Bartonella henselea Prosthetic Valve Endocarditis Mimicking Vasculitis: A Case Report With Literature Review.

Description We present one of the first reported cases of Bartonella henselae prosthetic valve endocarditis, which mimicked p-antineutrophil cytoplasmic autoantibody (p-ANCA), an anti-proteinase 3 positive necrotizing glomerulonephritis caused by a cat scratch resulting in temporary dialysis. Documentation of such infections is necessary as zoonotic infections are becoming more prevalent with early identification essential for proper treatment. Although pauci-immune patterns are not a unique finding in bacterial endocarditis associated with glomerulonephritis, they are an atypical finding in Bartonella henselae endocarditis. Furthermore, p-ANCA-associated vasculitis can also be responsible for renal and cardiac disease. Because of the similar disease presentation of different etiologies (autoimmune and infectious), it can make the diagnosis much more challenging. Our patient's presentation is unique as there are no documented cases in the medical literature of Bartonella henselae resulting in temporary hemodialysis from previously healthy kidneys with recovery. Our case documents the success of early identification and appropriate treatment.

Physicians at the crossroad of prognosis and faith: practical help communicating with patients and families during the COVID-19 pandemic.

Physicians will ultimately face the necessary but unpleasant task of caring for a dying patient at some point in their careers. Communicating with patients or their families during such dire times is very important especially when the patient or family members have unrealistic expectations. Herein, we have highlighted practical suggestions which if applied can prevent unnecessary draining encounters with patients and families; for example, incorporating ancillary staff such as palliative and pastoral care into the care team. We have also proposed a new concept of 'physician optimism'. Based on this concept, the physician can be classified as a pessimist or an optimist with realistic or unrealistic expectations and communicate to patients with or without requisite empathy. To ensure the best outcomes, we conclude that physicians must be realistic optimists who always communicate with empathy. Unrealistic optimism, no matter how well-intentioned, is deceiving to patients and their families will never allow a culture of trust.

COVID-19 Coagulopathy: Current knowledge and guidelines on anticoagulation.

COVID-19-associated coagulopathy (CAC) is a feature of COVID-19 that can lead to various thrombotic complications and death. In this review, we briefly highlight possible etiologies, including direct cytotoxicity caused by the SARS-CoV-2 virus, and the activation of proinflammatory molecules such as cytokines, underlying coagulopathy. Endothelial dysfunction has been highlighted as pivotal, irrespective of the mechanism involved in CAC. Specific features of CAC distinguishing it from disseminated intravascular coagulopathy and sepsis or ARDS-associated coagulopathy have been discussed. We have also highlighted some hematological parameters, such as elevated d-dimers and partial prothrombin and prothrombin times prolongation, which can guide the use of anticoagulation in critically ill patients. We conclude by highlighting the importance of prophylactic anticoagulation in all COVID-19 hospitalized patients and reiterate the need for institution-specific guidelines for anticoagulation COVID-19 patients since individual institutions have different patient populations.

Amiodarone induced "Blue man syndrome"; an unusual presentation.

Amiodarone is a common antiarrhythmic medication used in daily practice with excellent efficiency. While it has many benefits, there are several common adverse reactions, such as abnormal thyroid function and cornea verticillata, associated with its use. A much less common adverse reaction is the so-called "Blue man syndrome," occurring in 1-3% of patients. Blue man syndrome is thought to stem from the deposition of lysosomal membrane-bound dense bodies, similar to lipofuscin, in the dermis of patients on chronic amiodarone therapy. We present the case of a 77-year-old male who presented to us post-cardiac arrest secondary to hyperkalemia of 7.0. Although it was noted in the patient's chart that he had an "allergy" to amiodarone (it was noted in his chart it only turned his leg black), it was used in the emergency department because of the failure of other antiarrhythmics to treat his arrhythmia and all other medical options were exhausted. It was decided that the benefits of using amiodarone far outweighed the risks of it. Ultimately it was found that the patient did not have a true allergy to amiodarone, but suffered from a known benign adverse effect of the drug resulting in a greyish-blue tinge to his bilateral lower extremities. His-presentation differs from the normal presentation of blue man syndrome which appears more commonly on sun-exposed areas of the body such as the face and arms. While this is a benign adverse effect of amiodarone, it can be very distressing to patients and must be addressed.

Persistent Postprandial Angina in a Patient With Gastroesophageal Reflux Disease: A Diagnostic Dilemma.

Chest pain (CP) is a common reason for visits to the emergency department (ED). The underlying etiology of a good number of cases of CP can be diagnosed with adequate history taking and routine laboratory testing. However, atypical presentations of CP, in the settings of other causes of CP such as gastroesophageal reflux disease (GERD), can sometimes be tricky to diagnose with only routine lab tests and electrocardiogram (EKG). Herein, we present a 73-year-old male with a history of GERD and coronary artery disease who presented to our ED complaining of postprandial CP unaffected by exertion or rest. Initially, his symptoms were thought to be GERD-related but other heart-related causes of CP were considered due to the persistence of his CP postprandially. A cardiac stress test was subsequently done to rule out possible cardiac causes of his CP. His stress test was abnormal prompting heart catheterization that showed almost complete occlusion of his left anterior descending (LAD) and left circumflex (LCx) arteries. His symptoms resolved post-catheterization/stenting of his LAD and LCx arteries. He was later discharged unconditionally. His presentation highlights the required vigilance physicians must maintain when interrogating CP, even when other non-cardiac-related causes seem more plausible.

Convalescent Plasma in COVID-19.

Description The recent pandemic of SARS-CoV-2, which causes novel coronavirus disease 2019 (Covid-19), has had devastating impact on a global and national scale. In order to overcome this outbreak it is imperative we find treatments that are safe and effective. To date, no definitive treatment is available that can curtail the spread of this viral syndrome. Convalescent plasma (CP) is one such option that has repeatedly served as an important tool in treatment of various bacterial and viral infections, especially in the setting of no specific antimicrobial or vaccination against an infectious disease. Herein, we review the history of CP, prior usage of CP in various infections and pandemics to date, mechanism of action of the same and conclude with a brief overview of the experience gained so far with use of CP in COVID-19.

Recurrent Venous Thromboembolism in a Patient with Klippel-Trenaunay Syndrome Despite Adequate Anticoagulation with Warfarin.

Klippel-Trenaunay syndrome (KTS) is a rare genetic condition defined by capillary malformation, venous malformation, and soft tissue and bony overgrowth. Due to venous malformations, individuals are predisposed to intravascular coagulopathy leading to thrombosis and thromboembolism. However, anticoagulating these patients long-term remains a challenge because of the presence of capillary malformations that increase bleeding risk. We present a rare case of a 30-year-old Caucasian male with KTS and history of gastrointestinal bleeding who has been on anticoagulation since the age of 7 and has had three different inferior vena cava filters placed during his lifetime. At presentation, he had dyspnea with stable vital signs. His prothrombin time/international normalized ratio was 37.3 and 3.2, respectively and chest computed tomography showed bilateral segmental pulmonary embolism (PE). He was treated with heparin drip and his home anticoagulation was switched from warfarin to apixaban at the time of discharge for better anticoagulation optimization. KTS is a condition associated with venous thromboembolic complications that can be difficult to manage. PE should remain on the top of the list of differential diagnoses in patients with KTS presenting with dyspnea even if laboratory findings suggest an alternate diagnosis.

An atypical complicated left-sided bronchopleural fistula presenting more than seven months after lobectomy.

BACKGROUND: Bronchopleural fistulas (BPF) are abnormal sinus tracts connecting the bronchi and pleural cavity and form after surgical resection of a lung lobe. It is a complication with potentially disastrous sequelae including, failure of the bronchial stump to heal, ischemia of the affected area, and/or infection of the stump. Bronchopleural fistulas caused by surgical intervention most commonly present on the right side and within 7-12 days post-operatively, i.e., subacutely. While the fistula may initially be asymptomatic, they carry a mortality rate of 25-71% in the absence of other comorbidities. CASE PRESENTATION: A 60-year-old female developed a BPF more than seven months after a left lower lobe lung lobectomy for non-small cell adenocarcinoma is presented. She was seen at our hospital on multiple occasions after her lobectomy with no evidence of a developing fistula on chest computer tomography (CT) during those visits. During her most recent presentation, roughly 7 months postoperatively, she was noted on imaging to have a new left-sided bronchopleural fistula. Bronchoscopy with lavage and culture of the fistula grew Pseudomonas Aeruginosa, for which she received appropriate treatment. Further surgical interventions were deferred due to poor prognosis. Her presentation differed from the typical BPF presentation in that it was left-sided and occurred out of the window of its usual occurrence. CONCLUSION: Late-onset BPF is an important diagnosis to consider in patients who have undergone lung resection, regardless of the type of surgery or postoperative duration, especially when patients are known to have multiple predisposing factors.

Bullous cellulitis caused by Pseudomonas putida in a patient with end-stage renal disease.

We present a case of bullous cellulitis in a 75-year-old male caused by Pseudomonas putida (P. putida) acquired from contact with contaminated water. Careful documentation of P. putida soft tissue infection is warranted given the rise in infections, marked antimicrobial resistance, and fatalities observed in a limited number of cases.

ANCA-Associated Intrahepatic Duct Injury Associated with Levamisole-Adulterated Cocaine.

Damage to the liver or kidney can occur through direct toxic effects; however, damage can also be drug-induced immune-mediated. Levamisole-adulterated cocaine (LAC) is known to cause antineutrophil cytoplasmic antibody- (ANCA-) associated vasculitis and glomerulonephritis leading to acute kidney injury and end-stage renal disease. It remains unclear whether LAC is associated with hepatic duct damage. Here, we report a case with biopsy-proven evidence of intrahepatic duct damage months after being diagnosed with ANCA-associated crescentic and sclerosing glomerulonephritis caused by LAC use. This case represents the first report of LAC-induced ANCA-associated hepatic duct cholestasis in the setting of previous LAC-induced ANCA-positive glomerulonephritis.

Possible Association of Tremors and Dysarthria with Losartan Use: A Case Report.

Losartan is a common first-line antihypertensive medication particularly useful in a select patient population. Common side effects of the drug include headaches, dizziness, fatigue, nausea, vomiting, and anemia. The only well-documented detrimental side effect of losartan is angioedema/anaphylactoid reactions. Here, we present a case of a 56-year-old Caucasian male who developed tremors and dysarthria one hour after taking losartan. His symptoms were severe enough to require hospitalization and close monitoring. His symptoms later resolved without any targeted treatment. This is the first reported case of tremors and dysarthria associated with the use of losartan which could represent an entirely benign side effect or an initial sequela of a potentially detrimental side effect that warrants our attention.