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Raynaud’s phenomenon (RP) is an episodic digital vasospastic condition that is prevalent among 5% of the population. The symptoms range from reversible pallor to ischemia and gangrene. RP can be primary or secondary. We discuss a case of severe RP secondary to granulomatosis with polyangiitis (GPA) that presented with ischemia and gangrene. Studies show that approximately

Evans syndrome is a rare autoimmune disorder where patients develop autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and less commonly immune neutropenia. Patients typically present with fatigue, pallor, jaundice, petechiae, or epistaxis. A 27-year-old man with a history of atopic dermatitis for which he recently began treatment with dupilumab presented to the emergency department with a headache and blurry vision. Multiple Roth spots were seen on fundoscopic examination. Laboratory studies were consistent with warm AIHA, confirmed by a positive direct antiglobulin test (DAT), and severe thrombocytopenia. He was diagnosed with Evans syndrome. He was treated with corticosteroids, rituximab, and intravenous immunoglobulin (IVIG). His recovery was prolonged with the slow improvement of anemia and thrombocytopenia. This is an atypical presentation of Evans syndrome with isolated symptoms of new-onset blurry vision and headache along with the finding of Roth spots. Another interesting feature in the case is the recent use of dupilumab. Dupilumab is a monoclonal antibody that inhibits the T-helper cells type 2 (Th2) signaling pathway by blocking interleukin (IL)-4 and IL-13 binding. This alteration in the immune response could have a role in the development of Evans syndrome.

Lead poisoning, fairly common in the 20th century, has decreased drastically in the last decade. Severe lead poisoning in the form of encephalopathy has a fatality rate of 28% to 45% and neurological sequelae in about 82%. We present the management of a case of lead encephalopathy that recovered without any significant neurological sequelae in a resource-limited setting. A previously healthy seven-year-old boy presented with complaints of falling unconscious on the ground while playing, followed by multiple episodes of seizures, vomiting, and altered sensorium. The patient had pallor, Glasgow coma score of E2V3M3, with features of raised intracranial pressure. Lead poisoning was suspected as the patient had four months of exposure to a battery recycling factory. Management of seizures and raised intracranial pressure was done. X-ray long bones showed lead lines at the metaphysis. Blood lead levels were highly elevated (139.96 mcg/dL). Investigations revealed iron deficiency anemia, vitamin D deficiency, and renal tubular injury in the form of proteinuria. D-penicillamine with supplements was started due to unavailability of other chelating agents. Encephalopathy improved, but patient had psychiatric symptoms of hallucinations and delusions. On the 12th day, CaNa2 EDTA was started, which resulted in significant improvement in the psychiatric symptoms. The patient had near-complete recovery in another one month, the patient being able to read, write, recite and speak as the pre-illness state. In conclusion, lead poisoning remains a significant health problem even today. Early recognition and management are of paramount importance in its outcome.

Idiopathic intracranial hypertension (IIH) causes visual involvement secondary to papilledema but rarely presents with acute gross diminution of vision. Anemia is associated with IIH. Acute hemorrhage-related anemia causing severe sudden onset bilateral visual loss due to IIH has not been previously reported. A 28-year-old female attempted the first-trimester abortion by self-administration of oral drugs. She presented with bleeding per vaginum, followed by bilateral visual loss. Symptoms pertaining to intracranial hypertension were mild. Examination revealed pallor, normal hemodynamic parameters, bilaterally dilated pupils, bilateral lateral rectus palsy, and only perception of light in both eyes. Lumbar puncture demonstrated high pressures; neuroimaging was noncontributory. Blood transfusion and supportive therapy in the form of acetazolamide and pulse methylprednisolone improved her vision in the right eye to six of 24; optic nerve sheath fenestration was performed in the left eye. During follow-up, her vision improved to six of 24 (right) and two of 60 (left), respectively. The IIH can present with severe acute onset bilateral visual loss even if features of raised intracranial pressure are minimal or absent. Immediate correction of anemia and supportive measures may significantly improve visual outcomes in fulminant IIH without the necessity of surgery.

Raynaud's phenomenon (RP) is a vasospastic disorder of the digital blood vessels leading to pain, paresthesias, and pallor in response to cold or stress. RP can develop secondary to a number of pathologies or factors, including the use of chemotherapy agents. Typical first-line therapies for secondary RP may be contraindicated in patients with certain comorbidities. Here, we discuss a case in which botulinum toxin A (BTX-A) was used to treat chemotherapy-induced RP in a patient with non-small cell lung cancer (NSCLC). We provide a review of the existing literature on the clinical course and treatment modalities, including the use of BTX-A, for patients with secondary RP. A 56-year-old female with NSCLC received treatment with bevacizumab and pemetrexed. Her initial symptoms included progressive discoloration and pain in her fingertips, which hastily progressed to ischemia and subsequent dry gangrene. She was diagnosed with chemotherapy-induced RP, but traditional management options were complicated by acute congestive heart failure. BTX-A injections were administered at key locations on the wrist and hand, significantly improving her symptoms and slowing the progression of the gangrenous changes. RP can develop as sequelae of chemotherapy regimens. Clinical management may be complicated by underlying pathology and/or patient symptoms. BTX-A injections are an excellent non-operative therapeutic option for patients with secondary RP in cases where mainstay therapies may be contraindicated, thus decreasing pain, improving patient quality of life, and slowing the progression of gangrenous changes.

Penetrating aortic ulcer (PAU) is an important, albeit, rarer cause of embolization to internal organs and distal extremities. Embolization occurs as a result of the disruption of cholesterol deposition in the wall of the aorta by a PAU. The classic presentation of cholesterol embolization syndrome (CES) includes pain, pallor, poikilothermia, paresthesia, and paralysis with intact pulses. The patient will classically have livedo reticularis or "blue toes." We present a case of a patient who presented to the emergency department with the complaint of a painful, blue toe. The patient had intact distal pulses on exam with the distal 2/3 of the first toe having a markedly blue/black color with livedo reticularis spreading proximally on the other 1/3 of the toe. CT angiogram with runoff to the lower extremities revealed a 3.6-cm infrarenal abdominal aortic aneurysm with a 5-mm penetrating aortic ulcer with a three-vessel runoff to the distal lower extremities. The diagnosis of CES secondary to a PAU was made. While thrombotic embolization from PAU causing acute limb ischemia is less common, it is well described. In contrast, cholesterol embolization from PAU remains a rare phenomenon without adequate treatment options.

Isolated finger compartment syndrome is an uncommon condition and is not well-documented. It is usually associated with pain, decreased sensation, and intra-compartmental swelling. We present the case of a finger fracture after a crush injury that developed compartment syndrome, which responded well after surgical fixation and midline skin incision for digital decompression. A 20-year-old male with a history of a 200 lb crush-injury to the left index finger 24 hours prior presented to the emergency department with decreased sensation and range of motion, deformity, increasing pallor, and severe pain. Radiographs demonstrated a middle phalanx fracture of the index finger. Digital decompression of the index finger through a radial approach, along the middle line, and open reduction internal fixation of the middle phalanx improved perfusion almost immediately. The patient continued to improve at his one-week, 12-week, and six-month follow-up appointments, with a normal neurovascular exam, a capillary refill of less than two seconds, and, ultimately, he was able to make a full composite fist. Though finger compartment syndrome is uncommon, it should be suspected in cases where the patient demonstrates hallmark clinical signs and symptoms. Compartment syndrome is a clinical diagnosis that requires urgent diagnosis and intervention and must be suspected regardless of the anatomic location of the injury.

Breast cancer is the most common cancer in women. The common sites of metastasis include the lungs, liver, and, infrequently, the gastrointestinal (GI) tract. A 72-year-old Caucasian female presented to the hospital with nausea and vomiting, diarrhea, intermittent abdominal pain, and unintentional weight loss. She had had a past medical history of bilateral lobular breast carcinoma and severe iron-deficiency anemia treated with iron transfusions. On arrival, the examination was significant for hypotension and pallor. Laboratory investigations revealed abnormal liver enzymes and raised tumor markers Ca-125 and carcinoembryonic antigen. Imaging studies established a diagnosis of distal small bowel obstruction. The surgical intervention showed the presence of a small bowel tumor, the biopsy findings of which were consistent with metastatic breast cancer, with ER and PR positive but HER-2 negative. She was managed with a selective estrogen receptor degrader and CDK4/6 inhibitor and has been in remission since. Metastasis to the small bowel from the breast is a very rare occurrence. Clinicians should thus maintain a modest amount of suspicion when encountering an uncommon GI presentation of primary breast malignancy. We describe the case of metastatic breast cancer with an atypical GI presentation.

Despite being prevalent in the cities of Gilgit-Baltistan and Azad Jammu Kashmir in north-eastern Pakistan, diagnosing visceral leishmaniasis for doctors in Pakistan can be an arduous task. We present here, a case of a five-year-old boy, who presented to us with a history of intermittent, high-grade fever, abdominal pain that was localized to the left side and abdominal distention as well as pallor for the past two and a half months. The child also developed measles in the week before presenting to us at Civil Hospital Karachi. On examination, the child looked pale, with several hyperpigmented lesions on the face and nose. There was bilateral pedal edema, which extended upward to the thighs and generalized lymphadenopathy. The examination of the respiratory and cardiovascular system was normal. On examination of the abdomen, there was marked hepatosplenomegaly. A diagnosis of visceral leishmaniasis was made based on the findings of routine blood investigations indicative of pancytopenia, clinical manifestations, and epidemiology and, finally, a bone marrow biopsy report with demonstrable Donovan bodies. The patient's condition improved after five weeks of treatment with intravenous amphotericin B deoxycholate.

Introduction Drug-resistant tuberculosis (DR-TB) is a major concern to effective control of tuberculosis (TB) in India and the likelihood of drug resistance increases with repeated exposure to anti-TB drugs. India has emerged as one of the leading contributors of DR-TB in the world posing a major threat to TB control. In the current study, we aim to find the burden and factors associated with drug resistance in previously treated pulmonary TB patients. Methods A cross-sectional study was conducted among 230 previously treated pulmonary TB patients registered with Directly Observed Treatment, Short-course (DOTS) centers under Nehru Nagar Chest clinic in Delhi, India. The participants were selected consecutively as they registered with the chest clinic. A predesigned, pretested, semi-structured questionnaire in the Hindi language used to collect socio-demographic data and factors associated with the development of drug resistance. Physical examination of all the participants was done (height, weight, pallor). Data were analyzed using SPSS version 21. Binary logistic regression analysis was used to identify independent risk factors of drug resistance. Results Of 230 previously treated pulmonary TB patients, 80 (34.8% (95% CI:28.7-40.9%)) were drug-resistant. Age (p=0.021), ever consumption of alcohol (p= 0.001), pallor (p=0.06), BMI (p=0.028), fasting blood sugar (p=0.001), treatment failure (p=0.005) and the number of prior courses of anti-tuberculosis treatment (ATT) taken (p=0.004) were significantly associated with drug resistance. On applying binary logistic regression analysis, independently associated factors with drug resistance were ever consumption of alcohol, pallor, high fasting blood sugar level, previous treatment failure patients and the number of prior courses of ATT (p

A 55-year-old African American man with a history of abdominal aortic pseudoaneurysm repair presented to the ED with complaints of black-colored stools mixed with fresh blood and fever for three days duration. The exam was unremarkable except for abdominal bruits and pallor. CT angiogram showed perigraft fluid collection, bowel wall thickening, and loss of normal fat planes between the aorta and adjacent bowel at the level of the third portion of the duodenum. Polymicrobial infection was noted in the aortic graft and blood cultures grew Candida. The patient underwent urgent removal of the infected graft, duodenal repair along with appropriate antimicrobial therapy. He did well postoperatively and was discharged in a stable condition. Our case highlights the importance of maintaining a high index of suspicion of aortoenteric fistula (AEF) when a patient with a prior abdominal aortic graft develops gastrointestinal (GI) bleeding as this condition is universally fatal if unrecognized.

Tick-borne diseases are frequently seen in tick-inhabited areas. Lyme disease is the most common tick-borne illness. However, patients with co-infections can present with nonspecific symptoms, which can make the diagnosis far more challenging. We present a case of triple infection with babesiosis, Lyme disease, and anaplasmosis treated with antibiotics and red blood cell (RBC) exchange (erythrocytapheresis). A 74-year-old, avid female gardener presented with one week of progressive dyspnea, cough with mucoid expectoration, and fatigue. On presentation, she was afebrile, hypotensive, and tachycardic. General examination was significant for altered mental status, dyspnea, pallor, and peripheral edema. Lung examination was remarkable for bibasilar crackles. Pertinent laboratory findings were significant for hemolytic anemia and thrombocytopenia. A peripheral blood smear revealed the presence of intracytoplasmic parasites consistent with Babesia. The patient was started on azithromycin and atovaquone. Doxycycline was added empirically for Lyme disease, which was later confirmed by serology. In addition, Anaplasma titers were also positive. Further investigation revealed that the parasitic load was 9.04%, and RBC exchange (erythrocytapheresis) was performed for severe babesiosis. Repeat laboratory tests demonstrated an inadequate reduction in parasitic load (6.54%), requiring a second round of RBC exchange. Antimicrobials were changed to clindamycin, quinine, and doxycycline for a total of 14 days. There was an improvement in the patient's anemia and thrombocytopenia along with clinical improvement.

We present a rare case of rasburicase-induced methemoglobinemia and hemolytic anemia in the setting of presumed glucose-6-phosphate dehydrogenase (G6PD) deficiency. A 78-year-old male with a known history of chronic lymphocytic leukemia presented to the clinic with fever of unknown origin. Laboratory results were significant for hyperuricemia. He was empirically started on levofloxacin and rasburicase. He then presented to the emergency department with shortness of breath and syncope. Physical examination was remarkable for a fever of 102.8 °F, conjunctival pallor, and scleral icterus. An infiltrate was observed on his computed tomography (CT) angiogram of the chest. Arterial blood gas on 50% fraction of inspired oxygen was significant for an arterial oxygen level of 222 millimeters mercury and oxyhemoglobin of 85.9%. Co-oximetry was then obtained and methemoglobin level was 13.4%. Laboratory results were noteworthy for a drop-in hemoglobin, indirect hyperbilirubinemia, low haptoglobin and elevated lactate dehydrogenase; depicting hemolytic anemia. The patient received two units of packed red blood cells, intravenous broad-spectrum antibiotics and he clinically improved.