Unmasking Coronary Artery Disease With Intermittent Left Bundle Branch Block: A Case Report

Intermittent left bundle branch block (LBBB) is an unusual phenomenon, with very few cases documented in the literature. It is often considered a reflection of underlying conditions known to increase the risk of cardiovascular morbidity and death, including coronary artery disease (CAD), cardiomyopathy, hypertensive heart disease, and aortic valve disease. In rare instances, coronary vasospasm is the sole underlying condition. It is typically diagnosed by ECG and managed according to the underlying cause. We describe a case of intermittent LBBB presenting with chest pain. The ECG showed dynamic changes with transient/intermittent LBBB. An angiogram was performed, revealing significant coronary lesions. The patient was eventually managed conservatively and discharged on dual antiplatelet therapy for a duration of one year with a one-month clinic follow-up where his condition improved. Intermittent LBBB represents a transient disturbance in the intraventricular conduction system, where diseased conduction occurs secondary to an underlying cause, but normal conduction eventually restores. This results in complexes where LBBB appears alongside normally conducted beats in a single ECG tracing. There is limited knowledge about the prognosis of patients with intermittent LBBB; therefore, patients with LBBB should undergo careful evaluation due to the known association with serious cardiac pathologies, particularly cardiac ischemia. It is important to consider the potential adverse effects on ventricular function.

Navigating the Challenges of Delayed Subdural Hemorrhage and COVID-19: A Case Report

The delayed onset of posttraumatic subdural hemorrhage (SDH) represents non-specific clinical features, complicating the diagnostic process, especially in individuals predisposed due to pre-existing risk factors and comorbidities. This case report delineates the medical trajectory of a 61-year-old female patient who sustained a traumatic fall, initially displaying neither clinical nor radiological signs indicative of hemorrhage. However, three weeks post-injury, she developed altered mental status, cephalgia, and emesis. Diagnostic imaging unveiled a significant bilateral acute-on-chronic subdural hemorrhage exerting pronounced mass effect and leading to obliteration of the basal cisterns. Complicating her clinical picture was a concurrent SARS-CoV-2 infection and a medical history of hypertension. Emergent neurosurgical intervention was undertaken, encompassing the creation of bilateral burr holes for drainage and the placement of subdural drains. The patient was managed with the requisite medical therapies. Post-operatively, the patient regained consciousness and exhibited significant neurological improvement. Follow-up imaging demonstrated complete resolution of the subdural hemorrhage, and the patient achieved a full recovery of cognitive function. This case underscores the critical necessity for vigilant surveillance for delayed SDH in patients lacking initial radiographic findings and advocates for individualized therapeutic approaches in patients with concurrent pathologies. Prompt recognition, timely neurosurgical management, and care are pivotal to optimizing outcomes in delayed posttraumatic SDH cases.

Asymptomatic Presentation of Yellow Oleander Poisoning in a 57-Year-Old Saudi Woman: A Case Report

Yellow oleander (Thevetia peruviana), known for its cardiac glycosides, can cause severe poisoning with varied clinical manifestations, primarily affecting the cardiovascular system. We present a unique case of a 57-year-old Saudi woman with a history of type 2 diabetes, dyslipidemia, and previous meningioma excision who ingested 3.4 grams of yellow oleander fruit, mistaking it for an edible fruit. Remarkably, she remained asymptomatic with no gastrointestinal, neurological, or cardiovascular symptoms. Examination and investigations, including electrocardiograms and laboratory tests, showed no abnormalities. Despite the known high toxicity of yellow oleander and its documented fatal cases, our patient's asymptomatic presentation is rare. This case highlights the importance of close monitoring and observation in yellow oleander ingestion cases, even in the absence of symptoms, due to variable absorption kinetics and potential delayed onset of toxicity. Our findings also underscore the need for public health awareness regarding the identification and dangers of toxic plants like yellow oleander, especially as they are commonly grown at home.

A Case of Traumatic Diaphragm Rupture: A Differential Diagnosis Not to Be Missed

Traumatic diaphragmatic rupture is a rare condition with clinical stigmata that overlaps with a similarly fatal condition such as tension pneumothorax. Although the former is much rarer, early differentiation between a ruptured diaphragm and a tension pneumothorax is crucial to avoid incorrect interventions. In this case, we present a middle-aged male construction worker who fell from the roof of a two-story building and presented to our emergency department with a clinical presentation similar to that of tension pneumothorax. However, a chest X-ray later revealed a left diaphragmatic hernia, which completely altered the management. This case helps highlight the importance of widening one's list of differential diagnoses, especially in the setting of a hectic environment and a vague presentation.

Midgut Volvulus Evolving From Internal Herniation Following Roux-en-Y Gastric Bypass Surgery

In the literature, midgut volvulus is a well-known surgical complication following gastric bypass surgery that is serious and necessitates an immediate intervention. Here, we report a case of internal herniation that was misdiagnosed twice but eventually managed appropriately. A 27-year-old male with a surgical history of Roux-en-Y gastric bypass came to the emergency department complaining of severe epigastric abdominal pain. Two months earlier, he had a similar pain which was treated with Helicobacter pylori eradication therapy. Despite completing the eradication therapy, the pain reoccurred. Computed tomography angiography showed a filling defect in the superior mesenteric artery that was followed by a diagnostic laparoscopy ending with internal hernia reduction. Physicians should consider internal herniation as a differential diagnosis for every patient with a history of gastric bypass surgery presenting with abdominal pain.

Delayed Recognition, Surgical Dilemmas, and Complications: A Case Report of Acute-on-Chronic Subdural Hematoma With Ischemic Stroke

Acute-on-chronic subdural hematoma (SDH) is a new hemorrhage on a preexisting hematoma in the space between the dura mater and the arachnoid layer. Although chronic SDH is common, acute-on-chronic SDH is not. Herein, we present a case of a 70-year-old male with ischemic heart disease, diabetes mellitus, and hypertension who presented with worsening headaches for the past three days, associated with gait imbalance and dizziness. The patient was vitally stable on examination with a Glasgow Coma Scale/Score (GCS) of 15/15; his pupils were reactive bilaterally; and his neurological examination was unremarkable. Non-contrast computed tomography (CT) of the head yielded acute and chronic SDH. The patient was initially managed by embolization of the middle meningeal artery (EMMA), but one day later he developed a stroke. Hence, thrombectomy and burr hole craniotomy were performed to manage the stroke and evacuate the chronic subdural hematoma (CSDH). This paper presents this case as uncommon acute on chronic SDH presented with headache and vertigo, treated with embolization and with complications of stroke and pulmonary embolism.

Analysis of road traffic injuries presented to the emergency department in the Eastern Province of Saudi Arabia: a hospital-based study

The increasing incidence of road traffic injuries (RTIs) has contributed to the disability and death of millions of people on both a national and global level. This retrospective study was conducted at King Fahad University Hospital (KFUH), Khobar, Saudi Arabia, and included all patients who presented at the emergency department due to road traffic accidents (RTAs) between January 1st, 2022, and December 31st, 2022. Patient data was retrieved from the health information system at KFUH. Descriptive and inferential analysis were performed with several variables analyzed using multivariate logistic regression and factorial ANOVA (MANOVA). During this period, 921 patients were treated at the hospital's emergency department. Of these, 611 (66.3%) were men and 310 (33.7%) were women. The most frequently affected age group was 16-25, representing 427 (46.4%) cases. Most patients were Saudi citizens (837, 90.9%). Among the patients, 19 (2.1%) required surgical treatment within 24 hours of the RTA, and 29 (3.1%) were admitted to the surgical intensive care unit (SICU). There were eight fatalities, representing 0.9% of the cases. January had the highest number of RTAs (12.7%). Moreover, 463 individuals (50.3%) had some form of injury, the most common type being lacerations and abrasions (n=228, 24.8%). Upper limb fractures were the most frequent type of fracture, occurring in 73 cases (7.9%). Being male (P=0.001), non-Saudi (P=0.014), and experiencing accidents during June and July (P=0.002) were associated with an increased prevalence of injury. Mortality had a statistically significant relationship with different patient age groups (P=0.014), patient citizenship (P=0.005), and length of hospital stay (P<0.001).

Closed-Loop Bowel Obstruction Induced by Ventriculoperitoneal Shunt Catheter Coiling at the Sigmoid Colon: A Case Report

Intestinal obstruction is a rarely encountered complication in patients with ventriculoperitoneal (VP) shunt. The most common causes of bowel obstruction in this subset of patients include volvulus, formation of a spontaneous knot, and adhesions. Herein, we report a 21-year-old bedridden male with a history of congenital hydrocephalus on VP shunt, spina bifida, neurogenic bladder, and paraplegia who presented with a seven-day history of abdominal discomfort, distention, constipation, vomiting, and intolerance to oral intake. Abdominal x-ray showed dilated bowel loops. Computed tomography (CT) of the abdomen demonstrated a closed-loop bowel obstruction at the level of the sigmoid colon caused by the coiling of the VP shunt catheter. Diagnostic laparoscopy revealed the VP shunt tube coiling around a segment of the sigmoid colon with no signs of bands, ischemia, or perforation. Pulling and shortening of the tube was done. The procedure went uneventfully, and the patient was discharged home in stable condition. Maintaining a high index of suspicion for knotting the peritoneal catheter around the bowel is crucial when a patient on a VP shunt presents with a picture suggestive of intestinal obstruction. Early surgical intervention might be required to prevent further progression and complications.

Incidental finding of asymptomatic non-traumatic pericardial effusion in a trauma patient: a case report

Pericardial effusion can either be an incidental finding or a manifestation of systemic or cardiac disease. It has a wide range of presentations, from asymptomatic small effusion to rapidly progressive fatal tamponade. In a trauma setting, pericardial effusion is usually attributed to hematoma collection, with the concern of clinical evidence of tamponade that can lead to cardiopulmonary collapse. The Focused Assessment with Sonography for Trauma (FAST) is a widely used tool to diagnose pericardial effusion in trauma patients. We published this case report to emphasize that the presence of pericardial effusion alone in a trauma patient does not indicate the presence of tamponade. This case concerns a 39 years old male patient who presented to ER as a trauma case after a fall from two meters height and landing on his feet. ATLS protocol was followed, and FAST showed an incidental finding of massive pericardial fluid. The trauma team was consulted, and the patient was hemodynamically stable without clinical evidence of tamponade. Echocardiography showed mitral valve stenosis and large pericardial effusion. The close observation did not suggest the presence of cardiac tamponade. The pericardial catheter was inserted during admission with drainage of 900cc of serous fluid. The presence of pericardial fluid in a trauma setting does not confirm the diagnosis of tamponade. The mechanism of injury, clinical presentation, and the patient's stability are essential factors in determining further management of such patients.

Severe Traumatic Brain Injury Presenting with Wide Complex Tachycardia: a Case Report

Background

Ventricular tachycardia (VT) is an abnormal heart rhythm that can lead to pump failure and hypoperfusion. Its causes, presentation, and treatment are well established in the literature. However, the VT treatment algorithm is based on non-traumatic patients. Due to different pathophysiology and presentation, treating VT in trauma patients should be different.

Objective

The main purpose is to emphasize the approach to treating VT in severe head trauma patients.

Case presentation

This case is a unique presentation of severe head trauma with a paucity of treatment approaches in the literature. In this article, we present a case of a middle-aged male patient presented to a level one trauma center with a history of falls from 2 stories height with a Glasgow Coma Scale (GCS) of 3/15. ATLS approach was followed in treating this patient, his rhythm strip showed a wide complex regular rhythm, likely representing a VT with a pulse. The patient was treated as unstable because of a decreased level of consciousness. A 100 J synchronized cardioversion was given without restoration of normal sinus rhythm, followed by Mannitol 1g/kg, treating the possibility of high intracranial pressure (ICP), after which his rhythm was restored to sinus.

Conclusion

The restoration of sinus rhythm after treating the possibility of high ICP suggests that the cause of VT in this severe TBI patient was the high ICP.

Splenic Heterogeneity in Focused Assessment With Sonography for Trauma (FAST) Scan Led to the Diagnosis of Grade 2 Splenic Injury in a Pediatric Blunt Abdominal Trauma

Splenic injuries are one of the most common injuries following blunt abdominal trauma. It occurs in 32% of blunt abdominal trauma, with motor vehicle accidents being the most common cause. The patient may present with generalized abdominal pain or left upper quadrant pain associated with left shoulder pain. Hemodynamic instability is one of the most reliable signs of splenic injuries. A focused assessment with sonography for trauma (FAST) scan is the initial imaging used to assess for solid organ injury in the abdomen, followed by computed tomography (CT) scans. Evidence of free fluid in the abdomen in the FAST scan indicates a solid organ injury. However, the absence of the before-mentioned finding does not rule out the presence of solid organ injury. Hereby a case of a 13-year-old Saudi male with left-sided abdominal pain after falling from a motorbike. A set of the investigation was done with insignificant results. However, FAST revealed a heterogenous appearance in the spleen. Thus, the patient subsequently underwent abdominal CT scans. The patient was managed conservatively and then discharged against medical advice (DAMA). Previously documented cases have mentioned the presence of free fluid in the abdomen in FAST scan in a stable patient leading to undergoing a CT scan and further managing trauma victim patients, which was absent in the present case.

Late Presentation of Peritonitis Post Jejunal Perforation Due to Flank Stab Wound

Abdominal trauma injuries are caused by many mechanisms including blunt and penetrating trauma injuries. Penetrating injuries are far more common than blunt injuries. Subsequently, the most affected organ during such injuries is small intestine perforations. As far as we know, there were no cases reported before about jejunal injury due to penetrating trauma. We present a case of a 20-year-old male with a stab wound injury who was initially stable in the emergency department (ED). After a set of investigations were done, the patient was discharged home. Yet, the patient presented again with late signs of peritonitis. Imaging was done and showed pneumoperitoneum. Thereafter, the patient was rushed to the operation room (OR) where the jejunal repair was performed. ED physicians must be vigilant regarding any signs of deterioration in penetrating trauma patients and should provide clear instructions to patients regarding any symptoms of the acute abdomen before any discharge.

Unusual Presentation of Diffuse Axonal Injury: A Case Report

Diffuse axonal injury (DAI) is the microscopic axonal injury in the brain's neural pathways, corpus callosum, and brainstem, which has been linked to a major increase in morbidity and mortality. Patients present acutely with no lucid interval, abnormal pupil response, and decerebrate or decorticate posture. In this case report, we report on an 11-year-old girl who was agitated, crying, vomiting, had one episode of seizure, and had poor communication as a result of a high-risk mechanism side-impact motor vehicle collision (MVC).

A Cerebrovascular Incident Secondary to Extensive Aortic Arch Atheroma

Plaques can form across different parts of the aorta, from the aortic arch to the thoracic and abdominal aorta. Aortic arch atheroma, however, is highly associated with cerebrovascular insults due to their dislodgement. Although no concise management protocol has been defined for dealing with such presentations, antiplatelet agents and anticoagulants are most frequently used. In this case, we present a 78-year-old male with a known case of diabetes mellitus type 2, hypertension, and dyslipidemia who presented to the emergency department with acute onset of slurred speech. A CT angiography was performed that revealed extensive plaque formations across the aortic arch with a 90% occlusion of the distal left common carotid artery and carotid bifurcation along with 99% stenosis of the internal carotid artery. The patient underwent aspiration thrombectomy and was started on dual antiplatelets but passed away after developing decompensated heart failure.

Prevalence, Causes, and Adverse Clinical Impact of Delayed Presentation of Non-COVID-19-Related Emergencies during the COVID-19 Pandemic: Findings from a Multicenter Observational Study

Objective: The coronavirus disease (COVID-19) pandemic has disrupted healthcare systems worldwide, resulting in decreased and delayed hospital visits of patients with non-COVID-19-related acute emergencies. We evaluated the impact of the COVID-19 pandemic on the presentation and outcomes of patients with non-COVID-19-related medical and surgical emergencies. Method: All non-COVID-19-related patients hospitalized through emergency departments in three tertiary care hospitals in Saudi Arabia and Bahrain in June and July 2020 were enrolled and categorized into delayed and non-delayed groups (presentation ≥/=24 or <24 h after onset of symptom). Primary outcome was the prevalence and cause of delayed presentation; secondary outcomes included comparative 28-day clinical outcomes (i.e., 28-day mortality, intensive care unit (ICU) admission, invasive mechanical ventilation, and acute surgical interventions). Mean, median, and IQR were used to calculate the primary outcomes and inferential statistics including chi-square/Fisher exact test, t-test where appropriate were used for comparisons. Stepwise multivariate regression analysis was performed to identify the factors associated with delay in seeking medical attention. Results: In total, 24,129 patients visited emergency departments during the study period, compared to 48,734 patients in the year 2019. Of the 256 hospitalized patients with non-COVID-19-related diagnoses, 134 (52%) had delayed presentation. Fear of COVID-19 and curfew-related restrictions represented 46 (34%) and 25 (19%) of the reasons for delay. The 28-day mortality rates were significantly higher among delayed patients vs. non-delayed patients (n = 14, 10.4% vs. n = 3, 2.5%, OR: 4.628 (CI: 1.296−16.520), p = 0.038). Conclusion: More than half of hospitalized patients with non-COVID-19-related diagnoses had delayed presentation to the ED where mortality was found to be significantly higher in this group. Fear of COVID-19 and curfew restrictions were the main reasons for delaying hospital visit.

Late Diagnosis of a Patient With Gradual Onset of Lateral Medullary Syndrome Secondary to Spontaneous Vertebral Artery Dissection: A Case Report

Lateral medullary syndrome (LMS), also known as Wallenberg syndrome, is a cerebrovascular event following ischemia of the lateral part of the medulla oblongata. Some of its etiologies include atherosclerotic changes, hypertension, thromboembolism, vertebral artery dissection (VAD), and aneurysm. We present a case of a 45-year-old male with LMS with a gradual onset of atypical symptoms of LMS, which has led to a late diagnosis of our patient. VAD is a commonly recognized cause of stroke in young people and it is a more frequent cause of LMS than posterior inferior cerebellar artery diseases. This case highlights the importance of early identification of signs and symptoms and that appropriate investigation should take place to optimize patient life quality and prognosis.

Troponin Levels and the Severity of COVID-19 Pneumonia

Introduction

In late 2019, a novel coronavirus was identified as the pathogen responsible for a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. Elevated cardiac troponin is a marker of myocardial injury, which is commonly seen in hospitalized patients with COVID-19 due to unclear reasons. The frequency of elevated troponin levels in patients with COVID-19 is variable and is reported in up to 7-36% of patients. The troponin level may be associated with the severity of COVID-19, and mild cases of COVID-19 tend to have a normal troponin level. This study aims to determine the frequency of patients with COVID-19 who had elevated troponin levels on presentation to the ED and determine the factors associated with elevated troponin levels. Additionally, the study aims to identify the association of elevated troponin and the outcome of COVID-19.

Methodology

A retrospective study wherein the factors associated with elevated troponin levels in COVID-19 pneumonia were evaluated. The study was conducted in King Fahd Hospital of the Imam Abdulrahman Bin Faisal University. The Hospital Information System was used to identify all visits to the ED from March 2020 to November 2020 for patients who tested positive for SARS-CoV-2. In addition, a structured data collection form was used to collect data from the electronic health records. The data collection was conducted by emergency medicine physicians who were given a detailed explanation of the purpose of the study and had training and supervision by the principal investigator.

Results

The study involved 214 patients who presented to the ED and had positive results on the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) test and had troponin-I levels measured. Patients with elevated troponin levels were more likely to require supplementary oxygen compared with those with normal troponin levels (88.0 vs. 58.5%; P < 0.01). In total, 36 (76.6%) patients with elevated troponin levels required admission to the ICU compared with 58 (45.0%) patients with normal troponin levels (P < 0.01). Multivariable binary logistic regression analysis was used to identify the predictors of elevated troponin levels on presentation. The model revealed that being admitted in the ICU was the single independent predictor (P = 0.02).

Conclusion

The study demonstrated that the troponin level on presentation to the ED was a viable independent prognostic factor in COVID-19 pneumonia. However, further studies are needed to investigate targeted therapeutic interventions among patients with elevated troponin levels, such as cardioprotective therapies like corticosteroids, immunosuppressants, antivirals, or immunoglobulins.

Ketamine administration for acute painful sickle cell crisis: A randomized controlled trial

OBJECTIVE

The objective was to evaluate the efficacy and safety of single-dose ketamine infusion in adults with sickle cell disease (SCD) who presented with acute sickle vasoocclusive crisis (VOC).

METHODS

This study was a parallel-group, prospective, randomized, double-blind, pragmatic trial. Participants were randomized to receive a single dose of either ketamine or morphine, infused over 30 min. Primary outcome was mean difference in the numerical pain rating scale (NPRS) score over 2 h. NPRS was recorded every 30 min for a maximum of 180 min and secondary outcomes were cumulative dose of opioids, emergency department (ED) length of stay, hospital admission, change in vital signs, and drug-related side effects. Authors performed the analysis using intention-to-treat principle.

RESULT

A total of 278 adults with SCD and who presented with acute sickle VOC participated in this trial. A total of 138 were allocated to the ketamine group. Mean (±standard deviation [SD]) NPRS scores over 2 h were 5.7 (±2.13) and 5.6 (±1.90) in the ketamine and morphine groups. The ketamine group received significantly lower cumulative doses of morphine during their ED stay (mean ± SD = 4.5 ± 4.6 mg) than of the morphine group (mean ± SD = 8.5 ± 7.55 mg). Both groups had similar rates of hospital admission: 6.3% in the ketamine group had drug-related side effects compared to 2.2% in the morphine group.

CONCLUSION

Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.

Pathological Fracture as the Initial Presentation of Metastatic Pancreatic Cancer

Pancreatic cancer with bone metastasis is considered a very rare malignancy. Although the incidence rate of people with pancreatic cancer who develop bone metastasis is unknown, it is estimated as between 5% and 20%. We report a 61-year-old lady who had multiple emergency department visits complaining of lower back pain radiating to the lower limbs for five months. Clinical and imaging workup suggested pancreatic adenocarcinoma metastasis to the second lumbar vertebra (L2), lungs, and ovaries.

Scabies-Associated Leukocytoclastic Vasculitis: A Case Report and Review of Literature

Scabies is a common contagious ectoparasitosis. The association of scabies and leukocytoclastic vasculitis (LCV) is unclear, and only a few cases of scabies-related LCV have been documented. Here, we report a case of scabies complicated by LCV in an 86-year-old woman diagnosed with scabies and treated accordingly. The patient presented to our hospital with a one-day history of fever, increased rash, and itchiness. Histologic examination of a purpuric lesion revealed signs of LCV. Although histologic examination did not identify the scabies mite in the purpuric lesion, the LCV was likely a post-scabetic presentation following infestation based on other case reports, despite this being a rare occurrence.

Subacute Bilateral Subdural Hematoma: Delayed Presentation With Headache One Month Post Mild Trauma

We herein report a case involving the development of a bilateral subacute subdural hematoma (SDH) after minor trauma, with only two wounds over the nose and no abnormal clinical and radiological findings at first presentation. A 25-year-old male patient presented to the emergency department (ED) after a minor trauma. X-ray was done on the facial bone to rule out nasal fracture which showed no abnormalities and then he was subsequently discharged. Three weeks later, the patient complained of a headache that persisted for a week, which brought him to the hospital. The initial impression was migraine after the primary healthcare visit, for which MRI was arranged, but as the headache persisted, he went to the ED twice again, and a CT scan was done during his second visit to the ED, which showed bilateral subacute SDH (SASDH).

Severe Urosepsis Secondary to Xanthogranulomatous Pyelonephritis: A Case Report

Xanthogranulomatous pyelonephritis (XGP) is considered to be a rare variant of chronic pyelonephritis, which results in non-functioning kidneys in patients. The exact etiology of this disease is still unknown, and hence even its pathophysiology remains unclear. We present a case of a 27-year-old Saudi male patient who had been bed-bound with a known case of a congenital anomaly with severe kyphoscoliosis, bilateral lower limbs deformity with paraplegia, and a ventriculoperitoneal shunt since childhood. The patient was brought to the emergency department (ED) with right flank pain associated with fever and difficulty in breathing. The patient had a past medical history of recurrent urinary tract infection (UTI) with up to two incidences per year and renal stones. He had been recently discharged from the ICU of another hospital with sepsis due to UTI. An abdominal CT scan was performed, which showed a mass in the upper lobe of the right kidney measuring about 9 x 8 x 6 cm, suggestive of XGP. The final diagnosis was severe urosepsis secondary to right obstructive pyelonephritis. Patients with XGP usually present with nonspecific symptoms including back and abdominal pain, fever, UTI, and the condition is more common among middle-aged women. Ultimately, early detection and diagnosis, followed by prompt treatment with partial or total nephrectomy are associated witha good prognosis for patients with XGP.

Fulminant hepatic failure in a patient testing re-positive for SARS-CoV-2: a case report

Background

Infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may not elicit lifelong protective immunity and reinfection could occur. Liver function impairment is a common manifestation of coronavirus disease 2019 (COVID-19). However, acute hepatic failure in the setting of COVID-19 is very rare.

Case presentation

We report the case of a 47-year-old woman who presented with acute abdominal pain and vomiting. Abdominal examination revealed a soft and lax abdomen with mild tenderness in the right upper quadrant. The patient recovered from COVID-19 2 months previously with negative results on reverse transcription-polymerase chain reaction (RT-PCR). Laboratory investigations revealed markedly elevated transaminases with normal results on viral hepatitis serology panel and undetectable blood paracetamol level. Prior to admission, the patient underwent RT-PCR for SARS-CoV-2, which revealed a positive result. The patient experienced rapid deterioration in the neurological status with a remarkable increase in the liver enzyme levels. Despite aggressive resuscitation, the patient suffered irreversible cardiac arrest and died.

Conclusion

Fulminant hepatic failure is a rare manifestation in patients with re-positive RT-PCR tests for SARS-CoV-2. Clinicians should maintain a high index of suspicion for hepatic injury with active monitoring of liver enzymes.

Congenital Methemoglobinemia-Induced Cyanosis in Assault Victim

Methemoglobinemia is a blood disorder in which there is an elevated level of methemoglobin. In contrast to normal hemoglobin, methemoglobin does not bind to oxygen, which leads to functional anemia. The signs of methemoglobinemia often overlap with other cardiovascular and pulmonary diseases, with cyanosis being the key sign of methemoglobinemia. Emergency physicians may find it challenging to diagnose cyanosis as a result of methemoglobinemia.

Our patient is a healthy 28-year-old male, a heavy smoker, who presented to the emergency department with multiple minimum bruises on his body, claiming he was assaulted at work. He appeared cyanotic with an O₂ saturation of 82% (normal range is 95-100%) in room air. He also mentioned that his sister complained of a similar presentation of cyanosis but was asymptomatic. All these crucial points strengthened the idea that methemoglobinemia was congenital in this patient.

The case was challenging to the emergency physician, and there was significant controversy over whether the patient's hypoxia was a result of the trauma or congenital methemoglobinemia.

Moyamoya Syndrome Presenting as Refractory Status Epilepticus in a 32-Year-Old Female

Moyamoya disease (MMD) is a rare cerebrovascular occlusion condition characterized by ‎progressive stenosis in the terminal portion of the internal carotid arteries on both sides. The measured incidence of MMD is 0.086 per 100,000 people. MMD has variable ‎neurological manifestations, however, seizure is a significant manifestation of MMD with ‎few reported studies. The combination of sickle cell disease (SCD) and MMD confers a much ‎higher risk of ischemic stroke. In this paper, we describe a 32-year-old female with a known ‎case of SCD taking tramadol for a vaso-occlusive crisis, who was presented to the emergency ‎department by a family member due to a low level of consciousness. Despite ongoing ‎management, the patient developed multiple seizure attacks and intubation was ‎performed. A computed tomography (CT) brain angiogram was performed, and the ‎diagnosis of MMD was made. The patient was shifted to the intensive care unit (ICU) and in spite of the ongoing management in the ICU, the patient died. In this case, we highlight the importance of considering MMD as a ‎differential diagnosis when dealing with an SCD patient who developed refractory status epilepticus.‎

Transient Bilateral Sixth Nerve Palsy: A Rare Sequela of Head Trauma

Sixth cranial nerve palsy is uncommon but a well-recognized consequence of head trauma. Although few cases documented traumatic persistent bilateral sixth nerve palsy, a transient episode is extremely rare and not reported before. We report an unusual case of transient bilateral abducens nerve palsy after minor head trauma, which was completely resolved without any intervention after 20 min. Diplopia may relate to anatomical lesion, and even transient diplopia can guide us to a serious anatomical lesion that may occur. CT scan of the head revealed a left nondisplaced occipital fracture, which extends to the left petrous bone. The patient was admitted for 24-h observation and discharged home on paracetamol. This case emphasizes the need to recognize the rare sequences of minor head trauma and manage them appropriately.

Atypical Presentation of Perforated Viscus as Biliary Colic

Peptic ulcer is a defect in the mucosal layer of the stomach or duodenum that extends into the deeper layers of their walls. Patients with peptic ulcer disease (PUD) may be asymptomatic or have mild abdominal discomfort. It is one of the common etiologies of perforated viscus resulting in secondary peritonitis, a life-threatening condition that carries high risk for morbidity and mortality especially in those who present late to the hospital or due to unrecognized and misdiagnosed perforation. Early detection of perforation of peptic ulcers should be based on clinical data and imaging techniques. We report a case of a 56-year-old female who presented to our ED with right upper quadrant (RUQ) pain radiating to the right shoulder, alleviated by food, and not aggravated by anything. On examination, the patient was vitally stable, tenderness in the RUQ was appreciated, and Murphy sign was positive. Thus, she was diagnosed with perforation of anterior first part of the duodenum. What makes our case peculiar is the presentation of biliary colic in the setting of perforated peptic ulcer.

Warfarin-Induced Calciphylaxis in a COVID-19 Patient

Calciphylaxis is a rare but highly fatal vascular calcification disorder with a predilection for patients with end stage renal disease (ESRD). The pathogenesis of calciphylaxis is unknown, however, several risk factors have been identified such as hypercalcemia, hyperphosphatemia, hyperparathyroidism, low serum albumin, and history of warfarin therapy. This article presents a case of calciphylaxis induced by warfarin in a COVID-19 patient.

Intermittent Superior Vena Cava Syndrome Secondary to Malignant Pericardial Mesothelioma

Malignant pericardial sarcomatoid mesothelioma is a massively rare tumor accounting for 0.8% of all cases of mesothelioma. Superior vena cava syndrome (SVCS) occurs due to a partial obstruction or compression to the superior vena cava, which hinders the blood outflow to the upper body. It can be caused by an intrinsic factor such as thrombosis, or by an extrinsic factor such as tumors. Clinical presentation includes edema of the face and upper limbs, plethora, dyspnea, dysphagia, stridor and cough. we are reporting a case of a 56-year-old female, who is a known case of hypertension on angiotensin-converting enzyme inhibitors (ACEIs). Presented to the emergency department with intermittent facial swelling and dyspnea. Imaging and pathology reports confirmed the diagnosis of intermittent SVCS secondary to pericardial sarcomatoid mesothelioma with pericardial effusion. What makes our case unique is that both the etiology and the presenting complaint are rare entities, as most SVCS cases are continuously symptomatic throughout the disease course, and are usually caused by a lung cancer or lymphoma.

Acute Generalized Exanthematous Pustulosis After COVID-19 Infection: A Case Report From Saudi Arabia

There is a dearth of robust evidence regarding coronavirus disease 2019 (COVID-19)-related coetaneous manifestations, complications and adverse treatment events. Upon review of the literature there are only a few cases reported of acute generalized exanthematous pustulosis (AGEP) in COVID-19 patients after treatment. Therefore, we are reporting a case of a 34-year-old male not known to have any chronic illness. His severe COVID-19 infection resolved four days prior to presentation to the Emergency Department with pustular rash on erythematous base over his face, neck, upper limbs, anterior and posterior trunk including oral cavity and tounge. The rash started after he took azithromycin, oseltamivir, ribavirin, lopinavir, hydroxychloroquine, prednisolone, ceftriaxone, clindamycin, interferon (IFN) beta, and ceftazidime for COVID-19. Skin punch biopsy was done and he was diagnosed with AGEP but it was still not known if it was related to COVID-19 or a drug-induced condition. Patient was treated with betamethasone valerate 0.1% ointment and lotion, promethazine hydrochloride 25mg tablet, paracetamol 500mg tablet, calcipotriol 50mcg/g and betamethasone 0.5mg/g gel. He discharged the same day to manage at home despite not improving. In the end, we found only a few studies that describe the cutaneous manifestations of COVID-19 infection, which were mainly case reports. We can't be sure that AGEP is a late and severe complication of COVID-19 infection. However, AGEP could be a rare adverse effect of hydroxychloroquine therapy. Improving the knowledge about a wide range of different signs and symptoms of the disease and its severity in addition to all possible adverse treatment events and complications can improve patient safety, survival rate, and quality of life.