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Vulvar cancer comprises 5% of gynecological cancers with squamous cell carcinoma (SCC) being found in 90% of the cases. Vulvar intraepithelial neoplasia is human papilloma virus (HPV)-driven and is the precursor lesion in nearly 40% of all cases of vulvar SCC. Pruritus is reported as the most common initial manifestation of vulvar SCC which may be of a long duration with pain, discharge, and bleeding been less frequently reported which contributes to the delayed initial presentation of the disease. So far, there are no recommended screening strategies for vulvar cancer and HPV vaccination may be the only effective way for prevention. We present a case of advanced vulvar cancer in an immunocompromised host. We will review pertinent topics for the clinicians on HPV infection prevention, clinical course, staging and the need for strong efforts on patient education.

Guillain-Barré syndrome (GBS) in an immune mediated disease that affects peripheral nerves with possible life-threatening complications. GBS has multiple subtypes including acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor axonal neuropathy (AMAN) and acute motor sensory axonal neuropathy (AMSAN), which can make GBS difficult to diagnose. GBS commonly presents after viral infections such as influenza virus, campylobacter jejuni, and zika virus. GBS commonly presents with a prolonged clinical course leading to increased morbidity among affected patients. It is not surprising that COVID-19 has been connected with multiple cases of GBS, which may alter the recovery course for several patients post-COVID. In this report, we present a case of 69-year-old-female who presented with progressive motor weakness and loss of sensation in her extremities after testing positive for antibodies to COVID-19 one-month prior to presentation. Her presentation and treatment of GBS in the setting of COVID-19 is an example of one of the many COVID-19 complications and sheds light on the prolonged recovery course that we may experience as clinicians in the wake of this pandemic.

Acute Aortic dissection is relatively uncommon but can lead to fatal outcome due to misdiagnosis and/or delay treatment [1]. In this report we present a case of a 45-year-old man presenting with chief complaint of substernal chest pain with no remarkable laboratory and echocardiography finding. He was admitted to the cardiology service with clinical suspicion of acute coronary syndrome (ACS). However, further evaluation led to the diagnosed of acute aortic dissection and referral for urgent repair. Aortic dissection could mimic other disorders such as ACS and pulmonary embolism due to variation in the presenting symptoms [1]. Therefore, high clinical suspicious could lead to timely diagnosis and initiation of life-saving therapeutic interventions.

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Long COVID- 19 or post-acute COVID -19 syndrome is now recognized as a range of symptoms that can last weeks or months after first being infected with COVID-19 or SARS -CoV 2 virus. It can appear weeks after infection irrespective of the severity of the illness1. It can affect most, if not all, body systems including heart, lung, kidney, skin, and brain functions. Here we present a case with Covid-19 infection with hyporcortisolism presenting as dyspnea and fatigue as the dominant long Covid-19 symptom. CASE PRESENTATION: A 55-year-old female with a past medical history of hyperthyroidism on propranolol, was diagnosed with mild COVID -19 infection, advised to treat with self-isolation. She revisited ER 6 weeks later with persistent dyspnea, fatigue, and poor ability to focus and concentrate. She was given a trial of the direct oral anticoagulant for 4 weeks with no change in her symptoms. The subsequent workup done;head-computer tomography scan (CTS) was negative for subarachnoid hemorrhage and cerebral venous thrombosis. The Lungs CTS did not reveal any pulmonary fibrosis. The 6-minute walk test was impaired at 79%. The Pulmonary Function test did not show any significant obstruction or restriction. The Cardiopulmonary Exercise Test overall was suggestive of deconditioning. The laboratory work included creatine kinase, Aldolase, vitamin B12, Folic acid, C-reactive protein, Vitamin D, Antinuclear antibody Thyroid Function test all were unremarkable. The AM cortisol level came back as less than 2. The patient was started on oral prednisone for a diagnosis of relative adrenal insufficiency. All her symptoms improved within 2 weeks of treatment and resolved after 4 -6 weeks, she was tapered down and finally weaned off prednisone. DISCUSSION: The proposed mechanism of COVID-19 induced relative adrenal insufficiency is likely hypophysitis.2 The principal target for the virus entry is the angiotensin-converting Enzyme 2 (ACE-2) receptor which is found on pneumocytes, arterial and venous endothelial cells of many organs including adrenal glands and hypothalamic and pituitary tissues2. Furthermore, SARS- Cov2 virus has amino acid sequences which are similar to the host's ACTH, so antibodies made against the virus destroys the host ACTH and consequently may cause contribute to cortisol insufficiency.2,3 CONCLUSIONS: Post COVID-19 infection has a multifaceted manifestation. Hypocortisolism can persist in patients with post COVID-19 and should be sought for if the symptoms are suggestive. The treatment is simple and effective. REFERENCE #1: Naserghandi, S.F. Allameh and R. Saffarpour. All about COVID-19 in brief. New Microbes New Infect. 2020 May;35: 100678. Published online 2020 Apr 13. doi: 10.1016/j.nmni.2020.100678 PMID: 32292590. REFERENCE #2: Pal, R. COVID-19, hypothalamo-pituitary-adrenal axis and clinical implications. Endocrine 68, 251–252 (2020). https://doi.org/10.1007/s12020-020-02325-1. REFERENCE #3: R. Wheatland, Molecular mimicry of ACTH in SARS—implications for corticosteroid treatment and prophylaxis. Med. Hypoth. 63, 855–862 (2004) PMID: 15488660. DISCLOSURES: No relevant relationships by Parinaz Ayat, source=Web Response No relevant relationships by Aaliya Burza, source=Web Response No relevant relationships by Charlyn Habeeb, source=Web Response