When simulation doesn't simulate: Bearman uses dissociations between clinical practice, simulation to argue we need constant criticality to prevent assessment from disguising, replacing, altering what it is supposed to represent.

Known associations with autoimmune hemolytic anemia (AIHA) include lymphoproliferative neoplasms, autoimmune conditions, and viral infections. There are a few case reports that implicate a potential relationship between COVID-19 and either warm or cold AIHA. We present the case of combined warm and cold AIHA in the setting of COVID-19. A 51-year-old male with no known past medical history presented with weakness and jaundice. Initial workup revealed white blood cells 41.4, hemoglobin 3.1, platelets 343, total bilirubin 5.3, direct bilirubin 1.6, and COVID-19 positive. Direct antiglobulin test (DAT) found IgG and C3 antibodies and pathology revealed cold agglutinins, consistent with both warm and cold AIHA. He received a total of five blood transfusions and was started on prednisone 1 mg/kg daily with a gradual taper over months. Hemolysis labs normalized within two weeks after discharge although antibodies remained positive 70 days after admission. Our patient presented with IgG and C3 antibodies as well as cold agglutinins, consistent with both warm and cold AIHA. To our knowledge, this is the first case of both warm and cold AIHA presenting simultaneously in COVID-19 infection. Unlike most cases in the existing literature, this patient had no history of underlying hematologic malignancy and both warm and cold AIHA.

Voriconazole is a triazole antifungal agent commercially approved in 2002. It is commonly used in immunocompromised patients as a therapeutic and prophylactic agent. We present the case of a 26-year-old Caucasian female who is a double lung transplant recipient who presented with complaints of generalized left lower extremity swelling and extreme tenderness of her left thigh. Although her muscle enzymes were not significantly elevated, inflammatory changes were noticed on T2-weighted fat-suppressed short-TI inversion recovery (STIR) sequence magnetic resonance imaging (MRI). These findings were later confirmed with tissue biopsy. We hereby present the case of drug-induced myositis as a rare complication of voriconazole used as chemoprophylaxis in a double lung transplant recipient patient.

Cryptococcosis is an invasive fungal disease that most commonly affects immunocompromised individuals, typically causing pulmonary and central nervous system (CNS) symptoms. The fungus that causes cryptococcosis, Cryptococcus, is globally disseminated and often transmitted through bird droppings. The two most frequent and pertinent species responsible for clinical infections in humans include Cryptococcus neoformans, which has been known to cause the majority of cryptococcosis globally until recently, during which Cryptococcus gattii has been identified and reported more frequently.A 54-year-old male with a history of renal transplant on chronic immunosuppressants and type 2 diabetes mellitus was found to have multiple lung masses within the right upper and right lower lobes. He had also been experiencing syncope, multiple falls, worsening headaches, tinnitus, diplopia, and ongoing weight loss. The patient underwent a percutaneous biopsy of one of the lung masses in addition to a lumbar puncture (LP), both of which revealed positive cryptococcus antigen confirmed to be C. gattii. The patient was started on amphotericin B and flucytosine to treat cryptococcal meningitis. Despite treatment, his condition continued to worsen, necessitating daily therapeutic LP and temporary placement of a lumbar drain. Once his symptoms were better managed, he was discharged from the hospital but has continued to have serial LPs outpatient while concurrently taking fluconazole to prevent reaccumulation of cerebrospinal fluid (CSF) and recurrence of symptoms. This report describes a unique presentation of disseminated C. gattii infection presenting as multiple lung masses and the subsequent management of CNS cryptococcosis.

Mucormycosis is an opportunistic fungal infection. Cardiac involvement is a rare, yet fatal, complication that can occur in disseminated disease. A strong index of suspicion is necessary for prompt treatment, especially in high-risk patients. We present a 62-year-old male patient with a history of diabetes and acute myeloid leukemia; he had pulmonary mucormycosis that was complicated by cardiac involvement as part of disseminated mucormycosis syndrome.