The clinical behavior and optimal treatment of patients presenting with skin infiltration by B-cell lymphoma have not been established. To clarify this we assessed the clinical and laboratory features of 51 patients presenting with cutaneous infiltration by B-cell lymphoma. Follow-up data was available for 46 patients with a median age of 68 years (range 16-89 years) and a median follow-up of 32.5 months (range 5-123 months). Thirty-three of 51 (65%) patients had diffuse large B-cell lymphoma (DLBCL), and 15/51 (29%) had marginal zone lymphoma (MZL). The remaining 3 patients had follicular lymphoma, CLL, and post-transplant lymphoproliferative disease. Of the 33 patients with DLBCL, follow-up was available in 29; 24/29 (83%) had primary cutaneous disease, which was unifocal in 17/24 (71%). Following treatment, 8/24 (33%) of the primary cases relapsed. Of the 8 who relapsed, 7 had received local forms of treatment only. Follow-up data was available in 14/15 patients with MZL. 11/14 (79%) had primary cutaneous disease, which was unifocal in 8 (73%). Following treatment, 4 of these cases relapsed (36%); all had received local therapy only. It is evident from this study that a significant proportion (~20%) of patients who present with cutaneous infiltration by B-cell lymphoma have systemic disease. Staging is therefore mandatory in these patients. Approximately 1/3 patients with primary cutaneous DLBCL or MZL ultimately relapse, and relapse rates appear higher in thosepatients receiving local therapy only. Systemic or combined modality therapy may therefore be the most appropriate treatment at presentation. This should be assessed prospectively in randomized trials. Am.

Lambl's excrescences (LEs) are thin filiform strands of connective tissue found on the closure line of valves. Their exact etiology is unknown, and most of them are typically asymptomatic. We present a case of a 33-year-old African American male with a history of right upper extremity weakness that resolved on its own within a few minutes. On physical examination, no focal neurologic deficit was observed. MRI brain showed a tiny curvilinear focus of restricted diffusion with subtle T2-FLAIR hyperintensity in the left frontal/insular region, indicating a recent cortical infarct. Transesophageal echocardiogram (TEE) was performed as a part of cryptogenic stroke workup, which showed LE on aortic valve leaflet tips. Our patient had elevated blood pressure (BP) on arrival; however, in LE's presence, the embolic phenomena of stroke cannot be excluded. In conclusion, this case adds to a limited number of cases with such cardioembolic phenomena, which will help in further illustrating and highlighting the need for more prospective studies to establish a causal relationship between LE and cardioembolic strokes.

Brugada syndrome is a genetic disease with a characteristic electrocardiogram (ECG) findings of ST elevation in leads V1-V3 with a right bundle branch block (RBBB) appearance called Brugada ECG pattern and a tendency to develop malignant polymorphic ventricular arrhythmias that may lead to syncope or cardiac arrest. Common triggers for Brugada ECG pattern include fever, tricyclic antidepressants, lithium, cocaine and alcohol. This ECG pattern together with clinical findings mentioned above is termed Brugada Syndrome. We report a case of a 51-year-old male with a past medical history of hypertension presented to emergency department with 2-day complaint of fever, chills, sore throat, nasal congestion, malaise, productive cough, was positive for Influenza B and on ECG found to have type-I (coved) Brugada ECG pattern. Influenza fever associated with Brugada ECG pattern is a rare manifestation; in fact, to the best of our knowledge, only three case reports have been published in the literature to date.

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Background: Ventilator-induced Barotrauma is a complication of intubation that is associated with high driving pressures and positive end-expiratory pressure use. We attempt to determine the incidence of barotrauma in intubated patients with SARS-CoV-2 infection. Methods: Retrospective observation case series of patients with SARS-CoV-2 infection who were intubated in the ICU. Data were collected for a total of 3 months from electronic health records on patient's age, sex, BMI, incidence of barotrauma, total length of intubation and outcome. Results: Ninteen out of the 100 included patients developed barotrauma as defined by radiographic evidence of pneumothorax, pneumomediastinum or subcutaneous emphysema. The average BMI of patients with barotrauma was 32.06 kg/m 2 with an average age of 56.84 years and 9 patients being classified as obese (BMI ≥30 kg/m 2 ). Fourteen out of 19 patients (73%) with barotrauma were intubated for 10 or more days with a median of 16.52 days. The overall mortality rate was noted to be 92% amongst intubated patients. Conclusion: Rate of barotrauma in COVID-19 intubated patients was noted to be 19% in our study, which is on par with the rate of ventilator-induced barotrauma with the previous SARS virus-associated ARDS, and higher than that of the general population with ARDS. Patients who developed barotrauma were also noted to be intubated for a significantly longer duration (16.52 days) as compared to their non-barotrauma counterparts. These findings suggest a need for more data and randomized studies to establish appropriate ventilator management strategies for patients with lung injury associated with COVID-19.

Misoprostol is a synthetic E1 prostaglandin commonly used to induce abortion in the United States and elsewhere. There is limited literature on the cardiovascular adverse effects of misoprostol, and, to the best of our knowledge, very few such events have been reported. We describe the case of 52-year-old woman who was given misoprostol for cervical softening before endometrial ablation and experienced a cardiac arrest due to coronary vasospasm. She was successfully resuscitated and echocardiography showed features consistent with Takotsubo cardiomyopathy. Coronary angiography revealed coronary artery spasm which responded to nitroglycerin. Our case adds to the limited literature on this life-threatening adverse event of misoprostol.

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