Acute kidney injury in COVID-19: Considerations in pregnancy.

The clinical manifestations of COVID-19 are diverse with the involvement of different organ systems. Renal involvement is particularly noteworthy with acute kidney injury (AKI) being an important disease manifestation, particularly in pregnancy. Pregnancy itself serves as a high-risk condition for COVID-19 disease and a risk factor for deterioration, developing a more severe illness than nonpregnant women, and subsequent higher intensive care unit admission, oxygen therapy, and ventilatory support. There are reports in the literature highlighting the involvement of vital organs in pregnancy; however, data pertaining to AKI in pregnancy during COVID-19 are lacking in terms of risk factors, disease management, and outcomes. The entire spectrum of hormonal changes and adaptive mechanisms in pregnancy can be adversely affected by this viral infection. A literature search regarding AKI in COVID-19 in pregnancy was performed on PubMed, Scopus, Google Scholar, and ScienceDirect, and the relevant articles were selected. Our review highlights key issues pertaining to AKI in COVID-19 in pregnancy in an attempt to overcome, albeit partly, the scarcity of corroborative literature regarding the same.

Spontaneous Pneumomediastinum in COVID-19 Pneumonia.

Spontaneous pneumomediastinum (SPM) is the collection of air within the mediastinal cavity, which is commonly described in the literature for mechanical ventilation and perforation of hollow viscera. Coronavirus disease 2019 (COVID-19) is a rare but salient etiology of this complication in the current pandemic. Here, we are narrating a case of a 46-year-old male, in whom COVID-19 pneumonia was complicated by SPM. The complication was identified on chest computed tomography (CT) and was managed conservatively, leading to a favorable outcome. SPM has undemanding management, but timely identification and appropriate treatment institution are crucial in this milieu. A literature search revealed similar cases of SPM in COVID-19 with different outcomes and the important ones are included in this report.

Splenic and Portal Vein Thrombosis With Concurrent Splenic Infarction: A Rare Manifestation of Essential Thrombocythemia.

Mesenteric venous thrombosis (MVT) presents with a wide range of clinical presentations depending on the vessel involved, degree of thrombosis, and the extent of bowel wall ischemia. MVT usually has an insidious presentation and is often a forerunner of an underlying disorder. Essential thrombocythemia (ET) presenting itself as MVT along with splenic infarction is a rare presentation. Here, we report the case of a 54-year-old female with massive splenomegaly, thrombocytosis, and acute splenic and portal venous thrombosis along with multiple splenic infarcts. Bone marrow suggested ET with JAK2V617F mutation positivity. She was managed conservatively and made an uneventful recovery.

Idiopathic Symmetrical Peripheral Gangrene: A Rare Clinical Entity.

Symmetrical peripheral gangrene (SPG) is a rare disorder leading to ischemic necrosis of extremities. We present a rare case of idiopathic SPG in a 58-year-old male who did not seek any medical care, and history was elucidated only after he presented one year later for treatment of pneumonia. Extensive investigations revealed no etiology. SPG can result from a variety of conditions that cause disseminated intravascular coagulation and lead to distal hypoperfusion. The treatment is aimed at the control of the underlying disease and wound management.

Advances in the Treatment of Polycythemia Vera: Trends in Disease Management.

Treatment modalities for polycythemia vera (PV) have evolved over time. Phlebotomy and low-dose aspirin suffice in low-risk patients, but cytoreductive therapies are indicated in all high-risk patients (age ≥ 65 years or those with a history of PV-related thrombotic event) and may be considered for low-risk patients with progressively increasing splenomegaly, progressively increasing leucocyte and platelet counts, and for those who do not tolerate phlebotomy. Hydroxyurea/hydroxycarbamide or interferons can be used as first-line drugs. Hydroxyurea may not be tolerated by some patients, and it also carries risk of myelosuppression. Interferon alfa is especially useful for PV symptoms, and the newer preparation, ropeginterferon alfa-2b, has lesser incidence of flu-like reactions. Ruxolitinib reduces the JAK2V617F mutation burden and is used as a second-line drug. Anagrelide reduces platelet production and can be used in conjunction with hydroxyurea in patients with excessive thrombocytosis. The alkylating agent, busulfan, can also be used as a last resort in patients with a limited life expectancy. Prospective future treatments include givinostat, a histone deacetylase inhibitor, and idasanutlin, a murine double minute 2 antagonist.

Helminthic Infection in the Background of Active Pulmonary Tuberculosis: An Underreported Co-infection.

Helminthic infections are widely prevalent in resource-poor countries. Tuberculosis, a disease contributing significantly to morbidity and mortality in endemic areas, often co-exists with helminthic infections. Poor living standards predispose to both of them. Moreover, untreated helminthic infection enhances the deleterious impact of tuberculosis, largely through immunological alteration. We are reporting the case of a 22-year-old male who presented with a month-long history of abdominal pain, nausea, vomiting, fever and cough complicated by hemoptysis, along with an episode of the passage of a worm in the vomitus. A thorough workup revealed active pulmonary tuberculosis co-existing with intestinal ascariasis. Anti-helminthic therapy was initiated along with anti-tubercular therapy, leading to significant improvement.

Systemic Lupus Erythematosus Induced Central Variant of Posterior Reversible Encephalopathy Syndrome: A Rare Association.

Involvement of the posterior cerebral structures is well established in patients with posterior reversible encephalopathy syndrome (PRES). In striking contrast to this, a subset of patients may have an atypical presentation characterized by the involvement of central structures. This is usually seen in the backdrop of systemic lupus erythematosus (SLE), a rare but known cause of PRES. Timely diagnosis with judicious use of radiological modalities and therapeutic intervention is key for successful recovery; however, the prognosis of PRES in patients with SLE is not very promising. We are describing an extremely rare case of a patient diagnosed with a central variant of PRES with previously undiagnosed SLE.

Isolated Splenic Tuberculosis: A Diagnostic Conundrum.

Tuberculosis is an established cause of pyrexia of unknown origin and can implicate practically any human organ system. Splenic involvement is common in disseminated or miliary tuberculosis following hematogenous spread, but isolated splenic involvement is a very rare phenomenon. We report the case of a 30-year-old immunocompetent female who presented with high-grade fever and dull aching pain in the left hypochondrium for three months. Laboratory data provided no diagnostic information. Abdominal ultrasonography revealed an enlarged spleen with multiple small hypoechoic lesions that were corroborated on computed tomography. No pulmonary involvement or primary focus of infection was discernible elsewhere. Splenic fine needle aspiration cytology helped clinch a histopathological diagnosis of isolated splenic tuberculosis. Administration of anti-tubercular therapy resulted in resolution of the disease and an excellent outcome in our patient.

Atypical mucormycosis masquerading as non-resolving cavitatory pneumonia: A frequently misdiagnosed entity.

We are reporting an unusual case of cavitatory pulmonary mucormycosis in a patient with uncontrolled type 2 diabetes mellitus who was treated successfully. This is a unique case of pulmonary mucormycosis masquerading as cavitatory pulmonary disease. A 45-year-old female presented with fever, chest pain, cough and breathlessness. She was also found to have very high blood glucose due to previously undiagnosed diabetes. Diabetic ketoacidosis is the most common predisposing factor for mucormycosis. Our patient had uncontrolled diabetes and presented with bilateral cavitatory pulmonary lesions even in the absence of diabetic ketoacidosis. Appropriate investigations were ordered, and alternate causes of lung cavitation were diligently excluded. She was treated with amphotericin-B for three weeks followed by oral posaconazole for eight weeks with excellent outcome. A low threshold for detection as well as a differential of mucormycosis must be kept in immunocompromised patients presenting with cavitatory lung disease.