A rare case of long-term dialysis catheter-associated Agromyces mediolanus bacteremia: A case report and literature review.

Agromyces mediolanus is a catalase-positive gram-positive rod typically found in the soil and not commonly known to be pathogenic. We present a rare case of Agromyces mediolanus bacteremia with aortic valve endocarditis in a patient who required prolonged inpatient care with a tunneled dialysis catheter for renal replacement therapy (RRT). Infection is the second leading cause of mortality among patients with end-stage renal disease and vascular access. The incidence of bacteremia is higher in patients with indwelling tunneled catheters than in those with an arteriovenous fistula or graft. The most critical risk factor is its prolonged use. Anticipation of the need for long-term definitive renal replacement therapy and planning for the best approach is crucial in preventing catheter-related bloodstream infections (CRBSIs). Human infections caused by Agromyces mediolanus are rare; it has been reported twice, and both cases were associated with prolonged use of catheters, not only parenteral catheter but also peritoneal catheter, which is of special importance for patients with end-stage renal disease (ESRD). Limited data is available for the appropriate antibiotic therapy.

Metastatic insidious super giant basal cell carcinoma.

A middle-aged woman presented with a mechanical fall. Physical examination revealed a massive purulent ulcerated lesion spanning her entire back and axilla, which had reportedly been brewing for over a decade. Punch biopsy revealed infiltrative basal cell carcinoma. She was treated with Vismodegib, with a remarkable decrease in the size of the cancer. However, surveillance imaging after 6 months of treatment revealed new bone metastases. In the setting of progressive disease, medical therapy was switched to cemiplimab instead. Basal cell carcinoma is commonly known as a benign tumour of the skin, rarely larger than 5 cm. Here, we discuss the entity of metastatic super giant basal cell carcinoma; this case is one of the largest reported lesions. As locoregional therapy, such as surgery is sometimes not appropriate for such advanced lesions, we discuss the current forefront of therapy including oral hedgehog pathway and check point inhibitors.

Ischemic Stroke and Bilateral Pulmonary Embolism in COVID-19: COVID-Associated Coagulopathy or Heparin-Induced Thrombocytopenia.

A main feature of coronavirus disease 2019 (COVID-19) pathogenesis is the high frequency of thrombosis, predominantly pulmonary embolism (PE). Anticoagulation therapy is a crucial part of the management. Heparin use for anticoagulation could increase the risk of heparin-induced thrombocytopenia (HIT), a potentially fatal complication that presents with thrombocytopenia with or without thrombosis. We present a 69-year-old unvaccinated female patient with severe COVID-19 pneumonia. Initial laboratory investigation was significant for thrombocytopenia and low D-dimer levels. She was initially started on enoxaparin followed by unfractionated heparin. On hospital day 8, she developed left facial droop and dysarthria and was found to have non-occlusive thrombus in proximal middle cerebral artery as well as bilateral pulmonary emboli. She received intravenous thrombolysis followed by heparin infusion. On day 13 of hospitalization, platelet count dropped from 120,000/mm3 to 43,000/mm3, raising suspicion of HIT. Heparin was stopped and fondaparinux was started. After 3 days, HIT antibody testing returned positive, then a positive serotonin release assay confirmed the diagnosis. On discharge, she was transitioned to apixaban to complete 3 months of anticoagulation for provoked PE. This case represents the diagnostic challenge of HIT in COVID-19 patients. Thrombocytopenia after heparin infusion should raise clinical suspicion of HIT, which allows appropriate discontinuation of heparin products and initiation of alternative anticoagulants to limit devastating complications. To our knowledge, this is the first case report of a COVID-19 patient presenting with venous thrombosis as well as arterial thrombotic event in the context of underlying HIT.

Renal manifestations, incidence, pathogenesis and implications on prognosis and mortality in COVID-19 patients: A review of current evidence and the potential for future directions.

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has now spread into a worldwide pandemic. The pulmonary manifestations of this disease have been well described in literature, however COVID-19 can also cause severe and lasting harm in other organs including the kidneys, heart, and pancreas. Emerging evidence suggests that COVID-19 has multiple renal manifestations which impact the prognosis and mortality of this disease. Here we present a literature review of the current evidence of renal involvement in COVID-19 patients and the potential for future directions in management.

Ischemic Stroke After Tumor Resection in a Patient With Glioblastoma Multiforme.

Glioblastoma multiforme (GM) is the most common type of aggressive malignant glioma in the brain or spinal cord and represents 15% of all primary brain tumors among adults. Although ischemic strokes in the setting of an underlying glioma is a rare occurrence, its diagnosis is usually challenging due to the overlapping neurological manifestations with the underlying brain tumor. We report a case of a 58-year-old white male who presented with subacute worsening symptoms of expressive aphasia with focal neurological symptoms, including right-sided extremity motor weakness and intermittent vision spots. Magnetic resonance imaging (MRI) of brain revealed a large 9.5 cm infiltrating mass in the left frontal and temporal lobes, strongly indicative of a primary glioma. The patient underwent resection to confirm diagnosis and remove part of the tumor mass. Pathological examination revealed GM. Expressive aphasia was markedly improved following the surgery; however, on postoperative day 3, the patient developed acute onset of right-sided weakness and sensory deficit. MRI revealed acute left posterior, frontal, and parietal infarct. Unfortunately, recent brain surgery would not allow for intravenous thrombolysis, and, therefore, he was discharged with a plan for outpatient radiation treatment and oral temozolomide chemotherapy.

Giant Cell Myocarditis: A Time Sensitive Distant Diagnosis.

Giant cell myocarditis is a rare type of rapidly progressive myocarditis. We present a dramatic case of giant cell myocarditis in a young female with an initial presentation of acute heart failure. Her clinical course was complicated with recurrent cardiac arrhythmias, specifically non-sustained ventricular tachycardia, for which a dual chamber automated implantable cardioverter defibrillator (AICD) was implanted. Eventually, she presented with cardiac arrest despite being on antiarrhythmic medication and an implantable defibrillator. In the right clinical context, such as an acute presentation of unexplained new-onset heart failure and arrhythmias in a young patient, it is very important to maintain high suspicion of such a rare disease.