A Case of Intracardiac Thrombus in a Recovery Coronavirus Disease 2019 (COVID-19) Patient.

Coronavirus disease 2019 (COVID-19) was thought to mainly affect the respiratory system. However, studies have shown that it can be associated with hypercoagulability leading to thromboembolism. Although venous thromboembolism is a common complication associated with COVID-19, arterial thrombosis and intracardiac thrombosis are not frequently described. We herein report a case of a 54-year-old male with a past medical history of end-stage renal disease, diabetes mellitus, hypertension, heart failure, chronic obstructive pulmonary disease who presented to the emergency department with shortness of breath and was found to have intracardiac thrombus in post-recovery COVID-19 state.

A Rare Case of Takotsubo Cardiomyopathy in a Patient With No Identifiable Emotional or Physical Stressors.

Takotsubo cardiomyopathy (TCM) is a cardiac condition that presents with features of acute myocardial infarction and transient systolic dysfunction without angiographic findings of obstructive coronary heart disease. Common presenting symptoms include acute substernal chest pain, dyspnea and syncope. It is usually triggered by recent emotional or physical stress such as head trauma, stroke, sepsis, overproduction of catecholamines such as pheochromocytoma or following Myasthenia crisis. We are here to report a case of TCM who does not have any identifiable emotional or physical stress prior to the event. The patient was a 76-year-old Caucasian female with a past medical history of hypertension who presented to the hospital with chest pain which initially was treated as non-ST elevation myocardial infarction (NSTEMI) with aspirin, ticagrelor and heparin infusion. Cardiac catheterization later revealed non-obstructive coronary artery disease but showed akinesis of inferior, apical and anterior walls with hyperdynamic basal segments indicating TCM.

A New and Rare Presentation of Unilateral Recurrent Laryngeal Nerve Palsy in a COVID-19 Patient With No Recent History of Endotracheal Intubation.

The Coronavirus disease 2019 (COVID-19) infection has classical symptoms of high fevers, diarrhea, cough, and dyspnea; however, there are cases recording more unconventional features. In this case report, we will discuss recurrent laryngeal nerve palsy as a new and unusual presentation of COVID-19. The patient was a 58-year-old African American male with a history of hypertension, type-2 diabetes mellitus, and obstructive sleep apnea presenting with dyspnea, fatigue, and nausea. The patient was initially admitted to the medical intensive care unit (MICU) for acute hypoxic respiratory failure and completed intravenous Remdesivir for COVID-19. He never got intubated during the ICU stay and his condition improved on the 34th day of admission. However, two weeks later the patient suddenly developed hoarseness of voice. A bedside laryngoscopy revealed a left-sided vocal cord paralysis but patent airway. The computed tomography (CT) scan of the neck did not show any abnormalities, including any impinging masses or structures. The patient did not have any recent intubations to suggest the paralysis was due to traumatic injury, thus favoring that his neurologic injury was likely a post-viral symptom. One possible pathophysiology would be the invasion of nerve fibers (peripheral or cranial nerves) by the virus using the same mechanism as seen in alveolar cells and finally destroying them. Another hypothesis would be the inflammatory response of the host immune system affecting the peripheral and cranial nerves. Therefore, the potential association between neuro-invasiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the recurrent laryngeal nerve palsy resulting in the vocal cord paralysis should be considered and more studies need to be conducted for better understanding.

Neurocysticercosis Presenting With a New-Onset Seizure: A Case Report.

Neurocysticercosis (NCC) is a common infection that is found worldwide but is often neglected in the United States (US). This case report aims to illustrate the presentation of the disease, provide information on this globally prevalent pathogen, and shed light on the diagnostic workup and treatment of the infection. We discuss the case of a 31-year-old male patient of Central American origin presenting with a new-onset seizure. He had no significant past medical history and had never experienced similar events before. The diagnosis was made through neuroimaging, serum antibody testing, and biopsy of the brain lesion. This case highlights the importance of performing a good clinical history and a proper diagnostic workup that would help in the prompt recognization and treatment of this common worldwide illness that may not be endemic to the clinician's geographical area.

Unusual Case of Ischemic Colitis Caused by Low-Dose Sumatriptan Therapy in a Generally Healthy Patient After Strenuous Physical Activity.

Ischemic colitis refers to an inflammatory condition of the large bowel caused by ischemia. It usually presents with an acute onset abdominal pain followed by hematochezia. It can occur as a result of arterial occlusion (embolic or thrombotic), venous thrombosis, or hypoperfusion of mesenteric circulation secondary to dehydration, surgery, or medications. Herein, we present an unusual case of sumatriptan-induced ischemic colitis. Sumatriptan succinate is a selective serotonin (5-hydroxytryptamine-1) receptor agonist that is usually prescribed for refractory migraine headaches. This is a 59-year-old female who presented with acute onset abdominal pain followed by bloody diarrhea after vigorous physical activities. She has a past medical history of non-specific colitis (one time, 15 years ago) and chronic migraine for which she was on low-dose sumatriptan therapy (one tab once or twice a week). On the day of the event, the patient took sumatriptan in the morning and had strenuous activities throughout the day, and overnight she developed abdominal pain. It was followed by bouts of bloody diarrhea. The colonoscopy revealed erythematous mucosa with significant ulceration and necrosis involving the distal transverse colon, splenic flexure, descending colon, and proximal colon, suggestive of ischemic colitis. Unlike previously reported cases, this patient was only on low-dose sumatriptan therapy without frequent dosing. So, her risk of ischemic colitis from triptan therapy could have been accelerated by excessive sweating and strenuous physical activities. The patient was treated with intravenous hydration, bowel rest, intravenous antibiotics, and withdrawal of sumatriptan and her condition improved within the next two to three days.

Atypical Presentation of Descending Aortic Dissection in an Acute Heart Failure Patient.

Aortic dissection is relatively uncommon, but often presents with acute severe chest or back pain and acute hemodynamic compromise and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a heart failure patient and the challenges encountered to make the diagnosis. The patient was a 54-year-old African American female who presented with progressively worsening exertional dyspnea and orthopnea for three days and sensation of indigestion and bloating. The patient denied any recent history of chest pain and she was initially admitted for heart failure exacerbation. Her admission chest x-ray showed severe cardiomegaly with a prominence of pulmonary vascular but there was a borderline widening of mediastinum measuring 8.2 cm. Physical exam showed unequal dorsalis pedis pulses (fainter on the right side) and systolic blood pressure difference of more than 20 mmHg between bilateral upper extremities. Computed tomography angiography (CTA) of chest, abdomen, and pelvis confirmed the diagnosis of dissection of thoracic and abdominal aorta extending from the left subclavian artery to the femoral artery. The patient was managed with labetalol drip and later transferred to a tertiary center for an elevated level of care where the endovascular intervention was performed. The patient then followed up with a vascular clinic for serial CTA and heart failure clinic for optimization of core measures. In conclusion, this case highlights the importance of clinical suspicion of aortic dissection and discusses the various clinical presentations of aortic dissection and its management. Being a highly fatal condition, prompt diagnosis is extremely important and is often life-saving. Therefore, it is important for physicians to be aware of atypical presentations of aortic dissection to initiate timely interventions to avoid catastrophic complications.