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Damage to the liver or kidney can occur through direct toxic effects; however, damage can also be drug-induced immune-mediated. Levamisole-adulterated cocaine (LAC) is known to cause antineutrophil cytoplasmic antibody- (ANCA-) associated vasculitis and glomerulonephritis leading to acute kidney injury and end-stage renal disease. It remains unclear whether LAC is associated with hepatic duct damage. Here, we report a case with biopsy-proven evidence of intrahepatic duct damage months after being diagnosed with ANCA-associated crescentic and sclerosing glomerulonephritis caused by LAC use. This case represents the first report of LAC-induced ANCA-associated hepatic duct cholestasis in the setting of previous LAC-induced ANCA-positive glomerulonephritis.

The pathophysiology of coronavirus disease 2019 (COVID-19) involves multi-organ dysfunction, particularly involving the respiratory, cardiovascular and hematological systems. This dysfunction is partly due to systemic inflammation causing a wide array of pathological sequelae thus posing a significant challenge to management despite the advances in treatment made thus far. In this report, we present a COVID-19 patient who developed a transient complete heart block and was temporarily paced as a complication of a saddle pulmonary embolus (PE). The mechanism of complete heart block is unclear, may be related to strain, ischemia, or vagal response. We believe that this is a unique sequence of events in a COVID-19 patient and, to our knowledge, is the first of its kind to be reported.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to the emergence of a wide range of complications, including those affecting the cardiovascular system. In this case series, we present four patients who developed complete atrioventricular block, a serious and potentially lifethreatening heart rhythm disorder, during the course of their coronavirus disease 2019 (COVID-19) illness. The mechanisms by which SARS-CoV-2 may lead to arrhythmias are not fully understood but may involve direct infection and damage to heart tissue, as well as inflammation and cytokine storms. The extent and duration of complete heart block varied among these cases, highlighting the need for further research to understand the spectrum of disease and to improve mortality and morbidity in future waves of SARS-CoV-2 infections. We hope that this case series will draw attention to this serious complication of COVID-19 and inspire further research to improve management and outcomes for affected patients.

Zieve syndrome is a very rare syndrome that presents as a triad of hemolytic anemia, jaundice, and transient hyperlipidemia in patients with alcoholic liver disease. Herein, we present a case of a 30-year-old female with alcoholic liver disease and chronic hepatitis C. She presented with altered mental status and profound jaundice and was subsequently found to have acute hemolytic anemia due to Zieve syndrome. All other causes of hemolytic anemia were ruled out. She abstained from alcohol and received blood transfusions as needed, leading to the improvement of her anemia. This case highlights the need for more medical education about Zieve syndrome as the under-recognition of the disease can lead to unnecessary treatments. We review the existing literature to explain the epidemiology, pathogenesis, diagnosis, and treatment of Zieve syndrome. This case represents a rare presentation of Zieve syndrome in a patient with hepatitis C, and we have hypothesized a possible role of chronic hepatitis C infection in its pathophysiology.

The study by Omelchenko et al 1 concluded that, unlike the general population, low-density lipoprotein-cholesterol (LDL-C) levels were not associated with ischemic stroke risk among patients with atrial fibrillation treated with direct oral anticoagulants (DOACs). To arrive at this conclusion, they retrospectively analyzed data of 21,229 patients with a first-time diagnosis of nonvalvular atrial fibrillation treated with DOACs categorized according to the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category, or CHA 2 DS 2 -VASc, score and then further into 4 subgroups according to LDL-C levels. Of note, these patients were already on DOACs, which, as the authors rightly stated, provide cardiovascular benefits, including mitigating the risk of ischemic stroke in high-risk patients. 2 It, therefore, comes as no surprise that stratifying patients already on DOACs based on LDL-C levels showed no association with ischemic stroke. Also, these patients are likely going to have other cardiovascular comorbidities. As such, one will expect a good number of them, especially those with high CHA 2 DS 2 -VASc scores, to be on antiplatelet therapies (such as aspirin as mentioned in Table 1) that will further mitigate the risk of ischemic stroke. Although the authors adjusted for other comorbidities and prior statin therapy, no adjustment for antiplatelet therapy was reported. Also, individuals in the high CHA 2 DS 2 -VASc score category are likely to be on multiple other medications, such as

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