In addition to typical respiratory symptoms, patients with SARS-CoV-2 infections may also exhibit extra-pulmonary clinical manifestations. As we continue to discover more about SARS-CoV-2, it is becoming evident that its presentation, course of disease along with clinical manifestations differs from person to person. Not only that it is presenting with a wide range of findings, skin manifestations might be one of the rare signs of the disease. We encountered a unique case in our outpatient setting via telemedicine. Our patient presented with usual signs and symptoms of the disease and developed a total body urticarial eruption with red margins and raised skin colored center, four days after our initial encounter. Later she tested positive for COVID-19. She did not require hospitalization and was managed with supportive care and antihistamines.
Light’s criteria are the cornerstone to differentiate exudates from transudates. The traditional literature states that malignant pleural effusions are rarely transudative; therefore, cytology tends to be low yield and not a cost-effective decision. This case describes an 82-year-old female who developed a transudative pleural effusion despite having an underlying malignancy, highlighting the importance of integrating clinical judgment into pursuing thoracentesis with the cytological examination.
The coexistence of multiple myeloma and chronic myelomonocytic leukemia in the same patient is a rare entity. Here we describe a case of an 80-year-old man who presented to our hospital with symptoms of dyspnea and found to have anemia and leukocytosis with peripheral monocytosis. Bone marrow biopsy, flow cytometry, and fluorescence in situ hybridization studies were consistent with a laboratory diagnosis of multiple myeloma and chronic myelomonocytic leukemia. Due to advanced age and multiple comorbidities, the patient was treated conservatively. At 26 months follow-up, the patient continues to do well.
INTRODUCTION: Fulminant Myocarditis (FM) is characterized by diffuse myocardial inflammation and acute onset severe heart failure, high incidence of ventricular arrhythmias and cardiogenic shock, often requiring Mechanical Circulatory Support (MCS). The incidence of FM is undetermined, with high mortality rates. It is mostly found post-mortem and identified in up to 10% of cases of myocarditis. Gold standard for diagnosis is endomyocardial biopsy (EMB) that can direct further therapy. We present a case of fulminant lymphocytic myocarditis complicated with recurrent ventricular tachycardia (VT) storm requiring Mechanical circulatory support (MCS) responding to Intravenous immunoglobulin (IVIG) therapy. CASE PRESENTATION:A 47-year-old woman with no significant cardiac history presented after a witnessed VT arrest post defibrillation with return to spontaneous circulation in 5 minutes. Emergent Percutaneous Intervention (PCI) demonstrated nonobstructive coronary disease and ejection fraction (EF) of 10%. Her hemodynamic parameters were consistent with cardiogenic shock requiring left ventricular assistance with IMPELLA and subsequently veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Hospital course was complicated with recurrent sustained VT requiring multiple ablations and ICD placement. EMB was pursued for diagnosis and was consistent with multifocal eosinophilic and lymphohistiocytic inflammation associated with necrotic and ischemic cardiomyocytes. Immunohistochemistry was negative for viral markers, autoimmune, giant cell myocarditis and sarcoidosis. She was started on IVIG for 5 days and a steroid taper with subsequent clinical improvement and stabilization of hemodynamic parameters. The patient was ultimately decannulated with improvement of cardiac function with EF to 35% and reduction in arrhythmogenic activity.DISCUSSION: Major causes of myocarditis are infectious, toxic and immune-mediated. Fulminant myocarditis is an uncommon but potentially fatal condition with challenging management. Common histologic patterns include Giant cell, lymphocytic, eosinophilic, polymorphic and sarcoidosis. EMB guided early diagnosis can be beneficial for initiating specific therapy. Currently, there is conflicting data about the benefits of IVIG and steroids. As noted in our case, histological predominance was a lymphocytic/eosinophilic pattern and other causes were ruled out. This prompted therapy with immunomodulators and corticosteroids leading to clinical improvement.CONCLUSIONS: IVIG and Steroid use in non-viral eosinophilic/lymphocytic pericarditis can provide clinical benefit. Further studies and clinical trials are needed to ascertain the role of immunomodulatory therapy in such cases.
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