COVID-19-Induced Complete Heart Block: Case Series and Literature Review.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to the emergence of a wide range of complications, including those affecting the cardiovascular system. In this case series, we present four patients who developed complete atrioventricular block, a serious and potentially life-threatening heart rhythm disorder, during the course of their coronavirus disease 2019 (COVID-19) illness. The mechanisms by which SARS-CoV-2 may lead to arrhythmias are not fully understood but may involve direct infection and damage to heart tissue, as well as inflammation and cytokine storms. The extent and duration of complete heart block varied among these cases, highlighting the need for further research to understand the spectrum of disease and to improve mortality and morbidity in future waves of SARS-CoV-2 infections. We hope that this case series will draw attention to this serious complication of COVID-19 and inspire further research to improve management and outcomes for affected patients.

Zieve Syndrome in a Patient With Hepatitis C.

Zieve syndrome is a very rare syndrome that presents as a triad of hemolytic anemia, jaundice, and transient hyperlipidemia in patients with alcoholic liver disease. Herein, we present a case of a 30-year-old female with alcoholic liver disease and chronic hepatitis C. She presented with altered mental status and profound jaundice and was subsequently found to have acute hemolytic anemia due to Zieve syndrome. All other causes of hemolytic anemia were ruled out. She abstained from alcohol and received blood transfusions as needed, leading to the improvement of her anemia. This case highlights the need for more medical education about Zieve syndrome as the under-recognition of the disease can lead to unnecessary treatments. We review the existing literature to explain the epidemiology, pathogenesis, diagnosis, and treatment of Zieve syndrome. This case represents a rare presentation of Zieve syndrome in a patient with hepatitis C, and we have hypothesized a possible role of chronic hepatitis C infection in its pathophysiology.

Pneumopericardium, Epidural Pneumatosis, and Muscular Emphysema: Rare Complications of Spontaneous Pneumomediastinum Due to Refractory Hyperemesis Gravidarum.

Various complications of hyperemesis gravidarum and pneumomediastinum have been documented in the literature. Commonly, these cases resolve spontaneously or with the use of antiemetics and supportive care. In rare instances, these symptoms persist into the second trimester and are associated with an increased risk of complications. Herein, we present a case of a healthy 20-year-old female with a history of marijuana use who presented with intractable nausea and vomiting and was found to have multiple rare complications of spontaneous pneumomediastinum.

COVID-19 and the cardiovascular system: an update.

As COVID-19 continues to cause an increasing number of deaths worldwide, it is important that providers stay abreast with new research related to the pathophysiology of COVID-19 disease presentation states and clinical management. It is now well recognized that COVID-19 affects extrapulmonary organs, particularly the cardiovascular system. For example, cardiogenic shock has been increasingly observed in patients with COVID-19, owing to the various mechanisms involved and the affinity of the SARS-CoV-2 virus to cells comprising the cardiovascular system. In this review, we have briefly discussed the link between the cardiovascular system and COVID-19 infection, focusing on underlying mechanisms including but not limited to cytokine storm, direct virus-induced myocarditis, and ST-elevation myocardial infarction leading to cardiogenic shock. We have highlighted the cardiovascular risk factors associated with disease prognostication in COVID-19 patients. We have also briefly discussed vasopressors and inotropes used for treating shock and presented their mechanism of action, contraindications, and side effects in the hopes of providing a quick reference to help the provider optimize management of COVID-19 patients presenting with cardiovascular complications such as shock.

Septic Arthritis Masquerading as a Flare of Rheumatoid Arthritis: A Not So Straightforward Diagnosis.

A typical presentation of septic arthritis (SA) includes pain, swelling, and erythema in the affected joint. Often, patients complain of inability to bear weight on the affected limb. However, some patients may present with subtle symptoms of pain and no fever or obvious swelling of the affected limb thus making the initial suspicion of SA low. Especially, patients with rheumatoid arthritis (RA) may present with polyarticular joint pain and initial synovial fluid analysis from an infected joint not consistent with overt septic arthritis. In such situations, the diagnosis of septic arthritis could be missed on delayed. In this case report, we present a 79-year-old female with a history of RA who presents with polyarticular pain, most notably in her right knee. SA was not initially suspected because of her history of RA and her current presentation with polyarticular pain. The initial synovial analysis did not suggest SA as well. However, cultures of synovial fluid from her right knee confirmed SA. Thus, we have highlighted that physicians should have a high suspicion for SA when addressing joint pain in RA patients.

An atypical case of congenital lobar emphysema in an adult, non-smoker patient presenting with pneumothorax.

Congenital lobar emphysema (CLE) is a developmental anomaly of the lower respiratory tract characterized by hyperinflation of one or more pulmonary lobes in the absence of extrinsic bronchial obstruction. We present a case of a 24-year-old male, nonsmoker who presented with shortness of breath and severe left sided chest pain. A chest x-ray was significant for a very large left-sided pneumothorax and chest CT showed lobar emphysematous changes. Video assisted thoracoscopic surgery (VATS) and lobectomy was subsequently performed after persistence of pneumothorax despite chest tube insertion and conservative management. Surgical pathology of resected specimen showed chronic emphysematous changes with patchy chronic organizing pneumonitis. Histology showed advanced emphysematous changes of pulmonary parenchyma consistent with congenital lobar emphysema. This finding combined with features seen on computed tomography of the chest led to the diagnosis of congenital lobar emphysema. This case demonstrated that CLE can be a cause of tension pneumothorax in adults in rare cases.

Third-Degree Heart Block Associated With Saddle Pulmonary Embolism: A Rare Sequelae of COVID-19-Induced Hypercoagulable State.

The pathophysiology of coronavirus disease 2019 (COVID-19) involves multi-organ dysfunction, particularly involving the respiratory, cardiovascular and hematological systems. This dysfunction is partly due to systemic inflammation causing a wide array of pathological sequelae thus posing a significant challenge to management despite the advances in treatment made thus far. In this report, we present a COVID-19 patient who developed a transient complete heart block and was temporarily paced as a complication of a saddle pulmonary embolus (PE). The mechanism of complete heart block is unclear, may be related to strain, ischemia, or vagal response. We believe that this is a unique sequence of events in a COVID-19 patient and, to our knowledge, is the first of its kind to be reported.

Physicians at the crossroad of prognosis and faith: practical help communicating with patients and families during the COVID-19 pandemic.

Physicians will ultimately face the necessary but unpleasant task of caring for a dying patient at some point in their careers. Communicating with patients or their families during such dire times is very important especially when the patient or family members have unrealistic expectations. Herein, we have highlighted practical suggestions which if applied can prevent unnecessary draining encounters with patients and families; for example, incorporating ancillary staff such as palliative and pastoral care into the care team. We have also proposed a new concept of 'physician optimism'. Based on this concept, the physician can be classified as a pessimist or an optimist with realistic or unrealistic expectations and communicate to patients with or without requisite empathy. To ensure the best outcomes, we conclude that physicians must be realistic optimists who always communicate with empathy. Unrealistic optimism, no matter how well-intentioned, is deceiving to patients and their families will never allow a culture of trust.

Starvation Ketoacidosis Induced by Ketogenic Diet and Consumption of Ketone Supplement.

The ever-changing landscape of dieting and its correlation with health outcomes have continued to evolve with time. New diets appear and disappear just as quickly as they gain notoriety. This is a rare case of a 67-year-old female with a history of type II diabetes who presented with generalized weakness, nausea, and vomiting, and was found to have severe anion gap metabolic acidosis. In an effort to lose weight, she was combining a ketogenic diet with prolonged fasting and exogenous ketone supplement use that she purchased online. The patient reported drinking an exogenous ketone ester supplement that contained 30 g of D-beta hydroxybutyrate (BHB) per serving, three times per day. This case is unique in that the patient was initially thought to be in diabetic ketoacidosis upon arrival, but after further investigation into her initial labs, medication, and social history, the underlying factor for hospitalization became evident; that is, a combination of a ketogenic diet with prolonged fasting and exogenous BHB-induced ketoacidosis in the setting of type II diabetes. Thus, this case highlights the importance of thorough history taking, the dangers of over-the-counter supplement consumption, and the risks consumers inherit with trend dieting.

COVID-19 Coagulopathy: Current knowledge and guidelines on anticoagulation.

COVID-19-associated coagulopathy (CAC) is a feature of COVID-19 that can lead to various thrombotic complications and death. In this review, we briefly highlight possible etiologies, including direct cytotoxicity caused by the SARS-CoV-2 virus, and the activation of proinflammatory molecules such as cytokines, underlying coagulopathy. Endothelial dysfunction has been highlighted as pivotal, irrespective of the mechanism involved in CAC. Specific features of CAC distinguishing it from disseminated intravascular coagulopathy and sepsis or ARDS-associated coagulopathy have been discussed. We have also highlighted some hematological parameters, such as elevated d-dimers and partial prothrombin and prothrombin times prolongation, which can guide the use of anticoagulation in critically ill patients. We conclude by highlighting the importance of prophylactic anticoagulation in all COVID-19 hospitalized patients and reiterate the need for institution-specific guidelines for anticoagulation COVID-19 patients since individual institutions have different patient populations.

Marked Elevation of Carcinoembryonic Antigen Without an Identified Primary Gastrointestinal Tumor.

Whether profound carcinoembryonic antigen (CEA) elevations, such as > 20 times the upper limit of normal, are of diagnostic use remain unknown. Herein, we present a case of a 55-year-old female with profound serum CEA elevation and multiple pelvic masses but with no evidence of a primary gastrointestinal tumor following upper endoscopy and colonoscopy. Subsequent immunostaining of resected pelvic masses confirmed adenocarcinoma of colorectal origin. This case report highlights the possible diagnostic role of profound CEA elevation, particularly in cases of unknown primary tumors.

Induction of Hypopituitarism Following Ipilimumab/Nivolumab Therapy Followed by Radiation in the Treatment of Metastatic Scalp Melanoma.

Description Immune checkpoint inhibitors (ICI) are antagonistic antibodies that block specific immune checkpoint molecules, such as cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), programmed cell death protein (PD-1) and its ligand PD-L1. With FDA approval, the use of these checkpoint inhibitors has led to long-lasting tumor responses. However, by stimulating the immune system, checkpoint inhibitors can cause immune-related adverse events involving the endocrine organs, among others. Pituitary dysfunction (hypophysitis) leading to secondary adrenal insufficiency, or primary adrenal insufficiency caused by immune checkpoint inhibitors, have been documented. In this report, we present a case of a 70-year-old man with scalp melanoma with metastasis to the neck lymph nodes who remained asymptomatic 2 weeks after treatment completion with ipilimumab/nivolumab. However, he became lethargic, lost his appetite and was unable to perform activities of daily living following the initiation of radiation therapy to his neck. After hospitalization, he was found to have hyponatremia, hypocortisolism and hypopituitarism. He was treated with hydrocortisone, which lead to significant symptom improvement. His case suggests a dual-hit mechanism of injury to the pituitary caused by combined ICI and radiation therapies. Following ICI therapy, he was on the verge of pituitary dysfunction that fully materialized following a second insult. We suggest that for patients treated with ICIs, particularly with ipilimumab/nivolumab, a washout period may be considered before starting other forms of therapies, such as radiation therapy to the head/neck regions. Otherwise, prophylactic low dose corticosteroids may be initiated in cases where radiation therapy must not be delayed.

Persistent Postprandial Angina in a Patient With Gastroesophageal Reflux Disease: A Diagnostic Dilemma.

Chest pain (CP) is a common reason for visits to the emergency department (ED). The underlying etiology of a good number of cases of CP can be diagnosed with adequate history taking and routine laboratory testing. However, atypical presentations of CP, in the settings of other causes of CP such as gastroesophageal reflux disease (GERD), can sometimes be tricky to diagnose with only routine lab tests and electrocardiogram (EKG). Herein, we present a 73-year-old male with a history of GERD and coronary artery disease who presented to our ED complaining of postprandial CP unaffected by exertion or rest. Initially, his symptoms were thought to be GERD-related but other heart-related causes of CP were considered due to the persistence of his CP postprandially. A cardiac stress test was subsequently done to rule out possible cardiac causes of his CP. His stress test was abnormal prompting heart catheterization that showed almost complete occlusion of his left anterior descending (LAD) and left circumflex (LCx) arteries. His symptoms resolved post-catheterization/stenting of his LAD and LCx arteries. He was later discharged unconditionally. His presentation highlights the required vigilance physicians must maintain when interrogating CP, even when other non-cardiac-related causes seem more plausible.

Recurrent Venous Thromboembolism in a Patient with Klippel-Trenaunay Syndrome Despite Adequate Anticoagulation with Warfarin.

Klippel-Trenaunay syndrome (KTS) is a rare genetic condition defined by capillary malformation, venous malformation, and soft tissue and bony overgrowth. Due to venous malformations, individuals are predisposed to intravascular coagulopathy leading to thrombosis and thromboembolism. However, anticoagulating these patients long-term remains a challenge because of the presence of capillary malformations that increase bleeding risk. We present a rare case of a 30-year-old Caucasian male with KTS and history of gastrointestinal bleeding who has been on anticoagulation since the age of 7 and has had three different inferior vena cava filters placed during his lifetime. At presentation, he had dyspnea with stable vital signs. His prothrombin time/international normalized ratio was 37.3 and 3.2, respectively and chest computed tomography showed bilateral segmental pulmonary embolism (PE). He was treated with heparin drip and his home anticoagulation was switched from warfarin to apixaban at the time of discharge for better anticoagulation optimization. KTS is a condition associated with venous thromboembolic complications that can be difficult to manage. PE should remain on the top of the list of differential diagnoses in patients with KTS presenting with dyspnea even if laboratory findings suggest an alternate diagnosis.

An atypical complicated left-sided bronchopleural fistula presenting more than seven months after lobectomy.

BACKGROUND: Bronchopleural fistulas (BPF) are abnormal sinus tracts connecting the bronchi and pleural cavity and form after surgical resection of a lung lobe. It is a complication with potentially disastrous sequelae including, failure of the bronchial stump to heal, ischemia of the affected area, and/or infection of the stump. Bronchopleural fistulas caused by surgical intervention most commonly present on the right side and within 7-12 days post-operatively, i.e., subacutely. While the fistula may initially be asymptomatic, they carry a mortality rate of 25-71% in the absence of other comorbidities. CASE PRESENTATION: A 60-year-old female developed a BPF more than seven months after a left lower lobe lung lobectomy for non-small cell adenocarcinoma is presented. She was seen at our hospital on multiple occasions after her lobectomy with no evidence of a developing fistula on chest computer tomography (CT) during those visits. During her most recent presentation, roughly 7 months postoperatively, she was noted on imaging to have a new left-sided bronchopleural fistula. Bronchoscopy with lavage and culture of the fistula grew Pseudomonas Aeruginosa, for which she received appropriate treatment. Further surgical interventions were deferred due to poor prognosis. Her presentation differed from the typical BPF presentation in that it was left-sided and occurred out of the window of its usual occurrence. CONCLUSION: Late-onset BPF is an important diagnosis to consider in patients who have undergone lung resection, regardless of the type of surgery or postoperative duration, especially when patients are known to have multiple predisposing factors.

Bullous cellulitis caused by Pseudomonas putida in a patient with end-stage renal disease.

We present a case of bullous cellulitis in a 75-year-old male caused by Pseudomonas putida (P. putida) acquired from contact with contaminated water. Careful documentation of P. putida soft tissue infection is warranted given the rise in infections, marked antimicrobial resistance, and fatalities observed in a limited number of cases.