Post-inflammatory Hyperpigmentation in an African American Female: An Atypical Presentation and Treatment Dilemma.

We present the case of a 32-year-old African American female with a known history of primary Sjogren's syndrome, multiple vitamin deficiencies, and prior facial cellulitis who presented with diffuse facial post-inflammatory hyperpigmentation following a motor vehicle accident. Following glucocorticoid treatment, only select hyperpigmented areas associated with inflammation, infection, or trauma improved, which thereby posed a clinical challenge to improve the patient's appearance and condition. Such results may warrant the consideration of adjunctive topical therapies to lighten the remaining areas of hyperpigmentation.

A Rare Presentation of Congenital Chilaiditi Syndrome: Symptomatic Hepatobowel Entrapment.

The displacement and trapping of the colon between the liver and the right hemidiaphragm are known as the Chilaiditi sign or syndrome. The Chilaiditi sign presents in an asymptomatic patient, while Chilaiditi syndrome presents with symptoms such as abdominal pain, distension, and constipation, in addition to complications such as perforation, volvulus, and bowel obstruction. It is often misdiagnosed as pneumoperitoneum or free air under the diaphragm and liver, often seen on the abdomen and chest radiography. It more commonly presents in males than in females. Here, we present the case of a 37-year-old female who reported abdominal pain and persistent constipation. An abdominal CT scan showed entrapment of a bowel segment, which is referred to as the Chilaiditi sign. The patient's presentation with hepatobowel entrapment and persistent gastrointestinal symptoms was diagnosed as Chilaiditi syndrome. This presentation entails a conservative management approach. The aim of this report is to educate about the rare occurrence of Chilaiditi sign and Chilaiditi syndrome as a differential diagnosis to often misdiagnosed critical conditions such as pneumoperitoneum and intestinal perforation. Correctly identifying these patients will reduce overtreatment and help improve outcomes.

Case Series of Quadricuspid Aortic Valve.

Three patients presented with different symptoms to the emergency department. Further imaging of their hearts displayed an abnormal variant of their aortic valve called a quadricuspid aortic valve (QAV). There are seven types of QAVs, from type A to G, with varying presenting symptoms. The most common complication is aortic regurgitation. The management of QAV is based on these presenting symptoms and complications. Surgical valve repair or replacement is indicated when a QAV becomes symptomatic or a QAV results in ventricular remodeling, which can lead to ventricular dysfunction. Successful surgical repair of QAVs has been shown with both tricuspidization and bicuspidization methods.

Serum Procalcitonin as a Predictive Biomarker in COVID-19: A Retrospective Cohort Analysis.

INTRODUCTION:  Since the onset of COVID-19, physicians and scientists have been working to further understand biomarkers associated with the infection, so that patients who have contracted the virus can be treated. Although COVID-19 is a complex virus that affects patients differently, current research suggests that COVID-19 infections have been associated with increased procalcitonin, a biomarker traditionally indicative of bacterial infections. This paper aims to investigate the relationship between COVID-19 infection severity and procalcitonin levels in the hopes to aid the management of patients with COVID-19 infections. METHODS:  Patient data were obtained from the Renaissance School of Medicine at Stony Brook University. The data of the patients who had tested positive for COVID-19 and had an associated procalcitonin value (n=1046) was divided into age splits of 18-59, 59-74, and 74-90. Multiple factors were analyzed to determine the severity of each patient's infection. Patients were divided into low, medium, and high severity dependent on the patient's COVID-19 severity. A one-way analysis of variance (ANOVA) was done for each age split to compare procalcitonin values of the severity groups within the respective age split. Next, post hoc analysis was done for the severity groups in each age split to further compare the groups against each other.  Results: One-way ANOVA testing of the three age splits all had a resulting p<0.0001, displaying that the null hypothesis was rejected. In the post hoc analysis, however, the test failed to reject the null hypothesis when comparing the medium and high severity groups against each other in the 59-74 and 74-90 age splits. The null hypothesis was rejected in all pairwise comparisons in the 18-59 age split. We determined that a procalcitonin value of greater than 0.24 ng/mL would be characterized as a more severe COVID-19 infection when considering patient factors and comorbidities.  Conclusion: The analysis of the data concluded that elevated procalcitonin levels correlated with the severity of COVID-19 infections. This finding can be used to assist medical providers in the management of COVID-19 patients.

Diagnosing Pancreatic Adenocarcinoma With Contrast-Enhanced Ultrasonography: A Literature Review of Research in Europe and Asia.

The National Cancer Institute names pancreatic cancer the 11th most common type of cancer in the United States. However, even with a somewhat low prevalence, in 2017, the American Cancer Society reported pancreatic cancer as the fourth leading cause of cancer-related death. With a lack of symptomology and a broad range of risk factors, pancreatic cancer is frequently diagnosed in a later phase than many other types of cancers, thus resulting in higher metastasis along with a poorer prognosis. This highlights the need for early detection and diagnosis. Currently, abdominal ultrasound or contrast-enhanced CT imaging of the abdomen are standard of care. A new technology: contrast-enhanced ultrasound (CEUS), which employs contrast agents to act as acoustic enhancers for ultrasound, has FDA approval for use in hepatic and renal lesions, but not pancreatic. By examining seven individual studies from Europe and Asia, this review aims to examine the diagnostic value of CEUS to initially diagnose pancreatic adenocarcinomas, potentially followed by a biopsy to confirm, when compared against modalities currently used such as conventional ultrasound and CT imaging. CEUS would potentially be more accurate when compared to conventional ultrasound due to the addition of contrast, and when compared against CT and MRI, CEUS would be advantageous in its low cost, similar sensitivities, and specificities, limited renal toxicity, lack of ionizing radiation, short half-life, and its safe use in both adult and pediatric patients. Due to this, additional research is warranted for further FDA approval and future clinical implementation.

Anomalous Circumrenal Inferior Vena Cava Associated With Horseshoe Kidney.

A 69-year-old male presented with periumbilical pain radiating across his abdomen, with associated nausea and emesis. CT imaging of his abdomen and pelvis revealed calculi in the right and left ureterovesical junctions with hydroureteronephrosis bilaterally. Furthermore, the imaging revealed that the patient had a horseshoe kidney with an associated anomalous inferior vena cava (IVC) that split superiorly to the horseshoe kidney at the L1 level and rejoined inferior to the horseshoe kidney at the L5 level. The IVC took on a "circumrenal" course, as it traversed the right kidney with an anterior and posterior portion. Furthermore, the patient's right ureter was compressed between the anterior portion of the IVC and the right kidney. We hypothesize that the development of the horseshoe kidney around the 7 to 8th week of gestation created a path of resistance for the forming of IVC around the same time. While surgical correction is not warranted, recognition of this circumrenal IVC variant could have major implications for planning of procedures, such as IVC filter placement.

Cardiovascular Risk Associated With TNF Alpha Inhibitor Use in Patients With Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disease characterized by inflammation and pannus formation, with subsequent joint and cartilage degradation. Treatment commonly targets inflammatory cytokines, including tumor necrosis factor (TNF) alpha, which is a potent inflammatory cytokine required for cell signaling, regulation, and apoptosis, as well as for other cellular functions including immune response. TNF alpha inhibitors have demonstrated benefits in improving RA patient outcomes in terms of immune function and symptomatology. While TNF alpha inhibitors are generally beneficial, some studies have demonstrated that TNF alpha inhibitors may increase the risk of adverse cardiovascular events. While this continues to be debated, our study investigates the role of Tumor Necrosis Factor Receptor 1 (TNFR1) and Tumor Necrosis Factor Receptor 2 (TNFR2) in cardiac tissue. TNFR1 is an apoptotic receptor and its inhibition by TNF alpha inhibitors is subsequently cardioprotective. However, TNF alpha inhibitors may be inhibiting TNFR2 receptors even more so than TNFR1 receptors. TNFR2 is primarily a cardioprotective receptor and its greater inhibition results in the cardiovascular morbidity associated with TNF alpha inhibitors.