Extraosseous Ewing Sarcoma Manifesting as an Acute Abdomen in a Young Adult Male: a Case Report.

Ewing sarcoma is a tumor primarily affecting children and young adults, and usually affects long bones. Extraosseous Ewing sarcoma (EES) is a rare primary tumor of soft tissues. We present a case of abdominal EES with metastasis to thoracic cavity, which presented as abdominal pain and vomiting in a 21-year-old previously healthy gentleman.

A Rare Case of Lymphocytic Ascites.

Ascites can manifest as a result of many conditions, with cirrhosis being the most common cause in the United States. Here, we present a case of lymphocytic ascites, a less common variant that occurred due to infection with Chlamydia trachomatis. This was a 37-year-old female with a history of substance and sexual abuse who presented with the chief complaints of abdominal pain, abdominal distension, and weight gain. She was febrile on admission with a distended, tender abdomen. The more common cardiac, renal, and hepatic causes were ruled out with extensive workup. Diagnosis and therapeutic paracentesis were done with fluid analysis significant for lymphocyte predominance and absence of malignant cells. Multi-modal imaging had ruled out suspicious malignant masses but CT abdomen/pelvis did show complex large volume ascites. Urine chlamydia and gonorrhea polymerase chain reaction (PCR) had resulted positive for chlamydia, leading us to start Doxycycline. Other infectious workups were negative, but ascitic fluid chlamydia NAAT was positive. Though initially worsening, the patient started showing significant clinical improvement after starting doxycycline, with the resolution of ascites and associated symptoms. This case report intends to bring to attention the importance of testing for chlamydia infection in cases of lymphocytic ascites, especially in sexually active females.

Breakthrough Severe COVID-19 Infection After Triple Dose Pfizer Vaccination.

The impact of COVID-19 was felt across the globe when it first emerged in December 2019. However, within a year, there was a new hope with the development and approval of mRNA vaccines. The Comirnaty and Pfizer-BioNTech BNT162b2 mRNA vaccine showed an efficacy of 95 percent in preventing COVID-19 disease. However, subsequent studies conducted on immunocompromised hosts showed the efficacy to be significantly lower than the initial reported 95 percent, making these patients prone to COVID-19 disease despite the initially recommended two doses. On Sept. 22, 2021, a third dose was approved for immunocompromised hosts. In this article, we report the case of a 67-year-old female with overlap connective tissue disease on mycophenolate mofetil who had a prolonged hospital course because of severe COVID-19 disease complicated by pulmonary embolism despite receiving three doses of the BNT162b2 mRNA vaccine.

Statins and New Onset Diabetes Mellitus.

Statins have become one of the forefront medications in the prevention of cardiovascular morbidity and mortality in the 21st century. Apart from lowering low density lipoprotein-C (LDL-C), statins also play an important role in atherosclerotic plaque stabilization and regression. In the last two decades, there is growing evidence that statins have the potential to cause new onset diabetes mellitus (NODM). This is more pronounced in those with preexisting risk factors of developing diabetes. While several theories have been postulated, the exact mechanism behind the diabetogenic effect of statins remains unknown. Although NODM is associated with the use of statins, the overall benefits statins provide in terms of cardiovascular disease prevention far outweigh the effects of glycemic profile worsening.

Recurrent Catecholamine-Induced Cardiomyopathy and Hypertensive Emergencies: A presentation of Pheochromocytoma and Related Concerns.

Catecholamine-induced cardiomyopathy (CIC) and pheochromocytoma are both rare entities, and their exact incidence and prevalence are unknown. Pheochromocytoma has been implicated as one of the causes of CIC or Takotsubo syndrome (TTS) by means of case reports and retrospective reviews. However, the evaluation of any patient with TTS and pheochromocytoma is often faced with multiple challenges due to its rarity and atypical presentations, which subsequently leads to delay in diagnosis. Here, we present a case of a 51-year old female who had three distinct episodes of TTS and now presented in a hypertensive emergency with angina, palpitations, headache, nausea, and vomiting. She was treated for non-ST elevation myocardial infarction (NSTEMI) but coronary angiogram revealed patent coronary arteries. Due to the paroxysmal nature of her hypertensive emergencies and variable blood pressure response, pheochromocytoma was suspected. On further evaluation, she was found to have elevated metanephrines and a 6.3 cm left adrenal mass on CT scan. This case emphasizes the importance of considering or identifying pheochromocytoma as an underlying primary etiology for recurrent episodes of TTS and related concerns such as choice of anti-hypertensive agents.

Cardiac arrest in a young healthy male patient secondary to kratom ingestion: is this 'legal high' substance more dangerous than initially thought ?

Kratom is a psychoactive herb that has stimulant properties at low doses and has opioid-like properties at higher doses. It has been used for centuries in southeast Asia as a stimulant but has gained increasing popularity as a substitute for opioids in western countries as it is easily available. As most cases of kratom use involve other drugs too, the Food and Drug Administration (FDA) has stopped short of restricting kratom due to difficulty in assessing the adverse effects of kratom alone. We present the case of a young healthy 35-year-old man who suffered a cardiac arrest due to kratom use with no other coingestants. He was subsequently intubated and found to have systolic dysfunction and small brain infarcts. Fortunately, he made a successful recovery and was discharged after a stay at thebehavioural health centre. Our case highlights the potential adverse effects of kratom and the need to regulate its use.

The Impact of Molecular Testing for Pathogens of Community-Acquired Pneumonia on Antibiotic Utilization.

Community-acquired pneumonia (CAP) is a common and costly problem in U.S. healthcare. A major challenge in development of targeted treatment strategies has been limitations in diagnostic testing to confirm specific pathogens, including viruses. The recent and widespread use of multiplex polymerase chain reaction (mPCR) to identify pathogens has created an opportunity to improve diagnostic testing and subsequent antibiotic stewardship. We performed a retrospective cohort study examining 233 inpatients with pneumonia of which 70 patients underwent testing with mPCR. A specific pathogen was identified by mPCR in 24 percent of these patients and there was a statistically significant decrease in antibiotic use between patients who tested negative (average 8.3 days of antibiotics) versus patients who tested positive (average 4.9 days of antibiotics). This highlights the potential utility of mPCR implementation as an antibiotic stewardship strategy.

EBV-Associated Lymphoproliferative Disorder and Hemophagocytic Lymphohistiocytosis in a Patient with Severe Celiac Disease.

BACKGROUND: Epstein-Barr virus- (EBV-) associated lymphoproliferative disease (LPD) is a rare condition, usually occurring in immunocompromised patients. We report a case of EBV-associated LPD in a patient with severe celiac disease, the first report to describe this syndrome in a patient with this diagnosis. CASE SUMMARY: A 69-year-old Caucasian woman with recent diagnosis of celiac sprue presented to our hospital with persistent diarrhea, abdominal pain, weight loss, and fatigue despite adherence to gluten-free diet for a number of weeks prior to presentation. She underwent evaluation for occult malignancy and was found to have diffuse intra-abdominal mesenteric lymphadenopathy on CT scan. Biopsy of mesenteric nodes revealed an EBV positive, CD20 positive mixed lymphoproliferative process with T-cell predominance, but without a monoclonal cell population felt to be consistent with EBV-associated LPD. Bone marrow biopsy revealed hemophagocytic lymphohistiocytosis, complicating her course. She was treated with steroids and rituximab but continued to decline, eventually developing MSSA bacteremia and succumbing to her disease. CONCLUSION: To our knowledge, this is the first report of the constellation of celiac sprue, EBV-associated LPD, and hemophagocytic lymphohistiocytosis. Providers caring for patients with severe, uncontrolled celiac disease and adenopathy should consider EBV-associated LPD.

Pulmonary Embolism Caused by Popliteal Vein Aneurysm: A Case Report.

In this case report, we describe an unusual episode of bilateral submassive pulmonary embolism (PE) caused by a popliteal vein aneurysm (PVA). The development of PE stems from many risk factors including obesity (BMI³ 30 kg/m2), hypertension, cigarette smoking (greater than 25 cigarettes per day), increasing age, surgery, immobility, malignancy, and inherited thrombophilia. A PVA is a rare but significant cause of PE. A 28-year-old male presented to the emergency department with progressive shortness of breath. He had no significant past medical history, no family history of deep vein thrombosis or PE, and no recent surgeries, travel, or trauma. A physical exam revealed he was saturating 96 percent on 2 L/minute oxygen through a nasal cannula and was noted to have a heart rate in the 90 beats per minute range that quickly increased to 150 beats per minute with minimal exertion. An initial laboratory workup was unrevealing except for an elevated D-dimer. A chest radiograph demonstrated no cardiopulmonary abnormalities. Computed tomography angiography of the chest was performed and revealed multiple bilateral pulmonary emboli. An urgent echocardiogram then revealed evidence of right heart strain with a dilated right ventricle. A subsequent bilateral venous duplex scan of the lower extremities was performed, which revealed a left PVA. Vascular surgery was performed, specifically emergent catheter-directed lysis with the placement of a temporary inferior vena cava (IVC) filter. The patient was started on rivaroxaban oral anticoagulation therapy and then discharged home without incident. Several months later, he underwent uncomplicated surgical repair of his left PVA. This case illustrates PVA as a rare but noteworthy cause of PE. Doctors should consider this diagnosis in patients with recurrent PE or when the cause of PE is unknown. Although the exact etiology is not known, inflammation, trauma, degenerative changes, and congenital weakness of venous wall have all been proposed as causes of venous aneurysms. The definitive management of a PVA is surgical repair. Some studies suggest recurrent PE in as high as 80 percent of patients on oral anticoagulation alone. Therefore, an IVC filter is often placed to prevent further thrombi progression until definitive surgical treatment of the aneurysm has been performed.

A Primer on Diagnostic and Financial Implications of D-dimer Testing.

Given the high incidence of deep vein thrombosis/pulmonary embolism (DVT/PE) (300,000 to 600,000 per year in the U.S.) and the 30 percent mortality rate associated with undiagnosed PE, diagnostic evaluation is very important. One of the tools used to evaluate for DVT and PE is D-dimer testing. A negative D-dimer test, along with a low Wells clinical probability score, can safely rule out DVT/PE without the need for additional imaging. This approach can reduce cost; however, D-dimer testing is not indicated in all patients. D-dimers can be elevated in patients without DVT/PE, like the elderly. The consequences of over utilizing D-dimer testing can lead to excessive imaging, unnecessary contrast exposure, unnecessary exposure to radiation, and increased cost. In this primer, we provide a brief literature review of D-dimer testing for the diagnosis of DVT and PE. We also discuss the overutilization of D-dimer testing and its financial burden on the health care industry.

Acute cerebrovascular accident in an 18-year-old male with von Willebrand disease.

Compared to the older populations, stroke is an infrequent occurrence in children, adolescents, and young adults. Furthermore, individuals who have hypocoagulability disorders, such as von Willebrand disease (vWD), appear to possess a degree of protection against thrombotic events. Here, we describe an 18-year-old male with a history of vWD who presented to the emergency department with left sided hemiparesis that occurred shortly after being placed in a headlock while wrestling. MRI revealed a right paramedian pontine stroke. The relationship between vWD and stroke is discussed as well as the role of neck trauma in vertebral artery injury. While vWD does appear to decrease the incidence of thrombotic events, such patients are still at risk, especially in the context of common inciting events such as neck trauma.

Medicare charge-receipt data: results for South Dakota.

BACKGROUND: The 2013 release of 2011 financial information by the Centers for Medicare and Medicaid Services (CMS) caused concern because some hospitals had charges that appeared to be exorbitantly high compared to reimbursement rates. METHODS: Charges and receipts for South Dakota were compared to national data. The study was restricted to nine discharge codes likely to be seen by an adult hospitalist service. RESULTS: South Dakota hospitals had a lower charge-to-receipt ratio than the national average (p < 0.01). The average ratio in South Dakota was 2.74 compared to 3.75 nationally. South Dakota charged 29 percent less for these discharge codes and received 3 percent lower reimbursement than the national average. CONCLUSIONS: The relatively low charge-to-receipt ratio and low charges in South Dakota are encouraging. Unfortunately, the only South Dakotans likely to be asked to pay full charges are the uninsured, who thus face bills that are much higher than insurance companies pay for the insured population. This leaves uninsured patients and hospitals with trying to negotiate discounts or waivers on an individual basis, which is an inefficient and problematic approach for both parties.