148 ECG abnormalities in COVID-19 pneumonia: acute pericarditis, silent cad, or both? A case report

Aims We report the case of a hypertensive 70 year-old man, who presented to the Emergency Department (ED) with fever, dry cough, malaise, dyspnoea. A nasopharyngeal swab for SARS-CoV-2 test was done, being positive. Methods and results Chest TC demonstrated ground glass bilateral pneumonia. Laboratory test showed WBC 10680/mmc, CRP 20 mg/l, TnT 0.03 ng/l, NTproBNP 147 ng/l. The liver and kidney function were within normal values. ECG was normal. He was treated with high flow oxygen (cPAP), enoxaparin, dexamethasone, doxycycline. After an initial improvement, dyspnoea got worse in 8th day, with the evidence of a new rise of inflammatory markers (PCR 95 mg/l, IL6 49 pg/ml) and the clinical new onset of cardiac rubbings on medical examination. The ECG revealed a sinus rhythm with T wave inversion everywhere. TnT remained normal. Echocardiography revealed a normal ventricular function, without segmentary alterations, absence of valvular disease. A mild pericardial effusion was evidenced, without signs of tamponade. We treated the patient with tocilizumab, after exclusion of other active infective foci. The clinical response was good, the patient was progressively weaned by oxygen and he was discharged asymptomatic. After 15 days, for ECG alterations persistence, despite no signs of ACS, a Coronary TC was done and a subcritical multivessel coronary artery disease was demonstrated: a subcritical IVA stenosis and a calcific MO. Conclusions In conclusion we report a successful treatment of COVID pneumonia likely complicated by acute pericarditis, and we observe that in these patients hypoxemia and cytochine storm possibly bring out silent vascular diseases, otherwise neglected.

Agrobacterium radiobacter Endophthalmitis Associated with Baerveldt Tube Exposure

<i>Agrobacterium radiobacter</i> is a Gram-negative bacillus and a rare cause of endophthalmitis. An 85-year-male presented with late-onset endophthalmitis associated with exposure of an inferonasal Baerveldt tube. The patient was initially treated with anterior chamber paracentesis and intravitreal antibiotics. Aqueous humor culture revealed <i>A. radiobacter</i> resistant to cefazolin, ceftazidime, amikacin, tobramycin, and trimethoprim-sulfamethoxazole. Subsequently, the patient underwent explantation of the glaucoma drainage implant (GDI). After initial improvement, the patient had clinical worsening and was diagnosed with recurrence. Subsequent treatment involved explantation of the second GDI in addition to pars plana vitrectomy with silicone oil infusion, intraocular lens removal, and administration of intravitreal antibiotics. Visual acuity improved but remained at count fingers at 2 weeks. This is the first reported patient with <i>A. radiobacter</i> endophthalmitis associated with an exposed GDI. This report illustrates the resistant nature of this organism in addition to the efficacy of silicone oil administration and intraocular prosthesis explantation.

Initial Angiotensin Receptor Blocker Response in Young Marfan Patients Decreases After 3 Years of Treatment

Marfan syndrome is caused by mutations of the fibrillin-1 gene, which weakens the connective tissue integrity. Since 2003, bioavailability regulations of TGF-ß through fibrillin alterations have been presumed of being the culprit mechanisms for aortic aneurysm development. We present the analysis of our single-center Marfan children and adolescents cohort to assess the influence of age, sex, degree of cardiovascular involvement and dosage on losartan effectivity. This prospective longitudinal registered echocardiographical investigation (EudraCT 2009-016139-36) of 49 patients with an average follow-up of 72 months focused on aortic root z-scores, elasticity, and yearly progression rates. The 33 patients under medication with losartan showed an aortic root z-score reduction during the first 36 months compared to 22 patients without medication presenting constant mild progression. Yet, results diminished under losartan thereafter, adding up to similar progressions over 72 months in both groups (0.07 ± 0.10/year versus 0.04 ± 0.11/year). Although male patients exhibited higher root z-scores, progression with and without medication was comparable to females and not age-dependent. In conclusion, losartan evoked a significant aortic root z-score regression in young Marfan patients over the first 3 years, but this effect mitigated thereafter. The initial improvement concurred with ameliorated elasticity; lower stiffness levels predicted better clinical outcome, but likewise only up to 36 months. Sex differences in dilatation severity were observed but neither age nor sex had significant influence on progression rates. Losartan dosages were gradually increased in more severely affected patients and provided an equal rate of root progression over 72 months in comparison to patients under losartan treatment with lesser baseline dilatation severity.

Metabolic Ketoacidosis in a Gravida Diagnosed with COVID-19: A Case Report

We present a case of term pregnancy which presented with chief complaint of Breathlessness, chest pain as well as a one day history of vomiting. She tested positive for COVID19 through reverse transcriptase polymerase chain reaction of nasopharyngeal swab and the symptoms were attributed to Pneumonia caused due to COVID19.However,the arterial blood gas showed metabolic acidosis with high anion gap. This was a non lactate acidosis with no hypoxemia. Most reasonably the state of pregnancy with increased energy demands along with increased metabolic maternal demand due to infection coupled with maternal starvation had resulted in this Ketoacidosis . In view of non progression of labor caesarian section was carried out and a healthy neonate was delivered. There was an initial improvement in maternal ketoacidosis post partum however optimal management of COVID19 pneumonia required oxygen support and use of corticosteroids. Thus we highlight how an unusual metabolic demands of pregnancy might mimic COVID 19.

Hyper IgG4-Related Disease Presenting with Orbital Tumor and Immune Deficiency

We report a case of IgG4-RD in a patient with high IgG4 levels, low functional antibodies, and low IgM levels. He presented with bilateral orbital pseudotumors and, after initial improvement on corticosteroids, relapsed with recurrent pleural effusion and pelvic pseudotumor. He had a grossly elevated serum IgG (1905 mg/dl) with elevations in all IgG subclasses but marked elevation in IgG4 (412 mg/dl), low IgM, and low pneumococcal antibodies. Orbital mass biopsy showed polyclonal lymphocytic infiltration and increased IgG4 plasma cells. The patient was started on prednisone and tried several immunosuppressive medications including mycophenolate mofetil, methotrexate, hydroxychloroquine, and azathioprine with decrease in size of the orbital pseudotumor. During a period when the patient stopped his medications, the pseudotumor enlarged with new development of recurrent pleural effusions. He was also found to have a pelvic mass that was biopsy positive for IgG4 proliferation. This case with progression to multiorgan involvement highlights the importance of identifying patients with IgG4-related disease. In contrast to previous cases with normal-to-high IgM, the IgM was low with impaired functional antibodies.

Short-, long-, and very long-term results of secondary anterior sphincteroplasty in 20 patients with obstetric injury

Purpose More long-term follow-up studies beyond 10 years after secondary sphincteroplasty for obstetric damage are warranted. This prospective study aimed to compare reported data on incontinence and satisfaction in a cohort of such patients examined at short-, long-, and very long-term follow-up. Methods Twenty out of 33 obstetric patients (61%) operated with secondary anterior overlapping sphincteroplasty during February 1996 to April 2004 were evaluated preoperatively and at short-, long-, and very long-term follow-up. Anal incontinence was scored by a combination of Wexner’s and St. Mark’s incontinence scores. The patients also reported degree of treatment satisfaction. Results Twenty patients were examined preoperatively and after a median (range) of 5 (2–62), 102 (64–162), and 220 (183–278) months. Corresponding incontinence scores were 11.5 (5–18), 5.5 (1–17) (p < 0.01), 10.0 (0–18) (p > 0.05), and 12.0. (1–18) (p > 0.05). With increasing follow-up times, patients reporting a better outcome were 75%, 65%, and 45%. At very long-term follow-up patients, reports were more dismal than expected in those also reporting improved incontinence cores. Incontinence scores did not improve in patients with neuropathy (n = 5) or patients (n = 5) with more than 10 years of symptoms. Conclusion Initial improvement of anal incontinence attenuated with time, in particular from short- to long-term follow-up. Patients with neuropathy experienced no improvement of incontinence. Beyond stoma formation, in compliant patients, one should consider other treatment options like sacral nerve stimulation and neosphincter formation.

Post-Discharge Prophylactic Anticoagulation in COVID-19 Patients: A Clinical Dilemma

: COVID-19 pandemic has taken a great toll on the health care system worldwide. Along with the pandemic, there is also a concern regarding post COVID-19 complications in recovered patients. Thromboembolism (TE) has been reported as a fatal complication in recovered patients with COVID-19. There is still a great dilemma in post-discharge TE prophylaxis and its long-term benefits. We reported three cases of post COVID-19 with complications related to both diseases as well as post discharge anticoagulant therapy. The first case is about a 60-yr-old male who developed Covid-19 pneumonia (moderate disease) and was discharged on rivaroxaban after initial improvement. 3 weeks later, the patient was readmitted with lower gastro-intestinal bleeding. The other two cases developed pulmonary thromboembolism within a span of 2-3 months (after recovered from Covid-19 pneumonia). Both these patients were not prescribed anticoagulants for TE prophylaxis. There is an imperative need for effective guidelines for post discharge TE prophylaxis in COVID-19.

<i>Candida</i> fracture-related infection: a systematic review

Background: The aim of this study is to summarize and improve knowledge regarding a Candida fracture-related infection (CFRI) through a systematic review on the topic, accompanied by a case report. Methods: A systematic review and meta-analysis based on PRISMA statement were conducted on the CFRI topic. The following combined search terms were used to explore PubMed, Cochrane, and the Embase database: “fungal infection”, “candida”, “fracture related infection”, “bone infection”, “orthopedic infection”, “internal fixation”, “post-traumatic infection”, and “osteomyelitis”. Results: Out of 1514 records, only 5 case reports matched the selection criteria and were included. Moreover, a new case of CFRI, not previously described, was reported in this paper and reviewed. The main risk factors for CFRI were open wounds (three cases) and immunodeficiency (three cases). Initial improvement of clinical and laboratory signs of infection was noted in all cases. In the available short-term follow-up (mean 12.1 months; range 3–42), the reoperation rate was 33.3 %. Using a strategy based on extensive debridement/resection methods and prolonged systemic antifungal therapy (mean 8.8 weeks; range 6–18), four of six cases (66.6 %) were cured. Bone union occurred in three out of six cases. Conclusion: There is very low-quality evidence available regarding CFRI. Candida infections in surgically treated fractures are rare but difficult-to-treat events, with a slow onset, unspecific symptoms or signs, and a significant relapse risk; therefore, they still represent a current diagnostic challenge. The existing fracture-related infection treatment algorithm combined with long-term systemic antifungal therapy has an anecdotal value and needs more extensive studies to be validated.

Leveraging of Weighted Ensemble Technique for Identifying Medical Concepts from Clinical Texts at Word and Phrase Level

Concept identification from medical texts becomes important due to digitization. However, it is not always feasible to identify all such medical concepts manually. Thus, in the present attempt, we have applied five machine learning classifiers (Support Vector Machine, K-Nearest Neighbours, Logistic Regression, Random Forest and Naïve Bayes) and one deep learning classifier (Long Short Term Memory) to identify medical concepts by training a total of 27.383K sentences. In addition, we have also developed a rule based phrase identification module to help the existing classifiers for identifying multi- word medical concepts. We have employed word2vec technique for feature extraction and PCA and T- SNE for conducting ablation study over various features to select important ones. Finally, we have adopted two different ensemble approaches, stacking and weighted sum to improve the performance of the individual classifier and significant improvements were observed with respect to each of the classifiers. It has been observed that phrase identification module plays an important role when dealing with individual classifier in identifying higher order ngram medical concepts. Finally, the ensemble approach enhances the results over SVM that was showing initial improvement even after the application of phrase based module.

Sarcoidosis presenting as bilateral lacrimal gland swelling: a pediatric case report

Background To describe a case of pediatric sarcoidosis which initially presented as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without other known systemic involvement. Case presentation A 10-year-old female presented to the pediatric ophthalmology clinic with complaints of bilateral eyelid swelling, tearing and itching for approximately 1 month. Her history and exam were most consistent with allergic conjunctivitis, for which she was started on a standard topical regimen. Despite initial improvement, she re-presented with significantly worsened eyelid swelling and minimal allergic symptoms. Enlargement of the lacrimal glands were palpable at this time. Lacrimal gland biopsy was obtained which demonstrated noncaseating granulomas. Systemic workup did not reveal evidence of disease involvement elsewhere. Conclusions Sarcoidosis in the pediatric population may present in a myriad of ways and is well-known to mimic other disease entities. We present a case of pediatric sarcoidosis which presented initially as papillary conjunctivitis before manifesting as bilateral lacrimal gland swelling without systemic involvement.