Pop Goes the Lung: Bilateral Pneumothoraces Due to Delayed Pneumatocele Rupture in Coronavirus Disease 2019 (COVID-19).

Worldwide medical and scientific communities are focusing on further understanding coronavirus disease 2019 (COVID-19) complications and its long-term impact on survivors. Pneumatocele cases are being reported more as a consequence of this virus and a cause of pneumothorax in certain patients. In this case vignette, we present a previously healthy male with COVID-19 symptoms who required hospitalization for hypoxia and who required readmission for bilateral pneumothorax from the delayed rupture of pneumatoceles. We describe this rare pathology and provide hypotheses for possible etiologies.

The Clinical Caveat for Treating Persistent Hypokalemia in Diabetic Ketoacidosis.

The medical community seeks to provide evidence-based guidelines for treating any disease to ensure optimal care delivery. Occasionally, a patient's unique physiology does not respond to guideline-driven treatments and requires experienced clinical personalization for treatment. Failure of clinicians to recognize patient outliers and augment care can delay treatment, provide substandard care, and potentially threaten a patient's life. This paper describes a clinical caveat for treating profound or persistent hypokalemia in patients with DKA (diabetic ketoacidosis).

Monocyte Distribution Width Predicts Sepsis, Respiratory Failure, and Death in COVID-19.

Introduction Sepsis is the leading cause of hospital mortality nationwide. Early recognition has been shown to improve outcomes. This research investigates the use of monocyte distribution width's (MDW) ability to detect sepsis and clinically correlate to outcomes in COVID-19 infection. Methods This is a retrospective, single-center cohort study of adult patients with confirmed COVID-19 requiring hospital admission over a 14-month period (September 2020 to November 2021). MDW was evaluated as a cytomarker to predict disease severity, mortality, and determination of sepsis in patients with COVID-19. Additionally, MDW was compared to existing inflammatory markers, including procalcitonin, D-dimer, ferritin, and lactic acid. Results MDW was able to predict sepsis in patients with COVID-19. The average MDW was found to be significantly higher in the detection of sepsis (25.50 ± 5.93) vs. patients without (23.13 ± 4.46) (p < 0.01). MDW was able to correlate with clinical outcomes or respiratory failure/hypoxia and death. An MDW value of 24.9 was shown to be the best cut-off value in determining fatal outcomes; receiver operating characteristic curve analysis revealed an area under the curve value of 0.69 (95% CI: 0.55-0.71) with a sensitivity of 83% and specificity of 71%. A chi-square test was performed, which detected a significant association between MDW values and the final clinical outcome of COVID-19 (OR = 3.52, 95% CI: 1.78-7.11, p < 0.001). Additionally, the mean MDW of patients with hypoxia or respiratory failure was significantly higher (22 vs. 25, p < 0.1). MDW did not correlate with any of the existing inflammatory markers. Conclusion MDW is a novel and reliable cytomarker for identifying sepsis in patients with COVID-19 infection. High MDW values are associated with clinical outcomes of respiratory failure and death with a mortality rate or absolute risk of 25%. MDW is easily obtained from routine laboratory evaluation in the emergency room and has the potential to be a useful tool in the triage of COVID-19 patients.

Cardiovascular disease in women: A review of spontaneous coronary artery dissection.

Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.

A Rare Case of Raoultella planticola and Enterococcus casseliflavus Coinfection.

Raoultella planticola, a Gram-negative bacterium, is a nonmotile rod usually found in soil and aquatic environments. It can be found in association with gastrointestinal malignancy. Enterococcus casseliflavus is a rare vancomycin-resistant Enterococcus that is responsible for some bacteremia. Our case describes a unique presentation of colonization with both R. planticola and E. casseliflavus isolated from the biliary stent isolates of a patient with known pancreatic malignancy and concomitant E. casseliflavus bacteremia. This is the first case ever reported of infection with both species.

Lung Biopsy as Rare Cause of Thromboembolic Stroke: A Case Report.

BACKGROUND CT-guided lung biopsy is a routine procedure used to evaluate suspicious pulmonary lesions that may arise from malignancy or infectious etiology. Common complications such as pneumothorax, bleeding, and rare cases of air embolisms leading to stroke have been documented as well. It is reported that there is a 0.06-0.08% risk of air embolism resulting in stroke in patients undergoing CT-guided lung biopsy. However, other causes of ischemic stroke following lung biopsy should be considered. CASE REPORT A 36-year-old obese man presented with chronic shortness of breath, intermittent fever, and night sweats. Chest CT showed multiple bilateral pulmonary nodules with basilar predominance, and laboratory test results that showed no acute infections, a negative TB QuantiFERON, and a normal transthoracic echocardiogram. Therefore, elective lung biopsy was performed to direct future medical therapy. Shortly after the procedure, the patient reported having right-sided vision loss and decreased sensation on the right half of his face, arms, and legs. Non-contrast CT of the brain showed no hemorrhage and no air intracranially. Therefore, following a Neurology consult, the stroke protocol was initiated, which resulted in tPA being administered. TPA use resolved the patient's symptoms, with no signs of hemorrhage. CONCLUSIONS Air embolisms have commonly been the cause of strokes following CT-guided lung biopsies, which can be detected on CT brain with signs of air intracranially. However, our case presents an ischemic cause of stroke with no evidence of air embolisms intracranially. Multidisciplinary stroke team consultations and consideration of alternative causes of stroke following CT-guided lung biopsy can be lifesaving, as urgent medical therapy can be delayed without proper considerations.

Critical Limb Ischemia as a Rare Presentation of Malignant Solitary Fibrous Tumor of the Pleura.

BACKGROUND Solitary fibrous tumor (SFT) of the pleura is a rare fibroblastic neoplasm. It is commonly found incidentally on imaging and is usually benign but has significant potential to recur as a malignant tumor. Patients present asymptomatically or with pulmonary symptoms such as cough or shortness of breath. Cardiac invasion of an SFT can create an avenue for peripheral tumor embolization and critical limb ischemia, as in this case report. There is no prior published report of recurring malignant SFT presenting as critical limb ischemia. CASE REPORT We report a rare presentation of malignant SFT recurrence in a 57-year-old woman with critical limb ischemia of both lower extremities secondary to bilateral tumor emboli. The patient's primary tumor was treated with surgical resection alone. Upon recurrence, the tumor growth was so extensive that it was no longer amenable to surgical resection at the time of her critical limb ischemia. The patient presented with bilateral numbness and tingling, without any pulmonary symptoms. CONCLUSIONS Although it is sporadic, clinicians should know that an aggressive malignant SFT can embolize and present as critical limb ischemia. The possibility of tumor emboli provides a pressing reason to surgically resect SFT masses in their early stages before any cardiac invasion.

Case Report: Infective Endocarditis of Mechanical Aortic Valve Due to Neisseria elongata Bacteremia.

BACKGROUND Neisseria elongata is a infrequent cause of infective endocarditis (IE). Although considered a commensal bacterium of the human nasopharynx, N. elongata has been shown to be the cause of significant disease in humans, namely endocarditis, osteomyelitis, and septicemia. CASE REPORT We report the case of a 53-year-old man with a past medical history of mechanical aortic valve who presented to the hospital for evaluation of eleven days of recurrent and relapsing fevers and was admitted for severe sepsis with concern for endocarditis. Blood cultures revealed N. elongata bacteremia, and an echocardiogram did not show any vegetations, although it was limited by mechanical aortic valve shadowing. The patient recovered after six weeks of treatment with intravenous ceftriaxone and oral ciprofloxacin. CONCLUSIONS Clinicians should be aware of the possibility of the previously considered non-pathogenic N. elongata as a source of IE caused by gram-negative organisms, as it can potentially cause severe disease and multiple complications. Our case additionally highlights that IE has highly variable clinical presentations. Thus, it is essential to utilize the Duke criteria as only a clinical guide for the diagnosis of IE rather than a substitute for clinical judgment and the decision to treat a patient with suspected IE.

Mechanisms of Action of Nutritionally Rich Hibiscus sabdariffa's Therapeutic Uses in Major Common Chronic Diseases: A Literature Review.

Hibiscus sabdariffa, this beverage has been used for millennia as both a delicious cultural beverage and an ancient medicinal therapy. In recent years, many studies have investigated the uses and mechanisms of action of Hibiscus sabdariffa to treat common chronic diseases. In this literature review, we place the spotlight on Hibiscus sabdariffa's medical effect on common chronic diseases, the flower commonly used to make hibiscus tea. The databases PubMed, MEDLINE, Clinical Key, and CINAHL were searched for studies related to Hibiscus sabdariffa's compounds, antioxidative and anti-inflammatory features, mechanism of action on common chronic diseases including hypertension, hyperlipidemia, obesity, diabetes, and Alzheimer's disease. Hibiscus sabdariffa antihypertensive potentials originate from the vasodilator activity, diuretic efficacy, functionality as an ACE inhibitor, adipocyte differentiation inhibitor, heart rate reduction ability, and anti-inflammatory mechanistic. The antihyperlipidemic effect is dose-dependent and stems from the antioxidative effect and the activation of AMPK through phosphorylation and the inhibition of regulatory adipogenic transcription factors PPAR-γ, C/EBP-α, and SREBP-1c, which altogether results in lipid-lowering effect. As an antihyperglycemic, Hibiscus sabdariffa serves as anti-insulin resistance by inhibition of the phosphorylation of IRS-1 beside a similar effect to gliptins. Finally, Hibiscus sabdariffa was proven to protect against neuroinflammation in microglial cell culture exposed to LPS by decreasing IL-1, IL-6, TNF-α expression, and the protective effect against glucotoxicity, improve memory function by inhibiting the formation of hyperphosphorylated tau proteins in the mouse brain. Regular consumption of hibiscus tea or extract is beneficial for a reduction in chronic disease risk and diagnosis.Key teaching pointsHibiscus sabdariffa, or hibiscus, has been used for millennia as both a delicious cultural beverage and an ancient medicinal therapy. Recent studies have investigated the uses of Hibiscus sabdariffa to treat common chronic diseases.Its antihypertensive potential originates from the vasodilator activity, diuretic efficacy, functionality as an ACE inhibitor, adipocyte differentiation inhibitor, heart rate reduction ability, and anti-inflammatory mechanistics.The antihyperlipidemic effect is dose-dependent and stems from the antioxidative effect and the activation of AMPK through phosphorylation and also the inhibition of regulatory adipogenic transcription factors PPAR-γ, C/EBP-α and SREBP-1c which all together results in lipid-lowering effect.As an antihyperglycemic, Hibiscus sabdariffa serves as anti-insulin resistance by inhibition of the phosphorylation of IRS-1 beside the similar effect to gliptins.Hibiscus sabdariffa was proven to protect against neuroinflammation in microglial cell culture exposed to LPS by decreasing IL-1, IL-6, TNF-α expression, and the protective effect against glucotoxicity, improve memory function by inhibiting the formation of hyperphosphorylated tau proteins in the mouse brain.

Clinical presentation and management of myocardial infarction with nonobstructive coronary arteries (MINOCA): A literature review.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.

Association between COVID-19 and angiotensin-converting enzyme inhibitors with the spotlight on zinc: an opinion.

In the setting of the raging COVID-19 pandemic, the search for innovative therapeutics is desperately sought after. As we learn more about the characteristics and metabolic health of patients and as our understanding of COVID-19 pathophysiology and treatment progresses, so is our understanding of medication effects that might increase disease severity. As of late, ACE inhibitors have been under investigation for a potential increase in illness severity due to ACE2 upregulation. Given our knowledge of other nutrient-pharmaceutical interactions, could the ACE inhibitor impact on COVID be due to something else? In this paper, we discuss the possibility that ACE inhibitors might be affecting COVID-19 patients by causing zinc insufficiency.KEY MESSAGESZinc deficiency caused by chronic ACE inhibitor usage may exacerbate the pathogenicity of COVID-19 in susceptible patients.A multi-center study is needed to assess the zinc levels of patients with COVID-19 who are taking ACE inhibitors and other medications that may result in low zinc levels.

Refractory Spontaneous Bacterial Empyema in Cirrhotic Patient.

Spontaneous bacterial empyema (SBEM), also called spontaneous bacterial pleuritis, is an infection of the pleural space that arises in the setting of cirrhosis and, by definition, the absence of pneumonia. It is likely underdiagnosed as its symptoms are nonspecific and it lacks standardized diagnostic and therapeutic recommendations. SBEM represents a distinct complication of hepatic hydrothorax with different pathogenesis, presentation, and treatment strategy from those of empyema secondary to pneumonia. Surprisingly, nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis. Although SBEM is amenable to prompt antibiotic therapy, it has a high rate of mortality and morbidity. A high clinical suspicion is crucial for patient survival and timely initiation of appropriate antibiotics. Increased understanding, recognition, and standardization of treatment would help alleviate the relatively high burden of SBEM. In this case vignette, we provide a review of the relevant literature, and we describe a rare case of SBEM in a patient with a history of alcohol-associated liver cirrhosis and prior episode of spontaneous bacterial peritonitis (SBP). SBEM was diagnosed with thoracentesis and analysis of the aspirate, and he was treated with ceftriaxone with resolution of his presenting abdominal pain and leukocytosis.

Acute Pancreatitis with an Ongoing Pancreatic Duct Leak Complicated by Refractory Pleural Effusion: A Case Report.

BACKGROUND Acute pancreatitis causes a significant systemic inflammatory response that affects multiple organs. Pulmonary complications include pleural effusions, hypoxia, atelectasis, and acute respiratory distress syndrome. Pleural effusion is an indicator of poor prognosis in pancreatitis. This case report supports the few existing reports about best practice for the diagnosis and treatment of a pancreatic duct leak causing refractory right pleural effusion. CASE REPORT In this case report, a woman with long-term rheumatoid arthritis and recent severe gallstone pancreatitis required hospital readmission for progressive shortness of breath from recurrent massive right pleural effusion from the pancreatitis with an ongoing pancreatic leak and a pseudocyst. She had diagnostic thoracentesis and magnetic resonance cholangiopancreatography (MRCP) that was followed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as a therapeutic procedure, with complete resolution of her symptoms. CONCLUSIONS This case report demonstrates an atypical presentation of complications from severe pancreatitis. MRCP is the criterion standard and best initial test for diagnosing a fistula. When possible, ERCP is preferred for the initial evaluation and treatment of pancreatic leaks and fistulas. In the present case report, treatment with endoscopic cystogastrostomies was effective for the internal drainage of the pseudocyst, pancreatic duct leak, and eventual resolution of the pleural effusion.

Nonalcoholic fatty liver disease as a risk factor for cytomegalovirus hepatitis in an immunocompetent patient: A case report.

BACKGROUND: Almost 80 percent of adults in the United States have had cytomegalovirus (CMV) infection by age 40. The number of symptomatic CMV hepatitis cases has been increasing along with non-alcoholic fatty liver disease (NAFLD) cases in the United States that is estimated to be 25 percent of the population. In this paper, we try to link these two entities together. CASE SUMMARY: In this case report, we describe a young female who presented with fever, nausea, and vomiting who was found to have NAFLD and CMV hepatitis that was treated supportively. CONCLUSION: In this case report, we describe NAFLD as a risk factor for CMV hepatitis and discuss the possible impact on clinical practice. We believe, it is essential to consider NAFLD and it's disease mechanisms' localized immu-nosuppression, as a risk factor of CMV hepatitis and severe coronavirus disease 2019 infection.

Sepsis due to Actinomyces odontolyticus as a Rare Complication of Neobladder.

Sepsis due to Actinomyces odontolyticus (A. odontolyticus) is an extremely rare condition that has been reported only a handful of times. In this report, we showcase an 83-year-old male who had a complication of neobladder procedure and developed sepsis due to A. odontolyticus that was successfully treated with a prolonged course of doxycycline.

Torsades De Pointes Electrical Storm Induced by H1N1 in a Patient with KCNH2 Variant of Unknown Significance.

This report describes a case of an electrical storm of Torsades De Pointes in a structurally normal heart, following an H1N1 infection in the presence of a genetic variant of unknown significance. The patient was successfully treated with isoproterenol. This case highlights the dilemma of evaluating novel genetic testing results in a clinical setting.

Vaping-induced lung injury: brief report for the practicing clinician.

The USA is witnessing an outbreak of vaping-induced lung injuries associated with the drastic rise in e-cigarette use, especially among teenagers and young adults. Our understanding of the harmful effects of these products is expanding as an increasing amount of consumers seek medical care for lung-related illnesses. The knowledge of the long-term sequelae of e-cigarette use is limited due to their novelty, but a growing association exists between use and acute lung injury. We describe a case vignette of vaping-induced lung injury to increase physician awareness and discuss the applicability of preliminary diagnostic criteria.

ST-Segment Elevation Myocardial Infarction from Septic Emboli Secondary to Infective Endocarditis by Abiotrophia Defectiva.

This article showcases a young patient who presented with STEMI secondary to septic emboli due to endocarditis with Abiotrophia Defectiva in the setting of a congenital bicuspid aortic valve. We aim to discuss current considerations for STEMI in young individuals including embolism due to IE, especially in patients with known or suspected congenital heart valve disease.

Spontaneous Retroperitoneal Hemorrhage Secondary to Chronic Celiac Axis Compression Treated with Embolization Utilizing Cone Beam CT.

Median arcuate ligament syndrome (MALS) is a rare and often misdiagnosed vascular pathology. In this paper, we discuss a 51-year-old female with MALS presenting with hypotension due to retroperitoneal hemorrhage. Currently, there is no consensus regarding the optimal treatment approach for such patients. This case report demonstrates the utility of conventional mesenteric angiography, cone beam CT with 3D reconstruction, and selective mesenteric transarterial embolization as an effective treatment approach for patients with spontaneous aneurysm rupture in MALS.