Rhizobium radiobacter-Induced Peritonitis: A Case Report and Literature Analysis.

Rhizobium radiobacter (R. radiobacter) is a gram-negative bacterium, primarily a soil contaminant and rarely pathogenic to humans. Only a few cases of peritonitis secondary to R. radiobacter have been reported worldwide. A 66-year-old male with end-stage renal disease who was on peritoneal dialysis (PD) developed R. radiobacter-induced peritonitis. We have treated the infection successfully with intraperitoneal antibiotics and managed to keep his PD catheter intact without interruption in PD treatment. More prolonged antibiotic therapy and frequent clinical follow-up is required to treat this infection. Better clinician awareness is needed to prevent this rare infection.

Temporal trends in atherosclerotic cardiovascular disease risk among U.S. adults. Analysis of the National Health and Nutrition Examination Survey, 1999-2018.

BACKGROUND: Atherosclerotic cardiovascular diseases are a significant cause of disability and mortality. Study of trends in cardiovascular risk at a population level helps understand the overall cardiovascular health and the impact of primary prevention efforts. AIMS: To assess trends in the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among U.S. adults from 1999-2000 to 2017-18 with no established cardiovascular disease (CVD). METHODS AND RESULTS: Serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 (10 cycles), including 24 022 US adults aged 40-79 years with no reported ASCVD. ASCVD risk was assessed using the pooled cohort equations (PCEs). There was a significant temporal decline in the mean 10-year ASCVD risk from 13.5% (95% CI, 12.5-14.4) in 1999-2000 to 11.1% (10.5-11.7) in 2011-12 (Ptrend < 0.001) and to 12.0% (11.3-12.7) in 2017-2018 (overall Ptrend = 0.001), with the mean ASCVD risk score remaining stable from 2013-14 through 2017-2018 (Ptrend = 0.056). A declining trend in ASCVD risk was noted in females, non-Hispanic Blacks and those with income <3 times the poverty threshold with Ptrend of <0.001, 0.002, and 0.007, respectively. Mean total cholesterol and prevalence of smokers showed a downward trend (Ptrend <0.001 for both), whereas type 2 diabetes and mean BMI showed an upward trend (Ptrend < 0.001 for both). CONCLUSIONS: The 20-year trend of ASCVD risk among NHANES participants 40-79 years, as assessed by the use of PCE, showed a non-linear downward trend from 1999-2000 to 2017-18. The initial and significant decline in estimated ASCVD risk from 1999-2000 to 2011-12 subsequently stabilized, with no significant change from 2013-14 to 2017-18. Mean BMI and prevalence of diabetes mellitus increased while mean serum cholesterol levels and prevalence of smoking declined during the study period. Our findings support invigoration of efforts aimed at prevention of CVD, including primordial prevention of CVD risk factors.

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States.

BACKGROUND: The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States. METHODS: Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model. RESULTS: Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003). CONCLUSIONS: The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

The Jailed Sinoatrial Node: An Interesting Case of Cardiogenic Shock Secondary to Sinus Arrest Following Percutaneous Intervention.

Complete occlusion of the sinoatrial node artery can be a complication of percutaneous intervention (PCI) to the right coronary artery (RCA). When this happens, dysfunction of the sinus node may follow resulting in sinus arrest. When this occurs, it is usually transient and as such, is typically not accompanied by hemodynamic instability. Permanent sinus arrest and shock state may, however, occur on rare occasions. The presence of junctional rhythms on the electrocardiogram (ECG) may predict the occurrence of these permanent arrhythmias and cardiogenic shock. In this case report, we present a 78-year-old woman who developed cardiogenic shock secondary to sinus arrest following PCI to RCA. Her ECG showed junctional rhythm, and she went on to require permanent ventricular pacing. This illustrates a known but rare complication of PCI to RCA.

Brevibacterium casei Induced Peritonitis in a Patient Undergoing Continuous Cycler Peritoneal Dialysis: Case Report and Literature Review.

Brevibacterium casei is an extremely rare organism that can lead to peritonitis in End-stage renal disease patients of peritoneal dialysis. Out of only five overall Brevibacterium species peritonitis reported worldwide, only two of them had B. casei subspecies peritonitis detected, with both needing peritoneal dialysis catheter removal and change in dialysis modality to hemodialysis. Our patient, an elderly 63-year-old Hispanic male, was on peritoneal dialysis at home and presented with features suggestive of peritonitis. He was diagnosed subsequently with B. casei and started on broad spectrum intraperitoneal antibiotics. However, he did not need dialysis modality change and recovered fully after 3 weeks of appropriate intraperitoneal antibiotics therapy. Longer antibiotics therapy and frequent clinical follow-up plus better clinician awareness are needed to prevent this rare infection.

Successful Treatment of Calciphylaxis in a Young Female With End-Stage Renal Disease on Peritoneal Dialysis With Parathyroidectomy, Intensification of Dialysis, and Sodium Thiosulphate-A Case Report and Literature Review.

Calcific uremic arteriolopathy, commonly referred to as "calciphylaxis," is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn't need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.

Intravenous Drug Use-Associated Infective Endocarditis in Pregnant Patients at a Hospital in West Virginia.

Introduction Due to high levels of intravenous drug use (IVDU) in West Virginia (WV), there are increasing numbers of hospitalizations for infective endocarditis (IE). More specifically, pregnant patients with IE are a uniquely challenging population, with complex management and a clinical course that further affects the health of the fetus, with high morbidity and mortality. Timely recognition and awareness of the most common bacterial causes will provide hospitals and clinicians with valuable information to manage future patients. Methods This retrospective study analyzed the clinical course of pregnant patients admitted with IE and IVDU history presenting at Cabell Huntington Hospital from 2013 to 2018. Inclusion criteria were women between 16 and 45 years of age confirmed to be pregnant by urine pregnancy test and ultrasonography with at least eight weeks gestation, with a first-time diagnosis of endocarditis and an identified history of IVDU. We excluded charts with pre-existing risk factors including a history of valvular disease, rheumatic heart disease, surgical valve repair or mechanical valve replacement, or a diagnosis of coagulopathies. The resulting charts were evaluated for isolated organisms, reported clinical course, and complications of the pregnancy. Results A total of 10 patients were identified, with methicillin-susceptible and methicillin-resistant Staphylococcus aureus, Serratia marcescens, Haemophilus parainfluenza, and Enterococcus faecalis species. Complications included loss of fetus (30%), septic embolization (40%), hemorrhagic stroke (10%), and transfer to outside facilities for cardiothoracic surgical intervention (40%). Discussion IE in pregnancy, while rare, has serious complications. In the context of the IVDU epidemic, it has an increasing impact on WV hospitals. A better understanding of the clinical course may allow for early diagnosis and guide the development of rational empiric therapies. More effective management of IE in pregnant patients can reduce complications and potentially improve maternal and fetal morbidity or mortality.

Association of atrial fibrillation with outcomes in patients hospitalized with inflammatory bowel disease: an analysis of the National Inpatient Sample.

INTRODUCTION: We aimed to determine in-hospital outcomes, length of hospital stay (LOS) and resource utilization in a contemporary cohort of patients with inflammatory bowel disease (IBD) and atrial fibrillation (AFIB). MATERIAL AND METHODS: The National Inpatient Sample database October 2015 to December 2017 was utilized for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of IBD. RESULTS: Of 714,863 IBD patients, 64,599 had a diagnosis of both IBD and AFIB. We found that IBD patients with AFIB had a greater incidence of in-hospital mortality (OR = 1.3; 95% CI: 1.1-1.4), sepsis (OR = 1.2; 95% CI: 1.1-1.3), mechanical ventilation (OR = 1.2; 95% CI: 1.1-1.5), shock requiring vasopressor (OR = 1.4; 95% CI: 1.1-1.9), lower gastrointestinal bleeding (LGIB) (OR = 1.09, 95% CI: 1.04-1.1), and hemorrhage requiring blood transfusion (OR = 1.2, 95% CI: 1.17-1.37). Mean LOS ± SD, mean total charges and total costs were higher in patients with IBD and AFIB. CONCLUSIONS: In this study, IBD with AFIB was associated with increased in-hospital mortality and morbidity, mean LOS and resource utilization.

Prevalence and risk factors for the development of abdominal aortic calcification among the US population: NHANES study.

INTRODUCTION: Abdominal aortic calcification (AAC) is an important marker of subclinical cardiovascular disease and its prognosis. Advanced age, hypertension, smoking, dyslipidemia, diabetes mellitus, and higher truncal fat are known markers of AAC in studies conducted around the world. However, literature for these risk factors and their co-occurrence is limited in the US. MATERIAL AND METHODS: We used data from dual energy X-ray absorptiometry (Hologic, v4.0) to detect the occurrence of AAC in a sample population (n = 3140) of the NHANES survey using a computer-assisted interviewing system to assess the risk factors for AAC. RESULTS: We found the national prevalence of AAC in the US to be 28.8%. After adjusting for confounders, persons with hypertension: OR = 1.66 (95% CI: 1.30-2.13) and smokers: OR = 1.63 (95% CI: 1.24-2.14) were more likely to have AAC compared to their respective counterparts. Increasing age was positively associated with AAC: OR = 1.06 (95% CI: 1.04-1.08). There was a statistically significant negative association between body mass index (BMI) and AAC, more so in smokers than in non-smokers: OR = 0.97 (95% CI: 0.94-0.97). We did not observe any statistically significant association between diabetes and AAC. CONCLUSIONS: Advanced age, smoking, and hypertension was associated with increased occurrence of AAC. Paradoxically, increasing BMI was inversely associated with AAC and there was no statistically significant association between total body and trunk fat percentages and AAC. To the best of our knowledge, this is the first study to establish the nationwide prevalence and associated factors in the US.

Prevalence and association of iron deficiency with anemia among patients with heart failure in the USA: NHANES 2017-2018.

Background: Heart failure (HF) is a major debilitating disease. HF patients with iron deficiency(ID) have poorer outcomes and treatment significantly improves outcomes. We set out to update the national prevalence of ID in the USA and its association with anemia using data from NHANES 2017-2018. Methods: Diagnosis of HF was self-reported. ID was defined as serum ferritin levels <100 ng/mL or a ferritin level between 100 and 299 ng/mL with transferrin saturation <20%. Anemia was defined as a hemoglobin level of <13 g/dl and <12 g/dl for men and women, respectively. Differences in prevalence of ID across various groups were assessed using Chi-squared test for categorical variables and equality of means for continuous variables with p-values <0.05 considered statistically significant. Results: A total of 187 persons ≥20 years, corresponding to a 5.57million had HF. The prevalence of ID was 48.17% (95% CI 36.84-59.69) and the prevalence of anemia was 12.08%(95% CI 8.16-17.53). Diabetics (61.03%) were more likely to have ID compared to nondiabetics (35.38%), p 0.022. The prevalence of ID was similar in persons with anemia (47.45%) and persons without anemia (48.27%), p-value 0.983. The prevalence of ID has been constant for at least the past 20 years, making ID in HF an underdiagnose and/or undertreated condition among patients with HF and should be addressed. Conclusions: One in every two persons with HF has ID. Also, prevalence of ID was similar in patients with anemia and without anemia. Anemia should not be considered a prerequisite for screening for ID in patients with HF.

Outcomes of oesophageal variceal bleeding among patients with atrial fibrillation: a propensity-matched analysis of a nationwide inpatient sample.

INTRODUCTION: We aimed to determine the influence of atrial fibrillation (AF) on mortality, morbidity, length of hospital stay, and resource utilisation in patients with oesophageal variceal bleeding (OVB). MATERIAL AND METHODS: The National Inpatient Sample database (2016 and 2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify patients with the principal diagnosis of OVB and AF. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS), and total costs between propensity-matched groups of OVB with AF vs. OVB alone. RESULTS: We identified 80,325 patients with OVB, of whom 4285 had OVB with AF, and 76,040 had OVB only. The in-hospital mortality was higher in OVB with AF (OR = 1.4, 95% CI: 1.09-1.83; p < 0.001). OVB with AF had higher odds of sepsis (OR = 1.4, 95% CI: 1.1-1.8; p = 0.007), acute kidney injury (OR = 1.2, 95% CI: 1.12-1.32; p < 0.001), and mechanical ventilation (OR = 1.2, 95% CI: 1.12-1.32; p < 0.001). Advanced age (OR = 1.06, 95% CI: 1.05-1.07; p < 0.001), congestive heart failure (OR = 1.7, 95% CI: 1.3-2.3; p < 0.001), coronary artery disease (OR = 1.4, 95% CI: 1.03-1.92; p = 0.02), and sepsis (OR = 1.3, 95% CI: 1.06-1.70; p = 0.01) were identified as predictors of mortality in OVB with AF. Mean LOS (7.5 ±7.4 vs. 6.0 ±7.2, p < 0.001) and mean total costs ($25,452 vs. $21,109, p < 0.001) were also higher. CONCLUSIONS: In this propensity-matched analysis, OVB with AF was associated with higher odds of in-hospital mortality, sepsis, acute kidney injury, and mechanical ventilation.

Nocturia is an Independent Predictor of Abdominal Aortic Calcification in Women: Results from the National Health and Nutrition Examination Survey.

Nocturia is generally considered a urological condition, but may be an indicator of cardiovascular disease, as prior studies have found associations with cardiovascular risk factors as well as clinical and subclinical markers of coronary artery disease. This study aimed to explore potential associations between nocturia and abdominal aortic calcification (AAC). We analyzed 2013-2014 National Health and Nutrition Examination Survey dual energy x-ray absorptiometry-derived AAC data and concurrent interview data on kidney conditions from respondents aged 40-80 years. AAC was defined as a score ≥ 1 on the 24-point semi-quantitative AAC scale. Nocturia was defined as an average of ≥ 2 voids per night. Three incremental multivariate logistic regression models controlling for (1) age, (2) sex, race, and BMI, and (3) hypertension, diabetes mellitus, and smoking history were used to determine whether nocturia predicted AAC. These models were and modified to exclude age and/or sex to perform age- and/or sex-specific sub-analyses, respectively. Complete data were available from 2,945 participants (29.1% AAC, 31.4% nocturia). On univariate analysis, the association between nocturia and AAC was significant in women (OR 1.77 [95% CI 1.37-2.29], p < 0.001), but not in men (1.14 [0.74-1.76], p = 0.531). Multivariate analysis showed nocturia was an independent predictor of AAC in women in Models I-II (ORs 1.49-1.58, p ≤ 0.032) but not Model III (1.37 [0.90-2.09], p = 0.133). Stratification by age revealed a strong univariate association among women aged 50-59 (3.88 [1.97-7.61], p < 0.001), which persisted across all multivariate models (ORs 4.05-4.41, p ≤ 0.001). The presence of nocturia is an important clue of AAC in women, especially those middle-aged.

Prevalence and control rates of hypertension in the USA: 2017-2018.

BACKGROUND: Recent review of hypertension guidelines requires fresh updates of prevalence and control rates. Though retrospective analysis provided burden estimates, control rates were grossly misleading. We set out to update the prevalence and control rates of hypertension in the USA using contemporary NHANES data. METHODS: Persons with mean systolic blood pressure (mSBP) ≥130 mmHg or mean diastolic blood pressure (mDBP) ≥80 mmHg or self-reported current use of antihypertensive medications were classified as hypertensives. Hypertensives on medications with mSBP <130 mmHg and mDBP <80 mmHg were classified as having well-controlled hypertension. Subgroup comparisons of hypertension prevalence were computed using Chi-square test. Predictors of hypertension and well-controlled BP were assessed using multivariable logistic regressions. Two tailed p-values <0.05 were considered statistically significant. RESULTS: The prevalence of hypertension in the USA in 2017-2018 was 49.64% (95% CI 46.67-52.61) corresponding to 115(95% CI 104-128) million persons. NH Blacks: 58.53% (95% CI 55.39-61.60); Men: 54.46% (95% CI 51.01-57.87); older persons and obese individuals: 61.03% (95% CI 57.31-64.63) as well as persons with diabetes and CKD, comparatively. The overall rate of well-controlled hypertension was 39.64% (95% CI 36.20-42.81). Persons with at least a college degree: OR 2.20(95% CI 1.02-5.04, p=0.049) and persons with incomes ≥3 times the poverty threshold; OR 1.88(95% CI 1.1.8-2.99, p=0.011) had higher rates of well-controlled hypertension when compared to lowest categories. CONCLUSION: One in every two persons ≥20 years in the USA has hypertension with only 39.64% on medications having well-controlled hypertension. Significant discrepancies exist in the burden and control rates in different subpopulation categories. Targeted interventions could help improve the prevalence and hypertension control rates in the USA.

10-Year community prevalence and trends of severe asymptomatic hypertension among patients with hypertension in the USA: 2007-2016.

BACKGROUND: Severe asymptomatic hypertension (SAH) is associated with significant health cost, morbidity and mortality. AIM: Establish the nationwide prevalence, trends and associated sociodemographic characteristics of SAH among patients with hypertension in the USA. METHODS: We utilized the National Health and Nutrition Examination data collected over five survey cycles (2007-2016). Included were participants aged 20-80 years with self-reported diagnosis of hypertension. SAH was defined as having a mean systolic blood pressure (SBP) ≥180 mmHg and/or mean diastolic blood pressure (DBP) ≥120 mmHg at the time of examination. The Chi square test was used to compare prevalence across different categories. Associations between sociodemographic variables and SAH were assessed using multivariate binary logistic regression. RESULTS: The prevalence of SAH among patients with hypertension is 2.15% (95% CI 1.80-2.56), mainly explained by isolated mean SBP≥180 mmHg (86% of all cases), with no statistically significant change between 2007: 2.66% (95% CI 2.10-3.36) and 2016:2.61% [95% CI 1.73-3.94), p-trend = 0.17. Increasing age (OR 1.07, 95% CI 1.04-1.09), NH Blacks (OR 2.20, 95% CI 1.37-3.54), BMI< 25 (OR 2.52, 95% CI 1.48-4.28), lack of health insurance OR 4.92% (95% CI 2.53-9.54) and never married individuals (OR = 2.59%, 95% CI 1.20-5.60) were more likely to have SAH, comparatively. There was no significant association between duration of hypertension and SAH. CONCLUSION: The prevalence of SAH in the USA is 2.15% and has been stable over the past decade. Our study underscores the importance of identifying barriers to screening and treatment of hypertension which is a major treatable risk factor for cardiovascular disease.

10-Year trend in the prevalence and predictors of depression among patients with heart failure in the USA from 2007-2016.

BACKGROUND: Heart failure (HF) constitutes a major public health problem in the USA with self-management playing a key role in treatment. Depressed patients often have poor insights which correlates with increased rates of adverse events such as emergency room visits, admissions and readmissions, length of hospital stay and mortality. AIM: To determine the prevalence, trends, and predictors of depression among community-based patients with HF in the USA, and its association with self-perceived health status. METHODS: Using the 2007 through 2016 NHANES data, we identified patients with HF aged 20-80 years with completed PHQ-9 depression screening questionnaire. PHQ-9 scores ≥10 were considered diagnostic for depression. The Chi square test was used for comparison of prevalence of depression between subgroups with p < 0.05 considered statistically significant. RESULTS: The prevalence of depression among community-based patients with HF was 17.3% and remained stable from 2007 through 2016. Female participants, persons <60years, individuals with low socioeconomic status, and never married individuals were more likely to be depressed, comparatively. After controlling for confounders, living in poverty was the lone predictor of depression with OR 5.1 (95% CI 1.4-17.9), compared to those with incomes ≥3 times the poverty threshold. Depressed individuals were more likely to report a poor health status (76.4%) compared to non-depressed individuals (45.9%), p < 0.001. CONCLUSION: Over 1 in 6 community-based patients with HF suffers from depression with women, individuals <60years, never married, and persons with low socioeconomic status shouldering a disproportionately higher burden.

Disparities and drivers of early age at diagnosis of congestive heart failure in the USA.

AIM: Heart failure (HF) constitutes a major public health problem in the USA due to its high morbidity and mortality. Age at diagnosis of HF would refine burden quantification, budgeting, disease surveillance and assessment of interventions. We set out to determine the median age at diagnosis of HF and drivers of young age at diagnosis among patients 20 years or older in the USA. METHODS AND RESULTS: We utilized NHANES data collected across five survey cycles (2007-2016). Included were individuals aged 20 to 80 years diagnosed of HF with valid entries for age at diagnosis. Differences in age at diagnosis between groups and major drivers for younger age at diagnosis were assessed using linear regression models with p-values <0.05 considered statistically significant. The prevalence of HF in the USA was 2.44% with a median age at diagnosis of 59 years (IQR 47-70). Non-Hispanic (NH) Blacks -4.94 years (95% CI -7.95 to -1.93), individuals living below the poverty line -5.79 years (95% CI -10.36 to -1.01), obese persons -5.63 years (95% CI -8.35 to -2.92), individuals without health insurance -4.31 years (95% CI -7.87 to -0.75) and those without hypertension -3.99 years (95% CI -7.19 to -0.78) were diagnosed at significantly younger ages than their respective counterparts. CONCLUSION: The median age at diagnosis of HF in the USA is 59 years. NH Blacks, living in poverty, lack of health insurance and obesity are the main drivers of early age at diagnosis of HF in the USA.

Severe hypercalcemia in a patient with extrapulmonary Mycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case of Mycobacterium abscessus presenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review.

Background: Nontuberculous mycobacterium is a recognized cause of hypercalcemia, particularly in patients with acquired immunodeficiency syndrome (AIDS). Here we describe a case of severe hypercalcemia secondary to Mycobacterium abscessus (M. abscessus) in a patient with AIDS. To the best of our knowledge this is the first case report describing a case of M. abscessus presenting as retroperitoneal lymphadenopathy and severe hypercalcemia. Case description: A 56-year-old man with AIDS presented with altered mental status and somnolence for four days. Laboratory investigations were significant for calcium 16.49 mg/dL (RI 8.9-10.3 mg/dL), 1,25 dihydroxyvitamin D level 44.1 pg/ml (RI 19.9-79.3 pg/ml) and parathyroid hormone (PTH) 4 pg/mL (RI 15-65 pg/mL). CT scan of Abdomen and Pelvis showed hepatosplenomegaly with large retroperitoneal, retrocrural, and mesenteric lymphadenopathy which had an intense focal uptake on Gallium scan. Bone marrow biopsy revealed mild plasmacytosis (5%) with no evidence of myelodysplasia, acute leukemia or lymphoma. A subsequent lymph node biopsy showed fragments of fibrous tissue with lymphohistiocytic infiltrate and many acid-fast bacilli. Pre-antibiotic blood cultures grew Mycobacterium which was identified later as M. abscessus at four weeks. Conclusion: hypercalcemia in HIV-infected patients may suggest malignancy or infectious etiology, among other causes. Clinicians should be aware of the risk of hypercalcemia with nontuberculous mycobacterium (NTM) infection, whether as first manifestation or a late presenter in the disease course after initiating antiretroviral therapy (ART). We suggest careful monitoring of serum calcium level upon diagnosis of NTM infection and after initiation of ART, NTM therapy or vitamin D supplementation.

An unusual case of bilateral pulmonary embolism in a patient on dual venous thromboprophylaxis, secondary to heparin induced thrombocytopenia.

Heparin Induced thrombocytopenia (HIT) is a rare, immune-mediated complication of heparin, associated with both thrombocytopenia and paradoxical thrombotic events. Initial diagnosis is made clinically when platelet count falls by 30% to <100 × 109cells/l or a > 50% decrease from baseline count in association with heparin therapy. Thromboembolic complications are seen in 50% of the cases. We present a case of acute pulmonary embolism (aPE) in a 65 year old male secondary to HIT while on unfractionated heparin for venous thromboprophylaxis. He was admitted to the hospital for severe acute exacerbation of asthma and was on heparin and venodyne boots for venous thrombo-prophylaxis. His chief presenting complaints improved until day 13, when he had severe pleuritic chest pain with worsening of shortness of breath and was desaturating while breathing ambient air. Computed tomography (CT) of the chest with intravenous contrast revealed aPE involving bilateral upper lobe segmental pulmonary arteries. Given the pattern and timing of thrombocytopenia prior to onset of his symptoms and acute thromboembolism, diagnosis of HIT was made which was later supported by positive platelet factor- ELISA and serotonin release assay (SRA) laboratory testing. Heparin and heparin-related products were promptly discontinued and argatroban was started. Later platelet count increased over 150 × 103/µL and argatroban was switched to warfarin prior to discharge. As heparin is extensively used, all physicians are required to be attentive of this life threatening complication. Discontinuing heparin while substituting with an alternative anticoagulant such as argatroban may become a life-saving strategy in such a case.

Severe hypokalemia with cardiac arrest as an unusual manifestation of alcoholism.

Introduction: Unhealthy use of alcohol can be associated with serious adverse events. Patients with alcoholism and malnutrition are at high risk for electrolyte disturbances, commonly hypokalemia. Here in we describe a case of alcohol use disorder presented with weakness and subsequently developed cardiac arrest secondary to severe hypokalemia. Case description: A 51-year-old lady presented to our emergency department because of generalized body ache and marked weakness in both lower extremities for two days duration. She had a long-term history of alcoholism, consuming two to three pints of vodka every day for about 20 years. Her last drink of alcohol was about 48 hours prior to presentation. Her examination revealed bilateral lower limb weakness of 4/5, with intact sensory system and reflexes. Biochemical analysis of the serum showed severe electrolytes disturbance, a potassium level of 2.3 mmol/L (reference 3.6-5.1 mmol/L). Electrocardiogram (ECG) showed no arrhythmias, but changes characteristic of hypokalemia with marked corrected QT segment prolongation (QTc 551ms). Aggressive supplementation of electrolytes was initiated, however, potassium level failed to increase and subsequently she had a sinus bradycardia followed by cardiac arrest. Cardiopulmonary resuscitation was initiated, return of spontaneous circulation was obtained. During the following days, potassium supplementation was continued to achieve normal plasma potassium level. She was then discharged from the hospital with recommendations for abstinence from alcohol. Conclusion: Patients with chronic alcohol-use can have serious electrolyte disturbances including hypokalemia which can have life-threatening consequences. Prolonged potassium supplementation over several days is required to achieve normal level of plasma potassium and replenish total-body potassium deficit.

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study.

Introduction: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism. Methods: This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017. Results: A total of 79 patients were included, the mean age was 55.76 (SD = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age (p = .041), presence of lung disease (p = .036), number of comorbidities (p = .043), and pulmonary embolism severity index (PESI) scores (original and simplified; p = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS (OR 1.067, 95% CI [1.001, 1.137], p = .048). Similarly, sPESI significantly predicted long LOS (OR 0.223, 95% CI [0.050, 0.999], p = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities. Conclusion: Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.