A Case of Chronic Myelomonocytic Leukemia Unmasked After Receiving J&J COVID-19 Vaccine.

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disease that comes under the overlap syndrome (myelodysplastic and myeloproliferative disorders). CMML is characterized by peripheral blood monocytosis and bone marrow dysplasia. The pathogenesis of CMML is poorly understood. Although cytogenetic and molecular abnormalities are common, they are not diagnostic. Herein, we present a rare case of CMML after receiving the J&J COVID-19 vaccine with the rare association of limited scleroderma. Based on the Surveillance, Epidemiology, and End Result (SEER) cancer statistics review 2014-2018, the five-year age-adjusted incidence rate of CMML in both sexes is 0.5/100,000, with greater incidence in males (0.7/100,000) compared to females (0.3/100,000). We emphasize the fact that, based on the previous studies reported, the association of scleroderma with CMML is very rare. Our patient had concomitant CMML and scleroderma, which were unmasked after the patient received the COVID-19 vaccine. Our case suggests the possibility of developing CMML after receiving the J&J COVID vaccine. Immunization has always been a life-saving intervention in history. As the world is foreseeing getting the COVID-19 vaccine, it is essential to report all the possible adverse events for safety monitoring. Physicians should be aware of this unusual complication of the vaccine, and more cases are needed to confirm the association between them.

Cryoglobulinemia unmasked by nivolumab in a patient with hepatitis C-induced hepatocellular carcinoma: A case report and literature review.

Hepatocellular carcinoma (HCC) is ranked the fifth-most common cancer in men and ninth most common cancer in women. Immunotherapy has been shown effective in malignancies refractory to chemotherapy and has been used as a second-line therapies in many advanced cancers, including HCC. The advent of immunotherapy has resulted in a brand-new set of side effects, and it has been proposed that it was related to over activated immune system. Herein, we presented the case of 59-year-old African American gentlemen who was diagnosed with HCC caused by Hepatitis C virus, for which he was started on chemotherapy and immunotherapy. However, the patient developed cryoglobulinemia that prompted stopping both therapies and giving rituximab and steroids. We believe that the mixed cryoglobulinemia was unmasked by immunotherapy in our patient. To our knowledge, this is one of the few first cases to describe such adverse effect from immune checkpoint inhibitors.

Diffuse bone metastasis from cholangiocarcinoma involving the sternum: A case report and review of literature.

Cholangiocarcinoma (CCA) is a rare cancer of the bile duct epithelial cells and it commonly spreads to the regional lymph nodes, liver, and lungs. Bone metastasis has been reported in patients with CCA, involving both the axial and appendicular skeleton. Herein, we report a case of extrahepatic CCA with extensive bone metastases involving the calvarium, sternum, bilateral ribs and scapulae, entire spine, pelvis, and bilateral femur. To our knowledge, this is the first case report on sternum metastasis in CCA. The case presentation and review of literature highlighted the rarity of this metastasis, and health-care providers should be aware of the rare presentation of CCA.

Cardiac Tamponade Associated with Human Immunodeficiency Virus-Associated Immune Complex Kidney Disease.

Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.

An Unusual Presentation of Aggressive Primary Invasive Adenocarcinoma of Lung.

Bilateral diffuse infiltrates on chest imaging can present a diagnostic challenge due to a broader differential diagnosis which includes pulmonary and non-pulmonary causes. Malignancy is generally not considered under differential diagnosis at the time of initial presentation. Here we present a case of primary adenocarcinoma of lung manifesting as diffuse bilateral infiltrates on imaging. Our case is unique in regards to its acute presentation, rapid progression to respiratory failure, ultimately leading to the demise of the patient. This indicates the aggressive nature of this malignancy and its variable presentation, like male gender and young age, thus emphasizing the importance of entertaining malignancy in such presentations, especially if there is no response to conventional antibiotic therapy.

Acute upper limb ischemia in a patient with COVID-19.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.

Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV.

Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.

A Rare Case of Severe Starvation-induced Ketoacidosis in a Patient with Recurrent Pancreatitis.

Starvation-induced ketoacidosis in non-diabetic and non-pregnant, otherwise healthy patients is not common. In an otherwise normal healthy individual, short-term starving will only result in mild ketosis. Nonetheless, the effects of ketosis can become more severe if there is stress and insulin resistance, such as in pregnant or lactating woman or in very young individual such as neonates. We report a case of severe starvation-induced ketoacidosis in a non-diabetic and non-pregnant 37-year-old African American female patient with a history of multiple recurrent pancreatitis. The patient was initially presented to the emergency department with abdominal pain, nausea and vomiting over two days. The patient also reported starving for two days prior to admission. Biological findings, however, showed a severe degree of metabolic acidosis with an increased anion gap. Serum glucose was normal and 3+ ketonuria were present. Lactic acid was 1.7 mmol/L with no uremia. Salicylate acid, acetaminophen and ethanol level were normal. The patient's beta-hydroxybutyrate level elevated with ketonuria, suggestive of ketoacidosis as the cause of metabolic acidosis. To our knowledge, the presenting case was novel as no case reports or case series have been reported in these groups of patients. Short-term starvation, if it occurs during periods of stress and medication, may result in life-threatening ketoacidosis, even among non-diabetic women and non-pregnant patients. Awareness of this condition may facilitate prompt recognition and proactive treatment for dietary and stress control.

Hyperprogressive Disease in an Advanced Stage Colon Cancer Patient on Pembrolizumab: A Case Report.

The emergence of immune checkpoint inhibitors (ICIs) in recent years has transformed the landscape of the management of solid tumors. The advancement of immunotherapy has resulted in a brand new set of adverse outcomes not previously seen in classical chemotherapy. One such adverse effect has been termed as hyperprogressive disease (HPD), a phenomenon characterized by rapid tumor progression, which often leads to devastating outcomes. In this report, we present a unique case of a 48-year-old African American female who initially presented with abdominal pain, fatigue, and weight loss. Subsequent CT scan showed extensive irregular wall and luminal narrowing with an eccentric mass and adenopathy along the portacaval space. Tumor markers were found to be elevated and genetic testing was done. The patient was diagnosed with stage IIIC colon cancer with K-RAS wild type, associated with Lynch syndrome. The patient underwent surgical resection, chemotherapy, and targeted therapy for progressive/stage IV disease. In light of the progression of the disease, pembrolizumab was introduced into the treatment regimen. One month after the treatment, a repeat CT scan showed enlargement of the metastatic lesion with almost double the size. The progression of the disease was so rapid and, ultimately, pembrolizumab administration was withheld and the patient passed away after about two months on pembrolizumab. To our knowledge, this is one of the few cases of HPD reported in patients with advanced colon cancer, particularly in one with Lynch syndrome. Further studies are warranted to understand why some individuals benefit from immunotherapy, whereas others experience grave outcomes.

Clinical characteristics and outcome in patients with combined diabetic ketoacidosis and hyperosmolar hyperglycemic state associated with COVID-19: A retrospective, hospital-based observational case series.

AIM: One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with combined DKA/HHS to our institution. METHODS: A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 3/20/2020 and 4/20/2020. Inclusion criteria were: (1) Blood Glucose >250 mg/dL; (2) Serum bicarbonate <18 mmol/L; (3) Anion Gap >10; (4) serum pH <7.3; (5) ketonemia or ketonuria; (6) effective/calculated plasma osmolality >304 mOsm/kg and (7) positive SARS-CoV-2 RT-PCR. RESULTS: We reported 6 patients who presented during this period with combined DKA/HHS. Their median age was 50 years, all males, three Hispanic, and three African American. Hispanic patients, had more severe acidosis, and multiple comorbidities, with a higher mortality. The striking feature was that combined DKA/HHS was the initial presentation for COVID-19 for most of the cases. DISCUSSION: Our observational retrospective case series shows that diabetic patients are at risk of developing combined DKA/ HHS associated with COVID-19 and a substantial mortality. To our knowledge, we are first to report the clinical characteristics and outcome in this group of patients.