVID-19 Patients.

BACKGROUND: Venous thromboembolism (VTE) is increasingly reported in seriously ill patients with COVID-19 infection. Incidence of VTE has been reported before and results varied widely in study cohorts. AREA OF UNCERTAINTY: Incidence of major VTE (segmental pulmonary embolism and above and proximal deep vein thrombosis) which is a contributor to mortality and morbidity is not known. Also, data is unclear on the optimal anticoagulation regimen to prevent VTE. DATA SOURCES: Multiple databases including PubMed were searched until May 12, 2020, to include studies reporting VTE in hospitalized COVID-19 adult patients. MOOSE guidelines were followed in selection, and 11 studies were included. We conducted a systematic review and meta-analysis to quantitatively assess the VTE burden in hospitalized COVID-19 patients and potential benefits of therapeutic dosing of anticoagulation compared with prophylaxis dosing for VTE prevention. THERAPEUTIC ADVANCES: Many societies and experts recommend routine prophylactic anticoagulation with heparin for VTE prevention in hospitalized COVID-19 patients. In this meta-analysis, the pooled rate of major VTE was 12.5% in hospitalized patients and 17.2% in intensive care unit patients. When therapeutic anticoagulation dosing was compared with prophylactic anticoagulation, the pooled odds ratio of VTE was 0.33 (95% confidence interval 0.14-0.75; P = 0.008, I = 0%) suggesting statistical significance with therapeutic dosing of anticoagulation for primary prevention of VTE in all hospitalized patients. However, this should be interpreted with caution as the bleeding events and safety profile could not be ascertained because of lack of adequate information. We recommend applying this finding to hospitalized COVID 19 patients only after carefully weighing individual bleeding risks and benefits. CONCLUSION: Major VTE events, especially pulmonary embolism, seem to be high in COVID-19 patients admitted to the intensive care unit. Therapeutic anticoagulation dosing seems to significantly benefit the odds of preventing any VTE when compared with prophylactic dosing in all hospitalized patients.

SARS-CoV2 in Different Body Fluids, Risks of Transmission, and Preventing COVID-19: A Comprehensive Evidence-Based Review.

The world is combating a common and invisible enemy severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), a highly transmissible virus responsible for serious respiratory illness coronavirus disease-2019 (COVID-19). As with all respiratory viruses, public health measures are focused on contact tracing, isolation, and treatment of affected individuals, who have respiratory symptoms. However, it is spreading efficiently, and it can be explained from its stealth transmission from presymptomatic and asymptomatic individuals. Droplet and contact precautions are followed universally. Healthcare workers are at higher risk of acquiring infection and they are additionally required to follow airborne and eye protection. Recent studies indicate viral particles can be isolated from many body fluids including feces, saliva, semen, and tears, suggesting transmission could be possibly occurring through some of these routes as well. We have done an evidence-based review of all potential modes of transmission and discussed preventive measures to stop the spread. There is an urgent need for educating the healthcare professionals, governments, and public regarding other potential modes of transmission. Strict preventive measures need to be used to stop the spread.

COVID-19 and Avoiding Ibuprofen. How Good Is the Evidence?

Ibuprofen is an over-the-counter medication that is used widely for the treatment of pain and fever during COVID-19 pandemic. A concern was raised regarding the safety of ibuprofen use because of its role in increasing ACE2 levels within the Renin-Angiotensin-Aldosterone system. ACE2 is the coreceptor for the entry of SARS-CoV-2 into cells, and so, a potential increased risk of contracting COVID-19 disease and/or worsening of COVID-19 infection was feared with ibuprofen use. However, available data from limited studies show administration of recombinant ACE2 improves lung damage caused by respiratory viruses, suggesting ibuprofen use may be beneficial in COVID-19 disease. At this time, there is no supporting evidence to discourage the use of ibuprofen.

Secondary Aortoduodenal Fistula Presenting as Gastrointestinal Bleeding and Fungemia.

A 55-year-old African American man with a history of abdominal aortic pseudoaneurysm repair presented to the ED with complaints of black-colored stools mixed with fresh blood and fever for three days duration. The exam was unremarkable except for abdominal bruits and pallor. CT angiogram showed perigraft fluid collection, bowel wall thickening, and loss of normal fat planes between the aorta and adjacent bowel at the level of the third portion of the duodenum. Polymicrobial infection was noted in the aortic graft and blood cultures grew Candida. The patient underwent urgent removal of the infected graft, duodenal repair along with appropriate antimicrobial therapy. He did well postoperatively and was discharged in a stable condition. Our case highlights the importance of maintaining a high index of suspicion of aortoenteric fistula (AEF) when a patient with a prior abdominal aortic graft develops gastrointestinal (GI) bleeding as this condition is universally fatal if unrecognized.