Uncontrolled Primary Hypothyroidism Precipitating Non-cirrhotic Hyperammonemia: A Unique Interplay Between the Liver and Thyroid.

Hepatic encephalopathy is typically seen in advanced liver disease and in patients with a transjugular intrahepatic portosystemic shunt. Common triggers include infections, gastrointestinal bleeding, electrolyte disturbances, dehydration, and drug/toxin use such as benzodiazepines and alcohol. In rare instances, other metabolic abnormalities such as hypothyroidism may also exacerbate hyperammonemia in patients with underlying liver disease due to hypothyroidism-induced myopathy, which increases urea production and decreases clearance through reduced glutamine synthetase activity. We present the case of a 60-year-old female who presented with markedly elevated thyroid stimulating hormone, reduced free thyroxine, and elevated serum ammonia levels. Although lactulose and rifaximin were initially started, her symptoms did not clinically improve until the underlying cause of her hyperammonemia was treated. Levothyroxine was initiated, and she reported rapid clinical improvement in her symptoms. Hyperammonemia carries a 40% mortality rate, and therefore clinicians need to be aware of this rare but intricate relationship between advanced liver disease and hypothyroidism for the prompt diagnosis and management of this condition.

Single-Session Endoscopic Ultrasound-Directed Transgastric Intervention for a Fine Needle Biopsy of Pancreatic Head Mass Using Endoscopic Through-the-Scope Suturing in a Patient With Roux-en-Y Gastric Bypass Anatomy.

Endoscopic ultrasound (EUS) is a diagnostic tool used to examine pancreatic lesions. In patients who have undergone Roux-en-Y gastric bypass, lesions of the pancreatic head can be difficult to access because of altered foregut anatomy. To access the excluded stomach for better visualization of the pancreatic head, EUS-directed transgastric intervention can be used in a 2-step fashion. We present an interesting case of a 62-year-old woman who underwent a single-session modified EUS-directed transgastric intervention with a fine needle biopsy of a pancreatic head mass. A novel through-the-scope suturing system, the X-tack system (Apollo Endosurgery, Austin, TX), was used to allow for a successful single-session procedure.

The association between adverse cardiovascular outcomes in celiac disease and the role of inflammation: Retrospective analysis using the national inpatient sample.

Celiac disease (CD) is an immune-mediated disease with patients being prone to a proinflammatory state. With recent studies showing an association between adverse cardiovascular events in patients with CD, we aim to further elucidate this relationship. Furthermore, when risk-stratifying patients with cardiovascular disease (CVD), chronic inflammatory conditions such as CD are not included in these calculations. We conducted a retrospective analysis using the National Inpatient Sample database from 2016 to 2019 to investigate the relationship between CD and adverse cardiovascular events. Our secondary endpoints include examining patient demographics, underlying comorbidities, in-hospital mortality, and cost of hospitalization. In addition, we performed a subgroup analysis in the CD cohort to assess if concomitant iron deficiency anemia increased CVD. Our study aims to examine the association between atherosclerosis and inflammation and aims to be a stepping stone for future long-term randomized controlled trials for the incorporation into atherosclerotic CVD risk score stratification.

Impact of interhospital transfer status on outcomes of variceal and nonvariceal upper gastrointestinal bleeding: insights from the National Inpatient Sample analysis, 2017 to 2020.

Background: Variceal and nonvariceal upper gastrointestinal bleeding (VUGIB and NVUGIB, respectively) require prompt intervention. Existing studies offer limited insight into the impact of interhospital transfers on patients with VUGIB and NVUGIB. Methods: We conducted a retrospective study using the US National Inpatient Sample database from 2017 to 2020. The outcomes included in-hospital mortality, incidence of complications, procedural performance, and resource utilization. Results: A total of 28,275 VUGIB and 781,370 NVUGIB adult patients were included. Transferred VUGIB and NVUGIB patients, when compared to nontransferred ones, demonstrated higher inpatient mortality (adjusted odds ratio [AOR] 1.49 and 1.86, P < 0.05). Patients with VUGIB and NVUGIB had a higher likelihood of acute kidney injury requiring dialysis (AOR 3.79 and 1.76, respectively, P = 0.01), vasopressor requirement (AOR 2.13 and 2.37, respectively, P < 0.01), need for mechanical ventilation (AOR 1.73 and 2.02, respectively, P < 0.01), and intensive care unit admission (AOR 1.76 and 2.01, respectively, P < 0.01). Compared to their nontransferred counterparts, transferred VUGIB patients had a higher rate of undergoing transjugular intrahepatic portosystemic shunt (AOR 3.26, 95% CI 1.92-5.54, P < 0.01), while transferred NVUGIB patients had a higher rate of interventional radiology-guided embolization (AOR 2.01, 95% CI 1.73-2.34, P < 0.01) and endoscopic hemostasis (AOR 1.10, 95% CI 1.05-1.15, P < 0.01). Conclusion: Interhospital transfer is associated with worse clinical outcomes and higher resource utilization for VUGIB and NVUGIB patients.

A Rare Case of Bartonella henselae Infective Endocarditis Causing an Embolic Cerebrovascular Accident.

Bartonella is a facultative intracellular Gram-negative aerobic rod that is an important cause of culture-negative endocarditis that only accounts for 3% of all infective endocarditis (IE) cases. Throughout the literature, there have been very few documented cases of an embolic stroke caused by Bartonella henselae (B. henselae) IE. Following a comprehensive review of the literature, it appears that only a small number of articles have reported on the correlation between cerebrovascular accidents (CVAs) and Bartonella IE. Here, we present a case of a 42-year-old male with a cerebral embolic event as a complication of B. henselae IE.

Negative Serum Ascites Albumin Gradient (SAAG) in the Setting of Cholangiocarcinoma: A Case Report.

Ascites is the accumulation of fluid in the peritoneal cavity which leads to abdominal distention. Malignant ascites may occur in several tumor types including liver, pancreas, colon, breast, and ovary. Serum ascites albumin gradient (SAAG) is the difference between albumin in the serum and ascitic fluid. A SAAG greater or equal to 1.1 g/dL is characteristic of portal hypertension. A SAAG less than 1.1 g/dL can be seen in hypoalbuminemia, malignancy, or an infectious process. We report a rare case of malignant ascites in a 61-year-old female patient who presented with a chief complaint of abdominal pain with distention that was preceded by a 25-pound weight loss over the last three months. The patient underwent a paracentesis after a computed tomography (CT scan) revealed a heterogenous liver mass with associated ascites. Ascitic fluid analysis revealed a SAAG of -0.4 g/dL. CT-guided core needle biopsy of the hepatic mass revealed a poorly differentiated carcinoma with immunostaining suggestive of an underlying cholangiocarcinoma. Cholangiocarcinoma is an extremely uncommon etiology of acute new-onset ascites and has not been shown to produce high protein ascites with a negative SAAG. It is therefore important for clinicians to get ascitic fluid analysis in order to calculate a SAAG to help develop differential diagnosis for the cause of ascitic fluid buildup.

A Review on Clostridioides Difficile Testing and How to Approach Patients With Multiple Negative Tests: A Case Report.

Clostridioides difficile (C. difficile) is an important nosocomial infection that is commonly associated with antibiotic use with pseudomembranous colitis being present in only 13% of cases. Disease severity ranges from asymptomatic carriers to severe complicated disease, based on clinical and laboratory findings. There is no single rapid FDA-approved test to diagnose C. difficile infections (CDI) and diagnosis usually requires a multi-step diagnostic approach. C. difficile testing usually begins with the C. difficile toxin and glutamate dehydrogenase antigen screen (GDH). If testing is negative for either, then nucleic acid amplification testing (NAAT) is done to confirm the diagnosis. Endoscopic evaluation may be required in rare instances when there is a high clinical suspicion of disease with negative testing. Here, we present an interesting case of a patient with multiple negative C. difficile toxin and GDH tests. Given the high index of clinical suspicion of CDI, the patient underwent a colonoscopy which revealed diffuse pseudomembranous colitis. The patient was then appropriately treated with oral vancomycin. We aim to shed light on the different testing modalities available to clinicians and the indications for doing a colonoscopy to delineate between false positive testing and active CDI.

Rapidly Progressive Emphysematous Pancreatitis With Massive Hemorrhage and Multi-Organ Failure: A Severe Sequela of COVID-19.

The COVID-19 global pandemic continues to wreak havoc on a number of affected patients and poses a significant burden on the healthcare system. Even though it has been over two years since the pandemic emerged, clinical presentations in affected patients continue to appall clinicians. Emphysematous pancreatitis is a rare, fatal complication of acute necrotizing pancreatitis presenting with a high mortality rate. This rare entity stems from superinfection of acute necrotizing pancreatitis with gram-negative bacteria, most commonly from Escherichia coli (E. coli), among others. Herein, we present a rare case of acute necrotizing pancreatitis complicated by emphysematous necrosis with hemorrhagic conversion and E. coli septicemia in a 60-year-old morbidly obese male patient without any underlying risk factors. He presented with respiratory failure in the setting of COVID-19 and was subsequently diagnosed with acute necrotizing pancreatitis complicated by emphysematous necrosis. To our knowledge, emphysematous pancreatitis in the setting of COVID-19 with no other attributable causes for pancreatitis was not previously reported in the literature. This article aims to report an unusual association between COVID-19 infection and acute emphysematous pancreatitis with evidence of hemorrhagic conversion. Furthermore, given the neoteric nature of this viral infection, we hope to promote sensitivity toward capturing additional clinical features associated with active COVID-19 infection, with the goal to keep clinicians abreast with its many possible sequelae.

COVID-19-Induced Complete Heart Block: Case Series and Literature Review.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to the emergence of a wide range of complications, including those affecting the cardiovascular system. In this case series, we present four patients who developed complete atrioventricular block, a serious and potentially life-threatening heart rhythm disorder, during the course of their coronavirus disease 2019 (COVID-19) illness. The mechanisms by which SARS-CoV-2 may lead to arrhythmias are not fully understood but may involve direct infection and damage to heart tissue, as well as inflammation and cytokine storms. The extent and duration of complete heart block varied among these cases, highlighting the need for further research to understand the spectrum of disease and to improve mortality and morbidity in future waves of SARS-CoV-2 infections. We hope that this case series will draw attention to this serious complication of COVID-19 and inspire further research to improve management and outcomes for affected patients.

A Rare Case of Splenic Artery Thrombosis Provoked By Medroxyprogesterone Acetate Requiring Splenectomy.

Splenic artery thrombosis is estimated to occur in only 0.016% of hospital admissions. Hormonal contraception is known to have hypercoagulable side effects, but splenic artery thrombosis (SAT) followed by functional autosplenectomy is a very rare side effect. We report a case of a 48-year-old female with persistent SAT provoked by depot medroxyprogesterone acetate (DMPA). She initially presented with severe left lower quadrant abdominal pain, and imaging revealed an extensive thrombus in the splenic artery. She was immediately started on intravenous heparin, and her symptoms improved after a few days, at which point she was discharged on oral apixaban. Three months after discharge, the patient presented with symptoms similar to the initial presentation. Further history revealed that she received an injectable DMPA shot prior to her initial admission. Other possible causes of SAT were ruled out. On imaging, her previous thrombus had increased in size and now filled the entire splenic artery. Therefore, the patient underwent robotic splenectomy with remarkable improvement in her symptoms. This case represents a rare clinical manifestation of a hypercoagulable state induced by DMPA. We review the existing literature to explain the epidemiology, presentation, diagnosis, and treatment of SAT, and incorporate our patient's presentation into the existing literature regarding the effect of contraception in inducing thrombotic events.

Blame it on the Drug: A Rare Case of Recurrent Doxycycline-Induced Pancreatitis.

Doxycycline is a broad-spectrum bacteriostatic antibiotic that belongs to the tetracycline class. It is a relatively safe medication with reported side effects being gastrointestinal symptoms, bone and teeth discoloration, photosensitivity, and renal toxicity. Acute pancreatitis (AP) is an uncommon adverse effect with only a few reported cases in the literature. Despite tetracyclines being labeled as a probable causative agent of drug-induced pancreatitis (DIP), doxycycline has been rarely implicated. Herein we present the case of a 65-year-old patient who developed recurrent doxycycline-induced pancreatitis after she was inadvertently started on the medication for community-acquired pneumonia. The most common causes of pancreatitis were ruled out during her hospital admission and she was subsequently diagnosed with DIP. She was successfully treated with the cessation of the offending agent and with supportive therapy. It is critical that clinicians are aware of the possible association between doxycycline and pancreatitis to further aid in the prompt diagnosis and treatment of this condition.

Approach to Cefepime-Induced Neurotoxicity in the Setting of Chronic Kidney Disease: A Case Report and Review of Literature.

Cefepime-induced neurotoxicity is well-known, but an under-recognized event that can present with a myriad of neurological findings ranging from myoclonus to seizures to comatose state. It is more prevalent in patients with impaired renal clearance as it is mainly cleared by the kidneys. We present a case of a 52-year-old female who was managed in the intensive care unit with severe encephalopathy following empiric antibiotic therapy with cefepime. Although we encountered some unforeseen difficulties executing our initial plan of renal replacement therapy, our patient was successfully treated with fluids and intravenous diuresis with furosemide and was ultimately discharged home with full recovery.

An Unusual Case of Non-traumatic Chylothorax.

Chylothorax refers to the presence of chyle in the paraaortic space. This entity most commonly occurs from injury to the thoracic duct, which carries chyle from the gastrointestinal tract to the bloodstream. Common etiologies around traumatic chylothorax include iatrogenic causes, such as surgical procedures near the thoracic duct and penetrating and blunt injuries to the chest. We present a case of a 49-year-old female who initially presented to the hospital with progressively worsening dyspnea leading to acute hypoxic respiratory failure requiring intubation and admission to the ICU. The patient's presentation was initially thought to be due to and managed as an infectious process with empyema and septic shock until a diagnosis of nontraumatic chylothorax was established. In this article, we report a complicated case of chylothorax, initially masquerading as an infectious pulmonary process. We hope to raise this entity high on the differential when clinicians are confronted with the task of managing patients with similar presentations, which will, in turn, prevent delayed diagnosis and the unnecessary use of antibiotics.

Herpes Simplex Encephalitis: Detection, Management, and Outcomes.

The pathophysiology of herpes simplex encephalitis (HSE) is incompletely understood and proposed to be secondary to the retrograde transport of the herpes simplex virus type 1 (HSV-1) via the trigeminal and/or olfactory nerves to the central nervous system (CNS). In this case report, we present a 68-year-old female who presents to our emergency department after a fall. Upon initial admission, her neurological examination was benign, and a computer tomography (CT) scan of her brain showed a subdural hematoma for which she was treated conservatively. Day 4 of her hospitalization marked a rapid decline in her course of illness, beginning with confusion and hallucinations, progressing to subclinical seizures, and culminating in irreversible brain damage and palliative extubation on day 16 of hospitalization. This case report discusses our insight into the challenges of early diagnosis and treatment of herpes encephalitis and their impact on improving patient outcomes.

A Rare Case of a Life-Threatening Massive Upper Gastrointestinal Bleed and Airway Obstruction in a Patient With a Megaesophagus Secondary to Longstanding Achalasia.

Achalasia is a relatively rare motor disorder characterized by esophageal aperistalsis and incomplete relaxation of the lower esophageal sphincter. In only 10% of patients, untreated or poorly managed achalasia can progress to esophageal dilation and eventual loss of total functionality resulting in a characteristic sigmoid dolichomegaesopahagus. In extremely rare instances, this sigmoid dolichomegaesopahagus can present clinically as acute airway obstruction or a fatal, life-threatening hemorrhage requiring immediate intervention. We present the case of a 65-year-old female with a past medical history of long-standing achalasia who had complaints of shortness of breath, chest pain, and two episodes of life-threatening hematemesis requiring a blood transfusion. An angiography illustrated significant distention of the esophagus occupying most of the right hemithorax and non-specific intraluminal fluid with a small amount of gas. Emergent esophagogastroduodenoscopy showed fibrosis and necrosis of the esophageal mucosa with food debris, suggesting that the bleeding was likely coming from an ulcer caused by pressure necrosis. The patient was hemodynamically unstable after the procedure and was transferred to another facility the next day for an esophagectomy. Patients with achalasia have an increased susceptibility to develop pressure ulcers due to increased shear force on the esophageal wall, increased moisture of the esophageal wall from prolonged contact of food boluses, and underlying malnutrition and weight loss from the indigestion of food causing atrophy of the mucosal barriers. The management of these ulcers is to treat and manage the underlying cause. Although there are no curative treatments for achalasia, symptomatic relief through both surgical and medical therapies are the mainstay of management, with an esophagectomy reserved for refractory cases or in patients who develop end-stage complications.