Cerebrovascular Accident and SARS-CoV-19 (COVID-19): A Systematic Review.

BACKGROUND: While the most common neurologic symptoms reported in patients affected by SARS-CoV-2 are headache, dizziness, myalgia, mental fog, and anosmia, there is a growing basis of published peer-reviewed cases reporting stroke in the setting of SARS-CoV-2 infection. The peer-reviewed literature suggests an increased risk of cerebrovascular accident (CVA) in the setting of COVID-19 infection. METHODS: We searched 3 databases (PubMed, MEDLINE, and CINAHL) with search terms COVID-19, novel coronavirus, stroke, and cerebrovascular accident. Case series and case studies presenting patients positive for both COVID-19 and CVA published from January 1 through September 1, 2020, were included. Data collection and analysis was completed and risk of bias assessed. RESULTS: The search identified 28 studies across 7 counties comprising 73 patients. Amongst patients hospitalized for COVID-19 infection and CVA, the average age was 60; the most common preexisting conditions were hypertension and diabetes mellitus, and those without preexisting conditions were significantly younger with an average age of 47. Amongst hospitalized patients with COVID-19 and CVA, there was a bimodal association with COVID-19 infection severity with majority of patients classified with mild or critical COVID-19 infection. DISCUSSION: The data suggest SARS-CoV-2 is a risk factor for developing stroke, particularly in patients with hypertension and diabetes. Furthermore, the younger average age of stroke in patients with SARS-CoV-2, particularly those patients with zero identifiable preexisting conditions, creates high suspicion that SARS-CoV-2 is an independent risk factor for development of stroke; however, this cannot yet be proven without comparable control population. The data suggest the risk of developing CVA in the setting of COVID-19 infection is not dependent upon severity of illness. Continued studies must be done to understand the epidemiologic factors of COVID-19 infection and stroke and the pathophysiology of the COVID-associated hypercoagulable state.

New-Onset Heart Failure From Viral Myocarditis and Inflammatory Cardiomyopathy: A Case Report.

An inflammatory cardiomyopathy is a form of nonischemic cardiomyopathy that results from myocarditis associated with cardiac dysfunction and ventricular remodeling. It can be caused by a wide array of pathogens and toxins. We present a case of a 69-year-old female with a history of asthma who was admitted to our facility with recurrent asthma exacerbations, likely triggered by viral upper respiratory tract infections. In 5 months, serial echocardiograms showed a significant decline in her left ventricular systolic and diastolic function. Cardiac catheterization showed no clinically significant coronary artery disease. Despite normal renal function, her troponin remained elevated. This is an interesting case of a viral upper respiratory tract infection that led to myocarditis and ultimately resulted in inflammatory cardiomyopathy.

Secondary Immune Thrombocytopenic Purpura Due to Primary Epstein- Barr Virus Infection.

A rare complication of infectious mononucleosis is immune thrombocytopenic purpura (ITP). The majority of people affected by Epstein-Barr Virus (EBV) are below the age of 30, while ITP is usually seen with peaks of incidence in the elderly and children. The unique case of an otherwise healthy 22-year-old female will be discussed, with an initial presentation of ecchymosis, rash, and epistaxis, and was subsequently found to have severe thrombocytopenia. The diagnosis of primary EBV infection due to EBV was eventually made, responsive to intravenous (IV) Methylprednisolone. It is important to consider primary EBV infection in the differential diagnosis of a patient who presents with acute thrombocytopenia.

Recurrent, Complicated Diverticulitis With Atypical Features.

Diverticular disease is a common condition responsible for significant costs to the healthcare system in the Western world. It ranges from asymptomatic diverticulosis to complicated diverticulitis. Here, we present a unique case of recurrent, complicated diverticulitis in a 62-year-old Caucasian male. Within a span of one year, he was hospitalized six times with diverticulitis before undergoing elective sigmoid colon resection. Imaging showed diverticulitis of distal descending and proximal sigmoid colon with sealed perforation, recurrent abscesses, and formation of colocutaneous fistulas. During each hospitalization, the patient was advised to follow up with general surgery and/or outpatient gastroenterology but chose not to do so. Eventually, he required an elective sigmoid colectomy with a takedown of the colocutaneous fistulas. In this case report, we discuss the atypical features and criteria for prophylactic colon resection in diverticulitis to highlight the importance of outpatient follow-up with general surgery and gastroenterology.

Critical Limb Ischemia in a Young Patient With a Mechanical Aortic Valve Leading to Bilateral Above-Knee Amputation.

This case reports a 24-year-old female with prior aortic insufficiency who underwent a mechanical aortic valve replacement with subsequent transient ischemic attacks and documented subtherapeutic international normalized ratio (INR). She presented with pain and bilateral lower extremity pulselessness. Workup showed a supratherapeutic INR, no thrombus on echocardiogram, and computed tomography angiography demonstrating no flow in the bilateral common femoral arteries. Patient failed repeated thrombectomies and had a bilateral above-knee amputation. The patient was suspected to have acute on chronic emboli from the mechanical aortic valve and further testing did not elucidate contributory causes of her critical limb ischemia. We believe this is the first documented case of bilateral lower extremity ischemia due to mechanical valve complications.

Diabetic Ketoacidosis Secondary to New Onset Type 1 Diabetes Mellitus Related to Pembrolizumab Therapy.

Pembrolizumab is an immunoglobulin G4 (IgG4) monoclonal antibody used in the treatment of various types of cancers. Despite its efficacy, pembrolizumab does not specifically target cancer cells which often leads to common side effects seen in immunotherapies such as diarrhea, rash, fatigue, nausea, decreased appetite, pruritus, and endocrinopathies. Type 1 diabetes mellitus (T1DM) has been reported in 0.1% of the patients in pembrolizumab clinical trials. In this case report, we discuss a 65-year-old Caucasian male with a history of metastatic head and neck cancer that was previously treated with pembrolizumab and was subsequently admitted to the intensive care unit (ICU) due to new onset diabetic ketoacidosis (DKA). Based on the timing of his presentation and the pre-hospital/inpatient workup, notably a normal hemoglobin A1C (HbA1c) 72 hours prior to admission and a significant increase thereafter, it was concluded that his presentation of diabetic ketoacidosis was secondary to his most recent infusion of pembrolizumab. With immunotherapies like programmed cell death (PD1) receptor antibodies becoming a more common first-line treatment for various cancers, this case hopes to raise awareness about the possible endocrinologic-related adverse events to its use and may help guide outpatient management.

A Case of Immune Thrombocytopenia After COVID-19 Infection.

Immune thrombocytopenia (ITP) is a hematological condition that is characterized by a low platelet count. ITP can be primary or secondary. Secondary causes are diverse and include viral infections. The novel coronavirus has rarely been recognized as cause of ITP. This is a case of an 82-year-old Caucasian male who was infected by the novel coronavirus four weeks prior. His platelet count on admission was 1,000/mm3. He was diagnosed with ITP caused by the novel coronavirus as there were no other causes for his thrombocytopenia. The patient was treated with platelet infusions, high-dose corticosteroids, and intravenous immunoglobulin infusions.

Adrenal Crisis Secondary to Influenza and Tetanus Vaccination in an Adult Without Known Adrenal Insufficiency: A Case of Autoimmune Adrenalitis.

Adrenal crisis (AC) is a rare but known life-threatening condition in patients with adrenal insufficiency (AI). We report the case of a 21-year-old without known AI who developed AC after routine vaccinations. Workup revealed that the patient had underlying, undiagnosed autoimmune adrenalitis. This is the first report of AC induced by influenza and diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations in a patient without known AI.

Memantine Usage for Management of Korsakoff Syndrome in the Setting of Chronic Alcohol Use and Unspecified Eating Disorder.

Korsakoff syndrome is a neuropsychiatric condition frequently seen as a progression of Wernicke's encephalopathy and is often associated with long-term alcohol abuse. It is characterized by further cognitive impairments, such as indiscriminate anterograde and retrograde amnesia, in addition to executive function deficits. As the syndrome is a result of severe thiamine deficiency, its management primarily focuses on nutritional replenishment and electrolyte maintenance. In recent years, a few published reports have detailed the off-label use of Food and Drug Administration (FDA) approved drugs for Alzheimer's in an attempt to treat neurocognitive deficits associated with Korsakoff patients. In this particular case, we note subjective improvement in cognition after initiating memantine, an N-Methyl-d-aspartate (NMDA) receptor antagonist.

Hepatic Abscess as Early Presentation of Perforated Diverticulitis.

A hepatic abscess is a rare condition which can have multiple etiologies, including biliary disease, intra-abdominal collections (appendicitis, diverticulitis, and inflammatory bowel disease), abdominal surgery, liver transplantation, and liver trauma. The diagnosis is primarily based on imaging findings of ultrasound and computed tomography scan. Management includes antibiotics and percutaneous drainage or surgical drainage of the abscess. Here, we present a case of a 43-year-old Hispanic female who initially presented with left lower quadrant and right upper quadrant abdominal pain for 1 week. She was found to have a hepatic abscess and pelvic abscess likely secondary to perforated diverticulum.

Pheochromocytoma Presenting as Testicular Pain: An Unusual Case Report.

Pheochromocytoma (PCC) is a rare catecholamine-secreting tumor that arises from chromaffin cells of the adrenal medulla which are derived from the neural crest. This report illustrates a 51-year-old Caucasian male with a history of hypertension diagnosed two years ago who presented to the hospital due to acute onset of right testicular pain of 3-day duration. Laboratory results and imaging revealed a presumptive diagnosis of PCC. The patient had undergone robot-assisted laparoscopic right adrenalectomy 14 days after being diagnosed with PCC due to perioperative management with phenoxybenzamine. The final pathology report revealed a PCC. At follow-up two weeks after discharge, the patient reported complete resolution of his testicular pain.

Gastric Cancer Presenting as Persistent Pneumonia: An Unusual Case Report.

Worldwide, gastric cancer is the fifth most common cancer and the third leading cause of cancer deaths, which carries a poor prognosis as only 28.3% are expected to survive after five years. The incidence varies depending on the geographical locations and dietary patterns. Here, we present a case of a 59-year-old Hispanic male with a 10-month history of recurrent bilateral pneumonia and dysphagia. Diagnostic workup revealed metastatic gastric adenocarcinoma.

Pasteurella multocida Bacteremia in an Immunocompromised Patient After Multiple Cat Scratches.

Pasteurella multocida (P. multocida) is a zoonotic organism found in the normal flora of domestic and wild animals. In this case report, we present a 70-year-old Caucasian male who presented with fever, chills, and greenish sputum which began hours prior to presentation. His symptoms were initially thought to be due to refractory pneumonia because the patient had been discharged from our hospital three weeks prior to presentation. Blood cultures grew P. multocida, a rare pathogen to cause bacteremia. He was treated with cefepime and later amoxicillin/clavulanic acid and made an uneventful recovery. Later history of the patient's cats scratching him was thought to be the mode of transmission. P. multocida infection is rare, and can also be dangerous and even fatal in immunocompromised individuals. Clinicians must therefore operate with a high degree of suspicion especially when treating immunocompromised patients with bacteremia.

Hyperammonemic Encephalopathy: A Complication of Gastric Bypass Surgery.

Hyperammonemia is a metabolic abnormality characterized by elevated levels of ammonia in the blood. This case report illustrates a 72-year-old Caucasian female with a history of prior gastric bypass surgery done 15 years ago, who was admitted multiple times for acute encephalopathy over the course of a few months. The patient was found to have a gastro-gastric fistula seen on a CT scan of the abdomen, which was the culprit of her acute encephalopathy. The patient underwent fistula closure via esophagogastroduodenoscopy.

Cryptococcal Meningoencephalitis 10 Years After Bone Marrow Transplant in a Patient With Multiple Myeloma.

Cryptococcosis is a fungal infection that mostly affects immunocompromised patients. Diagnosis is based on the detection of cryptococcal antigen in the cerebrospinal fluid (CSF) or serum. Antifungal resistance is emerging, making treatment difficult and long. We report a case of cryptococcosis in a patient with multiple myeloma, years after undergoing a bone marrow transplant. Symptoms were mild, and imaging studies were nonspecific. CSF analysis revealed positive cryptococcal antigen. The patient was started on the standard three-phase antifungal therapy and recovered.

Cannabis Butane Hash Oil Dabbing Induced Lung Injury Mimicking Atypical Pneumonia.

"Dabbing" is the inhalation of concentrated marijuana, usually in butane solvent. This case report illustrates a previously healthy 25-year-old caucasian male with a 10-year history of cannabis butane hash oil (BHO) use. The patient presented with dyspnea and cough. The evaluation included a chest x-ray, basic laboratory investigations, computerized tomography angiogram of the chest and echocardiogram. Patient was diagnosed with acute lung injury mimicking atypical pneumonia. He was treated with steroids and had clinically improved and advised to stop dabbing. Further studies are needed to elucidate the full spectrum of the adverse effects of dabbing.

Adverse Side Effects: Empagliflozin-Related Acute Pancreatitis Case Report.

Acute pancreatitis is an acute inflammatory process of the pancreas that is associated with multiple etiologies. The two most common causes are gallstones and acute alcohol intoxication. However, medications are often overlooked when determining the cause. Empagliflozin is a type of sodium-glucose transport protein 2 (SGLT-2) inhibitor used for the treatment of type 2 diabetes mellitus. Given that this medication is new, the adverse effects have not been fully reported in the literature. Currently, the most commonly reported side effects are genitourinary infections such as cystitis or yeast infection although acute pancreatitis as a result of empagliflozin is very rare. Here, we discuss a case of a 64-year-old female who presented with severe pancreatitis after recently initiating the use of empagliflozin. Based on the timing of her presentation and her hospital workup to rule out many of the common etiologies, it was concluded that empagliflozin was the likely cause of her acute pancreatitis. With SGLT-2 inhibitors such as empagliflozin, becoming popular as first-line in the management of diabetes, this case may hope to raise awareness of the possible adverse effects related to it. Additionally, this case also emphasizes the importance of identifying iatrogenic related pancreatitis.

A Case Report of Babesiosis Seen Outside of its Endemic Area and Incubation Period.

Babesia microti is a parasitic alveolate that is usually transmitted by Ixodes scapularis tick, which also transmits Lyme disease. Babesiosis is endemic in the Northeast and Upper Midwestern regions of the United States. This case report illustrates a 29-year-old Hispanic male who presented to a Florida hospital emergency department with complaints of fever, generalized weakness, and flu-like symptoms over a duration of four days. Subsequently, he was diagnosed with babesiosis infection since he had a travel history to Cape Cod, Massachusetts about 10 weeks before presenting to the hospital. He was treated with atovaquone, clindamycin, and azithromycin. The importance of this report is to illustrate that babesiosis may occur outside its endemic area and incubation period.

Bilateral Pneumonia in a Patient with Chronic Bronchiectasis Caused by Achromobacter xylosoxidans Subspecies denitrificans.

Achromobacter xylosoxidans is a gram-negative bacillus that has a multitude of inherent and acquired antimicrobial resistance. It is a rare, isolated pathogen in patients without cystic fibrosis (CF). We report the case of a 76-year-old Caucasian male with a history of chronic obstructive pulmonary disease (COPD), previous Mycobacterium-avium intracellulare (MAI) infection, and chronic bronchiectasis who did not respond to three courses of outpatient antibiotics for a chronic cough. He also had a 21-lb weight loss. The diagnosis of Achromobacter xylosoxidans subspecies denitrificans was made through bronchoscopy with bronchoalveolar lavage (BAL). There are few case reports describing Achromobacter xylosoxidans subspecies denitrificans in non-CF patients. Achromobacter xylosoxidans colonization might be linked to predisposing lung damage such as in CF and bronchiectasis. The bacterium is frequently multidrug-resistant. More studies are needed to develop recommendations for clinical guidelines to address the increasing antibiotic resistance to Achromobacter xylosoxidans.