Subcutaneous Sarcoidosis.

This case report focuses on a 40-year-old female with multiple subcutaneous skin nodules presenting to the clinic for worsening skin lesions associated with erythema and mild tenderness. A biopsy of the skin lesions showed non-necrotizing granulomas with multinucleated giant cells. The patient was being worked up for non-necrotizing granulomatous skin lesions and was diagnosed with subcutaneous sarcoidosis. Sarcoidosis diagnosis is based on clinical presentation, histopathological changes, and ruling out other granulomatous causes. Our patient is being treated with systemic steroids, hydroxychloroquine, methotrexate, and adalimumab. The patient is nine months into the treatment. A clinically significant reduction in the nodule size was noted. Other systemic involvement of sarcoid was ruled out. This subcutaneous skin involvement is a rare finding called the Darier-Roussy sarcoid. Usually self-resolving but extensive, deformative lesions need to be treated.

COVID-19-Related Left-Sided Ptosis.

The coronavirus disease 2019 (COVID-19) infection commonly presents with symptoms of fever, cough, and anosmia. However, there have been case reports of unusual symptoms associated with COVID-19. We encountered one such case where a 55-year-old male who tested positive for COVID-19 was noted to have, along with cough and vomiting, a new onset of left eyelid ptosis. COVID-19 infection and ptosis association is seldom seen and very few similar studies are reported.

The Ugly Side of Colchicine.

We report a rare case of a 32-year-old male who ingested 32.4 to 54 mg of colchicine and presented after 44 hours. He developed progressive multiple organ failure with shock, acute kidney failure, troponemia, pancytopenia, absolute neutropenia, disseminated intravascular coagulation, acute liver failure, rhabdomyolysis, and lactic acidosis. He also developed electrolyte abnormalities and refractory hypoglycemia. Initial treatment consisted of activated charcoal, fluids, and broad-spectrum antibiotics with supportive treatment of mechanical ventilation, hemodialysis, vasopressors, N-acetylcysteine, colony-stimulating factors, and blood products. Literature shows potential benefit of colchicine-specific Fab fragments for acute toxicity with limited studies and is not currently available in the United States. Further research for N-acetylcysteine protocol for acute liver failure in colchicine toxicity and potential use of colchicine-specific Fab fragments is needed. Our case demonstrates the importance of early use of activated charcoal for ingestion overdose with the incorporation of poison control into multidisciplinary team for coordinated patient care.

Recurrent Chylous Ascites Leading to Transudative Chylothorax Due to Bi-Ventricular Heart Failure.

Chylothorax is a pleural effusion of >110 mg/dL of triglycerides with a milky appearance with transudative being rare. In this article, we present a case of transudative chylothorax with concurrent chylous ascites that is secondary to congestive heart failure (CHF). A 70-year-old male with CHF with ejection fraction of 10%, coronary artery disease status post coronary artery bypass graft, sleep apnea, chronic kidney disease stage 3, and chronic obstructive pulmonary disease presented with worsening abdominal distention, shortness of breath, and increased lower extremities edema. He denied any cough or fever but had orthopnea and paroxysmal nocturnal dyspnea. He requires monthly paracentesis with drainage of 5 to 9 L each time. On physical examination, he had crackles bilaterally with no wheezes or jugular venous distension. His cardiac examination was unremarkable. He did have abdominal distension with dullness to percussion and a positive fluid wave. There was +2 bilateral pitting edema of lower extremities. He had a diagnostic paracentesis where 9.2 L of cloudy milky fluid was drained and therapeutic thoracentesis where 1.1 L of milky fluid was drained. Pleural fluid for triglycerides was 280. His peritoneal fluid had triglycerides of 671 confirming chylous ascites. CHF can lead to chylous ascites due to the increased lymph production in the abdomen, which flows to the thoracic duct. Due to the stiffness at the lymphatic junction, there is high pressure for less flow. The diaphragm plays a role allowing the chylous ascites to be absorb into the thorax.

Immunotherapy: A Case Series.

Immunotherapy is on the rise as a treatment option for advanced melanoma, non-small cell lung carcinoma, renal cell carcinoma, and melanoma among others. It consists of two main classes being cytotoxic T lymphocyte antigen 4 (CTLA 4) inhibitors and programmed cell death 1 (PD 1) inhibitors. We report a case series of four patients who were started on either pembrolizumab or nivolumab for the treatment of melanoma or lung cancer. While on immunotherapy, they developed various side effects related to the immunotherapy including pneumonitis, transaminitis, thyroiditis, nephritis, and hypophysitis. To treat this complication, immunotherapy must be discontinued or held with immunosuppressant initiation as treatment. Most often the immunosuppressant of choice is steroids. After symptoms improve, patients can decide along with the clinician on restarting or completely stopping immunotherapy. Within our case series, three of four patients had resolutions of their symptoms with steroid treatment with one who was lost to follow up. Of the three patients who were being followed up, one had a relapse of side effects after resuming immunotherapy and decided against further treatment with immunotherapy. Another patient is doing well resuming immunotherapy on a daily dose of steroids. The last patient decided to not continue with immunotherapy after experiencing a flare of his symptoms when he was being treated since he missed a few doses of steroids. Further research is needed about the risk of flares of complications when resuming immunotherapy alone or with immunotherapy and steroid treatment.

COVID-19 Vaccine Acceptance Among Rural Appalachian Healthcare Workers (Eastern Kentucky/West Virginia): A Cross-Sectional Study.

Introduction The success of a vaccination program is dependent on vaccine efficacy and the number of people vaccinated. Healthcare workers are the first to receive the COVID-19 vaccine based on CDC phase 1a recommendations and are a point of contact for information for patients, so they must be well-educated on common misconceptions about the vaccine. Objective To identify acceptance/refusal rates of COVID-19 vaccine, reasons for refusal, and to understand the impact of demographics, work environment, and comorbidities on vaccine acceptance. Methods A cross-sectional study of 1076 healthcare employees in Rural Appalachian utilizing electronic and paper-based 12 question surveys from December 10, 2020, through December 20, 2020, followed up to April 2021. Results Within our study, 52.3% of our healthcare workers would accept vaccination with higher age, male gender, physicians, and those who receive annual flu vaccines more likely to accept vaccination. The most common reason for refusal was unknown side effects (88.5%). The second reason for refusal at 33.5% was waiting for someone else to take the vaccine first. In February 2021, the percentage of our healthcare workers who were vaccinated was 48%, which then increased to 55% in March 2021. By April 2021, the vaccination percentage of our healthcare workers reached 59%. Conclusions In order to predict how the public percentage of vaccination would be, healthcare workers need to address concerns about side effects from the vaccines and encourage the public to get the vaccines since healthcare workers themselves had already received the vaccines and can educate the patients on how they did after getting the shots.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis.

BACKGROUND: Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. METHODS: Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. RESULTS: A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. CONCLUSION: Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.