Unusual Presentation of Relapsing Polychondritis in a Patient with Human Immunodeficiency Virus and Reactive Arthritis.

BACKGROUND Relapsing polychondritis (RP) is an uncommon autoimmune condition that impacts cartilaginous structures involving the ears, nose, respiratory tract, and joints. Its etiology is unknown; however, it may be associated with other systemic autoimmune diseases, malignancy, and rarely with human immunodeficiency virus (HIV) infection. RP has a variable pattern at presentation and may be associated with constitutional symptoms such as fever and arthralgia, in addition to various auricular, ocular, respiratory, and cardiovascular manifestations. Auricular and ocular signs are the most common presenting features; however, idiopathic orbital inflammatory syndrome is considered a rare manifestation of the disease. Systemic corticosteroids are the mainstay of treatment, but immunomodulatory therapy may be required for refractory cases. CASE REPORT We present a challenging case of RP in a 58-year-old woman with HIV controlled by highly active anti-retroviral therapy (HAART) and stable chronic reactive arthritis on sulfasalazine who developed unilateral auricular chondritis associated with contralateral idiopathic orbital inflammation and scleritis as well as worsening arthralgia. She was initially treated empirically with antibiotics, without clinical improvement. The infectious diseases work-up was unrevealing, and other diagnostic possibilities were meticulously excluded. Clinical suspicion for RP ultimately led to appropriate therapy with corticosteroids and subsequent immunosuppression with methotrexate, resulting in clinical improvement and allowing for gradual tapering of steroids. CONCLUSIONS RP is an uncommon multisystem disorder that can occur in the setting of other underlying chronic illnesses, as seen in our patient. It has a variable presentation and course, with no diagnostic laboratory tests; therefore, clinical suspicion is imperative for appropriate diagnosis and management.

Self-Inflicted Traumatic Bilateral Upper Extremity Amputation as a Suicidal Gesture?

Traumatic amputations are partial or complete dismemberment of part of the human body (usually one limb) due to an injury that involves a component of blunt force trauma. It is usually caused by accidental events and only very rarely due to suicidal events. A 37-year-old female with major depressive disorder attempted suicide by placing her forearms on a railroad track, resulting in traumatic bilateral upper extremity amputations. Emergency Department resuscitation was initiated as the patient was taken immediately to the operating room; however, restoration of the limbs was unfeasible, and the patient had successful debriding and fashioning a flap to the distal ends of the upper extremities after hemostasis was achieved. Depression may still be an undertreated clinical entity in our society, and many preventable causes of suicide are attempted each year. Evidence exists that suggests severe suicide attempts occur generally in men and minor suicide attempts, or so-called suicidal gestures, occur generally in women. This case questions this notion.

Sprue-Like Enteropathy and Liver Injury: A Rare Emerging Association with Olmesartan.

Olmesartan-induced enteropathy is an underreported phenomenon, first described in 2012. While olmesartan's antihypertensive properties were confirmed early on, its association with a sprue-like enteropathy was subsequently noted. Although this association has been reported with olmesartan, there have been few reports of this association with other angiotensin-receptor blockers. We present a case of a 79-year-old male who presented with diarrhea, weight loss, jaundice, and transaminitis. Further history revealed that he had been taking olmesartan 40 mg daily for hypertension. Workup of his diarrhea and jaundice included duodenal and liver biopsies revealed findings consistent with a sprue-like enteropathy and an autoimmune hepatitis-like pattern. On discontinuation of olmesartan, his 1-month follow-up revealed significant improvement in his clinical status as well as his liver function tests. Olmesartan is an effective antihypertensive medication; however, physicians must be mindful of its side effect of causing a sprue-like enteropathy and liver injury. Patients should be counseled on discontinuing olmesartan, and they should be started on an alternative therapy for hypertension.

Nonischemic Dilated Cardiomyopathy in Untreated Long-Term Psoriatic Arthritis: A Newly Recognized Association: A Case Report with Mini Review.

BACKGROUND Psoriasis is a chronic inflammatory skin disease associated with multiple comorbidities including psoriatic arthritis (PsA), atherosclerotic disease, metabolic syndrome, diabetes, hypertension, obesity, and depression. Interestingly, nonischemic cardiomyopathy, especially dilated cardiomyopathy (DCM), has been associated with psoriasis and reported in only in a few cases in the literature. CASE REPORT We report the rare case of a 58-year-old man with a medical history of untreated severe psoriasis and PsA who presented with a sudden onset of shortness of breath. Laboratory and radiographic studies showed an elevated level of B-type natriuretic peptide and acute bilateral pulmonary edema. The patient had normal coronary arteries on cardiac catheterization and echocardiography showed newly diagnosed DCM with systolic and diastolic dysfunction. Cardiac magnetic resonance imaging was consistent with nonischemic DCM (NIDCM) with no evidence of hypertrophy, infiltrative process, or edema. The patient was diagnosed with acute congestive heart failure secondary to NIDCM in the setting of long-standing untreated psoriasis. He responded well to diuretics, was placed on guideline-directed medical therapy, and was discharged with a LifeVest personal cardiac defibrillator. As an outpatient, the patient was started on secukinumab, a monoclonal antibody against interleukin-17A. At his last follow-up appointment, the patient reported improvement in his cardiac symptoms and resolution of his psoriatic skin lesions; repeat echocardiography showed improvement in his ejection fraction. CONCLUSIONS Although studies have shown a higher prevalence of cardiovascular disease in patients with psoriasis, an association with NIDCM has not been studied sufficiently. We recommend further studies of the prevalence, pathogenesis, screening, and management of NIDCM in patients with psoriasis.

Psoriasis as risk factor for non-ischemic dilated cardiomyopathy: a population-based cross-sectional study.

BACKGROUND: Psoriasis is a chronic inflammatory skin condition commonly associated with psoriatic arthritis, malignancy, diabetes, inflammatory bowel disease, and cardiovascular disease. Several reports and studies have reported an association between psoriasis and non-ischemic dilated cardiomyopathy (NIDCM). We aim to study the relationship between psoriasis and non-ischemic dilated cardiomyopathy in a large population-based study. METHODS: We utilized the Healthcare Cost and Utilization Project National Inpatient Sample 2017 database, which represents a 20% sample of all payer hospitalizations in the United States. We investigated hospitalizations for patients aged 18 years old or older with diagnoses of any type of psoriasis and non-ischemic dilated cardiomyopathy. Psoriasis, cardiomyopathy, and other comorbidities were identified through their international classification of diseases, 10th revision codes recorded in the discharge record for each hospitalization. RESULTS: Of a total of 6,084,184 all-cause admissions, 0.5% were admissions for patients with psoriasis (n = 32,807). Of the patients with and without psoriasis who had non-ischemic dilated cardiomyopathy, after adjusting for age, sex, race, diabetes mellitus, hypertension, alcohol abuse, cocaine abuse, arrhythmias, and obesity in a multivariate analysis, the presence of psoriasis was not significantly associated with non-ischemic dilated cardiomyopathy. CONCLUSION: Psoriasis is a chronic autoimmune disorder which carries a higher cardiovascular events and more prevalent traditional atherosclerotic risk factors in comparison to the general population. However, association with non-ischemic cardiomyopathy or NIDCM in particular has not been studied sufficiently. Our study, being one of the first larger studies to assess this correlation, indicated no relationship between psoriasis and non-ischemic dilated cardiomyopathy.

Anti-synthetase syndrome: a rare and challenging diagnosis for bilateral ground-glass opacities-a case report with literature review.

BACKGROUND: Anti-synthetase syndrome (ASS) is an uncommon immune-mediated entity characterized by myositis, interstitial lung disease (ILD), non-erosive arthritis, and less common features such as fever, Raynaud's phenomenon, and skin changes in association with anti-aminoacyl-transfer-RNA antibodies, most commonly anti-Jo-1 antibodies. CASE PRESENTATION: We present a challenging and rare case of ASS-associated ILD presenting with unexplained respiratory symptoms and bilateral infiltrates on chest imaging during the COVID-19 pandemic. High clinical suspicion for ASS with early appropriate therapy with corticosteroids and immunosuppressive agents led to marked clinical improvement. CONCLUSION: High index of suspicion for ASS is mandated in patients with unexplained ILD. A comprehensive autoimmune work-up is important as an early treatment with corticosteroids with or without immunomodulators improves patient outcomes and survival in an otherwise poor prognostic disease.

Mixed Cryoglobulinemia Syndrome (MCS) due to untreated hepatitis B with uncommon presentation: case report and literature review.

BACKGROUND: The mixed cryoglobulinemia (MC) syndrome is a systemic inflammatory syndrome that causes small-to-medium vessel vasculitis due to cryoglobulin-containing immune complexes most commonly caused by chronic hepatitis C virus (HCV), and rarely by chronic hepatitis B virus (HBV). Its clinical presentation is significantly varied, with manifestations ranging from purpura, arthralgia, and myalgia to more severe neurologic and renal involvement. Pulmonary involvement as organizing pneumonia, alveolar hemorrhage, and pulmonary vasculitis have been reported, but appear to be quite rare. CASE PRESENTATION: We report an uncommon case of a patient who presented with primary pulmonary syndrome without renal involvement in the setting of MC, due to untreated chronic hepatitis B infection. Early diagnosis and consequent institution of glucocorticoids, B-cell-depleting monoclonal antibody and antiviral therapy led to a favorable outcome and prevented any fatal sequelae. CONCLUSION: Pulmonary compromise in MC syndrome is very uncommon and carries a high rate of mortality. Therefore, in patients with HBV presenting with hemoptysis, physicians must carry a high clinical suspicion for alveolar hemorrhage secondary to cryoglobulinemic vasculitis.

Symptomatic inguinal bladder hernia causes post-renal acute kidney injury: A rare case report.

INTRODUCTION: Inguinal bladder hernia (IBH) is a rare condition representing less than 5% of all inguinal hernias. Most cases occur in elderly overweight men. Patients may present with variable symptoms such as urinary symptoms, inguinal swelling, or pain; however, most of them are asymptomatic and only less than 7% are diagnosed pre-operatively. Different radiological studies can be used if IBH suspected preoperatively including ultrasound, computed tomography scan; however, cystography is the most sensitive test for diagnosis of IBH. Open reduction and hernia repair are the standard treatment of IBH. CASE PRESENTATION: We report a rare case of an-83-year-old male who presented with left inguinal pain associated with lower urinary tract symptoms including dysuria, nocturia, post-voidal dribbling, and urinary frequency. Laboratory studies showed acute kidney injury (AKI), and computed tomography (CT) of abdomen and pelvis without contrast CT revealed a herniation of 80% of the bladder through the left inguinal canal into the left scrotal sac, with moderate bilateral hydronephrosis and hydroureter, though no obstructing calculi are seen. Pre-operative diagnosis of incarcerated inguinal bladder hernia (IBH) was made, and a timely surgical intervention preceded by bladder catheterization led to a significant improvement of AKI and an excellent outcome without post-operative complications. DISCUSSION AND CONCLUSION: IBH is uncommon condition that can present with non-specific urinary symptoms; therefore, high index of suspicion is mandated for diagnosis especially in patients with risk factors. Pre-operative radiological evaluation to avoid iatrogenic bladder injury with subsequent surgical repair is the standard management for IBH as we accomplished in our case.

Hydrocephalus and myelopathy: A rare and challenging case of sarcoidosis and review of literature.

Neurological involvement is a rare presentation of sarcoidosis. Physicians should consider sarcoid as a cause of myelitis and hydrocephalus as early management with steroid improves patient survival and reduces long-term disability.

Pseudoaneurysm Development after Free Wall Rupture Post Myocardial Infarction.

Background: According to the World Health Organization, cardiovascular disease is the number one cause of death globally, claiming millions of lives each year with an increasing prevalence. Myocardial infarction (MI) makes up a large sum of these deaths each year. While MI in itself is lethal, there are several complications that can increase the morbidity and mortality of an MI, such as left ventricular wall rupture and aneurysms. Case Presentation: We present a case of an elderly male with an extensive cardiac history who presented with a non-ST segment myocardial infarction (NSTEMI) managed with percutaneous coronary intervention. Hours after, he became hemodynamically unable and was found to have a pseudoaneurysm of the left ventricle. Despite aggressive efforts, his pseudoaneurysm ruptured and he ultimately succumbed to his condition. Conclusions: Left ventricular pseudoaneurysm is usually seen after myocardial infarctions with a rupture rate of up to 45% leading to a mortality rate of about 50%. While cardiac catheterization with left ventriculography is the gold standard for diagnosis, echocardiography can also be used as an alternative. Treatment is emergent cardiac surgery but still holds a high operative risk. Therefore, patients may be medically stabilized and managed prior to ultimate surgical intervention.

Successful Maternal and Fetal Outcomes in COVID-19 Pregnant Women: An Institutional Approach.

BACKGROUND Novel Coronavirus 2019 (COVID-19) has been defined as a pandemic infecting millions of individuals with a significantly high mortality and morbidity rate. Treatment and management for pregnant patients infected with COVID-19 has been poorly described in the literature. Furthermore, vertical transmission of COVID-19 to the fetus has been poorly described. The purpose of this case series is to present 3 patients in their trimester who underwent emergent cesarean sections and were successfully managed in the intensive care unit. CASE REPORT We present the cases of 3 patients diagnosed with COVID-19 via RT-PCR in their third trimester of pregnancy. All patients underwent emergent cesarean sections and were managed on mechanical ventilation in the intensive care unit and eventually discharged in stable condition. CONCLUSIONS Early cesarean section and aggressive management with mechanical ventilation has been shown to be very beneficial for mothers diagnosed with COVID-19 and their infants. All 3 patients were successfully extubated, and all 3 infants tested negative for COVID-19, suggesting no vertical transmission; although, further studies are needed to confirm this finding.

Gardnerella vaginalis bacteremia in an elderly healthy male.

Gardnerella vaginalis is an anaerobic gram variable organism, which commonly causes bacterial vaginosis in women. It is uncommon for this organism to cause a urinary tract infection in males. We present a case of G. vaginalis bacteremia in the setting of urolithiasis in an otherwise immunocompetent elderly male. He was treated with metronidazole alone for a 10-day course with resolution of symptoms and negative repeat blood cultures. It is important for health care professionals to acknowledge this rare cause of infection in males and adequately treat to prevent increased morbidity and mortality.