Variant Angina and Cannabis-Induced Myocarditis: A Rare Presentation of Myocardial Inflammation.

Myocarditis is a rare but serious inflammatory disease of the myocardium, often caused by viral infections. We present a unique case of myocarditis in a previously healthy 29-year-old male who developed symptoms and electrocardiography changes of variant angina following cannabis use. This case report discusses the patient's atypical presentation, diagnostic evaluation, management, and outcome.

Cushing's Disease Associated With Partially Empty Sella Turcica Syndrome: A Case Report.

The association between empty sella turcica (EST) syndrome and Cushing's disease has been rarely reported. It is plausible to hypothesize that EST syndrome in association with Cushing's disease can be attributed to intracranial hypertension. In this case report, we present a 47-year-old male patient who presented with weight loss, fatigue, easy bruising, acanthosis nigricans, and skin creases hyperpigmentation. Investigations revealed hypokalemia and confirmed the diagnosis of Cushing's disease. Magnetic resonance imaging (MRI) brain showed a partial EST syndrome and a new pituitary nodule as compared with previous brain imaging. Transsphenoidal surgery was pursued and was complicated by cerebrospinal fluid leakage. This case reflects the rare association of EST syndrome and Cushing's disease, suggesting the increased risk of postoperative complications in this setting and the diagnostic challenge that EST syndrome imposes. We review the literature for a possible mechanism of this association.

Tick-Borne Myopericarditis With Positive Anaplasma, Lyme, and Epstein Barr Virus (EBV) Serology: A Case Report.

Myopericarditis has been reported only rarely in those with anaplasmosis and is typically difficult to diagnose. Lyme carditis can also be difficult to diagnose as it is relatively rare but potentially fatal and usually has nonspecific manifestations. We are presenting a 61-year-old male patient who presented in New Jersey, United States with unremitting fever, chills, and myalgia for two weeks along with nausea, vomiting, and diarrhea. Investigations were suggestive of perimyocarditis as was indicated by diffuse ST segment elevation on electrocardiography (EKG) with the presence of small pericardial effusion on echocardiography. A mild troponin leakage was also seen. This progressed to septic shock that required vasopressor therapy. Further history-taking revealed recent tick exposure and prompted empirical initiation of doxycycline. This proved to be successful with fever defervescence and clinical improvement. Serological tests confirmed both acute Lyme and anaplasma infections along with positive serology of Epstein Barr virus (EBV). This case highlights an uncommon presentation of carditis in acute Lyme and anaplasma infections with the associated false-positive serology of EBV.

Cannabis-Induced ST-Segment Elevation Myocardial Infarction With Possible Coronary Artery Dissection: A Case Report.

Spontaneous coronary artery dissection is a rare and commonly underdiagnosed cause of acute coronary syndrome. Here, we report the case of a 36-year-old male patient who presented with an acute onset of left-sided chest pain, preceded by several hours of nausea and vomiting. Past medical history was significant for chronic marijuana use and multiple episodes of nausea and vomiting requiring multiple hospitalizations. Urinary drug screen was positive for cannabinoids only, and electrocardiography revealed an ST-segment elevation myocardial infarction. This was complicated by an episode of ventricular fibrillation that was successfully defibrillated and prompted cardiac catheterization, which revealed a coronary intraluminal filling defect and a segmental lesion, suggestive of coronary dissection. No evidence of atherosclerotic plaque was noticed. Stent placement and thrombectomy were pursued and the patient was stabilized. As cannabinoid use is gaining legality and becoming widespread, this case aims to enhance physicians' awareness of potentially life-threatening complications of its use.

Cardiac Tamponade Risk Associated With Anticoagulation for Atrial Fibrillation in Dialysis-Associated Pericarditis: A Case Report.

Heparin is a preferred initial anticoagulant in patients with new-onset atrial fibrillation (AF). Despite continuous debate about the risk, there has been a concern about heparin-induced hemorrhagic pericarditis and cardiac tamponade. We present a case of a new onset atrial fibrillation (AF) in a patient with renal impairment and evidence of pericardial effusion complicated by hemopericardium development after starting anticoagulation. Although the risk of hemorrhagic conversion of uremic pericarditis induced by heparin in ESRD patients with new onset AF was suggested in the literature, this case raises the possibility of a similar complication in dialysis-associated pericarditis. Therefore, we aim to heighten alertness regarding this potential complication of a commonly used medication in clinical practice. We also aim to review the current anticoagulation recommendations in this setting.

A Possible Association Between COVID-19 Vaccine and Complicated Pleural Effusion: A Case Report.

As COVID-19 vaccines gain more prevalence, previously unrecognized side effects continue to be reported. We report a case of 78 male with no significant past medical history who was found to have a unilateral pleural effusion with symptoms that started two days after the administration of a COVID-19 vaccine. The initial presumption was bacterial pneumonia with parapneumonic effusion. However, the lack of clinical response prompted surgical intervention, and a diagnosis of empyema was established. No evidence of infectious etiology was found. This case helps to support the previously limited evidence in the recent medical literature that suggests a possible association between COVID-19 vaccines and pleurisy/effusion.

Spinal Hypertrophic Pachymeningitis in Antineutrophilic Cytoplasmic Antibody-Negative Vasculitis: A Case Report.

Hypertrophic pachymeningitis (HPM) is a rare but extremely debilitating disease. It is even rarer for HPM to be seen in association with antineutrophil cytoplasmic antibody (ANCA)-negative vasculitis. In this case, we are presenting HPM that was diagnosed in a 28-year-old female patient who presented with worsening back pain. Imaging revealed dural-based enhancing masses affecting the thoracic spinal cord with compression. Infectious etiologies were ruled out and a total of three biopsies failed to show any evidence of granulomatous inflammation, malignancy, or evidence of immunoglobulin G4-related disease. ANCA was negative on repeated testing. The patient was managed with repeated short courses of steroids that resulted in symptomatic control as well as radiological stability of the disease. This is an extremely rare case of atypical presentation of spinal HPM that is likely associated with granulomatous and polyangiitis without other manifestations of the disease except for nasal septal perforation. This case is a supplement to a limited body of knowledge and established cases of HPM in ANCA-negative, ANCA-associated vasculitis.

The Rare Adverse Effect of Cefepime-Induced Neutropenia.

Cefepime is widely considered a safe and effective antibiotic, but it can have rare and serious side effects. We present a case of a 33-year-old female patient who developed severe and potentially life-threatening neutropenia after being on cefepime for 25 days. Despite extensive investigations, no other causes of neutropenia could be identified. Discontinuing the medication and administering a single dose of filgrastim produced a rapid and dramatic response. This case highlights the rare but serious risk of cefepime-induced neutropenia and underscores the need for clinicians to remain vigilant for this potential adverse effect. It is important to note that discontinuing the medication can rapidly reverse the effects, making timely recognition and intervention crucial for patient outcomes.

A Case of Advanced Multifocal Cholangiocarcinoma With Excellent Response to Pembrolizumab.

The role of immune checkpoint inhibitors (ICIs) continues to receive more attention as evidence emerges of their efficacy and improved survival in patients with advanced biliary tract malignancies including cholangiocarcinoma (CCA). In line with this evidence, we describe the case of a 52-year-old male patient who presented initially in October 2019 with abdominal pain. Investigations revealed multifocal hepatic masses that proved to be CCA that was considered unresectable. Chemotherapy with cisplatin (C) and gemcitabine (G) was initiated. In January 2020, progressive disease was noted, prompting the initiation of 5-fluorouracil (5-FU) and oxaliplatin along with pembrolizumab. Since March 2020, pembrolizumab monotherapy was pursued with radiological evidence of excellent response. Pembrolizumab monotherapy was continued through August 2022, where positron emission tomography (PET)/CT scan showed no evidence of active disease. This case serves to supplement the ongoing evidence of ICI efficacy especially as a durable, sustained radiological response was evident for more than three years from the time of diagnosis.

Nivolumab-Induced Organizing Pneumonia in Management of Non-small Cell Lung Carcinoma: A Case Report.

Nivolumab is an immune checkpoint inhibitor (ICI) that has proven efficacy in managing certain malignancies, including non-small lung carcinoma. In this case, we present a 53-year-old female patient diagnosed with metastatic non-small lung carcinoma. After management with radiation (both external beam and brachytherapy) and tumor debulking by bronchoscopic cryotherapy, she developed an initial pneumonitis attributed to nivolumab and ipilimumab. This was successfully managed with steroid therapy and allowed nivolumab monotherapy to restart. However, several months later, she developed organizing pneumonia, prompting immunotherapy discontinuation and initiation of corticosteroid therapy. This case serves as a reminder to clinicians that although ICIs constitute a novel, effective therapy for certain malignancies, immunological side effects can be debilitating and prevent continued immunotherapy. Through this case, we aim to review the literature about this rare side effect of nivolumab-induced pneumonitis, risk factors, diagnosis, and management.

Miller Fisher Syndrome With Positive Anti-GQ1b/GQ1d Antibodies Associated With COVID-19 Infection: A Case Report.

The association between Guillain-Barré Syndrome (GBS) and its variants including Miller Fisher syndrome (MFS) has been reported and debated in the literature. Herein, we are reporting a 59-year-old male patient who had flu-like symptoms for 10 days prior to presentation with rapidly progressive weakness, dysphagia, and dysarthria. He tested positive for COVID-19 and further workup showed positive anti-GQ1b and GQ1d antibodies. The diagnosis of MFS was presumed and prompted the commencement of intravenous immunoglobulin (IVIG). Respiratory deterioration prompted intubation and failure of extubation necessitated plasmapheresis. This treatment culminated in successful extubation and discharge to a long-term care facility. This case adds to the currently limited body of cases that report the association of a rare GBS variant with COVID-19 infection. Only a few of the reported cases of COVID-19-related MFS cases had positive anti-GQ1b antibodies. This may well be the first reported case of COVID-19-related MFS with positive anti-GQ1b and anti-GQ1d antibodies.

Cortical Ribbon and Crossed Cerebellar Diaschisis in Subclinical Status Epilepticus: A Case Report.

Cortical ribbon is an uncommon finding that is characteristic of Creutzfeldt-Jakob disease but has a broad differential diagnosis. On the other hand, crossed cerebellar diaschisis is also an uncommon finding in brain magnetic resonance imaging (MRI). Herein, we are describing an 88-year-old male patient with dementia, ambulatory dysfunction, and frequent falls who presented with acute on chronic right-sided subdural hemorrhage that was discovered after an episode of seizure. Although the subdural hemorrhage was associated with mild midline shift and lateral ventricle compression, no surgical drainage was attempted, and only middle meningeal artery embolization was pursued. Lack of further evidence of seizure and clinical stability prompted discharge. However, he was soon re-admitted for left-sided focal seizure that failed multiple antiepileptic medications and evolved into status epilepticus. MRI brain showed evidence of both cortical ribbon as well as crossed cerebellar diaschisis. No evidence of infection or autoimmune inflammation was found with continuous mental status deterioration. Code status was changed by his family, and comfort care was pursued. This case is not only interesting because of the rarity of both cortical ribbon and crossed cerebellar diaschisis, but this case helps to remind clinicians of the relationship between these findings and seizure/status epilepticus.

The Importance of Early Imaging in Acute Pyelonephritis: A Case Report of Emphysematous Pyelonephritis.

Emphysematous pyelonephritis (EPN) is a rare life-threatening infection that is usually encountered in diabetic patients. Herein, we are reporting a 41-year-old male patient with a past medical history of stage 3B chronic kidney disease (CKD), neurogenic bladder, and poorly controlled diabetes who presented with left-sided pyelonephritis and septic shock. E. coli was detected in urine and blood. Lack of adequate clinical response to appropriate antibiotic coverage prompted computed tomography (CT) scan of the abdomen that revealed EPN. Despite aggressive conservative management along with nephrostomy, the patient had multiple risk factors to fail conservative management and require nephrectomy. This left the patient on life-long dependence on hemodialysis. This case report is not only interesting as EPN is a rare clinical pathology, but it also helps to remind clinicians to remain vigilant on when to consider early imaging in pyelonephritis. In the appropriate clinical scenario of acute pyelonephritis in a diabetic patient with urinary obstruction, it is important to rule out EPN as an early diagnosis and conservative management including relief of urinary obstruction can lead to a better outcome, help preserve renal function, and spare nephrectomy.

Extensive Unprovoked Thromboembolism in Steroid-Dependent Ulcerative Colitis: A Case Report.

The elevated risk of thromboembolism (TE) in association with inflammatory bowel disease (IBD) is well-established in literature. Herein, we present a case of a 70-year-old patient with steroid-dependent ulcerative colitis who presented with exertional dyspnea and abdominal pain. Investigations revealed extensive bilateral iliac and renal and caval venous thrombosis as well as pulmonary emboli. In addition to the rarity of such a finding in this location, this case serves to remind clinicians of the elevated risk of TE in those with IBD, even among those with IBD that has been in remission, especially in those presenting with unexplained abdominal pain and/or renal injury. TE can be life-threatening and requires a high index of clinical suspicion to establish early diagnosis and prevent propagation.

Chronic Cocaine Abuse as a Cause of Sinus Bradycardia.

Cocaine abuse has an overwhelming effect on the healthcare system due to its multiple complications. Cardiovascular complications carry the highest burden. Common cardiovascular manifestations of cocaine are related to its adrenergic effects due to the inhibition of dopamine and norepinephrine uptake at the postsynaptic terminal. However, chronic abuse can lead to desensitization of adrenergic receptors, which can lead to bradycardia. Sinus bradycardia can be one of the markers of chronic cocaine abuse, as exemplified in this case report. Therefore clinicians should be aware of this association.

Direct/Conjugated Hyperbilirubinemia as an Uncommon Presentation of Acute Alcoholic Hepatitis: A Case Report.

Alcoholic liver disease (ALD) is a common pathology in clinical practice and is clinically diverse. Acute alcoholic hepatitis is an acute inflammation of the liver with or without underlying cholestasis and steatosis. In this case, we are presenting a 36-year-old male with a past medical history of alcohol use disorder who presented with two weeks of right upper quadrant abdominal pain and jaundice. However, direct/conjugated hyperbilirubinemia with relatively low aminotransferases in labs prompted investigation for obstructive and autoimmune hepatic pathologies. Unrevealing investigations prompted consideration of acute alcoholic hepatitis with cholestasis and a course of oral corticosteroids that gradually improved the patient's clinical symptoms and liver function test. This case helps to remind clinicians that although ALD is usually associated with indirect/unconjugated hyperbilirubinemia and elevated aminotransferases, presentation of ALD with mainly direct/conjugated hyperbilirubinemia with relatively low aminotransferases is a possibility. Although imaging tests should be pursued to rule out obstructive etiologies, invasive tests and liver biopsies are not indicated in typical clinical settings.

Report of a Rare Case of Intracranial Extramedullary Hematopoiesis Mimicking a Brain Tumor.

Failure of the bone marrow to maintain adequate blood cell production to match blood metabolic demand incites the production of cell lines outside the bone marrow, which is known as extramedullary hematopoiesis. Herein, we are reporting an 80-year-old male patient who presented with two weeks of worsening headaches and behavioral changes. Labs showed thrombocytosis and imaging showed a large right-sided hemorrhagic brain mass. No evidence of malignancy was seen elsewhere. Brain mass biopsy showed intracranial extramedullary hematopoiesis (IEMH) and bone marrow biopsy confirmed the diagnosis of essential thrombocythemia (ET)/myelofibrosis. This case adds to a few reported cases of IEMH, and to the best of our knowledge, this is the first reported case of IEMH in association with ET. It helps remind clinicians to keep IEMH in the differential diagnosis of those presenting with signs and symptoms of elevated intracranial pressure (ICP) and a newly found brain mass on the background of previously diagnosed or suspected myeloproliferative neoplasms.

Bulbar Onset Amyotrophic Lateral Sclerosis in a COVID-19 Patient: A Case Report.

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disorder with a largely unknown etiology. In this case, we are presenting an 84-year-old male patient who was admitted for acute hypoxemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) infection. He was neurologically intact. His infection improved and oxygen requirement was gradually weaned off allowing for discharge. However, he was admitted again a month later with progressive dysphagia and aspiration that were confirmed on videofluoroscopic study. He was also found to have mild dysarthria, bulbar muscle weakness, bilateral lower motor neuron facial nerve palsy, diffuse hyporeflexia on four extremities with intact sensory function. Diagnosis of ALS was suspected after extensive workup was pursued and ruled out nutritional, structural, autoimmune, infectious and inflammatory disorders. This case is only the third reported case in medical literature to suggest COVID-19 infection as a triggering/accelerating factor of ALS progression.

A Probable Catastrophic Antiphospholipid Antibody Syndrome/Thrombotic Storm Presenting As Rapidly Evolving Multifocal Ischemic and Hemorrhagic Strokes: A Case Report.

Catastrophic antiphospholipid antibody syndrome (CAPS) is a life-threatening disorder. It is a rare and severe form of antiphospholipid antibody (APL) syndrome characterized by widespread multisystemic thrombosis. We present a 55-year-old male patient with acute cerebellar hemorrhagic stroke who developed widespread progressive microthrombosis and macrothrombosis manifesting as progressive bilateral ischemic strokes with lower extremities deep vein thrombosis (DVT) and acute renal failure within a week of presentation. The diagnosis and initiation of therapy were established after serological confirmation. This case adds to a limited number of cases of CAPS in literature and is interesting given the rarity of CAPS and thrombotic storm (TS) as well as the lack of inciting factor triggering CAPS/thrombotic syndrome. This case also helps to remind the clinicians of the importance to consider CAPS, even prior to serological confirmation, in those with rapidly progressive thrombotic events, as delayed diagnosis and therapy can yield poor clinical outcomes.

Subarachnoid Hemorrhage With Multifocal Cerebral Aneurysms in a Patient With Crohn's Disease and Sjögren's Syndrome: A Case Report and Literature Review.

Only a few reports of the association between Crohn's disease (CD) and Sjögren's syndrome (SS) have been documented in the medical literature. Herein, we are presenting a 61-year-old female patient who presented with subarachnoid hemorrhage (SAH). She has a past medical history of primary SS on no active treatment, and CD in remission while on maintenance immunotherapy. She also tested positive for COVID-19. Computed tomography angiography (CTA) brain as well as cerebral angiogram revealed multifocal cerebral aneurysms. Successful coiling was achieved with a cerebral angiogram. This case serves to add to a limited body of reported cases and remind clinicians of the association between SS/CD and cerebral aneurysms. Herein, we review the literature regarding this association and also the effect of immunotherapy and COVID-19 on the progression of cerebral aneurysms.