A Rare Case of Immunoglobulin G4-Related Constrictive Pericarditis Diagnosed Via Multimodality Imaging.

Constrictive pericarditis (CP) presents as a pathophysiological state where the pericardium becomes inelastic due to fibrotic changes, most commonly secondary to a protracted inflammatory process. The disease is characterized by compromised diastolic cardiac function due to loss of pericardial compliance. Immunoglobulin G4 (IgG4)-related disease, an entity marked by the insidious proliferation of IgG4-positive plasma cells and subsequent fibrosis within various organs, is an infrequent but recognized cause of CP. A case of a 55-year-old male patient with clinical manifestations of dyspnea and edema in the lower extremities elucidates the diagnostic complexity inherent to CP. Echocardiography revealed a constellation of signs, including annulus reversus, septal bounce, and a congested inferior vena cava; cardiac magnetic resonance imaging (MRI) demonstrated diffuse pericardial thickening with delayed gadolinium enhancement, suggestive of a long-term inflammatory state; and right heart catheterization confirmed the hemodynamic hallmark of CP-equalization of diastolic pressures across the cardiac chambers. The serological analysis elicited elevated serum levels of IgG4 and IgE, pointing to the differential diagnosis of IgG4-related disease. Given the nonspecific clinical presentation of IgG4-related CP, a heightened index of suspicion combined with a systematic approach to imaging and serological evaluation is paramount.

Rare Case of Refractory Hypokalemia in a Patient with Acute Monocytic Leukemia.

BACKGROUND Refractory hypokalemia has been rarely demonstrated in patients with acute monocytic leukemia (AMoL). Hypokalemia develops in these patients owing to renal tubular dysfunction, secondary to lysozyme enzymes that are released by monocytes in AMoL. Additionally, renin-like substances are produced from monocytes and can lead to hypokalemia and metabolic alkalosis. There is also an entity called spurious hypokalemia, in which high numbers of metabolically active cells in blood samples increase sodium-potassium ATPase activity, resulting in influx of potassium. Additional research is warranted regarding this specific demographic to create standardized treatment approaches to electrolyte repletion. CASE REPORT In this case report, we demonstrate a rare case of an 82-year-old woman with AMoL, complicated by refractory hypokalemia, who presented with concerns of fatigue. The patient's initial laboratory results were significant for leukocytosis with monocytosis and severe hypokalemia. Refractory hypokalemia was noted, despite administration of aggressive repletions. During her hospitalization, AMoL was diagnosed and an extensive workup was performed to evaluate the underlying cause of hypokalemia. Ultimately, the patient died on day 4 of hospitalization. We describe the correlation between severe refractory hypokalemia and leukocytosis and provide a literature review of multiple etiologies of refractory hypokalemia in patients with AMoL. CONCLUSIONS We evaluated the numerous pathophysiologic mechanisms responsible for refractory hypokalemia in patients with AMoL. Our therapeutic outcomes were limited owing to the patient's early death. It is of high importance to evaluate the underlying cause of hypokalemia in these patients and to treat accordingly with caution.

Acute Diarrhea Isn't Always Infectious: An Atypical Presentation of Adrenal Insufficiency.

Adrenal insufficiency can be a primary or secondary disorder occurring from a hormone deficiency or suppression of the hypothalamic-pituitary axis from various etiologies. The diagnosis can be challenging given the lack of specificity and indolence of symptoms. Diarrhea is not a typical presenting symptom of adrenal insufficiency and can be overlooked as an infectious disease during an adrenal crisis. Herein we present a patient with an undiagnosed adrenal insufficiency who presented with subacute diarrhea during an adrenal crisis after a dental procedure and esophagogastroduodenoscopy.

A Rare Case of HHV-6 Encephalitis in an Immunocompetent Host: Case Report and Literature Review.

Human herpesvirus-6 (HHV-6) is a virus known for causing the highly contagious infection, roseola infantum, and has been associated with causing encephalitis in pediatric patients and less commonly in adult patients as well. Regardless of the patient's age, the primary HHV-6 infection could be complicated by neurological sequelae including encephalitis, acute encephalopathy with biphasic seizures syndrome, or demyelinating disease. HHV-6 encephalitis does occur in an adult as a primary infection or reactivation. However, immunocompromised, hematopoietic stem cell transplantation patients, and solid organ transplant recipients are the most affected population. Here we present a rare case of HHV-6 encephalitis in a 26-year-old healthy immunocompetent male. HHV-6 viral DNA was detected in the cerebrospinal fluid during the acute stage of the disease, and the diagnosis was confirmed by quantitative polymerase chain reaction (PCR). The patient was treated with ganciclovir and had a complete response to treatment without any further complication. The pathophysiology, clinical course, and treatment in otherwise immunocompetent adult patients are also discussed.

Exploring the Antibacterial and Antibiofilm Efficacy of Silver Nanoparticles Biosynthesized Using Punica granatum Leaves.

The current research work illustrates an economical and rapid approach towards the biogenic synthesis of silver nanoparticles using aqueous Punica granatum leaves extract (PGL-AgNPs). The optimization of major parameters involved in the biosynthesis process was done using Box-Behnken Design (BBD). The effects of different independent variables (parameters), namely concentration of AgNO3, temperature and ratio of extract to AgNO3, on response viz. particle size and polydispersity index were analyzed. As a result of experiment designing, 17 reactions were generated, which were further validated experimentally. The statistical and mathematical approaches were employed on these reactions in order to interpret the relationship between the factors and responses. The biosynthesized nanoparticles were initially characterized by UV-vis spectrophotometry followed by physicochemical analysis for determination of particle size, polydispersity index and zeta potential via dynamic light scattering (DLS), SEM and EDX studies. Moreover, the determination of the functional group present in the leaves extract and PGL-AgNPs was done by FTIR. Antibacterial and antibiofilm efficacies of PGL-AgNPs against Gram-positive and Gram-negative bacteria were further determined. The physicochemical studies suggested that PGL-AgNPs were round in shape and of ~37.5 nm in size with uniform distribution. Our studies suggested that PGL-AgNPs exhibit potent antibacterial and antibiofilm properties.

Perirectal Extragastrointestinal Stromal Tumor: An Unusual Presentation.

Gastrointestinal stromal tumors (GISTs), even though rare, remain the most common mesenchymal tumors of the gastrointestinal (GI) tract. When GISTs occur outside of the GI tract, they are termed extragastrointestinal stromal tumors (EGISTs). Most GISTs arise from the stomach (50-70%) and small intestine (20-30%). A smaller percentage of these tumors also occurs in the large intestine (5%) and esophagus (2-5%). EGISTs have histopathological and molecular characteristics that are similar to GISTs. However, the precise incidence and tumor behavior of EGISTs are not fully understood. EGISTs have no specific symptoms or radiologic features, and in most cases, the presenting complaint is abdominal pain or discomfort. Yet, they tend to be more aggressive and have a worse prognosis than GISTs. Morphologic diagnosis based on microscopic examination of histological sections is the standard diagnostic procedure for GIST/EGIST. In this patient-centered study, we present a case of EGIST that originated in the anterior perirectal space, an extremely rare location; we also describe the endoscopic approach that was used to biopsy the tumor.

Acute upper limb ischemia in a patient with COVID-19.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.

Diosgenin Loaded Polymeric Nanoparticles with Potential Anticancer Efficacy.

This study aims to determine the anticancer efficacy of diosgenin encapsulated poly-glycerol malate co-dodecanedioate (PGMD) nanoparticles. Diosgenin loaded PGMD nanoparticles (variants 7:3 and 6:4) were synthesized by the nanoprecipitation method. The synthesis of PGMD nanoparticles was systematically optimized employing the Box-Behnken design and taking into account the influence of various independent variables such as concentrations of each PGMD, diosgenin and PF-68 on the responses such as size and PDI of the particles. Mathematical modeling was done using the Quadratic second order modeling method and response surface analysis was undertaken to elucidate the factor-response relationship. The obtained size of PGMD 7:3 and PGMD 6:4 nanoparticles were 133.6 nm and 121.4 nm, respectively, as measured through dynamic light scattering (DLS). The entrapment efficiency was in the range of 77-83%. The in vitro drug release studies showed diffusion and dissolution controlled drug release pattern following Korsmeyer-Peppas kinetic model. Furthermore, in vitro morphological and cytotoxic studies were performed to evaluate the toxicity of synthesized drug loaded nanoparticles in model cell lines. The IC50 after 48 h was observed to be 27.14 µM, 15.15 µM and 13.91 µM for free diosgenin, PGMD 7:3 and PGMD 6:4 nanoparticles, respectively, when administered in A549 lung carcinoma cell lines.

Anal squamous cell carcinoma with metastasis to duodenum causing duodenal stricture and gastric outlet obstruction.

Squamous cell carcinoma (SCC) of the anal canal is a rare entity encompassing only 2-4 percent of all colon, rectal, and anal cancers. SCC of the anal canal tends to be loco-regional, and in the event of distant metastasis, a most common site of spread is to liver and lung. We report an unusual case of SCC of the anal canal with duodenal metastases in a 49-year-old female who had presented with symptoms of abdominal pain, nausea, and vomiting eight months after the primary diagnosis of SCC of the anal canal. Esophagogastroduodenoscopy (EGD) revealed duodenal stricture with subsequent biopsy revealing duodenal mucosa with scattered malignant cell clusters within lymphatic spaces, consistent with metastatic carcinoma. Immunohistological staining demonstrated malignant cells positive for CK7, p16, p63 favoring a metastatic SCC.

Clinical Resolution of Osmotic Demyelination Syndrome following Overcorrection of Severe Hyponatremia.

Osmotic Demyelination Syndrome (ODS) occurs after rapid overcorrection of severe chronic hyponatremia usually in those with a predisposition such as chronic alcoholism, malnutrition, or liver disease. Rarely, do patients make a full recovery. We report a case of ODS secondary to overcorrection of severe hyponatremia with pathognomonic clinical and radiologic signs making a complete neurological recovery. A detailed course of events, review of literature, and optimal and aggressive management strategies are discussed. There is some controversy in the literature regarding the prognosis of these patients. Our aim here is to show that, with aggressive therapy and long-term care, recovery is possible in these patients.

Diabetic ketoalkalosis: misnomer or undiagnosed variant of diabetic ketoacidosis.

Usually, hyperglycaemia crisis presents with acidotic pH, but ketoalkalosis is a rare and unheard entity presenting in diabetic ketoacidosis. We describe three unique cases where the patients present with hyperglycaemia >250 mg/dL, normal or alkalotic pH, and bicarbonate >20 meq/L, which does not meet criteria for diabetic ketoacidosis. However, once these patients were supplemented with intravenous fluids, diagnosis of diabetic ketoacidosis was evident in laboratory analysis. These case series provide a learning opportunity in diagnosing and management of this rare phenomenon.

A Case of Diabetic Ketoacidosis Presenting with Hypernatremia, Hyperosmolarity, and Altered Sensorium.

Diabetic Ketoacidosis commonly presents with hyponatremia, but hypernatremia is a rare entity. We report a unique case of a 50-year-old woman admitted with altered sensorium with blood glucose 979 milligrams/deciliter, serum osmolarity 363 mOsm/kilograms, and serum sodium 144 milliequivalents/liter. Patient was given initial bolus of isotonic saline and continued on half isotonic saline for correction of hypernatremia along with insulin infusion therapy. Patient was successfully treated with intravenous fluids, insulin infusion, and the altered sensorium was resolved without any sequelae. This case illustrates a teaching point in the use of intravenous fluids for the treatment of Diabetic Ketoacidosis with hypernatremia.