Conservative treatment with mouthwashes followed by tongue photo biomodulation therapy in Covid-19: a case report.

BACKGROUND: Oral manifestations of coronavirus disease 2019 (COVID-19), including ulcers, herpetiform lesions, macules, and petechiae, among others, are becoming increasingly recognized, but there is little guidance on their treatment. Reported cases have described treatment with various mouthwashes containing antivirals, antifungals, antibiotics, anesthetics, or steroids. Our case report is unique in that we provide guidance on the judicious use of these medications, followed by photobiomodulation therapy if the manifestations are treatment resistant. CASE PRESENTATION: We describe a 30-year-old Caucasian woman who tested positive for COVID-19 after developing nasal congestion and cough. Ten days after testing positive, she developed a systemic rash on her extremities and torso. At the same time, she developed swelling of the tongue lasting 1 hour, with subsequent appearance of oral lesions that resembled geographic tongue. She also had an irritable sensation on her tongue and some mild loss of sense of taste. We opted for conservative therapy, including mouth rinses containing lidocaine to be used every 6 hours. The patient used the mouth rinse therapy for 1 month and experienced a 90% improvement in her oral lesions and tongue sensitivity. However, she had repeated flares every 3 weeks over a 6-month period, and the steroid mouthwash achieved incomplete resolution. After three sessions of photobiomodulation therapy, she had no further flares or tongue sensitivity and the lesions healed. CONCLUSIONS: The implication of our report is that we promote the judicious use of topical antibiotics, antivirals, antifungals, and steroids for when they are indicated. We propose lidocaine-containing mouth rinses and steroid mouthwash as an initial, symptomatic treatment regimen for 'COVID-19 tongue.' If there is failure of resolution, we recommend photobiomodulation therapy.

A Unique Case of Nonhypoxic Splenic Infarction in a Patient With Sickle Cell Trait Due to Dehydration and Sepsis From a Dental Infection: A Case Report.

Splenic infarction is a recognized complication occurring at high altitudes in patients with sickle cell trait (SCT). There have been a few cases of splenic infarction occurring in the setting of nonhypoxic events at sea level, and some cases of spontaneous splenic infarction without an inciting event in patients with SCT. We present the case of a 25-year-old male with a recent untreated dental infection who was drinking alcohol excessively and moving furniture over the last few weeks. He came to the hospital due to left-sided abdominal pain and was found to have a splenic infarction. He was found to have hemolysis on his blood work, with elevated lactate dehydrogenase, low haptoglobin, and elevated bilirubin levels. He underwent hemoglobin electrophoresis which revealed SCT. His blood cultures grew Streptococcus mitis and Streptococcus oralis, a normal oral commensal, which was thought to be due to the untreated dental infection. His workup for endocarditis as a source of splenic infarction was negative, and he had no other source of emboli. He was treated with antibiotics for the sepsis and fluids for the sickling and hemolysis. He developed multiple complications of the splenic infarction but ultimately recovered. Ours is the first example of nonhypoxic splenic infarction in an SCT patient that has been documented in a scenario of dehydration and sepsis. This link should be understood to prevent splenic infarction even at sea level by preventing overexertion and dehydration in individuals with known SCT.

Lemierre's Syndrome: A Comeback Story.

Lemierre's syndrome is a very rare and life-threatening complication of bacterial pharyngitis and tonsillitis. Often referred to as a 'forgotten disease', Lemierre's syndrome has seen a rise in cases over the years secondary to increased antibiotic resistance. With the potential for multiple organ failure secondary to widespread septic emboli, Lemierre's syndrome can no longer be forgotten. Prompt initiation of treatment is needed for better patient outcomes. We describe an unusual case of a young female without any significant past medical history who presented with left-sided pleuritic chest pain several days after experiencing a sore throat.

Large Vessel Stroke Following Multiple Other Strokes and Cardiomyopathy in a Forty-Nine-Year-Old COVID-19 Patient.

The novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has made its presence known on the centerstage of worldwide healthcare in 2020. Although it is widely known about its pulmonary presence and ensuing complications, evidence is emerging that there are other organ systems including the cardiovascular and cerebrovascular systems that may be damaged by this virus. There have been reports of large vessel stroke occurring in coronavirus disease 2019 (COVID-19) positive patients, with very few reported in the age group less than 50 years. In this case, we describe a previously healthy 49-year-old male who presented with signs of stroke, and was found to have the novel coronavirus as he had been suffering from upper respiratory tract symptoms for 3 weeks. He subsequently developed further large vessel stroke while in the hospital despite being started on antiplatelet therapy. He was also found to have new onset cardiomyopathy. He was started on anticoagulation and discharged with follow-up for cardiomyopathy testing outpatient. This case begs the question on which anticoagulation to utilize in COVID-19 positive patients to be effective in preventing thrombotic events. It is postulated that a pro-inflammatory state induced by the virus and the virus' affinity for angiotensin converting enzyme-2 receptors in the cerebral vasculature are predispositions to cause a stroke. The virus also directly damages cardiac myocytes causing a number of cardiac complications including cardiomyopathy. It is crucial that guidelines on anticoagulation choice and indications for when to start anticoagulation be developed in order to prevent the more devastating consequences of thrombosis and embolism and their subsequent clinical sequelae.

Graves disease-induced thrombotic thrombocytopenic purpura: a case report.

BACKGROUND: Thrombotic thrombocytopenic purpura is an autoimmune disease that carries a high mortality. Very few case reports in the literature have described a relationship between Graves disease and thrombotic thrombocytopenic purpura. We present a case of a patient with Graves disease who was found to be biochemically and clinically hyperthyroid with concurrent thrombotic thrombocytopenic purpura. CASE PRESENTATION: Our patient was a 30-year-old African American woman with a history of hypertension and a family history of Graves disease who had recently been diagnosed with hyperthyroidism and placed on methimazole. She presented to our hospital with the complaints of progressive shortness of breath and dizziness. Her vital signs were stable. On further evaluation, she was diagnosed with thrombotic thrombocytopenic purpura, depending on clinical and laboratory results, and also was found to have highly elevated free T4 and suppressed thyroid-stimulating hormone. She received multiple sessions of plasmapheresis and ultimately had a total thyroidectomy. The patient's hospital course was complicated by pneumonia and acute respiratory distress syndrome. Her platelets stabilized at approximately 50,000/µl, and her ADAMTS13 activity normalized despite multiple complications. The patient ultimately had a cardiac arrest with pulseless electrical activity and died despite multiple attempts at cardiopulmonary resuscitation. CONCLUSION: Graves disease is an uncommon trigger for the development of thrombotic thrombocytopenic purpura, and very few cases have been reported thus far. Therefore, clinicians should be aware of this association in the appropriate clinical context to comprehensively monitor hyperthyroid patients during treatment.

Subacute Stroke in a Young Female: A Case of Moyamoya Syndrome Initially Anchoring with Anxiety.

Moyamoya disease is an arterial disorder causing stroke in a young patient. This is a chronic condition causing progressive cerebrovascular disease due to bilateral stenosis and occlusion of the arteries around the circle of Willis, with prominent arterial collateral circulation. It was first described in Japan and subsequently reported in other Asian countries, but infrequently found in the Western world. Interestingly, there may be racial differences in the presentation and subsequent prognostication of treatment of moyamoya. It is diagnosed with classic angiographic findings of stenosis or occlusion of the circle of Willis vessels. Here, we describe a 28-year-old Caucasian female who was initially diagnosed with anxiety when she presented with symptoms of impaired concentration and fatigue. After the development of remitting slurred speech and facial droop, magnetic resonance imaging and cerebral angiogram yielded the discovery of high-grade stenosis of the origin of the left middle cerebral artery with associated thrombosis in that area. She did well after getting surgery and rehabilitation. This demonstrates a unique presentation of prominent psychiatric symptoms initially thought to be anxiety and culminated in the finding of ischemic stroke in an adult patient with moyamoya.

Clostridium difficile Peritonitis: An Emerging Infection in Peritoneal Dialysis Patients.

Recently, the incidence of Clostridium difficile- (C. difficile-) associated infection has increased significantly in hospital and ambulatory care settings in parallel to the increasing use of inappropriate antibiotics. According to the CDC, approximately 83,000 patients who developed C. difficile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis. Patients on dialysis (particularly peritoneal dialysis) are predisposed to this infection due to an inherent immunocompromised state and transmural translocation of the bacteria due to the close association of gastrointestinal tract and peritoneal cavity. C. difficile infection in peritoneal dialysis patients is problematic from two aspects: (1) because dialysis patients are immunocompromised, the infection can be devastating and (2) infection directly interferes with their renal replacement therapy. In this article, we present a case of peritoneal dialysis (PD)-related peritonitis caused by C. difficile-associated diarrhea and colitis. In this patient, the peritonitis was caused by transmural translocation of the enteric bacteria. While the peritoneal fluid culture did not grow the organism (possibly because of prior empiric broad-spectrum antibiotics use), the positive PCR on stool analysis suggested C. difficile-related peritonitis, along with the rapid clinical improvement induced by C. difficile-directed therapy (metronidazole) and discontinuation of broad-spectrum antibiotics. The patient was successfully treated with metronidazole without PD catheter removal. C. difficile infection is common and frequently internists are the first contact with such patients. This article highlights C. difficile infection in a PD patient and raises awareness of this infection in dialysis patients.