Sepsis Unveils T-cell Large Granular Lymphocytic Leukemia in the Setting of End-Stage Renal Disease: A Rare Hematologic Malignancy.

Large granular lymphocytic (LGL) leukemia is a rare chronic lymphoproliferative disorder originating from natural killer cells or T lymphocytes. In this report, we present the case of a 66-year-old female initially treated for sepsis, with methicillin-sensitive Staphylococcus aureus identified on initial blood culture prompting intravenous (IV) antibiotic therapy. The patient met systemic inflammatory response syndrome criteria upon admission due to severe neutropenia. Persistent fever led to neurological symptoms, and imaging revealed lung abnormalities along with chronic changes on the CT scan of the head. Multidisciplinary consultations were sought, resulting in treatment adjustments including antifungals and filgrastim. Flow cytometry and bone marrow biopsy confirmed the diagnosis of LGL leukemia.

Bradycardia, Renal Failure, Atrioventricular Block, Shock, and Hyperkalemia (BRASH) Syndrome Emergence in a Unique Intersection of COVID-19 and End-Stage Renal Disease: A Case Report.

Bradycardia, renal failure, atrioventricular (AV) block, shock, and hyperkalemia (BRASH) syndrome is a rare clinical entity that poses challenges for healthcare practitioners. It is characterized by bradycardia, renal failure, atrioventricular (AV) obstruction, shock, and hyperkalemia. This case is an interesting instance of BRASH syndrome in the setting of COVID-19 infection and end-stage renal disease (ESRD). Initial laboratory results revealed macrocytic anemia, renal dysfunction, acidosis, and mild hyponatremia, along with hyperkalemia. An electrocardiogram (EKG) and telemonitoring showed dopamine-resistant persistent bradycardia until transvenous temporary pacemaker placement was done, which resolved the bradycardia. Anti-hyperkalemic therapy, avoiding AV nodal-blocking medication, and temporary pacemaker placement were all part of the management. After receiving hemodialysis, the patient gradually recovered. Bradycardia improved and potassium normalized. The intricate interaction between hyperkalemia and AV nodal obstruction that causes BRASH syndrome results in severe bradycardia and shock. To the best of our knowledge, this is the first case of BRASH syndrome in a patient with an active COVID-19 infection in a previously vaccinated patient. Even though case reports make up the majority of the material currently in publication, to fully comprehend the mechanisms underlying this illness, more research is required, as early detection of this syndrome is crucial for better patient outcomes.

Unmasking the Silent Threat: Cefepime-Induced Thrombocytopenia.

Cefepime, a commonly prescribed fourth-generation cephalosporin, is well-known for its broad-spectrum antibacterial activity. While adverse drug reactions associated with cefepime are well documented, thrombocytopenia as a rare complication has gained attention due to its potential severity. Symptomatic patients present with purpura (bruising), petechiae (small red or purple spots on the skin), and mucosal bleeding. Drug-induced thrombocytopenia can be initiated by myelosuppression by halting platelet formation in the bone marrow or by a drug-induced immune thrombocytopenia reaction. We present a case of a 71-year-old male who experienced thrombocytopenia secondary to cefepime use. We further discussed the underlying mechanisms of cefepime-induced thrombocytopenia, highlighting the need for increased vigilance in monitoring platelet counts during cefepime administration. This case underscores the importance of recognizing and managing this uncommon but potentially life-threatening adverse reaction in clinical practice.

Streptococcal Bacteremia and Toxic Shock Syndrome: A Rare Etiology Requiring Prompt Diagnosis.

Bullous impetigo leading to streptococcal toxic shock syndrome (STSS) immune activation and massive cytokine release is a rare condition. It has a significant mortality rate, which calls for quick diagnosis, early suspicion, and integrated treatment. Herein, we discuss the case of a 66-year-old man who underwent evaluation for leg swelling before quickly going into shock and experiencing respiratory failure, which necessitated invasive mechanical intubation. Streptococcus pyogenes was identified by blood culture, and STSS was identified. Recommended antibiotics, intravenous (IV) immunoglobulin, and fluids made up the treatment regimen. In this case, the streptococcal infection deteriorated very quickly, and there was a rare relationship with bullous impetigo, which led to shock and respiratory failure. This case sheds lights on the need of having an early suspicion of this syndrome when a diabetic patient develops a skin lesion. A prompt diagnosis is necessary.

A Case Report and Literature Review of Thyroid Storm Precipitated by COVID-19 Infection: A Crucial Pointer for Early Suspicion.

Thyroid storm is a rare life-threatening condition characterized by severe and exaggerated clinical manifestations of thyrotoxicosis. It can be precipitated by a myriad of acute events and stressors including but not limited to surgery, trauma, or infections. Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily associated with respiratory symptoms, has been reported to be a likely precipitating cause of thyroid storm in a few cases. COVID-19 has been associated with both new-onset thyrotoxicosis and as a flare-up of the disease in remission. Even though the Burch-Wartofsky Point Scale (BWPS) scoring system has been used for years to help diagnose thyroid storms, the relatively low specificity of the score, especially in the setting of viral or bacterial infections, has been challenging for clinicians. Having a low threshold to consider the diagnosis of this life-threatening condition while at the same time meticulously ruling out other potential differential diagnoses is critical for saving lives. In this report, we discuss a case that highlights the importance that clinicians should accord to thyroid storm as one of the differential diagnoses in patients with a history of hyperthyroidism, with a positive test for COVID-19 infection on admission, and presenting with deranged vital signs and change in mentation from baseline.

A Case Report of Cannabis Abuse: A Surprising Etiology of Elevated Troponin.

Cannabis is the most commonly used additive drug after alcohol and tobacco. There has been literature proving the relationship between cannabis use and elevated troponin from myocardial infarction, with many mechanisms explaining them. However, limited data are available on elevated troponin due to cannabis-induced high myocardial oxygen demand due to vasospasm. We present a case of a 21-year-old female presenting with chest pain after cannabis abuse. She exhibited a steep rise in troponin with a normal electrocardiogram (EKG). She refused a coronary angiogram, but a bedside echocardiogram showed no wall motion abnormality. Therefore, the dramatic rise of troponin levels with the chest pain and the resolution of the symptoms were most likely explained by demand ischemia via the mechanism of reversible vasospasm.

Propofol Infusion Syndrome: A Rare Complication From a Common Medication.

Propofol infusion syndrome (PRIS) is a multifactorial condition that, upon propofol administration, can interrupt critical cellular processes. This can lead to cellular damage that translates as multi-organ system failure that has the potential to be life-threatening. Due to the rarity of this condition, we report a case of PRIS in a 46-year-old male to help bring awareness to this severe condition caused by a relatively common medication. This patient was brought in due to unresponsiveness secondary to multi-substance abuse and respiratory disease and initially had elevated creatinine kinase levels that eventually subsided with appropriate management. However, after prolonged infusion of propofol, his creatinine kinase levels began to drastically rise, alluding to the development of propofol infusion syndrome. Once the offending agent was discontinued, the patient's creatinine kinase levels once again began to normalize.

Parvovirus Infection Leading to Severe Anemia in an Adult Patient With HIV Disease.

Individuals with human immunodeficiency virus (HIV) disease frequently suffer from anemia. The causes include anemia of chronic disease, vitamin B12 and iron deficiency, opportunistic infections (Mycobacterium tuberculosis, Pneumocystis jiroveci), HIV-related bone marrow suppression, AIDS-associated malignancies, and antiretroviral therapy (ART), specifically zidovudine. In HIV patients with advanced immunodeficiency, failure to produce neutralizing antibodies can lead to chronic parvovirus B19 (B19) infection. Normally, in persons with intact immunity, the progression of B19 is self-limited. However, in chronic B19 infection, it can lead to pure red cell aplasia (PRCA) and chronic anemia. In human immunodeficiency virus (HIV)-infected patients, B19-related anemia is rare and underdiagnosed. It has a great response to intravenous immunoglobulin (IVIG) therapy. Hence, early diagnosis and prompt treatment can significantly reduce mortality. In this article, we described the case of a 25-year-old male with HIV infection who presented with a headache. He had severe normocytic anemia with a low reticulocyte count. The workup for blood loss, hemolysis, hemoglobinopathy, and iron deficiency was negative. Because of extremely low reticulocytopenia with severe anemia, the investigations favored multiple myeloma, parvovirus infection, and bone marrow aspiration biopsy. He was tested for parvovirus B19 deoxyribonucleic acid (DNA) polymerase chain reaction (PCR) test due to insufficient seroconversion. It turned out to be positive and he was treated with IVIG therapy.

Fluctuating Hyperthyroidism and Hypothyroidism in Graves' Disease: The Swinging Between Two Clinical Entities.

Autoimmune thyroid disorders are frequently encountered in clinical practice and consist of a spectrum ranging from Graves' hyperthyroidism to Hashimoto's hypothyroidism. Generally, patients with autoimmune thyroid disorders will lean towards one end of the spectrum or the other, with fluctuations between hyper- and hypothyroidism rarely seen. This is especially the case when persistent hyperthyroidism occurs after a prolonged period of hypothyroidism. Here, we present a case of a young female patient initially presenting with Graves' disease with a previous history of hypothyroidism.

Fournier's Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used for the management of type II diabetes mellitus targeting the kidneys. Within the last decade, several warnings have been issued regarding the development of severe genitourinary infections, including necrotizing fasciitis, or Fournier's gangrene, in those with pre-existing type II diabetes and concomitant use of this drug class. OBJECTIVE: The purpose of this review is to highlight and discuss the factors contributing to the development of Fournier's gangrene, its pathogenesis, and a review of existing literature describing patient outcomes, treatment, and future directions regarding early detection of this complication. METHODS: Articles and studies addressing effective treatment adherence and key factors contributing to Fournier's gangrene with SGLT2 inhibitors were identified by effective keyword searches in PubMed Central, Google Scholar, and Cochrane, as well as the references found within these articles. RESULTS: Using the keywords provided, 55 case reports, review articles, and meta-analysis reports written within the last 20 years were utilized as the source of the data presented in this systematic review article.

Acute Non-Obstructive Bilateral Pyelonephritis With Acute Kidney Injury Requiring Hemodialysis.

Acute pyelonephritis (APN) is considered a rare cause of acute kidney injury (AKI), especially when no anatomical abnormalities or predisposing factors are identified. Additionally, non-obstructive pyelonephritis is a very infrequent cause of rapidly progressive acute kidney injury. Herein, we present a rare case of a 55-year-old female patient who was diagnosed with acute non-obstructive pyelonephritis leading to AKI eventually requiring hemodialysis. The patient eventually recovered with the administration of intravenous antibiotics with a significant recovery of renal function.

Atrial Fibrillation With Myocardial Infarction Presenting as a Progressive Worsening Fatigue in a Young Male.

Atrial fibrillation (AF) is one of the most common arrhythmia exhibiting a dramatic rise in prevalence with associated increased risk of stroke, heart failure, and death. No standard symptoms have been categorized yet to set a gold standard in diagnosing this clinical attribute. A highly variable symptoms array has increased the challenges of management in terms of AF. An obvious relationship has not been established between symptoms and the onset or recurrence of arrhythmia. We present a case of a 43-year-old male patient who complained of chronic fatigue as a primary symptom and was diagnosed with AF with myocardial infarction.

Myocardial Bridging: Two Different Clinical Presentations in Young Males Involving Left Anterior Descending Coronary Artery.

Myocardial bridging is a rare anatomical variant that can lead to detrimental cardiac consequences when undiagnosed and untreated. This rare variant can induce anginal-type symptoms due to disrupted blood flow to the myocardium during systole. The patients presented in this report of two cases had previously undiagnosed myocardial bridging of the left anterior descending artery, however clinically, they presented quite differently. Here we present two cases discussing the course of diagnosis and treatment of myocardial bridging of these two patients. The goal of this case report is to highlight the significant cardiovascular injuries that can be a result of undiagnosed myocardial bridging.

Hemothorax With White-Out Lung After Intrapleural Tissue Plasminogen Activator and Deoxyribonuclease Therapy in a Patient With Complicated Parapneumonic Effusion.

Tissue plasminogen activator (tPA) and recombinant deoxyribonuclease (DNase ) are used in treating pleural infection due to their mucolytic activity by effectively reducing pleural fluid viscosity. The combination of tPA and DNase has attracted considerable interest as an alternative to surgical intervention for treating complicated parapneumonic effusion in high-risk patients who are not good candidates for surgery. However, intrapleural hemorrhage has been reported as a villainous outcome in a few cases which needs to be considered as a differential diagnosis with sudden clinical deterioration after the therapy. Here, we report the case of a patient who presented with pneumonia and later developed a large right complicated parapneumonic pleural effusion. A chest tube was placed with drainage of fluid while tPA and DNase were also considered as an additional treatment module. Following the first dose of DNase and tPA, the patient developed hypoxemia with hypotension and was found to have rapid development of white-out right hemothorax.

Symptomatic Sinus Bradycardia in a Patient With Acute Calculous Cholecystitis Due to the Cardio-Biliary Reflex (Cope's Sign): A Case Report.

Acute cholecystitis may present cardiovascular manifestation like cardiac ischemia leading to detailed cardiac workup without any obvious cardiac pathology. Here we describe a case who presented with typical signs and symptoms of cholecystitis exhibiting sinus bradycardia. This reflexive bradycardia was a result of autonomic vagal innervation and was resolved after cholecystectomy. This case highlights the importance of the cardio-biliary reflex and recommends clinicians ensure expedited management of cholecystitis to avoid unnecessary extensive cardiac workup.

Overlapping Symptoms of COVID-19 and Giant Cell Arteritis: The Need for a Higher Degree of Suspicion for Diagnostic Differentiation.

Giant cell arteritis (GCA) is a large cell vasculitis that can present with a plethora of symptoms affecting several different systems. Before the COVID-19 pandemic, diagnosis of GCA was straightforward since the list of differential diagnoses for this disease was relatively short. However, the development of a SARS-CoV-2 viral infection challenges this standard. COVID-19 is a viral illness that also can present with similar vascular symptoms as GCS and creates a substantial inflammatory reaction, similar to most vasculitis. We present a case of a patient who had developed GCA after recovering from a COVID-19 viral illness. This is a rare presentation of GCA in the setting of COVID-19, and recognition of the nuanced differences between the two diseases may significantly change a patient's prognosis if not detected early.

A Rare Case of Cocaine-Induced Muscle Hematoma Followed by Rhabdomyolysis in Association With Acute Kidney Injury and Severe Transaminitis.

Cocaine use can result in a few infrequent complications, among which is localized hematoma. As far as we know, there are very few cases reporting cocaine-induced non-traumatic muscle hematoma complicated by severe transaminitis and rhabdomyolysis. Here we present a patient who developed a significant lower extremity muscle hematoma secondary to inhalational cocaine use. We are reporting this case to bring to light this rare and unusual complication of cocaine use. With recreational use of this drug being so prominent in the patient population, early recognition of this complication can help expedite treatment and reduce the severity of end-organ damage.

An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence.

Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.

Dialysis Disequilibrium Syndrome: A Red Flag to Check Post Hemodialysis.

Dialysis disequilibrium syndrome (DDS) is a neurological disorder with varying severity which is primarily caused by the rapid removal of urea during hemodialysis, which was first described in the literature in 1962. Common risk factors are extreme age, high blood urea nitrogen, sudden change in dialysis regimen, presence of other conditions causing cerebral edema, preexisting neurological diseases, and increased permeability of the blood-brain barrier. Understanding these risk factors and preventing the syndrome is crucial as no specific treatment guideline has been established yet. In this case report, we are presenting a case with a conglomeration of clinical attributes suggesting DDS.

Sudden Vasopressin Withdrawal Causing Transient Central Diabetes Insipidus: A Case Report.

Vasopressin is a peptide hormone produced by the hypothalamus and stored in the posterior pituitary. It is secreted in response to hypotension and hyperosmolarity. Vasopressin and its analogs have been widely used in vasodilatory shocks such as septic shock and cardiogenic shock. The sudden withdrawal of vasopressin after its prolonged use can lead to polyuria and rising sodium levels, which is concerning for the diagnosis of diabetic insipidus (DI); likely central rather than nephrogenic in origin. We present a case of diabetic insipidus following the sudden discontinuation of a prolonged vasopressin infusion for septic shock, which responded to tapering doses of desmopressin.