Gout: A Rapid Review of Presentation, Diagnosis and Management.

Gout is inflammatory arthritis caused by monosodium urate crystal deposition in articular and non-articular structures. Acute gout flares are often monoarticular/polyarticular involving lower extremity joints characteristically involving 1st metatarsophalangeal joint. However, gout flares can also be polyarticular, involving upper extremity joints, especially in patients with multiple comorbidities and contraindications to urate-lowering therapies (ULT). Risk factors exacerbating gout flares include obesity, high alcohol and purine-rich food consumption, and the use of diuretics. Diagnosis requires synovial fluid analysis with direct visualization of monosodium urate crystals. Acute flares are managed with steroids, non-steroidal anti-inflammatory drugs, or colchicine. Long-term management includes lifestyle modifications including a heavy emphasis on weight loss, avoidance of alcohol, purine-rich foods, and diuretics. ULT is indicated in patients with 2 or more gout flares/year, tophi, or radiographic evidence of gouty arthropathy. Although allopurinol is the first-line ULT agent, it does carry a risk of inducing severe cutaneous adverse reactions, especially in patients with chronic kidney disease and patients harboring the HLA-B*5801 allele. Other ULT agents include febuxostat and probenecid. ULT is usually titrated to achieve goal serum uric acid (SUA) levels below 6 mg/dL. However, in patients with tophi, a lower SUA target of less than 5 mg/dL should be implemented for prompt urate crystal dissolution.

Statins Therapy and Intracranial Hemorrhage.

Statins have grown to become an important class of medications in the primary and secondary prevention of cardiovascular diseases. While lowering low-density lipoprotein-C (LDL-C) levels, statins also have a role in stabilization and regression of atherosclerotic plaques. In the last two decades, there is a mounting body of evidence that suggests that statins and lowering serum lipid levels may be associated with an increased risk of developing intracerebral hemorrhage (ICH). This review article provides a concise summary of the most important studies performed to date and the pathophysiology behind the association between statins and ICH.

Photo-Induced Sweet Syndrome: A Case Report.

Sweet syndrome is a rare dermatologic condition frequently accompanied by fever and neutrophilia. Underlying triggers and etiology of the sweet syndrome remain elusive, although infection, malignancy, medications, and more rarely, sun exposure have been associated with its development. We present a case of a 50-year-old female who developed a painful, mildly pruritic rash on sun-exposed areas of the neck, arms, and legs. She also reported chills, malaise, and nausea upon presentation. Before developing the rash, she had preceding upper respiratory infection symptoms, used ibuprofen for joint pain, and had extensive sunlight exposure on the beach. Laboratory findings were significant for leukocytosis with absolute neutrophilia, elevated C-reactive protein, and elevated erythrocyte sedimentation rate. Skin punch biopsy demonstrated papillary dermal edema with dense neutrophilic infiltration. Further evaluation for hematologic or solid organ malignancy was negative. Following the administration of steroids, the patient demonstrated significant clinical improvement. While rare, ultraviolet A and B sunlight has been shown in rare situations to be associated with the development of the Sweet syndrome. The underlying mechanism for the development of photo-induced Sweet syndrome remains unknown. However, excessive sunlight exposure should be considered a potential cause when evaluating the underlying triggers for the development of the Sweet syndrome.

Asymptomatic Pulmonic Valve Mass: A Diagnostic and Therapeutic Dilemma.

Cardiac masses are not common but remain important in cardiology practice as they can cause havoc to a patient's life through obstructive and arrhythmogenic symptoms. These lesions mostly include vegetation, thrombi, and tumors. Myxomas are the most common primary cardiac tumor, primarily arising from the left heart chambers. It is exceedingly rare for a myxoma to emerge from the right-sided cardiac valves. The standard treatment is surgical resection, regardless of size, which is not always possible. We report a unique case of a male with multiple co-morbidities who presented with an incidental finding of a pulmonary valve mass suspicious of being a myxoma. The myxomatous mass was asymptomatic with no right ventricular outflow tract obstruction. Echocardiogram can help identify and characterize these lesions, but this may not be easy, especially in the case of atypical location or morphology of the mass. Similarly, in some cases, the patient may not be able to undergo surgical excision. In such cases, there is no consensus or guidelines to help clinicians best manage the patients medically, creating a diagnostic and therapeutic dilemma.

Bedside Carotid Sinus Massage for Syncope Evaluation With Bifascicular Block and First-Degree Atrioventricular Block.

Symptomatic bifascicular block (BFB) with a reversible high-grade atrioventricular block (AVB) is an overlooked cause of syncope with differing diagnostic and therapeutic approaches. We present a case of a 79-year-old gentleman with multiple episodes of cardiac syncope. Initial electrocardiogram revealed a left bundle branch block and first-degree AVB worsened by bedside carotid sinus massage (CSM) obviating the need for electrophysiologic (EP) studies or continuous electrocardiographic monitoring for further evaluation. This case highlights the importance of CSM as a useful clinical tool in addition to EP studies and internal loop recorder (ILR) placement for assessment and appropriateness of permanent pacemaker (PPM) implantation. It also sheds light on the differing management protocols between EP studies and ILR evaluation versus empiric PPM implantation for patients with cardiac syncope secondary to BFB and AVB.

Breakthrough Severe COVID-19 Infection After Triple Dose Pfizer Vaccination.

The impact of COVID-19 was felt across the globe when it first emerged in December 2019. However, within a year, there was a new hope with the development and approval of mRNA vaccines. The Comirnaty and Pfizer-BioNTech BNT162b2 mRNA vaccine showed an efficacy of 95 percent in preventing COVID-19 disease. However, subsequent studies conducted on immunocompromised hosts showed the efficacy to be significantly lower than the initial reported 95 percent, making these patients prone to COVID-19 disease despite the initially recommended two doses. On Sept. 22, 2021, a third dose was approved for immunocompromised hosts. In this article, we report the case of a 67-year-old female with overlap connective tissue disease on mycophenolate mofetil who had a prolonged hospital course because of severe COVID-19 disease complicated by pulmonary embolism despite receiving three doses of the BNT162b2 mRNA vaccine.

MODERNA mRNA-1273 vaccine-associated myopericarditis in a patient with a subclinical autoimmune predisposition.

We present a rare case of myopericarditis developing one day after the injection of the second dose of the MODERNA mRNA-1273 vaccine (Cambridge, MA, USA). The patient complained of typical positional chest pain with initial laboratory results significant for elevated troponin, erythrocyte sedimentation rate, and C-reactive protein. Autoimmune predisposition was suggested by elevated anti-nuclear antibodies and anti-Sjögren's-syndrome-related antigen A autoantibodies titers. Subsequent cardiac magnetic resonance imaging (cMRI) revealed mild global hypokinesis with an ejection fraction of 48%, diffuse pericardial hyperenhancement suggestive of acute pericarditis, and T2-weighted short tau inversion recovery apical septal hyperenhancement suggestive of myocardial edema. Based on clinical, laboratory, and cMRI findings, a diagnosis of acute myopericarditis was made and the patient was treated with colchicine and ibuprofen with prompt resolution of symptoms. Vaccine-associated myopericarditis is rare, however, there have been reports of myocarditis developing after smallpox vaccination. The American College of Rheumatology has expressed concern about flaring or development of autoimmune inflammatory rheumatic disease (AIIRD) after COVID vaccination. Further studies are required to quantify AIIRD flaring/development including myopericarditis after mRNA-1273 vaccination. .

Peroral cholangioscopy with cholangioscopy-directed biopsies in the diagnosis of biliary malignancies: a systemic review and meta-analysis.

BACKGROUND AND AIM: Accurate diagnosis is essential in the appropriate management of biliary strictures. Our aim is to evaluate the efficacy of cholangioscopy-directed biopsies in differentiating biliary intraductal malignancies from benign lesions. MATERIALS AND METHODS: Articles were searched in Medline, PubMed, and Ovid journals. Pooling was performed by both fixed-effects and random-effects models. Only studies from which a 2×2 table could be constructed for true-positive, false-negative, false-positive, and true-negative values were included. RESULTS: Initial search identified 2110 reference articles for peroral cholangioscopy; of these, 160 relevant articles were selected and reviewed. Data were extracted from 15 studies (N=539) that fulfilled the inclusion criteria. Pooled sensitivity of cholangioscopy-directed biopsies in diagnosing malignancy was 71.9% [95% confidence interval (CI): 66.1-77.1] and pooled specificity was 99.1% (95% CI: 96.9-99.9). The positive likelihood ratio of cholangioscopy-directed biopsies was 18.1 (95% CI: 9.1-35.8), whereas the negative likelihood ratio was 0.3 (95% CI: 0.2-0.4). The pooled diagnostic odds ratio was 71.6 (95% CI: 32.8-156.4). All the pooled estimates calculated by fixed-effects and random-effect models were similar. Summary receiver operating characteristic curves showed an area under the curve of 0.98. The χ heterogeneity for all the pooled accuracy estimates was 5.62 (P=0.96). CONCLUSION: Peroral cholangioscopy with cholangioscopy-directed biopsies has a high specificity in differentiating intraductal malignancies from benign lesions. Cholangioscopy-directed biopsies should be strongly considered for biliary stricture evaluation.

Pancreas herniation into the mediastinum: a case report.

BACKGROUND: Pancreatic tissue found in the mediastinum (both true ectopic and herniated pancreas) is rare. It becomes even more challenging when there are complications associated with this entity. CASE PRESENTATION: We report an unusual case of pancreatic herniation into the mediastinum in a 90-year-old Caucasian female. This patient initially presented with nausea and vomiting associated with abdominal pain. Serum lipase and amylase both were elevated. Computed tomography scan of the chest, abdomen and pelvis revealed a large hiatal hernia with pancreas herniation into the mediastinum, with superimposed acute pancreatitis likely due to gallstone. Because of its unusual location, the patient also developed acute mediastinitis. The patient was management conservatively and did well. On the day of discharge; she was tolerating a diet, had no pain or nausea and was back to her baseline health. CONCLUSION: Acute pancreatitis can be managed conservatively even if it is in the mediastinum. Also, ectopic or herniated pancreatic tissue is extremely rare and leads to unique clinical presentations, along with diagnostic and therapeutic challenges. Clinicians should not only be vigilant to the presence of ectopic or herniated pancreatic tissue, but also be mindful of the resulting complications.

Gastro-intestinal stromal tumor (GIST) complicating a colonic interposition: a novel case report.

BACKGROUND: Gastrointestinal stromal tumor (GIST) is a rare tumor comprising 0.1-0.3% of all gastrointestinal (GI) malignancies. Stomach followed by small intestine is the most common sites of involvement, implicated in 95% of the cases. We present a case of GIST complicating a colonic interposition. To the best of the author's knowledge, this is the first reported case of GIST complicating a colonic interposition. CASE PRESENTATION: A 47 year old African American male presented to the emergency department with intermittent, severe chest pain. Past medical history was significant for alkali (NaOH) ingestion during 1980 for which esophageal resection and a colonic pull-through was performed. A CXR revealed a widened mediastinum and CT scan chest revealed showed a large (11.4 × 8.3 × 12.1 cm) vascular mediastinal mass. At endoscopy, a large, ulcerated, cratered and friable mass was found at 29 cm extending to 36 cm at which point the lower anastomosis of the colonic pull through was present. Multiple endoscopic biopsies were obtained which showed that the tumor was immunoreactive with CD117, CD34 and DOG1 while markers of carcinoma, melanoma and lymphoma were negative. In light of the pathology report, the immunohistochemistry and the CT scans, the tumor was classified as a stage 4 GIST of colonic interposition. CONCLUSIONS: GIST can complicate unusual locations such as colonic interposition and should be kept in the differential diagnosis of such unusual presentations.