Immune thrombocytopenic purpura (ITP) is an autoimmune disorder caused by autoantibodies against platelet antigens resulting in platelet destruction and inhibition of platelet production. Occasionally, an inciting event such as a virus or vaccination can precipitate ITP. Several cases of ITP have been reported after the BTN162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) SARS-CoV-2 (COVID-19) vaccines. All reported cases of post-vaccination ITP have resolved with medical therapy until this case.A man in his mid-20s developed bleeding from ITP 2 weeks after receiving the second dose of the Pfizer SARS-CoV-2 vaccine. All inpatient medical treatment attempts failed. On hospital day 40, a splenectomy was performed and he ultimately recovered and was discharged.Awareness of potential vaccination side effects is a fundamental element of refining and improving patient safety. This case illustrates that given the right circumstances, serious refractory ITP can develop in response to the second dose of the Pfizer SARS-CoV-2 vaccine.

Morbid obesity is a major health problem worldwide and the Roux-en-Y gastric bypass (RYGB) is a popular surgical treatment. A 40 year old woman, 17 years post RYGB presented with concurrent symptomatic gastric ulcers and acute pancreatitis. The diagnosis was difficult and after failed medical therapy, surgery was required. The gastric remnant is not easily accessible by endoscopy thus; detecting PUD in this excluded segment is difficult. As a result, alternative methods, such as exploratory laparotomy or pediatric endoscopy may be required to effectively diagnose the gastric remnant.

The recreational and medicinal uses of cannabis are increasing worldwide. Given the recent legalization of marijuana in some regions of the United States, the use of edible formulations has become increasingly popular, especially among the elderly. These new formulations can be up to 10 times more potent than previously available preparations and have been associated with a variety of cardiovascular adverse effects.Here, we present a case of an elderly male who presented with dizziness and altered mental status. He was found to be severely bradycardic and emergently required atropine. Further investigation revealed that he accidentally ingested large amounts of oral cannabis. An extensive cardiac workup revealed no other etiology for his arrhythmia. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are the most commonly studied cannabis compounds. With the increased access to and popularity of edible cannabis formulations, this case demonstrates the need for further research regarding the safety of oral cannabis.

Patient: Male, 24-year-old Final Diagnosis: Retroperitoneal choriocarcinoma Symptoms: Left sided • pleuritic chest pain and back pain radiating down his left leg of one year duration Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Rare disease Background: Primary retroperitoneal choriocarcinoma is a rare form of extragonadal germ cell tumor that is highly aggressive and responds poorly to chemoradiation. Extragonadal choriocarcinomas are notoriously challenging to diagnose, and have often progressed to advanced disease by the time of diagnosis. The survival rate for extragonadal choriocarcinoma is approximately 30%, which is much lower than that of extragonadal non-semi-nomatous germ cell tumors (GCT) in general. Case Report: A 24-year-old man with no significant past medical history presented with left-sided, pleuritic chest pain and back pain radiating down his left leg, of 1-year duration. Computed tomography (CT) of the chest revealed multiple bilateral pulmonary nodules and a CT of the abdomen and pelvis showed a large heterogeneous soft tissue mass measuring 9.3×8×10.5 cm. A CT-guided core needle biopsy of a lung nodule was performed and the findings were consistent with the diagnosis of metastatic choriocarcinoma. Magnetic resonance imaging (MRI) of the brain was negative for metastatic disease. Tumor markers were significant for a markedly elevated beta human chorionic gonadotropin (B-hCG) of 104 712 mIU/mL. He was diagnosed with a stage IIIC germ cell tumor, further classified as a primary retroperitoneal choriocarcinoma with lung metastasis, and was started on urgent inpatient chemotherapy. Conclusions: Due to the poor outcomes associated with extragonadal choriocarcinoma, it is important to promptly and correctly identify this malignancy in order to initiate treatment in a timely manner. The following case report explores the histopathologic characterization of this malignancy and describes the clinical course and outcomes from treatment for this patient.