A Retrospective Study on the Outcome of Coronavirus Disease 2019 (COVID-19) Patients Admitted to a District General Hospital and Predictors of High Mortality.

BACKGROUND: The clinical features and severity of coronavirus disease 2019 (COVID-19) vary between patients and countries. Patients with certain conditions are predisposed to poor outcomes compared with those without medical conditions, such as diabetes, dementia, and hypertension (HTN). METHODS: The aim of this retrospective study was to assess factors associated with higher mortality in patients with COVID-19 infections and to identify the reason for hospital admission in these patients. The study was performed on patients admitted between 1 and 31 March 2020. Data collection was done retrospectively from electronic medical records. RESULTS: There were 269 patient admissions during this period, of which 147 were included in this audit. The mean age of COVID-19-positive patients was 62.8 years and 65.9 years for COVID-19-negative patients during this period. Forty-seven patients requiring hospital admission were COVID-19 positive and 93 were COVID-19 negative. There were no COVID-19 swabs in the seven patients included in the audit. Approximately 50% of the COVID-19-positive patients presented with fever and shortness of breath (sob), followed by dyspnea and cough (seven patients). The most common comorbidity was HTN, followed by type 2 diabetes mellitus (T2DM) and ischemic heart disease (IHD). The survival rate was 72.3% in COVID-19-positive patients and 80% in COVID-19-negative patients. The average length of stay was 14.4 days for COVID-19-positive survivors compared to 7.8 days for COVID-19-negative survivors. Most patients who tested positive for COVID-19 infection received oseltamivir vaccination and antibiotics. The presence of HTN, diabetes mellitus (DM), age, and organ failure was associated with a high mortality risk. CONCLUSION: Our study supports the findings of previous studies that diabetes, HTN, coronary artery disease, old age, and organ failure were associated with high mortality in patients admitted to hospitals with COVID-19 infections.

Effectiveness of Bariatric Surgery in the Management of Type 2 Diabetes Mellitus: A Case Report and Literature Review.

Type 2 diabetes (T2DM) and obesity represent major global health burdens and economic costs to healthcare systems. T2DM management is challenging due to multiple comorbidities and limited drug efficacy. Bariatric surgery has emerged as an effective treatment approach. A 65-year-old man with refractory obesity (BMI > 35 kg/m2) and poorly controlled T2DM underwent gastric bypass surgery in 2018. Prior to surgery, medication noncompliance and dietary measures failed to achieve adequate glycemic control or weight loss. Postoperatively, the patient lost 20 kg and achieved improved T2DM control (HbA1C reduction), allowing complete cessation of diabetic medications. The patient's case demonstrates bariatric surgery's potential to significantly alter the clinical course of obesity and T2DM versus standard care. National guidelines outline eligibility criteria for bariatric referral; however, utilization rates remain low (<1%) despite over two million eligible individuals in the United Kingdom. Improved access could reduce disease burden and healthcare costs from diabetes complications over the long term. This case report provides a real-world example supporting bariatric surgery as an effective intervention for appropriately selected patients with obesity and uncontrolled T2DM, with the potential to improve clinical outcomes and lower costs associated with diabetes management.

A Case of Delayed Diagnosis of Idiopathic Infantile Hypercalcemia Due to CYP24A1 Mutation: A 10-Year Journey.

The parathyroid gland is responsible for the synthesis and secretion of parathyroid hormone, which is synthesized and released at an inverse relationship to the level of ionized calcium in the blood. Primary hyperparathyroidism affects women more than men. There are various causes for hyperparathyroidism-induced hypercalcemia and the most common cause is parathyroid adenoma. A less common cause of vitamin D-mediated parathyroid hormone-independent hypercalcemia is the loss of function mutation of the CYP24A1 gene. The CYP24A1 gene encodes the vitamin D 24-hydroxylase enzyme, responsible for hydroxylating the active form of vitamin D into an inactive form, and mutations in the CY24A1 gene can lead to elevated active vitamin D metabolite levels. It can result in hypercalcemia and hypercalciuria-related complications. We present a case of a 72-year-old male patient referred to the endocrine clinic, who had repeated treatments for hypercalcemia and recurrent renal calculi. He underwent ultrasound, computerized tomography, and sestamibi scans, all reported as normal. Following this, the patient underwent a positron emission tomography (PET) scan, which was also normal. He then finally underwent genetic testing and tested positive for the CYP24A1 gene. He was started on fluconazole 50mg once a day and cinacalcet 30mg twice with normalization of calcium level. Three of his family members also tested positive for the condition.

Acute Psychosis Related to Primary Hyperparathyroidism in a Patient With Bipolar Disorder.

Primary hyperparathyroidism (PHPT) can cause hypercalcemia secondary to high parathyroid hormone secretion. Hyperparathyroidism- and hypercalcemia-related acute psychotic symptoms can be challenging to diagnose in patients with mental health-related disorders, and it should be considered a possible differential in these patients besides medications. It can sometimes be the first manifestation of the disease, and diagnosis can be challenging, especially in patients with a previous psychiatric history without checking their biochemistry profile. The hypercalcemia severity can vary from mild to severe, and signs and symptoms may also vary depending on the calcium levels. Hypercalcemia can cause neuropsychiatric dysfunction, and patients may present with confusion, agitation, delusions, and hallucinations. We present a case of a 54-year-old patient with a previous history of bipolar disorder and a recent diagnosis of depression and schizophreniform disorder, who presented to the emergency department with acute agitation, violent behavior, and disorientation. She was being managed by the community mental health team at a local behavioral health hospital for new onset psychosis over the past few months. She was refusing blood tests prior to hospital admission. Calcium level on laboratory tests was 3.54 mmol/l, and parathyroid hormone level was 45 pg/ml. She was managed with intravenous fluids initially, followed by zoledronic acid (4 mg intravenously over 15 minutes). She was then commenced on cinacalcet 30 mg twice daily initially, which was later increased to 60 mg twice daily. Ultrasound of the neck demonstrated a large left parathyroid mass, and she underwent left parathyroidectomy as an urgent outpatient. She has remained asymptomatic, and her psychiatry symptoms resolved following parathyroidectomy.

Severe Tricuspid Regurgitation in a Patient With Previous Tricuspid Valve Surgery for Infective Endocarditis Secondary to Intravenous Drug Use: A Case Report.

Tricuspid regurgitation (TR) is an important but underappreciated disease in medical practice, and the severity can vary from moderate to severe. Right-sided infective endocarditis (RSIE) is more common in intravenous drug users (IVDUs), and the vast majority of these involve the tricuspid valve (TV). It is worth mentioning that right-sided valves are challenging to scan compared to left-sided valves. The incidence of severe tricuspid regurgitation (TR) immediately post-repair is not tangible, but it is considered to be rare. We present a case of a 47-year-old patient who had previous TV septal leaflet reconstruction using a bovine pericardial patch using 6/0 prolene, and an annuloplasty was performed by placing an annuloplasty ring in 2017 for infective endocarditis. The patient developed moderate to severe tricuspid regurgitation within a few weeks following the surgery. She was readmitted to the hospital four years later with a reduced consciousness level, and a subsequent repeat echocardiogram showed possible tricuspid valve vegetation. In addition, transoesophageal echocardiogram (TOE) demonstrated biventricular dysfunction and severe tricuspid regurgitation, along with moderate to severe mitral regurgitation (MR) that was variable depending on the rate of atrial fibrillation. The patient was not suitable for surgical intervention and was medically managed accordingly.

A Rare Manifestation of Unknown Hyperparathyroidism as a Perforated Peptic Ulcer.

Hypercalcemia is a common electrolyte abnormality with different causes. Hypercalcemia is most often associated with malignancy and primary hyperparathyroidism and malignancy together account for most cases. Primary hyperparathyroidism manifests as hypercalcemia owing to the overproduction of parathyroid hormone. In most cases, primary hyperparathyroidism manifests due to a solitary parathyroid adenoma. Based on calcium levels, hypercalcemia can be classified as mild, moderate, and severe. Hypercalcemia typically presents with non-specific clinical features. Here, we present the case of a 38-year-old male patient who presented to the emergency department (ED) with acute abdominal pain and a tender abdomen with absent bowel sounds. He had chest radiography and blood tests initially. Chest radiography showed left-sided pneumoperitoneum, and the patient was suspected to have a perforated peptic ulcer due to hypercalcemia secondary to a parathyroid adenoma during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. The findings were confirmed by a computerized tomography scan of the abdomen, and the patient was treated with intravenous fluids for hypercalcemia and was managed conservatively for a sealed perforated peptic ulcer following discussion in the multi-disciplinary team meeting (MDT). The COVID-19 pandemic led to a long waiting list and delays in the timely management of patients requiring elective surgical intervention, such as parathyroidectomy. The patient made a complete recovery and had parathyroidectomy of the inferior right lobe two months later.

Pellagra as a differential diagnosis in the confused patient on the acute medical unit.

A man in his 80s was admitted via the acute medical take after presenting with increased confusion and features of alcohol withdrawal. He had a several-month history of a worsening pruritic rash surrounding his neck, arms and legs in addition to new, profuse diarrhoea. In view of the background of known chronic alcoholism and the coexisting symptoms of rash, confusion and diarrhoea, pellagra was diagnosed via a multidisciplinary approach. Oral nicotinamide supplementation was commenced and his symptoms responded rapidly. The bias and challenge of reaching a unified diagnosis in the context of a multisystem condition are exemplified in this case report.

A Rare and Interesting Presentation of Diabetic Ketoacidosis Caused by Native Aortic Valve Endocarditis Complicated by Aortic Root Abscess Resulting in Multiple Septic Emboli Causing Bowel Ischemia and Splenic Infarction.

Diabetic ketoacidosis (DKA) is a serious life-threatening complication of diabetes, often precipitated by infection. Infective endocarditis (IE) is a serious precipitating factor for DKA, especially in patients with a previous cardiac surgery or valvular pathology. IE can be further complicated by life-threatening embolic events, which could be fatal if not detected and managed early and effectively. Our patient is a 54-year-old diabetic who presented with DKA precipitated by native aortic valve endocarditis complicated by an aortic root abscess, which was further complicated by septic emboli to the splenic artery and superior mesenteric artery leading to splenic infarction and bowel ischemia, respectively. To our knowledge and as per the literature reviewed, no case has been reported in a single patient who presented with DKA precipitated by IE complicated by aortic root abscess and multiple septic emboli resulting in bowel ischemia and splenic infarction.

A Rare Presentation of Acute Renal Failure Secondary to Rhabdomyolysis in a Patient Due to Atorvastatin Requiring Short-Term Renal Replacement Therapy.

Renal failure secondary to rhabdomyolysis due to statins is quite rare. We present a case of a 57-year-old patient who developed acute renal failure due to rhabdomyolysis secondary to atorvastatin. Interestingly, this patient had a similar presentation 27 years ago requiring dialysis only once resulting in complete resolution of symptoms. He presented to the hospital generally feeling unwell and then developed generalized body ache. He had an extremely elevated creatinine kinase level of 116,000 and it went up to 145,000. His urine dip was negative for nitrites and was positive for blood and protein. He was commenced on intravenous fluids. He also had a computerized tomographic scan of the kidneys, ureters, and bladder, which showed some fat stranding around both kidneys likely inflammatory in origin. His creatinine level continue to rise despite intravenous fluids and was acidotic on blood gases. He also tested positive for COVID-19 on day 7 of admission and eventually needed dialysis. His renal functions improved to baseline post dialysis and kidney functions returned to normal. His autoimmune screen was negative and his renal functions remained normal on a follow-up visit.

Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Patient Taking Lamotrigine: A Case Report Based Literature Review.

A 29-year-old patient presented to the hospital with worsening generalized rash for the last two days from a mental health facility. The patient was commenced on lamotrigine two weeks earlier, and he developed fever and generalized macular rash on his body. His blood tests showed deranged liver function tests (LFTs) and clotting with raised eosinophil count, and he was treated for lamotrigine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient was commenced on prednisolone 50 mg once daily with a proton pump inhibitor cover, and lamotrigine was suspended on advice from Dermatology. The patient showed improvement after 3-4 days of treatment. His skin biopsy showed prominent suppurative granulomatous folliculitis, mild perivascular chronic inflammation, and red blood cell extravasation, including the rare eosinophil. He was weaned off from prednisolone by 5 mg weekly and had complete resolution of symptoms.

The Future of Cross-Continental Telemedicine in the Management of Complicated Endocrine Patients and Its Suitability Based on a Case Report.

Telemedicine is rapidly evolving to provide increased access to high-quality healthcare, and it has gained more traction during the current COVID-19 pandemic. Telemedicine was mostly restricted to remote areas, but with the COVID-19 pandemic, it has been adopted by hospitals and its use has increased significantly. In addition, international collaboration has also increased, and we present a case report from Nigeria whereby a patient was diagnosed with a pituitary tumor through telemedicine, and he underwent successful surgery. This case report highlights the opportunity for collaboration beyond borders and for health care professionals to work with developing countries to improve patients' care.

A Case Presentation Based on Incidental Diagnosis of Atrial Myxoma in a Patient Presenting With Atrial Fibrillation and Suspected Carney Complex.

We present the case of a 54-year-old lady who presented to hospital with palpitations and was diagnosed with atrial fibrillation with rapid ventricular response. She was given intravenous metoprolol 5 mg initially followed by a further 5 mg and was commenced on bisoprolol 2.5 mg once daily. She reverted back to normal sinus rhythm and was referred for echocardiography following an episode of paroxysmal atrial fibrillation. The echocardiogram showed a large mobile atrial myxoma in the left atrium and mild-to-moderate mitral regurgitation with preserved left ventricular function. Her past medical history includes transsphenoidal surgery for acromegaly in 1979, followed by radiotherapy and partial thyroidectomy for goitre. Her chest radiograph was normal and blood results were unremarkable. She was accepted for inpatient transfer to a cardiothoracic centre for surgical removal of atrial myxoma. She underwent surgery with successful excision of the atrial myxoma, and biopsies confirmed the mass to be atrial myxoma. The surgery was complicated by the patient developing atrial fibrillation with fast ventricular response that was chemically cardioverted with an intravenous loading dose of amiodarone 300 mg over 2 hours followed by 900 mg infusion over 24 hours. She had follow-up in the outpatient clinic with cardiology and endocrine specialists for a year and no recurrence of myxoma was noted. Her blood tests including growth hormone and thyroid function tests were normal.

Arrhythmogenic Right Ventricular Cardiomyopathy in a Patient Experiencing Out-of-Hospital Ventricular Fibrillation Arrest Twice: Case Report and Review of the Literature.

We present a case of a 62-year-old male who was admitted to the hospital with out-of-hospital ventricular fibrillation (VF) arrest. He had a VF arrest in 2011 and was admitted to another hospital. He had several investigations excluding cardiac magnetic resonance imaging, all of which were normal. He was playing tennis on both occasions when he experienced the VF arrest. His electrocardiogram on admission showed AF with partial right bundle branch block, inverted T waves in V1-V2, low voltage QRS complexes, ventricular ectopic in lead V1-V2, and prolonged QTc. His echocardiogram showed normal left ventricular function and a dilated right ventricle. Cardiac magnetic resonance imaging showed a dilated RV cavity size with impaired systolic function and dyskinetic region in the mid-ventricular free wall proximal to the insertion of the moderator band and late gadolinium enhancement in both right and left ventricles insertion points and mid-wall late gadolinium enhancement in the basal inferolateral wall suggestive of arrhythmogenic right ventricular cardiomyopathy. He had a single chamber VVI implantable cardioverter-defibrillator fitted for primary prevention and was discharged home. He had outpatient follow-up and showed good improvement and his implantable cardioverter-defibrillator checks were satisfactory and did not experience any shocks.

Resolution of Thyrotoxicosis-Associated Pulmonary Hypertension With Treatment of Thyrotoxicosis: A Case-Based Report and Literature Review.

We present a case of a 41-year-old Afro-Caribbean female, who was diagnosed with thyrotoxic Graves' disease. She had a past medical history of hypertension and was on amlodipine and valsartan. There was no significant family history of note. She initially presented to Emergency Department with palpitations and excessive sweating. Her thyroid-stimulating hormone was <0.02mu/L and free triiodothyronine (T3) 29.5pmol/L at the time of diagnosis. The thyroid peroxidase antibody test was negative. She was started on carbimazole 15mg once daily and propranolol 40mg twice daily. She remained non-compliant to treatment for over two years and missed most outpatient clinic appointments and her condition remained poorly controlled during this time period. She was re-admitted to the hospital after 18 months, with high output congestive cardiac failure. An echocardiogram showed pulmonary hypertension and her right ventricular systolic pressure was measured to be 70-75mmHg. She was started on Lugol's iodine 0.2mls three times daily, propranolol 40mg three times daily, cholestyramine 4 gram four times a day, propylthiouracil 100mg four times a day. After 3 weeks of treatment, she became euthyroid and her pulmonary hypertension improved dramatically with treatment. She underwent total thyroidectomy after a few weeks and biopsies confirmed the findings of Graves' disease.

EkoSonic™ Endovascular System-Directed Thrombolysis in a Patient With COVID-19 Infection Presenting With Bilateral Large Pulmonary Embolism Causing Right Ventricular Strain: A Case Report.

We discuss a case of a 31-year-old male patient who presented to the accident and emergency department with shortness of breath and chest pain since the morning of the day of presentation. His polymerase chain reaction (PCR) test had returned positive for severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2), which causes coronavirus disease 2019 (COVID-19), two weeks ago and his main symptoms had been shortness of breath, dry cough, generalized body pain, and fever. He was not vaccinated against the COVID-19 virus. He had not required hospitalization for COVID-19 and his symptoms had improved on day 10 from the date of diagnosis; however, he developed pleuritic chest pain with shortness of breath on the day of presentation. He was found to have tachypnoea, hypoxia, and tachycardia on assessment. His electrocardiogram showed a right bundle branch block with sinus tachycardia. He underwent a CT pulmonary angiography (CTPA) that showed bilateral large pulmonary emboli extending from the main pulmonary arteries bilaterally extending to the sub-segmental level. There was evidence of right heart strain on the scan. He also had a bedside echocardiogram performed after the CT scan, which showed an enlarged right ventricle but no left ventricular thrombus. His blood results showed D-dimer levels of 14,000 ng/mL and troponin T of 255 ng/L. He received treatment with low molecular weight heparin (LMWH) and underwent emergency EkoSonic™ Endovascular System (EKOS) thrombolysis (Boston Scientific, Marlborough, MA). He remained on ultrasound-accelerated thrombolysis (USAT) for the next 12 hours and showed significant improvement and was taken off oxygen post-EKOS thrombolysis. He was discharged home on oral rivaroxaban after 48 hours of hospital stay; follow-up after two months showed normal-sized right ventricle with no evidence of pulmonary hypertension.

Systemic Manifestation of Miliary Tuberculosis in Patient With Advanced Diabetic Retinopathy Presenting With Electrolyte Imbalance, Seizures, and Adrenal Insufficiency.

Extra-pulmonary manifestations of tuberculosis can have diverse presentations depending on the affected organs. In this case report, we describe a case of a 50-year-old man of South Asian origin who presented with acute adrenal crisis on a background of undiagnosed miliary tuberculosis. Imaging after repeated episodes of adrenal crisis and seizures revealed bilaterally enlarged adrenals and cerebral tuberculomas, suggesting adrenal and central nervous system involvement. CT chest, abdomen and pelvis showed apical lung nodules and tree-in-bud appearance suggestive of tuberculosis. Due to high endogenous levels of adrenocorticotropic hormone and a flat response after a short synacthen test, a diagnosis of primary adrenal insufficiency secondary to tuberculosis infection was made. He remains well on anti-tuberculous chemotherapy, corticosteroids, and anti-epileptic medication. This case report exemplifies the unusual but life-threatening presentations of extra-pulmonary tuberculosis that may become increasingly common with immunosuppression because of the human immunodeficiency virus global epidemic and immunosuppressant therapies; therefore, a low index of suspicion is needed in these cases.

Acute Renal Impairment in Patients Due to Paracetamol Overdose in the Absence of Hepatic Impairment.

In general, paracetamol poisoning is associated with hepatotoxicity and very rarely with renal impairment in the absence of significant hepatic impairment. Paracetamol poisoning associated with renal impairment is rare, and it is mostly associated with hepatotoxicity. Most patients with acute renal impairment show a pattern of acute tubular necrosis or injury based on their blood, clinical presentation, and imaging. The level of injury was found to be associated with the dose of paracetamol taken. We describe a case of a 22-year-old patient presenting to the hospital with abdominal pain, back pain, and two episodes of vomiting after 36 hours of an intentional paracetamol overdose of 60 tablets. His lab results showed raised creatinine levels and C-reactive protein (CRP) despite normal liver function tests. His paracetamol and salicylate levels were not checked on his initial presentation. He was given N-acetyl cysteine (NAC) treatment for paracetamol overdose and had computed tomography of kidneys, ureters, and bladder (CT KUB) the following day, which showed mild, uncomplicated sigmoid diverticula. He was discharged the next day, but was readmitted two days later with severe abdominal pain and worsening renal function. He had an magnetic resonance imaging (MRI) abdomen that showed coronal/axial wedge like areas of relative hypo-intense change in the T2 acquisition. He received intravenous fluids and antibiotics, and his renal function improved. He was discharged home with outpatient follow-up and appeared to be fully recovered.