Acute Pericarditis Leading to a Diagnosis of SLE: A Case Series of 3 Patients.

In systemic lupus erythematosus (SLE), cardiac manifestations are known to be present in up to 50% of patients. However, it is rare for acute pericarditis to be the leading symptom at the time of diagnosis of SLE occurring in up to 1% of patients. We present a case series in which 3 patients with no prior history of SLE presented with acute pericarditis. This was found to be the leading manifestation of their disease, which ultimately led to the diagnosis of SLE. These patients were initially treated with nonsteroidal anti-inflammatory drugs and colchicines; however, steroids and disease-modifying anti-rheumatologic agents were ultimately added to their medical therapy.

An Unusual Case of Paraquat-Induced Rhabdomyolysis and Hepatic Injury Presenting With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is a syndrome of reversible left ventricular systolic dysfunction that, at presentation, can be easily conflated with acute coronary syndrome. TCM has a clinical preponderance for older, postmenopausal females. We report on a patient's case who presented with complaints of upper and lower extremity weakness with evidence of rhabdomyolysis and hepatic injury. Her occupation as a field worker exposed her to a toxic chemical known as paraquat, which has been banned by multiple countries across the world; a chemical we presume culminated in both. The subsequent clinical cascade and resulting acute physiological illness and emotional distress primed her to develop TCM. However, she neither endorsed chest pain nor dyspnea. Her subtle clinical presentation could have led to a missed diagnosis as she was also not in a fluid overloaded state consistent with the depressed left ventricular function discovered on transthoracic echo. The diagnostic uncertainty until coronary angiography is obtained, and its association with severe and acute emotional and physical stress prompts to a greater reliance on patient history to identify occupational and toxic exposures that can contribute to its development.

Isolated myeloid sarcoma of lumbar spine without bone marrow involvement: a rare case report and treatment dilemma.

Granulocytic sarcoma, chloroma, myeloblastoma, or here referred as myeloid sarcoma (MS), is a rare extramedullary tumor composed of immature myeloid cells called myeloblasts. MS is seen most commonly in patients with acute myeloid leukemia and less frequently in chronic myeloid leukemia, myelodysplastic syndrome. In rarer instances, MS has been shown to precede the development of myeloid tumors by acute myeloblastic leukemia (AML). In particular, isolated MS involving spine is extremely rare. We herein present a rare case of isolated spinal MS in non-leukemic patient. This is a previously relatively healthy 47-year-old man who presented with signs of lumbar spinal cord compression, initially reported as schwannoma on imaging, later diagnosed with spinal MS on pathology. Further workup did not reveal any evidence of bone marrow or other hematological involvement. The patient successfully treated by L4/L5 laminectomy and debulking with subsequent radiation resulting in substantial decrease in size of tumor with significant improvement in symptoms during follow up. This case not only describes a rare case of isolated MS of lumbar spine, but also highlights the potential treatment challenges of such a rare diagnosis. We review the available literature, discuss available treatment options, and highlight the need for further investigations along with increased clinician awareness.

Locus Minoris Resistentiae: Two Cases of Malignant Metastasis and Review of Literature.

Locus minoris resistentiae refers to a region of decreased resistance within the body. This occurs from changes to the microenvironment secondary to previous trauma and results in increased vulnerability. As a result, infection, inflammatory processes, and malignancy may localize to this area. In this article, we describe 2 unique cases of malignancy, primary prostate carcinoma and serous carcinoma of the ovary, both of which disseminated to sites of prior trauma. We review the available literature, discuss proposed pathophysiology, and highlight the need for further investigations along with increased clinician awareness.

Successful Clozapine Re-Challenge After Suspected Clozapine-Induced Myocarditis.

BACKGROUND Clozapine plays a unique role in the management of treatment-resistant schizophrenia (TRS). Clozapine re-challenge following an episode of myocarditis is controversial, with a very limited literature, although it may be crucial in the recovery of certain patients. To date and to the best of our knowledge, only 10 of 22 studied cases reported successful clozapine retrial after myocarditis. CASE REPORT We present the case of a 22-year-old Hispanic man with treatment-resistant schizophrenia and polysubstance use disorder (methamphetamine, cannabis, and alcohol) initiated on aggressive clozapine titration after lack of response to several other therapies. Approximately 16 days after clozapine trial, the patient developed cardiac function impairment, presenting with chest pain, notable elevation in several biomarkers (troponin: 0.72 ng/ml, ESR >100 mm/h, CRP: 20.8 mg/dl, and BNP: 999 ng/ml), and a depressed ejection fraction at 25%. Further assessments also showed positive hepatitis A serology. Following discontinuation of clozapine and providing supportive care, the patient's physical symptoms resolved. He had a relapse of psychotic symptoms, which were refractory to treatment with other antipsychotic agents. Subsequently, the patient underwent a second clozapine trial under close monitoring, with resolution of his psychosis. Repeated echocardiography demonstrated improved EF to 50%, transaminitis was resolved, repeat blood test results were normalized, and the patient was discharged while he was stabilized and asymptomatic. CONCLUSIONS This case adds to the previous case reports and suggests that clinicians may consider clozapine re-challenge following an episode of myocarditis based on clinical judgment, on a case-by-case basis, and under close monitoring. We highlight the need for development of clinical guidelines for clozapine re-challenge.

A Progressive Case of Eosinophilic Myocarditis Due to Eosinophilic Granulomatosis With Polyangiitis in a Caucasian Male.

Vasculitis is an inflammatory process involving blood vessels of various sizes, including the small vessels in the kidneys to the large vessels, such as the aorta. This inflammatory condition is usually autoimmune in nature and is associated with involvement of many locations, such as the sinuses, lungs, kidneys, and even the heart. Specifically, eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis that may initially hide as asthma, allergic rhinitis, and/or sinusitis. However, it is known to become a lethal disease once progressed to include cardiovascular manifestations. It is important to remember EGPA as a differential for any patient with a history of asthma, allergic rhinitis, and/or sinusitis who also presents with cardiovascular complaints and eosinophilia. Treatment recommendations focus on immunosuppression in such cases. In this article, we discuss the case of a 62-year-old male, with a known history of asthma, who presented to the emergency department with concern for his chest pain and right-sided weakness. He was later diagnosed with EGPA with eosinophilic myocarditis. Diagnosis and treatment are described.

Acute Interstitial Nephritis: A Rare and Unusual Side Effect of Omalizumab.

Acute interstitial nephritis (AIN) is a relatively common cause of acute kidney injury with etiologies that include drug therapy, infections, and systemic diseases. Of these etiologies, drug therapy accounts for ~70% of AIN cases. Although any drug can cause AIN, there are no reported cases of AIN caused by omalizumab, a humanized monoclonal antibody that binds to and inhibits circulating immunoglobulin E. In this article, we share the first reported case of AIN following administration of omalizumab for the treatment of moderate to severe persistent asthma.

Acute Myelogenous Leukemia With Trisomy 8 and Concomitant Acquired Factor VII Deficiency.

Acquired isolated factor VII deficiency is a rare bleeding disorder and has been reported in 31 cases. This is in contrast to congenital factor VII deficiency, which while also infrequent is the most common rare congenital bleeding disorder. Acquired isolated factor VII deficiency has been described primarily in patients with solid malignancies, sepsis, and in the presence of anti-factor VII autoantibodies. We report a case of acute myelogenous leukemia with an associated trisomy 8 cytogenetic abnormality presenting with factor VII deficiency. The factor VII deficiency cleared after induction chemotherapy and with the disappearance of the cytogenetic and molecular abnormalities. We discuss a possible link between trisomy 8 and vitamin K metabolism, which might result in acquired factor VII deficiency in acute myelogenous leukemia.

Concomitant Central Nervous System Toxoplasmosis and Seronegative Disseminated Coccidioidomycosis in a Newly Diagnosed Acquired Immune Deficiency Syndrome Patient.

Opportunistic infections (OIs) are a significant cause of morbidity and mortality in immunosuppressed patients and may be due to bacteria, virus, protozoa, or fungi. Toxoplasmosis is a common cause of central nervous system infection in human immunodeficiency virus (HIV) patients. Coccidioidomycosis is a relatively common fungal infection that may lead to disseminated disease and fungemia in immune-compromised hosts living in endemic regions. This single-patient case report documents the presentation, diagnosis, management, and outcome of concomitant central nervous system toxoplasmosis and diffuse miliary pneumonia with fungemia due to disseminated seronegative Coccidioides immitis in a 33-year-old male patient recently diagnosed with chronic advanced HIV. Impaired cellular immune function, such as defects in the IL-12/IFN-γ pathway or T-helper IL-17-mediated response, is associated with increased severity of coccidioidomycosis. Fungemia and acute respiratory distress syndrome are both associated with very high mortality in coccidioidomycosis. In HIV hosts, negative Coccidioides serology can be seen in up to 25% of cases and therefore other diagnostic modalities should be initiated promptly and simultaneously. This case demonstrates simultaneous OI in the setting of advanced acquired immune deficiency syndrome and emphasizes the need for early diagnosis of HIV and OI in order to ensure prompt initiation of antiretroviral therapy, prophylactic, and therapeutic medications.

Leptomeningeal Carcinomatosis From Carcinoma of Unknown Primary in a Young Patient: A Case Report and a Literature Review.

Leptomeningeal carcinomatosis, leptomeningeal meningitis, or, as referred here, leptomeningeal metastasis (LM), is a rare but frequently fatal complication seen in advanced stage of cancer either locally advanced or after a metastasis of a known primary cancer. We present a rare and uncommon case of leptomeningeal metastases from carcinoma of unknown primary. A 32-year-old female was diagnosed with LM; however, no known primary carcinoma was identified after 2 separate biopsies. The first biopsy of the right pre-tracheal lymph node showed poorly differentiated pan-keratin (AE1 and AE3) and placental alkaline phosphatase with the possibility of germ cell origin. Second cytology of cervical lymphadenopathy was remarkable for cytokeratin 7 and 20, placental alkaline phosphatase, and CDX2 suggestive of germ line tumor with both mucinous ovarian and gastrointestinal carcinomas. Unfortunately, the LM progressed rapidly despite multiple cycles of germ cell origin directed systemic and intrathecal chemotherapy, and the patient opted for hospice care without getting a chance to identify the primary source.

An Unusual Presentation of Spinal Giant Cell Glioblastoma in a 21-Year-Old Female.

Primary spinal cord giant cell glioblastoma multiforme of the thoracic spinal cord is a rarely-diagnosed primary spinal cord tumor in comparison to neoplasms in intracranial locations. In this article, we highlight a young adult who was diagnosed with intramedullary giant cell glioblastoma, IDH wild-type, World Health Organization grade IV/IV of the thoracic spinal cord. This case report describes the treatment approach with a postsurgical combination of radiation therapy and temozolomide, which resulted in the patient to return to her baseline of health only to later develop neurological symptoms significant for a recurrence of malignancy. In a review of the literature of described cases of primary spinal cord glioblastoma multiforme, prognosis continues to be unfavorable as current treatment options of the aggressive malignancy remain absent of a cure.

A Synchronous Diagnosis of Metastatic Male Breast Cancer and Prostate Cancer.

In this article, we present a patient diagnosed synchronously with metastatic male breast cancer and prostate cancer. This is a 63-year-old male and recent immigrant from Nigeria, who sought medical attention for progressively worsening of shortness of breath and acute progression of a chronic right breast mass. An invasive breast carcinoma was diagnosed by the core biopsy of the right breast mass. Within 2 months of his breast cancer diagnosis, the patient also was diagnosed with prostate adenocarcinoma after being worked up for urinary retention. By presenting this patient with a synchronous diagnosis with metastatic male breast cancer and prostate cancer, history of chronic right breast mass, and gynecomastia, we speculate on possible cancer etiologies and risk factors.