Urinary Ascites: An Imitator of Portal Hypertension-Related Ascites.

Urinary ascites is a rare and lesser-known etiology of ascites that may mimic portal hypertension (pHTN). We present an unusual case of urinary ascites in a patient with no apparent risk factors for bladder rupture. A 56-year-old woman with an uncomplicated, remote history of abdominal surgery presented with recurring episodes of ascites of unknown etiology. Of note, she has a history of functional, chronic urinary retention due to paruresis, a phobia of public urination. She had abdominal distension on the exam. Paracentesis revealed an elevated serum-ascites albumin gradient (SAAG), concerning portal hypertension. Additionally, the ascites creatinine to serum creatinine ratio was found to be extremely elevated at over 1, and a CT cystogram ultimately revealed bladder rupture, indicating a source of urinary leakage into the peritoneal space. This case report discusses the clinical recognition of urinary ascites as a mimic of apparent portal hypertension-related ascites and appropriate management.

COVID-19 and the eye: Systemic and laboratory risk factors for retinopathy and detection of tear film SARS-CoV-2 RNA with a triplex RT-PCR assay.

PURPOSE: To assess hospitalized COVID-19 inpatients for the prevalence of retinopathy and tear film SARS-CoV-2 RNA, and associated risk factors for their detection. METHODS: Hospitalized COVID-19 patients underwent dilated ophthalmic examination and fundus photography. Conjunctival swabs were assessed for SARS-CoV-2 RT-PCR via a triple target assay. We assessed the relationships of retinopathy with clinical outcomes, systemic risk factors and laboratory data. RESULTS: The median age was 59.5 years and 29 (48%) were female. Retinopathy associated with COVID-19 was observed in 12 of 60 patients (20%). The median age of patients with COVID-19 retinopathy was 51.5 compared to 62.5 years in individuals without retinopathy (p = 0.01). Median BMI was 34.3 in patients with retinopathy versus 30.9 in those without retinopathy (p = 0.04). Fifteen of 60 patients (25%) tested SARS-CoV-2 RNA-positive in their tear film without a relationship with timing of illness and hospitalization. The N2 gene was particularly sensitive with 18 of 19 eyes (94.7%) showing N2-positivity, including 2 patients with alpha variant-positivity (B.1.1.7). CONCLUSION: Retinopathy was observed in 20% of patients hospitalized for COVID-19. Patients with retinopathy were more likely to be younger and have higher BMI than hospitalized patients without retinopathy. Tear film SARS-CoV-2 RNA was detected in 25% of patients. The relationship of obesity and age with retinopathy requires further investigation.

An Unusual Cause of Sudden Bilateral Lower Extremity Weakness.

Acute bilateral quadriceps tendon rupture is a musculoskeletal injury that requires urgent orthopedic surgical evaluation. Bilateral quadriceps tendon rupture is exceptionally rare, yet a missed diagnosis can result in long-term disability for the patient. This article presents a patient's case including the history, physical examination, key imaging findings, and management. This article emphasizes the importance of a detailed physical examination in patients presenting with musculoskeletal complaints as well as maintaining a broad differential diagnosis, which will assist the advanced practice provider in recognizing both the common and rare diagnoses in the emergency department.

Droxidopa as an effective treatment for refractory neurogenic orthostatic hypotension and reflex bradycardia in amyloid light-chain amyloidosis: a case report.

BACKGROUND: Droxidopa is an oral treatment for the stepwise treatment of neurogenic orthostatic hypotension from autonomic dysfunction. It has been shown to be useful predominantly with neurogenic orthostatic hypotension secondary to Parkinson's disease, but only a few cases have documented its usefulness in patients with neurogenic orthostatic hypotension due to amyloidosis, which is often severe and refractory. In addition, only one source in the literature reports the concomitant use of midodrine and droxidopa for such patients. Finally, we argue that droxidopa seems to have a protective effect against episodes of reflex bradycardia, which is not previously reported. CASE PRESENTATION: A 64-year-old white man was admitted for 1 year of worsening syncopal episodes, diarrhea, failure to thrive, heart failure, and neuropathy. Medical emergencies were called five times on the overhead hospital intercom over a 4-day period in the beginning of his admission due to severe hypotension and bradycardia. He was eventually diagnosed as having amyloid light-chain amyloidosis and myeloma. After starting droxidopa, both his systolic blood pressure and reflex bradycardia improved, and no more medical emergency events were called during the remaining 30 days of admission. He felt much better subjectively and was able to sit upright and engage in physical therapy. CONCLUSIONS: We show that droxidopa is effective when used with midodrine to treat refractory neurogenic orthostatic hypotension in patients with amyloidosis. There are very few cases reporting the use of droxidopa in amyloidosis, with only one study that uses droxidopa and midodrine concomitantly. In addition, our patient's reflex bradycardia improved drastically after starting droxidopa, which we believe is mediated by increased systemic norepinephrine. There were no side effects to droxidopa, and the benefits lasted well beyond the reported duration of 1-2 weeks that was noted to be a limitation in some studies.