Takotsubo Cardiomyopathy Associated With Influenza A and a Ground-Level Fall.

Our case involves a 92-year-old female who presented to the emergency department due to a ground-level fall and difficulty breathing. She was found to have influenza A, elevated troponin, and decreased left ventricular ejection fraction. However, cardiac catheterization did not reveal any coronary artery stenosis, supporting a diagnosis of takotsubo cardiomyopathy (TC). The patient's ejection fraction was normal after nine months. This case highlights the importance of considering TC in elderly female patients who have reduced ejection fraction and elevated troponin in the setting of infection and a recent fall.

Mirtazapine Therapy for a Patient With Weight Loss and Gastroparesis Associated With Limited Systemic Sclerosis.

Objective: Gastroparesis may be present in individuals with systemic sclerosis. In the United States, metoclopramide is the only medication approved for treating gastroparesis. Our case involves using mirtazapine therapy to help with weight loss and gastroparesis associated with systemic sclerosis. Case: A 70-year-old female with limited systemic sclerosis and sicca syndrome began experiencing weight loss, dysphagia, nausea, and abdominal fullness. Neither an esophageal dilation procedure nor six weeks of metoclopramide therapy alleviated her symptoms. However, 15 mg of mirtazapine once daily provided some symptomatic relief. A gastric emptying scan confirmed gastroparesis. The dose of mirtazapine was later increased to 30 mg once daily. With the mirtazapine therapy, the patient experienced both symptomatic improvement and weight gain benefits. Discussion/Conclusion: Mirtazapine therapy has anti depressive, appetite stimulating, anti-emetic, and prokinetic benefits. Consideration of mirtazapine therapy for patients with weight loss and gastroparesis associated with systemic sclerosis may be beneficial.

COVID-19 Infection and ST-Elevation Myocardial Infarction: Lessons in Disease Management During a Pandemic.

The emergence of the SARS-CoV-2 virus, causing the COVID-19 pandemic, has profoundly impacted global health, resulting in significant morbidity and mortality worldwide. This paper presents a case study highlighting the heightened risk of severe cardiovascular complications following COVID-19 infection. A 61-year-old male with hyperlipidemia was discharged after COVID-19 pneumonia treatment and experienced a severe ST-elevated myocardial infarction (STEMI) within a day of discharge. A retrospective chart review, supplemented by a literature review, revealed a pattern of increased severity in STEMI cases associated with COVID-19, particularly in patients with pre-existing cardiovascular comorbidities. SARS-CoV-2 induces a prothrombotic state, which causes endothelial dysfunction and systemic inflammation, potentially precipitating thrombotic events. Managing concurrent COVID-19 and STEMI poses unique challenges, emphasizing the critical role of timely intervention, such as percutaneous coronary intervention (PCI), in improving patient outcomes. Despite advancements, uncertainty persists regarding optimal thromboembolism prophylaxis post COVID-19, necessitating ongoing research and meticulous clinical management. While COVID-19 infection rates have declined since the pandemic, this case report hopes to emphasize the need for continued awareness in recognizing the potential thrombotic risks of COVID-19 infection and underscore the need for further investigation into cardiovascular risk as new viral strains develop in the future.

Non-metastatic Nephrogenic Hepatic Dysfunction (Stauffer Syndrome) and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in a Patient With Renal Cell Carcinoma Coinciding With Liposarcoma.

Stauffer syndrome is a non-metastatic, nephrogenic, hepatic dysfunction syndrome that is linked to extrahepatic paraneoplastic tumors. It manifests with varying clinical signs that include jaundice, anicteric transaminitis, elevated alkaline phosphatase, thrombocytosis, elevated erythrocyte sedimentation rate, prolonged prothrombin time, and, in some cases, hepatosplenomegaly in the absence of hepatobiliary obstruction. Stauffer syndrome is mostly associated with renal cell carcinoma, but research shows other solid malignancies are implicated with this syndrome. Stauffer syndrome is characterized by elevated liver function tests, specifically those that indicate the presence of cholestasis with or without hepatosplenomegaly. The abnormality is not due to tumor infiltration but rather indirect paraneoplastic effects that are poorly understood. Additionally, emerging literature also supports the association of syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to malignancy in the setting of elevated interleukin-6. In this article, we present the case of a 76-year-old patient with SIADH and abnormalities in liver function tests in the context of Stauffer syndrome tied to renal cell carcinoma coinciding with liposarcoma.

Disseminated Histoplasmosis Mimicking Macrophage Activation Syndrome in a Patient With Rheumatoid Arthritis.

Infections caused by Histoplasma capsulatum typically do not produce symptoms. However, in individuals who are immunocompromised, progressive disseminated histoplasmosis may occur. A 67-year-old female, with lengthy history of immunosuppression due to management of rheumatoid arthritis, reported a two-month history of fatigue, headaches, and intermittent fevers following hip surgery. Due to the concern for macrophage activation syndrome and hemophagocytic lymphohistiocytosis, a bone marrow biopsy was performed. However, the results indicated the presence of Histoplasma, which was supported by the presence of Histoplasma antigens in the serum and urine, Histoplasma antibodies in the serum, positive (1,3)-beta-D-glucan results, and fungal blood cultures. The patient initially received amphotericin B, but it was switched to itraconazole due to adverse effects. The patient remains on itraconazole therapy and follows as an outpatient with an infectious diseases specialist.

A Case of Ceftaroline-Associated Thrombocytopenia.

Ceftaroline is a fifth-generation cephalosporin that can be used for the treatment of serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA). A rare adverse effect of ceftaroline therapy is thrombocytopenia. Our case involves a 45-year-old male with active intravenous drug usage who presented with persistent fever, lower back pain, and left elbow pain. His bloodcultures were found to be positive for MRSA. He was initially started on vancomycin; subsequently, the antibiotic was changed to daptomycin and ceftaroline, as vancomycin failed to clear the bacteremia. Seven days after initiation of ceftaroline, it was unintentionally discontinued by the electronic health record. Following its resumption two days later, the patient started having epistaxis accompanied by an acute drop in his platelet count from 422,000 cells/µL to less than 2,000 cells/µL. The ceftaroline therapy was discontinued, and he received a platelet transfusion. However, daptomycin was continued, resulting in successful resolution of his bacteremia. The patient's platelet count at discharge improved to 582,000 cells/µL. The patient was diagnosed with ceftaroline-induced thrombocytopenia, and it was added to his list of allergies.

A Case of Hand-Foot-and-Mouth Disease in an Adult Male.

Hand-foot-and-mouth disease (HFMD) is commonly seen in infants and children; less frequently, it may be seen in adults as well. The disease is usually associated with viral infections, including many variants of enteroviruses and coxsackieviruses. We discuss the case of a 39-year-old male who presented with constitutional symptoms, fever, and lesions on his hands, feet, and mouth. His children, who had been recently diagnosed with HFMD, were likely the source of his infection. A comprehensive history and physical examination enabled us to identify the lesions, some of which were faint and difficult to visualize. Viral panel testing indicated positive results for human rhinovirus/enterovirus. Treatment and testing associated with the patient's condition were supportive, largely based on the history and physical findings which helped us narrow down our differential diagnoses. Complete resolution of the symptoms within one to two weeks is generally expected in these patients.

Oxidative stress and redox signaling in CRPC progression: therapeutic potential of clinically-tested Nrf2-activators.

Androgen deprivation therapy (ADT) is the mainstay regimen in patients with androgen-dependent prostate cancer (PCa). However, the selection of androgen-independent cancer cells leads to castrate resistant prostate cancer (CRPC). The aggressive phenotype of CRPC cells underscores the need to elucidate mechanisms and therapeutic strategies to suppress CRPC outgrowth. Despite ADT, the activation of androgen receptor (AR) transcription factor continues via crosstalk with parallel signaling pathways. Understanding of how these signaling cascades are initiated and amplified post-ADT is lacking. Hormone deprivation can increase oxidative stress and the resultant reactive oxygen species (ROS) may activate both AR and non-AR signaling. Moreover, ROS-induced inflammatory cytokines may further amplify these redox signaling pathways to augment AR function. However, clinical trials using ROS quenching small molecule antioxidants have not suppressed CRPC progression, suggesting that more potent and persistent suppression of redox signaling in CRPC cells will be needed. The transcription factor Nrf2 increases the expression of numerous antioxidant enzymes and downregulates the function of inflammatory transcription factors, e.g., nuclear factor kappa B. We documented that Nrf2 overexpression can suppress AR-mediated transcription in CRPC cell lines. Furthermore, two Nrf2 activating agents, sulforaphane (a phytochemical) and bardoxolone-methyl (a drug in clinical trial) suppress AR levels and sensitize CRPC cells to anti-androgens. These observations implicate the benefits of potent Nrf2-activators to suppress the lethal signaling cascades that lead to CRPC outgrowth. This review article will address the redox signaling networks that augment AR signaling during PCa progression to CRPC, and the possible utility of Nrf2-activating agents as an adjunct to ADT.

StepWatch accuracy during walking, running, and intermittent activities.

INTRODUCTION: The purpose of this study was two-fold: 1) to investigate effects of cadence and sensitivity settings for the StepWatch (SW3) on step count accuracy over a wide range of ambulatory speeds, and 2) to compare the preprogrammed "quick start" settings to modified settings during intermittent lifestyle activities. METHODS: Part 1: Fifteen participants (18-57 years of age) performed two trials of treadmill walking and running at ten speeds ranging from 26.8 to 268mmin-1 while wearing four SW3 devices. During the first trial, the cadence setting was maintained while sensitivity was varied; in the second trial sensitivity was maintained while the cadence setting was varied. Part 2: Fifteen participants performed four intermittent activities and drove an automobile while wearing two SW3 devices, one with preprogrammed settings and the other with the modified settings determined in Part 1. RESULTS: Part 1: The modified settings (cadence setting of 70% of default and sensitivity of 16) provided the greatest step counting accuracy across a wide range of speeds reporting 96.0-104% of actual steps between 53.6 and 268mmin-1. Part 2: The preprogrammed settings tended to have higher accuracy for light household tasks (recording 88% to 94% of actual steps) than the modified settings (recording 82% to 86% of actual steps) which showed a trend towards higher accuracy for tennis (recording 93% vs. 89% of actual steps) (p<0.05). CONCLUSION: The preprogrammed "quick start" StepWatch settings should be used with individuals who do not engage in running and vigorous sports. However, for individuals who engage in running and tennis, use of modified settings may result in improved step counting accuracy.