Patient: Male, 55-year-old
Final Diagnosis: Acute intestinal infarction • COVID provoked thromboembolism • superior mesenteric artery thrombosis
Symptoms: Abdominal pain • diarrhea • nausea
Medication:—
Clinical Procedure: Exploratory laparotomy • primary anastomosis • small bowel resection • thromboembolectomy
Specialty: Gastroenterology and Hepatology • General and Internal Medicine • Surgery
Objective:
Unusual clinical course
Background:
The novel COVID-19 disease caused by the SARS-CoV-2 virus is a highly infectious disease that originated in Wuhan, China, and has rapidly spread throughout the world. In addition to respiratory complications, the virus has also been implicated in damage to other organ systems as well as coagulopathy. The present report describes the first presumptive case of COVID-19-associated acute superior mesenteric artery thrombosis and acute intestinal ischemia.
Case Report:
A 55-year old man presented to the emergency department with nausea, generalized abdominal pain and diarrhea; he denied having a fever or any respiratory symptoms. Computed tomography (CT) of the abdomen and pelvis revealed bilateral pulmonary ground-glass opacities. He tested positive for SARS-CoV-2, and was treated with hydroxychloroquine, azithromycin and ceftriaxone, and was discharged home after five days of inpatient treatment. One week later, the patient returned with recurrent nausea, vomiting and worsening diffuse abdominal pain. A CT scan of the abdomen showed a 1.6-cm clot, causing high grade narrowing of the proximal superior mesenteric artery and bowel ischemia. The patient emergently underwent exploratory laparotomy, thromboembolectomy and resection of the ischemic small bowel. A post-operative complete hypercoagulable workup was unrevealing.
Conclusions:
Despite the absence of respiratory symptoms, patients infected with SARS-CoV-2 may show atypical presentations, such as gastrointestinal symptoms. Clinicians managing patients with suspected or confirmed SARSCoV-2 infection during the COVID-19 pandemic should monitor these patients for potential complications that may arise from this disease.
Several studies have reported influenza A (H1N1) virus as a cause of fulminant myocarditis. We report the first fatal case of fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and ventricular tachyarrhythmia associated with influenza A (H1N1) in a previously healthy pregnant woman. A 38-year-old Asian woman, gravida 3, para 1-0-1-1, presented with flu-like symptoms. Initially, she developed wide-complex tachycardia requiring several defibrillations and was later intubated. Electrocardiogram showed ST-segment elevation. Coronary angiogram was negative and a pulmonary angiogram ruled out pulmonary embolism. Fetal compromise was noted on the monitor, and the patient underwent an emergent cesarean section. She subsequently expired. Autopsy confirmed severe myocarditis. Further testing confirmed influenza A (H1N1) virus. This case of a rare, yet lethal, complication of H1N1 infection underscores the importance of increased awareness among health care professionals to provide pregnant women with vaccination and prompt treatment.
One-half of patients with newly diagnosed pancreatic cancer will have metastatic disease at the time of diagnosis, mainly due to its non-specific initial clinical presentation which includes abdominal pain, dyspepsia, weight loss, bowel habit changes, jaundice and pruritus. The signs, symptoms and stage of the disease at initial diagnosis depends on the origin of the primary tumor, with tumors of the head presenting earlier with obstructive symptoms while tumors of the body/tail are often diagnosed at an advanced stage due to their non-specific presentation. The most common sites of metastasis are the lymph nodes, liver, lung, and peritoneum. The presence of metastatic disease in the skeletal muscles is a rare manifestation of pancreatic cancer and has been described in a limited number of cases. We report the case of a pancreatic cancer patient with a solitary muscle lesion as the only site of extra-nodal metastasis upon initial presentation.
Amyloidosis involves the deposition of abnormal proteins in various tissues and results in progressive organ dysfunction, commonly affecting multiple organs. Two types of systemic amyloidosis are AA and AL; the former is associated with acute phase reactions and the latter is composed of light chain immunoglobulins. This disease commonly affects the kidneys and is evidenced by massive proteinuria. A biopsy is the gold standard of diagnosis, with Congo Red staining revealing an apple-green birefringence under polarized light. Although the kidneys are frequently affected in this disease, it is rare that amyloidosis is limited to the kidneys without involvement of other organs. We present an 83-year-old female with bilateral lower extremity swelling for several months who was found to have 12.374 grams of protein in a 24-hour urine sample and a large amount of free lambda chains. A renal biopsy demonstrated renal amyloidosis of the AL type. Serum immunofixation and flow cytometry were unremarkable for any plasma dyscrasia; a bone marrow biopsy did not reveal systemic amyloidosis and imaging with PET/CT scan did not show evidence of other organ involvement. She was diagnosed with renal-limited amyloidosis and started on bortezomib, melphalan, and steroids. Clinicians should be aware of the signs and symptoms of amyloidosis, specifically its ability to present with unusual involvement of individual organs.
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