Unusual case of propofol-related infusion syndrome complicating severe COVID-19 ARDS.

An elderly man presenting with shortness of breath and hypoxaemia was admitted with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Due to worsening hypoxaemia, he was transferred to the intensive care unit and required mechanical ventilation. Propofol was infused at 1.5-4 mg/kg/hour. Within 48 hours of initiation, we noticed worsening metabolic acidosis, acute kidney injury, hyperkalaemia, hyperphosphataemia, hypertriglyceridaemia, elevated creatine kinase and elevated myoglobin levels. Suspecting propofol-related infusion syndrome (PRIS), we discontinued his propofol infusion immediately and initiated supportive measures. In 48 hours, there was a significant improvement in metabolic acidosis, hypertriglyceridaemia, rhabdomyolysis and renal function. The propofol infusion rate and cumulative propofol dosage (under 140 mg/kg) were well below levels associated with PRIS. COVID-19's pathogenesis, still under investigation, may have contributed to this presentation. It is imperative for clinicians to maintain a high degree of suspicion once propofol is initiated, regardless of the cumulative dose or rate of infusion.

Type A acute aortic dissection presenting as a stroke in a young male patient.

A male patient in his 40s with a history of nephrolithiasis and found in the desert after 10 days without oral intake was admitted to the hospital for severe dehydration, acute kidney injury and rhabdomyolysis. He had acute-onset loss of consciousness during hospitalisation with new left-sided hemiparesis and hemineglect. After haemorrhage was excluded, prompt thrombolysis was given. He later had chest pain and became hypotensive. An echocardiogram revealed pericardial effusion and dilation of the ascending aorta with suspected dissection. Magnetic resonance angiography of the brain and neck reported bilateral parieto-occipital areas of stroke in a watershed distribution and dissection of the right internal carotid artery. CT angiography showed type A aortic dissection from the ascending aorta extending into the bilateral common iliac arteries. Thrombolysis was reversed and the patient underwent ascending aorta replacement, resuspension of the aortic valve and aortic arch debranching at outside facility with complete recovery.

Refractory Checkpoint Inhibitor Colitis Responsive to Ustekinumab.

Immune checkpoint inhibitors have transformed the treatment of cancer. Nonetheless, multiple immune-related adverse events have been reported, including checkpoint inhibitor colitis. Severe colitis can be complicated by ileus, megacolon, intestinal perforation, and death. Current appropriate treatment includes steroids, followed by antitumor necrosis factor biologic therapy, infliximab. Alternatively, vedolizumab and fecal microbiota transplantation have reported efficacy for refractory cases. In this study, we present the first case report of a patient with steroid-refractory checkpoint inhibitor-induced colitis due to pembrolizumab for Stage IV anaplastic thyroid carcinoma successfully treated with ustekinumab after failure of infliximab, vedolizumab, and fecal microbiota transplantation. This may lead to a better understanding of treatment options for refractory checkpoint inhibitor colitis.

Purple Glove Syndrome: Recognizing a Rare Complication of Intravenous Phenytoin.

An uncommon but serious adverse drug reaction after phenytoin administration is known as purple glove syndrome (PGS). Initial presentation is characterized by pain, skin discoloration, and edema, that can progress to necrosis. The pathophysiology remains uncertain; however, multiple mechanisms have been reported including extravasation. We describe a case of a 61-year-old patient who was brought to the hospital with altered mental status due to status epilepticus. The patient received multiple doses of lorazepam; eventually was started on levetiracetam and valproate, including loading doses. The seizures were poorly controlled despite treatment, and intravenous (IV) phenytoin was added. The next day, bluish discoloration and swelling to bilateral upper distal extremities were noted on physical examination. Consequently, IV phenytoin was discontinued immediately due to high suspicion of PGS. Skin discoloration and edema gradually improved after one week, confirming a case of mild PGS.

Disseminated histoplasmosis in an immunocompetent patient with COVID-19 pneumonia.

Disseminated histoplasmosis is usually associated with immunosuppressive conditions like AIDS. People with respiratory distress syndrome secondary to SARS-CoV-2 pneumonia are vulnerable to bacterial infections. Additionally, coinfection with fungal pathogens should be considered as a differential diagnosis even in immunocompetent patients who remain on mechanical ventilation secondary to COVID-19. The case presents a 61-year-old immunocompetent man, admitted to the medical ward due to COVID-19 pneumonia. Despite appropriate therapy, the patient required transfer to the intensive care unit for invasive mechanical ventilation. He remained critically ill with worsening respiratory failure. Two weeks later, coinfection by disseminated histoplasmosis was detected. After immediate treatment with amphotericin B and itraconazole, the patient tolerated weaning from mechanical ventilation until extubation. Awareness of this possible fungal coinfection in immunocompetent patients is essential to reduce delays in diagnosis and treatment, and prevent severe illness and death.

Birt-Hogg-Dubé Syndrome: Two Patients With Different Initial Presentations.

Birt-Hogg-Dubé syndrome (BHD) is a rare genetic disorder caused by germline mutations in the tumor suppressor folliculin gene (FLCN). This condition is characterized by benign skin hamartomas, pulmonary cysts, spontaneous pneumothorax, and an increased risk for developing kidney tumors which range from benign oncocytomas to malignant renal cell carcinomas including chromophobe, clear cell, or papillary subtypes. We describe two cases of BHD with different initial presentations. Patients underwent genetic testing and an FLCN mutation was identified, confirming the diagnosis. Through this case series, we aim to highlight the importance of recognizing key manifestations of BHD whether alone or in combination, followed by genetic testing and counseling and the need for regular follow-ups with surveillance imaging tests to detect renal cancer early on.

Incidental massive lower gastrointestinal hemorrhage caused by a rectal Dieulafoy's lesion.

A Dieulafoy's lesion is a rare cause of massive gastrointestinal (GI) bleeding. It represents an abnormally dilated submucosal artery that erodes the overlying epithelium in the absence of a primary ulcer. These lesions are usually located in the stomach, nevertheless, they have been found in all areas of the GI tract, including the oesophagus, duodenum and colon. Bleeding episodes are often self-limited, although bleeding can be recurrent and profuse. The case describes a 50-year-old woman who developed haemorrhagic shock secondary to a rectal Dieulafoy's lesion and discusses the diagnostic and therapeutic approaches.

Double Valve Infective Endocarditis Complicated by Systemic Arterial Embolization.

A 26-year-old male with a past medical history of intravenous opioid abuse was admitted with the diagnosis of double valve infective endocarditis and methicillin-resistant Staphylococcus aureus bacteremia. Imaging, excluding the head, was indicative of systemic arterial embolization, as abscesses had developed in the retroperitoneum and prostate. There was evidence of splenic infarct, and the presence of extensive pulmonary infiltrates indicative of showering septic foci from the heart. Antibiotic therapy was started and a transesophageal echocardiogram demonstrated mitral and tricuspid valve vegetations with a preserved ejection fraction. Fortunately, the valvular repair was successful and artificial valves were not needed. The patient had an uncomplicated postoperative course in the intensive care unit and was transferred back to the ward in stable condition. He remained on the ward for six weeks due to his unfunded status until his antibiotic course and physical rehabilitation were completed.

Diffuse Gastrointestinal Polyposis in Bannayan-Riley-Ruvalcaba Syndrome: A Rare Phenotype Among Phosphatase and Tensin Homolog Hamartoma Tumor Syndromes.

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is a rare genetic disorder caused by germline mutations in the phosphatase and tensin homolog (PTEN) gene. Clinical manifestations arise early during childhood and include multiple lipomas, hamartomatous intestinal polyps, macrocephaly, developmental delay, and autism spectrum disorder among others. The case describes a 24-year-old female with a recent diagnosis of BRRS who presented for evaluation of burning epigastric pain for the previous six months. The esophagogastroduodenoscopy (EGD) and colonoscopy revealed an erosive gastric mucosa as well as numerous polyps throughout the gastrointestinal tract. Histopathologic examination confirmed gastric Helicobacter pylori infection and different histologic types of polyps.