An Extragastrointestinal Stromal Tumor Arising From the Omentum in a Young Hispanic Male.

Gastrointestinal stromal tumors (GISTs) are neoplasms arising from the bowel wall, most often in the jejunoileum of the small intestine, but rarely from extragastrointestinal locations. GISTs most often occur in patients older than 40 years of age and can present with a multitude of gastrointestinal symptoms. We present a rare case of an extragastrointestinal stromal tumor (EGIST) causing abdominal pain and melena in a 34-year-old Hispanic male. The patient presented with diffuse abdominal pain, melena, and severe anemia. Computed tomography of the abdomen revealed a large mass abutting the small bowel. The patient was taken to surgery where the mass, which appeared to be deriving from the omentum and invading the adjacent small bowel, was completely excised and found to be a spindle cell GIST. Excision margins were determined to be negative, and the patient was started on a tyrosine kinase inhibitor for maintenance therapy. The patient continues to follow up on an outpatient basis for surveillance. This case represents the rare disease entity EGIST presenting outside the typical demographics of the disease in a young patient with no identified previous genetic syndromes. Gross examination of the mass in this case was also atypical given the appearance that the mass was rooted in the omentum and invading the small bowel which would suggest the primary tumor site was extragastrointestinal. This case demonstrates the need to build a differential diagnosis that includes GIST and the ability to successfully treat this disease if it is identified early in the clinical course.

Moyamoya Disease Causing Stroke in the Setting of Cocaine Use and Uncontrolled Hypertension Due to Primary Hyperaldosteronism.

Moyamoya disease is a cerebrovascular disease characterized by stenosis of large intracranial arteries and the development of smaller collateral vessels. Moyamoya may cause strokes and stroke-like symptoms in young patients. It has also been linked to autoimmune diseases and neuropsychiatric conditions. We present a case of moyamoya disease in a young patient with concomitant hyperaldosteronism, uncontrolled hypertension, and cocaine use disorder, along with features of antisocial personality disorder. This is a unique presentation of an underlying neurological disease causing psychiatric features exacerbated by cocaine use, and it describes a rare clinical presentation that physicians should consider in patients with moyamoya disease.

Anticoagulation Use as an Independent Predictor of Mortality and Major Adverse Cardiovascular Events in Hospitalized COVID-19 Patients: A Multicenter Retrospective Analysis.

Background: Coronavirus disease 2019 (COVID-19) is associated with increased incidence of cardiac arrhythmias and thrombotic events. The adverse cardiovascular outcomes related to ambulatory anticoagulation (AC) therapy in COVID-19 patients are unknown. The goal of this study was to identify the effects of AC use in hospitalized COVID-19 patients. Methods: This is a multicenter, retrospective study that identified 2,801 hospitalized COVID-19 polymerase chain reaction (PCR)-positive patients admitted between March 2020 and July 2021. Of these, 375 (13.4%) were ambulatory AC users. Data were collected from the electronic health records of hospitalized patients. Mortality included in-hospital death and hospice referral. Major adverse cardiovascular events (MACEs) included acute heart failure (HF), myocardial infarction (MI), myocarditis, pulmonary embolism (PE), deep venous thrombosis (DVT), pericardial effusion, pericarditis, stroke, shock, and cardiac tamponade. A Chi-square test was used to analyze categorical variables, and multivariate logistic regression analysis was performed to account for comorbidities. Results: AC non-users exhibited a higher incidence of mortality than AC users (13.9% vs. 7.7%, P = 0.001). However, MACE incidence was higher in AC users than AC non-users (44.8% vs. 26.8%, P < 0.001). The higher MACE incidence was driven by higher rates of acute HF (8.3% vs. 2.5%, P < 0.001), MI (26.9% vs. 18.2%, P < 0.001), PE/DVT (16.3% vs. 2.7%, P < 0.001), pericardial effusion (1.6% vs. 0.5%, P = 0.025), and stroke (2.9% vs. 1.2%, P = 0.018). After multivariate logistic regression, MACE incidence remained higher (odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.27 - 2.05, P < 0.001) and all-cause mortality rate lower (OR = 0.34, 95% CI: 0.23 - 0.52, P < 0.001) in AC users. Conclusions: Ambulatory AC use is associated with increased MACEs but decreased all-cause mortality in patients hospitalized with COVID-19. This study will help physicians identify patients at risk of cardiovascular mortality and direct management based on the identified risk.

HHV-6 Infection in a 19-Year-Old Liver Transplant Recipient - Much More Than Roseola!

Human herpesvirus 6 (HHV-6) infections, most commonly occurring during childhood, are frequently mild and self-limited. However, immunosuppression due to transplantation may cause reactivation of HHV-6 with manifestations ranging from fever and skin exanthem to pneumonitis, hepatitis, encephalitis, and myelitis. Because these infections may be devastating for liver transplant recipients leading to transplant organ fibrosis and failure, it is imperative that internists recognize the manifestations, establish early diagnosis, institute appropriate therapy, and make timely referrals to transplant specialists. We present a case of a 19-year-old liver transplant recipient with HHV-6 viremia, encephalopathy, and hepatitis. The patient's symptoms improved with ganciclovir and intravenous immunoglobulin treatment, serum HHV-6 copies gradually decreased, and she was discharged with outpatient follow-up. After approximately one month of antiviral therapy, the patient's viral load was undetectable. Early recognition of HHV-6 viremia, appropriate laboratory assessment, and early institution of therapy is important for internal medicine physicians to decrease morbidity and mortality in liver transplant recipients.

Coronary Artery Disease as an Independent Predictor of Cardiovascular Mortality in COVID-19 Patients.

Background: Coronavirus disease 2019 (COVID-19) is associated with increased risk of cardiovascular mortality. However, little is known about the combined effect of coronary artery disease (CAD) and COVID-19 on mortality. We aimed to investigate the incidence of cardiovascular and all-cause mortality in COVID-19 patients with CAD. Methods: This multicenter retrospective study identified 3,336 COVID-19 patients admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess whether CAD and its subtypes were associated with mortality. Results: This study shows that CAD was not an independent predictor of all-cause mortality (odds ratio (OR): 1.512, 95% confidence interval (CI): 0.1529 - 14.95, P = 0.723). However, there was a significant increase in cardiovascular mortality in patients with CAD compared to those without (OR: 6.89, 95% CI: 2.706 - 17.53, P < 0.001). There was no significant difference in all-cause mortality in patients with left main artery and left anterior descending artery disease (OR: 1.29, 95% CI: 0.80 - 2.08, P = 0.29). However, CAD patients with a history of interventions (e.g., coronary stenting or coronary artery bypass graft) showed increased mortality compared to those solely treated by medical management (OR: 1.93, 95% CI: 1.12 - 3.33, P = 0.017). Conclusions: CAD is associated with a higher incidence of cardiovascular mortality but not all-cause mortality in COVID-19 patients. Overall, this study will help clinicians identify characteristics of COVID-19 patients with increased risk of mortality in the setting of CAD.

Immune-Mediated Necrotizing Myopathy Manifesting after Five Years of Statin Therapy.

Immune-mediated necrotizing myopathy (IMNM) is an increasingly common and serious condition in which autoantibodies attack muscle fibers causing clinically significant muscle weakness, fatigue, and myalgias. Recognizing the clinical presentation of IMNM is difficult but necessary, as rapid intervention decreases morbidity. We present a case of a 53-year-old female with IMNM induced by statin therapy with confirmed anti-3-hydroxy-3-methylglutaryl coenzyme A reductase antibodies present on serologic testing. The patient's statin therapy was halted, and the patient was provided with one dose of methylprednisolone and ongoing therapy with mycophenolate. She showed subsequent slow improvements in her muscle weakness and myalgias. It is important for clinicians to be aware of the possible consequences of statin therapy, as these drugs are generally regarded as benign in the medical community. Clinicians should also be aware that statin-induced myopathy can occur at any time during statin therapy. The condition does not necessarily correlate with beginning a new statin medication, as demonstrated in this case in which the patient was on chronic statin therapy before developing symptoms. Continued clinician education and building the fund of medical knowledge regarding this disease are vital to enable clinicians to recognize this disease and act promptly to reduce patient morbidity and improve outcomes.

Purple Urine Bag Syndrome: A Rare and Surprising Clinical Presentation.

Purple urine bag syndrome (PUBS) is a rare finding that can be very alarming to patients and physicians. PUBS has a simple visual diagnosis with clinical symptoms that can aid in a quick and appropriate treatment plan. However, a lack of physician awareness could be harmful to the patient and cause unnecessary treatment and increased morbidity and financial burden to the patient. We present a case with this surprising finding and discuss the pathophysiology and management options for this rare syndrome.

A Rare Presentation of Primary Central Nervous System Lymphoma in an Immunocompetent Patient.

Primary central nervous system lymphoma (PCNSL) is a rare non-Hodgkin's lymphoma (NHL) that can develop in the brain, spinal cord, leptomeninges, and vitreoretinal space. The majority of cases are diffuse large B-cell lymphomas. Risk factors include immune dysfunction, prior Epstein-Barr viral infection, HIV, and a family history of non-Hodgkin's lymphoma. Although the majority of the patients are immunocompromised, PCNSL is still seen in immunocompetent patients. PCNSL has a poor prognosis and a high relapse rate despite its radiosensitive and chemosensitive nature. It is important to recognize and diagnose PCNSL early to improve outcomes. We present a case of PCNSL in an immunocompetent adult with no previously known risk factors. We present a case of a 66-year-old male who presented with a 1.5-week history of right-sided headache and left-sided weakness. After being admitted for further evaluation, he underwent multiple laboratory tests and imaging studies. The CT head indicated ill-defined hypodensities in the pons and left cerebellum. CTA revealed a 1.5 cm outpouching along the medial aspect of the distal left cervical internal carotid artery at the C1-C2 level concerning a pseudoaneurysm. Neurology was consulted, and an MRI of the brain revealed equivocal brain lesions. Neurosurgery was consulted, and the patient underwent an open brain biopsy, which revealed a high likelihood of primary CNS lymphoma based on intraoperative pathology findings. CSF analysis revealed an elevated percentage of lymphocytes, including the presence of atypical lymphocytes as well as elevated oligoclonal bands. Subsequent pathology results confirmed PCNSL. The oncology service was consulted, and the patient was started on corticosteroids and methotrexate for chemotherapy as well as leucovorin. This case represents a rare presentation of PCNSL in which the patient had no known history to support an immunocompromised state. Imaging findings, in this case, were also atypical for a primary CNS lesion as they were mostly equivocal. Furthermore, imaging findings showed diffuse CNS disease rather than an obvious primary lesion as typically demonstrated in the literature. In this case, the open brain biopsy was pivotal in making a timely diagnosis and beginning disease-modifying therapy as early as possible. This case demonstrates the imperative need for clinicians to be aware of varying presentations of PCNSL and possibly consider pursuing a definitive diagnosis with biopsy when the differential includes PCNSL but remains broad after advanced imaging.

A Rare Case of p190 BCR-ABL B-cell Acute Lymphocytic Leukemia With Excellent Response to Hyper-CVAD and Ponatinib.

Acute lymphoblastic leukemia (ALL) is a hematologic cancer that begins in the bone marrow and results in an overproduction of lymphocytes. It can present as palpable purpura, which is also seen in many other pathologies, including vasculitides such as IgA vasculitis. We present a case of a 52-year-old male who presented to our hospital from an outside facility specifically for plasma exchange for treating a previously diagnosed IgA vasculitis. After being admitted for further evaluation, it was noted that the patient had a diffuse petechial non-blanching purpuric rash bilaterally covering the lower extremities, trunk, upper extremities, and tongue. The patient was also noted to have severe pancytopenia. Fluorescence in situ hybridization (FISH) demonstrated the presence of t(9:22), indicating Philadelphia chromosome rearrangement. The patient was diagnosed with ALL. The patient underwent induction chemotherapy and was continued on hyper-CVAD protocol with intrathecal chemotherapy. The patient appeared to respond well to treatment and is currently undergoing subsequent intermittent chemotherapy. In this case, the diagnosis of B-cell ALL (B-ALL) blast crisis was pivotal in providing the correct therapy to this patient, and the case demonstrated that even rare presentations of B-ALL in this population with rare mutations responds avidly to tyrosine kinase inhibitors.