Progression of Skin Ulcer Secondary to Calciphylaxis in a Patient With End-Stage Renal Disease (ESRD) on Hemodialysis and the Therapeutic Approach.

Calciphylaxis is a rare and severe medical condition characterized by the calcification of small blood vessels and soft tissues, leading to tissue damage, skin ulcers, and intense pain. It most commonly affects individuals with underlying health conditions such as kidney disease, particularly end-stage renal disease (ESRD), and is associated with high mortality rates. Understanding the diagnosis and management of calciphylaxis is crucial for improving patient outcomes. Diagnosing calciphylaxis can be challenging due to its rarity and overlapping symptoms with other skin conditions. Healthcare professionals typically use a combination of clinical evaluation and diagnostic tests to reach a conclusive diagnosis. The management of calciphylaxis is multifaceted and typically involves a collaborative effort between various healthcare specialists, including nephrologists, dermatologists, and wound care experts. The primary goals of treatment are to alleviate pain, promote wound healing, address underlying causes, and prevent further complications.

Association of serum digoxin concentration with morbidity and mortality in patients with atrial fibrillation, heart failure and reduced ejection fraction of 45 % or below.

BACKGROUND: Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) are common cardiovascular conditions linked to significant health burdens. This review aims to study the relationship of serum digoxin concentration and mortality and morbidity outcomes in defined population. METHODS: We conducted a thorough search of databases such as PubMed, Google Scholar, and Cochrane Library, from inception until 20th Aug 2023. Studies that explored the relationship between serum digoxin concentration and mortality, morbidity, or other clinical endpoints in AF and HFrEF patients (ejection fraction ≤45 %) were eligible for inclusion. RESULTS: The selected studies exhibited a wide range of designs, patient cohorts, and measured outcomes. The association between serum digoxin concentration, mortality and morbidity endpoints like hospitalization rates and cardiovascular events were assessed in these studies. Despite the methodological diversity, our systematic review uncovered consistent trends across the studies, suggesting that elevated serum digoxin concentrations may correlate with higher mortality and morbidity in AF and HFrEF patients. CONCLUSION: This systematic review emphasizes the need for cautious management of serum digoxin levels in patients with concurrent AF and HFrEF. While digoxin remains a valuable treatment for heart failure, its potential adverse effects on outcomes in this specific patient subgroup call for vigilant monitoring and individualized treatment approaches. Further research is required to elucidate the dose-response relationship and potential confounding factors influencing outcomes associated with serum digoxin concentration in AF and HFrEF patients. Clinicians should consider these findings when making therapeutic decisions to enhance patient care and outcomes.

Large B-cell Lymphoma-Associated Membranous Nephropathy With Positive PLA2R on Kidney Biopsy.

Large B-cell lymphoma associated with membranous nephropathy (MN) is a rare and complex medical condition that involves the simultaneous presence of two distinct diseases: a malignant lymphoma and a kidney disorder called membranous nephropathy. In this case, there is an additional element of interest, which is the presence of positive Phospholipase A2 Receptor (PLA2R) in the kidney. The case involves a 53-year-old Caucasian male with a three-week history of lower leg edema and a past medical history of recurrent upper respiratory infections. The upper respiratory infections were characterized by symptoms of fever, sore throat, and headache, and they required multiple rounds of antibiotics for treatment, including Augmentin and Keflex. A diagnosis of nephrotic syndrome was made based on proteinuria of fourteen grams with no RBC cast on urinalysis. Kidney biopsy stained positive for antiposophlipase A2 receptor on a frozen section. Thrombospondin type 1 domain-containing 7A (THSD7A) was not detected.  Given his biopsy and absence of clinical symptoms, he was treated as a case of primary membranous nephropathy with angiotensin-converting enzyme (ACE) inhibitors, steroids, and immunosuppressive. Three months following the treatment, his condition deteriorated, and after a thorough investigation, he appeared to have large B-cell lymphoma as a secondary cause of membranous glomerulopathy (MGN). When large B-cell lymphoma is associated with membranous nephropathy, it presents a unique clinical challenge. The interaction between these two conditions is not fully understood, but it is believed that the lymphoma may provoke an immune response that leads to the development of membranous nephropathy. Moreover, the presence of positive PLA2R in the kidney indicates a specific mechanism at play in this complex disease scenario. Treatment for this condition typically involves addressing both the lymphoma and the kidney disorder. This may include chemotherapy or other treatments to target the lymphoma and immunosuppressive therapy to manage the autoimmune response causing membranous nephropathy. Close monitoring and coordination between oncologists and nephrologists are essential for the best possible outcome in managing this rare and challenging condition.

Asymptomatic COVID-19 presenting with features of mixed pattern acute liver injury in a young healthy female, a case report.

COVID-19 associated severe acute liver injury in a young healthy patient has not been reported much in the literature. And currently, there are no standard management guidelines. We want to report a case of acute liver injury of mixed pattern in a young healthy female with asymptomatic COVID-19 infection. She presented with abdominal pain, nausea, vomiting and yellowish discoloration of her skin. Further laboratory investigations revealed mixed pattern liver injury with highly raised liver enzymes. She was managed with N-acetyl cysteine protocol and monitoring of her liver enzymes. Other causes of acute liver injury were ruled out. She remained stable during her hospital stay and follow up. Our aim is to highlight the significance of acute liver injury in COVID 19 patients that may lead to fatal outcomes if not managed and monitored accordingly.

Obstructive Jaundice Secondary to Extramedullary Hematopoiesis.

Extramedullary hematopoiesis (EMH) is the development of hematopoietic tissue outside of the bone marrow. In adults, the bone marrow is the main site of hematopoiesis. When this process occurs outside of the bone marrow, it is a sign of disease or deficiency. Clinically, the findings of EMH may be diverse. One rare complication that can arise from EMH is obstructive jaundice. This occurs when there is a blockage of bile flow leading to retention of bilirubin in hepatocytes. Identifying the markers of EMH and obstructive jaundice is important for optimizing positive outcomes. While often asymptomatic, EMH can be deadly if left untreated. In this case, we present a patient with obstructive jaundice secondary to EMH.