Lung cancer is one of the most common cancers in America. Frequent sites of metastasis include the Hilar lymph nodes, adrenal glands, liver, brain, and bone. The following case report is of a primary lung cancer with metastases to the breast and skin. Case. A 48-year-old African American male with a past medical history of poorly differentiated left breast cancer status after modified radical mastectomy (MRM), chronic obstructive pulmonary disease, and smoking (20 pack-years) presents to the ER with progressive shortness of breath on exertion, upper back pain, and weight loss for 2 months in duration. On physical examination he is found to have a MRM scar on his left breast and a left periumbilical cutaneous mass. Chest X-ray and chest CT reveal a right upper lobe mass and biopsies from the breast, lung, and the periumbilical mass indicate a poorly differentiated carcinoma of unclear etiology; all tumor markers are negative. The patient is male and a chronic smoker; therefore the diagnosis is made as lung carcinoma with metastases to the breast and skin. Conclusion. A high index of suspicion for cutaneous metastases should be cast when investigating cutaneous pathologies in patients at risk for primary lung malignancy.

Primary Pulmonary Diffuse Large B Cell Lymphoma (PPDLBCL) is an extremely rare entity, which exhibits an aggressive behavior by compressing local blood vessels. It represents only 0.04% of all lymphoma cases and is extremely rare in young age. We present a case of a primary pulmonary lymphoma with superior vena cava syndrome (SVCS) in a young female. 27-year-old African American female presented with fever, cough, and facial puffiness for 2 weeks and unintentional weight loss. Chest examination showed decreased breath sounds and dullness on percussion on right side. Labs were normal except for mild leukocytosis, high lactate, and lactate dehydrogenase. Chest X-ray showed a large right side infiltrate with pleural effusion but chest CT showed 10 × 14 × 16 cm mass in the right lung without hilar and mediastinal lymphadenopathy. CT guided biopsy of the right lung mass was done and large B cell lymphoma was diagnosed. She received “involved field radiation” because of the bulky tumor size and superior vena cava involvement prior to R-CHOP to which she responded well. PPDLBCL should be considered as one of the differentials in a young patient with a large lung mass, which needs timely diagnosis and management.

Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by 'Anxiety' and 'Nervousness' were reported by 8.5% on 'Almost every day' while 46.3% reported on 'several days in the two weeks duration'. 'Uncontrollable worrying', 'Feeling down', 'Depressed,' or 'Hopeless' was reported as 'Not at all' by 78.8% and 3.7% reported it to 'occur nearly every day for the last two weeks'. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

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Objective:We present a rare case of pernicious anemia presented as multi-organ dysfunction syndrome, later found to have pseudo-thrombotic thrombocytopenic purpura.Methods:An 86-year-old female presented with respiratory distress, altered mental status, acute renal failure and was intubated in emergency room. She was found to have severe anemia, thrombocytopenia, high lactate, high lactate dehydrogenase and low haptoglobin. Peripheral smear revealed multilobulated neutrophils with schistocytes, poikilocytes and anisocytes.Results:She was admitted to intensive care unit for altered mental status, multi-organ dysfunction syndrome with severe metabolic acidosis in setting of hemolysis. She was intubated and managed with intravenous antibiotics and blood transfusion. Patient improved significantly after blood transfusion. Lactic acid normalized, acute kidney injury resolved and mentation improved after transfusion. Laboratory investigation revealed low vitamin B12, high methylmalonic acid, high homocysteine, high lactate dehydrogenase, low haptoglobin, high anti-parietal antibody and high anti-intrinsic factor antibody. Patient was diagnosed with pernicious anemia and pseudo-thrombotic thrombocytopenic purpura with concomitant intramedullary hemolysis. Her hematological parameters and her clinical condition improved significantly after starting therapy with cyanocobalamin.Conclusion:Pernicious anemia is a chronic disease with subtle presentation but may present as life-threatening complications. Hemolysis and pseudo-thrombotic thrombocytopenic purpura may present as multi-organ dysfunction syndrome which has dramatic response to appropriate therapy.

Myxedema coma is a decompensated hypothyroidism which occurs due to long-standing, undiagnosed, or untreated hypothyroidism. Untreated hypothyroidism is known to affect almost all organs including the heart. It is associated with a decrease in cardiac output, stroke volume due to decreased myocardial contractility, and an increase in systemic vascular resistance. It can cause cardiac arrhythmias and the most commonly seen conduction abnormalities are sinus bradycardia, heart block, ventricular tachycardia, and torsade de pointes. The authors report a case of an elderly man who presented with sudden cardiac arrest and myxedema coma and who was successfully revived.

Objective: To evaluate influence of asthma on polysomnographic variables of patients with obstructive sleep apnea (OSA). Methods: A longitudinal retrospective study using data collected from the Sleep Heart Health Study (SHHS). Results: All 2822 patients included had OSA, 2599 were non-asthmatic whereas 223 were asthmatics. Average BMI for non-asthmatics was 28.8 kg/m 2 whereas asthmatics had 29.5 kg/ m 2 . Median pack-years of smoking was 1.42 vs. 1.98 in non-asthmatic and asthmatic groups, respectively. Sex distribution, age (in years), BMI, FEV 1 , FVC, AHI ≥ 4% (all apneas, hypopneas with ≥4% oxygen desaturation or arousal per hour of sleep), RDI ≥ 3% (overall respiratory distribution index at ≥3% oxygen desaturation or arousal), sleep latency, percentage of sleep time in apnea/hypopnea and Epworth sleep scale score were all statistically significant. Nonasthmatics had greater AHI (12.63/hr) compared to asthmatics (11.34/hour), p = 0.0015. RDI in non-asthmatics and asthmatics was (23.07 vs 20.53; p = 0.009). Sleep latency was found to be longer in asthmatics 19.8 minutes vs. 16 minutes (p = 0.008). Epworth sleepiness scale score was high in asthmatics (9 vs. 8, p = 0.002). Conclusion: OSA was found more severe in non-asthmatic subgroup, but asthmatics had statistically significant higher Epworth sleepiness scale score and sleep latency. Clinicians should be vigilant and keep low threshold to rule out OSA particularly on patients with difficult to control asthma, smoker, GERD, obese and nasal disease. ARTICLE HISTORY

INTRODUCTION: Cannabis is the most commonly used recreational drug in the United States. Its abuse has been associated with Coronary thrombosis, Myocardial Infraction (MI), Ischemic stroke and central retinal vein thrombosis. We report a case of Sub-massive Pulmonary Embolism (PE) in a young male following heavy cannabis smoking. CASE PRESENTATION: 35-year-old Male with history of Schizophrenia presented to ER with worsening pleuritic chest pain, SOB and pain in the right leg for few days. Other review of systems was negative. He was incarcerated for last 16 months and was released 2 weeks prior to presentation. He was smoking cannabis heavily since his release. Physical examination was unremarkable except for tachycardia and initial labs showed troponin 0.16, BNP 419 and respiratory alkalosis. Urine toxicology was positive for cannabinoids. EKG revealed sinus tachycardia with T wave inversion in lateral leads. Chest X-Ray was unremarkable. CT chest revealed multiple large bilateral emboli and Echo showed right heart strain with moderate pulmonary hypertension. In next 24 hours he was hemodynamically unstable in respiratory distress requiring 10 Litre oxygen. He underwent catheter directed thrombolysis and was symptomatically better.the following day. Right pulmonary artery pressure decreased from 68/26 to 34/13. Duplex of leg veins showed a thrombus in right popliteal vein. Patient had no obvious risk factors for VTE. All workup for hypercoagulability was negative. DISCUSSION: Cannabis abuse has been associated with MI, Ischemic stroke, and Central retinal vein thrombosis in young patients. It is also known to trigger thrombosis in women using oral contraceptive pills. Cannabis induced VTE has not been reported except one case of PE in a young male. The exact mechanism by which cannabis induces hypercoagulability and thrombosis is still not well known. Some studies have reported that Cannabinoids, the active component of cannabis causes endothelial cell disruption leading to vascular thrombosis. In our case, cannabis in association with tobacco was the only risk factor, which we believe was the potential trigger that increased the risk of VTE. CONCLUSIONS: We illustrate a cause of VTE that mostly will be overlooked. Given the prevalence of cannabis use clinicians should consider it in their differential in a thrombotic event especially in young patients.