Leukocytoclastic Vasculitic Rash Following Second Dose of Moderna COVID-19 Vaccine.

The immunization against coronavirus disease (COVID-19) via vaccination serves as a significant milestone in the fight against the pandemic. Rapid introduction of various COVID-19 vaccines to stem the spread of virus has researchers scrambling to document the adverse effects left in its wake. Thus far, there have been singular examples of cutaneous vasculitis associated with COVID-19. A history of vasculitis leaves little error to miss its inclusion in diagnostic differentials. It also invokes the physiologic possibility that afflicted patients possess a more susceptible landscape for recurrence that was then triggered by the vaccine when compared with those who lack similar history. In our case report, we build on those findings with one of the first documented examples of vaccination-induced vasculitic rash in a previously asymptomatic patient.

Cerebellar infarction as the initial presentation of IgG4-related disease.

Although IgG4-RD has CNS manifestations, cerebellar involvement has only been reported in three cases. Our patient presented with cerebellar symptoms, several cerebellar infarcts were evident on the brain MRI, and CT abdomen revealed retroperitoneal tumor. Endoscopic biopsy confirmed IgG4-RD. Steroids are the first-line therapy for IgG4-RD, but our patient was lost to follow-up before treatment.

Case of recurring Kikuchi disease and autoimmune hepatitis.

We present a case of a 47-year-old female patient with a history of diagnosed Kikuchi disease and autoimmune hepatitis 13 years ago who presented with recurrent fevers and a desquamative rash on the lower extremities. Computed tomography neck showed enlarged lymph nodes, and with her daily fevers and skin rashes the presentation was concerning for recurrence of her Kikuchi disease. The patient was also found to have an elevated anti-smooth muscle antibody titer, and subsequent liver biopsy confirmed the diagnosis of autoimmune hepatitis. She was started on methylprednisolone with improvement. Our case emphasizes the association of Kikuchi disease with autoimmune conditions other than systemic lupus erythematosus. Given the recurrence of the disease after a decade of quiescence, long-term follow-up of patients with Kikuchi disease should be implemented.

A rare presentation of necrotizing sarcoidosis.

Sarcoidosis is a disease with unknown aetiology and pathogenesis which affects young adults and is usually a non-necrotizing granulomatous disease seen in histology. Variants of the disease, such as necrotizing sarcoidosis, were first described by Liebow in 1973 and are rarely seen. This case report describes the case of a 60-year-old Bengali female who presented with vague symptoms and was found to have chronic granulomatous inflammation with foci of calcifications involving the lungs, liver and spleen consistent with necrotizing sarcoidosis.

Case Report: A Great Mimicker of Neoplasm: Pulmonary Cryptococcosis in an Immunocompetent Host After High-Altitude Descent.

Cryptococcus exposure in certain global regions is common and yet virulence in the immunocompetent host remains rare. Radiological findings of pulmonary cryptococcosis may include nonspecific lung nodules or masses indistinguishable from lung cancer or pulmonary tuberculosis. We present a case of an immunocompetent diabetic female who presented with progressively worsening pleuritic chest pain and cough with travel between Tibet and New York 2 months earlier. Chest imaging demonstrated a large lobulated mass, acid-fast bacillus smears were negative, and our patient underwent pulmonary biopsy, which grew rare budding yeast later confirmed by mucicarmine staining as Cryptococcus. Our patient was successfully treated with fluconazole therapy. We hypothesize that the high altitude of Tibet may allow for clinical latency followed by symptomatic reactivation on descent. A raised index of suspicion for pulmonary cryptococcosis with careful attention to travel history is expected to facilitate timely diagnosis.

An Unexpected Case of Malignant Mesothelioma in a Young Woman.

A 41-year-old female with a past medical history significant only for right retinal vein occlusion presented with chest pain, cough, and shortness of breath. After being found to have a large right-sided pleural effusion and undergoing a nondiagnostic thoracentesis, a noncontrast chest computed tomography scan revealed multiple diffuse nodules in the right lung with irregular paraspinal pleural thickening. An extensive workup followed, with computed tomography-guided biopsy ultimately revealing the diagnosis. The following report describes the patient presentation, laboratory findings, and extensive clinical investigation, and provides a discussion of the epidemiology, imaging findings, prognosis, and differential diagnoses for the illness in question.

Delayed hemodialysis in COVID-19: Case series with literature review.

BACKGROUND: Increased incidence of kidney injury has been seen in patients with COVID-19. However, less is known about COVID-19 susceptibility and outcomes in end-stage renal disease (ESRD) patients on hemodialysis (HD). Reduced angiotensin-converting enzyme 2 (ACE-2) from SARS-CoV-2 binding and increased angiotensin II (Ang-II) activity have been suggested as mechanisms for COVID-19 renal pathophysiology. MATERIALS AND METHODS: In this case series, we analyzed the data of 3 patients with ESRD who had a delay in receiving their regular HD. Reduced oxygen requirement, resolved hyperkalemia, and normalized fluid status were used for the basis of discharge. RESULTS: Presenting symptoms included fever, dyspnea, and dry cough. Laboratory markers were characteristic for COVID-19, such as lymphopenia, elevated D-dimer, C-reactive protein (CRP), and interleukin 6 (IL-6). All 3 of our reported patients required urgent HD upon admission. However, we report no fatalities in our case series, and our patients did not have a severe course of illness requiring endotracheal intubation. We reviewed COVID-19 pathophysiology and how patients with ESRD on HD may be particularly at risk for infection. CONCLUSION: New renal failure or ESRD sequelae, such as hyperkalemia, uremic encephalopathy, and fluid overload, can be exacerbated by a delay in receiving HD due to COVID-19 infection. Both direct COVID-19 infection and the challenges this pandemic creates to health care logistics present unique threats to ESRD patients on HD.

Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention in STEMI: Systematic Review and Updated Meta-analysis.

BACKGROUND: Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial. METHODS: PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model. RESULTS: We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year. CONCLUSION: TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.

Bacterial Superinfection of Amoebic Liver Abscess.

A 78-year-old male, originally from China, was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. He was started on empiric antibiotics, which were narrowed when blood cultures produced gram-negative bacteremia speciating to Klebsiella pneumoniae, sensitive to ceftriaxone. Computed tomography scan of the abdomen and pelvis demonstrated a large cystic region with air-fluid level in the left lobe of the liver. Suspecting this to be the source of the patient's bacteremia, the lesion was percutaneously drained and the fluid cultured, which also revealed ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or past infection. This suggested possible prolonged subclinical infection with bacterial superinfection, especially given that Klebsiella pneumoniae is one of the most common organisms cultured from these abscesses. In patients with liver abscesses who immigrated from developing and/or endemic regions or have a relevant recent travel history, an underlying amoebic etiology of an abscess should be considered.