We report a case of fulminant liver failure in a patient with acute active hepatitis B infection who was found to have COVID-19 without lung involvement. A 24-year-old male was brought by ambulance service to Hamad General Hospital, Emergency Department (ED), in Doha on April 8, 2020, with chief complaints of fever and cough for 3 days. Upon initial evaluation, the patient was febrile (39.4°C), jaundiced, and disoriented regarding time, place, and person, with an unremarkable past medical history. Initial blood tests showed severely elevated urea, creatinine, transaminases, and ammonium in addition to an impaired coagulation profile consistent with fulminant liver failure. A swab was taken for COVID-19 PCR testing and found to be positive. Serological tests revealed hepatitis B surface antigen positivity and other serology indicating acute hepatitis B. Initial X-ray and repeat chest X-rays did not show lung infiltrates. On the 6th day after admission, the patient developed fixed dilated pupils, with brain edema on CT; cardiac arrest occurred on the 10th day after admission, and the patient died. Although it is still largely unclear, HBV0-activated sudden-onset strong cytotoxic T lymphocyte response and enhanced viral replication and/or retention of the viral capsid in infected hepatocytes may cause the pathogenesis of FH. These pathophysiological events cause extensive hepatocyte apoptosis and necrosis, which results in deadly severe liver failure. Our findings support that the liver damage occurring in COVID-19 is caused by an impaired innate immune system rather than by direct cell damage caused by SARS-CoV-2. We think that more consideration should be given to the presence of acute hepatitis B, especially in COVID-19 patients.
Background:Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality.Vasoactive medications such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output and blood pressure, thus preventing multiorgan failure. Objective:A critical review was conducted to analyse the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. Methods:PubMed database search was conducted to identify randomized controlled trials on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. Results:Nine studies randomized 2,388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction. The studies evaluated the comparisons of norepinephrine (NE) versus dopamine, epinephrine versus NE, levosimendan versus dobutamine, enoximone or placebo, and nitric A c c e p t e d M a n u s c r i p t oxide synthase inhibitors versus placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. Conclusions:The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.
Subsequent development and implantation of embryo outside the uterine lining are defined as an ectopic pregnancy. Ectopic pregnancies have a wide range of presentations, for example, acute hemoperitoneum to chronic ectopic pregnancy. The case presented is an unusual case of ectopic pregnancy with large hematosalpinx with classic symptoms. To the best of the authors’ knowledge, this case is the largest intact tubal ectopic pregnancy reported ever in the 14th week of gestation. A 40-year-old patient presented to the emergency department with lower abdominal pain, mild dysuria, and loose motion. The patient’s previous menstrual cycles were regular till four months ago, then started to be irregular, and she had no history of chronic diseases except repeated pelvic inflammatory diseases (PID). Clinically, the patient was hemodynamically stable. On palpation, the abdomen was tender, and cervical movements were not tender. BHCG in the blood came very high. The bedside point-of-care ultrasound (POCUS) showed free fluid in the abdomen and a sac in the left adnexa with a living fetus (visible heartbeats). The conventional ultrasound showed 14 weeks of an extrauterine gestational sac with visible early pregnancy. Differential diagnosis was either an abdominal pregnancy versus a complicated tubal pregnancy. The surgical pathology report confirmed the diagnosis of ectopic tubal pregnancy as the tube was dilated in the middle portion containing chorionic villi, decidual reaction, and the whole gestational sac consistent with the ectopic tubal pregnancy. The patient had a successful laparotomy with salpingectomy and hemostasis and did well after the operation. So, an intact ectopic tubal pregnancy may last until the 14th week of gestation.
BackgroundSpontaneous oesophagal rupture is a rare and non-common presentation which requires a high level of clinical suspicion. Case presentationA 39-y-old patient presented with atypical symptoms of severe abdominal pain, constipation, and vomiting. Abdominal pain resolved after initial treatment, thought to have acute abdominal pathology, initial chest X-ray & abdominal X-ray were normal studies with no identified acute pathologies. The patient was kept under observation till deterioration happened, a computed tomography scan (CT scan) was done for suspected intra-abdominal sepsis, and then images showed a ruptured oesophagus. Eventually, the patient was admitted for urgent surgical intervention. ConclusionsThis case report describes a rare Emergency Department (ED) presentation which requires a high index of suspicion, early diagnosis, and urgent management.
Superior vena cava (SVC) syndrome is a group of symptoms caused by complete or partial obstruction of the flow of blood through the SVC. The obstruction is, in most cases, caused by the formation of thrombus or infiltration of a tumour through the vessel wall. The result is venous congestion that creates a clinical situation relating to increase in the venous pressure in the upper part of the body. Symptoms commonly associated with vena cava syndrome include cough, dyspnoea, swelling of the neck, face and the upper extremities and dilation of the chest vein collaterals. In this paper, we examine the case of a 50-year-old man who presented to the emergency department with ‘sore throat’ which can be easily misdiagnosed as a case of uncomplicated acute pharyngitis. It was a real challenge to diagnose our patient as SVC syndrome caused by bronchogenic carcinoma.
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