The world has faced the most challenging pandemic of the modern era, that of severe acute respiratory syndrome coronavirus 2 infection, causing coronavirus disease and affecting over 35 million people globally. The wide range of clinical manifestations associated with this viral disease is thought to be related to the overexpression of inflammatory markers. Due to a dysregulated host response, the most severe form involves multi-organ failure and thromboembolic complications. Immunomodulatory therapies may help prevent its progression and anticoagulation has been shown to reduce the risk of thrombotic complications. As this is a new entity for the medical world, there are no known therapeutic options nor has the prevention of complications been established. Anti-inflammatory agents, antimicrobial therapy, and vitamin supplements are short of clear benefits, but there is limited data to review. Other agents, such as convalescent plasma, eculizumab, immunoglobulins, neutralizing IgG1 monoclonal antibodies, remdesivir, steroids, and tocilizumab, have shown a possible impact on inpatient length of stay and mortality rate. This review aims to assess the efficacy and safety of these available therapies in light of current evidence. We compare these treatment options based on their impact on symptom management, inpatient length of stay, and overall morbidity and mortality.

BackgroundDiabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus requiring aggressive medical management. We attempted to study the incidence and various clinical and laboratory variables associated with acute gastrointestinal bleeding (AGIB) and acute upper AGIB (AUGIB) in patients with DKA.MethodsWe conducted a retrospective chart review of all the patients admitted to our hospital with DKA between January 2010 and December 2015. We collected demographic, clinical, laboratory, endoscopy and hospitalization details using an electronic medical-record database. Patients were divided into two groups based on the occurrence of gastrointestinal bleeding.ResultsA total of 234 patients with DKA were admitted during this period, of which 27 (11.5%) patients had documented AGIB. The majority of patients had hematemesis (n=22, 9.4%) except two had rectal and three had occult bleeding. We did not notice any difference in age, gender and ethnicity distribution between the two groups. There was no difference in the serum levels of electrolytes, anion gap, pH and hemoglobin A1C between the two groups. However, patients with AGIB had significantly higher initial blood glucose levels (738 vs 613 mg/dL, p =0.014). There was also increased mortality (7.4% vs 4.8%) in patients with AGIB, but this did not reach statistical significance.ConclusionWe conclude that higher initial serum blood glucose was associated with increased incidence of AGIB in patients admitted with DKA. We also noted increased in-patient mortality in patients with DKA who had AGIB, even though statistically insignificant. More aggressive measures to correct blood glucose levels may result in decreased incidence of AGIB, thereby reducing mortality during hospitalization in patients with DKA.

Purpose of Review The syndrome of myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is not uncommon and has multiple potential coronary etiologies. With the use of more sensitive cardiac biomarkers and advanced cardiovascular imaging, MINOCA presentations have gain increasing attention among researchers and cardiologists. Despite the presence of a myocardial infarction and elevated future risk, many patients are sent home with little or no cardio-protective treatment and no explanation for their symptoms. In this review, we emphasized the importance of MINOCA treatment based on the underlying etiology. Recent Findings As there are multiple pathophysiological mechanisms potentially involved in MINOCA, it should be considered a working diagnosis until there is a better understanding regarding the underlying cause. It is critical to use multimodality imaging when treating patients with MINOCA to help determine the underlying etiology and rule out mimics of MINOCA, so that therapies appropriate to the etiology can be provided. Summary A more systematic approach to managing patients with MINOCA should result in better treatment and an improved prognosis for these patients.

A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serum creatinine. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the association between quinolones and TTP. A high index of suspicion for detection and early and aggressive management are vitally important for a successful outcome.