Fungal Pyelonephritis and Fungemia Due to Obstructive Uropathy.

INTRODUCTION: Funguria is often a benign and common occurrence in the hospital. However, invasive fungal pyelonephritis due to obstructive uropathy is uncommon and can be difficult to treat. Typically, there are 2 mechanisms by which Candida albicans infects the upper urinary tract: by ascending from the lower urinary tract or via hematogenous spread to the kidneys. CASE PRESENTATION: We present a case of fungal pyelonephritis, likely due to obstructive uropathy, leading to fungemia in a 70-year-old man who had a recent history of colovesicular fistula and indwelling foley catheter. DISCUSSION: The patient had many identified risk factors contributing to the development of fungal pyelonephritis, including diabetes mellitus and structural urinary tract aberrancies, which were further complicated by his recent colovesicular fistula and repair. CONCLUSION: Although fungal pyelonephritis with fungemia is relatively rare, it should not be excluded from differential diagnostics. Despite a unique host of risk factors, a direct approach led to successful treatment.

Impact of Delayed Pain to Needle and Variable Door to Needle Time On In-Hospital Complications in Patients With ST-Elevation Myocardial Infarction Who Underwent Thrombolysis: A Single-Center Experience.

Background Myocardial infarction is a life-threatening event, and timely intervention is essential to improve patient outcomes and mortality. Previous studies have shown that the time to thrombolysis should be less than 30 minutes of the patient's arrival at the emergency room. Pain-to-needle time is a time from onset of chest pain to the initiation of thrombolysis, and door-to-needle time is a time between arrival to the emergency room to initiation of thrombolytic treatment. Ideally, the target for door-to-needle time should be less than 30 minutes; however, it is unclear if the door-to-needle time has a significant impact on patients presenting later than three hours from the onset of pain. As many of the previous studies were conducted in first-world countries, with established emergency medical services (EMS) systems and pre-hospital ST-elevation myocardial infarction (STEMI) triages and protocols, the data is not completely generalizable to developing countries. We, therefore, looked for the impact of the shorter and longer door-to-needle times on patient outcomes who presented to the emergency room (ER) with delayed pain-to-needle times (more than three hours of pain onset).  Objective To determine the impact of delayed pain-to-needle time (PNT) with variable door-to-needle time (DNT) on in-hospital complications (post-infarct angina, heart failure, left ventricular dysfunction, and death) in patients with ST-elevation myocardial infarction (STEMI) who underwent thrombolysis. Methods and results A total of 300 STEMI patients who underwent thrombolysis within 12 hours of symptoms onset were included, which were divided into two groups based on PNT. These groups were further divided into subgroups based on DNT. The primary outcome was in-hospital complications between the two groups and between subgroups within each group. The pain-to-needle time was ≤3 hours in 73 (24.3%) patients and >3 hours in 227 (75.7%) patients. In-hospital complications were higher in group II with PNT >3 hours (p <0.05). On subgroup analysis, in-hospital complications were higher with longer door-to-needle time in group II (p<0.05); however, there was no difference in complications among group I. Conclusion Our study is consistent with the fact that shorter door-to-needle time, even in patients with delayed PNT (>3 hours), has a significant impact on in-hospital complications with no difference in mortality.

The Impact of Door to Diuretic Time in Acute Heart Failure on Hospital Length of Stay and In-Patient Mortality.

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further.

Splenic infarction and spontaneous rectus sheath hematomas in COVID-19 patient.

Multiple studies and reports have suggested that coronavirus disease-19 (COVID-19) promotes arterial and venous thrombotic events in multiple organ systems, although the mechanism leading to a hypercoagulable state is still unknown. Few cases of splenic infarction associated with COVID-19 have been reported, of which half were found incidentally upon autopsy. This may be due to a clinically silent presentation or the symptoms being wrongfully attributed to pain caused by the effects of COVID-19. Due to the rarity of the condition and its lack of consistent symptomatology, splenic thromboembolism can be difficult to diagnose. Awareness of the condition and high clinical suspicion will help the clinician identify and manage the problem. Hemorrhage in patients with COVID-19 is uncommon in the hypercoagulable state that threatens thrombus formation in patients with COVID-19 infection. Despite prophylactic treatment with anticoagulation therapies, patients are more prone to developing clots. It is also well-known that therapeutic anticoagulation can place patients at a higher risk of bleeding. Thus, this unique population is at risk of developing both thrombotic and hemorrhagic events. We report a rare case of splenic infarction in a patient with confirmed COVID-19 infection despite prophylactic treatment with low-molecular-weight heparin which was found incidentally during workup for 2 other rare conditions: spontaneous rectus sheath hematoma and microhemorrhage or thrombus of the mesenteric vessels.

Case report: Spontaneous pneumothorax in resolved, uncomplicated COVID-19 Pneumonia-A literature review.

As the global COVID-19 pandemic has progressed, awareness of uncommon presentations and complications has increased. The actual incidence of spontaneous pneumothorax was found to be 0.66%, or six patients out of 902 who tested positive in recently published literature of 3368 patients (Zantah M, Dominguez Castillo E, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease-incidence and clinical characteristics. Respir Res. 2020 Sep 16; 21 (1):236.). Of those six patients, only two (0.22%) were not associated with mechanical ventilation barotrauma or comorbid lung disease such as COPD. Here, we present a spontaneous pneumothorax and pneumomediastinum in a patient four days after he had been discharged from hospitalization due to uncomplicated COVID-19 pneumonia.

A Rare Case of Non-Small Cell Lung Cancer with BRAF V600E Gene: Case Report and Literature Review.

Non-small cell lung cancer is one of the leading causes of mortality in the United States. The BRAF mutation, which has been associated with malignant melanoma, has been documented in only 3.5-5% of the non-small cell lung cancer (NSCLC) patient population.The involvement of the BRAF mutation in NSCLC and the treatment for tumors with such mutations is still an evolving topic of interest, which is why more in depth information is warranted. We present a rare case of stage IV non-small cell lung adenocarcinoma, who presented first with a complicated pericardial effusion with evidence of malignant effusion. He had genetic testing done, revealing he had a positive BRAF V600E mutation. He was put on multiple chemotherapy regimens, but was most responsive to Vemurafenib. This case will shed light into the importance of the BRAF V600E gene and its importance in NSCLC for better prognosis value.

Rivaroxaban-Induced Acute Interstitial Nephritis: A Case Report.

BACKGROUND Direct oral anticoagulant agents (DOACs) have become increasingly more popular in recent years and have largely replaced warfarin in the treatment of certain conditions, such as atrial fibrillation, and in the prevention of thromboembolic events. Rivaroxaban is one of the most commonly used direct anticoagulant drugs for conditions such as atrial fibrillation and thromboprophylaxis. CASE REPORT We present a case of a 70-year-old male who developed acute interstitial nephritis after starting rivaroxaban, and who responded to medical treatment, which included corticosteroid therapy. A renal biopsy was not performed because the patient was on essential anticoagulation therapy secondary to a high CHADS2VASc score. CONCLUSIONS Dose adjustments when using rivaroxaban are necessary in patients with underlying renal failure. Acute interstitial nephritis is a rare condition associated with direct anticoagulant drugs. The treatment of acute interstitial nephritis is usually to remove the offending agent and treat the underlying cause.

Iatrogenic Hepatic Portal Venous Gas in a Patient With Crohn's Disease After Colonoscopy.

Hepatic portal venous gas is a radiologic sign and is associated with several abdominal disorders. The prognosis and survival of the patient depends on the underlying etiology. Most cases respond to broad-spectrum antibiotics, but some may need surgical intervention. We report a case of hepatic portal venous gas after colonoscopy in a patient with Crohn's disease.

Actinomyces turicensis: An unusual cause of cervicofacial actinomycosis presenting as ludwig angina in an immunocompromised host - Case report and literature review.

Actinomyces is an anaerobic, gram-positive bacillus that is known to cause chronic granulomatous infections. Common risk factors predisposing patients to this life-threatening infection are recent dental procedures, immunosuppression from malignancy, or history of smoking and alcohol use. Actinomyces, commonly found in the normal flora of the oral cavity, is one of the pathogens that can cause Ludwig's angina. Ludwig's angina is diffuse cellulitis and edema of the soft tissues of the neck and floor of the mouth. Cervicofacial actinomyces is an invasive infection that can form life-threatening abscesses through its rapid spread. Actinomyces turicensis is an isolate that has emerged recently to cause infections in humans. There are few reported cases of this species causing abdominal and genital infections; however, there is no report of it invading the cervicofacial space. A feared complication of Ludwig's angina and cervicofacial actinomyces is airway compromise. Therefore, prompt initiation of intravenous antibiotics is required for the treatment and prevention of deadly complications. We present a patient with left-sided neck swelling after a recent oral surgical procedure and was found to grow Actinomyces turicensis on wound culture. The patient was treated with intravenous ampicillin-sulbactam, which not only decreased the swelling but improved the necrotic appearance of his abscess wound.

Spontaneous Fungal Peritonitis as a Rare Complication of Ascites Secondary to Cardiac Cirrhosis: A Case Report.

BACKGROUND Spontaneous fungal peritonitis (SFP) is a life-threatening infection which occurs more commonly in patients with liver failure. SFP is not as common as spontaneous bacterial peritonitis (SBP) and has higher mortality rates due to late recognition and difficulty in differentiation between SFP and SBP. Spontaneous fungal peritonitis is extremely uncommon in patients with cardiac ascites due to a high protein content, which predisposes to a low risk of infections. CASE REPORT This report presents a rare case of spontaneous fungal peritonitis in a patient with cardiogenic ascites. To the best of our knowledge, this is the second known case of SFP occurring in a patient with cardiac cirrhosis. The patient did not respond to initiation of SBP treatment and after ascitic fluid grew Candida glabrata, the diagnosis of SFP was made. The patient's clinical status improved after initiation of intravenous caspofungin. CONCLUSIONS SFP should be a differential diagnosis in patients who have cardiac or liver cirrhosis, who are not improving with empirical antibiotic therapy for spontaneous bacterial peritonitis.

Complete Eye Ophthalmoplegia: the unusual initial presentation of Leptomeningeal Carcinomatosis.

Ophthalmoplegia is a paralysis or weakness of extraocular muscles that have a variety of different etiologies including and not limited to Leptomeningeal Carcinomatosis (LC). LC is caused mainly by metastatic cancers and can cause a wide variety of symptoms. We present a case of LC with no preexisting condition who presented with a unilateral ophthalmoplegia as initial presentation who was found to have LC secondary to large B-cell lymphoma.

Atypical Hemolytic Uremic Syndrome: A Case Report.

Hemoytic uremic syndrome (HUS) is a rare type of thrombotic microangiopathies. Manifestations include thrombocytopenia, microangiopathic hemolytic anemia, and thrombi in small blood vessels. The prognosis is poor. Herein, we present a case of atypical HUS, which is very rare.

Marijuana Induced Sick Sinus Syndrome: A Case Report.

BACKGROUND Marijuana is a commonly abused illicit drug in the United States (US). Regular marijuana usage has been linked to many adverse cardiovascular effects. Our case describes the association of abusing marijuana and the development of sick sinus syndrome. CASE REPORT A 27-year-old male carpenter was admitted to the hospital for recurrent syncopal episodes. He reported 2 episodes of syncope every month for the last 5 years. He denied alcohol or nicotine intake but reports using marijuana daily. He also reported cervical injuries due to syncope in the past. Physical examination was unremarkable. Orthostatic vitals were negative. Electrocardiogram (ECG) showed sinus bradycardia. A series of investigations, including a stress test and tilt table testing, were negative. The drug screen was positive for marijuana. A loop recorder was implanted to evaluate the cause of syncope and was positive for a long sinus pause of more than 3 second, indicative of sick sinus syndrome. The patient was successfully treated with a permanent pacemaker with no further events on follow-up after 6 months. CONCLUSIONS The case we report here adds to the literature that several reversible etiologies are shown to be associated with the development of sick sinus syndrome, in which marijuana abuse can be one of them. We strongly suspect that marijuana was the cause of this patient's sick sinus syndrome after ruling out all the possible etiologies. The relation between marijuana use and sick sinus syndrome needs to be further investigated in the future.

The Conversion of Wolff-Parkinson-White (WPW) Pattern into WPW Syndrome in the Presence of Ischemia: A Case Report.

Wolff-Parkinson-White (WPW) syndrome is defined by the presence of a short PR interval, delta waves on the electrocardiogram (EKG), and symptomatic tachycardia. The condition is rare but can be life-threatening if not recognized in a timely manner. The WPW pattern on EKG can mask ischemic changes and may also increase the risk of arrhythmia and subsequent mortality. Our case describes the conversion of an underlying WPW pattern into WPW syndrome in the scenario of an acute myocardial infarction (AMI).

Atheroma of the Innominate Artery Presenting as a Transient Ischemic Attack.

Supra-aortic atherosclerotic lesions, including innominate artery atheromas, are an uncommon but established cause of transient ischemic attacks, stroke, upper extremity ischemia, and vertebrobasilar insufficiency. We present a patient with a transient ischemic attack admitted with right hemispheric symptoms who was found to have a severe ulcerated innominate artery atheroma. The patient underwent an aortic arch angiogram with stenting of the innominate artery. The proper diagnosis, treatment, and management of innominate artery atheromas are imperative to prevent further cardiovascular morbidity and mortality in patients. Currently, both endovascular and surgical options are available for revascularization, and there have been no randomized controlled trials comparing endovascular versus open repair to standardize one as the standard of care over the other. No randomized controlled trials are examining the benefit of dual versus single antiplatelet therapy post-stenting in supra-aortic atherosclerotic lesions. We believe that this topic warrants further research and needs evidence-based guidelines to help direct physicians about treatment and management.

Isolated Starvation Ketoacidosis: A Rare Cause of Severe Metabolic Acidosis Presenting with a pH Less than 7.

Anion gap metabolic acidosis (AGMA) occurs when an anion gap exists along with metabolic acidosis, most commonly due to diabetic ketoacidosis (DKA) and lactic acidosis (LA). Isolated starvation ketoacidosis (ISK) is one of the rare causes of AGMA; however, it usually presents with a mild disturbance in pH. We report a rare case of a 45-year-old female with previously diagnosed squamous cell cancer (SCC) of the larynx. She presented to the emergency department complaining of difficulty in breathing following laryngectomy and tracheostomy for SCC. Her laboratory results on admission were consistent for isolated starvation ketoacidosis and the patient responded quickly to the appropriate treatment.

Pulmonary arterial hypertension: A rare yet fatal complication of Neurofibromatosis Type 1.

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder with an incidence of approximately 1 in 4,000 live births [1]. Pulmonary arterial hypertension (PAH) is a rare but extremely life-threatening complication associated with NF1. Timely recognition of this unusual and severe association between NF1 and PAH is imperative in prolonging the survival in this specific patient population. We present the clinical outcomes of a 47-year old female previously diagnosed with NF1, who presented with progressively worsening dyspnea.

Delftia acidovorans: A rare cause of septic pulmonary embolism from catheter-related infection: Case report and literature review.

Septic pulmonary emboli is a rare condition due to the dislodgement of an infected thrombus traveling to the pulmonary vasculature via the venous system. Staphylococcus spp. and Candida spp. are the most common causative agents. The most common risk factor is intravenous drug abuse, but there has been an association with intravenous catheters. Delftia acidovorans (DA) is a rare organism causing catheter-related infection, which has a tendency to embolize and clog up major vessels. It is highly resistant to all available aminoglycoside agents. There are only a few cases reported in children showing DA as a cause of septic emboli with none of the cases reported in a young patient. We report a similar case but in a young adult who developed septic emboli due to DA that was caused by an infected peripherally inserted central catheter (PICC) line. Since the organism is highly susceptible to recurrent embolization, the PICC line was removed and the patient was treated successfully with an appropriate antibiotic regime.

Mycoplasma pneumonia with hydropneumothorax: A case report.

Mycoplasma pneumoniae is one of the most common causes of community-acquired pneumonia in adults. Mycoplasma pneumoniae pneumonia (MPP) presents with pulmonary and extrapulmonary manifestations. Pneumothorax is a rare MPP complication in children. But, we reported a case of MPP with hydropneumothorax in an adult. The association of MPP, hydropneumothorax, and empyema is extremely rare.

Atrial Myxoma Presenting as Positional Vertigo: A Case Report.

Cardiac myxoma is an uncommon diagnosis but presents with common manifestations. There is a wide range of symptomatology from non-specific fever and weight loss to stroke-like symptoms. It is also one of the rare causes of cardiac syncope and thromboembolic events. We present a case of a 67-year-old female who presented with seemingly benign vertigo symptoms which she ignored for years before seeking medical attention. An echocardiogram revealed a 3.5 x 3.0 x 1.0 cm atrial myxoma which was surgically excised. Her symptoms have resolved entirely with no recurrence since surgery.