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Since March 2020, the SARS-CoV-2 virus known to cause COVID-19 has presented in many ways and it seems to affect almost all organ systems. One of its detrimental effects is on the coagulation system. Disruption of the coagulation pathway or hypercoagulability has been reported extensively in many articles and studies. It seems there is no specific pattern or location of the coagulopathy. The coagulopathy can present as part of the respiratory disease process or as an isolated phenomenon. Many articles had reported that the thrombus can be a venous thromboembolic phenomenon such as deep venous thrombosis (DVT), portal vein thrombosis, pulmonary embolism (PE), or as arterial thrombosis, for instance, coronary artery thrombosis, cerebrovascular thromboembolic disease (i.e., stroke), or an aortic thrombus. One of the disastrous presentations is what is called “catastrophic thrombosis syndrome.” This syndrome is characterized by multiple thromboses that take place in different parts of the vascular system at different parts of the body at the same time. In many studies, D-dimer levels have been shown to predict the risk of increased thromboembolism in SARS-CoV-2. However, an appropriate anticoagulation agent, dosage, and duration are yet to be determined. We are presenting an interesting case of a female who suffered catastrophic thrombosis syndrome despite being on prophylactic anticoagulation. She presented with leg pain and was found to have extensive multiple thrombi starting from the ascending/descending aorta and extending to the distal peroneal arteries.

Inflammation of the meningeal linings of the central nervous system (CNS), also known as meningitis, is one of the serious presentations in the emergency because it carries high morbidity and mortality. The most common cause is pus-producing organisms. However, non-suppurative meningitis, termed aseptic meningitis, is another cause of meningeal inflammation. Many etiologies stand behind aseptic meningitis. Those etiologies include viral and non-viral, drug-induced, malignancy, and systemic inflammation. Drug-induced aseptic meningitis is a rare type of meningitis. Although it is easily treated, it can be a challenging disease if not present in the differential diagnosis. It is commonly associated with nonsteroidal anti-inflammatory drugs (NSAIDs). Nonetheless, other medications have been also reported to cause aseptic meningitis, including antibiotics. Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the most prescribed antibiotics as a prophylactic and therapeutic drug due to its effectiveness and low cost. Although immunocompromised patients are at a higher risk to develop aseptic meningitis, immunocompetent patients are also at risk. Unrelated to the source of the infection, TMP-SMX carries a risk of aseptic meningitis and should be considered as an etiology in patients presenting with meningeal signs and symptoms. Hereby, we report a young immunocompetent patient who developed aseptic meningitis eight days after being prescribed TMP-SMX. Like all drug-induced aseptic meningitis, all his symptoms resolved two days after stopping the medication.

Gout is an arthritic syndrome that causes extensive joint damage and discomfort. It is due to an elevated uric acid level in the blood which deposits in the joints. This causes an inflammatory response and joint damage. Gout typically presents as an acute monoarticular attack, resulting in hot, erythematous, swollen, and exquisitely tender joint. Tophaceous gout, which is commonly a later complication of long-standing gout, can rarely be the presenting manifestation of gout. Tophaceous gout is considered a late complication of chronic gout. As early recognition of gout can lead to prompt initiation of treatment and improvement in clinical status, a patient with an alcohol use history who presents with polyarticular swelling and tenderness should raise the suspicion of a tophaceous gout exacerbation even if the patient does not have a documented history of gout.

Background Posterior reversible encephalopathy syndrome (PRES) is usually a benign, yet underdiagnosed clinical condition associated with subacute to acute neurological manifestations primarily affecting white matter. PRES is reversible when recognized promptly and treated early by removal of the insulting factor; however, can lead to irreversible and life-threatening complications such as cerebral hemorrhage, cerebellar herniation, and refractory status epilepticus. Methods We utilized the National Inpatient Sample database provided by the Healthcare Cost and Utilization Project (HCUP-NIS) 2017 to investigate the demographic variables (age, sex, and race) for patients with PRES, concomitant comorbidities and conditions, inpatient complications, inpatient mortality, length of stay (LOS), and disposition. Results A total of 635 admissions for patients aged 18 years or older with PRES were identified. The mean age was 57.2 ± 0.6 years old with most encounters for female patients (71.7%, n = 455) and white as the most prevalent race. Half the patients in our study presented with seizures (50.1%, n = 318), sixty-three patients (9.9%) presented with vision loss, and sixty-four patients (10.1%) had speech difficulty. In addition, 45.5% of patients had hypertensive crisis (n = 289). 2.2% of hospitalizations had death as the outcome (n = 14). The mean LOS was 8.2 (±0.3) days, and the mean total charges were $92,503 (±$5758). Inpatient mortality differed between males and females (1.7% vs. 2.4%) and by race (3.6% in black vs. 1.8% in white) but was ultimately determined to be not statistically significant. Most patients who present with vision disturbance have a high risk of intracranial hemorrhage. Furthermore, end-stage renal disease, atrial fibrillation, and malignancy seemed to be linked with a very high risk of mortality. Conclusion PRES, formerly known as reversible posterior leukoencephalopathy, is a neurological disorder with variable presenting symptoms. Although it is generally a reversible condition, some patients suffer significant morbidity and even mortality. To the best of our knowledge, this is the largest retrospective cohort of PRES admissions that raises clinician awareness of clinical characteristics and outcomes of this syndrome.

Background: A patient decides to leave the hospital against medical advice. Is this an erratic eccentric behavior of the patient, or a gap in the quality of care provided by the hospital? With a significant and increasing prevalence of up to 1–2% of all hospital admissions, leaving against medical advice affects both the patient and the healthcare provider. We hereby explore this persistent problem in the healthcare system. We searched Medline and PubMed within the last 10 years, using the keywords “discharge against medical advice,” “DAMA,” “leave against medical advice,” and “AMA.” We retrospectively reviewed 49 articles in our project. Ishikawa fishbone root cause analysis (RCA) was employed to explore reasons for leaving against medical advice (AMA). This report presents the results of the RCA and highlights the consequences of discharge against medical advice (DAMA). In addition, the article explores preventive strategies, as well as interventions to ameliorate leaving AMA.

Heart attacks in young populations are frequently misdiagnosed as reflux disease or anxiety. Spontaneous coronary artery dissection (SCAD) is a coronary artery disease that classically manifests around the age of 45 years and has a fatal outcome if missed. Since it was first described in 1931, our understanding of SCAD has evolved tremendously, particularly with the advent of advanced coronary angiography. Electrocardiograms can show abnormality in the ST-segment, with an elevation of cardiac damage markers. The involvement of the coronary arteries is variable. The left main coronary artery is frequently reported as the main culprit. We are hereby reporting a case of SCAD in a young woman who presented with a heart attack. Particularly, her age is younger than the reported cases, cardiac catheterization revealed a left main artery dissection with a thrombolytic extension, and her complicated case was managed with coronary artery bypass and heart transplantation.

Case series Patients: Female, 26-year-old • Female, 27-year-old • Female, 19-year-old Final Diagnosis: Acute Respiratory Distress Syndrome (ARDS) • COVID-19 Symptoms: Fever • hypoxia • shortness of breath Medication: — Clinical Procedure: Cesarian section • mechanical ventilation Specialty: Critical Care Medicine • Infectious Diseases • Medicine, General and Internal • Obstetrics and Gynecology Objective: Management of emergency care Background: Novel Coronavirus 2019 (COVID-19) has been defined as a pandemic infecting millions of individuals with a significantly high mortality and morbidity rate. Treatment and management for pregnant patients infected with COVID-19 has been poorly described in the literature. Furthermore, vertical transmission of COVID-19 to the fetus has been poorly described. The purpose of this case series is to present 3 patients in their trimester who underwent emergent cesarean sections and were successfully managed in the intensive care unit. Case Reports: We present the cases of 3 patients diagnosed with COVID-19 via RT-PCR in their third trimester of pregnancy. All patients underwent emergent cesarean sections and were managed on mechanical ventilation in the intensive care unit and eventually discharged in stable condition. Conclusions: Early cesarean section and aggressive management with mechanical ventilation has been shown to be very beneficial for mothers diagnosed with COVID-19 and their infants. All 3 patients were successfully extubated, and all 3 infants tested negative for COVID-19, suggesting no vertical transmission; although, further studies are needed to confirm this finding.

Infective endocarditis (IE) is a well-known complication of bacteremia with high-risk microorganisms such as Staphylococcus and Streptococcus. Skin and soft tissue infections with Staphylococcus remain a significant cause of bacteremia and IE, even with proper prompt management of the source of infection and the absence of risk factors. Although methicillin-resistant Staphylococcus aureus is a well-known etiology for osteoarticular septic emboli in IE, healthcare providers should be aware of the hidden virulence of methicillin-sensitive Staphylococcus aureus for metastatic osteoarticular infection. We report a case of IE with septic vertebral embolic lesion complicating a properly managed acute paronychia.

Streptococcus agalactiae is well known to be a potential etiology of bacterial meningitis in neonates. Invasive S. agalactiae has been also reported in nonpregnant adults. Among adults, the incidence of invasive group B Streptococcus (GBS) has been increasing 2-4 times in the past 2 decades. Chronic medical disease was suspected to increase the susceptibility for invasive GBS, especially diabetes mellitus. There was only one case reported to have GBS meningitis from acute otitis media infection in otherwise healthy individual. Hereby, we are reporting the second invasive GBS meningitis from acute otitis media infection with mastoiditis.

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 19 (SARS-CoV19) is a known viral pneumonia However, gastrointestinal involvement is not uncommon, and can be the only presenting feature Our case presented with only diarrhea;then the patient developed respiratory symptoms CASE DESCRIPTION/METHODS: A 80 y/o man with history of hypertension and chronic renal failure He presented with lethargy, generalized weakness, diarrhea, nausea, and oliguria for several days The patient denied coughing, shortness of breath, fever, or abdominal pain Social history showed his daughter had a mild febrile illness Where both reported testing COVID19 positive after the patient was admitted On physical examination, vitals were stable, except blood pressure 91/54 mm Hg The patient was alert, and oriented Mucus membranes were dry Cardiovascular, lung and abdominal examination were unremarkable The initial laboratory results showed leukopenia with normal WBC count, serum creatinine 8 84 mg/dL, RT PCR-nasal was positive on admission CXR was clear on admission The 4th day, the patient's reported anxiety, non-productive cough Crackles and cyanosis on examination Failure to maintain oxygenation lead to mechanical ventilation CXR showed bilateral infiltration The patient finished 5-day course of hydroxychloroquine, azithromycin, ascorbic acid, zinc, and one dose of Intravenous interleukin 6 inhibitor He also required hemodialysis, and vasopressors The family decided on providing comfort care with no invasive interventions DISCUSSION: Fever is the most common symptom (85%), then cough (68%) vomiting (5%) and diarrhea (3 7%) COVID19 cases who present with gastrointestinal symptoms have a worse prognosis compared to those with respiratory presentations Our patient had severe diarrhea that lead to hypovolemic shock with multiple organ failure As seen in previous reported cases, respiratory symptoms started within a week of the first gastrointestinal complaint, which correlates with the surge in the inflammatory markers Screening for COVID19 infection through fecal PCR has shown to have similar accuracy as the PCR from respiratory samples RT PCR-stool is potentially one of the methods for early detection of SARS-CoV2 disease when it has non-respiratory symptoms or in asymptomatic cases