Multiple sclerosis (MS) has classically been described as a disease of the young Caucasian female. While the prevalence may seem to be higher in Caucasians (CAs), recent studies suggest that the real incidence of MS may actually be higher in African Americans (AAs). Here, we discuss a nonclassical case of MS in an older African American male, prognostic factors, disease patterns in African Americans, and how a delay in diagnosis and socioeconomic factors can lead to worse outcomes. In patients that present with possible symptoms of MS, a high suspicion for MS should be entertained even in epidemiologically atypical patients to prevent delay in diagnosis and irreversible disability.

INTRODUCTION: Pyogenic liver abscess typically develops via systemic seeding of an infection or from biliary disease through direct spread or portal circulation. Invasive liver abscess though may occur in Beta-thalassemia major patients are a rarity in Beta-thalassemia minor. CASE DESCRIPTION/METHODS: 36-year-old woman with a history of B-thalassemia minor presents to the ED with complaints of acute onset severe, non-radiating right upper quadrant pain. She endorses fevers, chills and night sweats but denied anorexia, nausea, vomiting, diarrhea or urinary symptoms. Never been transfused. Physical exam was pertinent for a temperature of 102.8 F, tachycardia of 138 bpm, and an upper quadrant abdominal tenderness with some guarding. Labs was notable for leukocytosis with neutrophil predominant, anemia with Hb of 5.3 g/dl. Elevated ESR and CRP. Lipase and amylase were normal. CT abdomen showed 10.3 cm thick-walled, complex fluid collection in the right hepatic lobe and splenic abscesses consistent with a pyogenic abscess. Blood cultures were negative. She was started on empiric antibiotic with vancomycin and piperacillin/ tazobactam and was subsequently taken to interventional radiology for drainage of the abscess, with a J-P drain left insitu. The patient received 2 units of packed red blood cells. Fluid culture from drain was positive for Klebsiella pneumoniae which was sensitive to Levaquin. The patient's condition improved while on antibiotics with subsequent removal of the J-P drain. She was successfully discharged on oral Flagyl and Levaquin for 14 days. DISCUSSION: Typically, thalassemia minor carriers are clinically asymptomatic with very little to no complications. Infections however, are a major complication, and constitute the second most common cause of mortality and a main cause of morbidity in patients with thalassemia. The major culprit bacterial infections in thalassemia patients are Klebsiella sppand Yersinia enterocolitica. K. pneumoniae is also associated with a community-acquired primary invasive liver abscess syndrome. Liver abscess occur more commonly in beta- thalassemia major as these group of patient have predisposing factors such as underlying hepatobiliary dysfunction and recurrent transfusions. This condition is rare in beta- thalassemia minor. Abscess rupture is a rare complication, while metastatic infection to other sites can occur. Diagnosis is usually made with CT scan of the abdomen while treatment is should be started with empiric broad-spectrum and drainage of the abscess.

The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m2 or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR – listing eGFR/listing glomerular filtration rate (GFR)] × 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13–1.81]; p = 0.002) or tobacco use (1.40 [1.11–1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03–1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival.