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Typical or atypical presentations of rare diseases may be confounded by co-morbidities in critically-ill patients. It is imperative to diagnose and treat appropriately, despite this difficulty. Scleroderma renal crisis mimics many other conditions, and can be potentially fatal if not caught early enough. Particularly, in critically-ill patients with multiple pathologies, it can be difficult to distinguish scleroderma renal crisis from other diseases, such as thrombotic thrombocytopenic purpura (TTP), hypertensive emergency, posterior reversible encephalopathy syndrome (PRES), or atypical hemolytic uremic syndrome (HUS). Herein, a patient who presented with encephalopathy and seizures was initially treated for thrombotic thrombocytopenic purpura, but was ultimately diagnosed with scleroderma renal crisis. Given her numerous laboratory abnormalities, such as thrombocytopenia, hemolytic anemia, kidney and liver dysfunction, and elevated inflammatory markers, various differentials were considered. During her hospitalization, she suffered a cardiac arrest, seizures, nosocomial infections and worsening kidney disease requiring dialysis, making the final diagnosis of scleroderma renal crisis a diagnosis of exclusion. Subsequently, the management of a patient with multiple co-morbidities and confounding laboratory abnormalities difficult to treat. This article highlights these intricacies and formulates the thought process behind the diagnosis of Scleroderma Renal Crisis., Competing Interests: Disclosure of interest The authors report no conflict of interest. Ethical review is not necessary, because this is a case report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2023 Greater Baltimore Medical Center.)

Sickle Cell Disease (SSD) can present with acute painful crises, most commonly manifesting as diffuse bony pain; however, rare presentations of acute coronary syndrome, acute papillary necrosis, or multi-organ failure may also present in these patients. TTP has been rarely described in conjunction with sickle cell pain crisis (SS crisis). In both TTP and sickle cell crises, widespread platelet activation is present with thrombocytopenia as a result. Thrombocytopenia can be utilized as a poor prognostic indicator in patients with SS crisis. Multi-organ failure may appear similar to TTP and patients may benefit from similar therapy. Here, we present a 27-year-old female with a history of SSD who presented with a painful crisis who was found to have worsening renal failure and thrombocytopenia and was treated empirically with therapeutic plasma exchange (TPE), later discovered to have SS crisis with multi-organ failure with unremarkable ADAMSTS13 values. Given the high fatality risk of TTP, the benefits outweighed the risks for empiric TPE therapy, and our patient benefited from the treatment, as patients with both TTP and/or SS crisis multi-organ failure have demonstrated improvement following this treatment. Given the severity of multi-organ failure in SSD patients, additional research is warranted for improvement in the diagnosis and management of these patients., Competing Interests: Conflict of interest The authors report no conflict of interest. Ethical review is not necessary, because this is a case report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2023 Greater Baltimore Medical Center.)

Cardiovascular disease, COPD, and diabetes (DM) are associated with increased complications with COVID-19. A correlation between COVID-19 and diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic Syndrome (HHS) has been suggested; however, the precise mechanism remains unclear. We present a case series of six patients with COVID-19 infections who were found to have DKA, HHS, or mixed picture. Wedescribe an association between COVID-19 and hyperglycemic emergencies. Six patients (50% male, 50% female, mean age 47.667 ± 18.747) were identified from November 2021 to February 2022. Comorbidities included DM (83.3%), HTN (50%), as well as ESRD, A-Fib, ISLD, HIV, and dementia (each 16.7%). Common review of systems included nausea and vomiting (50%), abdominal pain (33.3%), dyspnea (33.3%), and decreased appetite (33.3%). Additional findings were dysarthria, facial droop, generalized weakness, productive cough, myalgias, and increased urinary frequency (16.7%). Patients were diagnosed with DKA (50%), mixed process (33.3%), andHHS(16.7%). In terms of COVID-19 symptoms, most patients were asymptomatic (83.3%), with one patient developing hypoxia. The survival rate was 100%. Infections can incite DKA/HHS; yet, COVID-19 may have factors that amplify this process, in the setting of pancreatic beta-cell dysfunction from the virus itself. This may contribute to why diabetic patients have a ten times higher risk of death if they develop COVID-19. This virus binds to ACE2 receptors in the pancreas and damages the islets, ultimately decreasing insulin release. Here, we introduce cases of DKA/HHS in the setting of COVID-19, to understand the relationship between how COVID-19 infections may exacerbate diabetic complications., Competing Interests: Conflicts of interest No conflict of interest to disclose., (© 2023 Greater Baltimore Medical Center.)

Alcoholic hepatitis (AH) usually presents after decades of alcohol consumption and can even manifest with recent abstinence. The clinical presentation may be compounded by underlying liver cirrhosis and liver function enzymes are not a reliable means of diagnosing AH due to poor sensitivity and specificity. One feature of alcoholic hepatitis is thrombocytopenia; however, patients may also have thrombocytopenia due to another underlying condition, such as Immune Thrombocytopenic Purpura (ITP). ITP is an autoimmune disease caused by autoantibodies against platelet glycoproteins. ITP is a diagnosis of exclusion and secondary causes of thrombocytopenia must be ruled out with persistent thrombocytopenia that is refractory to treatment for AH. Although there is limited data demonstrating a correlation between AH and ITP, both conditions respond to steroids. We present a case of a 42 YO M with an unknown cause of hepatitis and concomitant ITP who responded well to steroids., Competing Interests: Conflict of interest The authors report no conflict of interest. Ethical review is not necessary, because this is a case report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2023 Greater Baltimore Medical Center.)

SIADH is more commonly associated with small cell lung cancer but has also been associated with other malignancies such as oropharyngeal, gastrointestinal, genitourinary, endocrine, lymphomas, and sarcomas. There have been few reports of small cell carcinoma of the cervix complicated by SIADH; however, not many cases are associated with squamous cell carcinoma of the cervix. We present a case of a patient with squamous cell carcinoma of the cervix with a paraneoplastic syndrome of inappropriate secretion of antidiuretic hormone. The pathophysiology, clinical picture, and treatment are also discussed., Competing Interests: Conflict of Interest The authors report no conflict of interest. Ethical review is not necessary, because this is a case report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2022 Greater Baltimore Medical Center.)

FOLFIRINOX has been commonly utilized to treat patients with pancreatic cancer; however, it can manifest with rare, significant adverse effects. In particular, 5-FU has been associated with cardiotoxic effects, including but not limited to ischemic events, myocarditis, cardiac arrhythmias, cardiac death, heart failure, as well as coronary vasospasm. Two common thought processes regarding the mechanism of cardiotoxicity with 5-FU include exacerbation of ischemia secondary to coronary vasospasm and direct cell injury to the myocardium. Management of cardiotoxic adverse effects includes discontinuing 5-FU therapy if the patient can tolerate an alternative regimen or initiating prophylactic antianginal treatments with very close monitoring of the patient while they receive 5-FU therapy. Here, we describe a case of a 77-year-old patient with stage III pancreatic cancer who developed coronary vasospasm after initiation of combination therapy including 5-FU. Additional studies to gain further understanding of 5-FU cardiotoxicity are warranted, especially considering the common use of this medication with regards to pancreatic cancer patients. Further research of this topic may benefit patient care, prevent cardiovascular events, and determine which patients may benefit from prophylactic therapy while receiving 5-FU., Competing Interests: Conflict of interest The authors report no conflict of interest. Ethical review is not necessary, because this is a case report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2022 Greater Baltimore Medical Center.)

Cancer patients are at a higher risk of complications such as venous thromboembolism (VTE). This risk increases in patients who receive chemotherapy. Despite the increased risk, common locations for VTE are similar to those in patients without cancer. Chemotherapy-port-related thrombosis represents a rare complication due to the location and frequent use of access (with Heparin flushes) as part of the standard care. Attention should be made to this rare complication, which may progress to superior vena cava (SVC) syndrome. SVC syndrome typically presents in females around the age of 57 years old. Management of this syndrome can be difficult and generally requires the initiation of systemic anticoagulation therapy. Here, we present a rare case of a 45-year-old female who presented to the Emergency Department with right arm swelling, found to be secondary to her chemo port thrombosis, causing SVC syndrome., Competing Interests: Conflicts of interest There is no conflict of interest., (© 2022 Greater Baltimore Medical Center.)