Southern Tick-Associated Rash Illness: Florida's Lyme Disease Variant.

Southern tick-associated rash illness (STARI) is an emerging zoonotic disease causing an annular rash with central clearing that is almost identical to erythema migrans seen in Lyme disease. It is spread by Amblyomma americanum tick bite. Although it is still debatable, this zoonotic disease is thought to be caused by Borrelia lonestari spirochete. At this time, there is no approved diagnostic modality nor approved treatment for such an illness. Here we describe a rare case of STARI in a 63-year-old female and shed light on the differences between STARI and Lyme disease.

Adult Anomalous Left Coronary Artery Arising From the Pulmonary Artery (ALCAPA) Syndrome as First Presentation With Atrial Fibrillation in a Marathon Runner.

Anomalous left coronary artery arising from the pulmonary artery (ALCAPA) syndrome is a very rare congenital heart disease with an incidence of one in 300,000 and a high rate of mortality early in life if left untreated. Adult-type ALCAPA presents when significant collaterals develop from the right coronary artery (RCA) to the left coronary artery (LCA). Even with the collaterals, chronic sub-endocardial ischemia occurs in most cases, and patients die from sudden cardiac death. Here we present a case of a 38-year-old female who lived an active and healthy life and presented with chest pain and palpitations. Initial electrocardiography (EKG) showed atrial fibrillation with rapid ventricular response. Although initial cardiac enzymes were negative and there were no ischemic EKG changes, troponins became elevated over the course of the hospital stay and the patient underwent a left heart catheterization. Results revealed a dilated RCA extending to the left ventricle and an anomalous left main originating from the pulmonary artery with complete occlusion. The patient received medical management for acute coronary syndrome, including heparin infusion for 48 hours, aspirin, metoprolol, and atorvastatin. She was referred to a tertiary care facility for surgical correction of anomaly of the coronary arteries. The next day, the patient arrived in the emergency department with an acute onset of speech difficulty and left-sided weakness. A brain CT without contrast showed hematoma in the right frontal lobe. The patient underwent surgical evacuation of the hematoma with marked improvement of her weakness. The patient recovered after a successful surgical repair involving translocation of the left main coronary artery to the aorta. It has been reported that ALCAPA should be considered in a young adult with dilated cardiomyopathy and mitral regurgitation (MR). Other common presentations include acute myocardial infarction, angina, and dyspnea on exertion. Sudden cardiac death is not uncommon; however, it tends to decrease with age of diagnosis. Interestingly, our patient was known to have MR with regular follow-up at the cardiology clinic for years. Echocardiogram never showed any abnormalities other than MR. She never received further workup to address the reason of MR, although she has no underlying chronic conditions that can explain it. In relatively young patients with a healthy lifestyle presenting with chest pain, a broader look at etiologies should be considered. We would like to emphasize the importance of looking up for possible coronary artery disease, especially in young individuals.

Asymptomatic Spontaneous Pneumopericardium, Pneumomediastinum, and Subcutaneous Emphysema: A Case Report of an Incidental Rare Presentation.

Pneumopericardium (PP), pneumomediastinum (PM), epidural pneumatosis, and subcutaneous emphysema (SE) are identified by the existence of free air or gas in the associated spaces. They are normally self-limited unless tension pneumothorax, tension PM, cardiac herniation, air tamponade, and esophageal rupture accompany these disorders. PM and PP can be divided into "spontaneous" or "secondary" based on the preceding etiologies. Spontaneous PM is often extremely rare and benign in course. On the other hand, secondary PM and PP are more common and result from intrathoracic infections, trauma-related esophageal rupture, or tears along the tracheobronchial tree. Our patient presented four days after a fall from a chair and was found to have suffered a stroke, with complete left side paralysis. CT imaging on arrival was significant for PM, PP, and SE, the cause of which remains unclear. The patient was diagnosed with COVID-pneumonia approximately six months prior to presentation. As the COVID-19 pandemic has evolved, several scientific papers have been published reporting infected patients who had developed spontaneous PT, PM, or even PP, in the absence of invasive mechanical ventilation. Is it possible that the spontaneous findings in our patient were COVID-related? Or could the spontaneous PP, PM, and SE be a sequel to the trauma of her fall from a chair? The answer still remains unclear.

FOXA1 expression in breast cancer--correlation with luminal subtype A and survival.

PURPOSE: FOXA1, a forkhead family transcription factor, is essential for optimum expression of approximately 50% of estrogen receptor alpha (ERalpha):estrogen responsive genes. FOXA1 is expressed in breast cancer cells. It segregates with genes that characterize the luminal subtypes in DNA microarray analyses. The utility of FOXA1 as a possible independent prognostic factor has not been determined in breast cancers. MATERIALS AND METHODS: A tissue microarray comprising tumors from 438 patients with 15.4 years median follow-up was analyzed for FOXA1 expression by immunohistochemistry. Interpretable FOXA1 expression obtained in 404 patients was analyzed along with other prognostic factors like tumor grade, size, nodal status, ER, progesterone receptor (PR), and HER2/neu. RESULTS: FOXA1 expression (score >3) was seen in 300 of 404 breast cancers and it correlated with ER (P = 0.000001), PR (P = 0.00001), and luminal A subtype (P = 0.000001). Loss of expression was noted with worsening tumor grade (P = 0.001). Univariate analysis showed nodal status (P = 0.0000012), tumor size (P = 0.00001), FOXA1 (P = 0.0004), and ER (P = 0.012) to be predictors of breast cancer-specific survival. Multivariate analysis showed only nodal status (P = 0.001) and tumor size (P = 0.039) to be significant prognostic factors, whereas FOXA1 (P = 0.060) and ER (P = 0.131) were not significant. In luminal subtype A patient subgroup, FOXA1 expression was associated with better cancer-specific survival (P = 0.024) and in ER-positive subgroup, it was better predictor of cancer-specific survival (P = 0.009) than PR (P = 0.213). CONCLUSION: FOXA1 expression correlates with luminal subtype A breast cancer and it is significant predictor of cancer-specific survival in patients with ER-positive tumors. Prognostic ability of FOXA1 in these low-risk breast cancers may prove to be useful in clinical treatment decisions.