Plasmodium falciparum Malaria Presenting as a Thrombotic Thrombocytopenic Purpura (TTP) Mimic: A Case Report.

Malaria can present with clinical manifestations overlapping with thrombotic thrombocytopenic purpura (TTP). We present the case of a 55-year-old female who presented with abdominal pain, fever, confusion, dehydration, and recent travel to Nigeria. Laboratory investigations were remarkable for low hemoglobin, decreased platelets, and elevated lactate. Suspicion for TTP occurred when the patient's platelet count and hemoglobin progressively decreased along with acute kidney injury and confusion. There was an elevated ADAMTS13 antibody level and mildly reduced ADAMTS13 activity suggesting possible TTP. However, Plasmodium falciparum was seen on peripheral blood smears. Treatment with artemether-lumefantrine was initiated which led to improvement in parasitemia, platelet count, and anemia. The similarity between malaria and TTP is mostly explained by thrombotic microangiopathic anemia (TMA) present in both diseases. Awareness of the common pathogenesis of TMA in both diseases and clinical judgment are pivotal in determining the timely initiation of appropriate treatment.

Bradycardia, Renal Failure, Atrioventricular Block, Shock, and Hyperkalemia (BRASH) Syndrome Emergence in a Unique Intersection of COVID-19 and End-Stage Renal Disease: A Case Report.

Bradycardia, renal failure, atrioventricular (AV) block, shock, and hyperkalemia (BRASH) syndrome is a rare clinical entity that poses challenges for healthcare practitioners. It is characterized by bradycardia, renal failure, atrioventricular (AV) obstruction, shock, and hyperkalemia. This case is an interesting instance of BRASH syndrome in the setting of COVID-19 infection and end-stage renal disease (ESRD). Initial laboratory results revealed macrocytic anemia, renal dysfunction, acidosis, and mild hyponatremia, along with hyperkalemia. An electrocardiogram (EKG) and telemonitoring showed dopamine-resistant persistent bradycardia until transvenous temporary pacemaker placement was done, which resolved the bradycardia. Anti-hyperkalemic therapy, avoiding AV nodal-blocking medication, and temporary pacemaker placement were all part of the management. After receiving hemodialysis, the patient gradually recovered. Bradycardia improved and potassium normalized. The intricate interaction between hyperkalemia and AV nodal obstruction that causes BRASH syndrome results in severe bradycardia and shock. To the best of our knowledge, this is the first case of BRASH syndrome in a patient with an active COVID-19 infection in a previously vaccinated patient. Even though case reports make up the majority of the material currently in publication, to fully comprehend the mechanisms underlying this illness, more research is required, as early detection of this syndrome is crucial for better patient outcomes.

Sepsis Unveils T-cell Large Granular Lymphocytic Leukemia in the Setting of End-Stage Renal Disease: A Rare Hematologic Malignancy.

Large granular lymphocytic (LGL) leukemia is a rare chronic lymphoproliferative disorder originating from natural killer cells or T lymphocytes. In this report, we present the case of a 66-year-old female initially treated for sepsis, with methicillin-sensitive Staphylococcus aureus identified on initial blood culture prompting intravenous (IV) antibiotic therapy. The patient met systemic inflammatory response syndrome criteria upon admission due to severe neutropenia. Persistent fever led to neurological symptoms, and imaging revealed lung abnormalities along with chronic changes on the CT scan of the head. Multidisciplinary consultations were sought, resulting in treatment adjustments including antifungals and filgrastim. Flow cytometry and bone marrow biopsy confirmed the diagnosis of LGL leukemia.

A Retrospective Cohort Study From the National Inpatient Sample Database (2016-2019): Does Obesity Affect the Outcomes of Hospitalization Due to Hepatocellular Carcinoma?

INTRODUCTION: Obesity is commonly reported to be associated with hepatocellular carcinoma (HCC) along with higher risks of mortality. However, there is a significant research gap regarding the outcomes of hospitalization due to HCC among obese patients compared to those without obesity. This study compares the outcomes of hospitalization among those two groups. METHODS:  A total of 50,845 patients admitted from 2016 to 2019 with a principal admission diagnosis of HCC were identified using the International Classification of Disease 10 (ICD-10) coding from the National Inpatient Sample (NIS) database. Patients with a body mass index (BMI) >30 were stratified into the obese cohort, and those with BMI ≤30 into the non-obese cohort as per the ICD-10 coding criteria for obesity based on BMI. The primary outcome of the study was mortality, whereas the length of stay, total hospitalization charges, acute kidney injury (AKI), sepsis, and shock were the secondary outcomes. We also compared additional complications such as ascites, portal hypertension, acute liver failure, disseminated intravascular coagulation (DIC), hepatic encephalopathy, and hepatorenal syndrome between the two groups. A multivariate regression model was used to estimate the effect of obesity on outcomes of hospitalization due to HCC. RESULTS: The obese cohort comprised 10.64% of the study population, whereas the non-obese cohort comprised 89.36% of the study population. Compared to the non-obese cohort, the obese cohort of patients with HCC were more likely to have a higher comorbidity index (CCI ≥4: 79.76% in the obese vs 71.17 % in the non-obese cohort). Obesity was found to be a protective factor for in-hospital mortality; that is, the odds of in-hospital mortality among the obese cohort was 0.713 times than that of the non-obese group of patients with HCC. The obese cohort had a higher mean length of stay (6.3 days vs 5.6 days; p value: <0.001) and total hospitalization charges (109,108$ vs 85,406$; p value: <0.001), which was further validated on multivariate analysis. The obese cohort had 1.26 times odds of developing AKI compared to the non-obese cohort (p value: 0.005). Sepsis, shock, and other complications such as acute liver failure, DIC, hepatic encephalopathy, hepatorenal syndrome, and portal hypertension were not significantly different between the two groups. CONCLUSION:  Obesity was associated with reduced in-hospital mortality among patients with HCC. However, obese patients with HCC were found to have higher healthcare resource utilization in terms of length of stay and total hospitalization charge along with the development of AKI. Clinicians should be mindful of the potential longer length of stay and associated complications such as AKI while managing obese patients with HCC. Contrary to commonly held notions, obesity and its relation with in-hospital mortality reported in this study warrants further explorative research.

Primary Effusion Lymphoma Secondary to Human Herpesvirus 8 (HHV-8) Infection in an Immunocompetent Host: A Case Report.

Primary effusion lymphoma (PEL) is a rare, aggressive, mature type of B-cell lymphoma that usually causes malignant, lymphomatous effusions in the absence of a solid mass. This is commonly seen in immunosuppressed individuals such as those with underlying malignancies, human immunodeficiency virus infection (HIV), cirrhosis, and a history of solid organ transplantation who are infected with human herpesvirus 8 (HHV-8). Clinical presentation varies depending on the extent of disease like shortness of breath, abdominal distention, and typical B symptoms like weight loss, fever, and night sweats. Morphological and immunohistochemical analysis of pleural fluid is required for diagnosis of PEL. Recent case studies are increasingly being reported with cases of PEL presenting in immunocompetent individuals infected with HHV-8. We present a case of PEL in an immunocompetent host and highlight its presentation, diagnosis, and management approaches. Due to the well-known association of PEL with immunocompromised status, the diagnosis is often overlooked in immunocompetent individuals. This case would further highlight the increasing association and the need for clinical vigilance in diagnosing PEL in immunocompetent patients.

Hypernatremia and Its Rate of Correction: The Evidence So Far.

Hypernatremia or high serum sodium levels can have many different causes, including insufficient free water intake, or excess free water losses. The management of hypernatremia focuses on resolving the underlying cause, replenishing free water deficit, and preventing further losses while closely monitoring serum sodium concentration. This systematic review was carried out using medical databases such as PubMed, PubMed Central, and Google Scholar for relevant medical literature. The identified articles were reviewed, eligibility criteria were applied, and seven research articles were identified. The effect of the rate of hypernatremia correction on both short- and long-term outcomes in volume-resuscitated patients was the focus of our search for randomized or observational studies. Based on our analysis of the clinical evidence, we concluded that the present recommendations for treating acute and chronic hypernatremia in resuscitated patients do not stem from high-quality research.