A Rare Presentation of Lyme Disease in an Immunocompromised Patient.

Lyme disease is a progressive infectious disease caused by the Borrelia species that affects multiple organ systems, including the brain, heart, skin, and musculoskeletal systems. The cardiac manifestations of Lyme disease typically present with atrioventricular nodal conduction abnormalities and, more rarely, myocarditis. We report a case of an immunocompromised 57-year-old woman who presented with acute onset shortness of breath, hypervolemia, injective conjunctiva, and global vision loss of the left eye in the setting of a recent tick bite. Serologic testing confirmed borreliosis, and cardiac testing demonstrated acute isolated systolic heart failure without any cardiac conduction system abnormalities on the electrocardiogram. The diagnosis of Lyme carditis was made, and the patient was started on doxycycline with complete recovery of cardiac systolic function. This case demonstrates atypical cardiac manifestations of Lyme disease and highlights the difficulty in workup and understanding of Lyme carditis particularly in immunocompromised patients.

Understanding Traumatic Brain Injuries in Military Personnel: Investigating the Dynamic Interplay of the Cerebrospinal Fluid and Brain During Blasts.

Background It is estimated that around 450,000 traumatic brain injury cases have occurred in the 21st century with possible under-reporting. Computational simulations are increasingly used to study the pathophysiology of traumatic brain injuries among US military personnel. This approach allows for investigation without ethical concerns surrounding live subject testing. Methodology The pertinent data on head acceleration is applied to a detailed 3D model of a patient-specific head, which encompasses all significant components of the brain and its surrounding fluid. The use of finite element analysis and smoothed-particle hydrodynamics serves to replicate the interaction between these elements during discharge through simulation of their fluid-structure dynamics. Results The stress levels of the brain are assessed at varying time intervals subsequent to the explosion. The regions where there is an intersection between the skull and brain are observed, along with the predominant orientations in which displacement of the brain occurs resulting in a brain injury. Conclusions It has been determined that the cerebrospinal fluid is inadequate in preventing brain damage caused by multiple abrupt directional shifts of the head. Accordingly, additional research must be undertaken to enhance our comprehension of the injury mechanisms linked with consecutive changes in acceleration impacting the head.

Aortic Valve Replacement: A Case of Aortic Valve Insufficiency Secondary to Infective Endocarditis.

Acute aortic valve insufficiency (AAVI) is a pathologic medical condition that has a presentation on a spectrum of severity and is attributable to numerous etiologies. Most often, it is caused by infective endocarditis, which depending on the patient's clinical status may require treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This case presents a patient with acute aortic valve insufficiency secondary to infective endocarditis, requiring intervention. Further, it also provides real-time use of the general guidelines used in the determination of SAVR vs. TAVR candidacy. This case will further help providers in the cardiology realm to identify this presentation and increase comfort in referring to existing guidelines, as well as highlight where the current guidelines appear limited.

Clinical Importance of Differentiating Epstein-Barr Virus (EBV)-Positive Plasmacytoma From Plasmablastic Lymphoma: Another Unique Case of EBV-Positive Plasmacytoma in an Immunocompetent Patient.

Epstein-Barr virus (EBV)-positive plasmacytoma is a rare and unique plasma cell neoplasm that could arise in immunocompetent individuals. Given the molecular and immunohistochemical similarity of EBV-positive plasmacytomas to their significantly more aggressive counterpart, plasmablastic lymphoma (PBL), providers must distinguish between the two neoplasms. This case elucidates a presentation of EBV-positive plasmacytomas in a healthy, immunocompetent individual originating in the C4/C5 cervical neck region. The patient's clinical presentation, in combination with the surgical pathology from the mass biopsy, pointed toward EBV-positive plasmacytoma. Factors such as cellular proliferation rate, cellular atypia, and immunohistochemical staining help differentiate the two diseases. This case will further help providers in the oncologic world to identify these masses.

Cutaneous Necrosis of the Skin Secondary to Methicillin-Resistant Staphylococcus aureus (MRSA) and Bacteroides With Superimposed Herpes Simplex Virus Type II (HSV-II) in the Setting of Infective Endocarditis.

Herpes simplex virus type II (HSV-II) with superimposed bacterial skin infection is an uncommon presentation of cutaneous necrosis in the setting of infective endocarditis. This case reflects a unique presentation of an immunosuppressed patient with infective endocarditis complicated by septic emboli and cutaneous skin lesions attributable to HSV-II and superimposed bacterial skin infection. The patient presented from an outside hospital with symptoms consistent with acute onset heart failure and skin lesions. Transthoracic and transesophageal echocardiography performed there demonstrated focal thickening of the anterior mitral valve leaflet with severe mitral regurgitation. The patient then underwent extensive infectious work-up and was put on broad-spectrum antibiotics. Further work-up demonstrated greater than three DUKE minor criteria and reiterated the focal thickening of the anterior leaflet of the mitral valve, making infective endocarditis the most likely etiology. Biopsies of the skin lesions were performed which stained positive for HSV-II and grew methicillin-resistant Staphylococcus aureus and Bacteroides fragilis. The cardiothoracic surgery service ultimately decided not to perform any surgical intervention to the mitral valve during her hospitalization as she was deemed to be too high of a risk due to her thrombocytopenia and significant comorbidities. She was later discharged in hemodynamically stable condition on long-term intravenous antibiotics with repeat echocardiography demonstrating significant reduction in the mitral regurgitation and the focal thickening of the anterior leaflet of the mitral valve.

Hemorrhagic Pericardial Effusion as the Presenting Symptom of Newly Diagnosed Rheumatoid Arthritis.

Hemorrhagic pericardial effusion is a rare presenting sign of undiagnosed rheumatoid arthritis (RA). We present a case of a 58-year-old female with a history of mucinous cystadenoma with subsequent omental caking status-post small bowel resection, chronic intermittent bilateral knee pain, carpal tunnel syndrome of the left hand, and drainage of a peritoneal inclusion cyst two days prior to admission. The patient had pleuritic chest pain and acute-onset shortness of breath but was hemodynamically stable on presentation. Transthoracic echocardiogram and CT scan demonstrated a large pericardial effusion measuring 1.5 cm anteriorly, 2.21 cm posteriorly, and 2.5 cm laterally. Diagnostic pericardiocentesis revealed a hemorrhagic pericardial fluid with a glucose level of 133 mg/dL, pH of 7.34, albumin of 2.6 g/dL, red blood cell count of 401,000 cells per cubic millimeters (CUMM), white blood cell count of 1,400 CUMM, lactate dehydrogenase (LDH) of 930 U/L, and protein of 5 g/dL. Infectious and malignancy workups were negative. Rheumatologic workup was positive for elevated rheumatoid factor and anti-cyclic citrullinated peptide. The patient was diagnosed with RA; she was started on methotrexate with folic acid, and a pericardial drain was kept in place for three days. We present a brief review of the workup, etiologies, and therapeutic approach for patients who present with hemorrhagic pericardial effusion secondary to undiagnosed RA.

Atypical Presentation of Infective Endocarditis With Native Aortic Valve Involvement Secondary to Staphylococcus aureus Bacteremia in the Setting of Non-Hodgkin Lymphoma.

Infective endocarditis (IE) is a condition that can involve endocardial tissue and possibly lead to valvular disease. Not only is it important to recognize the clinical presentation difference between acute and subacute IE, but physicians should understand that underlying risk factors, such as immunosuppression secondary to non-Hodgkin lymphoma (NHL), can alter an acute presentation into that of a subacute one. We report an NHL patient, who presented with subacute clinical symptoms of IE, but had a clinical test workup that showed evidence of acute IE rather than subacute.

Potential Role of the Moderna COVID-19 Vaccine in Enoxaparin's Effects on Liver Functions.

Enoxaparin is commonly used for prophylaxis as an anticoagulant in hospital settings. Although enoxaparin has been known to cause many minor adverse reactions, hepatocellular injury is one of the rare side effects which can impact clinical course, marked by an asymptomatic rise in liver function panel tests. In this paper, we not only delineate the relationship between enoxaparin-induced hepatocellular injury but also associate it with fevers that have not been previously documented. Furthermore, we posit the Moderna COVID19 vaccine as a potential contributor to this outcome. We hypothesize that the link between enoxaparin and hepatic injury is possibly due to the inflammatory state, which may be augmented by the vaccine.

Elevated Beta-Human Chorionic Gonadotropin in a Non-pregnant Female With Altered Kidney Function.

Elevated beta-human chorionic gonadotropin (beta-hCG) levels in postmenopausal women is a finding known in the literature; however, it still commonly leads to unnecessary and extensive diagnostic workup. We present the case of a 48-year-old African-American postmenopausal female with acute kidney injury on chronic kidney disease (CKD) stage 5 and an incidental finding of elevated serum beta-hCG. Abdominal and transvaginal ultrasound showed no evidence of intrauterine or ectopic pregnancy or gestational trophoblastic disease. Menopausal status was confirmed with follicle-stimulating hormone (FSH) measurement, and following the improvement of renal status, beta-hCG levels were normalized to expected values for the patient's age group. The etiology of elevated beta-hCG was suspected to be from the pituitary as previous literature has shown decreasing beta-hCG levels in postmenopausal women following the administration of gonadotropin-releasing hormone (GnRH) antagonist.

Rapid Development of Autoimmune Hepatitis Secondary to Minocycline.

Autoimmune hepatitis (AIH) is a condition that affects the liver which, potentially, may render it fibrotic and eventually cirrhotic. This condition has many etiologies ranging from genetic predispositions and immunological defects to medication and environmental side effects. Essentially, we will explore the risks, presentation, diagnosis, and treatment of this condition as it relates to a medication-induced etiology. Here we report a case where a patient developed this condition from taking the antibiotic minocycline. The patient was treated with prednisone therapy and went into complete remission with no reoccurrence of AIH. The purpose of this case report is to highlight the fact that these cases have the potential to occur fairly sooner than expected, in a matter of weeks or months, after the induction of minocycline. Hence, carefully monitoring liver functions more frequently may aide in the prevention of minocycline-induced AIH.

Chilaiditi Syndrome Presenting as Partial Colonic Obstruction.

Chilaiditi sign is a rare incidental radiographic finding where bowel is interposed between the diaphragm and the liver, often seen as air under the right hemidiaphragm. A majority of patients with Chilaiditi sign are asymptomatic and remain so throughout their lifetime. Chilaiditi sign is recategorized as Chilaiditi syndrome if it becomes symptomatic and is a very rare etiology of bowel obstruction. As bowel obstruction confers a huge financial burden to the health care system, studies of even the rarer etiologies are of significant value. Particularly in the case of Chilaiditi syndrome, the free air under the right hemidiaphragm can lead physicians to prematurely conclude pneumoperitoneum, which would require an emergent surgical evaluation. It is through the incorporation of a broad differential and clinical presentation that physicians can decrease the inappropriate allocation of hospital resources and unnecessary surgical procedures; additionally, keeping Chilaiditi syndrome on the differential may prevent unnecessary surgical intervention, cost to the patient, and downstream complications. Bowel obstruction secondary to Chilaiditi syndrome is most commonly treated with conservative management including intravenous fluids, bowel rest, decompression, and laxatives. If the symptoms worsen and progress to full bowel obstruction, surgical intervention has shown great efficacy. We report a case of a 69-year-old male who presented to the emergency department for progressively worsening abdominal pain, nausea, and vomiting incidentally found to have colonic interposition with mild colonic dilatation on computed tomography (CT) imaging. The patient was diagnosed with bowel obstruction secondary to Chilaiditi syndrome and treated non-surgically with rapid recovery.

Atretic Parietal Cephalocele With First Trimester Chiari Malformation and Sinus Pericranii Companion Case.

Encephaloceles are the type of dysraphism in which a skull defect allows for herniation of meninges, with or without the inclusion of neural tissue, and are commonly associated with agenesis of the corpus callosum. Encephaloceles are classified as frontal, occipital, or parietal, with parietal cephaloceles, or vertex cephaloceles (VC), being the least common. Despite this, VCs present as the most common cause of a midline scalp mass, displaying complex venous and neural malformations commonly referred to as the "tip of the iceberg." Atretic parietal encephaloceles (APC), a type of VC, are benign lesions arising from meningeal and vestigial tissue which have undergone fibrotic degeneration. As a result, prognosis will generally be better than other encephaloceles due to vestigial tissue involvement. Here, we report a neonate presenting with APC, corpus callosum agenesis, and a cingulate gyrus lesion, along with a sinus pericranii companion case for comparison.

Pure Insular Cortex Infarct in Sepsis-Induced Hypoxic Ischemic Encephalopathy.

Each year there are an estimated 1.7 million adults in the United States that develop sepsis and nearly 16% of these adult patients die because of this disease process. Sepsis, however, can impact patients of all ages. Neonatal sepsis is currently one of the leading causes of morbidity and mortality among neonates. There are many complications of neonatal sepsis including meningitis, seizures, and hypoxic ischemic encephalopathy (HIE). HIE is estimated to impact one to five in 1000 live births worldwide, primarily impacting neonates. It is more commonly seen in premature infants and infants with low birth weights due to immature organ systems and a lack of adequate auto-regulatory mechanisms that would otherwise manage brain perfusion. In premature neonates, the most commonly recognized pathological pattern found on MRI is focal non-cystic white matter injury. HIE can also impact term infants as well. In these neonates, there exist two common MRI patterns that include either basal ganglia-thalamus ischemia, most often involving deep gray nuclei and perirolandic cortex, or watershed predominant ischemic changes that involve cortical gray matter.  We report a 38-week-old male neonate born at gestation diagnosed with HIE secondary to neonatal sepsis with an MRI finding of isolated insular cortex hypersensitivity on fluid-attenuated inversion recovery (FLAIR) and T1-weighted imaging. Isolated insular cortex hypersensitivity can be seen in non-lacunar ischemic middle cerebral artery (MCA) territory strokes but it is not common for it to present as a sole finding. In our case, these findings persisted for several weeks without evidence of any common patterns of hypoxia-induced cerebrovascular insult on MRI imaging.