Background: Percutaneous endoscopic gastrostomy (PEG) is a popular method for long-term enteral feeding. Our aim was to determine potential risk factors for adverse events related to PEG, as well as consequent prolonged hospitalization. Methods: Data were retrospectively collected from the admission records of a tertiary center between July 2015 and June 2018. Possible predictors of the 3 following outcomes were evaluated: minor PEG-related adverse events, major PEG-related adverse events, and length of hospital stay. Data were tested for correlation using the Spearman coefficient and for association using Kruskal-Wallis tests for significance. Results: A total of 362 admissions involving 146 patients were included in the study. Of the admissions, 221 (61.0%) had only minor adverse events, 100 (27.6%) had only major adverse events, and 41 (11.3%) had both. Eighty (22.1%) had PEG-site infection and 128 (35%) had aspiration pneumonia. Serum albumin levels at presentation were negatively correlated with the length of hospitalization (P<0.001), which also differed between patients presenting with major and minor adverse events (P<0.001 and P=0.026). The Charlson comorbidity index was positively correlated with the duration of hospitalization (P<0.001). Higher index scores were found more among patients presenting with aspiration pneumonia (P=0.004) and lower scores were found among patients presenting with PEG site infection and inadvertent PEG removal compared with those presenting with a major complication (P<0.001). Conclusion: The patient’s general medical condition and nutritional status are the greatest risk predictors for developing adverse events related to their PEG feeding, as well as a consequent extended hospital stay.

A 62-year-old previously healthy male was admitted with new onset generalised tonic-clonic seizures. Treatment was initiated with the antiepileptic levetiracetam and he had no further episodes of seizures. Creatine kinase (CPK) level was 1812 IU/L 12-hour postadmission. Despite good hydration, his CPK levels continued to rise dramatically and reached a level of 19 000 IU/L on day 5. This rise was unexplained as he did not have any further seizures and had a normal renal function. In the absence of other risk factors, the rare possibility of levetiracetam being responsible for the disproportionately high CPK was considered. Within 12 hours of withdrawal of levetiracetam, there was a downward trend in the CPK levels, with a 10-fold decrease in CPK levels over the next 4 days. This is only the ninth case reported in literature regarding this rare and potentially serious adverse effect of levetiracetam.

A 41-year-old male with type 2 diabetes mellitus (T2DM) presented with complaints of recent onset limb weakness, diffuse body rash and fever. Computerized Tomography (CT) scan of the brain did not reveal a stroke but laboratory investigations of the patient portrayed multi-systemic involvement. Naso-pharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was taken which resulted as positive. Soon after, a biopsy of the skin lesions revealed histo-pathological features of leukocytoclastic vasculitis. The patient was further investigated for connective tissue disease and vasculitis only to yield a negative result for all relevant antibodies, with the exception of the anti-phospholipid antibody which was positive. The patient suffered through a complex and prolonged hospital stay that required the input of multiple sub-speciality teams. Although initially presenting with a normal chest X-ray the patient went on to have severe bilateral pneumonia and a progression of initial skin rash leading to severe necrosis of the left foot with dry gangrene of the left big toe. Due to these issues, coronavirus-disease-2019 (COVID-19) aimed therapy was started along with multiple skin debridements, antibiotics and eventual amputation of the patient’s affected large toe. The following case-study details all the before-mentioned events with discussion of the possible reasons behind the patient’s presentation and eventual outcome.

Objective: To analyze the coronavirus disease-2019 (COVID-19) patients presenting with acute stroke by determining their clinical characteristics, hospitalization course and prognosis. The common and conventional stroke risk factors in these patients were assessed with the aim of determining the role and contribution of the COVID-19 infection to stroke pathogenesis. Methods: Retrospective observational study involving 24 patients from a single tertiary care center over a time period of three months. Risk factors such as Age, Hypertension, Diabetes Mellitus, smoking status and underlying cardiac history were analyzed. COVID-19 relevant laboratory and radiological data were documented. Results: 87.5% of patients had ischemic stroke, with 58.3% of total patients being younger than 55 years. An equal incidence of both Diabetes Mellitus and Hypertension (37.5%) was identified. 29.2% were completely asymptomatic for COVID-19, of which 85.7% had no chest X-ray changes on admission. Eight patients (61.5%) developed pneumonia during admission despite an initially normal chest X-ray. Conclusion: Patients without COVID-19 symptoms and with normal chest radiography presenting with stroke does not rule out a possible underlying COVID-19 infection. Such patients may be positive for the virus and may go on to develop pneumonia shortly after suffering from strokes. This could suggest that stroke in COVID-19 patients is a possible initial presenting feature and consequence of the inflammatory state triggered by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. It is imperative to analyze the association of COVID-19 and stroke, and to maintain a high index of suspicion of COVID-19 infection in stroke patients, to enhance early detection and reduce transmission.

A 43-year-old woman with no known cardiovascular risk factors was admitted with a second episode of ischaemic stroke. She was not a known case of connective tissue disease like systemic lupus erythematosus or antiphospholipid syndrome (APS). During the current episode, she was found to have markedly deranged coagulation parameters and laboratory evidence of microangiopathic haemolysis, but no evidence of sepsis or active bleeding. Further investigation revealed multiple organ infarcts. A diagnosis of probable catastrophic APS was made and she improved dramatically with a combination of plasmapheresis, corticosteroids and therapeutic anticoagulation. Serological markers of APS were negative. Her hospital course was complicated by Libman Sacks endocarditis with significant aortic regurgitation that improved markedly with anticoagulation obviating the need for high-risk cardiac surgery. At discharge, she was stable and well and was advised long-term anticoagulation and rheumatology follow-up.

Background: Streptococcus suis is a zoonotic infection known to cause meningitis and sepsis, in addition to several other rare manifestations. Infection with this organism is rare in the absence of pork ingestion or a handling history. Case presentation: The authors report the case of a 62-year-old male with no animal contact history, who presented with symptoms of urinary tract infection. It was his second infection over the course of 2 years. His urine culture was positive for Escherichia coli but his blood culture was positive for S. suis. Ultrasound of the abdomen ruled out underlying predisposing urinary pathology. However, it did show several heterogeneous liver masses with abnormal vascularity. A follow-up abdominal CT revealed a malignant neoplastic process involving the sigmoid colon with metastatic liver lesions. Colonoscopy demonstrated a fungating mass at the sigmoid colon and biopsies revealed a moderately differentiated adenocarcinoma. Conclusion: This case suggests the possibility of associated colon cancer in patients presenting with S. suis with no explicit history of animal or pork contact. It also proposes the existence of an association between colon cancer with Streptococcus species other than bovis.

A young man with a history of recurrent respiratory tract infections for the past 8 years presented with generalised anasarca. He was found to have advanced renal disease (stage 4) and a profound proteinuria of 82.9 g/day. Further workup revealed the presence of advanced bronchiectatic changes in the lungs. Rectal biopsy showed the characteristic pattern of amyloid deposition. A diagnosis of systemic amyloidosis secondary to bronchiectasis was made. To the best of our knowledge no other cases of bronchiectasis-associated renal amyloid disease with such marked proteinuria have been reported in the literature. Our patient had a relatively short duration between the onset of his symptoms related to underlying bronchiectasis and his clinical presentation of renal amyloidosis. He had an aggressive course of disease and unfortunately died at a very young age.

SUMMARYWe present a case of a middle-aged woman who presented with acute onset of non-erosive oligoarthritis and cutaneous lesions. Her laboratory work up revealed mild anaemia with positive antinuclear antibody. Her skin biopsy confirmed the presence of interstitial granulomatous dermatitis. She was treated with a successful trial of non-steroidal anti-inflammatory agents. Interstitial granulomatous dermatitis with arthritis (IGDA), or Ackerman syndrome, is an under-recognised cause of arthritis with dermatitis. This is primarily due to the varied clinical presentation of the skin lesions and the non-specific laboratory findings. Our aim is to highlight the pivotal role of skin biopsy as part of the diagnostic assessment of patients who present with arthritis and concomitant skin lesions. BACKGROUND