Pulmonary Embolism in a Patient with Rheumatoid Arthritis on Etanercept Therapy.

Pulmonary embolism (PE) represents mechanical obstruction of one or more branches of pulmonary vasculature due to thromboembolism from a deep vein thrombosis. Hormonal contraceptives, hormonal replacement therapy, antipsychotics and fibrates are medications that are associated with increased risk of venous thromboembolism(VTE). Etanercept is a TNF alpha and beta receptor blocker. Rarely this medication has been identified as a risk factor for VTE. There is a possible correlation between rheumatoid arthritis(RA) and risk of VTE in patients with RA. Use of medication that can increase risk of VTE in a patient with systemic inflammatory condition that in itself may be a risk factor for VTE requires shared decision and risk versus benefit discussion with the patient. We present a case of unprovoked PE in a patient on Etanercept treatment for RA. Though in this case, a causal relationship between the drug use and the event could not be proved, the patient preferred to discontinue the medication. In newer classes of medications, when the mechanism of side effects is unclear, we strongly recommend extensive discussion with patients about available scientific literature and encourage shared decision making with the patient.

Postnatal Kangaroo mother care practice at home and comparison of improvement in vital parameters in low-birth-weight babies in-home setup and non-teaching hospital setup in rural coal mines area Jharkhand, India: A community-based observational study.

Introduction: Low birth weight (LBW) newborns especially those <2000 g are more prone to hypothermia due to which other physiological parameters gets deteriorated in the 1st week of life. The objective of this observational study was to continue Kangaroo mother care practice at home and to ascertain whether KMC was effective in improving the vital parameters of LBW babies when it is given at home in a rural coal mines area, in Jharkhand, India. Materials and Methods: This study was a community-based prospective observational study, done over three years from November 2019 to November 2022. In this study, we included 156 pairs of both mothers and LBW babies (weight 1500 g to <2000 g). After discharge from the hospital on day 3, KMC was continued at home on day 4, day 5, and day 6. Data of four physiological parameters, namely, temperature, oxygen saturation, respiratory rate, and heart rate were collected before and after KMC and analyzed. Results: Among 400 newborns, 156 LBW babies (39.0%) who were given KMC at home showed similar but statistically significant improvement of vital parameters, especially in temperature and oxygen saturation (P < 0.0001) compared to the same babies 156 (39.0%) given KMC in the hospital (P < 0.001). Conclusion: Kangaroo mother care, which was continued at home, has a significant role in the Improvement of vital parameters, especially concerning temperature and oxygen saturation. If the babies in the weight range of 1500 g to <2000 g are healthy, well-breast-fed, and have no other risk factors, they can be discharged early and managed at home by delivering supportive care and nursing care along with Kangaroo mother care with continuous follow-up.

Prevalence of Hypothyroidism in the Population of West Bokaro Coal Mine Area, Jharkhand: A Hospital-Based Observational Study.

Background Hypothyroidism is a common endocrine disorder worldwide. Studies on the prevalence of hypothyroidism in different geographical territories of India are sparse. Data on the prevalence of hypothyroidism in India's coal mine areas are lacking. Therefore, we conducted a cross-sectional study to determine the prevalence of hypothyroidism in the adult population living in the coal mine areas of West Bokaro, Jharkhand, India. Methods In total, 1484 individuals of both sexes attending the outpatient department (OPD) of Tata Central Hospital, West Bokaro, Jharkhand, with varied symptoms were screened for thyroid-stimulating hormone (TSH) levels from January 2021 to February 2022. The age of the study participants ranged from 15 to 80 years. Results In total, 366 participants had hypothyroidism (subclinical as well as overt). The prevalence of hypothyroidism was greater in women than in men. Among the 366 patients with hypothyroidism, 311 were women and 55 were men, and the ratio was 5.5:1. The percentage of the population having hypothyroidism was 24% in this study, which is higher than that reported in other parts of India; however, our results are similar to those of a study conducted in Assam in 2017. Among patients with high TSH levels, 47%, 25%, and 19% had TSH in the range of 5.6-7.5, 7.6-10.6, and 10.6-20 µU/mL, respectively. Conclusions Subclinical and overt hypothyroidism are common in eastern India. Patients with undiagnosed fatigue and weight gain must be screened for TSH levels. Hypothyroidism is no longer a rarity, and coal mine areas are no exception to this phenomenon. A population­based epidemiological study of thyroid disorders in coal mine areas is an urgent need.

Listeria Meningitis in a Patient With Plaque Psoriasis on Ustekinumab Therapy.

Listeria monocytogenes is a foodborne infection and is a leading cause of meningitis. The at-risk population includes patients over age 65, neonates, pregnant females, and patients with impaired cell immunity. Ustekinumab is a human monoclonal antibody that binds to and interferes with the proinflammatory cytokines, interleukin-12 (IL-12) and interleukin-23(IL-23). The drug is used for the treatment of Crohn's disease, ulcerative colitis, psoriatic arthritis, and plaque psoriasis. We present a case of listeria meningitis in a patient on ustekinumab therapy for plaque psoriasis.

Deaths due to delayed presentation to the hospital from fear of contracting COVID-19 during lockdown period: a tertiary care center experience.

Background: Sudden rise in COVID-19 cases in March 2020 due to spread of pandemic led to immediate lockdown order in many states and cities across the USA. Everyone had to stay home to stop the spread of the virus. We investigated all deaths in our hospital during lockdown period and assessed how many presented and died from non-COVID-19-related illness. Among those deaths, we assessed how many presented late due to excessive fear of catching coronavirus in the hospital and succumbed to the same illness due to very late presentation. Methods: We retrospectively reviewed charts of every patient who expired in the hospital in a 45-day period, March-April 2020. Results: Three of 107 (2.8%) deaths during lockdown period in this hospital were clearly attributable to delayed presentation arising specifically from fear of coming to the hospital. All three died from non-COVID-19-related illnesses. Conclusions: Authors hereby propose enhanced efforts in the direction to alleviate unnecessary fear among public even during lockdown. People should be encouraged to continue to access health care for serious/fatal medical conditions regardless of the pandemic.

Isolated Non-Resolving Vulvar Lesion as a Presentation of Disseminated Histoplasmosis in a Woman with HIV.

Disseminated histoplasmosis is most commonly caused by Histoplasma capsulatum and is a known opportunistic infection in immunocompromised patients. The clinical presentation of histoplasmosis varies from asymptomatic to a progressive disseminated form. Pulmonary and CNS involvement is common in disseminated histoplasmosis. Rarely, disseminated disease can present as vulvar lesion in the absence of pulmonary symptoms, causing a delay in diagnosis. As per our PubMed literature search, there have only been two reported cases where vulvar lesion was the only presenting symptom of disseminated disease. In our patient, a histopathological diagnosis was made with staining showing budding yeast forms of histoplasma. LEARNING POINTS: Histoplasmosis can be a cause of isolated non-resolving vulvar lesion in immunocompromised patients.In patients at risk, we recommend work-up for disseminated histoplasmosis with urine histoplasma antigen and further imaging to rule out disseminated infection when histoplasma is identified on local biopsy samples.In patients from endemic regions and in non-resolving vulvar lesions, fungal infection should be considered.

Testicular Adrenal Rest Tumour (TART) or Testicular Malignancy: A Clinical Dilemma.

Testicular adrenal rest tumour (TART) is a known entity in patients with congenital adrenal hyperplasia. An adult patient presenting with testicular enlargement raises a concern for malignancy and this creates a diagnostic dilemma between non-malignant conditions such as TART versus testicular malignancy. We describe a case where the patient underwent orchiectomy due to clinical concern for malignancy but, retrospectively, this outcome could have been prevented by medical treatment. This case emphasises the need to learn from errors. There is a need to increase awareness of the condition among medical professionals to reduce the chances of unnecessary surgical intervention. LEARNING POINTS: To recognize testicular adrenal rest tumour (TART) as cause of testicular enlargement in adult patients with congenital adrenal hyperplasia.To differentiate TART from other types of testicular malignancy.Consider medical treatment with exogenous glucocorticoid and mineralocorticoid replacement to prevent unnecessary surgical intervention.

Spontaneous coronary artery dissection, a commonly overlooked etiology of acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD) is a type of non-atherosclerotic coronary artery disease, initially thought to be uncommon but is now being increasingly recognized as a cause of acute coronary syndrome in females. The exact incidence of this remains unknown and most of these cases undergo emergent percutaneous intervention (PCI) due to concern for acute coronary syndrome (ACS). Prior studies have shown that PCI can be detrimental in these cases. It is important to recognize the possibility of SCAD in young female patients so that potentially harmful interventions, such as starting these patients immediately on heparin, use of thrombolytic therapy, and emergent PCI that can lead to worse outcomes, are avoided.

Segmental arterial mediolysis: a commonly overlooked aetiology of acute abdominal pain.

Segmental arterial mediolysis (SAM) is an uncommon condition and commonly missed diagnostic aetiology of acute abdominal pain, initially described in 1976. SAM is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries with notable asymmetric involvement of the walls of the mesenteric arteries and their branches. Clinical presentation ranges from postprandial abdominal discomfort suggestive of mesenteric ischaemia to intra-abdominal bleeding. Pathophysiological explanation and prognosis of these cases are not well understood and therefore no clear guidelines for management exist. In this case report, we emphasise the imaging modalities used to reach the diagnosis and the management options available.

Rare presentation of vertebral discitis, osteomyelitis and polyarticular septic arthritis due to disseminated Neisseria gonorrhea infection.

Disseminated Neisseria gonorrhea (N. Gonorrhoeae) infection can present with polyarticular involvement. Acute vertebral discitis/osteomyelitis due to this organism infection has been rarely reported. We present a case of vertebral discitis and osteomyelitis due to N. gonorrhea in an immunocompetent host, treated successfully with a prolonged antibiotic course.

Ocular syphilis in an immunocompetent host.

Syphilis is an old disease that experienced a resurgence with the emergence of HIV/AIDS. Syphilis is a reportable infection that is monitored by the Centers for disease Control (CDC) in the U.S. and rates have been rising since 2000. Although ocular syphilis is a well known consequence of syphilis infection it continues to be less frequently diagnosed, partially because ocular manifestations are not reportable to CDC. While the majority of recent cases in the U.S. have been reported in men who have sex with men (MSM) population, 50 % of these cases are HIV negative. We present a case of acute iridocyclitis and ocular hypertension due to syphilis infection. This case reiterates the need to increase healthcare workers' awareness of the importance of timely recognition of potential ocular syphilis to prevent visual sequelae from the infection. Ocular syphilis should be kept in the differential diagnosis in immunocompetent/HIV negative patients, and the importance of obtaining a detailed sexual history should not be forgotten.

Successful rapid oral desensitization for dual hypersensitivity to isoniazid and rifampin while treating central nervous system tuberculosis.

Tuberculosis of the central nervous system (CNS-TB) is a critical disease with poor prognosis if not diagnosed and treated early. A regimen of drugs with good CNS penetration is required for treatment. Treatment options are limited in case of hypersensitivity reaction of the recommended regimen. We are reporting a rare instance where a patient developed hypersensitivity to both first line agents (isoniazid and rifampin) for CNS-TB and was successfully desensitized against both these medications to complete the treatment course using the rapid desensitization process. There have been reported cases of desensitization to anti tuberculous medications in cases with pulmonary tuberculosis and hypersensitivity reaction. In this review article we discuss the prior used methods of slow and rapid desensitization in case on non-CNS tuberculosis infections. This is the first reported case to use similar method of rapid desensitization in treatment of central nervous system infection.

Cryptococcus neoformans infective endocarditis of native valves in an immunocompetent host.

With the emergence of Human immunodeficiency virus (HIV) and the resulting immunocompromised state, Cryptococcus neoformans infections have gained more importance in clinical practice. Cryptococcal infections in immunocompetent hosts continue to be uncommon. We present a rare case of Cryptococcus neoformans infective endocarditis (IE) in a young immunocompetent male. As per our literature review, this is the first reported case of native valve Cryptococcus neoformans endocarditis in an immunocompetent host. All cases till date have been reported in patients with underlying immunocompromised state or prosthetic valve.

Recurrent dyspnea and wheezing- pulmonary function test and dynamic computed tomography may unfold the diagnosis of tracheobronchomalacia.

Tracheomalacia patients often present with nonspecific symptoms like cough, wheezing and dyspnea. Tracheomalacia diagnosis is usually attributed to alternative common conditions such as asthma or chronic obstructive lung disease. Certain maneuvers, like forced expiration, or recumbent position may elicit subtle signs of tracheomalacia. Ordering novel pulmonary function testing in sitting upright and supine positions may provide additional clues to suspect tracheomalacia, which can be confirmed by either dynamic chest tomography or bronchoscopy.

Septic arthritis of knee joint due to Parvimonas micra.

Parvimonas species are anaerobic, Gram-positive cocci that are a constituent of normal oral and gastrointestinal flora. We present a case of right knee joint septic arthritis due to Parvimonas micra in an immunocompromised patient. A 61-year-old male renal and pancreatic transplant recipient on immunosuppressive therapy was admitted to our hospital due to intense pain, joint swelling and inability to move his right knee over the past 9 months. After synovial fluid was drawn, cultures were positive for P. micra, an anaerobic pathogen that is part of the flora of the oral cavity. We report a rare causative pathogen for septic arthritis in an immunocompromised patient.

Invading beyond bounds: extraintestinal Clostridium difficile infection leading to pancreatic and liver abscesses.

Clostridium difficile has become a common healthcare-associated infection over the past few years and gained more attention. C. difficile was estimated to cause almost half a million infections in USA in 2011 and 29 000 died within 30 days of the initial diagnosis. Although colitis due to C. difficile is the most common presentation, there have been reported cases of extraintestinal infections. As per our review of literature, this is the third reported case of liver abscess due to the organism.

Prevalence and predictors of inappropriate anticoagulation in patients with a CHA2DS2-VASc score of 0 and atrial fibrillation.

BACKGROUND: Previous studies have shown underutilization of anticoagulation therapy in patients with atrial fibrillation and a CHA2DS2-VASc score ≥2; however there exists little data regarding the inappropriate use of anticoagulation in patients with a CHA2DS2-VASc score of 0. We aimed to determine the true prevalence and predictors of inappropriate anticoagulation therapy in patients with atrial fibrillation and a CHA2DS2-VASc score of 0. METHODS: A retrospective chart review was performed on all patients with atrial fibrillation and a CHA2DS2-VASc score of 0 in our institution from January 2009 to January 2016. Demographic and clinical data were collected from the electronic medical record. We utilized multivariable logistic regression analysis to determine independent clinical predictors of inappropriate anticoagulation administration. RESULTS: 512 patients were identified with a CHA2DS2-VASc score of 0 and a diagnosis of atrial fibrillation. Of the 137 patients prescribed anticoagulation, 64 patients were identified as inappropriately treated with anticoagulation therapy after assessing for other indications of warfarin or novel anticoagulant therapy. Independent variables associated with inappropriate anticoagulation administration were age (OR 1.07; 95% CI 1.03-1.10), body mass index (OR 1.06; 95% CI 1.01-1.10), absence of current aspirin use (OR 13.50; 95% CI 6.00-30.54) and persistent atrial fibrillation (OR 2.34; 95% CI 1.11-4.94). CONCLUSIONS: Our study shows that 12% of patients with a CHA2DS2-VASc score of 0 were inappropriately prescribed anticoagulant therapy. Independent predictors of unnecessary anticoagulation were age, body mass index, absence of current aspirin use and persistent atrial fibrillation.

Free Floating Thrombus in Carotid Artery in a Patient with Recurrent Strokes.

We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up.