Case Presentation: Infective endocarditis (IE) can sometimes be a diagnostic challenge because its presentation in its early stages may coincide with that of several other disease processes. It has an incidence of ~7 per 100,000 annually yet has an in-hospital mortality of about 20-25%. We present a case of a 56-year-old immunocompetent male with a recent diagnosis of leukocytoclastic vasculitis (LCV) who was admitted for acute renal failure (ARF). With his history of LCV (Figure 1), renal vasculitis was thought to be contributing to his ARF. On admission, he was afebrile and had a creatinine of 5.25 (baseline of 0.8), hyponatremia, anemia, mild leukocytosis, and mildly elevated lactate. No other infectious sequelae were noted. Nephrology was consulted for workup of renal failure, and a renal biopsy was recommended. Before the biopsy was able to be performed, blood cultures returned positive for Enterococcus faecalis. Transesophageal echocardiogram revealed a large, mobile 1.3-centimeter vegetation attached to the left ventricular outflow tract side of the non-coronary cusp of the aortic valve. Parenteral antibiotics were initiated, and cardiothoracic surgery was consulted for surgical correction. The patient ultimately underwent aortic valve replacement successfully with renal recovery to baseline and resolution of his leukocytoclastic vasculitis soon thereafter. Discussion: LCV has been established as a rare, but well-reported sign of IE. Similarly, only a few cases of IE presenting as ARF have been reported. In patients presenting with both LCV and ARF, it is important to maintain a high index of suspicion for IE. Going down the pathway to work up renal vasculitis may unnecessarily expose patients to invasive procedures, incorrect treatment modalities, and other complications.

INTRODUCTION: BH is a 41-year-old Nepalese male with a history of ulcerative colitis (recently on adalimumab) and type two diabetes mellitus was transferred for the evaluation of ECMO. He presented to an outside hospital two days prior with a complaint of fevers, hemoptysis, and five-pound weight loss over one month. Despite pre-biologic testing showing indeterminate interferon, negative acid fast culture and a normal chest x-ray, a CT scan of his chest revealed diffuse miliary pattern, consistent with tuberculosis.CASE PRESENTATION: On arrival, the patient was intubated and required norepinephrine, vasopressin and phenylephrine to maintain mean arterial pressures over 65 mmHg. White blood cell count was 5.75 K/uL, lactic acid was 6.5 mmol/L, troponin was 0.5 ng/mL, brain natriuretic peptide was 66,716 pg/mL, ALT of 2827 unit/L and AST greater than 7000 unit/L, concerning for shock. Patient was anuric for which continuous renal replacement therapy was initiated. An echocardiogram showed an ejection fraction of 20-25%. Dobutamine was started due to a rising lactate despite adequate blood pressure. Patient was not a candidate for ECMO given presumed TB infection. Patient was started on Amikacin, Moxifloxacin, Meropenem, Ethambutol and Amphotericin. After a week, he was weaned from pressors and was extubated. He also regained renal function. A repeat echocardiogram two weeks following demonstrated improvement of ejection fraction to 50%. Acid fast bacillus testing confirmed tuberculosis.DISCUSSION: Adalimumab, a TNF-a inhibitor, are among biologic medications that are used in treatment of ulcerative colitis. Although one of its main infectious complications is tuberculosis, there can be other side effects including initiation of heart failure, cytopenia, and elevated transaminases [4]. All mentioned side effects may worsen the clinical picture of septic shock. There are only a handful of cases, some in pediatric literature [3], that conveys the degree of sepsis related to disseminated tuberculosis. Most literature of disseminated tuberculosis are often in the setting of human immunodeficiency virus or in pediatrics [4].CONCLUSIONS: This case highlights the atypical presentation of disseminated tuberculosis masquerading as septic shock in the setting of recent adalimumab use. Despite the negative screen, it may be possible to develop tuberculosis during biologic therapy. Our case suggests that it may be of utility to retest for tuberculosis during therapy in individuals who may be at high risk for developing tuberculosis or those with indeterminant interferon results.

Coronavirus Disease 2019 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has become a worldwide pandemic. Since 2019, the virus has mutated into multiple variants that have made it harder to eradicate and have increased the rate of infection. This virus can affect the structure and the function of the heart and can lead to cardiovascular symptoms that can have long-lasting effects despite recovery from COVID-19. These symptoms include chest pain, palpitations, fatigue, shortness of breath, rapid heartbeat, arrhythmias, cough or hypotension. These symptoms may persist due to myocardial injury, cardiac inflammation, or systemic damage that may have been caused during infection. If these symptoms persist, the patient should visit their cardiologist for diagnosis and treatment plan for any type of cardiovascular disease that may have developed Post-COVID 19.

A 73-year-old woman with history of breast cancer status post radiation and chemotherapy was eval-uated in our emergency department (ED) for left sided chest pain that worsened over the previous month. She had two weeks of progressive physical limitation, and developed orthopnea the night prior which prompted her to seek care. CASE PRESENTATION:In the ED she was noted to have unrelenting left sided pleuritic chest pain. Physical exam was nota-ble for diminished breath sounds on the left side. Computed tomography (CT) scan of her chest re-vealed a 9.7 x 5.5 cm left lung mass with an associated complex loculated effusion. A left sided chest tube was placed for the loculated pleural effusion. It was exudative by Light's criteria, and pleural flu-id hematocrit was consistent with a hemothorax. She underwent a biopsy of the left lung mass which demonstrated CD34, BCL2, STAT6, spindle cell features and staghorn vasculature indicating a ma-lignant solitary fibrous sarcoma (SFS). She eventually underwent resection as an outpatient once staging confirmed no distant metastatic disease. DISCUSSION:The majority of thoracic solitary fibrous tumors (SFTs) are asymptomatic benign intrathoracic masses discovered incidentally on chest imaging. SFS are a malignant subtype of SFT [1]. Our case demon-strates a rare finding of a large left sided malignant solitary fibrous sarcoma that presented with a large hemothorax. SFTs generally arise from CD34þ dendritic mesenchymal cells which are present in nearly all connective tissues [2]. Association with pleural effusion may be associated with an in-creased risk of a malignant tumor [3]. The presence of a hemothorax has also been reported to cor-relate with rapid tumor enlargement [3]. STAT6, CD34, BCL2 are the most commonly found positive markers, with STAT6 sensitivity being reported as high as 100% [4]. CONCLUSIONS:Our patient did have a history of radiation treatment for left sided breast cancer which has been im-plicated in the development of SFS, particularly in the same radiation fields [5, 6]. Prognosis is usual-ly unpredictable with surgery being the gold standard in treatment [7]. In malignant tumors, chemo-therapy and radiation have limited efficacy [7]. Recurrence rates in malignant SFS are high even with complete resection, reported to be around 63% [8].