A Rare Presentation of Sarcoidosis in a Young Male With Acute Renal Failure: A Case Report and Literature Review.

Sarcoidosis presents in a variety of ways, but historically, renal involvement has been considered rare with an incidence of 0.7% and is seldom the presenting feature of the illness. Concomitant involvement of kidney and bone marrow is extremely rare. Atypical forms of presentation, such as in this case, may pose a true diagnostic challenge. A 20-year-old African-American male presented to the emergency department with vague symptoms including fatigue, malaise, anorexia, right-sided lower back pain, and nausea. Acute kidney injury was clearly evident, creatinine was 19.78 mg/dL (normal range 0.60-1.20 mg/dL), and BUN was 124.0 mg/dL (normal range 5.0-25.0 mg/dL). Laboratory results were also remarkable for leukopenia, microcytic anemia, hyperkalemia, anion gap metabolic acidosis, and non-PTH dependent hypercalcemia. Interestingly, urinalysis was equivocal and both chest x-ray (CXR) and abdominopelvic computed tomography (CT) scan were unrevealing. The patient was admitted to the hospital and required renal replacement therapy to stabilize his clinical condition while planning for a renal biopsy that was later performed. While awaiting pathological results, pancytopenia developed, and a bone marrow biopsy was then obtained. On further investigation, angiotensin-converting enzyme (ACE) turned out to be significantly elevated suggesting sarcoidosis. Renal biopsy showed moderate acute tubular injury, tubulitis, extensive interstitial edema, and infiltration by numerous non-caseating granulomas, which confirmed the diagnosis of sarcoidosis. Bone marrow histopathology revealed hypocellularity but no granulomatous infiltration. The patient remained largely asymptomatic throughout his hospital stay, with no signs or symptoms suggesting the involvement of other organs. High-dose corticosteroids were started and continued outpatient after discharge while still on hemodialysis. Pancytopenia resolved while on glucocorticoids and improvement in renal function was such that after roughly two months of steroids, renal replacement therapy was no longer necessary. Overall, kidney injury severe enough to require hemodialysis associated with pancytopenia in a previously healthy 20-year-old constitutes a rather rare sarcoidosis presentation. This highlights the importance of considering sarcoidosis as a possible cause of kidney and bone marrow dysfunction and emphasizes the need for timely biopsy to facilitate accurate diagnosis and early initiation of appropriate therapy to avoid delayed or inadequate care, especially considering that even severe damage is potentially reversible when identified early and treated promptly.

Dermatomyositis Flare-Up Following the SARS-CoV-2 Vaccine: A Case Report and Literature Review.

Dermatomyositis is a rare auto-immune inflammatory myopathy of unknown etiology. Several environmental factors, including vaccines, have been identified as potential triggers in genetically susceptible individuals. Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, the development of vaccines (mRNA and vector-based) has been the most effective tool in reducing the incidence, hospitalization rates, and mortality of COVID-19. However, among individuals with immune dysregulation and auto-immune conditions, unique challenges may arise with immune stimulation. We present a case of a dermatomyositis flare-up following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. A 40-year-old Hispanic female presented to the emergency department with shortness of breath, muscle pain and weakness, and skin rash for two days. She had been recently diagnosed with dermatomyositis six months prior based on clinical presentation, laboratory investigations, and characteristic muscle biopsy findings. She had been on treatment with mycophenolate mofetil, prednisone, and hydroxychloroquine since. She reported receiving the second dose of the BNT162b2 COVID-19 vaccine one day prior to the onset of symptoms. Physical examination revealed erythematous plaques over her cheeks, upper chest, and arms, in addition to Gottron papules on her hands. She had reduced proximal muscle strength and scattered dry crackles bilaterally on lung auscultation. Her laboratory investigations were remarkable for elevated erythrocyte sedimentation rate, C-reactive peptide, creatinine kinase, and troponin T. The SARS- CoV-2 PCR test was negative. CT scan of the chest showed evidence of pneumonitis. A diagnosis of the dermatomyositis flare-up potentially secondary to the SARS-CoV-2 BNT162b2 vaccine was established. The patient was admitted and treated with pulse steroids and intravenous immunoglobulin. She responded well to therapy and was discharged home four days later. There have been several reports of a new onset of dermatomyositis following the SARS-CoV-2 vaccine which highlights the need for further large-scale studies to estimate the prevalence of such adverse effects. The benefits of the SARS-CoV-2 vaccine outweigh the risks even among patients with auto-immune and rheumatologic conditions; however, it is important for clinicians to recognize the possibility of occurrence of such events in order to manage patients appropriately.

Multisystem Inflammatory Syndrome in an Adult Who Received Casirivimab-Imdevimab (REGEN-COV).

Multisystem inflammatory syndrome in adults (MIS-A) is a systemic inflammatory syndrome that presents with a heterogeneous collection of signs and symptoms in adults. Here we present a case of a 38-year-old male who met the case definition of the MIS-A four weeks after a mild, symptomatic case of coronavirus disease 2019 (COVID-19) despite receiving casirivimab-imdevimab (REGEN-COV). Given the presence of signs and symptoms consistent with MIS-A, the patient was started on intravenous immune globulin (IVIG) and IV methylprednisolone. He promptly demonstrated clinical improvement over the next several days.

Antisynthetase Syndrome Post Shingrix and Pneumovax Vaccinations, Possible Correlation.

This is a case report of a patient who developed acute progressive shortness of breath that started two days following the administration of Shingrix and Pneumovax vaccinations. Eight days after the onset of his symptoms he was diagnosed with acute interstitial pneumonitis based on CT scan of the chest which later appeared to be consistent with the diagnosis of antisynthetase syndrome in light of findings consistent with mechanic's hands on examination, elevated Anti-Jo-1 antibody titers and aldolase on laboratory studies.

Gordonia sputi related multiple brain abscesses, an AIDS-presenting illness: Thinking outside the box.

HIV/AIDS has been recognized as a global health issue with significant burden on healthcare services worldwide. Diagnostic and therapeutic challenges include wide range of difficult to identify and treat infections. Gordonia sputi is known to cause multi-system infections in setting of HIV/AIDS. It is often difficult to isolate this organism requiring high suspicion index and special testing techniques. While there is no guidelines-recommended antibacterials regimen for Gordonia sputi infection, extended combined broad spectrum antibacterials have been successfully used. Our patient in this report is a 50-year-old male with no past history who presented with progressive weakness on the right side of the body and urinary incontinence over the duration of one month. MRI scan of the brain showed bilateral ring-enhancing lesions. Gordonia sputi was identified from a tissue biopsy using 16S ribosomal RNA sequencing technique. HIV test for antibodies came to be reactive and a CD4 cell count of 7/µL. The patient was treated with combination of antibacterials and had remarkable radiological interval changes and relatively slower yet apparent clinical improvement. Unfortunately, and despite initial recovery, patient has later developed multi-drug resistant hospital acquired pneumonia leading to his death in ICU during course of hospitalization. Treatment of Gordonia sputi in setting of HIV infection with a combination of antibacterials over extended period appears to be safe and effective. To our knowledge, this is the first report of Gordonia sputi related multiple brain abscesses as AIDS-presenting illness.