Clinical impact of pulmonary arterial hypertension on SARS-CoV-2 outcomes: U.S. pre-vaccination analysis.

Our retrospective study aimed to determine how pulmonary arterial hypertension (PAH) influences the clinical outcomes of COVID-19 admissions by using data from the 2020 nationwide inpatient sample (NIS). Among the 1,018,915 adults who were hospitalized with COVID-19 in 2020, 155 also had a PAH diagnosis. After adjusting for all baseline demographics and co-morbidities through multivariate analysis, we found that in patients admitted with a principal diagnosis of COVID-19, PAH was not associated with an increased risk of mortality compared to those without PAH. (adjusted OR 0.58 [95% CI 0.2-1.6] p=0.3). In addition, patients with both COVID-19 and PAH showed no statistically significant difference in the odds of requiring mechanical ventilation (adjusted OR 1.1 [95% CI 0.5-2.6] p=0.9), vasopressor needs (adjusted OR 0.4 [95% CI 0.1-3.5] p=0.4), acute kidney injury necessitating renal replacement therapy(adjusted OR 0.7 [95% CI 0.3-1.7] p=0.5), mean length of stay (LOS) (11.1 vs. 7.5 days), adjusted difference 3.1 [95% CI -3.8- 10.1] p=0.37) or mean total hospitalization charges ($195,815 vs $79,082, adjusted difference 107,146 [95% CI -93,939 - 308,232] p=0.29). Further studies are needed to investigate this subpopulation during the post-vaccination era to observe the effects of outcomes in these patients.

A Case of Hepatitis C Related Mixed Cryoglobulinemia Syndrome.

Hepatitis C virus (HCV) is an RNA virus that preferentially infects hepatocytes and is transmitted through infected blood contact. Chronic hepatitis C can result in serious life-threatening conditions like fibrosis, cirrhosis, and liver cancer. Additionally, it can result in extrahepatic conditions including lymphoproliferative disease and mixed cryoglobulinemic vasculitis. Mixed cryoglobulinemic vasculitis occurs as a result of immune system dysfunction leading to immunoglobulin deposits into different blood vessels in the body. The main manifestations commonly seen are purpura, weakness, arthralgias. Other symptoms include peripheral neuropathy, arthritis, vasculitic skin ulcers, liver, and renal involvement. This case highlights a 57-year-old male with a medical history of substance use disorder, bilateral lower extremity ulcers, and chronic hepatitis C infection who presented with complaints of bilateral lower extremity wounds, abdominal distension, and scrotal swelling. Our patient was confirmed to have new-onset cirrhotic liver secondary to intravenous drug use, with worsening renal function. Further investigations confirmed the diagnosis of mixed cryoglobulinemia secondary to hepatitis C virus.

A Rare Case of Pancreatic Ascites Secondary to Chronic Pancreatitis.

Pancreatic ascites refer to continuous leakage of pancreatic secretions in the peritoneum leading to accumulation of pancreatic fluid in the peritoneal cavity. Although literature on the incidence of pancreatic ascites and presenting signs and symptoms is scarce, it may be seen in patients with chronic alcoholic pancreatitis. Patients typically present with acute chronic pancreatitis and new-onset ascites, with or without abdominal pain. A diagnostic paracentesis is usually the first step to determine the etiology of the ascites. Mild cases may resolve with conservative management. Optimization of nutrition status is an important factor to reduce morbidity and mortality. More severe cases or cases refractory to conservative management may require endoscopic or surgical intervention. This case report describes a rare presentation of pancreatic ascites in a 35-year-old female.

A Case of Adult Clival Osteomyelitis.

Clival osteomyelitis is a potentially life-threatening skull base infection. It is rare and generally challenging to diagnose and treat. Clival osteomyelitis is typically seen in the pediatric population and is very rare in the adult population. It occurs as a complication of recurring paranasal infections and malignant otitis externa. The exact pathophysiology of osteomyelitis of the clivus is relatively uncertain. Here, we describe a case of a 36-year-old man with medical history significant for hypertension and poorly controlled type 1 diabetes mellitus who experienced recurrent paranasal sinus infection for 2 years. He received multiple antibiotic treatments and underwent adenoidectomy without substantial improvement of symptoms. Ultimately, a diagnosis of the clival osteomyelitis through the help of a computed tomography (CT) scan of the paranasal sinus and neck was made. This diagnosis allowed for adequate intervention and treatment of our patient with subsequent resolution of his presenting symptoms. This case highlights the importance of high suspicion for clival osteomyelitis in patients with recurring sinus infections.

Non-Articular Felty Syndrome Refractory to Granulocyte Colony-Stimulating Factor Therapy.

Felty syndrome (FS), an uncommon manifestation seen in patients with rheumatoid arthritis (RA), usually presents as a triad of erosive arthritis, splenomegaly, and neutropenia. It is extremely rare for RA to present as FS or develop after initially presenting as neutropenia and splenomegaly. In this report, we describe a case of a 55-year-old woman who initially presented with fever and vaginal pain. Her sepsis workup revealed genital herpes in the setting of leukopenia, with an incidental finding of splenomegaly on imaging. The patient was managed with filgrastim and valacyclovir. Two weeks later, she presented again with pleuritic chest pain and worsening leukopenia. This led to an extensive workup by the hematology team to diagnose and confirm the diagnosis of FS. We also engage in a review of the existing literature of such cases and emphasize the importance of serological testing for RA in patients with leukopenia and splenomegaly, even in the absence of joint symptoms or prior diagnosis of RA. The management should be guided towards treating the infection, correcting the neutropenia, and treating the underlying chronic disease.

A Case of New Onset Diabetes and Severe Diabetes Ketoacidosis in a Patient With COVID-19.

Diabetic ketoacidosis (DKA) is a significant complication of poorly controlled diabetes. In diabetics, it typically occurs due to insulin deficiency resulting in lipolysis and subsequent ketone body formation and acidosis. The emergence of the COVID-19 infection has been associated with several complications, with the most prominent being pulmonary and cardiovascular-related. However, in some cases, patients with COVID-19 infection present with diabetic ketoacidosis. The pathophysiology of DKA in COVID-19 infection is different and currently not completely understood. The manifestation of DKA in COVID-19 patients is associated with increased severity of mortality and length of stay in these patients. Here, we describe a patient with no past medical history who presented with COVID-19 symptoms and was found to be in DKA. This case report highlights the possible underlying pathophysiology associated with this complication.

Hepatosplenic Abscess From Klebsiella pneumoniae in Poorly Controlled Diabetic.

Invasive Klebsiella pneumoniae infection and pyogenic liver abscess in patients with underlying diabetes mellitus has been well described over the past 3 decades, predominantly in the Southeast Asian population, especially in Taiwan and Korea. K pneumoniae has now become the most common causative pathogen of pyogenic liver abscess in Asian countries. This shift from Escherichia coli to K pneumoniae may also be increasingly occurring in the United States of America and European countries. Compared with the >80% incidence described in Taiwan, the incidence in the United States is still reported to be lower, around 30% to 40%. However, as more evidence and reports come to light, it has become of prime importance to recognize Klebsiella as a significant emerging cause of metastatic infections in patients with uncontrolled diabetes in the United States and not just Southeast Asia, given the significant morbidity and mortality associated with the condition. In this article, we discuss the case of a 53-year-old African American female who presented with diabetic ketoacidosis and was subsequently found to have K pneumoniae pyogenic liver abscess primarily in the left hepatic lobe, bacteremia, and septic metastases to the spleen. She required extensive percutaneous drainage of abscesses and a prolonged course of multiple antibiotics. This case illustrates the growing incidence of invasive K pneumoniae infection in the diabetic population in the United States, and better patient outcomes from prompt recognition and treatment.

Reactive Thrombocytosis after Splenectomy in Hereditary Spherocytosis: Case Report and Literature Review.

Reactive thrombocytosis after splenectomy is a feared cause of thrombosis throughout the arterial and venous system. There are many causes of splenomegaly, ranging from cirrhosis to lymphoma to hereditary spherocytosis. In this report, we will discuss a case of reactive thrombocytosis after splenectomy in a patient with hereditary spherocytosis. Splenomegaly is a relatively common finding in HD patients, causing extravascular haemolysis and thus leading to haemolytic anaemia. Splenectomy is usually considered when patients start to manifest severe symptoms such as abdominal pain, jaundice or worsening liver function tests. Our patient was a good surgical candidate and successfully underwent splenectomy but afterwards developed arterial and venous thrombosis due to reactive thrombocytosis. An extensive hypercoagulable work-up was unremarkable. The patient was started on hydroxyurea and anticoagulation with eventual improvement of platelet levels. LEARNING POINTS: Reactive thrombocytosis can be a significant complication after splenectomy and can range from mild (500,000-700,000/mm3), to moderate (700,000-900,000/mm3), severe (>900,000/mm3) and very severe thrombocytosis (>1,000,000/mm3).The use of low-dose hydroxyurea in patients with very severe thrombocytosis can reduce the platelet count to safe levels, and thus, the risk of developing thrombosis.

Acute Pancreatitis Induced Splenic Vein Thrombosis.

Acute inflammation of the pancreas, known as pancreatitis, can result in many complications ranging from acute distress respiratory syndrome to pancreatic necrosis. A relatively common vascular complication of pancreatitis is splenic vein thrombosis (SVT) due to intimal inflammation leading to platelet aggregation and thrombosis. The management of SVT with regard to anticoagulation (AC) might appear to be perplexing at first given the recommendation to withhold any sort of AC. Research studies have shown that these patients have an increased risk of gastrointestinal bleeding without AC. In this report, we discuss a case of hypertriglyceridemia-induced pancreatitis. During hospitalization, our patient complained of worsening abdominal pain with objective fevers and leukocytosis in which CT scan of the abdomen was significant for hemorrhagic pancreatitis with necrosis, acute SVT, and splenomegaly. The patient was managed conservatively with IV fluids, pain relief medications, and antibiotics.

DPP-IV Inhibitor-Associated Angioedema in Patient With Known History of ACE Inhibitor Angioedema.

The patient is a 69-year-old male with a past medical history of intellectual disability, hypertension, type 2 diabetes mellitus, and angiotensin-converting enzyme (ACE) inhibitor-associated angioedema who presented to the emergency department with difficulty breathing. On physical examination, the patient had significant facial edema. Nasal fiber-optic visualization revealed extensive airway edema involving the supraglottic region and the arytenoids. The patient was successfully intubated through the collective teamwork of ENT, anesthesia, and critical care teams. He was managed in the intensive care unit until recovery. Workup for markers for allergic causes of angioedema were within normal limits. Further investigation revealed that symptoms developed following the initiation of a dipeptidyl peptidase 4 (DPP-IV) inhibitor. The angiotensin-converting enzyme and DPP-IV play a significant role in the metabolism of bradykinin and substance P to their inactive metabolites. The complex interplay between the enzymes in the high-molecular-weight kininogen (HWMK) system may increase the risk of angioedema in patients with a known history of ACE inhibitor-associated angioedema when placed on a DPP-IV inhibitor. This case report highlights the pathophysiology involved.

Oxcarbazepine-Induced Hyponatremia: A Case Report and Comprehensive Literature Review.

Oxcarbazepine is a well-known and effective anti-convulsant used for patients with underlying seizure disorder. It is a structural analog of carbamazepine; however, it follows a different metabolic pathway in which it is converted to a different active metabolite. Side effects associated with this medication are vast; however, in this report, we will hone in on the renal adverse effects, e.g., syndrome of inappropriate anti-diuretic hormone secretion (SiADH). SiADH is a condition in which the body is making too much anti-diuretic hormone, which, in turn, results in "too much" water absorption, causing hyponatremia with neurologic sequelae. Our patient is a 31-year-old gentleman with a history of depression, anxiety, bipolar disorder, and previous suicide attempts who presented to the emergency department following oxcarbazepine overdose and was subsequently found to be hyponatremic secondary to having SiADH.

A Rare Complication of Rhabdomyolysis: Peripheral Neuropathy.

Rhabdomyolysis is a complex medical condition characterized by muscle necrosis and the release of intracellular components into the circulation. Although its most common cause is a direct traumatic injury, it can result from non-traumatic factors as well, including infection, toxins, and drugs. Serum creatine phosphokinase (CPK) levels are usually elevated in this condition and they correlate with the severity of the muscle damage (the higher the CPK peak, the greater the magnitude of muscle damage), although lower levels of CPK do not necessarily rule it out. The common complications associated with rhabdomyolysis include acute kidney injury, compartment syndrome, and, in rare cases, peripheral neuropathy. In this report, we present a case of a young patient, with a history of alcohol abuse, who presented with bilateral numbness of the feet post-immobilization and was subsequently found to have severe rhabdomyolysis.

Acute Renal Failure in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious viral pathogen with high morbidity and mortality rate. The infection affects multiple organ systems leading to systemic organ failure. There is an increased incidence of acute kidney injury (AKI) in patients who become critically ill. In the critical care setting, the incidence of AKI has been variable amongst different studies. Patients with acute kidney injury who progress to renal replacement therapy are associated with worse outcomes. We describe a case of a 42-year-old male who presented with hypoxemic respiratory failure secondary to SARS-CoV-2 associated pneumonia. The patient was initially managed with the nasal cannula and then required high flow nasal cannula with worsening hypoxemic respiratory failure, requiring invasive mechanical ventilation. On top of worsening respiratory status, the patient developed new onset renal failure requiring hemodialysis.

Naloxone induced pulmonary edema.

Naloxone-induced noncardiogenic pulmonary edema is a rare but reported entity that can occur following naloxone use in the reversal of opioid overdose. Proposed mechanisms include an adrenergic crisis secondary to catecholamine surge which causes more volume shift to pulmonary vasculature, subsequently leading to pulmonary edema. It appears to be more common when higher doses of naloxone are used. We present a case of a patient with opioid overdose came with altered mental status developed early features of pulmonary edema following the administration of multiple doses of naloxone. She responded well with the administration of diuretics and oxygen supplementation. Her oxygen requirements improved and didn't require mechanical ventilation.

Subacute COVID-19 Infection Presenting as Indolent Large Pericardial Effusion.

Reports of complications as a result of COVID-19 infection are emerging since the virus became a pandemic. Although not fully understood, reports show that the COVID-19 virus has shown acute pericardial involvement resulting from this infection. It can cause a wide range of manifestations from minimal effusion to large effusion with tamponade; however, there is little or no data on an indolent course of COVID-19 infection and its resulting manifestations. Here we describe a patient who had minimal disease symptoms for weeks, resulting in sizeable pericardial effusion formation.