Complicated Management of Left-Sided Loculated Empyema Secondary to Streptococcus intermedius and Prevotella in a 53-Year-Old Male.

We present the case of a 53-year-old male with complicated left-sided parapneumonic effusion due to Streptococcus intermedius and Prevotella buccae. Management required video-assisted thoracoscopic surgery and partial decortication of the left lung. Complications during the hospital stay were extensive, including sepsis, acute hypoxic respiratory failure, alcohol withdrawal, and transient ischemic attack.

A Novel Case of Weissella confusa Infective Endocarditis of a Bio-Prosthetic Valve: Management and Treatment.

Weissella confusa is a rare gram-positive, non-spore-forming, catalase-negative, gram-positive coccobacillus, and a pleomorphic gram-positive rod (GPR) often misidentified as Lactobacillus genus. It was first discovered in 1993 and is becoming identified due to the increasing use of DNA sequencing. The true incidence of this species has likely been underestimated and it has been implicated in poly-microbial bacteremia. We present an exceedingly rare case of its presentation found incidentally in a patient with a bio-prosthetic aortic and mitral valve that was successfully managed and treated.

Cocaine-Induced Rhabdomyolysis Causing Lumbosacral Plexopathy in an Adult Male.

A 48-year-old male presented three days after cocaine use with acute, rapid onset of bilateral lower extremity weakness, bilateral foot numbness, acute urinary retention, and significantly elevated creatinine kinase. Further testing revealed unusual symmetrical edema with contrast enhancement on MRI of the lower extremities. The patient was diagnosed with severe non-traumatic, non-exertional rhabdomyolysis causing lumbosacral plexopathy following cocaine use. The treatment was centered around aggressive fluid resuscitation and electrolyte replacement.

Fulminant Coxsackievirus Myocarditis in an Immunocompetent Adult: A Case Report and Literature Analysis.

Myocarditis is an inflammatory condition that impacts cardiac myocytes and is caused mostly by viruses. It can manifest as chest pain, dyspnea, palpitations, fatigue, syncope, shortness of breath, and in severe cases frank cardiogenic shock. It accounts for around 10 percent of all sudden cardiac deaths in young adults, who are described as being in their early thirties. Inflammatory cardiomyopathy resulting from acute myocarditis may also appear as new-onset heart failure (HF), delaying the diagnosis and treatment of these patients. It is crucial to recognize the sensitivity of symptom onset, especially in young individuals; mildly elevated troponin levels that are inconsistent with the severity of left ventricular ejection fraction (LVEF) impairment and associated left ventricular dilatation strongly suggest inflammatory cardiomyopathy rather than acute myocarditis. The current treatment for myocarditis is primarily supportive, with an emphasis on the management of heart failure and arrhythmias in accordance with clinical practice guidelines. In this case report, we describe a male in his early forties who presented with abrupt onset exertional shortness of breath and chest discomfort. His cardiac catheterization did not show evidence of coronary artery disease; however, an echocardiogram revealed new-onset heart failure with reduced ejection fraction, the diagnosis of coxsackievirus myocarditis was made based on his clinical presentation, and a positive coxsackievirus immunoassay.

Rapidly Progressive Frontotemporal Dementia With Amyotrophic Lateral Sclerosis in an Elderly Female.

A 69-year-old female with a family history significant for early onset dementia and a past medical history significant for coronary artery disease, primary hypertension, type two diabetes mellitus, and Crohn's disease presents to our facility with rapidly progressive cognitive decline, delusions, hallucinations, and ambulatory dysfunction over the past two months. Neurological examination was remarkable for bilateral horizontal nystagmus, tongue fasciculations, bilateral upper extremity incoordination, and bilateral lower extremity spasticity, atrophy, and weakness. Laboratory and microbiological testing were remarkable for low serum thiamine levels. Computed tomography (CT) of the head without contrast showed significant brain atrophy in the frontal and temporal regions as compared to a CT without contrast of the head 5 years prior. Magnetic resonance imaging (MRI) of the head with and without contrast showed significant atrophy in the frontal and temporal regions as well as the cerebellum. Follow-up electromyography was consistent with lower motor neuron disease. The patient was given adequate thiamine supplementation for her thiamine deficiency and discharged on donepezil with instructions to follow up with the amyotrophic lateral sclerosis clinic for further monitoring and initiation of riluzole.

Epstein-Barr Virus Coinfection in COVID-19.

Epstein-Barr virus (EBV), a member of the herpes virus family, is a causative agent for infectious mononucleosis in young adults. It has an asymptomatic and subclinical distribution in about 90% to 95% of the world population based on seropositivity. EBV is associated with various lymphomas, nasopharyngeal carcinoma, and in immunocompromised states can give rise to aggressive lymphoproliferative disorders. Symptomatic patients mostly present with mild hepatitis, rash, oral symptoms, lymphadenopathy, and generalized malaise. Recently with the COVID-19 (coronavirus disease-2019) pandemic, hepatitis has been found to be related to acute EBV and cytomegalovirus reactivation versus acute infection in the absence of other major causes. We describe a case of EBV coinfection in a patient with resolving mild COVID-19 infection.

Spontaneous Retroperitoneal Hematoma: A Rare Presentation of Polyarteritis Nodosa.

Spontaneous retroperitoneal hematoma is a rare clinical entity that is most commonly caused by renal tumors and vascular disease. In this article, we present a case of spontaneous retroperitoneal hemorrhage caused by polyarteritis nodosa in a patient who presented with severe left flank pain. He underwent computed tomography angiography of his abdomen that showed left retroperitoneal hematoma, which was followed by arteriogram that showed multiple bilateral renal artery aneurysms with active extravasation, findings consistent with polyarteritis nodosa. The patient underwent successful coiling of the bleeding vessel that secured the bleeding and was started on high-dose prednisone, which resulted in resolution of his symptoms.

Slipping Rib Syndrome in a Female Adult with Longstanding Intractable Upper Abdominal Pain.

Slipping rib syndrome is a rare cause of abdominal or lower chest pain that can remain undiagnosed for many years. Awareness among health care personnel of this rare but significant disorder is necessary for early recognition. Prompt treatment can avoid unnecessary testing, radiographic exposure, and years of debilitating pain. A 52-year-old female was evaluated for a 3-year history of recurrent abdominal and lower chest pain. Pain was sharp, primarily located in the lower chest and subcostal region left more than right, waxing and waning, nonradiating, and aggravates with specific movements. She underwent frequent physical therapies, treated with multiple muscle relaxants and analgesics with minimal improvement. Imaging modalities including CT scan, MRI, and X-rays performed on multiple occasions failed to signify any underlying abnormality. Complete physical examination was unremarkable except for positive hooking maneuver. Dynamic flow ultrasound of lower chest was performed which showed slipping of the lowest rib over the next lowest rib bilaterally left worse than right, findings consistent with slipping rib syndrome. Slipping rib syndrome is caused by hypermobility of the floating ribs (8 to 12) which are not connected to the sternum but attached to each other with ligaments. Diagnosis is mostly clinical, and radiographic tests are rarely necessary. Hooking maneuver is a simple clinical test to reproduce pain and can aid in the diagnosis. Reassurance and avoiding postures that worsen pain are usually helpful. In refractory cases, nerve block and surgical intervention may be required.

Scenario Analysis for Programmatic Tuberculosis Control in Western Province, Papua New Guinea.

Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are major health problems in Western Province, Papua New Guinea. While comprehensive expansion of TB control programs is desirable, logistical challenges are considerable, and there is substantial uncertainty regarding the true disease burden. We parameterized our previously described mathematical model of Mycobacterium tuberculosis dynamics in Western Province, following an epidemiologic assessment. Five hypothetical scenarios representing alternative programmatic approaches during the period from 2013 to 2023 were developed with local staff. Bayesian uncertainty analyses were undertaken to explicitly acknowledge the uncertainty around key epidemiologic parameters, and an economic evaluation was performed. With continuation of existing programmatic strategies, overall TB incidence remained stable at 555 cases per 100,000 population per year (95% simulation interval (SI): 420, 807), but the proportion of incident cases attributable to MDR-TB increased from 16% to 35%. Comprehensive, provincewide strengthening of existing programs reduced incidence to 353 cases per 100,000 population per year (95% SI: 246, 558), with 46% being cases of MDR-TB, while incorporating programmatic management of MDR-TB into these programs reduced incidence to 233 cases per 100,000 population per year (95% SI: 198, 269) with 14% MDR-TB. Most economic costs were due to hospitalization during the intensive treatment phase. Broad scale-up of TB control activities in Western Province with incorporation of programmatic management of MDR-TB is vital if control is to be achieved. Community-based treatment approaches are important to reduce the associated economic costs.