Superior mesenteric artery syndrome (SMAS), also known as Wilkie’s syndrome, is an exceedingly rare condition concerning intestinal obstruction. SMAS occurs when the space between the superior mesenteric artery (SMA) and the abdominal aorta narrows, resulting in compression of the duodenum. Functionally, the SMA supplies the distal duodenum, two-thirds of the transverse colon, and the pancreas. The location of the SMA is at about the level of the first lumbar vertebra branching off the anterior portion of the abdominal aorta. Generally, SMAS is due to rapid, excessive weight loss, resulting in the loss of the duodenal fat pad. The loss of the fat pad consequently changes the angle between the abdominal aorta and the SMA, or aortomesenteric angle, causing intestinal obstruction. Typical symptoms of acute cases of SMAS include postprandial abdominal pain, nausea, and vomiting; however, chronic cases may present with vague gastrointestinal symptoms and further weight loss. Herein, we discuss the case of a woman with chronic abdominal pain and previous substantial weight loss in whom we note features consistent with SMAS. Several factors can contribute to the syndrome, but, most commonly, it is observed after sudden, significant weight loss accompanied by nonspecific symptoms such as postprandial epigastric pain, emesis, and anorexia. Given that there is continued debate whether the syndrome even exists, SMAS is usually a diagnosis of exclusion, if diagnosed at all. First-line treatment involves conservative management, but if symptoms become too severe, several proven surgical methods are available. SMAS is a rare condition and is difficult to diagnose, but it should be suspected if clinical manifestations are present. This case illustrates the need for primary care physicians to receive additional training on the recognition of rare diseases to broaden their differentials. Training of this sort is especially crucial for rural family medicine residency programs focused on producing full-spectrum physicians.

The novel coronavirus disease 2019 (COVID-19) spread quickly worldwide following the first report of pneumonia of unknown cause in Wuhan, China. Since then, the incidence and mortality have continued to rise, with over 120 million cases of COVID-19 globally. The agency for Food and Drug Administration approved Remdesivir for the treatment of COVID-19, in October 2020. This approval supports the use of Remdesivir to treat SARS-CoV-2 infection in adults and children ≥12 years of age who weigh ≥40 kg. The use of Remdesivir in the treatment of COVID-19 patients was timely considering the rapid rate of spread and mortality from the disease, especially among elderly patients and those with existing comorbidities, including renal disease. There have been reports of increased mortality rate in patients with acute kidney injury (AKI) requiring renal replacement therapy following exposure to the virus. While Remdesivir has been considered safe and effective in the treatment of SARS-CoV-2 infection, recommendations have been issued against its use in End-Stage Renal Disease (ESRD) – patients with glomerular infiltration rate (eGFR) <30mL/min/1.73m2. This is due to minimal safety data from clinical trials involving the use of Remdesivir in patients with ESRD and concerns of liver necrosis and renal tubule obstruction from earlier animal studies. This review focuses on existing literature on the use of patients with ESRD and their outcomes. While further studies are needed to prove the safety of Remdesivir among patients with ESRD, available literature shows that the advantages of short-duration therapy (5-10 days) outweigh the risk, especially when combined with hemodialysis and constant monitoring of Remdesivir concentration.

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