Splenic Marginal Zone Lymphoma in a Patient With Antiphospholipid Syndrome Treated With Rituximab: A Case Report.

Splenic marginal zone lymphoma (SMZL) usually presents with splenomegaly or symptoms related to cytopenia. We report a case of a 56-year-old female with previously diagnosed antiphospholipid syndrome (APS) on warfarin therapy who initially presented with abdominal pain and was found to have massive splenomegaly and splenic infarction on CT imaging. Initial clinical presentations and imaging findings were attributed to the subtherapeutic coagulation profile. The patient was later diagnosed with SMZL following workup for pancytopenia including bone marrow biopsy, flow cytometry, and PET scan. Cytopenias, splenomegaly, and abnormal metabolic activity in the spleen on the PET scan improved after treatment with four cycles of weekly rituximab. Our report presents a case of a patient with longstanding APS presenting with splenic infarction and pancytopenia who was subsequently diagnosed with SMZL and successfully treated with rituximab.

Type II Heparin-Induced Thrombocytopenia: An Underrecognized Cause of Dialysis Catheter Dysfunction - A Case Report.

Heparin-induced thrombocytopenia (HIT) is categorized into type 1 and type 2. It causes a decrease in platelet count during or shortly after exposure to heparin. Type 1 is mild and has a non-immune mechanism. Type 2 is a hypercoagulable state resulting from anti-heparin platelet factor 4 (PF4) IgG antibodies. These antibodies cause the activation of endothelium and thrombin generation. Type 2 HIT is complicated by life-threatening thromboembolic events such as deep venous thrombosis, pulmonary embolism, and myocardial infarction. HIT remains an under-recognized cause of dialysis catheter dysfunction and thrombosis. We present a case of a 66-year-old male with recurrent dialysis catheter thrombosis secondary to Type 2 HIT. Avoiding heparin-based dialysis or switching to non-heparin-based anticoagulation or peritoneal dialysis are the possible management strategies for such patients.

Amiodarone-Induced Liver Attenuation on CT Scan: Alarming Signal for Toxicity and Prompt Discontinuation.

Amiodarone, a class III antiarrhythmic drug, is commonly used for the management of life-threatening ventricular arrhythmias, atrial fibrillation, and other refractory supra-ventricular arrhythmias. Factors like a large volume of distribution, lipophilic property, deposition in tissues in large amounts, etc. have led to the development of amiodarone-induced multisystem adverse events. We report a case of amiodarone-induced hepatic attenuation on computed tomography (CT) of the abdomen in an elderly female patient. Amiodarone with a composition of 40% iodine by weight deposits in the liver, leading to characteristically increased radiodensity reported as increased attenuation on CT scan. Surprisingly, the severity and extent of hepatic attenuation on CT scans do not necessarily correlate with the total exposure to amiodarone over time. Individual factors may influence the liver's response to the drug, leading to varying degrees of hepatic changes. To minimize the risk of adverse events associated with amiodarone, clinicians should carefully adjust the dosage to the lowest effective level and regularly monitor liver function tests in patients. This proactive approach enables early detection of liver dysfunction and facilitates timely adjustments or discontinuation of amiodarone, thereby reducing potential harm.

A Rare Case of Valproic Acid Toxicity Requiring Hemodialysis.

Valproic acid poisoning can have mild to fatal consequences depending on its body concentration. There are rare case reports and barely any known controlled studies on the use of hemodialysis as a last treatment resort. We report a rare valproic acid poisoning case at One Brooklyn Health/Interfaith campus, New York City, warranting intubation and hemodialysis. The patient is a 47-year-old male with a past medical history of seizure disorder, polysubstance use disorder, schizophrenia, and gastroesophageal reflux disease (GERD) who was brought to the medical emergency department (ED) for intentional valproic acid overdose with 60 tablets of his prescribed home Depakote DR 500 mg (~30 g). The patient's other outpatient medications included valproic acid, trazodone, acetaminophen, famotidine, fluoxetine, folic acid, hydrocortisone-aloe, multivitamin, nicotine polacrilex, and thiamine. The patient's initial blood tests showed high valproic acid, ammonia, ethanol, and lactate. About six hours after ED admission, the patient became somnolent, desaturated to 74% on a non-rebreather oxygen mask, warranting intubation and hemodialysis after noticing persistently high serum concentrations of valproic acid. The relatively low molecular weight (144 Daltons) and low volume of distribution of valproic acid suggest a potential benefit from hemodialysis, especially at a serum concentration of >850 mg/L or in the event of a shock. In this patient, mentation and stability status were improved after hemodialysis. Hemodialysis appears to be the last treatment resort for severe valproic acid poisoning.

Veillonella Bacteremia in a Patient With Metastatic Colorectal Carcinoma.

Colorectal carcinoma has increasingly been reported to be associated with gut microbial dysbiosis. Bacteroides, Fusobacterium, Faecalibacterium, Blautia, etc., are gut microbes commonly associated with colorectal carcinoma. Gut microbial dysregulation secondary to infectious, inflammatory, toxin exposure or change in dietary habits coupled with the disruption of the inner mucosal layer overlying the luminal epithelium is hypothesized as the inciting events leading to microbial invasion and subsequent tumorigenesis. Although the precise mechanism is unclear, disruption of normal host responses like inflammation, apoptosis, cellular proliferation, free radical injury, production of oncogenic toxins, etc., is postulated to play a role. We report a case of Veillonella bacteremia in a patient with metastatic colorectal carcinoma without a preceding history of periodontal disease. The patient was managed with ampicillin-sulbactam, which was followed by subsequent negative blood cultures. This case report signifies the association of gut microbiota like Veillonella with colorectal carcinoma and the importance of subsequent screening for colorectal cancer following Veillonella bacteremia.

Fluctuating Hyperthyroidism and Hypothyroidism in Graves' Disease: The Swinging Between Two Clinical Entities.

Autoimmune thyroid disorders are frequently encountered in clinical practice and consist of a spectrum ranging from Graves' hyperthyroidism to Hashimoto's hypothyroidism. Generally, patients with autoimmune thyroid disorders will lean towards one end of the spectrum or the other, with fluctuations between hyper- and hypothyroidism rarely seen. This is especially the case when persistent hyperthyroidism occurs after a prolonged period of hypothyroidism. Here, we present a case of a young female patient initially presenting with Graves' disease with a previous history of hypothyroidism.

Acute Non-Obstructive Bilateral Pyelonephritis With Acute Kidney Injury Requiring Hemodialysis.

Acute pyelonephritis (APN) is considered a rare cause of acute kidney injury (AKI), especially when no anatomical abnormalities or predisposing factors are identified. Additionally, non-obstructive pyelonephritis is a very infrequent cause of rapidly progressive acute kidney injury. Herein, we present a rare case of a 55-year-old female patient who was diagnosed with acute non-obstructive pyelonephritis leading to AKI eventually requiring hemodialysis. The patient eventually recovered with the administration of intravenous antibiotics with a significant recovery of renal function.

Atrial Fibrillation With Myocardial Infarction Presenting as a Progressive Worsening Fatigue in a Young Male.

Atrial fibrillation (AF) is one of the most common arrhythmia exhibiting a dramatic rise in prevalence with associated increased risk of stroke, heart failure, and death. No standard symptoms have been categorized yet to set a gold standard in diagnosing this clinical attribute. A highly variable symptoms array has increased the challenges of management in terms of AF. An obvious relationship has not been established between symptoms and the onset or recurrence of arrhythmia. We present a case of a 43-year-old male patient who complained of chronic fatigue as a primary symptom and was diagnosed with AF with myocardial infarction.

Myocardial Bridging: Two Different Clinical Presentations in Young Males Involving Left Anterior Descending Coronary Artery.

Myocardial bridging is a rare anatomical variant that can lead to detrimental cardiac consequences when undiagnosed and untreated. This rare variant can induce anginal-type symptoms due to disrupted blood flow to the myocardium during systole. The patients presented in this report of two cases had previously undiagnosed myocardial bridging of the left anterior descending artery, however clinically, they presented quite differently. Here we present two cases discussing the course of diagnosis and treatment of myocardial bridging of these two patients. The goal of this case report is to highlight the significant cardiovascular injuries that can be a result of undiagnosed myocardial bridging.

Hemothorax With White-Out Lung After Intrapleural Tissue Plasminogen Activator and Deoxyribonuclease Therapy in a Patient With Complicated Parapneumonic Effusion.

Tissue plasminogen activator (tPA) and recombinant deoxyribonuclease (DNase ) are used in treating pleural infection due to their mucolytic activity by effectively reducing pleural fluid viscosity. The combination of tPA and DNase has attracted considerable interest as an alternative to surgical intervention for treating complicated parapneumonic effusion in high-risk patients who are not good candidates for surgery. However, intrapleural hemorrhage has been reported as a villainous outcome in a few cases which needs to be considered as a differential diagnosis with sudden clinical deterioration after the therapy. Here, we report the case of a patient who presented with pneumonia and later developed a large right complicated parapneumonic pleural effusion. A chest tube was placed with drainage of fluid while tPA and DNase were also considered as an additional treatment module. Following the first dose of DNase and tPA, the patient developed hypoxemia with hypotension and was found to have rapid development of white-out right hemothorax.

Symptomatic Sinus Bradycardia in a Patient With Acute Calculous Cholecystitis Due to the Cardio-Biliary Reflex (Cope's Sign): A Case Report.

Acute cholecystitis may present cardiovascular manifestation like cardiac ischemia leading to detailed cardiac workup without any obvious cardiac pathology. Here we describe a case who presented with typical signs and symptoms of cholecystitis exhibiting sinus bradycardia. This reflexive bradycardia was a result of autonomic vagal innervation and was resolved after cholecystectomy. This case highlights the importance of the cardio-biliary reflex and recommends clinicians ensure expedited management of cholecystitis to avoid unnecessary extensive cardiac workup.

Overlapping Symptoms of COVID-19 and Giant Cell Arteritis: The Need for a Higher Degree of Suspicion for Diagnostic Differentiation.

Giant cell arteritis (GCA) is a large cell vasculitis that can present with a plethora of symptoms affecting several different systems. Before the COVID-19 pandemic, diagnosis of GCA was straightforward since the list of differential diagnoses for this disease was relatively short. However, the development of a SARS-CoV-2 viral infection challenges this standard. COVID-19 is a viral illness that also can present with similar vascular symptoms as GCS and creates a substantial inflammatory reaction, similar to most vasculitis. We present a case of a patient who had developed GCA after recovering from a COVID-19 viral illness. This is a rare presentation of GCA in the setting of COVID-19, and recognition of the nuanced differences between the two diseases may significantly change a patient's prognosis if not detected early.

A Rare Case of Cocaine-Induced Muscle Hematoma Followed by Rhabdomyolysis in Association With Acute Kidney Injury and Severe Transaminitis.

Cocaine use can result in a few infrequent complications, among which is localized hematoma. As far as we know, there are very few cases reporting cocaine-induced non-traumatic muscle hematoma complicated by severe transaminitis and rhabdomyolysis. Here we present a patient who developed a significant lower extremity muscle hematoma secondary to inhalational cocaine use. We are reporting this case to bring to light this rare and unusual complication of cocaine use. With recreational use of this drug being so prominent in the patient population, early recognition of this complication can help expedite treatment and reduce the severity of end-organ damage.

Unprovoked Isolated Pulmonary Embolism and Graves' Disease in a Patient With Dyspnea: A Case Report.

Graves' disease is a commonly diagnosed disease with a plethora of manifestations that can lead to its diagnosis. One of the rarer presentations of Graves' disease is hypercoagulability with the development of spontaneous venous thrombosis. In patients presenting with unprovoked pulmonary embolism, we suggest evaluating the patient's thyroid function tests as a potential underlying cause. To bring this issue to attention, we are presenting a rare case of isolated spontaneous pulmonary embolism development secondarily to underlying Graves' disease.

Persistent Hypokalemia in a Patient With Ogilvie's Syndrome.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare disease characterized by acute dilatation of the colon in the absence of anatomic intestinal obstruction. It is of clinical importance because of its preponderance in elderly males in the seventh decade of life who may present with constipation or diarrhea. We present an 80-year-old male who presented with diarrhea, with laboratory investigations showing hypokalemia and a CT abdomen revealing colonic distension. The patient was wasting potassium both from colon and renal losses, despite low aldosterone levels. The patient was treated with Neostigmine, which helped relieve abdominal distention. Subsequently, potassium was corrected with aggressive replacement. This case sheds light on newer modalities of treatment such as neostigmine, as in this case.

Augmented Renal Clearance in a Case of Sepsis Leading to Vancomycin Failure Despite Increasing Dose As per the Estimated Glomerular Filtration Rate.

Augmented renal clearance (ARC) is a unique clinical scenario observed in critically ill patients. We present a case of a 30-year-old male with sepsis secondary to methicillin-resistant Staphylococcus aureus (MRSA) bacteremia treated with vancomycin. ARC was observed in the patient with a maximum estimated glomerular filtration rate (eGFR) of 161.9 ml/min/1.73 m2, and therapeutic drug monitoring was used to adjust the vancomycin dosage. Despite the maximal recommended dose of vancomycin, the therapeutic vancomycin level was not achieved, leading to treatment failure and subsequent mortality. Our case report suggests the necessity of other strategies, such as early dose adjustment of vancomycin based on vancomycin clearance and continuous vancomycin infusion, not merely conventional adjustment based on eGFR and vancomycin levels.

Staphylococcal toxic shock syndrome in a lactating mother with breast abscess: A case report.

INTRODUCTION: The highest risk for Staphylococcal Toxic Shock Syndrome are female patients with pre-existing Staphylococcal vaginal colonization who frequently use contraceptive sponges, diaphragms or tampons. In addition patients with burns, soft tissue injures, retained nasal packing, post-abortion, post-surgical, post intrauterine device placement and abscess formation are also at high risk. CASE PRESENTATION: A 19 years old female complaint of high fever with altered level of consciousness. She also had history of nausea, vomiting, diarrhea and pain on her left breast for 5 days. She developed desquamation on her palms and soles on the day three of her admission to ICU. Ultrasonography of her left breast showed 2*2*1 cm abscess collection and the culture report from breast abscess showed Staphylococcus aureus, sensitive to clindamycin, vancomycin and resistant to methicillin. She showed clinical improvement after commencing vancomycin and clindamycin as per culture sensitivity report of breast abscess. DISCUSSION: Toxic shock syndrome secondary to breast abscess in adult is infrequently reported. The diagnosis of Toxic shock syndrome is made by the Centers for Disease Control and Prevention (CDC) definition. Antibiotics for treatment of this condition should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) in combination with either clindamycin or linezolid. CONCLUSION: Treatment for breast abscess warrants incision and drainage as important as antibiotics with anti-toxin. Focused history, physical examination, and laboratory investigations are crucial for the diagnosis and management of this condition.

Acute mountain sickness induced diabetic ketoacidosis managed with hemodialysis: A case report.

INTRODUCTION: The risk of developing ketoacidosis in patients with type 1 diabetes at high altitude is high. Anorexia associated with acute mountain sickness, dehydration and additional exercise associated with climbing exacerbates the generation of ketones and the development of ketoacidosis. CASE PRESENTATION: A 33-year-old gentleman with known history of uncontrolled type 1 diabetes mellitus trekked to Everest Base Camp at an altitude of 3440 m and became unwell. He developed altered sensorium and shortness of breath. He ingested eight tablets of acetazolamide (250 mg each) to address these symptoms. Upon presentation to emergency, he was diagnosed with severe diabetes ketoacidosis (DKA) with shock. Resuscitation was started with fluid, insulin, vasopressors and mechanical ventilation. Despite adequate fluid resuscitation, insulin, bicarbonates and other supportive measures, his acidosis and shock persisted and then managed with hemodialysis. After the first session of hemodialysis, improvement in acidosis and shock was noted. He was successfully extubated and later discharged. DISCUSSION: In this case report, DKA due to acute mountain sickness was complicated by acetazolamide use and noncompliance to his regular insulin intake. There is no proper guideline regarding the role of renal replacement therapy in management of DKA. However, evidence of hemodialysis in DKA is limited to few case reports. Improvement seen in our patient after dialysis is related to dialyzable nature of acetazolamide. CONCLUSION: We present a case of a severe DKA potentially precipitated by acute mountain sickness, use of acetazolamide, noncompliance to his regular insulin intake and managed with hemodialysis in addition to conventional treatment for DKA.

Prevalence of behavioral risk factors of cardiovascular diseases and associated socio-economic factors among pregnant women in a rural area in Southern Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) have dramatically infiltrated populations living in abject poverty in Low- and Middle-income Countries (LMICs), and poor maternal and child health outcomes have been frequently reported for those with CVD risk factors. However, few studies have explored the behavioral risk factors of CVDs among pregnant women in rural settings. This study aimed at determining the prevalence and identifying the socio-economic predictors of behavioral risk factors of CVDs among pregnant women in rural area in Southern Nepal. METHODS: A Community-based cross-sectional study was conducted in 52 clusters of Dhanusha District of Nepal in a total of 426 pregnant women in their second trimester using multistage cluster sampling method. Multivariable logistic regression model was used to assess independent associations between behavioral risk factors during pregnancy and maternal socio-economic characteristics. RESULTS: Of the 426 study participants, 86.9, 53.9, 21.3 and 13.3%, respectively, reported insufficient fruits and vegetables consumption, insufficient physical activity, tobacco use, and harmful alcohol drinking. Socio-economic factors significantly associated with more than one behavioral risk factors in expectant mothers with a primary level education (adjusted odds ratio (AOR) 2.78; 95% Confidence Interval (CI) (1.35-5.72)), 20-34 years age group (Adjusted Odds Ratio (AOR) 0.27; 95% CI (0.13-0.56)), and those with the highest wealth index (AOR 0.36; 95% CI (0.16-0.84)). CONCLUSION: Higher prevalence of behavioral risk factors for CVDs and their socio-economic factors prevailing among pregnant women living in rural Nepal call for immediate health promotion interventions such as community awareness and appropriate antenatal counseling.

Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting, Nepal.

BACKGROUND: Healthcare ethics is neglected in clinical practice in LMICs (Low and Middle Income Countries) such as Nepal. The main objective of this study was to assess the current status of knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses in a tertiary teaching hospital in Nepal. METHODS: This was a cross sectional study conducted among resident doctors (n = 118) and ward nurses (n = 86) in the largest tertiary care teaching hospital of Nepal during January- February 2016 with a self-administered questionnaire. A Cramer's V value was assessed to ascertain the strength of the differences in the variables between doctors and nurses. Association of variables were determined by Chi square and statistical significance was considered if p value was less than 0.05. RESULTS: Our study demonstrated that a significant proportion of the doctors and nurses were unaware of major documents of healthcare ethics: Hippocratic Oath (33 % of doctors and 51 % of nurses were unaware), Nuremberg code (90 % of both groups were unaware) and Helsinki Declaration (85 % of doctors and 88 % of nurses were unaware). A high percentage of respondents said that their major source of information on healthcare ethics were lectures (67.5 % doctors versus 56.6 % nurses), books (62.4 % doctors versus 89.2 % nurses), and journals (59 % doctors versus 89.2 % nurses). Attitude of doctors and nurses were significantly different (p < 0.05) in 9 out of 22 questions pertaining to different aspects of healthcare ethics. More nurses had agreement than doctors on the tested statements pertaining to different aspects of healthcare ethics except for need of integration of medical ethics in ungraduate curricula (97.4 % doctors versus 81.3 % nurses),paternalistic attitude of doctor was disagreed more by doctors (20.3 % doctors versus 9.3 % nurses). Notably, only few (9.3 % doctors versus 14.0 % nurses) doctors stood in support of physician-assisted dying. CONCLUSIONS: Significant proportion of doctors and nurses were unaware of three major documents on healthcare ethics which are the core principles in clinical practice. Provided that a high percentage of respondents had motivation for learning medical ethics and asked for inclusion of medical ethics in the curriculum, it is imperative to avail information on medical ethics through subscription of journals and books on ethics in medical libraries in addition to lectures and training at workplace on medical ethics which can significantly improve the current paucity of knowledge on medical ethics.