Severe Thrombocytopenia in Decompensated Liver Disease: An Example of Accelerated Intravascular Coagulation and Fibrinolysis.

INTRODUCTION: Advanced liver disease can present with severe thrombocytopenia that can be difficult to delineate and manage. Here we describe a unique entity of accelerated intravascular coagulation and fibrinolysis (AICF) in a patient with decompensated liver disease. CASE PRESENTATION: A 56-year-old male with a history of alcoholic cirrhosis was admitted for weakness, nausea, metabolic derangement, and acute kidney injury determined to be secondary to decompensated liver disease. During admission, his platelet count declined to <10 000/µL requiring 8 total platelet transfusions. Laboratory and clinical evaluation supported a diagnosis of AICF, and the patient gradually improved with supportive management. DISCUSSION: AICF can present similarly to disseminated intravascular coagulation, and careful evaluation of specific laboratory values is required for accurate diagnosis. Appropriate management minimizes the associated increased risk of bleeding and prevents delay in procedural intervention. CONCLUSIONS: This case highlights the importance of early clinical and laboratory correlation, multidisciplinary care, and supportive treatment in the management of AICF.

Intra-abdominal omental mass as a desmoplastic round cell tumor: A rare case report.

Key Clinical Message: Desmoplastic round cell tumor, though rare, must be taken into consideration as a differential diagnosis, thus aiding in early evaluation and changing the trajectory of the natural history of the disease condition, and improving the prognosis of patients. Abstract: Desmoplastic small round cell tumor is a rare, aggressive tumor of mesenchymal origin with an incidence of 0.74 cases per million. We present a young adult with a periumbilical mass who was diagnosed as a desmoplastic round cell tumor and later was treated with exploratory laparotomy and resection of the tumor with no recurrence during a 6-month follow-up period.

Recurrent Pericardial Effusion in a Patient With Delayed Progression of Melanoma Treated With Immune Checkpoint Inhibitors.

Two commonly used immune checkpoint inhibitors (ICIs) utilized in the treatment of metastatic melanoma are nivolumab, a programmed death (PD-1) checkpoint inhibitor, and ipilimumab, a cytotoxic T-lymphocyte antigen (CTLA-4) checkpoint inhibitor. However, due to the activation of the immune system, ICIs have been associated with cardiotoxic immune-related adverse events (irAEs). Here, we present a 40-year-old male with stage 4 metastatic melanoma treated with nivolumab and ipilimumab who developed recurrent pericardial effusions and subsequent constrictive pericarditis 10 months after initiation of treatment. He initially received a total of four cycles and was started on maintenance nivolumab on 8/2022. On 3/23/2023, he complained of chest pain and was found to be hypotensive. He subsequently underwent an emergent pericardiocentesis where 330cc of serosanguinous fluid was drained. Repeat echo on 3/24 demonstrated a re-accumulation of a moderate-sized pericardial effusion, and a subxiphoid pericardial window was placed. He again presented on 5/24/2023 with similar complaints, and a CT scan of chest showed enlarged pericardial effusion with new bilateral pleural effusions.  To our knowledge, this is one of few case reports discussing pericardial effusions in the setting of nivolumab and ipilimumab ICI immunotherapy.

Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis.

BACKGROUND: With an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care. METHODS: A systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3). RESULTS: We identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care. CONCLUSION: The provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.

Empyema Presentation Secondary to Streptococcus constellatus.

A 60-year-old male presented to our institution for abdominal pain and was later admitted to the intensive care unit for shock, acute hypoxemic respiratory failure, and acute kidney injury. He was subsequently found to have a large left-sided pleural effusion with empyema secondary to Streptococcus constellatus. With the emerging threat and growing prevalence of Streptococcus anginosus group pathogens, there is now greater clinical importance in identifying viridans streptococci at the species level. While immunosuppressed individuals are at greater risk of opportunistic pathogens, this case presentation demonstrated that Streptococcus constellatus can remain a serious community-acquired pathogen for the non-immunosuppressed. Continued interprofessional team care management and a greater look into the reasons for greater Streptococcus anginosus pathogenicity may be indicated.

Unusual Presentation of Disseminated Histoplasmosis in an Immunocompetent Host.

Histoplasmosis, a fungal infection caused by the inhalation of Histoplasma capsulatum conidia spores, has been shown to cause disseminated disease in immunocompromised individuals. Disseminated histoplasmosis manifests as multi-system involvement including pulmonary and/or neurological disease. Imaging findings, such as pulmonary focal infiltrates, cavitary nodules, mediastinal, and hilar lymphadenopathy, are common. Here, we report a rare case of disseminated histoplasmosis in a 58-year-old immunocompetent male with no occupational exposure. This patient presented with primary adrenal insufficiency, and a subsequent CT-guided biopsy of the adrenal gland was performed and revealed numerous spores containing Histoplasma capsulatum. This patient also suffered from numerous pulmonary and neurological derangements, which are likely sequelae of the disseminated fungal infection. Ultimately, the patient succumbed to their illness and died. Preventing such outcomes relies on early detection and prompt management, which are crucial in treating disseminated histoplasmosis. Increased awareness of atypical presentations can enhance patient outcomes and alleviate the impact of this severe fungal infection. This case not only underscores the importance of considering disseminated histoplasmosis in an immunocompetent patient presenting with unexplained weight loss and adrenal insufficiency but also contributes to the limited literature on disseminated histoplasmosis in immunocompetent individuals.

An Unusual Presentation of Blastomycosis.

INTRODUCTION: Blastomycosis is a rare pyogranulomatous infection that most commonly involves the lungs and sometimes the skin. Other manifestations are much less common. Diagnosis relies on biopsy, histopathology, and culture of suspicious lesions. CASE PRESENTATION: In this case, a healthy 42-year-old male from Wisconsin presented to the emergency department with a chief complaint of 2 weeks of knee pain without a clear mechanism of injury. Upon further examination, he was found to have lesions on his abdomen, which he had first noticed over 3 years prior and had been treated with antibiotics as cellulitis for nearly 18 months. Biopsy of these lesions was consistent with blastomycosis infection, and further work-up and examination was notable for brain and laryngeal lesions without any pulmonary involvement. Intense anti-fungal treatment was immediately initiated with dramatic improvement in his symptoms. DISCUSSION: This case highlights the importance of a thorough physical exam and consideration of rare infections in cases without clear answers. To our knowledge, this is the first published example of a blastomycosis infection involving brain, laryngeal, skin, and knee lesions without pulmonary infection.

Olmesartan-Induced Enteropathy: A Case Report.

Patients with olmesartan-induced enteropathy, a rare illness, frequently endure prolonged diarrhea and weight loss with no apparent cause. Because this adverse event's clinical and histological characteristics mimic those of other small intestine illnesses, it can be challenging to recognize it in a timely manner. We report a case of olmesartan-induced enteropathy in a 58-year-old male who had been on olmesartan for several years. Recently, during his travel to Greece, he developed diarrhea lasting several weeks. This was accompanied by a significant weight loss of 35 lbs, acute kidney injury, and hypokalemia. Extensive negative workup, including esophagogastroduodenoscopy (EGD) with normal biopsy of esophagus, stomach, duodenum, and terminal ileum, and colonoscopy with biopsies, autoimmune serologies, and infectious disease workup, led to a diagnosis of olmesartan-induced enteropathy as a diagnosis of exclusion. Diarrhea improved/resolved within a few days after stopping olmesartan in our patient.

Babesiosis: An Atypical Cause of Respiratory Failure.

Babesiosis is a parasitic infection of the Babesia protozoa, which has been increasing in incidence in endemic areas of the United States. Symptoms of babesiosis can occur on a wide spectrum, from a mild flu-like illness to a fulminant disease course. Known complications of severe cases include intravascular hemolytic anemia and may involve the coagulation system, heart, spleen, kidneys, and in some cases, the lungs. This case report describes an 81-year-old, asplenic female in northern Wisconsin who presented to a hospital with shortness of breath and a non-productive cough. Definitive diagnosis of babesiosis, which was made through both a nucleic acid panel and blood smear, was initially delayed given the rare pulmonary manifestation of babesiosis. When the lungs are involved in the disease course, non-cardiogenic pulmonary edema leading to acute respiratory distress syndrome is among the most commonly seen complications. The pathophysiology of pulmonary involvement has not been made entirely clear but is most likely multifactorial, including the sequelae of changes to both the patient's red blood cells and pulmonary vasculature. This report highlights that atypical tick-borne illnesses like babesiosis should be considered as a cause of acute respiratory failure, particularly in the setting of sepsis and fever. The threshold for parasitic testing should be low in patients in endemic regions with risk factors, including increased age and history of asplenia, as babesiosis frequently has no localizing symptoms to suggest a protozoan infection. As babesiosis incidence continues to rise, prompt diagnosis and proper treatment can prevent severe complications and death in patients.

Legionella-Induced Hepatitis: A Case Report.

Legionnaires' disease is caused by a potentially life-threatening infection with the opportunistic Gram-negative bacilli species Legionella pneumophila, which is transmitted via inhalation or aspiration of water droplets. Legionnaires' commonly presents as atypical community-acquired pneumonia with accompanying diarrhea. Although hepatic and renal involvement are relatively uncommon, in this report, we present a case of Legionella pneumonia with acute hepatitis.

Modern Malignant Mesothelioma Manifestation.

Malignant pleural mesothelioma (MPM) involves the uncontrolled growth of mesothelial cells that form the lining of pleural serous layers. MPM has been linked with asbestos exposure in mining and manufacturing occupations with an unforgiving prognosis of 4-18 months. In this case report, we present a 56-year-old male with a significant past medical history of hypertension, hyperlipidemia, hepatic steatosis, and ulcerative colitis who presented to the emergency department for worsening cough, eight-pound weight loss over the previous year, night sweats, and fatigue. The patient was admitted due to right pleural effusion with lower lobe collapse seen on imaging; upon diagnostic workup including pleural biopsy, results were consistent with malignant mesothelioma of the epithelioid type. Over the course of six months post-diagnosis, the patient underwent multiple hospital admissions due to acute hypoxic respiratory failure from the segmental left upper lobe and subsegmental right upper lobe pulmonary emboli, recurrent pleural effusion, and anemia. Given the aggressive nature of MPM, the patient was determined not to be a surgical candidate and underwent palliative chemotherapy sessions until his passing. As the patient worked in heating/ventilation/air conditioning with asbestos exposure, taking a full occupational history was crucial. MPM is relatively rare; however, the incidence has increased over the last decade due to tumor development lag time post-asbestos exposure and an increase in do-it-yourself projects. There is no cure for MPM. Multimodal treatment approaches with surgery, chemotherapy, radiotherapy, and immunotherapy have been noted in the literature.

Post-embolization Syndrome Following Yttrium-90 Radiation Segmentectomy.

Post-embolization syndrome (PES) is a complication that commonly occurs after treatment with transarterial embolization for hepatocellular carcinoma (HCC). Patients with PES often present with clinical symptoms such as fever, nausea, abdominal pain, and elevated liver enzymes typically 24-72 hours after the procedure. While cases of PES have been documented in patients treated with transarterial chemoembolization, here, we present an unusual case of delayed onset PES in a 70-year-old male with HCC following treatment with a form of transarterial radioembolization.

Crohn's Disease Initially Presenting With Anterior Sclerouveitis.

This report examines the case of a 32-year-old male who initially presented with symptoms of eye pain, redness, and vision changes, and was subsequently diagnosed with anterior sclerouveitis. One week after his initial visit, the patient presented to the emergency department (ED) with daily bloody stools and left lower quadrant (LLQ) pain. Further workup and examination revealed a diagnosis of Crohn's disease. This report expands on ocular manifestations of Crohn's disease and touches on the importance of early gastrointestinal examination in patients who present with ocular symptoms.

Complex Case Management of Mycobacterium Tuberculosis Extrapulmonary Manifestation to the Right Sacroiliac Joint.

While Mycobacterium tuberculosis is a common bacterial pathogen that infects the respiratory system, especially in endemic regions, it may uncommonly manifest in other organ systems, such as the nervous, gastrointestinal, or musculoskeletal systems. Sacroiliac joint infections are rare, and only 1%-5% of all infections are tuberculous in nature. Given nonspecific inflammatory signs in both laboratory and radiologic examinations, early identification of the causative agent can be difficult. In this report, we present the case of a 29-year-old Eritrean woman who presented with an uncommon extrapulmonary tuberculosis manifestation of the right sacroiliac joint. The patient reported pain for two years before a formal diagnosis with multiple computed tomography scans demonstrated fluid collections about her right hip and thigh. The patient's medical history of developmental delay, psychosis, outdated medication documentation, non-therapeutic use of numerous psychiatric medications contraindicated for traditional anti-tubercular therapy, and socioeconomic history of a lack of social support and treatment arrangements with the patient's caregiver all complicated the treatment course. Given the rise in tuberculosis cases worldwide and vulnerability factors in patients with mental illnesses such as poverty, homelessness, diabetes, and HIV infection that can predispose patients to tuberculosis infections, early diagnosis and treatment are essential to reduce long-term consequences and improve clinical outcomes. Further research in the development of new tuberculosis treatment plans is essential to addressing an equitable treatment course alongside fighting against the recent rise in drug-resistant tuberculosis.