Infection following SARS‐Co V‐2 leading to COVID‐19 disease is associated with significant morbidity and mortality. The clinical entity, COVID‐19 cytokine storm syndrome (CSS) is a severe immunological manifestation of the disease associated with ominous consequences. Tocilizumab is interleukin‐6 inhibitors that has been shown to hamper the catastrophic outcomes of CCS including the need for mechanical ventilation as well as reduce mortality, but the usage is limited by warnings of reactivation of potential latent infections or immune dysfunctions including severe neutropenia. We describe a case of 39‐year‐old Nepalese male patient with a background of scleritis maintained on azathioprine and rituximab therapy with normal baseline parameters including complete blood count who presented with acute COVID‐19 infection including associated leukopenia as well as severe neutropenia (absolute neutrophil count of 300 cells/µl), then progressed to critical disease culminating into CSS. Based on risks and benefits evaluation, the patient was treated with tocilizumab reinforced with granulocytes‐colony stimulating factor (G‐CSF, Filgrastim) to full recovery and safe outcome including reversal of neutropenia.

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Implantable cardioverter defibrillator lead endocarditis due to Brucella melitensis is a rare and life-threatening complication of brucellosis. Successful management requires a combination of medical treatment and device extraction. We present a case of relapsing brucellosis manifested as infective endocarditis colonizing the lead of the implantable cardioverter defibrillator with formation of vegetation on the lead. A 63-year-old male presented to the rehabilitation unit with hypotension. No other signs of infection were noted. The patient had a history of drinking unpasteurized milk since childhood and a previous episode of Brucella infective endocarditis. A transthoracic echocardiography showed an oscillating vegetation on the lead of the tip of the right atrial ICD, and the blood cultures were positive for Brucella melitensis. Surgical removal of the device was infeasible, and medical management was the only feasible option in this case.

Rationale: Septic arthritis due to Nocardia is rare, with Nocardia otitidiscaviarum being the rarest Nocardia species isolated from septic arthritis. Patient concerns: Here we present a case of a 47-year-old man with a history of nephrotic syndrome on active treatment who developed signs and symptoms of septic arthritis. Diagnosis: Initial Laboratory test results showed high inflammatory markers, Right knee joint ultrasound revealed effusion. Therefore, knee arthrocentesis was performed, which revealed a milky orange fluid that grew gram-positive branching forms identified as moderate Nocardia otitidiscaviarum. Despite being asymptomatic, the patient underwent Head computed tomography, which revealed dissemination to the brain. Intervention: The patient was started on appropriate antibiotics, immunosuppressant medications were stopped, and arthroscopic drainage was performed. Outcomes: Repeated arthrocentesis after 2 weeks was sterile. After 1 month, the patient felt better, pain-free, and was able to ambulate. Lessons: Nocardial arthritis is rare, and joint management requires an internist, a rheumatologist, a surgeon, and an infectious disease expert because early identification of the bacteria can improve the outcomes and quality of life.