An Extragastrointestinal Stromal Tumor Arising From the Omentum in a Young Hispanic Male

Gastrointestinal stromal tumors (GISTs) are neoplasms arising from the bowel wall, most often in the jejunoileum of the small intestine, but rarely from extragastrointestinal locations. GISTs most often occur in patients older than 40 years of age and can present with a multitude of gastrointestinal symptoms. We present a rare case of an extragastrointestinal stromal tumor (EGIST) causing abdominal pain and melena in a 34-year-old Hispanic male. The patient presented with diffuse abdominal pain, melena, and severe anemia. Computed tomography of the abdomen revealed a large mass abutting the small bowel. The patient was taken to surgery where the mass, which appeared to be deriving from the omentum and invading the adjacent small bowel, was completely excised and found to be a spindle cell GIST. Excision margins were determined to be negative, and the patient was started on a tyrosine kinase inhibitor for maintenance therapy. The patient continues to follow up on an outpatient basis for surveillance. This case represents the rare disease entity EGIST presenting outside the typical demographics of the disease in a young patient with no identified previous genetic syndromes. Gross examination of the mass in this case was also atypical given the appearance that the mass was rooted in the omentum and invading the small bowel which would suggest the primary tumor site was extragastrointestinal. This case demonstrates the need to build a differential diagnosis that includes GIST and the ability to successfully treat this disease if it is identified early in the clinical course.

Moyamoya Disease Causing Stroke in the Setting of Cocaine Use and Uncontrolled Hypertension Due to Primary Hyperaldosteronism

Moyamoya disease is a cerebrovascular disease characterized by stenosis of large intracranial arteries and the development of smaller collateral vessels. Moyamoya may cause strokes and stroke-like symptoms in young patients. It has also been linked to autoimmune diseases and neuropsychiatric conditions. We present a case of moyamoya disease in a young patient with concomitant hyperaldosteronism, uncontrolled hypertension, and cocaine use disorder, along with features of antisocial personality disorder. This is a unique presentation of an underlying neurological disease causing psychiatric features exacerbated by cocaine use, and it describes a rare clinical presentation that physicians should consider in patients with moyamoya disease.

Anticoagulation Use as an Independent Predictor of Mortality and Major Adverse Cardiovascular Events in Hospitalized COVID-19 Patients: A Multicenter Retrospective Analysis

Background

Coronavirus disease 2019 (COVID-19) is associated with increased incidence of cardiac arrhythmias and thrombotic events. The adverse cardiovascular outcomes related to ambulatory anticoagulation (AC) therapy in COVID-19 patients are unknown. The goal of this study was to identify the effects of AC use in hospitalized COVID-19 patients.

Methods

This is a multicenter, retrospective study that identified 2,801 hospitalized COVID-19 polymerase chain reaction (PCR)-positive patients admitted between March 2020 and July 2021. Of these, 375 (13.4%) were ambulatory AC users. Data were collected from the electronic health records of hospitalized patients. Mortality included in-hospital death and hospice referral. Major adverse cardiovascular events (MACEs) included acute heart failure (HF), myocardial infarction (MI), myocarditis, pulmonary embolism (PE), deep venous thrombosis (DVT), pericardial effusion, pericarditis, stroke, shock, and cardiac tamponade. A Chi-square test was used to analyze categorical variables, and multivariate logistic regression analysis was performed to account for comorbidities.

Results

AC non-users exhibited a higher incidence of mortality than AC users (13.9% vs. 7.7%, P = 0.001). However, MACE incidence was higher in AC users than AC non-users (44.8% vs. 26.8%, P < 0.001). The higher MACE incidence was driven by higher rates of acute HF (8.3% vs. 2.5%, P < 0.001), MI (26.9% vs. 18.2%, P < 0.001), PE/DVT (16.3% vs. 2.7%, P < 0.001), pericardial effusion (1.6% vs. 0.5%, P = 0.025), and stroke (2.9% vs. 1.2%, P = 0.018). After multivariate logistic regression, MACE incidence remained higher (odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.27 - 2.05, P < 0.001) and all-cause mortality rate lower (OR = 0.34, 95% CI: 0.23 - 0.52, P < 0.001) in AC users.

Conclusions

Ambulatory AC use is associated with increased MACEs but decreased all-cause mortality in patients hospitalized with COVID-19. This study will help physicians identify patients at risk of cardiovascular mortality and direct management based on the identified risk.

HHV-6 Infection in a 19-Year-Old Liver Transplant Recipient - Much More Than Roseola!

Human herpesvirus 6 (HHV-6) infections, most commonly occurring during childhood, are frequently mild and self-limited. However, immunosuppression due to transplantation may cause reactivation of HHV-6 with manifestations ranging from fever and skin exanthem to pneumonitis, hepatitis, encephalitis, and myelitis. Because these infections may be devastating for liver transplant recipients leading to transplant organ fibrosis and failure, it is imperative that internists recognize the manifestations, establish early diagnosis, institute appropriate therapy, and make timely referrals to transplant specialists. We present a case of a 19-year-old liver transplant recipient with HHV-6 viremia, encephalopathy, and hepatitis. The patient's symptoms improved with ganciclovir and intravenous immunoglobulin treatment, serum HHV-6 copies gradually decreased, and she was discharged with outpatient follow-up. After approximately one month of antiviral therapy, the patient's viral load was undetectable. Early recognition of HHV-6 viremia, appropriate laboratory assessment, and early institution of therapy is important for internal medicine physicians to decrease morbidity and mortality in liver transplant recipients.

Coronary Artery Disease as an Independent Predictor of Cardiovascular Mortality in COVID-19 Patients

Background

Coronavirus disease 2019 (COVID-19) is associated with increased risk of cardiovascular mortality. However, little is known about the combined effect of coronary artery disease (CAD) and COVID-19 on mortality. We aimed to investigate the incidence of cardiovascular and all-cause mortality in COVID-19 patients with CAD.

Methods

This multicenter retrospective study identified 3,336 COVID-19 patients admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess whether CAD and its subtypes were associated with mortality.

Results

This study shows that CAD was not an independent predictor of all-cause mortality (odds ratio (OR): 1.512, 95% confidence interval (CI): 0.1529 - 14.95, P = 0.723). However, there was a significant increase in cardiovascular mortality in patients with CAD compared to those without (OR: 6.89, 95% CI: 2.706 - 17.53, P < 0.001). There was no significant difference in all-cause mortality in patients with left main artery and left anterior descending artery disease (OR: 1.29, 95% CI: 0.80 - 2.08, P = 0.29). However, CAD patients with a history of interventions (e.g., coronary stenting or coronary artery bypass graft) showed increased mortality compared to those solely treated by medical management (OR: 1.93, 95% CI: 1.12 - 3.33, P = 0.017).

Conclusions

CAD is associated with a higher incidence of cardiovascular mortality but not all-cause mortality in COVID-19 patients. Overall, this study will help clinicians identify characteristics of COVID-19 patients with increased risk of mortality in the setting of CAD.