A Case Report of Esophageal Perforation: Complications of Orogastric Tube Placement.

Orogastric tube (OGT) insertion is a routine procedure in medical care. It is often inserted in patients after endotracheal intubation. OGT insertion is often a blind procedure. Misplacement of the tube can cause a variety of complications and can sometimes be life-threatening. We present the case of a 71-year-old male patient who experienced a rare proximal esophageal perforation as a complication of blind insertion of the OGT; he required OGT insertion after receiving endotracheal intubation for hypoxic respiratory failure secondary to COVID-19 infection. The esophageal perforation was revealed on a post-procedural roentgenogram and confirmed by a subsequent computed tomography of the chest. Given the small size of the perforation and the absence of clinical instability, conservative management was pursued leading to improvement of the mediastinitis. Although the complications of OGT insertion are uncommon, their consequences can be potentially serious and require a high degree of suspicion.

Legionella Coinfection in a Patient With COVID-19 Pneumonia.

Bacterial superinfection is a well-reported complication of viral pneumonia leading to significantly increased morbidity and mortality. Such superinfections have been reported in patients with pathogenic coronaviruses including severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), but there are scant reports pertaining to superinfection in the context of coronavirus disease 2019 (COVID-19). We report a case of a middle-aged man who presented with worsening shortness of breath in the context of COVID-19 complicated by superimposed Legionella pneumophilia pneumonia. This case serves to highlight the possibility of bacterial superinfections and to be aware of such possibilities when patients are not responding to standard courses of treatment for COVID-19 as quick clinical deterioration is likely to develop.

Syphilitic Aortic Aneurysm: A Rare Entity in the Era of Antibiotics.

A thoracic aortic aneurysm is a rare entity of tertiary syphilis in the era of antibiotics. The diagnosis of the aortic aneurysm due to tertiary syphilis may be challenging due to deceptive clinical presentation and rarity of the disease in the western world. We report the case of a 59-year-old man, who presents with worsening shortness of breath and was found to have a large ascending aortic aneurysm on computed tomography angiogram (CTA) of the chest. Further workup demonstrated a positive syphilis test. Untreated earlier stages of syphilis attribute to the development of the ascending aortic aneurysm. The patient was medically treated with IV penicillin and underwent surgical repair of the aortic aneurysm. Histopathology confirmed the diagnosis of syphilitic aortitis. Tertiary syphilis often presents several years after initial infection and usually after a latent phase, making it difficult to diagnose. Syphilitic aortic aneurysms may result in a high mortality rate in untreated patients. Therefore, a high index of suspicion is required for the early recognition of a syphilitic aortic aneurysm. Early treatment with antibiotic therapy and surgical repair of syphilitic aortic aneurysms can prevent life-threatening complications.

Morbidity Among Athletes Presenting for Medical Care During 3 Iterations of an Ultratrail Race in the Himalayas.

INTRODUCTION: Although ultratrail races are increasing in popularity, there is a dearth of data regarding illnesses and medical care at these events. Data about injuries and illnesses for races taking place in the Himalayas, where the nearest medical facility can be hundreds of miles away, are even harder to find. This study aimed to describe the injuries and illnesses befalling the participants of a 7-stage 212 km (132 mi) trail race at high altitude. METHODS: Ethical approval was obtained from Nepal Research Health Council. A retrospective study of the record of medical encounters among the 100 participants competing in the Manaslu trail race in Nepal from 2014 to 2016 was performed. Diagnoses were classified into various categories. Informed consent was taken from all participants. RESULTS: Acute diarrhea was the most common ailment reported among the participants (18%), followed closely by musculoskeletal problems (17%). Altitude illness made up 6% of care provided. Approximately 35% of the athletes were using acetazolamide as prophylaxis for high altitude illnesses. The 1 case needing evacuation in the 3 iterations was high altitude pulmonary edema. CONCLUSIONS: Ultratrail races at high altitude pose a challenge in terms of provision of medical care in a remote setting with limited resources. However, most of the illnesses are minor in nature and easily managed by the race doctor. Knowledge of common illnesses among travelers to the area can help aid in preparation and provision of proper care, especially in remote settings with limited resources.

Extramedullary Manifestations of Chronic Myelomonocytic Leukemia: Do We Treat like an Acute Myeloid Leukemia?

Chronic myelomonocytic leukemia (CMML) is a relatively rare clonal hematologic disorder with features of myelodysplastic syndrome and myeloproliferative disease. Extramedullary leukemic involvement is rarely a presenting feature of CMML. As there are no clear guidelines in regard to the treatment of patients with extramedullary manifestations, its management is challenging. In this report, we discuss the management of our patient who presented with submandibular lymphadenopathy and gingivitis and was diagnosed with CMML.

Neuromyelitis Optica in a Nepalese Man.

BACKGROUND: Neuromyelitis optica is a severely disabling inflammatory disorder of the central nervous system of autoimmune etiology that mainly affects the optic nerves and spinal cord. Here, we present a case report detailing a patient with tingling and weakness of right upper and lower limbs who was neuromyelitis optica immunoglobulin G-positive. CASE PRESENTATION: A 46-year-old Nepalese man presented to the hospital with a history of tingling and weakness of right upper and lower limbs that developed over a period of two months. Clinical evaluation showed diminished power across all major muscle groups in the right upper and lower limbs. Magnetic resonance imaging of his cervical spine showed T1 iso- to hypointense signal and T2 hyperintense signal in central cervical spinal cord from first to sixth cervical level, probably suggestive of myelitis or demyelination. The patient was immediately started on intravenous methylprednisolone. The diagnosis of neuromyelitis optica was later confirmed with strongly positive neuromyelitis optica immunoglobulin G. CONCLUSION: In resource limited setting, in the absence of tests for neuromyelitis optica immunoglobulin G, treatment was started and the patient's condition started to get better. Hence, early initiation of aggressive immunosuppressive treatment is essential in such cases.