Case Report: Tuberculosis-Induced Autoimmune Hemolytic Anemia.

Tuberculosis (TB) is an infectious disease that affects different organs, causing multiple complications, including hematological sequelae. One of the most common TB-hematological complications is anemia of chronic disease. Very rarely autoimmune hemolytic anemia (AIHA) has been reported as an uncommon manifestation of TB. In this case, we present a female who presented with refractory AIHA, which was attributed to disseminated TB. The patient responded well to steroids, anti-TB medications, and rituximab.

Clinical, Radiological, and Outcome Characteristics of Acute Pulmonary Embolism: A 5-year Experience from an Academic Tertiary Center.

BACKGROUND: Acute pulmonary embolism (PE) is a common and potentially life-threatening condition. This comprehensive study from a Gulf Cooperation Council (GCC) country aimed to evaluate the clinical, radiological, and outcome characteristics associated with acute PE. METHODS: This retrospective observational study analyzed data of patients with confirmed acute PE who were admitted to the largest academic tertiary center in the State of Qatar from January 1, 2014, to December 31, 2018. Data on the clinical presentation, radiologic, and echocardiographic findings, as well as outcomes were collected. RESULTS: A total of 436 patients were diagnosed with acute PE during the study period (male, 53%). Approximately 56% of the patients were < 50 years old at presentation, with a median age of 47 years. In approximately 69% of cases, the PE occurred outside the hospital. The main associated comorbidities were obesity (34.6%), hypertension (29.4%), and diabetes (25%). Immobilization (25.9%) and recent surgery (20.6%) were the most common risk factors. The most frequent presenting symptom was dyspnea (39.5%), and the most frequent signs were tachycardia (49.8%) and tachypnea (45%). Cardiac arrest was the initial presentation in 2.2% of cases. Chest X-ray findings were normal in 41%. On computed tomography pulmonary angiography (CTPA), 41.3% of the patients had segmental PE, 37.1% had central PE, and 64.1% had bilateral PE. The main electrocardiographic (ECG) abnormality was sinus tachycardia (98%). In patients who underwent echocardiography, right ventricular (RV) enlargement was the main echocardiographic finding (36.4%). Low-, intermediate-, and high-risk PE constituted 49.8%, 31.4%, and 18.8% of the cases, respectively. Thrombolysis was prescribed in 8.3% of the total and 24.4% of the high-risk PE cases. Complications of PE and its treatment (from admission up to 6 months post-discharge) included minor bleeding (14%), major bleeding (5%), PE recurrence (4.8%), and chronic thromboembolic pulmonary hypertension (CTEPH) (5%). A total of 15 (3.4%) patients died from PE. CONCLUSIONS: Acute PE can manifest with complex and variable clinical and radiological syndromes. Striking findings in this study are the younger age of acute PE occurrence and the low PE-related mortality rate.

Rare case of simultaneous cerebral artery and venous sinus thrombosis in the setting of elevated factor VIII and combined oral contraceptive pills.

We report a rare case of combined cerebral venous sinus thrombosis and ischemic stroke in a 35-year-old female on combined oral contraceptive pills (COCPs) with persistently elevated factor VIII, presenting with headache and sudden onset vertigo, found to have extensive cerebral venous sinus thrombosis and PICA territory ischemic infarct.

Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics.

The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P= .001), and tachypnea (58.9% vs. 42.1%, P= .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P= .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P= .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P= .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P= .000), RV dysfunction (45.8% vs. 22%, P= .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P= .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P= .864) and hypoxemia (41.1% vs. 34.3%, P= .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.

Complement C5a and Clinical Markers as Predictors of COVID-19 Disease Severity and Mortality in a Multi-Ethnic Population.

Coronavirus disease-2019 (COVID-19) was declared as a pandemic by WHO in March 2020. SARS-CoV-2 causes a wide range of illness from asymptomatic to life-threatening. There is an essential need to identify biomarkers to predict disease severity and mortality during the earlier stages of the disease, aiding treatment and allocation of resources to improve survival. The aim of this study was to identify at the time of SARS-COV-2 infection patients at high risk of developing severe disease associated with low survival using blood parameters, including inflammation and coagulation mediators, vital signs, and pre-existing comorbidities. This cohort included 89 multi-ethnic COVID-19 patients recruited between July 14th and October 20th 2020 in Doha, Qatar. According to clinical severity, patients were grouped into severe (n=33), mild (n=33) and asymptomatic (n=23). Common routine tests such as complete blood count (CBC), glucose, electrolytes, liver and kidney function parameters and markers of inflammation, thrombosis and endothelial dysfunction including complement component split product C5a, Interleukin-6, ferritin and C-reactive protein were measured at the time COVID-19 infection was confirmed. Correlation tests suggest that C5a is a predictive marker of disease severity and mortality, in addition to 40 biological and physiological parameters that were found statistically significant between survivors and non-survivors. Survival analysis showed that high C5a levels, hypoalbuminemia, lymphopenia, elevated procalcitonin, neutrophilic leukocytosis, acute anemia along with increased acute kidney and hepatocellular injury markers were associated with a higher risk of death in COVID-19 patients. Altogether, we created a prognostic classification model, the CAL model (C5a, Albumin, and Lymphocyte count) to predict severity with significant accuracy. Stratification of patients using the CAL model could help in the identification of patients likely to develop severe symptoms in advance so that treatments can be targeted accordingly.

Non-pregnancy-related ovarian vein thrombosis: A rare cause of chronic abdominal pain.

BACKGROUND: Ovarian vein thrombosis (OVT) commonly occurs during the peripartum and postpartum period. However, few cases of idiopathic OVT unrelated to pregnancy have been described. CASE REPORT: We report a case of a previously healthy, 32-year-old female who presented with chronic right-sided abdominal pain. Abdominal and pelvic gadolinium-enhanced MRI showed a right OVT. The patient was not in the peripartum or postpartum period. Thrombophilia test results were negative, and no risk factors for thrombosis were noted. The patient received warfarin for 6 months, with resolution of her symptoms. CONCLUSION: The presented case emphasizes the significance of considering OVT as a cause of unexplained abdominal pain in a young female. We describe a rare case of idiopathic OVT with a unique presentation.

Urinary Retention and Severe Hyponatremia: An Unusual Presentation of COVID-19.

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China, in December 2019. The disease is caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2). A few published cases have linked COVID-19 and hyponatremia. The mechanism of hyponatremia in these cases is related to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Here we present a unique case of urinary retention and SIADH as unusual presenting features of SARS-CoV-2 infection. LEARNING POINTS: Urine retention could be an unusual presenting symptom of severe hyponatremia of COVID-19.Hyponatremia and SIADH could be unusual presenting features of SARS-CoV-2 infection.Careful correction of hyponatremia related to COVID-19 is necessary to avoid osmotic demyelination syndrome.

The utility of kidney injury molecule-1 as an early biomarker of kidney injury in people living with HIV.

There are increasing reports of antiretroviral therapy (ART) drug-related kidney dysfunction. Traditional markers of kidney dysfunction such as urine protein/creatinine ratio and estimated glomerular filtration rate (eGFR) have thus far proven ineffective at detecting some sub-clinical forms of ART-related kidney injury. This is a cross-sectional examination of 114 people living with HIV (PLWH), either naïve (N =104) or treatment experienced (N =10). Urinary kidney injury molecule-1 (KIM-1 ng/mg) thresholds were estimated using electrochemiluminescent assays from stored urine samples and normalised for urinary creatinine excretion (KIM-1/Cr). Correlation coefficients and predictors of kidney tubular injury were compared and derived for both adjusted and unadjusted urinary KIM-1/CR (ng/mg). In PLWH (both ART-naïve and treatment experienced) had a higher baseline unadjusted and adjusted median (≥3.7 ng/mg) and upper tertile (≥6.25 ng/mg) urinary KIM-1/Cr levels compared to either non-normal volunteers (0.39 ng/mg) or those with acute kidney injury in the general population (0.57 ng/mg). When upper tertile KIM-1/Cr (≥6.25 ng/mg) was utilised as a marker of kidney injury, eGFR (ml/min/1.73 m2), white Caucasian ethnicity, and protease inhibitor exposure were significantly associated with increased risk of kidney injury in multivariate analyses (odds ratio 0.91, confidence interval [CI] 0.68-0.98, P = 0.02; odds ratio 8.9, CI 1.6-48.6, p = 0.01; and odds ratio 0.05, CI 0.03-0.9, p =0.04, respectively). We found a significant degree of sub-clinical kidney injury (high unadjusted and adjusted KIM-1/Cr) in PLWH with normal kidney function (eGFR ≥60 ml/min/1.73 m2). We also found a higher baseline KIM-1/Cr (ng/mg) in our study cohort than reported both in normal volunteers and patients with kidney injury in the general population.

Case Report: Paralytic Ileus: A Potential Extrapulmonary Manifestation of Severe COVID-19.

The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.

Case Report: COVID-19-Related Pneumothorax-Case Series Highlighting a Significant Complication.

COVID-19 is a recent outbreak in China and rapidly spread worldwide. Lung consolidation is the most common radiologic finding of COVID-19 pneumonia. Pneumothorax has been rarely reported as a complication of severe COVID-19 pneumonia. Early recognition and management are detrimental to the outcome. We here report three cases of SARS-CoV-2 infection complicated by pneumothorax. In addition, we present a brief literature review.

Acute abdomen -like-presentation associated with SARS-CoV-2 infection.

As the cases of COVID-19 are flooding around the world, atypical presentations are being recognized, making the diagnosis challenging. Gastrointestinal symptoms and mild abdominal pain are common. However, severe abdominal pain associated with COVID-19 warranting surgical evaluation has been rarely described; recognizing such presentations and differentiating them from a surgical abdomen is critical to effectively and safely manage COVID-19 patients. Here we present a case of a middle-aged gentleman who developed features resembling secondary peritonitis. Eventually, he was found to have COVID-19 and was managed conservatively. In this report, we discuss his management course, and we explore pertinent relevant literature.

A 73-Year-Old Man with a History of Hypertension and Ischemic Heart Disease Who Presented with Pain in the Right Flank as a Symptom of COVID-19 Pneumonia.

BACKGROUND Coronavirus disease 2019 (COVID-19) has been increasing all over the world. During the pandemic, a variety of presentations have been described. Nevertheless, some patients remain asymptomatic. Respiratory symptoms and gastrointestinal symptoms are often reported among these patients. CASE REPORT Here, we report a case with flank pain. Radiological images were significant for bilateral consolidation, which raised a high suspicion of COVID-19. Hence, on further investigation, he was diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CONCLUSIONS In the time of the COVID-19 pandemic, patients with multiple comorbidities may present atypically. Flank pain, which is not a usual presentation, may raise the suspicion of COVID-19 infection.

Frequency of Abnormalities Detected by Point-of-Care Lung Ultrasound in Symptomatic COVID-19 Patients: Systematic Review and Meta-Analysis.

The COVID-19 pandemic has resulted in significant morbidity, mortality, and strained healthcare systems worldwide. Thus, a search for modalities that can expedite and improve the diagnosis and management of this entity is underway. Recent data suggested the utility of lung ultrasound (LUS) in the diagnosis of COVID-19 by detecting an interstitial pattern (B-pattern). Hence, we aimed to pool the proportion of various reported lung abnormalities detected by LUS in symptomatic COVID-19 patients. We conducted a systematic review (PubMed, MEDLINE, and EMBASE until April 25, 2020) and a proportion meta-analysis. We included seven studies examining the role of LUS in 122 COVID-19 patients. The pooled proportion (PP) of B-pattern detected by lung ultrasound (US) was 0.97 (95% CI: 0.94-1.00 I 2 0%, Q 4.6). The PP of finding pleural line abnormalities was 0.70 (95% CI: 0.13-1.00 I 2 96%, Q 103.9), of pleural thickening was 0.54 (95% 0.11-0.95 I 2 93%, Q 61.1), of subpleural or pulmonary consolidation was 0.39 (95% CI: 0.21-0.58 I 2 72%, Q 17.8), and of pleural effusion was 0.14 (95% CI: 0.00-0.37 I 2 93%, Q 27.3). Our meta-analysis revealed that almost all SARS-CoV-2-infected patients have abnormal lung US. The most common abnormality is interstitial involvement depicted as B-pattern. The finding from our review highlights the potential role of this modality in the triage, diagnosis, and follow-up of COVID-19 patients. A sizable diagnostic accuracy study comparing LUS, computed tomography scan, and COVID-19-specific tests is warranted to further test this finding and to delineate the diagnostic and prognostic yield of each of these modalities.

An Unusual Case of Modified Lemierre's Syndrome Caused by Staphylococcus aureus Cellulitis.

BACKGROUND Lemierre's syndrome is a potential life-threatening disease commonly occurring in young, healthy individuals. It is often preceded by an oropharyngeal infection causing bacteremia. This may rapidly progress into thrombophlebitis of the internal jugular venous system, its branches, and septic embolization and often fulminant organ failure. CASE REPORT A previously healthy 31-year-old male with recent history of facial herpes zoster infection, presented with 1-week history of increasingly painful nasal, and periorbital swelling. Imaging confirmed superior ophthalmic vein thrombosis. Staphylococcus aureus was isolated in blood cultures and had an uncomplicated hospital course with full recovery. CONCLUSIONS Early recognition of Lemierre's syndrome contributes significantly in reducing morbidity and mortality associated with it. Staphylococcus aureus skin infection is a very rare cause of Lemierre's syndrome, and its association with superior ophthalmic vein thrombosis has not yet been reported in literature.

Post-Epstein-Barr Virus Acute Cerebellitis in an Adult.

BACKGROUND Acute cerebellitis in adults is a rare disease. The etiology is unknown but postulated to be due to primary infection or para-infection. Different presentations have been reported, which complicates the diagnosis process. CASE REPORT We report the case of a young man who presented with headache, vomiting, and vertigo. He was found to have ataxia and cerebellar signs, bradycardia magnetic resonance imaging (MRI) of the brain showed acute cerebellitis, and cerebrospinal fluid (CSF) studies showed lymphocytosis. Further investigations showed the presence of Epstein-Barr virus (EBV) immunoglobulin M (IgM) and IgG. His symptoms resolved completely with corticosteroid and antiviral treatments. CONCLUSIONS Acute cerebellitis can present in various ways. Bradycardia, along with neurological deficits, should raise the suspicion of acute cerebellitis.

Prevalence of Venous Thromboembolism in Critically Ill COVID-19 Patients: Systematic Review and Meta-Analysis.

Background: Recent studies revealed a high prevalence of venous thromboembolism (VTE) events in coronavirus disease 2019 (COVID-19) patients, especially in those who are critically ill. Available studies report varying prevalence rates. Hence, the exact prevalence remains uncertain. Moreover, there is an ongoing debate regarding the appropriate dosage of thromboprophylaxis. Methods: We performed a systematic review and proportion meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed and EMBASE for studies exploring the prevalence of VTE in critically ill COVID-19 patients till 25/07/2020. We pooled the proportion of VTE. Additionally, in a subgroup analysis, we pooled VTE events detected by systematic screening. Finally, in an exploratory analysis, we compared the odds of VTE in patients on prophylactic compared with therapeutic anticoagulation. Results: The review comprised 24 studies and over 2,500 patients. The pooled proportion of VTE prevalence was 0.31 [95% confidence interval (CI) 0.24, 0.39; I 2 94%], of VTE utilizing systematic screening was 0.48 (95% CI 0.33, 0.63; I 2 91%), of deep venous thrombosis was 0.23 (95% CI 0.14, 0.32; I 2 96%), and of pulmonary embolism was 0.14 (95% CI 0.09, 0.20; I 2 90%). Exploratory analysis of few studies, utilizing systematic screening, VTE risk increased significantly with prophylactic, compared with therapeutic anticoagulation [odds ratio (OR) 5.45; 95% CI 1.90, 15.57; I 2 0%]. Discussion: Our review revealed a high prevalence of VTE in critically ill COVID-19 patients. Almost 50% of patients had VTE detected by systematic screening. Higher thromboprophylaxis dosages may reduce VTE burden in this patient's cohort compared with standard prophylactic anticoagulation; however, this is to be ascertained by ongoing randomized controlled trials.

Participation of MyD88 and interleukin-33 as innate drivers of Th2 immunity to Trichinella spiralis.

Trichinella spiralis is a highly destructive parasitic nematode that invades and destroys intestinal epithelial cells, injures many different tissues during its migratory phase, and occupies and transforms myotubes during the final phase of its life cycle. We set out to investigate the role in immunity of innate receptors for potential pathogen- or danger-associated molecular patterns (PAMPs or DAMPs). Focusing on the MyD88-dependent receptors, which include Toll-like receptors (TLRs) and interleukin-1 (IL-1) family members, we found that MyD88-deficient mice expelled worms normally, while TLR2/4-deficient mice showed accelerated worm expulsion, suggesting that MyD88 was active in signaling pathways for more than one receptor during intestinal immunity. A direct role for PAMPs in TLR activation was not supported in a transactivation assay involving a panel of murine and human TLRs. Mice deficient in the IL-1 family receptor for the DAMP, IL-33 (called ST2), displayed reduced intestinal Th2 responses and impaired mast cell activation. IL-33 was constitutively expressed in intestinal epithelial cells, where it became concentrated in nuclei within 2 days of infection. Nuclear localization was an innate response to infection that occurred in intestinal regions where worms were actively migrating. Th2 responses were also compromised in the lymph nodes draining the skeletal muscles of ST2-deficient mice, and this correlated with increased larval burdens in muscle. Our results support a mechanism in which the immune system recognizes and responds to tissue injury in a way that promotes Th2 responses.