Perturbation-based dual task assessment in older adults with mild cognitive impairment.

Background: Dual tasking (i.e., concurrent performance of motor and cognitive task) is significantly impaired in older adults with mild cognitive impairment (OAwMCI) compared to cognitively intact older adults (CIOA) and has been associated with increased fall risk. Dual task studies have primarily examined volitionally driven events, and the effects of mild cognitive impairment on reactive balance control (i.e., the ability to recover from unexpected balance threats) are unexplored. We examined the effect of cognitive tasks on reactive balance control in OAwMCI compared to CIOA. Methods: Adults >55 years were included and completed the Montreal Cognitive Assessment (MoCA) to categorize them as OAwMCI (MoCA: 18-24, n = 15) or CIOA (MoCA: ≥25, n = 15). Both OAwMCI [MoCA: 22.4 (2.2), 65.4 (6.1) years, 3 females] and CIOA [MoCA: 28.4 (1.3), 68.2 (5.5) years, 10 females] responded to large magnitude stance slip-like perturbations alone (single task) and while performing perceptual cognitive tasks targeting the visuomotor domain (target and tracking game). In these tasks, participants rotated their head horizontally to control a motion mouse and catch a falling target (target game) or track a moving object (track). Margin of stability (MOS) and fall outcome (harness load cell >30% body weight) were used to quantify reactive balance control. Cognitive performance was determined using performance error (target) and sum of errors (tracking). A 3 × 2 repeated measures ANOVA examined the effect of group and task on MOS, and generalized estimating equations (GEE) model was used to determine changes in fall outcome between groups and tasks. 2 × 2 repeated measures ANOVAs examined the effect of group and task on cognitive performance. Results: Compared to CIOA, OAwMCI exhibited significantly deteriorated MOS and greater number of falls during both single task and dual task (p < 0.05), and lower dual task tracking performance (p < 0.01). Compared to single task, both OAwMCI and CIOA exhibited significantly deteriorated perceptual cognitive performance during dual task (p < 0.05); however, no change in MOS or fall outcome between single task and dual task was observed. Conclusion: Cognitive impairment may diminish the ability to compensate and provide attentional resources demanded by sensory systems to integrate perturbation specific information, resulting in deteriorated ability to recover balance control among OAwMCI.

Motor adaptation and immediate retention to overground gait-slip perturbation training in people with chronic stroke: an experimental trial with a comparison group.

Background: Perturbation-based training has shown to be effective in reducing fall-risk in people with chronic stroke (PwCS). However, most evidence comes from treadmill-based stance studies, with a lack of research focusing on training overground perturbed walking and exploring the relative contributions of the paretic and non-paretic limbs. This study thus examined whether PwCS could acquire motor adaptation and demonstrate immediate retention of fall-resisting skills following bilateral overground gait-slip perturbation training. Methods: 65 PwCS were randomly assigned to either (i) a training group, that received blocks of eight non-paretic (NP-S1 to NP-S8) and paretic (P-S1 to P-S8) overground slips during walking followed by a mixed block (seven non-paretic and paretic slips each interspersed with unperturbed walking trials) (NP-S9/P-S9 to NP-S15/P-S15) or (ii) a control group, that received a single non-paretic and paretic slip in random order. The assessor and training personnel were not blinded. Immediate retention was tested for the training group after a 30-minute rest break. Primary outcomes included laboratory-induced slip outcomes (falls and balance loss) and center of mass (CoM) state stability. Secondary outcomes to understand kinematic contributors to stability included recovery strategies, limb kinematics, slipping kinematics, and recovery stride length. Results: PwCS within the training group showed reduced falls (p < 0.01) and improved post-slip stability (p < 0.01) from the first trial to the last trial of both paretic and non-paretic slip blocks (S1 vs. S8). During the mixed block training, there was no further improvement in stability and slipping kinematics (S9 vs. S15) (p > 0.01). On comparing the first and last training trial (S1 vs. S15), post-slip stability improved on both non-paretic and paretic slips, however, pre-slip stability improved only on the non-paretic slip (p < 0.01). On the retention trials, the training group had fewer falls and greater post-slip stability than the control group on both non-paretic and paretic slips (p < 0.01). Post-slip stability on the paretic slip was lower than that on the non-paretic slip for both groups on retention trials (p < 0.01). Conclusion: PwCS can reduce laboratory-induced slip falls and backward balance loss outcomes by adapting their post-slip CoM state stability after bilateral overground gait-slip perturbation training. Such reactive adaptations were better acquired and retained post-training in PwCS especially on the non-paretic slips than paretic slips, suggesting a need for higher dosage for paretic slips. Clinical registry number: NCT03205527.

The Effect of Cognitive Task, Gait Speed, and Age on Cognitive-Motor Interference during Walking.

Dual-tasking can cause cognitive-motor interference (CMI) and affect task performance. This study investigated the effects of age, gait speed, and type of cognitive task on CMI during gait. Ten younger and 10 older adults walked on a pressure-sensitive GAITRite walkway which recorded gait speed and step length. Participants walked at a slow, preferred, or fast speed while simultaneously completing four cognitive tasks: visuomotor reaction time (VMRT), serial subtraction (SS), word list generation (WLG), and visual Stroop (VS). Each combination of task and speed was repeated for two trials. Tasks were also performed while standing. Motor and cognitive costs were calculated with the formula: ((single-dual)/single × 100). Higher costs indicate a larger reduction in performance from single to dual-task. Motor costs were higher for WLG and SS than VMRT and VS and higher in older adults (p < 0.05). Cognitive costs were higher for SS than WLG (p = 0.001). At faster speeds, dual-task costs increased for WLG and SS, although decreased for VMRT. CMI was highest for working memory, language, and problem-solving tasks, which was reduced by slow walking. Aging increased CMI, although both ages were affected similarly by task and speed. Dual-task assessments could include challenging CMI conditions to improve the prediction of motor and cognitive status.

Cognitive Task Domain Influences Cognitive-Motor Interference during Large-Magnitude Treadmill Stance Perturbations.

Reactive balance is postulated to be attentionally demanding, although it has been underexamined in dual-tasking (DT) conditions. Further, DT studies have mainly included only one cognitive task, leaving it unknown how different cognitive domains contribute to reactive balance. This study examined how DT affected reactive responses to large-magnitude perturbations and compared cognitive-motor interference (CMI) between cognitive tasks. A total of 20 young adults aged 18-35 (40% female; 25.6 ± 3.8 y) were exposed to treadmill support surface perturbations alone (single-task (ST)) and while completing four cognitive tasks: Target, Track, Auditory Clock Test (ACT), Letter Number Sequencing (LNS). Three perturbations were delivered over 30 s in each trial. Cognitive tasks were also performed while seated and standing (ST). Compared to ST, post-perturbation MOS was lower when performing Track, and cognitive performance was reduced on the Target task during DT (p < 0.05). There was a larger decline in overall (cognitive + motor) performance from ST for both of the visuomotor tasks compared to the ACT and LNS (p < 0.05). The highest CMI was observed for visuomotor tasks; real-life visuomotor tasks could increase fall risk during daily living, especially for individuals with difficulty attending to more than one task.

Cerebello-cortical functional connectivity may regulate reactive balance control in older adults with mild cognitive impairment.

Background: Older adults with mild cognitive impairment (OAwMCI) experience a two-fold increased risk of falling compared to their cognitively intact counterparts. This increased risk could be attributed to impairments in balance control mechanisms (both volitional and reactive), however, the exact neural substrates contributing to the balance impairments remain unclear. While changes in functional connectivity (FC) networks in volitional balance control tasks have been well highlighted, the relationship between these changes and reactive balance control has not been examined. Therefore, this study aims to explore the relationship between FC networks of the brain obtained during resting state fMRI (no visualization or active task performed) and behavioral measures on a reactive balance task in OAwMCI. Methods: Eleven OAwMCI (< 25/30 on MoCA, > 55 years) underwent fMRI and were exposed to slip-like perturbations on the Activestep treadmill. Postural stability, i.e., dynamic center of mass motion state (i.e., its position and velocity) was computed to determine reactive balance control performance. The relationship between reactive stability and FC networks was explored using the CONN software. Results: OAwMCI with greater FC in default mode network-cerebellum (r2 = 0.43, p < 0.05), and sensorimotor-cerebellum (r2 = 0.41, p < 0.05) network exhibited lower reactive stability. Further, people with lower FC in middle frontal gyrus-cerebellum (r2 = 0.37, p < 0.05), frontoparietal-cerebellum (r2 = 0.79, p < 0.05) and cerebellar network-brainstem (r2 = 0.49, p < 0.05) exhibited lower reactive stability. Conclusion: Older adults with mild cognitive impairment demonstrate significant associations between reactive balance control and cortico-subcortical regions involved in cognitive-motor control. Results indicate that the cerebellum and its communications with higher cortical centers could be potential substrates contributing to impaired reactive responses in OAwMCI.

Atypical Hemolytic Uremic Syndrome in a Pregnant Patient with a Thrombomodulin Gene Variant Treated with Plasma Exchange and Eculizumab.

BACKGROUND Hemolytic uremic syndrome (HUS) includes the triad of thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. The atypical form of HUS is a rare disease characterized by complement overactivation, and it can be from genetic or acquired causes. Genetic causes involve mutation in one of the factors in the alternative complement pathway or inhibitors. Malignant hypertension and pregnancy are the most important acquired causes. The optimal management of patients with aHUS is with eculizumab, which is recombinant antibody against human complement component C5. CASE REPORT This report describes the case of a 25-year-old woman with frequent hospitalizations for poorly controlled hypertension who presented at 20 weeks of gestation with headache, vomiting, and a blood pressure of 230/126 mmHg. The patient had acute kidney injury with hematuria and proteinuria, and kidney biopsy showed hypertensive arteriolar nephrosclerosis and fibrinoid arteriolar necrosis consistent with thrombotic microangiopathy. Further work-up with a genetic panel showed heterozygosity for the thrombomodulin (THBD) gene. She was started on treatment with plasma exchange and eculizumab, a recombinant monoclonal antibody that inhibits terminal complement activation at the C5 protein. The patient responded well to the treatment at the time of her initial outpatient follow-up. CONCLUSIONS This case shows the potential of severe renal manifestation of aHUS, and the need for a kidney biopsy in cases of severe uncontrolled hypertension presenting with kidney injury. If evidence of aHUS is found, prompt treatment with plasma exchange and eculizumab should be initiated.

Atrial fibrillation gut syndrome: severe gastroparesis with pyloric spasm following radiofrequency catheter ablation of drug resistant symptomatic atrial fibrillation: a case report.

BACKGROUND: Atrial fibrillation is the most common cardiac arrhythmia, and cardiac ablation is one of the treatment modalities for persistent symptomatic atrial fibrillation. Gastroparesis is a rare complication of radiofrequency catheter ablation for atrial fibrillation, which may be associated with high morbidity. CASE PRESENTATION: We present a 44-year-old Caucasian male with persistent atrial fibrillation who presented with nausea, vomiting, bloating, and constipation after radiofrequency catheter ablation. He was found to have gastroparesis due to pyloric spasm that was treated with botulinum toxin injection. CONCLUSION: This case signifies the importance of identifying gastric complications after radiofrequency catheter ablation atrial fibrillation, and the need for prompt diagnosis and treatment of gastroparesis with botulinum toxin injection.

A Case Series of Uncommon Sodium Disorders in Common Clinical Scenarios.

Dysnatremias or sodium disorders (either hyponatremia or hypernatremia) are the most common electrolyte problems in clinical medicine. They pose diagnostic and therapeutic challenges and have high mortality. Even mild changes in sodium levels from normal are associated with worse outcomes and considerable morbidity and mortality. We present a series of four patients with either hypo- or hypernatremia in different clinical scenarios requiring immediate treatment with close monitoring to avoid overcorrection. This case series shows that uncommon or unusual sodium disorders can happen in an otherwise usual situation.

Purple urine in a patient with UTI and constipation.

Purple urine bag syndrome (PUBS) is a visually striking and a rare side effect in a patient with urinary tract infection where urine in the catheter bags and tubing turn purple. The urine in PUBS gets its color from the combination of two pigments, indirubin and indigo, which are breakdown products of tryptophan. The most important risk factors include long-term catheterization, female gender, chronic constipation, old age and being bed bound. Here, we present a case of PUBS in an elderly female with a history of bladder cancer that needed catheterization along with constipation.

Adverse Events Related to Tirzepatide.

Context: Tirzepatide is a dual glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) approved by the US Food and Drug Administration in May 2022 for patients with type 2 diabetes mellitus (T2DM). Objective: We aimed to determine the rates of individual adverse events (AEs) related to 3 studied doses of tirzepatide. Methods: We performed a systematic review with meta-analysis including 5 databases (PubMed, Embase, CINAHL, Scopus, and Web of Science) for all clinical trials reporting AEs related to tirzepatide. The safety data from individual studies were extracted and analyzed through meta-regression to assess rates of individual AEs. Study quality assessment was performed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Ten trials (6836 participants) were included. Gastrointestinal (GI) AEs were the most commonly reported AEs and were dose dependent 39% (95% CI, 35%-43%), 46% (95% CI, 42%-49%), and 49% (95% CI, 38%-60%) for the 5, 10, and 15 mg dose, respectively. Among all GI AEs, nausea and diarrhea were most frequent at any dose of tirzepatide. Drug discontinuation due to AEs was highest with the 15 mg dose of tirzepatide (10%). Incidence of mild hypoglycemia (blood glucose < 70 mg/dL) was highest with tirzepatide 10 mg dose 22.6% (9.2%-39.8%). Rates of fatal AEs, severe hypoglycemia, acute pancreatitis, cholelithiasis, and cholecystitis were extremely low (≤ 1%) across all doses of tirzepatide. Conclusion: Tirzepatide is associated with a dose-dependent increase in incidence of GI AEs and AEs leading to drug discontinuation. Severe hypoglycemia, fatal AEs, acute pancreatitis, cholelithiasis, and cholecystitis are rare with this medication.

Overlapping Syndromes: Drug-Induced Vasculitis From Hydralazine With Positive Antinuclear Antibodies.

Hydralazine is an antihypertensive medication that has been associated with drug-associated autoimmune syndromes like interstitial lung disease, pauci-immune glomerulonephritis, and hypocomplementemia. Hydralazine-induced ANCA-associated vasculitis and hydralazine induced positive antinuclear antibodies are rare. Clinical manifestations range from arthralgia, petechiae, or rash to multiorgan involvement. When presented as pulmonary-renal syndrome, it can be rapidly progressive and fatal. Here, we describe a case of hydralazine-associated vasculitis with rapidly progressive glomerulonephritis and highlight the importance of early diagnosis and prompt treatment.

Renal manifestations of recreational drugs: A narrative review of the literature.

Drug abuse has become a major problem of the modern world where drug-induced kidney injury can be caused by both prescribed drugs for clinical conditions and illegal (illicit) drugs or drugs of abuse. Heroin, cocaine, nicotine and alcohol are the most commonly abused drugs but with the emergence of various synthetic drugs, numerous novel descriptions of their nephrotoxic effects have been described. This review summarizes the key renal manifestations of recreational drugs as reported in case reports and case. A comprehensive review of published case reports and case series in English language of renal toxicity related to recreational drugs/drugs of abuse was conducted using search engines like PubMed/Medline. Publications which reported renal injury with raised creatinine levels, clinically symptomatic patients, those with oliguria and with renal biopsies are chosen. The medical literature on recreational drugs is full of claims of renal complications including different glomerular diseases, acute kidney injury, rhabdomyolysis, interstitial nephritis, and debilitating irreversible conditions like renal infarction and end stage renal disease, even though the pathogenesis of drug- related renal manifestations are not available for all the newer agents. The outcome of this review paper will help multidisciplinary physicians to understand the renal side effects of recreational drugs, their pathophysiology, and most importantly, the clinical presentations of renal dysfunction in relation each drug. Emphasizing these adverse effects will prevent future unfavorable outcomes.

A Unique Case of Membranous Lupus Nephritis Identified After Pronase Digestion.

Membranous nephropathy (MN) is a common etiology of nephrotic syndrome (NS) in Caucasian adults. With treatment strategies heavily dependent on differentiating between primary versus secondary MN, tissue diagnosis remains paramount in the setting of indeterminant serological studies and remains the gold standard. Direct immunofluorescence on frozen sections remains standard practice, though with inadequate kidney tissue, antigen retrieval with proteases on formalin-fixed paraffin-embedded tissue can be a viable alternative for direct immunofluorescence. We report a patient who presented with nephrotic syndrome, indeterminant serological workup including primary antigen phospholipase-2 receptor antibody (PLA2R). Histology revealed a membranous pattern of injury with a negative standard panel of immunocomplex deposits on direct immunofluorescence. Upon re-examination of paraffin-embedded tissue via protease processing, Immunofluorescence unmasked membranous lupus nephritis. This case highlights the possibility of negative direct immunofluorescence on viable frozen tissue which is unmasked after protease treatment on formalin-fixed paraffin-embedded tissue sample revealing immunocomplex deposits.

Case report: Uridine triacetate in the management of delayed onset 5-fluorouracil toxicity: A case report and review of literature.

5-fluorouracil (5FU) and capecitabine are fluoropyrimidine anti-neoplastic drugs commonly used in the treatment of different types of cancer. Hereditary dihydropyrimdine deaminase (DPD), thymidylate synthase mutations and drug overdose may lead to life-threatening toxicities. Uridine triacetate (UTA) is an emergency treatment for overdoses and early onset, severe or life-threatening toxicities from fluoropyrimidines. It is approved for use in adults and children within 96 h of last fluoropyrimidine administration. We present the case of a 64-year-old male treated with 5-FU and oxaliplatin as adjuvant systemic therapy for stage IIIA rectal cancer who developed delayed central nervous system toxicity 18 days after initiating chemotherapy. He had rapidly worsening encephalopathy and ataxia. Laboratory workups, MRI brain and EEG were negative. He was started on UTA with concerns of 5-FU toxicity due to the life-threatening nature of his condition even beyond the recommended 96-h time cut-off. He had rapid improvement in clinical status and resolution of encephalopathy. DPD deficiency testing later resulted as heterozygous for IVS14+1G>A allele indicating enzyme deficiency. This report demonstrates the importance of identifying delayed side effects with fluoropyrimidine therapy and potential treatment for reversing these effects. We also did an extensive literature review and obtained reports from the uridine triacetate clinical trials on patients receiving UTA after the 96-h cut-off. Based on our experience and previous published reports, a patient developing life-threatening delayed 5-FU toxicity should also be considered for UTA on a case-by-case basis.

Case report: SARS-CoV-2 infection as a trigger for diabetic ketoacidosis and newly detected pancreatic autoantibodies.

A 39-year-old-woman with a past medical history of type 2 diabetes mellitus (T2DM) on oral hypoglycemic agents presented to the emergency room with nausea, vomiting, shortness of breath, and altered mental status. Seven days prior to presentation, she was diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Laboratory workup on presentation confirmed the diagnosis of diabetic ketoacidosis (DKA) (blood glucose 523 mg/dl, beta-hydroxybutyrate 8.91 mmol/l, pH 6.9, bicarbonate 11 mEq/l, anion gap 25 mEq/l, and HbA1c 10.8%). She was managed for DKA with hydration and insulin drip and discharged home. However, to our surprise, at the 2-week follow-up visit, she was found to have positive antibodies for zinc transporter 8 (ZnT8) (samples were collected on day of presentation). The rest of her antibodies associated with T1DM were negative. She was therefore started on a basal-bolus regimen and managed as type 1 diabetes mellitus (T1DM). Our case illustrates that there is an increased risk of T1DM following infection with SARS-CoV-2.

Acute Spinal Cord Ischemia Associated With Cocaine Use: A Case Report.

Cocaine is one of the most common causes of acute drug-related emergency department visits in the United States. It produces a dose-dependent increase in heart rate and blood pressure accompanied by increased arousal and a sense of self-confidence, euphoria, and well-being. Its use is typically followed by a craving for more of the drug. It can also lead to acute events such as myocardial infarction, seizures, and cerebrovascular events. Here, we present a case of cocaine-induced spinal cord ischemia resulting in quadriplegia. Our case highlights that, in a young patient presenting with acute non-traumatic myelopathy, it is important to consider cocaine use among other differentials.

Sodium-glucose cotransporter 2 inhibitor-associated severe epididymo-orchitis.

A man in his late 50s, with uncontrolled type 2 diabetes mellitus (T2DM) and morbid obesity, presented to the hospital with complicated epididymo-orchitis. The onset of symptoms (scrotal pain, erythema and swelling) occurred after the use of empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, for 2 months. His baseline antidiabetic medications were insulin, glipizide and metformin. Initially, he had failed treatment of epididymo-orchitis with oral levofloxacin for 3 weeks, followed by 2 weeks of doxycycline therapy. At the presentation to the hospital, an ultrasound of the scrotum revealed scrotal and right testicular abscess. The patient underwent right inguinal orchiectomy. Postoperatively, pus culture was positive for Enterococcus faecalis and Candida glabrata, and hence, he was treated with oral antibiotics including high-dose antifungal medications. Adequate wound care and regular follow-up demonstrated resolution of infection. This case highlights the risk of severe urogenital infection associated with the use of SGLT2 inhibitors in the setting of uncontrolled T2DM.

Association of balance control mechanisms with brain structural integrity in older adults with mild cognitive impairment.

BACKGROUND: Older adults with mild cognitive impairment (OAwMCI) exhibit subtle balance control and gait deficits which are predominantly associated with structural brain pathologies such as impaired white matter integrity and reduced gray matter volume. However, the relationship between balance recovery mechanisms and neural substrates in OAwMCI remains unknown. This study thus aimed to explore the associations of volitional (self-initiated) and reactive balance (in response to an external perturbation) control with structural brain integrity. METHODS: Ten OAwMCI (MoCA 18-25/30; greater than 55 years) were examined on the limits of stability test (volitional balance via Equitest), stance perturbation test (reactive balance via ActiveStep treadmill) and underwent magnetic resonance imaging. Forward movement (frequently performed functional activity of daily living) was quantified by maximum excursion (maximum ability to shift one's center of gravity toward the theoretical limit [MXE-%])and directional control (amount of movement exhibited towards the target proportional to the movement away from the target [DCL-%]) on the limits of stability test. Slip-like (prevalent type of accidental falls) perturbations were quantified by postural stability (shortest distance of the COM motion state, i.e., its position and velocity, to the theoretical boundary) on the ActiveStep treadmill. White matter integrity was quantified by fractional anisotropy (FA, movement of water molecules directionality) and gray matter volume measured in mm3. RESULTS: For volitional balance control, reduced forward MXE was significantly (p < 0.05) associated with lower FA in left (R2 = 0.56) and right (R2 = 0.60) corticospinal tract, left (R2 = 0.49) and right (R2 = 0.51) corticothalamic tract, left (R2 = 0.70) and right (R2 = 0.57) frontopontine tract, right (R2 = 0.67) cingulum, anterior commissure (R2 = 0.82), and corpus callosum (R2 = 0.62). Reduced forward DCL was significantly (p < 0.05) associated with reduced gray matter volume in the left (R2 = 0.75) and right (R2 = 0.81) cerebellum, brainstem (R2 = 0.64), right (R2 = 0.49) thalamus. For reactive balance control, reduced postural stability (p < 0.05) was significantly associated with reduced FA in the left (R2 = 0.75) and right (R2 = 0.64) corticospinal tract, left (R2 = 0.67) and right (R2 = 0.65) frontopontine tract. Reduced postural stability was significantly (p < 0.05) associated with reduced gray matter volume in the brainstem (R2 = 0.72) and right cerebellum (R2 = 0.70). CONCLUSION: Our results indicate that structural brain integrity influences stability control in OAwMCI for both volitional and reactive balance tasks, which may share some common cortico-subcortical motor pathways and relay centers. Results also show that the integrity of descending pathways from cortical attentional centers could influence stability control for both tasks.

Case Report: Vancomycin-Associated Tubulointerstitial Nephritis in Clinical Practice-Case Report and Review of Literature.

Nephrotoxicity is one of the major limiting factors for vancomycin use. The most common histological patterns of kidney injury are acute tubulointerstitial nephritis and acute tubular necrosis. Patients who develop acute tubulointerstitial nephritis are prone to develop acute kidney injury with vancomycin rechallenge and, in most cases, present alone or as a part of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). The purpose of the review study is to identify biopsy-proven vancomycin-associated-tubulointerstitial nephritis in literature, determine possible underlying pathophysiology and identify the consequences of vancomycin rechallenge in such patients.

Coexisting portal vein thrombosis and aortic thrombosis in a patient with COVID-19: A case report and literature review.

The Coronavirus Disease 2019 (COVID-19) pandemic has rapidly progressed, resulting in significant global morbidity and mortality. Predominantly affecting the respiratory tract, it has been found to be associated with extrapulmonary manifestations such as coagulopathies. We hereby report a case of an elderly man with no predisposing risk factors or history of hypercoagulable disorder who presented with acute onset abdominal pain and was diagnosed with portal vein thrombosis and splenic infarct two weeks following mild COVID-19. Incidentally, the patient was also noted to have aortic thrombosis. The patient was treated with therapeutic anticoagulation with complete resolution in his symptoms. Our case highlights a high risk of coagulopathy following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).