A novel coronaravirus, identified as SARS-CoV-2, spread throughout the world in 2020. The COVID-19 pandemic has led to many discoveries and clinical manifestations. A young patient is presented with new, self-resolving neutropenia presenting weeks after a prolonged hospital stay for COVID-19 pneumonia. Workup included analysis for underlying infection, nutritional abnormalities, malignancy, medication and toxin exposure, all of which were negative. From 2020 to the present, few reports have described neutropenia associated with a recent COVID-19 infection. In particular, no reports have described a delayed presentation of neutropenia. The authors would like to propose that the significant inflammatory response associated with COVID-19 is likely what led to this patient’s postviral neutropenia. Furthermore, in young healthy patients, bone marrow biopsy may be deferred and a watchful-waiting approach may be taken to assess for neutropenia resolution.

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Barranco-Trabi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Shewanella algae is a gram-negative, nonfermenting, oxidase-positive, motile bacillus that is ubiquitous in aquatic ecosystems. Human infections are rare and the immunocompromised are left most vulnerable. Risk factors for this infection include exposure to seawater, consumption of raw seafood, and underlying comorbid conditions such as hepatobiliary disease and chronic cutaneous ulcers. Previously documented cases of S. algae have involved near drownings, contaminated raw shellfish, or wound exposure to seawater, mud, sand, and sewage. This case study is unique in that it describes Shewanella bacteremia without any of these typical preceding exposures. We present a case of S. algae pneumonia and bacteremia in an elderly male patient living at a long-term care facility without any recent open water exposure.

INTRODUCTION: Cocaine use is associated with arterial vasoconstriction and enhanced thrombus formation. Rarely, these effects on the intestinal blood supply result in intestinal ischemia. Cocaine-induced ischemic colitis is a relatively poorly-defined variant of this phenomenon, but some studies suggest it may be associated with higher morbidity and mortality than other etiologies. Therefore, timing is critical in both diagnosis and initiating treatments to prevent poor outcomes. We present a case of a middle-aged patient who had an unusual presentation for ischemic colitis due to cocaine abuse. CASE DESCRIPTION/METHODS: A 49-year-old male with a history remarkable only for alcohol and cocaine use disorders presented with a two day history of hematemesis with syncope and severe abdominal pain. Urine drug screen was positive for cocaine on admission, and initial workup with EGD was grossly unremarkable. An abdominal CT scan showed extensive circumferential submucosal fat but without colonic wall thickening or other signs of acute process, and a mesenteric angiography was similarly unrevealing. However, his clinical condition continued to deteriorate over the next 48 hours with worsening abdominal pain, and he began passing large melanic stools with occasional frank red blood. He subsequently became septic; due to concern for ischemic bowel, a colonoscopy was emergently performed. Diffuse severe ischemic changes with deep cratered ulcers in the descending, transverse, and ascending colon were noted. Emergent laparotomy was performed for a near-total colectomy, after which the patient began to stabilize. DISCUSSION: Long-term cocaine abuse is associated with multiple vascular morbidities, including bowel ischemia. Our patient presented in extremis due to bowel ischemia of both SMA and IMA territories requiring intensive care and emergent colectomy. Interestingly, despite the widespread vascular compromise, initial symptoms were nonspecific without blood per rectum and imaging was unremarkable, including CT and angiography. This illustrates the importance of maintaining clinical suspicion and the utility of colonoscopy in diagnosis, as his unusually diffuse disease eventually necessitated a colectomy in this middle-aged man with otherwise unremarkable medical history.

Urate crystal gout arthritis and calcium pyrophosphate deposition disease (CPPD) are crystalline arthropathies seen in middle age to elderly patients, but are also seen in the active duty military population. Flares of either can be identified by acute joint pain, associated swelling, tenderness, and warmth. Definitive diagnosis involves synovial analysis from arthrocentesis. Gout and CPPD are common inflammatory joint diseases. Both arthropathies presenting themselves in the same joint are rather rare. An elderly female with a history of gout presented to the hospital with severe hip pain. She was on urate-lowering therapy at the time, and uric acid levels on admission were not significantly elevated. Radiographic imaging of her hip demonstrated periarticular cartilage calcifications. A review of radiographic imaging over the last 20 years found significant erosive arthropathy in multiple joints and radiographic evidence of chondrocalcinosis, suggesting CPPD. Synovial analysis was not obtained during this admission as the patient declined procedures due to her elderly age. Her condition improved with oral steroids. Few literatures have demonstrated that gout and CPPD are common crystal arthropathies that can occur concomitantly in the same joint. A 20-year review of imaging in an elderly female with known gout arthropathy found that she had radiographic evidence of concomitant CPPD-associated damage to many of her joints. Clinicians should be aware of the different erosive arthropathies, their corresponding imaging findings, evaluation for underlying metabolic disorders if appropriate, and the possibility that they may occur in the same joint. Early prevention can reduce joint destruction later in life.

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Health inequalities based on race are well-documented, and the COVID-19 pandemic is no exception. Despite the advances in modern medicine, access to health care remains a primary determinant of health outcomes, especially for communities of color. African-Americans and other minorities are disproportionately at risk for infection with COVID-19, but this problem extends beyond access alone. This study sought to identify trends in race-based disparities in COVID-19 in the setting of universal access to care. Tripler Army Medical Center (TAMC) is a Department of Defense Military Treatment Facility (DoD-MTF) that provides full access to healthcare to active duty military members, beneficiaries, and veterans. We evaluated the characteristics of individuals diagnosed with SARS-CoV-2 infection at TAMC in a retrospective, case-controlled (1:1) study. Most patients (69%) had received a COVID-19 test within 3 days of symptom onset. Multivariable logistic regression analyses were used to identify factors associated with testing positive and to estimate adjusted odds ratios. African-American patients and patients who identified as “Other” ethnicities were two times more likely to test positive for SARS-CoV-2 relative to Caucasian patients. Other factors associated with testing positive include: younger age, male gender, previous positive test, presenting with >3 symptoms, close contact with a COVID-19 positive patient, and being a member of the US Navy. African-Americans and patients who identify as “Other” ethnicities had disproportionately higher rates of positivity of COVID-19. Although other factors contribute to increased test positivity across all patient populations, access to care does not appear to itself explain this discrepancy with COVID-19.