We report a case of a 67-year-old man who presented to urgent care with a one-week history of left-sided abdominal pain and oliguria. Over the past month, he reported feeling fatigued as well as noticed decreased urine output. The patient does have a significant cardiac medical history that includes coronary artery disease with a previous myocardial infarction, reduced ejection fraction, and hypertension. Imaging studies were conducted which revealed the likely etiology of his current symptoms. A transthoracic echocardiogram (TTE) revealed the presence of a large non-mobile apical thrombus occupying most of the apex of the left ventricle. Computed Tomography (CT) confirmed an apical left ventricular thrombus and showed decreased perfusion to the spleen and ischemia/infarction of the left kidney. The patient was initially treated with heparin but subsequently given enoxaparin with bridging to warfarin. He began to feel better with less left flank pain. Although this presentation of an LV thrombus is a rare occurrence, it is important for physicians to consider abdominal pain as a presenting complaint.

A significant portion of all invasive fungal infections in solid organ transplants are due to cryptococcus. It can be a debilitating infection and affects the quality of life in transplant patients. We report a case of a 57-year-old male patient with recent kidney transplant, who presented with cryptococcal meningitis, after exposure to birds during a trip to Mexico 1 week ago. In addition to a two-day history of generalized weakness, dizziness, intermittent fever, and lightheadedness, the patient presented with on and off headaches, increased sinus pressure, neck stiffness, clogged ear sensation, confusion, and night sweats. The patient was initially treated empirically with fluconazole. Lumber punctuation showed elevated opening pressure, increased WBC, with neutrophil predominance. Cryptococcal antigen tests were positive in both serum and cerebrospinal fluid sources. After confirmation from CSF analysis, he was administered liposomal amphotericin B and flucytosine. Patient’s symptoms rapidly improved. Due to his immunocompromised state, the patient will require lifelong fluconazole maintenance therapy. Even though kidney transplant recipients have a positive outcome in terms of longevity, they are at increased risk of post-transplant infection, such as zoonotic infections. Therefore, in any recent kidney transplant patient with meningitis symptoms, cryptococcal meningitis should always be considered. We report the appropriate criteria, procedures, and tests that allow for a cryptococcal meningitis diagnosis in immunocompromised patients.

No abstract

Importance COVID-19 has adversely affected global healthcare infrastructure since 2019. Currently, there are no large-scale published reports on the efficacy of combination therapy of dexamethasone, remdesivir, and tocilizumab on COVID-19 patients. Objectives Is the combination therapy of dexamethasone, remdesivir, and tocilizumab superior to other treatments on hospitalized COVID-19 patients? Design This is a retrospective, comparative effectiveness study. Setting Single-center study Participants/interventions We analyzed different inpatient COVID-19 treatment options available in the United States and their impact on hospital length of stay (LOS) and mortality. Hospitalized COVID-19 were categorized as “mild,” “moderate” and “severe'' based on the highest level of oxygen required; room air, nasal cannula, or high flow/PAP/intubation, respectively. Patients were treated in accordance with the availability of medications and the latest treatment guidelines. Main outcomes The endpoints of the study are hospital discharges and death during hospitalization. Results 1233 COVID-19 patients were admitted from 2020 to 2021. No treatment combinations showed a statistically significant decrease in hospital LOS in mild COVID-19 patients (p = 0.186). In moderate patients, the combination of remdesivir and dexamethasone slightly decreased LOS by 1 day (p = 0.007). In severe patients, the three-drug combination of remdesivir, dexamethasone, and tocilizumab decreased LOS by 8 days (p = 0.0034) when compared to nonviable treatments, such as hydroxychloroquine and convalescent plasma transfusion. However, it did not show any statistically significant benefit when compared to two-drug regimens (dexamethasone plus remdesivir) in severe COVID-19 (p = 0.116). No treatment arm appeared to show a statistically significant decrease in mortality for severe COVID-19 patients. Conclusions Our findings suggest that three-drug combination may decrease LOS in severe COVID-19 patients when compared to two-drug therapy. However, the trend was not supported by statistical analysis. Remdesivir may not be clinically beneficial for mild hospitalized COVID-19 patients; considering its cost, one could reserve it for moderate and severe patients. Triple drug therapies, while potentially reducing LOS for severe patients, do not affect overall mortality. Additional patient data may increase statistical power and solidify these findings.

FMD is a rare systemic vascular disease characterized by abnormal cell proliferation in the artery walls, leading to artery narrowing, twisting, or bulging. It commonly affects the carotid and renal arteries and can result in renal diseases and stroke. This paper presents a case study of a 39-year-old unhoused female patient who experienced a stroke secondary to fibromuscular dysplasia (FMD) and left ventricular thrombus. The patient presented with asymmetric movement of the extremities and psychosis, so intoxication was initially suspected. However, further examination revealed facial asymmetry and motor weakness. CT scans showed a left anterior cerebral artery infarction and irregular contour of the cervical internal carotid arteries, consistent with FMD and carotid thrombus. Management involved stabilizing the patient, providing supportive treatment, and controlling blood pressure. Thrombolytic therapy was not administered due to the time elapsed since symptom onset. The patient was started on anticoagulation for the carotid plaque and left ventricular thrombus. A transthoracic echocardiogram revealed a large left ventricular thrombus and left atrial enlargement, and the patient was started on heart failure medications. FMD and left ventricular thrombus are not directly related, but FMD can contribute to thrombus development through its impact on the cardiovascular system, including hypertension, arterial wall damage, aneurysm development, or dissection. Treatment for FMD may involve medication, observation, or surgical interventions like angioplasty and stenting. Anticoagulation therapy is essential for managing the left ventricular thrombus. This case highlights the importance of early diagnosis and treatment of FMD to prevent complications such as stroke. It is important to consider FMD in the diagnosis of younger patients with a stroke, especially those with a history of hypertension, substance abuse, or other risk factors. Further research is needed to better understand the relationship between FMD and stroke and to optimize treatment strategies for these patients.