The protein level in the cerebrospinal fluid (CSF) is an important diagnostic tool and, when abnormal, can provide clinicians with clues to the etiology of a patient's condition. Froin's syndrome has been described in previous literature as the combination of xanthochromia, elevated protein, and hypercoagulated CSF. The pathophysiology behind Froin's syndrome is thought to be due to stagnant CSF causing passive and/or active diffusive processes, resulting in hyperproteinosis and hypercoagulation. We present a case of Froin's syndrome in a patient with cervical spine trauma whose extraordinary level of CSF proteinosis helped raise suspicion for underlying obstructive and infectious etiology.

Pulmonary lymphangitic carcinomatosis (PLC) is the diffuse infltration of lymphatic systems by adenocarcinomas. Because of its vague clinical symptoms and absence of malignant features, confrmatory diagnosis requires transbronchial or open-lung biopsy. Tumor spread is postulated to occur by means of retrograde lymphatic permeation with tumor growth along the lymphatic channels and involvement of vascular endothelial growth factor-C in a signaling pathway. The authors describe the case of a 45-year-old woman whose presentation with cough and dyspnea led to diagnosis of pulmonary lymphangitic carcinomatosis with superimposed pulmonary hypertension, tumor thrombotic microangiopathy, and ultimately metastatic signet ring cell gastric adenocarcinoma. Because of the patient's poor prognosis, she was given palliative care and died 29 days after admission. This case emphasizes the importance of the osteopathic principle of treating the whole patient and evaluating all organ systems. Physicians should be aware of PLC from gastric adenocarcinoma and consider it in patients with pulmonary symptoms who are unresponsive to antibiotics.

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital.

BackgroundSmall cell lung carcinoma (SCLC) is one of the deadliest forms of lung cancer due to its poor prognosis upon diagnosis, rapid doubling time, and affinity for metastasis. As 60–70% of patients with SCLC have disseminated disease upon presentation, it is imperative to determine the extent of disease burden for treatment. As a neuroendocrine carcinoma, clinicians must pay close attention to abnormal findings in a smoker that could lead to earlier diagnosis and better prognostication.Case presentationA 64 year-old 20-pack year smoker presented to the emergency department with nausea and vomiting for 3 days. No inciting events were elicited. History and review of symptoms were negative including symptoms most-commonly associated with malignancy such as fevers and weight loss. He also denied any pulmonary symptoms. Physical examination was benign except for right lung end-expiratory wheezing. Our patient was clinically euvolemic. Initial blood laboratories showed a sodium 110, serum osmolarity 227, and urine osmolarity of 579. Fluid restriction led to normalization of his sodium and resolution of nausea & vomiting. Chest radiography was obtained to follow-up on the wheezing, which was read as no acute cardiopulmonary disease by radiology. Due to high suspicion of SIADH from malignancy, a CT of the chest was performed which showed a conglomerate of nodules and opacities in the right upper lobe. Biopsy revealed SCLC. At outpatient follow-up, patient had a PET-CT showing one active mediastinal lymph node as the only site of metastasis. He received three round of chemotherapy, chest and prophylactic cranial radiation, and deemed in remission by oncology.Discussion and conclusionsDue to its affinity for metastases, 70% of patients with SCLC present with symptoms related to the spread of cancer to affected organ systems. Given the aggressive nature of this disease, screening measures have been implemented to help diagnose limited stage SCLC. Unfortunately, in our patient and many others, screening guidelines may fail to identify appropriate patients to scan. It is therefore imperative to use our clinical index of suspicion and identify any early presentations (including paraneoplastic syndromes) which may tip off the beginning stages of SCLC. This could improve survival rates by up to 45%.

Infection by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is known to have the highest mortality rate among the elderly and those with pre-existing medical conditions. Viral load has been directly correlated with increased risk of mortality in hospitalized patients. Once infected, symptoms first arise approximately six to seven days later followed by immunoglobulin M (IgM) antibodies appearing 8-12 days after onset of clinical symptoms. Recent studies have noted that the monoclonal antibody combination of casirivimab and imdevimab (REGN-COV2) effectively reduces viral load in infected seronegative non-hospitalized patients. However, research supporting the use of REGN-COV2 in an inpatient setting is limited. We present the case of a 45-year-old male with confirmed SARS-CoV-2 infection with moderate dyspnea and progressive worsening of his symptoms over a week period. The patient showed drastic improvement of his symptoms after a single low-dose regimen of REGN-COV2 infusion while admitted to the hospital and was subsequently discharged without further medical complications.