While widespread coronavirus disease 2019 (COVID-19) vaccination has helped achieve some control of the pandemic, vaccines have presented with side effects of their own, both common and rare. We present an unusual case of a 66-year-old who presented with severe thrombocytopenia following vaccination with the Pfizer-BioNTech mRNA vaccine. Our patient is a 66-year-old African American female with a known history of Sjogren’s syndrome and hepatitis C who presented to our facility as a direct admit from our affiliated infusion clinic where routine lab work revealed a platelet count of 14,000. On arrival, she reported a one-month history of progressive tiredness, intermittent epistaxis, and bruising on her legs. Her physical exam was notable for multiple petechiae and non-palpable purpura on all four extremities. Further questioning revealed that she had received her COVID-19 vaccine booster (Pfizer-BioNTech) three weeks prior to presentation and that is when all the symptoms had started. Rheumatology was consulted and the patient was started on intravenous immunoglobulin infusion for two days and pulse dose prednisone. Her platelet count showed improvement after treatment, and she was discharged home with a platelet count of 42,000. Though largely safe and efficacious, COVID-19 vaccines can present with rare systemic side effects and physicians must have a high index of suspicion and report these cases so that more data is available for interpretation.

Case Description/Methods: An 84-year-old male presented with epigastric abdominal pain. 3-years prior he had wide local excision for cutaneous malignant melanoma of the upper back (R0 resection). His abdominal pain had worsened over the last 4-weeks and was preceded by jaundice and unintentional weight loss. Initial studies were significant for elevated alkaline phosphatase (1295), AST (270) ALT (212), total bilirubin (10.1) and lipase (12085). Computed tomography (CT) showed a 2.4 cm lesion in the pancreatic head along with dilated pancreatic duct and biliary dilation. Carbohydrate antigen 19-9 (CA19-9) was elevated (628). Cholangiogram showed a 15 mm distal biliary stricture with upstream dilation. Brushings of the biliary stricture were unsatisfactory due to insufficient cells. Subsequent endoscopic ultrasound (EUS) demonstrated a 25mm by 25mm mass in the pancreatic head invading the distal CBD. Fine-needle aspiration (FNA) showed a poorly differentiated malignancy with epithelioid and focal spindle cell features with positive S100 and SOX-10 immunophenotype. Findings consistent with melanoma. Additional imaging did not reveal other potential sites of metastasis. The patient has since been discharged and is undergoing further evaluation. Discussion: Approximately one-third of patients with malignant melanoma develop metastases. However, metastatic melanoma of the gastrointestinal system is only seen in 2-4% of patients affected by cutaneous melanoma. This patient had a unique presentation with invasion of his pancreatic lesion into the distal common bile duct which lead to obstructive jaundice and pancreatitis. Pancreatitis as a result of metastatic melanoma is a rare presentation only described in a few case reports. Based on imaging it appears the patient initially had isolated metastatic disease of the pancreas which then invaded into the common bile duct. Isolated pancreatic metastasis represents less than 1% of all metastatic melanomas. It is difficult to differentiate a primary cancer from metastatic disease of the pancreas based on imaging alone. The use of EUS-FNA is essential for diagnosis. Though the exact prognosis of metastatic melanoma of the pancreas is unclear, generally metastatic melanoma carries a poor prognosis.

heterozygous individuals. Individuals arent routinely screened for A1AT, however a biopsy may aide in arriving to the correct diagnosis. Early detection, allows for early transplant evaluation, genetic counseling and education.[2962] Figure 1. The biopsy shows a core liver biopsy with overall preserved architecture and few portal tracts seen. PAS with diastase highlights a very patchy distribution of bright, magenta-colored globules in mainly periportal hepatocytes (black arrows).

Objective: Primary aim of this study is to identify prevalence of organic sleep disorders (OSDs) [REM sleep behaviour disorder (REMSBD), hypersomnia, parasomonia, insomnia, circadian rhythm] and compare prevalence of stroke [acute ischemic stroke (AIS), transient ischemic attack (TIA), intracerebral hemorrhage (ICeH), subarachnoid hemorrhage (SAH)] amongst OSDs. Secondary aim of the study is to evaluate the association between OSDs and stroke subtypes. Methods: A retrospective study was performed using National Inpatient Sample [2016-2017] for adult hospitalizations. We extracted a cohort of diagnoses of OSDs amongst which diagnoses of stroke were identified using ICD 10 code. Weighted analysis using chi-square test and mix-effects multivariable survey logistic regression was performed to evaluate the prevalence and odds of stroke amongst OSDs. Results: Out of 58,259,589 US hospitalizations, 2715 (0.00005%), 4120 (0.01%), 3420 (0.01%), 1,301,209 (2.23%) and 24870 (0.04%) had REMSBD, parasomnia, circadian rhythm, insomnia, and hypersomnia, respectively. Prevalence of AIS was higher in REMSBD [3.1 vs 2.1% p<.0004], hypersomnia [2.7 vs 2.1% p<.0001], parasomnia [2.6 vs 2.1% p=.0714], and circadian rhythm [2.8 vs 2.1% p=.0102]. Prevalence of TIA was higher in REMSBD [1.3 vs 0.6% p<.0001], parasomnia [1.3 vs 0.6% p<.0001] and hypersomnia [0.7 vs 0.5% p=.0188]. Prevalence of ICeH was higher in hypersomnia [0.5 vs 0.4% p=.0043], parasomnia [0.5 vs 0.4% p=.3239], and circadian rhythm [1.3 vs 0.4% p=.0188]. Prevalence of SAH was higher in circadian rhythm [0.6 vs 0.1% p<.0001]. In analysis, patients with parasomnia had higher odds of TIA [aOR 2.8; 95%CI 1.02-7.5] and a weak association with ICeH [1.9 (0.5-7.9)]. Circadian rhythm OSD had 214% [3.1 (1.6-6.1)] and 310% [4.1 (1.5-11.0)] higher risk of ICeH and SAH, respectively and a weak association with AIS [1.3 (0.8-2.1)]. Hypersomnia had a weak association with AIS [1.2 (1.0-1.4)], TIA [1.1 (0.8-1.6)] and ICeH [1.4 (0.9-2.0)]. REMSBD had a weak association with AIS [3.6 (0.8-15.4)]. Conclusion: Our study shows organic sleep disorders (OSDs) are associated with strokes. Even Though the extent of association varies in each OSDs, early identification and prompt management of OSDs may mitigate the risk of stroke.