COVID-19: Its Impact on Delayed Management of Pre-established Chronic Conditions

Chronic venous insufficiency (CVI) is a common condition affecting the venous system, typically arising in the setting of increased venous pressure and impaired blood return secondary to weakened valves or damaged veins. Diabetes mellitus causes impaired circulation, neuropathy, impaired healing, and increased susceptibility to infection. Because diabetes and CVI are interconnected, ulcerations can progress to necrotizing fasciitis if not treated promptly and appropriately. The coronavirus disease 2019 (COVID-19) pandemic has further complicated patient care and is a potential risk for complications and delays in the management of time-sensitive conditions like necrotizing fasciitis. Here, we present a case study highlighting the impact of COVID-19 on the delayed management of necrotizing fasciitis in a 51-year-old male with multiple comorbidities.

Throwing Shoulder Range of Motion and Hamstring Flexibility in Adolescent Baseball Players: A Pilot Study

Overhead throwing athletes with limited hamstring flexibility should be counseled appropriately regarding their risk for shoulder injury. Baseball players should stretch and prepare their bodies to throw to reduce the compensatory mechanisms that may occur from hamstring stiffness. We aim to identify the association between the contralateral hamstring-popliteal angle and throwing shoulder total range of motion (ROM) in high school baseball players. Fifteen high school varsity baseball players (ages 14-18 years old) volunteered for this observational study. All the athletes played five times a week and played different positions. Bilateral hamstring and throwing shoulder total ROMs were measured using a goniometer by the same examiner. Three examiners determined the maximum ROM by joint end feel for each measurement to ensure quality control. Contralateral hamstring flexibility was measured using the popliteal angle test. These measurements were compared to the throwing shoulder total ROM to determine the presence of an association. The relationship between the contralateral hamstring flexibility and throwing shoulder total ROM was determined using a linear regression analysis. The correlation coefficient (r) was +0.3928, indicating a positive linear relationship. We conclude that higher contralateral hamstring-popliteal angles may cause a compensatory increase in throwing shoulder total ROM. We highlight the role hamstring stiffness may play in shoulder injury development in adolescent baseball players.

Nonatopic Eosinophilic Duodenitis in an Adult: A Case Report and Overview

Eosinophilic duodenitis is an inflammation of the duodenum, characterized by an abundance of eosinophils, typically triggered by hypersensitivity reactions. Typically, recurrent abdominal pain with eosinophilic duodenitis is rare in individuals without a history of atopic conditions like asthma. Here, we present the case of a 62-year-old man who experienced recurrent upper abdominal pain for 12 months and unintended weight loss for the past six months. The patient reported no allergies to food, drugs, or the environment, and has no history of other atopic conditions. Esophagogastroduodenoscopy (EGD) with biopsy of the duodenum and stomach revealed 32 eosinophils per high-power field (HPF), which is mild. Skin prick testing yielded negative results. Following initial treatment with H2 inhibitors, proton pump inhibitors, and budesonide for a total of 12 weeks, the patient reported an improvement in symptoms and subsequent weight gain. This report emphasizes a rare case of eosinophilic duodenitis in a nonatopic individual with a successful treatment regimen. His quality of life improved with weight gain, resolved abdominal pain, and improved appetite. Although the patient's condition lasted about 12 months, our report showcased the importance of timely clinical diagnosis and appropriate combination therapy to alleviate progressive pain associated with eosinophilic duodenitis.

The Value of Interdisciplinary Collaboration in Lateral Medullary Syndrome Rehabilitation: A Case Report

Wallenberg's syndrome, also known as lateral medullary syndrome (LMS), is a neurological condition resulting from damage to the lateral portion of the medulla oblongata. We present a case of a 64-year-old man with Wallenberg's syndrome who presented for acute rehabilitation after sustaining a cerebrovascular accident (CVA). As seen in our patient, common symptoms of LMS include difficulty swallowing, hoarseness, ipsilateral weakness, and ipsilateral loss of sensation or numbness. Although the prognosis following infarction is often good, dysfunction in swallowing is one of the key deficits that have a long-term impact on patient quality of life. We aim to emphasize the significance of the interdisciplinary approach to achieving favorable health outcomes in patients with LMS.

Renal Endometriosis in a Postmenopausal Female Mimics Renal Cell Carcinoma

A 61-year-old postmenopausal female with a past medical history of type 2 diabetes, nephrolithiasis, and recurrent urinary tract infections presented to an outpatient urology clinic with a chief complaint of urinary frequency, urgency, and burning after micturition. Associated symptoms included nausea, a low-grade fever with chills, and right flank pain. After treatment with antibiotics did not relieve all of her symptoms, imaging was obtained, showing a cystic mass with calcifications in the right kidney. Following laparoscopic partial right nephrectomy and total hysterectomy with bilateral salpingo-oophorectomy, pathological examination of the right kidney mass highlighted endometrial stromal cells consistent with endometriosis of the right kidney. The left ovary also contained endometrial stromal cells, confirming another diagnosis of endometriosis of the left ovary. This case highlights the importance of considering renal endometriosis in the differential diagnosis of renal masses in women, even if they are postmenopausal.

Successful Surgical Management of Urethral Prolapse in a Postmenopausal Female

Urethral prolapse is a rare and benign condition where the inner urethral lining protrudes through the external urethral opening. This condition is mostly seen in prepubertal and postmenopausal women. Risk factors include obesity, multiparity, and the onset of menopause. It has a low occurrence, resulting in frequent underdiagnosis. This is compounded by its typical delayed diagnosis. We present a case of a 71-year-old postmenopausal woman who presented with persistent urinary symptoms. After multiple failed conservative treatments, she underwent a successful urethral prolapse excision. Our case highlights the importance of considering urethral prolapse as a differential diagnosis in a postmenopausal woman with continual urinary symptoms.

Mediastinal Follicular Dendritic Cell Sarcoma With Underlying Sjogren's Syndrome

Follicular dendritic cells help advance B-Cells in becoming memory B-Cells or antibody-producing plasma cells in the light zone, or undergo additional affinity maturation in the dark zone. Follicular dendritic cell sarcoma (FDCS) is an extremely rare soft tissue malignancy derived from follicular dendritic cells. Autoimmune disease increases the risks for the development of hematological malignancies. To the best of our knowledge, there are few cases of FDCS development in the setting of underlying Sjogren's syndrome (SS). Therefore, in this report, we present a novel case of FDCS associated with new-onset SS. In SS, the follicular dendritic cells are organized within germinal centers within the glands it infiltrates and is involved in B-Cell development. Because FDCS is derived from follicular dendritic cells, our report postulates that the unregulated follicular dendritic cell proliferation that may occur in SS could increase the risk for FDCS. Due to this possible connection observed in our patient, we highlight FDCS as a differential diagnosis when considering soft tissue cancers. We urge additional research to outline and explore the possible pathologic link between SS and FDCS.

Pleural Schwannoma Presenting As Musculoskeletal Type Pain: A Case Report

Schwannomas are benign peripheral nerve sheath tumors typically found in the neck, flexor surfaces of the extremities, mediastinum, posterior spinal roots, cerebellopontine angle, and retroperitoneum. Pleural schwannomas are a type of neoplasm that arises from autonomic nerve fiber sheaths in the pleura and rarely originate in the thoracic cavity. These schwannomas tend to be asymptomatic, benign, and slow-growing neoplasms. Although pleural schwannomas commonly occur in males, our report highlights a unique presentation of a pleural schwannoma presenting as musculoskeletal-type chest pain in an adult female. Our patient's diagnosis of pleural schwannoma was supported after X-Ray, Computed Tomography (CT) Scan, and Positron Emission Tomography (PET) Scan imaging was complete. All imagining and immunohistochemical staining yielded pleural schwannoma as the final diagnosis. We aim to bring awareness to the necessity of imaging and histopathological staining in atypical clinical cases of pleural schwannoma. Our novel case highlights pleural schwannoma as a differential diagnosis for patients with intermittent, musculoskeletal-type chest pain.

Portal Hypertension Due to Hepatoportal Sclerosis in an HIV-Positive Patient Secondary to Didanosine Use

Noncirrhotic portal hypertension (NCPH) has recently been found in human immunodeficiency virus (HIV)-infected patients taking didanosine. Here, we describe an HIV-infected patient with portal hypertension due to hepatoportal sclerosis who presented with hematemesis at the emergency department (ED). CT angiography of the abdomen and pelvis with and without contrast revealed a diminutive portal vein with corresponding massive lower esophageal varices and superior mesenteric vein to the right gonadal vein varices. Esophagogastroduodenoscopy (EGD) revealed grade II varices were found in the lower third of the esophagus, for which the patient's symptoms improved with emergency endoscopic band ligation, octreotide and didanosine discontinuation. Our case demonstrates a rare complication that can occur with continued didanosine use in an HIV-positive patient. We highlight the need for a standard diagnostic upper gastrointestinal endoscopy to screen for portal hypertension and high-risk esophageal varices in patients with long-term didanosine use as seen in our patient.

Breakthrough Hemolysis Associated With COVID-19 Vaccination and Active COVID-19 Infection in a Patient With Paroxysmal Nocturnal Hemoglobinuria Maintained on Pegcetacoplan: A Case Report

Breakthrough hemolysis (BTH) is the return of hemolytic disease resulting in an overall increase in complement activation in a patient being treated for paroxysmal nocturnal hemoglobinuria (PNH) with complement inhibitors (CI). BTH after COVID-19 vaccination has only been reported in PNH patients treated with the traditional C5 CI eculizumab and ravulizumab. We report on a new association of BTH in a newly COVID-19 vaccinated, previously stable PNH patient treated with pegcetacoplan, a C3 CI. The patient is a 29-year-old female diagnosed with PNH in 2017 and was started on eculizumab but was switched to pegcetacoplan in 2021 after continuing to exhibit symptomatic hemolysis. Subsequently, the patient returned to PNH remission serologically and symptomatically until her first COVID-19 vaccination. Since then, her lactate dehydrogenase (LDH) and hemoglobin counts have not fully returned to previous baseline levels, with significant exacerbations after her second COVID-19 vaccine and de novo COVID-19 infection. As of May 2022, the patient requires packed red blood cell transfusions every two to three months and has undergone a bone marrow transplant evaluation. This case study suggests that the administration of the upstream C3 CI, pegcetacoplan, is associated with active extravascular hemolysis in the setting of COVID-19 vaccinations and active COVID-19 infection. The pathophysiology of this hemolysis is unclear as hemolysis could be related to the underlying complement factor deficiency or amplification of complement factors causing extravascular hemolysis. There are conflicting reports in the literature regarding the mechanism by which COVID-19 vaccination and infection cause BTH in PNH patients, regardless of the choice of CI treatment. Bringing awareness to this case of BTH secondary to COVID-19 in a PNH patient treated with pegcetacoplan can further warrant the investigation of the role of COVID-19 in complement disruption and its role in BTH.

Acute Psychosis in the Setting of Undiagnosed Normocalcemic Hyperparathyroidism: A Case Report

Hyperparathyroidism (HPT) causes an elevation of parathyroid hormone (PTH). This can result in elevated calcium levels, which can cause bone, kidney, muscle, gastrointestinal, and neuropsychiatric symptoms, including psychosis. Our report presents a unique case of an elderly woman who presented to the emergency department in an unconscious state with a working diagnosis of metabolic encephalopathy secondary to sepsis and urinary tract infection. Despite fluids and antibiotic treatment, the patient showed hallucinations. The acuteness of her psychotic episodes prompted the medical team to further investigate the cause of her hallucinations. Additional labs revealed HPT, which she had never been diagnosed with prior to the hospital admission. Our patient's novel clinical presentation revealed elevated PTH and normal calcium levels as the cause of her psychosis. We determined that the normal calcium levels were due to the patient's calcium loss secondary to acute kidney injury. Cinacalcet administration showed resolution of the patients' hallucinations, highlighting the importance of PTH screening even in normocalcemic patients. In this report, we present a rare clinical presentation of acute psychosis in the setting of undiagnosed normocalcemic HPT.

Rapid-Onset Temporal Encephalitis With Negative Cerebrospinal Fluid Polymerase Chain Reaction Testing

Herpes simplex encephalitis is a rare disease presentation that is usually characterized by its temporal involvement and positive cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for the herpes simplex virus (HSV). HSV PCR has a sensitivity of 96% and specificity of 99%. Even when the test is negative, if clinical suspicion is high, acyclovir therapy should be continued with a repeated PCR within a week. In this case, we report a 75-year-old female patient who presented with signs of hypertensive emergency with rapid deterioration to seizure-like activity on electroencephalogram (EEG) and signs of temporal encephalitis on magnetic resonance imaging (MRI). The patient did not respond to the initial regimen of antibiotics but did show significant clinical response to acyclovir though she had a negative CSF PCR for HSV ten days after the start of her neurological symptoms. In this case, we argue that alternative methods of diagnosis should be considered in cases of acute encephalitis. Our patient had negative PCR but her computerized tomography (CT), EEG, and MRI results pointed to temporal encephalitis caused by HSV.