This 60-year-old male was hospitalized due to moderate ARDS from COVID-19 with symptoms of fever, dry cough, and dyspnea. We encountered several difficulties during physical therapy on the acute ward. First, any change of position or deep breathing triggered coughing attacks that induced oxygen desaturation and dyspnea. To avoid rapid deterioration and respiratory failure, we instructed and performed position changes very slowly and step-by-step. In this way, a position change to the 135° prone position () took around 30 minutes. This approach was well tolerated and increased oxygen saturation, for example, on day 5 with 6 L/min of oxygen from 93% to 97%. Second, we had to adapt the breathing exercises to avoid prolonged coughing and oxygen desaturation. Accordingly, we instructed the patient to stop every deep breath before the need to cough and to hold inspiration for better air distribution. In this manner, the patient performed the breathing exercises well and managed to increase his oxygen saturation. Third, the patient had difficulty maintaining sufficient oxygen saturation during physical activity. However, with close monitoring and frequent breaks, he managed to perform strength and walking exercises at a low level without any significant deoxygenation. Exercise progression was low on days 1 to 5, but then increased daily until hospital discharge to a rehabilitation clinic on day 10.
A 39-year-old man was hospitalized due to an increasingly reduced general health condition, after persistent fever and dry cough for 2 weeks. The patient initially needed 4 L/min of oxygen, had a rapid and shallow breathing pattern at rest and became severely breathless during minor physical activities. In the beginning, physical therapy focused on patient education about dyspnea-relieving positions, the importance of regular mobilization, and deep-breathing exercises. However, it quickly became evident that his anxiety from fear of dying and worries about his future aggravated his dyspnea and vice versa. The patient was so dyspneic, anxious, and weak that he was barely able to walk to the toilet. To counter this vicious circle, the physical therapist actively listened to the patient, explained why he was experiencing breathlessness, and tested suitable positions to relieve his dyspnea. He seemed to benefit from the education and the relaxing breathing exercises, as seen on day 2, when his respiratory rate could be reduced from 30 breaths/min to 22 breaths/min and his oxygen saturation increased from 92% to 96% on 4 L/min oxygen after guiding him through some deep-breathing exercises. Over the next days, his dyspnea and anxiety started to alleviate and he regained his self-confidence. Therapy was progressively shifted to walking and strength training and the patient rapidly advanced to walk 350 m without a walking aid or supplemental oxygen before his discharge home.
One week after a positive COVID-19 result this 57-year-old male was admitted to the ICU because of oxygen desaturation (70%) with worsening tachypnea and dyspnea. Physical therapy started immediately after ICU admission. We found a highly dyspneic patient with a high breathing frequency and significant symptom exacerbation from the slightest effort. With hands-on physical therapy guidance, the patient managed to achieve a 135° prone position and to perform deep-breathing exercises resulting in an increase in oxygen saturation from 88% to 96%. Intensive physical therapy and positioning was continued along with 6 to 12 L/min of oxygen therapy over the next days and intubation was avoided. The major challenges in achieving a prone position were the patient’s profoundly reduced respiratory capacity and the high risk of exacerbating his symptoms. However, standard ICU monitoring enabled safe implementation at an individually adapted pace to allow sufficient time for convalescence. After 3 days with this regime, he could be transferred to the normal ward, where physical therapists carried on his rehabilitation with walking and strength training. The patient’s severe instability remained a challenge. Nevertheless, 9 days after ICU admission, the patient was able to leave the hospital as a pedestrian.
This 69-year-old male was admitted to the ICU after a dry cough for 2 weeks, oxygenation was poor and computer tomographic imaging showed typical COVID-19 pneumonia. Initially the patient received lung-protective ventilation and targeted sedation, but was otherwise stable. Treatment interventions included passive range of motion and positioning including passive mobilization into a side-edge position (). Over the next days, the patient deteriorated with hemodynamic instability and severe ARDS leading to intermittent prone positioning and continuous renal replacement therapy. The role of physical therapists during proning was to ensure correct joint positioning and pressure prophylaxis to prevent secondary complications such as nerve lesions, contractures, or pressure ulcers. Nevertheless, the long duration and repeated positioning resulted in a small pressure ulcer on the patient’s forehead. After tracheostomy, passive range-of-motion exercises, and passive side-edge mobilization were slowly resumed, whereby asynchronous ventilation and hemodynamic instability remained 2 major problems leading to further sedation and relaxation, thus inhibiting any active participation. After 24 days in the ICU, the patient scored 1/50 points on the Chelsea Critical Care Physical Assessment Tool (CPAx) and showed severe signs of muscle loss. The patient died soon after withdrawal of life support.
This 57-year-old male was admitted to the ICU with dyspnea, heavy dry cough, and fever 6 days after testing positive for COVID-19. Initially, he was able to exercise and sit in a chair with a physical therapist, but progressive respiratory failure necessitated intubation and proning. The patient had large amounts of bronchial mucus and required regular suctioning along with respiratory therapy. Secretions were assessed with pulmonary auscultation (presence of crackles) and by analyzing expiratory flow on the ventilator (sawtooth pattern). When suctioning failed to improve these clinical signs, 1 to 2 physical therapists used manual airway clearance techniques. The goal of these techniques was to sufficiently increase expiratory flow for effective airway clearance while avoiding alveolar collapse. To achieve this, manual compressions on the chest and abdomen were performed with just enough intensity to modify expiratory flow. After extubation, the patient was still unable to effectively clear his mucus due to weak cough. He continued to need intensive manual airway clearance techniques, nasal rinsing to induce cough and to help expectoration as well as upper and lower airway suctioning. To this end, the patient was treated up to 6 times per day/night. Additional physical therapist interventions included passive range of motion, assisted exercising, and mobilization. At the time of writing, the patient was still in the ICU without ventilatory support.
This 52-year-old male tested COVID-19 positive 4 days after the beginning of a dry cough, fever, and head and limb pain. One day later, he was hospitalized with exertional dyspnea. He was diagnosed with pneumonia that developed into moderate ARDS needing mechanical ventilation and intermittent dialysis. After extubation, oxygenation was stable with 2 to 3 L/min of oxygen. However, the patient was disoriented and could not communicate verbally. His global weakness (CPAx 11/50) was accompanied by oral and pharyngeal weakness and paresthesia. Spontaneous swallowing frequency and tongue control were severely reduced, and the patient showed insufficient protection from aspiration. This was confirmed by a specialized physical therapist with the Gugging Swallowing Screen, which confirmed severe dysphagia with 2/20 points. He was treated nil by mouth and received dysphagia therapy such as intensive oral stimulation, facilitation of swallowing, and training of protection mechanisms. After initial agitation and disorientation, the patient started to communicate in single-word phrases, but dysphagia continued to be severe with massive oral and pharyngeal dry saliva residuals that compromised his paresthesia and required regular mouth care. Over the next days, the patient managed to swallow pureéd food and mildly thick fluids under supervision, although cough strength was still weak (Gugging Swallowing Screen 13/20, CPAx 30/50). Nevertheless, he continued to progress and became capable of independent food ingestion (Gugging Swallowing Screen 20/20, CPAx 39/50) before his discharge to a rehabilitation clinic 25 days after admission.
Paramedics found this 59-year-old female with dyspnea and an oxygenation of 65% on room air and performed immediate tracheal intubation. Moderate ARDS with reduced lung compliance was diagnosed and treated with deep sedation, neuromuscular blocking agents, and prone positioning. On day 14, a trial of sitting on the edge-of-bed (SOEB) was performed, while she was still intubated and under pressure support ventilation. SOEB required 3 physical therapists to maintain the position, but resulted in a significant increase in her level of consciousness and collaborative state. The next day, she was able to hold her head and sit for about 15 minutes with 2 therapists. Her muscle strength indicated ICU-acquired weakness, with a Medical Research Council sum-score (MRC-SS) of 40/60; still she continued with small but consistent improvements and started to participate actively in physical therapy sessions. She was encouraged to mobilize herself with exercises against gravity and was actively transferred to a chair each day with the help of 2 physical therapists. She was successfully extubated, but presented postextubation dysphagia. The physical therapy team closely monitored her for secretion management and cough stimulation and continued her physical rehabilitation. On day 19, she started to walk with a walking aid, although at this point oxygen desaturation during exercise training became evident (89% with 3 L/min of oxygen). After 25 days, she was transferred to the institution’s rehabilitation facilities, where a battery of tests indicated persistent physical function impairment (MRC-SS 52/60, physical function ICU test score17 9/12, Timed Up & Go 23 seconds, short physical performance battery 4/12).
This 33-year-old female patient had typical COVID-19 symptoms such as high fever, dry cough, headache, and dyspnea about 1 week before ICU admission. She was intubated and proned due to rapid respiratory deterioration. For the following 6 days, her situation was unstable, and physical therapy consisted of prone positioning and prevention of secondary damage. From day 7 onwards, she started to improve rapidly and could be mobilized passively into a side-edge position. After extubation, she presented postextubation dysphagia and severe ICU-acquired weakness (MRC-SS 36/60). She also suffered from pronounced delirium and anxiety and said repeatedly that she had been abducted and that she believed she had to die. She seemed to feel threatened by us and it was difficult to calm her down. Due to the pandemic measures of the Swiss government, hospital visits were not generally allowed, but because her anxiety was limiting her rehabilitation, her husband was granted an exceptional permission to visit her. This seemed to give the patient a short sense of security, and she started to participate in some basic functional activities (CPAx 21/50). Nevertheless, the delirium did not resolve upon her transfer to a peripheral acute hospital.
This 66-year-old male patient was admitted to the hospital due to an ischemic left-hemispheric stroke in addition to a dry cough and fever. He tested positive for SARS-CoV-2 the following day but continued to deteriorate resulting in severe ARDS, intubation, and ICU admission. Despite repeated proning, gas exchange did not improve sufficiently and the patient was placed on veno-venous extracorporeal membrane oxygenation for 7 days. After sedation was stopped, the patient continued to be somnolent and unable to communicate or to follow commands. Physical therapy therefore focused on perception training, movement exercises, airway-clearing techniques, dysphagia therapy, and mobilization. A first SOEB trial had to be discontinued due to hemodynamic instability. Instead, the patient was positioned in a side-edge position (), which he tolerated better and where an intensive exercise training including trunk and head control was conducted. Nevertheless, muscle tone and strength remained severely reduced, particularly on his hemiplegic side, and a second SOEB trial failed again. Physical therapy was also limited because of reduced self-activity and suspected impaired perception and visual acuity. Consequently, occupational therapy was involved to create a basis of communication, to support functional initiation of upper limb movements, and to integrate perception-training into activities of daily living. Currently, the patient tolerates spontaneous breathing trials, shows signs of being alert during therapy, but cannot communicate. He is hemodynamically stable, even in an SOEB position, but remains functionally dependent (CPAx 6/50).
A 66-year-old male started to present symptoms of fever, dyspnea, coughing, asthenia, lack of appetite, nausea, and vomiting. He was admitted to the acute care unit for observation and oxygen therapy, but his oxygen requirements constantly increased due to moderate ARDS. After 12 days of deep sedation, neuromuscular blocking agents, and proning with daily passive range of motion, the patient finally started to initiate active movements and was passively transferred to a chair. However, due to a persisting difficult weaning status, probably related to respiratory muscle weakness, tracheostomy was performed [ventilator settings: pressure support 10 cmH2O, positive end-expiratory pressure (PEEP) 8 cmH2O]. Subsequently, the patient showed significant improvement in his physical functions with active SOEB, chair-transfer with the help of 2 physical therapists, and active in-bed cycling against resistance for 20 minutes (). The strategy was to increase pressure support (by 5 cmH2O) during efforts to reinforce exercise training effects, unloading respiratory muscles. This strategy along with a highly collaborative patient culminated in his rapid improvement in physical function (MRC-SS 58/60, physical function ICU test score 10/12, walking distance 10 m), although he was still experiencing fatigue, inspiratory muscle weakness (maximal inspiratory pressure of −45 cmH2O) and dysphagia upon his transfer to a step-down unit.
This 77-year-old male patient was transferred to our ICU 1 week after his COVID-19 diagnosis due to continuing respiratory decompensation requiring intubation. Following the acute phase, with intermittent proning, the patient continued to be hemodynamically unstable and was difficult to wean. Rehabilitation proved challenging under these conditions, and physical therapists had to reevaluate and adapt their interventions daily according to his condition. After 2 weeks, he was tracheotomized and started to improve very slowly. One week after tracheostomy, the patient was able to speak for the first time after a cuff-down trial and with the help of a speaking valve. But the patient spoke only a few words with us and it was often difficult to involve him in exercises. Two days later, he was able to communicate with his relatives via video telephony. This was a very emotional moment for everyone involved, but it improved his communication and he was able to express to his wife that he had no strength left to continue. However, through the family’s active participation in his early rehabilitation process, they were able to reinforce his confidence and motivation. He was discharged to a rehabilitation clinic severely weak (MRC-SS 40/60) and functionally impaired (CPAx 22/50), but continued to progress in slow steps.
A 45-year-old female was brought in by ambulance after collapsing at home secondary to a hypoglycemic event (capillary blood glucose of 1 mmol/L with paramedics). She had a history of restrictive AN, binge-purge behaviour, and an old traumatic brain injury, leaving her with memory problems. She was well known to mental health services, having been admitted multiple times to eating disorder centres for nasogastric feeding. She had never smoked in her life and denied any alcohol intake. The patient was on ferrous fumarate, fexofenadine, fluoxetine, ibuprofen, lansoprazole, quetiapine, supplemental vitamins, regular morphine (modified release), and gabapentin. On admission, her blood pressure was 106/85 mmHg, respiratory rate was 20 breaths/minute, heart rate was 64 beats/minute, temperature was 35.1 °C, and capillary blood glucose was 6 mmol/L. Her weight on admission was 37.3 kg (body mass index [BMI] = 12.6). On examination, she was clearly malnourished, cachexic, and dehydrated. The rest of the clinical examination was normal, as shown in Table . Her chest radiograph showed patchy consolidations in the right middle and lower lobes (Figure ). She was prescribed appropriate antibiotics. She was refusing treatment and was deemed to lack the capacity to make that decision. Therefore, Section 5(2) under the Mental Health Act was put in place. She was commenced on oral supplements as per guidance from the dietitian, and then switched to nasogastric feeding. On the night of the second day, she had an episode of decreased consciousness, bradypnoea (RR-6), and hypotension (83/64). Her blood sugar level was 6.6 mmol/L. After receiving Naloxone, her symptoms improved, and her opiates were discontinued. The following day she mentioned right upper quadrant pain. Blood tests showed worsening liver enzymes, as shown in Table . An abdominal ultrasound was performed on the fourth day of admission, which showed multiple small calculi and biliary debris, with gallbladder oedema, and a small amount of peri-cholecystic fluid (Figure ). She was treated for cholecystitis with amoxicillin, clavulanic acid, and clarithromycin, which led to improvement in her inflammatory markers in the following days. She underwent an inpatient magnetic resonance cholangiopancreatography (MRCP) to rule out intra-biliary pathology, which was negative. Subsequently, she was referred to surgeons for consideration of elective laparoscopic cholecystectomy once deemed fit. She had a protracted and difficult admission. Due to the coronavirus disease 2019 pandemic, her transfer to an Eating Disorders Unit proved difficult. By the fourth week of admission, her liver enzymes had improved, as can be seen in Table . Nasogastric feeding was successfully weaned as her weight improved. She was discharged on day 51 to an Eating Disorders Unit weighing 56.4 kg (BMI = 18.1) from her admission weight of 37.3 kg (BMI = 12.6).
A 29-year-old male was brought to the hospital by ambulance after collapsing at home. He was found to be bradycardic and hypoglycaemic with a capillary blood glucose level of 2.3 mmol/L. He had a history of eating and anxiety disorders and was not on any regular medications. On admission, his weight was 37.3 kg (BMI = 11.6). His blood pressure was initially un-recordable but subsequently was recorded to be 104/72 mmHg. His capillary blood glucose level was 4.7 mmol/L, and his Glasgow Coma Scale score was 15/15. On examination, he was noted to be severely malnourished and cachexic. The rest of the clinical examination was normal. LFTs were very abnormal, as shown in Table . Since admission, he seemed to lack insight. Due to problems keeping him compliant with medication and intravenous glucose, he had a number of hypoglycaemic events in the first two days of admission. The following day, he was deemed not to have the capacity. He underwent Mental Capacity Assessment and Deprivation of Liberty Safeguards. He was ultimately placed under Mental Health Act 5(2) and was started on nasogastric feeding. His liver enzymes worsened further after the introduction of nasogastric feeding, but we were reassured by a normal non-invasive liver screen and ultrasound. His condition, liver tests, and liver synthetic function improved over the course of his 24-day admission (Table ), but his stay was associated with difficult behaviour. He was eventually discharged to an Eating Disorders Unit.
A 36-year-old G4P2 premenopausal woman with a family history of colorectal, hepatobiliary cancers felt an abnormal right breast lump. Diagnostic mammogram and ultrasound showed a hypoechoic lesion in the upper outer quadrant of right breast measuring 14 mm x 13 mm x 18 mm and 5 x 4 mm satellite lesion is noted 6 mm inferior to the dominant mass, BI-RADS 5 highly suggestive of malignancy. Due to concern for multifocal disease, MRI breast with without contrast was done and it showed 2.3 x 1.1 x 2.7 cm irregular-shaped, heterogeneous mass with irregular margins in the upper outer quadrant of right breast, 7 cm from the nipple, 1.2 cm from the skin and there was an additional mass measuring 8 mm x 4 mm x 1.6 cm at 12:00 along with 4 mm lesion, 7 mm from the nipple at 10:00 (Figures (a) and (b)). Right breast biopsy from the dominant lesion showed invasive mammary carcinoma with features of both lobular and ductal carcinoma, Nottingham histological grade 2, estrogen receptor 90%, progesterone receptor 100%, HER2 2+ by IHC but negative by FISH, Ki-67 50%. Status post right breast simple mastectomy and axillary lymph node evaluation. Surgical pathology showed a multifocal invasive mammary carcinoma of the breast with ductal and lobular features, size of largest invasive carcinoma was 55 mm, size of additional invasive foci was 1.5 mm, Nottingham histological grade 2 of 3, low to intermediate nuclear grade DCIS without central necrosis measuring at least 6 mm, margins uninvolved, one benign sentinel lymph node. Pathological staging (m)pT3 (sn)N0. Oncotype DX breast recurrence score of 16 (for patients <50 years of age, benefit from chemotherapy 1.6%). Genetic testing did not reveal any clinically significant mutations. The patient has received adjuvant PMRT 5000 cGy dose, 25 fractions along with 1000 cGy scar boost. Based on TEXT/SOFT data ovarian suppression could be considered in patients with high-risk features. The patient's tumor was multifocal, and the largest lesion measured 5.5 cm. The patient elected against surgical menopause. The patient was started on ovarian suppression with goserelin 3.6 mg every 28 days along with letrozole 2.5 mg once daily. Sixteen months after initiation of ovarian suppression patient started having a regular menstrual cycle while on goserelin. No medication interaction or missed doses were noted. The patient's BMI was 41.1 and BSA was 2.19 m2. Estradiol was 92 pg/mL and follicle-stimulating hormone (FSH) was 4.3 mIU/mL in the premenopausal range. Few prior case reports showing failure of goserelin ovarian ablation in a premenopausal woman were reported. Given high-risk disease, discussed benefit of continued ovarian suppression plus AIs versus tamoxifen alone, and discussed the role of oophorectomy which results are reliable and prompt reduction in circulating estrogens. The patient was hesitant and wished to wait before the oophorectomy. She was started on triptorelin 3.75 mg IM once every 28 days.
The patient was a 62-year-old male with a past medical history of liver cirrhosis secondary to hepatitis C, tobacco use, and post-stent coronary artery disease, who initially came to the hospital for elective left and right heart catheterization as a pre-transplant evaluation. Physical examination showed abdominal distension and diffuse tenderness with the presence of prominent superficial abdominal veins. A computed tomography (CT) scan of the abdomen with contrast was obtained immediately. The CT showed an occlusive thrombus of the IVC extending from the renal veins to the level of the cavoatrial junction. Thrombus was also observed in the portal vein, and multiple subcutaneous varicosities were found. Initially, a plan was made to start the patient on anticoagulation, but because of the patient’s history of advanced cirrhosis, large esophageal varices on recent endoscopy, and thrombocytopenia, we concluded that the patient was not a candidate for anticoagulation. Given that the patient had significant abdominal distention with pain that did not improve even after therapeutic paracentesis; we inserted a stent in the IVC to relieve the patient’s pain as a palliative procedure to improve his quality of life. Right internal jugular (IJ) and right femoral vein accesses were obtained for the procedure. A 6F pigtail diagnostic catheter was advanced from the right IJ to the right atrium, and contrast was injected into the right atrium that showed an occluded IVC at the junction of the right atrium. Another pigtail catheter was advanced through the right femoral vein and an inferior venogram was performed that showed the IVC was 100% occluded 2 cm above the renal veins (Figures , ). A Glidewire advantage was advanced through the right femoral vein but was unable to cross the 100% occluded IVC. Then, a 7-French Swan-Ganz catheter was tried and was successfully advanced through the IVC all the way to the right atrium. A Swan wire was inserted through the Swan-Ganz catheter. Then, a multipurpose catheter was advanced over the Swan wire into the right atrium, and the Swan-Ganz wire was successfully replaced with a Glidewire Advantage (Figure ). Initially, a 9 × 80 Mustang balloon was used to perform the IVC ballooning; after IVC ballooning; however, the inferior venogram showed no flow to the IVC, which was still 100% occluded. Then, a 22 × 70 mm Wallstent was advanced via the right femoral vein to the right atrial side. The stent was deployed with a considerable waist in the mid area (Figure ). After stent placement, an 18 × 60 Boston Scientific esophageal balloon was successfully used to post-dilate the stent (Figure ). The final venogram (Figures , ) and digital subtraction imaging mode showed excellent flow in the IVC to the right atrium. Small clots floating around at the lower edge of the stent above the renal artery were successfully removed with a 7-Fr snare. Usually, if IVC occlusion is of thrombosis in etiology anticoagulation is advised after venous stent placement, since our patient had an advanced liver failure with elevated INR, anticoagulation was not started [].
We report a case of a 45-year-old woman, a non-smoker, treated for type II diabetes under insulin and primary hyperparathyroidism. Her medical history dates back to 2006 with an infiltrated nodule associated with ulcers that grew gradually in her right thigh. The patient underwent surgery with an anatomopathological study. Skin biopsy objectified ulcerated epidermotropic dermo-hypodermal tumor proliferation whose morphological appearance and immunohistochemical data are in favor of LCH. Langerhans cells present positivity of the anti-PS100 antibody, anti-CD1a antibody, and anti-Ki67 antibody (60%), and negativity of the anti-CD68 antibody. The patient subsequently received 25 sessions of radiotherapy followed by six courses of chemotherapy with a low dose of oral methotrexate. After these treatments, skin lesions are stable. In 2020, the patient complained of an increase in skin lesions, with the appearance of several infiltrating nodules, scaling, crusted papules, and ulcerated plaques. The patient received chemotherapy as single-system LCH (SS-LCH) based on methotrexate, associated with prednisone and vinblastine, with the obtainment of stable response and limited regression of the lesions. After two courses, the patient was lost to follow-up. One year later, the oncologist referred the patient to the hematology department for a major increase in skin lesions, with the appearance of new ones on her thigh. Dermatological examination found ulcers and necrotic lesions, purplish, well-limited, of variable size, not painful, not warm to the skin, and localized to the right thigh. The mucous membranes and integuments were unharmed (Figure ). Furthermore, the examination found an afebrile, obese patient (body mass index (BMI) at 44.8). Abdominal and cardiovascular examinations were unremarkable. The physical examination did not find any tumoral syndromes, and the patient did not present have B signs (fever, weight loss, and night sweats). A complete assessment was carried out in favor of a cutaneous location without visceral involvement. A CT scan of the chest and abdomen was normal. Extensive investigation revealed no systemic involvement, central nervous system (CNS) evaluation was not done, serum thyroid hormone levels were normal, endocrine workup was performed, including cortisolemia, and parathormone assessment were done in favor of primary hyperparathyroidism. A skin biopsy was performed. The microscopic examination revealed a cutaneous tissue with an infiltrate of large cells involving the dermis and realizing an epidermotropism. The infiltrate was composed of atypical cells with abundant, pale eosinophilic cytoplasm, irregular and elongated or lobed nuclei with prominent nuclear grooves and folds, fine chromatin, and indistinct nucleoli. Multinucleated giant tumor cells, high cytonuclear atypia, and marked nuclear pleomorphism were seen. The mitotic figures were increased. The neoplastic cells also showed a mixed inflammatory background with variable numbers of reactive lymphocytes, plasma cells, benign histiocytes, and eosinophils associated (Figure ). The immunohistochemical stains had shown a diffuse strong and heterogeneous positivity for CD1a and S100 and variable positivity for CD45. All other markers studied were negative, including CD68, cytokeratins (AE1/AE3), and melanocytic marker (MelanA). The Ki-67 proliferation index was high (50%) (Figure ). In the light of microscopic and phenotypic results, the diagnosis of Langerhans cell sarcoma was confirmed. The patient did not receive any maintenance therapy and she received only two courses of chemotherapy; consequently, the patient was included in the LCH protocol as single-system LCH (SS-LCH), and she received the same chemotherapy combining prednisone (60 mg / m2), high-dose of methotrexate (5000 mg/m2), and vinblastine (10 mg/m2). The evolution was favorable after five cycles of chemotherapy with significant regression of lesions in the thigh without the appearance of any new lesions (Figure ).
We describe the case of a 55-year-old male who presented to the emergency department via emergency medical services for the chief complaint of sudden onset shortness of breath that woke him from his sleep just prior to arrival. He reported three days of non-radiating lumbar back pain and two episodes of non-bloody emesis leading up to this event. His medical history included hypertension and type 2 diabetes mellitus. His current medications were metformin, amlodipine, losartan, and atenolol. Initial vital signs revealed heart rate (HR) 75, respiratory rate (RR) 29, blood pressure (BP) 119/62, and oxygen saturation 99% on 2L nasal cannula. Temperature was 36.3°C. Physical examination was significant for an ill-appearing male patient who was anxious and tachypneic. He also had significant work of breathing with retractions and abdominal breathing. Lungs were clear to auscultation, with no wheezing, rhonchi, or rales. Abdominal exam revealed mild epigastric tenderness with no rebound, guarding, or palpable pulsatile mass. No costovertebral angle (CVA) tenderness or midline tenderness was elicited. Neurological exam revealed no focal deficits. Due to his presentation and multiple comorbidities we had significant concern for the possible acute coronary syndrome, dissection, sepsis, or pulmonary embolism. Blood work including complete blood count (CBC), comprehensive metabolic panel (CMP), lactic acid, troponin, urine analysis (UA) was ordered. CT-angiogram of his chest, abdomen, and pelvis was also ordered. Complete blood count revealed a white blood cell count of 20.4 x 103/uL, hemoglobin of 11.2 g/dL, and platelet count of 376 x 103/uL. Comprehensive metabolic panel was significant for a sodium of 145 mmol/L, potassium 6.1 mmol/L, chloride 100 mmol/l, bicarbonate <7 mmol, blood urea nitrogen (BUN) 67 mg/dl, creatinine 14.7 mg/dL, calcium 9.1 mg/dL, and glucose of 165. Troponin I was <0.012 ng/mL. Initial lactic acid was recorded at 13.9 mmol/L. An arterial blood gas revealed severe anion gap metabolic acidosis with a pH of 6.9, pCO2 of 22.3 mmHg, pO2 of 105.5 mmHg, HCO3 of 5.3 meq/L, and a Base Excess of -24.8 mmol/l. The patient was anuric at this time. Initial EKG showed normal sinus rhythm (NSR), nonspecific ST abnormalities, vent rate 73, QTC 471. The CT scan revealed an obstructing stone at the left proximal ureteropelvic junction (Figures , ) and at the right ureterovesical junction (Figure ), with resultant bilateral hydronephrosis (Figure ). While in the ED the patient progressively became hypotensive and was given broad-spectrum antibiotics, Vancomycin and Cefepime, due to concern for sepsis and aggressive fluid resuscitation was initiated. The patient did not respond to fluid resuscitation and was started initially on Levophed. In addition, the patient received 100 mL of 8.4% sodium bicarbonate and 2 grams of calcium gluconate for severe metabolic acidosis and hyperkalemia. Due to the expected clinical decline, the patient was intubated in the emergency department. Critical Care, Nephrology, and Urology were consulted emergently in the ED. After initial stabilization, the patient was taken for immediate bilateral percutaneous nephrostomy (PCN) placement by Interventional Radiology (IR) and placement of a trialysis catheter for initiation of hemodialysis afterward. Urinalysis from the PCN revealed hematuria, but no evidence of infection. After successful placement of bilateral PCN, the patient was transferred to the intensive care unit (ICU) in critical condition. He was maintained on multiple vasopressors consisting of combinations of norepinephrine, vasopressin, epinephrine, and phenylephrine along with stress dose hydrocortisone. Repeat blood gas and labs revealed a worsening metabolic and lactic acidosis with a repeat pH of 6.7 and a lactic acid of 15.9. The patient was started on hemodialysis with a high bicarbonate dialysate for emergent clearance of hyperkalemia and refractory acidosis. After hemodialysis, the patient’s pH was 7.1, despite a worsening lactic acidosis of 17.0 mmol/L. Overnight the patient was converted to continuous venous-venous hemodialysis, a form of continuous renal replacement therapy (CRRT). Within 24 hours the patient’s acidemia corrected and blood pressure stabilized allowing for a de-escalation of vasopressors. A repeat chemistry revealed recovering renal function along with urine production in the nephrostomy tubes. On hospital day 3, the patient was successfully extubated, weaned off all vasopressors, and CRRT was stopped. Blood and urine cultures taken prior to dialysis were negative after five days. On hospital day 6, Urology performed a cystoscopy with bilateral ureteral stent placement and removal of bilateral percutaneous nephrostomy tubes. On hospital day 8, the patient had made a remarkable recovery from being critically ill. His creatinine was 1.5, BUN 27, and he was discharged home with urology follow-up in 1-2 weeks.
A 58-year-old Caucasian (American) male with an unremarkable past medical history presented for evaluation of nausea, vomiting, and a 30-pound weight loss over the past two months at our hospital. He also reported dark-colored urine and intermittent episodes of hemoptysis during the same period. Specifically, he stated that his symptoms started four days after receiving his second dose of the mRNA-1273 (Moderna) vaccine for COVID-19. His first dose taken three weeks earlier was well tolerated. He denied any flank or abdominal pain, melena, fever, cough, hematuria, urinary frequency or urgency, and trauma. He denied smoking. Vital signs were stable upon admission. Physical examination was insignificant for any lower extremity pitting edema, petechiae, or rash. The patient was not on any medication prior to his hospitalization. Laboratory analysis was remarkable for serum creatinine of 4.1 mg/dL (0.8-1.4 mg/dL) along with hematuria and sub-nephrotic proteinuria of 1796 g/24 hours (<150 mg/24 hours). Our differential diagnosis at this point was wide including all nephritic syndromes given AKI, hematuria and proteinuria. All serological workup was subsequently sent. C-ANCA (anti-neutrophil cytoplasmic antibodies) were elevated 160 AU/mL (20-25 AU/mL) and anti-proteinase 3 (anti-PR3) antibodies were also elevated >100 EU/ mL (normal <3.5 EU/mL) (Table ). Immunohistochemical staining for the SARS-CoV-2 spike protein was not performed. All previous routine laboratory parameters including urinalysis were within normal range. He underwent computed tomography (CT) scan of the chest for evaluation of hemoptysis that showed a right upper lobe consolidation and moderate bilateral pleural effusion. The renal ultrasound was unremarkable. Renal biopsy was subsequently performed and showed acute, pauci immune, focal necrotizing, and diffuse crescentic glomerulonephritis (Figures , ). The patient was diagnosed with anti-PR3-associated ANCA glomerulonephritis. He received intense immunosuppression with plasma exchange x 5 cycles, intravenous prednisone 1 gram x 3 doses followed by prednisone 60 mg daily, cyclophosphamide x 2 doses, and rituximab x 4 doses. The patient achieved remission after 10 weeks of diagnosis with a resolution of symptoms and improvement in renal function with a creatinine of 1.5 mg/dl. He is following in our nephrology office regularly since discharge.
A 67-year-old Caucasian female presented to our hospital with a chief complaint of persistent bright red blood per rectum. Her medical history was significant for hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease with three prior myocardial infarctions, recurrent cerebrovascular accidents requiring anticoagulation with warfarin, gastroesophageal reflux disease, asthma, and endometrial cancer status post radiation therapy. Fifteen months prior to the current presentation, the patient was noted to have a grade 1 endometrial adenoma but was not considered a good surgical candidate due to multiple comorbidities. Vaginal hysterectomy was considered but due to her long and narrow vagina, this option was deferred initially. Her only treatment option was radiation therapy and brachytherapy. She eventually underwent total abdominal hysterectomy with bilateral salpingo-oopherectomy due to continued pelvic pain. The patient denied any prior history of gastrointestinal (GI) bleeding. Her bleeding was described as one large episode of bright red blood per rectum associated with blood clots. She denied any abdominal pain, nausea, vomiting, diarrhea, constipation, or melena. The most recent colonoscopy was performed four months ago and revealed three diminutive polyps in the transverse colon with pathology confirming tubular adenoma. Her physical examination was significant for mild left-sided abdominal tenderness but was otherwise unremarkable. Rectal examination was notable for nonbleeding hemorrhoids and no visible blood. Blood work revealed white blood cells of 14.3k/uL (normal range 4.3-10.0 k/uL) and hemoglobin of 9.6 g/dL (normal range 11.8-14.8 g/dL), which is similar to the patient’s baseline. Creatinine was slightly elevated to 1.2 and blood urea nitrogen was elevated to 39. International normalized ratio was 2.0. Due the large volume of hematochezia and presence of anemia, the patient was admitted to the hospital and underwent a colonoscopy, which revealed a large, fungating, friable, and ulcerated nonobstructing mass in the sigmoid colon. The mass was noncircumferential, measured 4 cm in length, and was located 15-19 cm from the anal verge (Figures , ). Biopsies were obtained with cold forceps for histology and the proximal and distal margins of the mass were tattooed. Histology showed invasive and moderately differentiated carcinoma without visible goblet cells. Given the patient’s history of endometrial cancer, immunohistochemistry was performed and was consistent with an endometrial (endometrioid subtype) primary. Pan-computed tomography was negative for any obvious distant disease. The tumor marker carcinoembryonic antigen level was normal as well. The patient subsequently underwent surgical resection of the affected colon followed by radiation therapy. At a follow-up visit one year later, the patient was doing well without active GI complaints.
A 71-year-old African American female with a medical history of hypertension, type 2 diabetes mellitus, stage 3 chronic kidney disease, and osteoarthritis initially presented to the emergency room with intermittent bilateral hand tingling and numbness, which was gradual in onset over months. Her symptoms were associated with seeing red spots and experiencing a burning sensation in the bottom of her feet. She was concerned because she was having difficulty picking up objects due to her hand symptoms. Her basic lab work was unremarkable, and she was provided gabapentin and magnesium oxide with close follow-up with her primary care physician. At follow-up, she complained of one to two months of unsteady gait as well as increased confusion. Her reported medications included losartan and metformin. Physical exam revealed normal pupils with reaction and accommodation (3mm diameter bilaterally), no cranial nerve deficits, normal strength throughout, and normal reflexes throughout except for diminished reflexes in the bilateral knees and ankles. She endorsed blurry vision; no ophthalmologic exam was performed, but she was able to read a name badge from one foot away. She additionally was found to have decreased vibratory and proprioception in a stocking pattern as well as a wide-based and unsteady gait. To investigate further, tests for thyroid-stimulating hormone (TSH), folate, B12, and rapid plasma regain (RPR) titer were ordered. Her TSH, folate, and B12 levels were within normal limits, but her RPR titer was reactive at 1:1. A subsequent reflex Treponema pallidum particle agglutination (TP-PA) test was reactive. She was told to go to the hospital for further workup and treatment. Further questioning revealed that she had had two sexual partners in her life, both ex-husbands. However, she noted that her husbands committed adultery several times and that she was not currently sexually active; her last sexual encounter occurred several years ago. She endorsed that she did not notice any ulcers or skin lesions, and she had not been treated for syphilis. During hospitalization, she received a lumbar puncture that revealed a negative venereal disease research laboratory (VDRL) test result. Her glucose level (61 mg/dL) and white blood cell level (3 x 109/L) were normal, but her CSF protein level was markedly elevated at 156 mg/dL. Due to her exposure history, a constellation of symptoms, RPR titer with positive TP-PA, and protein elevation in her CSF, our infectious disease colleagues believed that she contracted syphilis earlier in life from one of her husbands and was never treated. The decision was made to start treatment with intravenous (IV) penicillin (24 million units, continuous infusion) for two weeks. At follow-up, her vision had improved and she no longer had sensory symptoms in her hands. Her gait was somewhat improved, but still unsteady, and she still had burning pain in her feet. Her physical exam showed improvement in sensation in hands and improved gait; all other neurological exam was unchanged. It was thought that neuropathy in feet could have been due to poorly controlled diabetes; although, no formal nerve conduction study was pursued.
Our patient is a 78-year-old male with a past medical history of cutaneous T-cell lymphoma/mycosis fungoides (on regular outpatient extracorporeal photopheresis), type II diabetes mellitus, atrial flutter on Xarelto, and sick sinus syndrome on dual-chamber pacemaker, presented to the hospital with right upper quadrant abdominal pain. The patient was a former smoker and denied any alcohol use. In the emergency department, he was hemodynamically stable. Laboratory workup was significant for abnormally elevated liver function tests including aspartate aminotransferase/alanine aminotransferase (AST/ALT) of 204/188 U/L, alkaline phosphatase (ALP) of 550 U/L, and total bilirubin of 2.5 mg/dL. Ultrasound of the abdomen was negative for any focal liver or gallbladder lesions. There was no evidence of intrahepatic or extrahepatic biliary duct dilation. Hepatobiliary iminodiacetic acid (HIDA) scan was normal, and hence cholecystitis was ruled out. CT abdomen and pelvis and CT angiography of the chest were negative for acute pathology. As the patient had a pacemaker, magnetic resonance cholangiopancreatography (MRCP) could not be performed. Further laboratory evaluation for elevated liver enzymes, including viral hepatitis panel, thyroid-stimulating hormone (TSH), iron panel, antinuclear antibody (ANA), anti-mitochondrial antibody, alpha-1-antitrypsin antibody, anti-smooth muscle antibody, and ceruloplasmin was negative. Given that the patient has a history of cutaneous T-cell lymphoma, the important differential diagnosis included leukemic infiltration of the liver and adverse reaction to the prior chemotherapy. However, the patient received only a short course of the chemotherapeutic regimen mogamulizumab (due to insurance issues), and hence it was unlikely to cause this current clinical picture. Subsequently, a percutaneous liver biopsy was performed to confirm the diagnosis, which showed replacement of the normal liver parenchymal cells by high-grade tumor cells with a high nuclear-cytoplasmic ratio (Figures -). The tumor cells showed positive immunohistochemical staining for cytokeratin AE1/AE3, cytokeratin 20 (CK20), synaptophysin, chromogranin, and negative for CK7, caudal type homeobox transcription factor 2 (CDX-2), and thyroid transcription factor 1 (TTF-1) (Figures -). All these features were suggestive of metastatic Merkel cell carcinoma. There was no evidence of leukemic infiltrates. As the patient had no evidence of MCC involvement of the skin, he was diagnosed with metastatic MCC of the liver of unknown primary. Hematology/Oncology and Dermatology was consulted. Considering the medical comorbidities, the patient and family opted for comfort care measures and were discharged home.
A 24-year-old healthy woman presented with difficulty breathing and dissatisfaction with her facial appearance. She had a history of childhood trauma resulting in nasal septum deviation and external nasal deformity. Four months after a successful and uneventful septorhinoplasty, she presented to the emergency department with blunt nasal trauma resulting in a septal hematoma, which was drained successfully; the patient was discharged with no adverse sequelae. Four months later, the patient sustained nasal trauma again, this time accompanied by clear nasal discharge, raising suspicion of cerebrospinal fluid (CSF) leak. The patient was discharged after managing the nasal injury, as the CT brain showed an intact cribriform plate with no evidence of a CSF leak. Ten days later, she presented at the emergency department with dizziness and an unstable gait. She also had complaints of paresthesia for the past two months, beginning in her right hand and progressing to the right shoulder, arm and leg, associated with some difficulty in the execution of movements in the first and second finger of the right hand. Her right leg was quite stiff with difficulty in walking. On close inquiry, she gave history of pain in the right eye and double vision many months back, which had resolved spontaneously. Examination showed a positive Romberg’s and Lhermitte’s sign, with right-sided sensory impairment. Magnetic resonance imaging (MRI) of the brain, cervical and thoracic spine demonstrated demyelinating lesions in the brain and cervical segment of the spinal cord (Figure ). Some of the lesions demonstrated enhancement on post gadolinium administration sequences, suggestive of active demyelinating diseases like MS. A lumbar puncture was performed which demonstrated the presence of oligoclonal bands in the CSF. The diagnosis of MS was confirmed by a neurologist and treatment was initiated. The initial neurological symptoms have largely vanished with only persistent light paresthesia in the right hand. Two years later she has had no new symptoms and continues with the same medication with good tolerance.
A 64-year-old Caucasian male smoker with a horseshoe kidney with a history of open pyelolithotomy 18 years ago, presented to King Abdulaziz Medical City in mid-2020 with a report from another hospital stating that he developed gross hematuria six months prior, which was treated as a urinary tract infection. A CT of the abdomen and pelvis was performed in that hospital, showing a horseshoe kidney with severe left hydronephrosis and enlarged retroperitoneal lymph nodes, with the largest one located in the posterior part of the left renal artery measuring 4.7 × 3.5 × 2.6 cm. Additionally, there were multiple stones (Figures , , ). Urine culture was performed and revealed that various organisms were isolated (10-100,000 CFU/ml). Urinalysis showed a small amount of blood with a moderate presence of leukocytes and a trace protein. At the end of 2020, the patient underwent magnetic resonance imaging (MRI). The MRI showed a horseshoe kidney with chronic hydronephrosis of the left kidney and a large mass within it centrally with further satellite lesions, which all likely represent UC and associated lymphadenopathy along the para-aortic chain (Figure ). Additionally, a finding of chronic pancreatitis was noted with dilated duct and stone, for which the patient was referred to the gastroenterology department. Furthermore, a bone scan and chest CT were performed, and no significant abnormality or metastasis was found. After a couple of days, the patient presented to the emergency department with non-radiating progressive lower abdominal and left colicky flank pain for three days with hematuria and constipation with fullness. The patient denied any history of fever or vomiting. There were no other genitourinary symptoms, scrotal pain, or change in the level of consciousness. Vital signs were measured and were as follows: blood pressure, 151/71 mmHg; heart rate, 109; respiratory rate, 20; and temperature, 37.1℃. The weight of the patient was 48.4 kg, and height was 166 cm. The chest was clear, while the abdomen was tender over the left side and the left flank area. Lab results were obtained (Table ). Urine culture was performed and showed more than 100,000 CFU/ml of Staphylococcus aureus being isolated. Abdomen and pelvis CT was performed to rule out any intra-abdominal collections, but it was negative. The urology team was consulted for his chief complaint, as his case is already known to them. On examination, they found that the abdomen was soft with lower left quadrant tenderness. They concluded that the pain was less likely to be from the left kidney as the CT findings were stable. Furthermore, based on the urine culture result, the patient was prescribed Bactrim and was given an appointment for admission a week later to perform a flexible ureteroscopy with biopsy. After one week, the patient underwent ureteroscopy with cytology and culture based on his MRI findings. Cystoscopy and retrograde pyelography showed normal bilateral ureters. However, the left kidney was severely dilated, and cloudy urine was noticed from the left ureteric orifice. Thus, culture and cytology were taken; then, a double-J (DJ) stent was inserted (Figure ). Urine culture was positive for S. aureus, and the patient was already on Bactrim. The urine cytology result was negative for high-grade UC, but benign urothelial cells, squamous cells, inflammatory cells, and red blood cells were present. Furthermore, since cancer could not be excluded, the patient was discharged and given an appointment for a left nephroureterectomy. After two weeks, the patient presented to the emergency room complaining of left flank pain for five days with hematuria and constipation. The urology team was again consulted and suspected urinary tract infection at the site of the double J stent. Thus, the patient was admitted, given antibiotics, and was planned for the open left radical nephroureterectomy the following day. The surgery was successfully performed, and samples were sent to the histopathology department. Macroscopic examination showed a fairly-circumscribed, bulging, gray-white mass located mainly in the renal pelvis and mostly replacing the entire kidney. It measured 14 cm in maximum dimension. The mass cut sections were homogenous with areas of necrosis, with a stent present (Figure ). The mass is away from margins and Gerota’s fascia by 2 cm. The remaining kidney parenchyma showed dilated cystic spaces containing multiple brownstones. Furthermore, the resected left renal hilum lymph node measured 7 cm in maximum dimension. Microscopically, the tumor showed urothelial carcinoma of the renal pelvis with dysplasia in the background. In addition, the tumor had a predominance of sarcomatoid differentiation. Furthermore, foci of squamous formation containing keratin formation, and other foci of glands with mucinous and goblet cells lining were seen. The tumor was focally extending to the perinephric fat. Margins were negative; however, the ureteric margin showed dysplasia. The left renal hilum lymph node was positive for metastatic carcinoma. The final diagnosis based on the examination was UC of the renal pelvis with sarcomatoid differentiation (70%) and unusual histological differentiation including squamous (25%), and glandular (<5%) (Figure ). In addition, there was no outside pathology confirmation done. Immunohistochemistry profile was positive for CK7, epithelial membrane antigen (EMA), vimentin, and focally for smooth muscle antigen (SMA). However, it was negative for desmin, cytokeratin (AE1/3), and GATA-3 (Figure ). According to the American Joint Committee on Cancer (AJCC), the pathological stage is pT3N2Mx. After a couple of days, the patient underwent a cystourethrogram, and there was no leak. The patient was eventually discharged in good health the next day and was given an appointment. The plan of the oncology team was to start adjuvant chemotherapy and perform positron emission tomography-CT (PET-CT) for the suspicious distant lymphadenopathy. In addition, CT, cystoscopy, and urine cytology were supposed to be done regularly. However, the patient missed the appointment, so the current status of the patient is unknown.
A 47-year-old Caucasian male with a history of an aortic valve replacement, Factor V Leiden anomaly, migraines, and a competitive cycling hobby presented with new paracentral blind spots in the right eye following a fishing trip in Florida on August 28, 2014. The patient reported that the vision loss began during a fishing trip when he became dehydrated and had not resolved. He described three to four similar events that occurred previously following episodes of extreme physical activity, however, all resolving. On presentation in 2016, visual acuity was 20/20 in both eyes. No fundus abnormalities were noted. Amsler grid testing revealed two scotomas about 1 and 4 degrees superior nasal to fixation in the right eye. Spectral-domain OCT imaging also revealed several hyperreflective bands in the middle retina of the right eye (Figure ). In Figure , the hyporeflective lesions seen at the border of the fovea inferior temporal and slightly further out were consistent with his subjective superior nasal scotomas on Amsler grid testing. Spectral-domain OCT findings of PAMM were corroborated with the Chief of the Retinal Service at the New York Eye and Ear Infirmary. The patient was diagnosed with findings consistent with PAMM. At that time, no treatment was given. While diagnostic measures were not taken during this patient’s first few described episodes, it was thought that the previous episodes were also consistent with PAMM, given their similar presentation on the Amsler grid testing and symptomatology. In mid-2018, the patient presented with a left-sided visual scotoma that had developed following a recent episode of febrile gastroenteritis. Treatment started with niacinamide OTC minerals, which helped initially over 30-40 minutes. After consulting with his cardiologist, nitroglycerin was prescribed but not taken. The patient was treated with 325 mg of aspirin and 200 mg of ibuprofen every 4 hours, with minimal relief. Aspirin and ibuprofen were administered because they are anti-inflammatory and blood thinners. The scotoma improved over the course of the next week but did not fully resolve. A permanent small scotoma remained. In 2019, the patient began to experience similar symptoms after vigorous exercise. The patient was treated with 0.4 mg nitroglycerin sublingually previously prescribed by his cardiologist. Within 45 minutes, the visual scotoma improved, and within a few hours, it completely resolved. Since this occasion, the patient experienced two subsequent episodes of the development of visual scotomas, both resolving within minutes of the administration of sublingual nitroglycerin. The patient described the lesions as permanent obstructions in the field of vision. They appear as small opaque structures, with a purple hue. The structures blend into the background without a distinct outline. The right eye lesions seen in Figure appeared at about 11 o’clock in the field of the patient's vision and did not move.
The patient was a 68-year-old female with a G3P2 (G, gravidity; P, parity) pregnancy history who had undergone a pancreatoduodenectomy of the pancreas to remove a tumor (adenocarcinoma) of the duodenal papillae at our hospital five years ago. She underwent computed tomography (CT) during the postoperative follow-up and was suspected of having an ovarian tumor (Figure ); thus, she visited our Department of Obstetrics and Gynecology. Transvaginal ultrasound showed a mass with abundant internal blood flow in the bladder mucosa (Figure ). Although the patient had no urinary tract symptoms, an examination by a urologist was deemed necessary. Accordingly, the patient was referred to the Department of Urology, and urinalysis and urine cytology were performed because early-stage bladder cancer was suspected. Urinalysis showed no hematuria, but urine cytology showed dysmorphic cells that were indicative of a tumor. Cystoscopy revealed a stalked papillary tumor at the apex of the posterior wall of the bladder. Transurethral resection of bladder tumor was performed the following month. A 2-cm papillary tumor was found at the apex of the bladder (Figure ), and the lesion was resected, followed by intravesical chemotherapy administration. The pathological diagnosis revealed that the removed mass was a non-muscle-invasive bladder tumor (transitional cell carcinoma, stage 0a). At the three-month postoperative follow-up, no recurrence was noted. Postoperative CT examination has not yet been performed.
A 54-year-old Caucasian female, without significant past medical history, unvaccinated for COVID-19 presented with shortness of breath, cough, myalgias, nausea, vomiting, diarrhea, and fevers a week starting with headache. Upon initial evaluation in the emergency room, vital signs were as follows: blood pressure (BP) was 115/77 mmHg, heart rate (HR) was 103 beats per minute (bpm), temperature was 99.0°F, and oxygen saturation was 84% on room air. Lab work showed nasopharyngeal swab positive for SARS-CoV-2, elevated D-dimer (772 ng/mL), elevated international normalized ratio (INR) (1.3), hyperglycemia (117 mg/dL), hyponatremia (130 mmol/L), hypokalemia (3.3 mmol/L), hypochloremia (91 mmol/L), elevated liver enzymes (aspartate aminotransferase {AST}: 157 U/L, alanine aminotransferase {ALT}: 87 U/L), elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) (508 pg/mL), and elevated troponin (13 ng/L). Chest x-ray showed bilateral infiltrates. CT chest with contrast showed bilateral pneumonia. The patient was admitted to the telemetry unit and started on ceftriaxone, azithromycin, dexamethasone, and remdesivir. Initial EKG on admission showed sinus tachycardia and left axis deviation with HR of 101 bpm (Figure ). After three days of remdesivir, EKG was repeated and showed sinus bradycardia with nonspecific intraventricular conduction delay, with HR of 57 bpm (Figure ). Third day after discontinuing remdesivir, the patient developed a transient arrhythmia noted on telemetry which resolved within a few seconds. This prompted nurse to get an EKG which showed normal sinus rhythm (Figure ). Potassium levels were low initially and after repletion potassium normalized on day two of hospital stay. Magnesium levels were normal throughout the hospital stay.