Blood Alcohol Level as a Predictor of Withdrawal Severity.

Few studies have explored the correlation between the severity of alcohol withdrawal and blood alcohol level at the time of admission. Specifying prognostic factors for life-threatening withdrawal necessitating inpatient pharmacologic management over the course of days would be useful to identify at-risk patients at the time of admission. Hence, we present the case of a 34-year-old Caucasian male with a past medical history of poly-substance abuse who has presented to our emergency department 11 times over the past four years with a mean blood alcohol level (BAL) of 287 mg/dL upon withdrawal. BAL at the time of withdrawal is highly variable depending on the chronicity of abuse; however, a BAL this elevated is highly unusual and indicative of severe and long-term use. While in the unit at this admission, the patient's BAL was 437 and his withdrawal symptoms were severe, necessitating ICU admission and strong sedating medications to control his symptoms. Even after these interventions, he still demonstrated severe withdrawal symptoms including full body tremors, vital sign instability, and continuous visual, auditory, and tactile hallucinations. This patient presents an interesting case of severe alcohol withdrawal at an abnormally elevated blood alcohol level progressing to a prolonged withdrawal course in the ICU. Alcohol level at the time of withdrawal could be a helpful predictor of the course of severity of alcohol withdrawal; however, more studies are required to prove this relationship.

Post-COVID-19 fatigue as a major health problem: a cross-sectional study from Missouri, USA.

BACKGROUND: Fatigue following acute viral illnesses is a major issue that complicates the clinical course of several epidemic and non-epidemic viral infections. There is a noticeably higher trend of patients with symptoms that persist after initial recovery from acute COVID-19. This study seeks to obtain more data about the prevalence of post-COVID-19 fatigue and the factors associated with higher fatigue frequency among patients who had COVID-19. METHODS: A single center cross-sectional study was performed between May 2021 and January 2022 at University Health, Kansas City, Missouri, USA. The Fatigue Assessment Scale (FAS) was utilized to measure post-COVID-19 fatigue. Descriptive and comparative statistics were used to describe clinical and sociodemographic features of patients. Analysis of variance (ANOVA), the chi-square test, and Fisher's exact test were used to examine the statistical association between the FAS score and other clinical and sociodemographic factors. RESULTS: One hundred and fifty-seven patients who had been diagnosed with COVID-19 and diagnosed at University Health were enrolled in our study. Overall, 72% of patients (n = 113) were female. The mean ± standard deviation of the FAS score was 21.2 ± 9.0. The prevalence of post-COVID-19 fatigue among our studied sample was 43.3%. The findings of this study suggest that female patients have a significantly higher fatigue score compared with male patients (P < 0.05). CONCLUSIONS: Post-COVID-19 fatigue is a major issue following the initial acute illness with COVID-19, with a prevalence of 43.3%. We recommend implementing standardized measures to screen for post-COVID-19 fatigue, especially among female patients.

COVID-19 Presenting as Acute Icteric Hepatitis.

As the coronavirus pandemic continues to evolve, so does the understanding of different presentations of disease. In this case report, we describe a patient whose presentation of COVID-19 was with acute icteric hepatitis without respiratory symptoms. This is the first case in the literature to our knowledge to report jaundice as the initial presentation of disease and adds to just a handful of cases in the literature of acute hepatitis as the sole presentation of COVID-19. Additionally, despite severe hepatitis, the patient had a benign course of COVID-19 and did not require aggressive medical care; this strays from conventional paradigms that associate severity of COVID-19 with a degree of aminotransferase elevation. The purpose of this report is to make physicians aware of acute icteric hepatitis as a presentation of COVID-19 infection and to facilitate discussion and further research in the area of COVID-19-induced hepatitis.

A Case Report of Acquired Factor X Deficiency in a Patient With Multiple Myeloma.

Multiple myeloma is a plasma cell neoplasm characterized by clonal proliferation of immunoglobulin producing terminally differentiated B cells. Classically patients are described to present with bone pain, hypercalcemia, anemia, and/or renal impairment. A less described clinical manifestation related to the myeloma is acquired coagulation abnormalities including paraprotein interfering with the coagulation cascade or exhibiting specific antibody activity. Factor X deficiency is reported in patients with secondary amyloidosis. We describe a patient who presented with bleeding tendency and an abnormal prothrombin and activated partial thromboplastin times (PT/PTT) due to factor X deficiency. A thorough workup revealed the diagnosis of multiple myeloma with the presence of monoclonal lambda light chain restricted plasma cells with qualifying end-organ damage without evidence of amyloidosis. Prior to the ultimate diagnosis, the patient succumbed to septic shock and acute respiratory distress syndrome due to Streptococcus Pneumonia infection.

Nafcillin-Induced Hepatic Injury: A Case Report and Literature Review.

BACKGROUND: Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the Western world. While it requires a diagnosis of exclusion, it is exceedingly prevalent in patients taking multiple hepatotoxic agents, the foremost of which are antibiotics, followed by herbal and dietary supplements. Below we will discuss a case of nafcillin-induced liver injury suggested by a thorough work-up and rule-out of other hepatic and biliary pathologies. CASE PRESENTATION:  We report the case of a 66-year-old white male who presented with painless jaundice. Clinical, laboratory and radiographic features demonstrated a cholestatic pattern of liver injury without significant abnormalities in the biliary tract. All workup for viral hepatitis and autoimmune diseases with liver involvement was negative. Liver biopsy showed acute necro-inflammatory changes suggestive of drug-induced liver injury. The patient had received 18 days of IV nafcillin for blood culture positive methicillin-susceptible Staphylococcus aureus (MSSA) four weeks prior to his presentation. He showed clinical and laboratory improvement of his liver functions with supportive care only. CONCLUSION: Nafcillin is a safe and effective antibiotic for the treatment of methicillin-susceptible Staphylococcal infections. However, physicians and prescribing healthcare professionals should be aware of the rare, but serious side effects, especially one of drug-induced liver injury with emphasis on the need for early cessation of nafcillin if liver function abnormalities develop.

Infective Endocarditis Presenting as Subarachnoid Hemorrhage: An Appeal for Caution.

Spontaneous subarachnoid hemorrhage (SAH) as the presenting feature of infective endocarditis (IE) is rare. It has classically been described in association with the rupture of intracranial mycotic aneurysms (ICMA). Here we describe a very rare case of non-aneurysmal spontaneous SAH in a patient with IE. The patient originally presented with a headache and low-grade fever. Neuroimaging including computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed SAH. She was eventually diagnosed with streptococcus gallolyticus (formerly streptococcus bovis) IE. Through this case, we advocate consideration of the diagnosis of IE in patients with SAH so that there is timely recognition of this reversible but serious disease.

Henoch-Schönlein Purpura Presenting as Severe Gastrointestinal and Renal Involvement with Mixed Outcomes in an Adult Patient.

Henoch-Schönlein purpura (HSP) is typically seen as a self-limiting disease in children, but can present more severely in adults, especially when there is renal involvement. Management of HSP in adults also remains a controversial topic with very few studies evaluating available therapies. In this case, HSP presenting as a combination of severe gastrointestinal involvement and a rapid decline in renal function in an adult patient directed our therapy. The patient was a 48-year-old Caucasian male with no known past medical history, who presented with a combination of purpuric rash over the lower extremities, severe abdominal pain with upper gastrointestinal bleeding and a rapidly increasing serum creatinine, with hematuria. He initially underwent a skin biopsy, along with investigation for other possible causes, including autoimmune and infectious etiologies, which were negative. He was started on therapy for presumed HSP with intravenous methylprednisolone. The skin biopsy, however, was not conclusive, and the patient had no improvement in his clinical status. He then underwent a kidney biopsy that was consistent with HSP nephritis (immunoglobulin A (IgA) predominant glomerulonephritis with crescents), and esophagogastroduodenoscopy (EGD) that showed mucosal inflammation, ulcerations, and stigmata of bleeding-findings that were consistent with ischemia. Cyclophosphamide was added to the regimen at this time. However, he had worsening abdominal pain, continued gastrointestinal bleeding, now with hematochezia, and also worsening renal function that required dialysis. Plasmapheresis was then initiated on days alternating with dialysis. This resulted in the improvement of his gastrointestinal symptoms, but no recovery was seen of his renal function, and the patient required outpatient dialysis. This case report exhibits the unique presentation of severe gastrointestinal (GI) manifestations and rapid progression to renal failure in an adult patient with partial resolution of his severe manifestation after therapy was escalated as above. There was no established protocol that guided this therapy, which reflects the need for more studies on adult HSP.

Hypothyroid cardiomyopathy complicated by a left ventricular laminar thrombus.

Clinical hypothyroidism is the most common hormone deficiency in the United States and is found in 0.3% of the U.S. population. It is associated with characteristic symptoms that can be readily identified by a careful history and physical examination. Hypothyroidism affects many bodily systems; in particular the cardiovascular system is impacted via multiple mechanisms.3 Occasionally hypothyroidism leads to transient left ventricular systolic dysfunction, termed hypothyroid cardiomyopathy. A rare sequela of this condition is a left ventricular thrombus, which has been described in two case reports thus far. Here we report a third case of reversible hypothyroid cardiomyopathy complicated by a left ventricular laminar thrombus.

Detachable endoloop vs. elastic band ligation for bleeding esophageal varices.

BACKGROUND: Variceal bleeding is a serious complication with a mortality rate that ranges from 20% to 50%. Patients who have variceal hemorrhage usually are treated by endoscopic injection sclerotherapy or elastic band ligation to eradicate the varices. Endoloop ligation is a newly developed technique for achieving hemostasis and variceal eradication. This study compared endoloop ligation with elastic band ligation in patients with acute esophageal variceal bleeding. METHODS: Fifty patients with acute esophageal variceal bleeding were recruited: 25 were treated by elastic band ligation and 25 by endoloop ligation. RESULTS: Although the number of patients in whom bleeding recurred during a follow-up period of 6 months was smaller in the endoloop group (12%) vs. the band group (28%), this difference was not statistically significant. Furthermore, no statistically significant difference was found between the two groups with respect to the number of patients in whom variceal eradication was achieved, the number of treatment sessions required for variceal eradication, or the frequency of variceal recurrence. The total cost for variceal obliteration by endoloop ligation was 342 dollars per patient, whereas, the total cost of variceal eradication by elastic band ligation was 356 dollars per patient. The endoloop had certain technical advantages over band application: a better field of vision, tighter application, good results with junctional varices, and a lack of strain exerted by the device on the endoscope. CONCLUSIONS: Endoloop ligation is a promising new technique for management of patients with bleeding esophageal varices.

Contribution of hepatitis C virus and Helicobacter Pylori co-infection as possible predisposing factors in the occurrence of gastric mucosal dysplasia.

BACKGROUND AND PURPOSE: Current views on B-cell lymphoma genesis suggest that several exogenous factors, acting in a multistep fashion upon a predisposing condition, may be involved in B-cell clonal expansion, a potentially prelymphomatous stage. This study was done to investigate the extrahepatic localization of Hepatitis C virus (HCV)in the gastric mucosa and the possibility of its involvement besides Helicobacter pylori (H. pylori) as possible predisposing factors that might play a role in the occurrence of gastric dysplasia or lymphoproliferation following gastritis and may end in carcinogenesis. PATIENTS AND METHODS: A well characterized series of 45 patients with chronic liver disease complaining of gastric dyspepsia were subjected to Upper Gastrointestinal Endoscopy and histological examination of gastric biopsy with studying the prevalence of serologic and molecular markers of HCV and H. pylori in the patients' serum and their gastric tissue. HCV-RNA detection in gastric tissue was done only for those who showed gastric dysplasia. RESULTS: Histopathological examination of the gastric biopsies revealed that 20 patients (44.4%) had chronic active gastritis, 15 patients (33.4%) had chronic gastritis and 10 patients (22.2%) had gastric dysplasia with chronic gastritis. As for hepatitis C virus, 38 patients (84.4%) were reactive for serum antibodies (HCV-Abs) and 18 patients (40%) showed Polymerase Chain Reaction (PCR) positivity. Helicobacter pylori antibody reactivity was detected in 37 patients (82.2%) while PCR positivity was detected in 24 patients (53.3%) both in their serum as well as in gastric tissues. Seventeen out of twenty cases showing chronic active gastritis were serologically positive for both H. pylori and HCV. Patients who showed dysplasia on pathological examination (n=10) were all HCV-Abs positive (p-value = 0.32), seven patients were serum HCV-RNA positive (p-value = 0.083) and 3 of them showed HCV-RNA positivity in their gastric tissue. Nine out of the patients with gastric dysplastic changes proved positive for H. pylori DNA both in serum (p-value= 0.027) and tissue (p-value= 0.029). CONCLUSIONS: We suggest that Hepatitis C virus may be considered, in addition to Helicobacter pylori, as another potential infectious co-factor in the occurrence of gastric mucosal dysplasia and thus might be associated in the multistep hypothesis of carcinogenesis.