Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) primarily affects the lungs, causing respiratory symptoms. However, the infection clearly affects all organ systems including the gastrointestinal system. Acute pancreatitis associated with coronavirus disease 2019 (COVID-19) has been widely reported Recent studies have discussed pancreatic compromise incidentally in asymptomatic patients, or in a form of clinical symptoms such as abdominal pain, nausea, or vomiting, which is further reflected in some cases with abnormal serum lipase and amylase levels It was suggested that upregulation of angiotensin-converting enzyme II cell receptors or inflammatory cytokines play a major role in predisposing pancreatic injury in SARS-CoV-2 positive patients To date, there is insufficient data to establish the causality of acute pancreatitis in SARS-CoV-2 infected cases. In this paper, we organize recent studies conducted to observe the frequency of acute pancreatitis associated with COVID-19 cases while highlighting present hypotheses, predisposing factors, and their effect on the outcome, and point to gaps in our knowledge.

Patient: Female, 69-year-old Final Diagnosis: Neurosyphilis Symptoms: Altered mental status • unresponsiveness Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine • Neurology Objective: Unusual clinical course Background: Neurosyphilis is a bacterial infection of the brain and the spinal cord, caused by Treponema pallidum. Its non-specific clinical presentation includes cognitive impairment and motor and/or sensory function compromise. Neurosyphilis infections in patients with HIV have increased over the past few years and many cases of neurosyphilis manifest in patients with HIV who have low CD4 T-cell counts and high viral loads (VL). However, there is extremely limited acknowledgement in the literature about neurosyphilis presentations in patients with HIV who have normal CD4 counts. Case Report: We present a neurosyphilis and HIV coinfection in a patient with a normal CD4 count and an undetectable VL. A 69-year-old woman with a medical history of HIV was on a prescribed antiretroviral treatment regimen. She presented in the Emergency Room in an unresponsive state, although this had been preceded by a period of rapidly progressive cognitive decline. Her brain computed tomography scan without contrast was unremarkable. Laboratory test results were within normal limits, except for a positive result for the microhemagglutination assay for Treponema pallidum antibodies and rapid plasma regain (RPR) test, which was highly suggestive of neurosyphilis as a presumed diagnosis. She showed remarkable clinical improvement after the initiation of conventional treatment for neurosyphilis, which is a 14-day regimen of intravenous penicillin G. Conclusions: Given the broad neurological manifestations of neurosyphilis and its increasing incidence in patients with HIV, it is important to consider neurosyphilis in the differential diagnosis after ruling out other causes of encephalopathy, especially in patients with an undetectable VL and a normal CD4 count.

Introduction: Multiple myeloma is an uncommon hematological neoplasm. This malignancy involves unchecked plasma cell growth in the bone marrow, but in a subset of often more advanced cases, these cells may migrate to soft tissues causing extramedullary plasmacytoma. This is unusual, and, in the literature, few cases of extramedullary plasmacytomas involve the gastrointestinal tract. Within this system, the more common locations are the stomach, the liver, the large bowel, and more rarely, the small bowel. Case Description/Methods: A 59-year-old male with a medical history of chronic hepatitis C, and Stage III multiple myeloma status post four cycles of chemotherapy presented with altered mental status. Upon evaluation, he had significant electrolyte abnormalities, remarkable anemia, severe renal and liver dysfunction, and a positive hemoccult test. Our patient received intravenous fluid, and multiple blood products. He was then admitted to the intensive care unit for a high level of care. On the second day of admission, he developed new onset hematemesis, and the gastroenterology team was consulted. The patient was started on a pantoprazole drip. Urgent esophagogastroduodenoscopy showed several polypoid appearing masses with overlying ulceration in the gastric fundus (Figure a &b), and tissue biopsies were obtained. Biopsy result of the polypoid fundal mass showed a large cell neoplasm with plasmocytic differentiation. Gastric tissue sections showed an ulcerated lesion with submucosal, tightly packed atypical large cells with multinucleation, prominent nucleoli and relatively identifiable mitoses (Figurec). A panel of immunohistochemical stains with plasma cell markers were positive for kappa, Multiple Myloma-1 nuclear protein, and CD138 (Figure d-f). The overall findings were compatible with gastric involvement by a plasma cell neoplasm. Discussion: This case highlights a complicated, yet a uniquely rare presentation of extramedullary plasmacytoma in a patient diagnosed with multiple myeloma. Although the gastrointestinal tract is rarely involved in patients with multiple myeloma, it should be considered as the differential diagnosis in patients with gastrointestinal bleeding especially with a known concurrent systemic hematological malignancy. The presence of gastrointestinal involvement and the malignant phase of multiple myeloma are associated with a poor prognosis despite aggressive therapy, and it is therefore paramount to establish an accurate diagnosis early to avoid any delays in treatment.[2691] Figure 1. (a,b) EGD shows polypoid EMP in the gastric fundus. (c) Infiltration of plasmablasts with highly atypical nuclei and prominent nucleoli (hematoxylin-eosin 20x). (d) Granular positivity for kappa immunoglobulin light chain. (e) Positive immunostaining for MUM-1. (f) Positive CD138 immunostaining highlights the plasma cells in the lamina propria of the gastric fundus EMP.

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