Gastric sleeve surgery is a frequently performed procedure. Although it is one of the safest bariatric procedures, it is like any other operation that carries significant risks and complications. Moreover, the hepatic abscess is an infrequent complication of laparoscopic gastric sleeve surgery, the infected late gastric leakage is a rare etiology of the hepatic abscess. We present a case of liver abscess developed one month after sleeve gastrectomy secondary to infected walled-off late-gastric leak. The case highlights this rare complication of gastric sleeve surgery. Moreover, early treatment of liver abscesses with imaging-guided drainage and intravenous antibiotics can prevent life-threatening outcomes.

Neurosyphilis is any involvement of the central nervous system (CNS) by Treponema pallidum. The CNS may be involved at any stage of infection.A 54-year-old previously healthy African American male was hospitalized due to a two-year history of progressive cognitive decline. One year after symptoms began, he developed, over a four-month period, gait disturbance resulting in frequent falls, speech impairment, worsening memory loss, psychosis, and an inability to perform activities of daily living.A diagnosis of neurosyphilis was established upon cerebrospinal fluid (CSF) positive results and new changes in his mental status. The CSF showed predominant lymphocytic pleocytosis (17), elevated protein (111), and IgG index (4.25). Other viral and bacterial panels were negative. Intravenous penicillin G, 24 million units daily for 14 days, was given. Two months later, the patient was transferred to the hospital for altered behavior and mental status changes from the cognitive baseline. The repeat CSF rapid plasma reagin (RPR) titer (1:4) was the same as at initial diagnosis, despite appropriate treatment. Brain MRI showed progressive volume loss in both temporal lobes, thalamus, and cerebellum, consistent with evolving encephalitis. Treatment with intravenous penicillin G, 24 million units, was repeated. The patient improved clinically.Hence, in emerging cases of syphilis, this patient has been diagnosed with a neurosyphilis flare, unresponsive to the usual dose and duration of penicillin. We recommended a repeat CSF examination every six months and having a lower threshold for CSF examination for possible flare or resistance. Our case showed a failure to respond to the usual course of penicillin, requiring a second course of IV Penicillin G, although no resistance to penicillin has been reported.

Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses angiotensin-converting enzyme-2 receptors on host cells to enter the cells. These receptors are expressed on heart muscle tissue and the tissues of other major organs, which supports the primary accepted theory for the direct cardiac cell injury of coronavirus disease 2019 (COVID-19) and the associated cardiorespiratory manifestations. The SARS-CoV-2 infection leads to unstable myocardial cell membranes due to hypoxia, myocarditis, myocardial ischemia, and abnormal host immune response. This is the main reason behind arrhythmia and electrocardiogram (ECG) changes during COVID-19. However, the specific effect on QTc has not been studied well. Therefore, this study aimed to examine the association between COVID-19 and QTc changes. Methodology We conducted an observational, retrospective review of hospital medical records of 320 adult participants diagnosed with COVID-19 at our facility. After applying the exclusion criteria, 130 participants were included and distributed into two groups. One group had long QTc, and one group had normal QTc. Data were collected and recorded using Microsoft Excel. We used SPSS Statistics for Windows, Version 20.0. (IBM Corp., Armonk, NY, USA) to analyze the data. Student’s t-tests were performed for independent groups. Quantitative data were summarized using mean and standard deviation. Statistical significance was taken as p < 0.05. Results A total of 63 (48.4%) participants met the criteria for long QTc, and 67 (51.5%) participants had normal QTc (p < 0.001). There was no statistically significant difference in mortality outcomes between long QTc and normal QTc (0.8% vs. 3.8%, respectively; p = 0.21). Conclusions This study aimed to examine the association between COVID-19 and QTc changes. Nearly half of the participants had an increased QTc with COVID-19, and QTc length was not associated with mortality outcomes. Our results indicate that COVID-19 is an independent risk factor for QTc prolongation on ECG. Identifying COVID-19 as an independent risk factor for QTc prolongation is a clinically significant finding, and physicians should consider this when treating cardiac patients and possible COVID-19-positive patients.

TWI has a wide differential diagnosis that can range from benign causes including normal variants to life-threatening causes including coronary artery disease and rarely can be related to non-cardiac causes [1].CASE PRESENTATION: Our patient is an 18-years-old female with a past medical history of asthma and major depressive disorder. She presented to the psych emergency department (ED) because of suicidal attempts. Patient complaints of worsening feelings of sadness, loss of interest, and decreased energy. Also, she reported having suicidal ideations. Review of systems was unremarkable She was vitally stable. On physical examinations, lungs were clear to auscultation, cardiovascular exam of normal heart sounds, no murmurs or gallops. Labs were within normal limits, including electrolytes, TSH, D-Dimer, and cardiac enzymes. The routine evaluation protocol in the psych ED includes Electrocardiogram (EKG) mainly to look for QTC intervals, as many of the medications that are used for the psych population may alter the QTC interval. Her EKG showed sinus rhythm with T wave inversion in leads II, III, aVF, and V3-V6 with QTc of 483; there were no previous EKGs for comparison. The EKG was repeated on different days and showed the same findings. The patient reported no family history of cardiovascular diseases. Cardiology was consulted, an echocardiogram showed a large extracardiac mediastinal mass which appears to press on the right ventricle; otherwise, ejection fraction was normal, and no significant valvular disease was observed. A computerized tomography scan of the chest revealed a large, 12 x 7 x 6 cm mediastinal mass along the inferior wall of the heart, exerting mass effect and displacing the heart superiorly. The patient was discharged and referred to a cardiothoracic surgeon for further evaluation.DISCUSSION: Different clinical conditions can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia and pulmonary embolism, to entirely benign conditions [1]. The mediastinum is a potential space in the thoracic cavity that is subdivided into anterior, middle, posterior, and superior mediastinum to form a differential diagnosis for the lesion [2]. In our case, our patient was presented with Inferolateral TWI that was investigated and was found to have a lesion in the middle mediastinum that could be a pericardial cyst, bronchogenic cyst, esophageal implications cyst or lymph node enlargement that can be secondary to tuberculosis or sarcoidosis or histoplasmosis.CONCLUSIONS: This case highlights that inferolateral TWI should always be investigated thoroughly, including by imaging studies when the cause is not clear to prevent life threatening conditions.

INTRODUCTION:Laryngospasm is a sudden involuntary muscular spasm of the vocal cords, it can lead to cardiac arrest due to hypoxia if not timely treated. Negative pressure flash pulmonary edema (NPPE) is a rare complication secondary to laryngospasm in adults after the acute treatment, which results from forceful inspiration against blocked airways and the resulting high negative pressure in alveoli, causing fluids to flux to the interstitial and alveolar spaces. Healthy individuals are more prone for NPPE due to the strength to induce higher intrathoracic negative pressure to challenge an obstruction. This case illustrates a young adult developed postoperative laryngospasm resulting in a flash NPPE. CASE PRESENTATION:A 40 year-old male, with a history of type 1 diabetes and recent mild COVID-19 Pneumonia was admitted for minor surgery. Pre-operative assessment concluded with ASA class 2, and moderate functional status. He has no history of anesthetic complications. Surgery was done under general anesthesia with a laryngeal mask (LMA). During Recovery after the LMA was removed, he started to desaturate, with audible stridor, cyanosis and retractions. High flow oxygen mask and IV Succinylcholine were given with no response. He was immediately intubated, ET tube suctioning showed large amounts of frothy pink secretions, his saturation had improved immediately to 100% with manual positive pressure ventilation. Sustained closure of the vocal cords was observed during intubation. However, his oxygen requirement didn't improve during the first day, and he failed a spontaneous breathing trial(SBT). Chest radiograph showed diffuse haziness suggestive of pulmonary edema. Chest CT showed pulmonary edema more significant in the dependent areas with atelectasis, it also showed diffuse ground glass opacities of recent COVID-19 pneumonia. He was started on parenteral furosemide, negative fluid balance of five liters was achieved in 24 hours. Surprisingly, his breathing effort was significantly improving with fluid elimination, oxygen requirements was weaned to minimum, passed SBT on CPAP mode, and later extubated. Patient was discharged with no evidence persistent airways pathology.DISCUSSION: Laryngospasm is less common in adults, usually it results from physical manipulation of the airways. Forceful inspiration against obstructed airways results in negative intrathoracic pressure above physiological limit, which disrupts the balance of hydrostatic pressures of alveoli, interstitium and the capillaries, leading to fluid accumulation in the alveolar space, it manifest clinically with desaturation, and diffuse opacities on imaging. High negative pressure increases the permeability as well, which drive the RBCs to extravasate and manifest as bloody mucous secretions.CONCLUSIONS: Fortunately, if NPPE gets timely recognized, patients respond magically to treatment with higher positive pressure ventilation and diuretics.