Patient: Male, 49-year-old Final Diagnosis: Rhinosinusitis Symptoms: Cough • fatigue • headache • seizure Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare coexistence of disease or pathology Background: We present a case of invasive sinusitis with rhinocerebral infection in a patient who had mild symptoms of COVID-19 infection and did not receive any immunosuppressive therapies. Case Report: A 49-year-old man with a history of uncontrolled diabetes presented to the hospital with multiple generalized tonic clonic seizures. He had recently been diagnosed with mild COVID-19 and was treated at home with supportive care only. He was found to have cerebritis in the right frontal lobe along with right fronto-ethmoid sinusitis. He underwent extensive testing with nasal endoscopy with gram stain and culture, cryptococcal studies, 1–3-Beta-D glucan, blood cultures, fungal CSF studies, Lyme disease, HIV, Fungitell assay, and galactomannan studies, which were all negative. He was started on i.v. antibacterial therapy with cefepime, vancomycin, and metronidazole along with amphotericin B. After 2 weeks, his repeat imaging revealed progression of cerebritis along with new early abscess. Given these findings, his antibiotics were changed to meropenem and the amphotericin B dose was increased. He was recommended debridement and sinus surgery but refused. During the course of treatment, he developed acute kidney injury and was switched to Posaconazole. Unfortunately, the patient decided to leave against medical advice 6 weeks into admission. He was advised to continue Posaconazole and levofloxacin but he could only afford levofloxacin. He was then recommended long-term levofloxacin. He has since recovered, with resolution of cerebritis noted in follow-up imaging 1 year later. Conclusions: Our patient had mild COVID-19 infection and presented with secondary infective complications, which are usually associated with an immunocompromised state, despite receiving no immunosuppressives. It is imperative that all clinicians treating COVID-19 be watchful for fungal or bacterial co-infections in patients with active SARS-CoV-2 infection, even if the presenting symptoms are mild, particularly if other risk factors are present.

A 36-year-old male presented with progressive exertional dyspnea over months. Physical examination showed jugular venous distension, lung crecipitations, femoral bruit and pitting pedal edema. Echocardiogram showed a dilated right ventricle with severe pulmonary hypertension and a non collapsing inferior vena cava (IVC). On right heart catheterization, IVC oxygen saturation was noted at 92% suggesting arterial mixing; a computed tomography of the abdomen showed a fistula between the right common iliac artery to the right common iliac vein at L4 level and a massive IVC; this was linked to trauma from a disectomy done 16 years ago at L4–L5 level. Endovascular sealing with a 16 × 60 mm bifurcated stent graft (S & G Biotech, Seoul, Korea) was performed which led to complete resolution of the patient’s dyspnea. Iatrogenic vascular injury during lumbar disc surgery, although rare, can lead to high output cardiac failure developing over months to years.

Drug-induced (insulin/insulin secretagogue) hypoglycaemia is the most common cause of hypoglycaemia particularly in the elderly. It is estimated that hypoglycaemia of any severity occurs annually in 5-20% of patients taking antihyperglycaemic agents. Although these hypoglycaemic episodes are rarely fatal, they can be associated with serious clinical sequelae. The half-life for most sulfonylurea medications is 14-16 h; they can cause severe, prolonged hypoglycaemia. It is important to recognise, prevent and treat hypoglycaemic episodes secondary to the use of antihyperglycaemic agents. Patient education has become focused on minimising hyperglycaemia but emphasis must be placed on minimising even minor subclinical hypoglycaemia because it will contribute to a vicious cycle of hypoglycaemia begetting hypoglycaemia. Ten per cent dextrose is recommended for the reversal of all hypoglycaemic episodes rather than the conventional 50% dextrose. Octreotide can be an option for recurrent and relapsing hypoglycaemia in an acute setting.

‘Legal highs’ are substances of synthetic or natural origin having psychotropic properties. ‘Legal highs’ are often new and, in many cases, the actual chemical ingredients in a branded product can be changed without notifications and the risks are unpredictable. Acute recreational drug toxicity is a common reason for presentation to both hospital and prehospital medical services. It appears that, generally, the pattern of toxicity associated with ‘legal highs’ is broadly similar to that seen with classical stimulant recreational drugs such as cocaine, MDMA (3,4 methylenedioxy-N-methyl amphetamine) and amphetamine. Lack of clear literature pertaining to their chemical properties, pharmacology and toxicology makes an evaluation of their effects difficult. We describe a unique case in which consumption of such a substance led to hospital admission and a diagnosis of ‘lateral medullary stroke’ or ‘Wallenberg syndrome’. We believe that this is the first described case of a ‘legal high’ intake linked to a posterior circulation stroke.