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This is a case of a 69-year-old male, with well-controlled rheumatoid arthritis and benign prostatic hyperplasia, who presented with fever and generalized weakness. He was found to have atrial fibrillation on his second emergency department visit and later diagnosed with human granulocytic anaplasmosis (HGA). Atrial fibrillation subsided with the commencement of HGA-specific treatment. This is the first case of HGA and atrial fibrillation reported in the English literature. It highlights the importance of being vigilant for unusual presentations of tick-borne diseases in the endemic areas.

Methamphetamine is an amphetamine type stimulant that adversely impacts multiple organ systems and is a growing public health problem worldwide. We present a case of a 35-year-old farmer with no previous cardiac history, yet significant history of methamphetamine abuse who experienced worsening shortness of breath, productive cough with hemoptysis, bilateral leg swelling, and orthopnea. Initial laboratory testing were remarkable for mildly elevated levels of troponin, C-reactive protein, beta natriuretic peptide, and D-dimer. Chest radiography revealed cardiomegaly and a small, right-sided pleural effusion. Further diagnostic imaging by computed tomography angiography highlighted bilateral sub-segmental pulmonary embolism (PE) while cardiac echocardiography detected severely dilated cardiomyopathy of all chambers with severely reduced ejection fraction (EF). Additional cardiac and hematological workups were negative for ischemic disease, infection, or thromboembolic disease. The patient was diagnosed with methamphetamine-associated cardiomyopathy (MAC) and PE and treated for new onset heart failure with reduced ejection fraction. Though symptoms improved with cessation of drug use, follow up imaging at two years revealed sustained cardiac damage. MAC can rarely present in association with PE in patients with a history of methamphetamine abuse. A high index of clinical suspicion is necessary to identify this life-threatening combination in young adults.

Background. Acute kidney injury (AKI) requiring dialysis during pregnancy is uncommon. We present a case of a young female diagnosed with antiglomerular basement membrane (anti-GBM) disease during pregnancy. Case Presentation. A 23-year-old woman approximately 15 weeks pregnant experienced weakness, nausea, vomiting, and anorexia for one week and anuria for 48 hours. No known drug allergies and no significant social or family history for kidney or genitourinary disease were reported. Laboratory analysis revealed anemia, life-threatening hyperkalemia, AKI, and elevated antiglomerular basement membrane (GBM) antibodies. Renal biopsy revealed 100% cellular crescents, confirming the diagnosis. The patient was treated using plasmapheresis and methylprednisolone followed by oral steroids, azathioprine, and tacrolimus. At 24 weeks and 4 days of gestation, the patient had hypoxic respiratory failure as well as preterm premature rupture of membranes. Due to the development of infection and lack of renal recovery, immunosuppression was discontinued. At 28 weeks and 0 days of gestation, the patient developed uncontrollable hypertension requiring emergent delivery. Postpartum, her hypertension improved without signs of preeclampsia though still requires dialysis. Discussion. Pregnancy presents a unique challenge for providers treating patients with anti-GBM disease. Fetal safety should be considered and risks thoroughly discussed with the patient when choosing an immunosuppressive regimen for this condition.

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