Hepatic Portal Venous Gas: A Potentially Lethal Sign Demanding Urgent Management.

BACKGROUND Hepatic portal venous gas is a rare and concerning finding occasionally seen on computed tomography (CT) scans, and must be emergently managed, often in the operating room. This condition can present in conjunction with bowel distension, pneumatosis intestinalis, and intestinal ischemia, so care must be taken to examine the imaging closely so as not to miss this dire condition. This report summarizes our experience with a patient who had this problem and how urgent management prevented a lethal outcome. CASE REPORT The patient was a 77-year-old morbidly obese man whose complicated hospital course began with admission for abdominal pain evaluation. This led to a flexible sigmoidoscopy for concerning CT findings suggestive of colitis or malignancy, leading to a perforation at the anterior wall of the sigmoid-rectal junction. Urgent sigmoid colectomy and Hartmann's procedure were performed along with pelvic drainage. Blood cultures returned positive for Klebsiella. After 10 days, the patient decompensated, and a CT scan showed pneumatosis intestinalis, hepatic portal venous gas, and diffuse small bowel distension. Rectal stump dehiscence had occurred; therefore, 2 repeat abdominal wash-outs were performed with aggressive intensive care. The patient eventually stabilized and was ultimately discharged to a skilled nursing facility 32 days later. CONCLUSIONS This case illustrates the importance of prompt imaging, medical management, and, if necessary, surgical exploration in the patient with bowel distension and hepatic portal venous gas on a CT scan. Although uncommon, this finding indicates a potentially poor prognosis and must be addressed emergently to prevent bowel ischemia from progressing in patients with underlying abdominal pathology.

Contralateral Tongue Deviation Due to Paramedian Pontine Infarction: A Brief Review of Cortico-Hypoglossal Projections.

BACKGROUND Motor function of the tongue is controlled by the hypoglossal nucleus (the lower motor neuron) and its supranuclear innervation (the upper motor neuron). Tongue deviation due to muscle weakness on one side is common in brain stem stroke and is usually associated with dysarthria and dysphagia that decrease the patient's quality of life. This case report presents a typical but rarely discussed case of tongue deviation secondary to a brain stem stroke. In addition, it also offers a concise review of both the ipsilateral and the contralateral cortico-hypoglossal fibers that innervate the hypoglossal nucleus. Even though the direction of the tongue deviation offers essential clues to localizing the brain lesion, many providers lack experience and knowledge in this area. CASE REPORT We report the case of an 81-year-old right-handed male patient with right-sided hemiparesis, right lower facial droop, dysarthria, and tongue deviated to the right side without fasciculation or atrophy. The Babinski sign was positive on the right. Magnetic resonance imaging revealed an infarct in the left paramedian pontine. Since both the tongue deviation and the hemiparesis were right-sided, contralateral to the side of the lesion, we concluded that the lesion affected the cortico-hypoglossal fibers and the corticospinal fibers prior to their decussations. CONCLUSIONS The case report reviews the projections of the corticospinal fibers. Each hypoglossal nucleus receives input from both hemispheres, with the contralateral descending fibers passing through the medial part of the ventral pons and the ipsilateral descending fibers passing through the more lateral aspect of the pons. The decussation is generally located at the pontomedullary junction, with exceptions due to individual variance.

A Mysterious Fever and Retropharyngeal Edema on a Previously Healthy 10-Year-Old Boy Without Known Exposure to COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) is considered a late manifestation of COVID-19 infection, and it is a diagnosis of exclusion after ruling out other causes of systemic inflammations. We present a case of MIS-C to highlight the importance of cardiac workup in MIS-C due to frequent cardiac involvement and discuss the possible association between retropharyngeal edema and MIS-C. The case patient is a 10-year-old previously healthy boy who presented with persistent fever, right-side neck pain, and a new rash. The rash was attributed to recent amoxicillin use by his parents. Pertinent workups included elevated inflammatory markers, a benign electrocardiogram test, a negative urine analysis, blood culture, and retropharyngeal edema by computerized tomography. On day four of hospitalization, the patient failed to improve with broad-spectrum antibiotics and became tachycardic. A repeat echocardiogram revealed a decreased ejection fraction with mitral valve regurgitation. The cardiac finding, the skin finding, the persistent fever, and the initial negative workups fulfilled the case criteria for MIS-C. A positive test for anti-SARS-CoV-2 spike protein receptor-binding domain antibodies confirmed the diagnosis, and the patient improved with intravenous immune globulin (IVIG) and steroids. The retropharyngeal edema was thought to be coincidental; however, there seem to be frequent associations between MIS-C and retropharyngeal edema, suggesting that the retropharyngeal edema could be one of the initial manifestations of MIS-C. More study is needed to study the association between retropharyngeal edema and MIS-C and shed light on the diagnosis and medical management of MIS-C.

Case Report: Rocky Mountain Spotted Fever with Adrenalectomy and a Hard-to-Find Tick.

BACKGROUND Rocky Mountain spotted fever (RMSF) is a potentially fatal infectious disease caused by the gram-negative intracellular bacterium Rickettsia rickettsii. The classic triad includes fever, rash, and history of tick exposure; however, the triad presents in only 3% to 18% of cases at the initial visit, and the tick bite is often painless and overlooked. RMSF can present with other manifestations, including hyponatremia, lymphopenia, thrombocytopenia, and coagulopathy. Some of these manifestations can be overlooked if they overlap with manifestations of a patient's pre-existing conditions. CASE REPORT A 43-year-old woman with RMSF presented with fever and treatment-resistant hyponatremia before developing a rash. Initially, the cause of her hyponatremia was attributed to adrenal insufficiency and dehydration. After appropriate treatments with hormone replacement therapy and intravenous hydration, her laboratory values remained relatively unchanged. A rash later appeared with an atypical RMSF pattern, warranting a detailed integumentary examination, which uncovered the culprit tick in an unusual location. After starting doxycycline, the patient's signs and symptoms, including her sodium level, improved. CONCLUSIONS We conclude that the diagnosis of RMSF is an empiric diagnosis based on clinical signs, symptoms, and appropriate epidemiologic settings for tick exposures. However, typical clinical signs do not always display at presentation. Other manifestations that a patient's pre-existing conditions can simultaneously cause should not be overlooked and should be examined holistically with other signs, symptoms, laboratory values, and physical examinations. Early treatment with doxycycline is encouraged as evidence strongly suggests that early treatment is correlated with lower mortality.

Characterization of a novel affinity binding ligand for tyrosine nitrated peptides from a phage-displayed peptide library.

As an important post-translational modification in response to oxidative and nitrosative stress, protein tyrosine nitration is deeply involved in many physiological and pathological processes. Identifying tyrosine nitration in proteins is challenging due to its low abundance.Consequently, pre-separation and enrichment of tyrosine-nitrated peptides (TNPs) are necessary before submitting them to mass spectrometry analysis. However, the most popularly used anti-nitrotyrosine antibody pull-down method showed limitations like sequence preference and unspecific binding. Therefore, developing novel affinity purification materials for TNPs is of significance. In the present study, we screened the phage-displayed 12-mer randomized peptide library for affinity binding peptide of the synthetic standard TNP (sTNP, sequence: H2N-GGGGY*GGG-COOH) and identified a peptide named NT-1 (H2N-TLWPFDLWLKTR-COOH) as a promising candidate. NT-1 at extremely low concentration (3 nM) in solutions could be efficiently captured by immobilized sTNP as determined by pull-down and subsequent MALDI-TOF MS analysis. Surface plasmon resonance (SPR) measurement confirmed that NT-1 possesseed a good selectivity, showing more than 100-fold higher binding affinity with TNP than its non-nitrated counterpart. Moreover, NT-1 could efficiently capture various types of TNPs in solutions even in the presence of 1000-fold excessive amount of trypsinized BSA fragments. Most importantly, NT-1 showed superiority to commercially used nitrotyrosine antibody as the former captured more TNPs, with less sequence preference. In summary, our study provided NT-1 as a novel affinity binding ligand for TNPs and should be useful in developing an alternative enrichment strategy for TNPs.

Trends in Use and Expenditures for Brand-name Statins After Introduction of Generic Statins in the US, 2002-2018.

Importance: The high and increasing expenditures for prescription medications in the US is a national problem. Objective: To explore the association of generic statin competition on relevant use and cost savings and to provide use and expenditure trends for all available statins for private and public payers and for out-of-pocket spending. Design, Setting, and Participants: This survey study evaluated data from the January 1, 2002, to December 31, 2018, Medical Expenditure Panel Survey by using a difference-in-differences analysis. Participants included noninstitutionalized individual statin users. Data were analyzed from November 1, 2020, to March 30, 2021. Exposures: The market entry of 5 generic statin medications (atorvastatin, rosuvastatin, simvastatin, lovastatin, and pravastatin). Main Outcomes and Measures: National- and individual-level reductions in the annual number of statin purchases and total expenditures across private insurance, public insurance (Medicaid and Medicare), and out-of-pocket spending (presented in 2018 US dollars). Results: Between January 1, 2002, and December 31, 2018, an average of 21.35 million statins (95% CI, 16.7-25.5 million) were purchased annually, with an average total annual cost of $24.5 billion (95% CI, $18.2-$28.8 billion). The number of brand-name statin purchases decreased by 90.9% (95% CI, 56%-98%) nationally and 27.4% (95% CI, 13%-40%) individually after the end of market exclusivity. Among major payers, the end of market exclusivity was associated with individual cost savings of $370.00 (95% CI, $430.70-$309.20) for private insurers, $281.00 (95% CI, $346.80-$215.30) for Medicare, $72.34 (95% CI, $95.22-$49.46) for Medicaid, and $211.90 (95% CI, $231.20-$192.50) for out-of-pocket spending. Combining all payers, the decrease translates to $925.60 (95% CI, $1005.00-$846.40) of annual savings per individual and $11.9 billion (95% CI, $10.9-$13.0 billion) for the US. Conclusions and Relevance: Results of this survey study suggest that full generic competition of statins was associated with significant cost savings across all major payers within the US health care system.