Atypical Presentation of Thrombotic Thrombocytopenic Purpura (TTP) as an Initial Manifestation of Systemic Lupus Erythematosus (SLE) in a Young Male.

Thrombotic thrombocytopenic purpura (TTP) is a rare but life-threatening hematologic disorder characterized by thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal impairment, and fever. The etiology of TTP often involves a severe deficiency in ADAMTS13 activity, resulting in the accumulation of ultra-large von Willebrand factor multimers and subsequent microvascular thrombosis. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect multiple organ systems, and although the initial presentation of SLE with TTP is rare, it necessitates a comprehensive diagnostic and therapeutic approach. We present a case of a 27-year-old male with no significant past medical history who developed altered mental status, headache, and right-sided numbness, leading to the diagnosis of TTP and subsequent detection of SLE.

Sub-massive Pulmonary Embolism and New-Onset Diabetes Mellitus.

Pulmonary embolism (PE) is a life-threatening disease with variable clinical signs and symptoms, and the diagnosis often requires a high index of suspicion. Patients can have a variety of risk factors that predispose them to venous thromboembolic (VTE) disease. This is a case of a female who presented to the emergency room with new-onset fatigue and shortness of breath for five days. The patient was diagnosed with a sub-massive PE with high-risk features. The patient was also hyperglycemic and diagnosed with new-onset diabetes mellitus. For the PE, she was treated with systemic thrombolysis followed by a standard oral factor Xa inhibitor; for her new onset of diabetes, the patient was started on glargine and lispro insulin. This case underscores the importance of comprehensive management for patients with PE and concurrent metabolic conditions.

Psoriasis Vulgaris Masked by Tinea Pedis in Two Unhoused Patients.

Psoriasis is a chronic inflammatory disease characterized by clearly marginated silvery plaques that affect men and women equally. Symptoms can vary among individuals; typically, it presents on the scalp, elbows, and knees. We present two cases of patients initially diagnosed with tinea pedis who showed no improvement with medical treatment. The first patient is an African American male in his 50s who arrived at a free clinic for unhoused persons with lesions to both feet initially diagnosed as tinea pedis. Although the patient was compliant with applying topical formulations of tolnaftate and clotrimazole, there was no discernible improvement in his symptoms and the skin lesions. After a thorough examination of the skin throughout the entire body, the diagnosis of psoriasis was considered. The patient started treatment with steroidal cream with improvement of the symptoms and lesions. The second patient is a Caucasian male in his 20s who also presented initially with complaints of a dry, intensely pruritic, and scaly rash on the dorsum of both his feet, as well as in between the digits of his feet for which an initial diagnosis of tinea pedis was also made. The patient remained non-compliant with treatment and, after reevaluation of his lesions along with an extensive survey of his body, was deemed to have psoriasis and prescribed topical hydrocortisone. The patient continued to remain non-compliant with his therapeutic regimen and subsequently developed cellulitis which is yet to resolve with treatment.

Rapidly Growing Giant Squamous Cell Carcinoma of the Head: A Case Report.

Giant squamous cell carcinoma (GSCC) of the skin arising on the head presents a distinctive clinical challenge due to its rarity, aggressive behavior, and potential for disfigurement. A male in his 70s with a history of tobacco cigarette use presented to the emergency department with a painful, bleeding mass on the right parietal scalp. On admission, a brain CT revealed a fungating mass with no cortical breakthrough or osseous erosion, measuring 7.9 x 5.7 x 2.5 cm. An ultrasound-guided tissue biopsy was performed and revealed poorly differentiated squamous cell carcinoma. The patient was discharged home with instructions from oncology to continue with outpatient treatment. At this time, the prognosis is good if treatment is received.

A Giant, Neglected Leiomyosarcoma on the Left Shoulder.

This paper examines the impact of delayed diagnosis and treatment on the prognosis of patients with leiomyosarcomas (LMS). We present a case study highlighting the consequences of neglected LMS, focusing on vascular involvement and metastatic potential. Our findings underscore the importance of early detection and intervention in improving patient outcomes. Additionally, we discuss the challenges associated with diagnosing rare skin LMS and the implications of limited access to medical screening. Through a comprehensive analysis of the literature, we elucidate the critical role of routine surveillance in detecting these malignancies at an earlier stage, thus facilitating timely intervention and potentially curative treatment. This study underscores the urgency of raising awareness among both healthcare providers and the general population about the significance of early detection and prompt management in mitigating the adverse outcomes associated with neglected LMS.

Myositis Ossificans Traumatica of Bilateral Sternocleidomastoid Muscles After Chiropractor Adjustment: A Case Report.

A woman in her 20s with a past medical history of surgical debulking of a right neck mass presented to the hospital for persistent and worsening right shoulder pain. The shoulder pain was associated with trismus and back and neck pain. A CT scan of the neck with contrast revealed post-surgical changes with increased heterotopic ossification throughout the surgical site extending to the supraclavicular soft tissues and the left sternocleidomastoid muscle, suggesting muscle ossification. A biopsy was performed, and the patient was diagnosed with myositis ossificans (MO). Initial treatment began with the administration of steroids and analgesics. She was scheduled for a follow-up with orthopedics, rheumatology, and genetics, but she was lost for follow-up. MO is a very rare medical condition usually associated with trauma, and in our patient, the symptoms started after a chiropractic adjustment.

Extraskeletal Ewing Sarcoma: A Case Report.

Ewing sarcoma is one of the most common primary bone tumors arising from neuroectodermal cells mainly presenting in the younger population. Instances of this highly malignant tumor manifesting outside of the bone and outside of the typical age range create an unfamiliar clinical scenario. In this report, we present a rare extraskeletal Ewing sarcoma in a 42-year-old woman with a subcutaneous soft tissue mass in the posterior chest displaying a positive EWSR1 gene rearrangement via fluorescence in situ hybridization. The patient is currently on a chemotherapy regimen showing favorable response to the tumor size despite additional complications. This overall presentation of Ewing sarcoma allows further understanding of the malignancy and fosters better care for future cases.

ECG Changes Post-pericardiocentesis for Cardiac Tamponade Secondary to Non-small Cell Carcinoma of the Lung.

Electrical alternans on electrocardiograph (ECG) is an uncommon but nearly pathognomonic sign of cardiac tamponade. Here, we present a male quadragenarian who came to the emergency department complaining of low back and right upper abdominal pain. Work-up revealed a large pericardial effusion associated with electrical alternans on ECG and clinical findings of cardiac tamponade. Pericardiocentesis drained approximately 1 liter of hemorrhagic fluid with resolution of cardiac tamponade and normalization of the ECG. Further evaluation with right hilar lymph node biopsy confirmed a diagnosis of poorly differentiated non-small cell adenocarcinoma of the lung.

Atypical Dermal Findings in a Patient Following a Lightning Strike Injury.

Lightning is a common atmospheric occurrence. However, lightning strikes are not a frequent environmental cause of human injury. Survivors may present with Lichtenberg figures, a fern-like skin manifestation, and burns of varying severity. After a lightning strike, our patient demonstrated atypical cutaneous manifestations of large, ecchymotic discolorations on the medial upper extremities. After a comprehensive evaluation, the patient fully recovered and was discharged home without limitations. This case highlights lightning strike injury, including common findings, epidemiology, mechanisms, and prevention.

Glioblastoma Multiforme in a Patient With Alpha-1-Antitrypsin Deficiency.

Alpha-1 antitrypsin (A1AT) is a common genetic disease caused by a mutation in the SERPINA1 gene, predisposing patients to severe premature lung and liver disease. Higher expression of SERPINA1 has been associated with a poor prognosis in patients with high-grade glioblastoma. We present a woman in her 70s with a history of A1AT deficiency treated with weekly plasma-purified A1AT infusions, who presented with metabolic encephalopathy. A CT scan of the brain obtained during admission revealed a left frontal lobe mass measuring 1.1 cm. A craniotomy and resection of the lesion were performed, and the pathology studies revealed a glioblastoma multiforme, WHO grade IV. She is currently healing and awaiting treatment with temozolomide with concomitant radiation and tolerating treatment well.

Cocaine-Induced Four-Extremity Ischemia Caused by a Hypercoagulable State.

The use of cocaine is associated with serious complications including coronary vasospasm and myocardial, renal, intestinal, and neurological ischemia. Among these feared complications lies limb ischemia which is a rare potential side effect of chronic cocaine use. We present the case of a 50-year-old female with an extensive history of cocaine use who developed ischemia in all four limbs. Imaging studies revealed pulmonary emboli, multisystem thromboses, and microhemorrhages in the brain. Laboratory studies were significant for leukocytosis, thrombocytopenia, schistocytes on blood smear, and normal rheumatologic and hematologic studies. The patient was diagnosed with cocaine-induced thrombotic microangiopathy and she was treated symptomatically and with continuous heparin infusion. However, she ultimately requested to be discharged home and was lost to follow-up. Cocaine-induced thrombotic microangiopathy has been reported in only a few other patients to date and although there are some theories describing the possible pathophysiology, a clearly defined explanation has not yet been widely accepted.

Vertigo: An Atypical Presentation of Neurocysticercosis Successfully Treated With Albendazole.

A 20-year-old male presented to our facility with a worsening sensation of "the room spinning around" himself for the past three weeks. In the last week, he began to experience daily spells lasting for three hours each without losing consciousness. The patient had recently migrated from Central America six weeks prior to admission. On physical examination, his vital signs were within normal limits, with no focal neurological deficits. Magnetic resonance imaging (MRI) of the brain revealed a cystic-appearing lesion in the fourth ventricle with associated mass effect on the posterior aspect of the brainstem and mild periventricular edema. Laboratory studies were unremarkable except for a positive anti-cysticercus IgG antibody, which confirmed the diagnosis of neurocysticercosis. Initially, surgery was considered, but the neurosurgeons advised medical management due to the small size of the lesion. The patient was started on albendazole 400 mg orally twice daily and dexamethasone 6 mg orally daily for 14 days. The patient responded well; his symptoms resolved by the eighth day. He was discharged home to complete his treatment and remained asymptomatic at the follow-up appointment two weeks later.

Medicinal Leeches to Aid in Post-procedural Hematoma Evacuation.

Patients presenting with a post-invasive procedure hematoma can be treated with medicinal leeches to evacuate the hematoma. Our patient, a postmenopausal woman in her 60s, with a past medical history of hypothyroidism, presented to the outpatient clinic with pain, redness, warmth, and swelling on her right thigh. Ten days prior, the patient had undergone a subcutaneous pellet implant procedure in the right thigh for hormonal replacement therapy. The patient developed post-procedure cellulitis and soft tissue infection and was treated with antibiotics. The patient developed a progressively enlarged hematoma at the implant site. The hematoma was treated with medicinal leeches. Two weeks after treatment, the implant area healed. The patient had a family history of von Willebrand disease and a history of prolonged bleeding during childbirth, menstruation, and dental procedures. A von Willebrand panel was obtained, and the results were consistent with a new diagnosis of von Willebrand disease.

Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome and Metastatic Breast Cancer: A Rare Overlap in a Postpartum Patient With Disseminated Intravascular Coagulation and Refractory Thrombocytopenia.

A middle-aged female arrived at a tertiary care hospital after a referral from her primary care physician to evaluate a left breast mass found on ultrasound concerning malignancy. The patient was also 27 weeks gestational with monochorionic diamniotic twins. During triage, she was found to have severe hypertension and lab abnormalities concerning HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome and underwent cesarean delivery of the infants. She had a biopsy of the left breast mass post-delivery, later diagnosed as invasive ductal cell carcinoma with spinal metastasis and numerous metastatic pulmonary nodules. Her hospital stay was complicated by a right lower extremity deep vein thrombosis, acute subdural hematoma, and disseminated intravascular coagulation with refractory thrombocytopenia resulting in her death.

Uterine Artery Embolization in a Patient With Large Uterine Fibroids.

A woman in her 20s with no past medical history presented to the emergency department with a 4-day history of abdominal pain. Imaging revealed several large uterine fibroids that compressed various intra-abdominal structures. Options of observation, medical management, surgical management with abdominal myomectomy, and uterine artery embolization (UAE) were discussed. The patient was counseled about the associated risks of UAE and myomectomy. Since both procedures have a risk of infertility, the patient elected to proceed with uterine artery embolization due to the less invasive nature of the procedure. She was discharged after one day in the hospital following the procedure and readmitted three days later for suspected endometritis. The patient was treated with antibiotics for five days and discharged home. Eleven months post-procedure, the patient became pregnant. The patient had achieved a full-term delivery at 39 weeks and two days via a cesarean section secondary to a breech presentation.

Primary Ovarian Mucinous Adenocarcinoma, Expansile Type, Misperceived As Pregnancy by the Patient.

We present the case of a woman in her 20s with an eight-month history of increasing abdominal distention, dyspnea, and night sweats. The patient believed she was pregnant despite being told at another hospital that the pregnancy tests were negative, and no fetus was seen on an abdominal ultrasound. The patient delayed obtaining follow-up because of a distrust of the healthcare system and presented to our hospital at the behest of her mother. On physical examination, the abdomen was distended with a positive fluid wave, and a large mass was palpated in the abdomen. Gynecological examination was limited because of severe abdominal distension but a mass was palpable in the right adnexa. A pregnancy test and fetal ultrasound were performed, and the patient was not pregnant. A CT scan of the abdomen and pelvis revealed a large mass arising from the right adnexa. She underwent right salpingo-oophorectomy, appendectomy, omentectomy, lymph node dissection, and peritoneal implant resection. The biopsy confirmed intestinal-type IIB primary ovarian mucinous adenocarcinoma, expansile type, with peritoneal spread. Chemotherapy was provided for three cycles. A follow-up CT scan of the abdomen showed no evidence of a tumor six months after surgery.

Penile calciphylaxis in a patient with concurrent haemodialysis and Coumadin treatment.

A man in his 30s, with a medical history of end-stage renal disease on haemodialysis three times a week after kidney transplant rejection, anaemia of inflammatory disease, hypertension, atrial fibrillation, hyperlipidaemia, subtotal parathyroidectomy and aortic valve replacement on Coumadin treatment, presented to our institution with glans penis pain. Examination of the penis revealed a painful black eschar with ulceration on the glans penis with surrounding erythema. CT scan of the abdomen and pelvis and penile Doppler ultrasound revealed calcifications of the abdominal, pelvic and penile blood vessels. He was diagnosed with penile calciphylaxis, a very rare manifestation of calciphylaxis characterised by penile blood vessel calcification leading to occlusion, ischaemia and necrosis. Treatment with low calcium dialysate and sodium thiosulfate was initiated with haemodialysis. Five days after the treatment started, the patient's symptoms improved.

A Fatal Case of Staphylococcus capitis Endocarditis in a Patient With Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) has evolved to become a standard management modality for high-risk, moderate, and even low-risk patients with symptomatic aortic stenosis. Infective endocarditis (IE) after a TAVR is rare and difficult to diagnose. Typical sonographic characteristics observed with an echocardiogram in native valve endocarditis may not be present in TAVR-IE cases. Enterococcal species are identified to be the most frequent causative agents. Coagulase-negative staphylococci (CoNS) can infrequently lead to a fatal course of endocarditis in the TAVR population. There are only seven previously reported cases of Staphylococcus capitis (S. capitis) prosthetic valve endocarditis noted in the literature. Here we present a man in his 60s who presented to our facility for evaluation of fever and shortness of breath. He was subsequently diagnosed with S. capitis TAVR-IE. He was not considered a surgical candidate and was treated medically for IE with a fatal outcome.