Daptomycin-Induced Eosinophilic Pneumonia Mimicking Multifocal Pneumonia.

A 71-year-old female presented to the emergency department with worsening dyspnea, dry cough, malaise, weight loss, fever, chills, and diaphoresis for one week. The patient had been hospitalized four weeks prior with right knee methicillin-resistant Staphylococcus aureus (MRSA) bursitis and was initially treated with IV vancomycin but was switched to IV daptomycin at the time of discharge for convenience of dosing. On presentation to the ED, vitals were normal. Physical examination revealed bilateral scattered rhonchi and crepitations. Chest X-ray revealed new patchy bilateral interstitial and airspace opacities concerning for multifocal pneumonia. Labs were pertinent for mild peripheral eosinophilia. CT chest revealed moderate diffuse ground glass opacities involving both lungs, with subpleural predominance and some areas of septal thickening seen as well. Daptomycin-induced pneumonitis was suspected, and empiric antibiotics were discontinued. The patient subsequently underwent fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial lung biopsy. BAL fluid showed leukocytosis and eosinophilia of 25 mm3. Right upper lobe biopsy demonstrated foci of alveolar spaces with collections of eosinophils and histiocytes consistent with acute eosinophilic pneumonia. The patient was started on oral prednisone and albuterol breathing treatments with significant improvement after 48 hours from admission. She was discharged on albuterol inhalers and prednisone taper. Acute eosinophilic pneumonia (AEP) is a lung condition that can be rapidly progressive, leading to significant morbidity and mortality. Daptomycin-induced AEP can mimic community-acquired pneumonia, resulting in delayed diagnosis and management. Recognizing the temporal association between drug initiation and the development of symptoms is crucial in the diagnosis of drug-induced AEP. If it is recognized and treated in a timely manner, the prognosis is generally excellent, with rapid and complete clinical recovery as demonstrated by our case.

Acute Pancreatitis in a Patient With Recent History of SARS-CoV-2 Infection.

Acute pancreatitis (AP) is caused by inflammation of the exocrine pancreas. It is often due to loss of compartmentalization and subsequent activation of pancreatic enzymes prior to leaving the pancreatic duct. AP caused by viral infections is commonly referenced in the literature. The association of AP with SARS-CoV-2 has been reported in the past several months in both retrospective cohort studies and case reports. However, there is currently limited evidence regarding the incidence of AP in the setting of SARS-CoV-2. We present a unique case of AP as an early complication in a patient three days after hospitalization for SARS-CoV-2. It is imperative to consider AP in the differential diagnoses of patients with a recent history of SARS-CoV-2 infection presenting with acute abdominal pain.

COVID-19 Infection as a Possible Cause of Ogilvie's Syndrome.

Ogilvie's syndrome is defined as acute dilatation of the colon in the absence of mechanical obstruction. Even though the precise mechanism is unknown, studies have suggested its association with autonomic nervous system dysfunction. Some of the common causes include infections, orthopedic surgery, renal failure, electrolyte disturbance, and narcotic use. Viral causes are considered to be rare; however, it is a well-known fact that viral infections can cause autonomic dysfunction. A few cases have been reported discussing the incidence of Ogilvie's syndrome in the setting of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). We present a unique case of Ogilvie's syndrome in a patient who initially presented with respiratory manifestations and subsequently developed acute colonic pseudo-obstruction.

Dronedarone-Mediated Acute Hepatic and Renal Toxicity.

Dronedarone, a drug similar in chemical properties to amiodarone, was designed to have similar pharmacodynamic properties as amiodarone with fewer side effects. Although there have been cases of chronic liver enzyme elevation with dronedarone, only a few cases have been reported in literature where it has led to rapid onset of liver failure. We present the case of an 86-year-old male who developed acute liver failure concomitantly with acute kidney failure after he was started on dronedarone therapy.

Multiple, Large Colonic Xanthomas Presenting as Intestinal Obstruction.

Gastrointestinal (GI) xanthomas are rare entities found incidentally on endoscopy. There have been only a few cases where they presented with symptoms of bowel obstruction. We present a case of an 89-year-old woman with a history of short-gut syndrome due to partial colectomy who had multiple admissions with recurrent nausea/vomiting, abdominal distension, and bloating. She was found to have multiple, large, mass-like xanthomas in the rectosigmoid colon. The unusual location, mass-like lesions, and large size led to luminal narrowing causing the patient to have obstructive symptoms, which is a very unusual presentation of colonic xanthomas as most are discovered incidentally.

A Case of Intussusception in a Patient with Marijuana Use: Coincidence or Possible Correlation?

'Intussusception' means invaginating or telescoping and is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception is rare in adults with an incidence of two to three cases per population of 1,000,000 annually. The most common cause of intussusception in adults is a neoplasm. In this case report, we are describing the case of a 22-year-old female with a past medical history of chronic constipation and a 60-pound unintentional weight loss who presented with the sudden onset of progressively worsening, severe abdominal pain associated with nausea, episodes of non-bloody, non-bilious emesis, and dark-colored loose stools. The patient's social history was significant for extensive marijuana use for more than one year. Upon presentation, vitals were significant for mild bradycardia and examination was remarkable for diffuse abdominal pain. Initial laboratory testing was positive only for lactic acidosis. A computed tomography (CT) scan of the abdomen and pelvis revealed small bowel intussusception in the left hemiabdomen, along with periportal edema, and a small amount of pericholecystic fluid. The patient underwent both upper endoscopy and colonoscopy but no lead points for the intussusception could be identified. The patient responded to conservative management, including bowel rest, which resulted in the resolution of the intussusception on a follow-up small bowel series. Intraluminal irritants as the possible etiology of intussusception should be considered in the absence of a pathological lead point. Marijuana has been shown to act on various bowel segments and disrupts gastrointestinal motility through inhibition of cholinergic mechanisms. We believe the chronic use of marijuana could be the possible etiology of intussusception observed in our patient. Therefore, this case brings attention to the adverse effects of marijuana in light of increasing legalization and the increasing therapeutic use of marijuana and its derivatives.

A Delayed Splenic Tragedy Beyond the Scope of a Colonoscope: A Rare Find.

Colonoscopy is considered a low-risk procedure worldwide. Complications include hemorrhage, bowel perforation, and splenic rupture on rare occasions. The incidence of splenic rupture estimates between 0.00005 and 0.017%. Due to its nonspecific presentation, many cases may be misdiagnosed. We present a 76-year-old female on apixaban for atrial fibrillation who presented to us with sudden-onset, left-sided atraumatic chest pain radiating to the left shoulder, 10/10 in intensity, associated with nausea. The patient underwent an uncomplicated colonoscopy 16 days earlier with the excision of a 1.3 cm polyp. On presentation, her blood pressure was 96/58 mmHg, hemoglobin of 7.2, an international normalized ratio (INR) of 1.6. An abdominal computed tomography scan showed findings suspicious for splenic rupture. In the emergency department, two packed red blood cells (PRBCs) were transfused, and the patient was shifted to the operating room for emergent exploratory laparotomy where a splenectomy was performed for splenic rupture. The patient was discharged six days later without any postoperative complications. We speculate the use of apixaban and our patient's unusual site of pain following splenic rupture to be somehow correlated.

Lafora Disease Masquerading as Hepatic Dysfunction.

Lafora disease is fatal intractable progressive myoclonic epilepsy. It is frequently characterized by epileptic seizures, difficulty walking, muscle spasms, and dementia in late childhood or adolescence. We chronicle here an unusual case of an asymptomatic young male soccer player who presented with elevated liver enzymes. Neurological examination was unremarkable. The diagnostic workup for hepatitis, infectious etiologies, autoimmune disorders, hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, and other related diseases was inconclusive. He subsequently underwent an uneventful percutaneous liver biopsy. Based on the pathognomonic histopathological findings, Lafora disease was considered the likely etiology. The present study is a unique illustration of this rare disorder initially manifesting with abnormal liver enzymes. It underscores the importance of clinical suspicion of Lafora disease in cases with unexplained hepatic dysfunction. Prompt liver biopsy and genetic testing should be performed to antedate the onset of symptoms in these patients.

Primary Gastrointestinal Diffuse Large B-cell Lymphoma.

Primary gastrointestinal lymphoma is a rare neoplasm that accounts for less than 5% of all gastrointestinal malignancies. We present a case of a 37-year-old woman positive for human immunodeficiency virus who presented with abdominal pain and vomiting for three months. She underwent endoscopic biopsy and was found to have high-grade diffuse large B-cell lymphoma in the jejunum. This report discusses her treatments and includes a brief literature review highlighting the rarity of this entity, the etiological agents implicated in its pathogenesis, and the lack of specific guidelines for treatment.

Fatal Fulminant Hepatitis from Rituximab-induced Hepatitis B Reactivation in a Patient with Follicular Lymphoma: A Case Report and a Brief Review of Literature.

The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.

Hypertriglyceridemic Pancreatitis Treated with Insulin Therapy: A Comparative Review of 34 Cases.

Although the clinical presentation of hypertriglyceridemic pancreatitis is usually similar to other forms of acute pancreatitis, it is frequently associated with increased clinical severity and rate of complications. Therefore, appropriate and timely management is of paramount importance in these patients. We performed a structured literature search of the medical databases PubMed and Google Scholar, using the terms "hypertriglyceridemia," "acute pancreatitis," "insulin," and "treatment." In this search, we identified 34 cases of hypertriglyceridemia-related pancreatitis available in the full-text form in English. The data on patients' characteristics, epidemiology, clinical features, comorbid conditions, and diagnostic modalities were collected and summarized. This review illustrates that the use of insulin therapy with close monitoring of blood glucose levels is safe. It can be considered as an important component of management in patients with hypertriglyceridemia-related pancreatitis, especially in a clinical setting without the availability of plasmapheresis. Randomized clinical trials are warranted to outline a generalized and efficient treatment regimen for hypertriglyceridemic pancreatitis.

Unresectable Undifferentiated Embryonal Sarcoma of the Liver in an Adult Male Treated with Chemotherapy and Orthotopic Liver Transplantation.

Undifferentiated embryonal sarcoma of the liver (UESL) is a malignancy of mesenchymal origin observed predominantly in the pediatric population and very rarely in adults. We describe the case of a 21-year-old male who presented with acute onset of right upper quadrant pain and distention. Physical examination of the patient revealed right upper quadrant tenderness with the lower border of the liver palpable, 4 cm below the right costal margin. Laboratory tests performed on admission showed that the patient's liver function tests, urinalysis, complete blood count, and basic metabolic panel were within reference range. The levels of viral hepatitis and tumor serum markers were all within normal limits except for an elevated level of cancer antigen (CA) 19-9. Magnetic resonance imaging (MRI) and a computerized tomography (CT) scan showed two well-circumscribed lesions in the right lobe. The biopsy of the lesion showed UESL. The patient was started on chemotherapy. On his fifth cycle of chemotherapy, the patient was offered orthotopic liver transplantation (OLT). The patient underwent a successful OLT. There were no postoperative complications. Increased survival time and prevention of the recurrence of USEL can be achieved by surgical resection of the tumor combined with adjuvant and neoadjuvant chemotherapy. For unresectable tumors, OLT with chemotherapy can be a potential cure in younger patients.

Prevalence of Obesity in Carpal Tunnel Syndrome Patients: A Cross-Sectional Survey.

Carpal tunnel syndrome (CTS) is the most common compressive entrapment neuropathy caused by the compression of the median nerve at the wrist space known as the carpal tunnel. The epidemiologic factors related to CTS include genetic, medical, social, vocational, and demographic factors. The common symptoms experienced include pain, paresthesia, and numbness in the median nerve distribution. If left untreated, it can lead to irreversible median nerve damage, causing a loss of hand function. Body mass index (BMI) has been attributed as a risk factor for the development of CTS. We planned to determine the frequency of obesity among CTS patients in the neurophysiology department of a tertiary care center in Islamabad, Pakistan. The survey was designed as a cross-sectional descriptive study from March 2016 to August 2016 using a consecutive nonprobability sampling technique. A total of 112 patients with a mean age of 54 ± 5 years were included in the study. In the study population, 39 patients (35 percent) were males and 73 were females (65 percent). Based on BMI, 74 patients (66 percent) had a normal weight and 38 (34 percent) were obese. The frequency of obesity in our study was 34 percent, excluding the other comorbid conditions, which is quite high. Targeted therapy in those with CTS should also include weight reduction measures because obesity poses a cause-and-effect relationship for both the severity and the pathogenesis of CTS.

Role of Sex Hormone Levels and Psychological Stress in the Pathogenesis of Autoimmune Diseases.

The aim of this review article is to assess the connection between psychological stress and sex hormones and their effect on the development of autoimmune diseases. Psychological stress describes what people feel when they are under mental, physical, or emotional pressure. We searched for online articles using MEDLINE®, Embase, Cochrane Library and Google Scholar. Our research yielded a total of 165 articles out of which 30 articles were considered for further perusal. The articles were reviewed from February 2016 to February 2017. Case reports and patients suffering from hematolymphoid malignancies and active infections were excluded from the review. Estrogen and testosterone are potential physiological regulatory factors for the peripheral development of CD4+CD25+ T regulatory cells. Stress at any age leads to the depletion of estrogen and testosterone stores in the body, leading to the loss of expansion of T regulatory cells, making the immature B cells evade the negative selection at the germinal center, or in other words, leading to the loss of central tolerance, a triggering event in autoimmune diseases like systemic lupus erythematosus. Autoimmune diseases in women are most likely due to changes in estrogen levels during mental, physical, pre-menopausal, post-menopausal, and pregnancy-induced stress. We conclude that modulating estrogen in females (pre-menopausal and post-menopausal) and testosterone in males can be used to treat stress-related immune imbalance resulting in autoimmune diseases in both sexes.