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The convergence of takotsubo and Kounis syndromes, collectively referred to as the \"ATAK complex\" (short for adrenaline, takotsubo, anaphylaxis, and Kounis syndrome), poses a unique and challenging clinical scenario, especially in the context of chemotherapy-related anaphylaxis. We present a case report involving a 63-year-old woman undergoing chemotherapy for endometrial adenocarcinoma who experienced anaphylactic symptoms during treatment. Immediate administration of epinephrine was followed by the emergence of ST elevation, a reduced left ventricular ejection fraction, and wall motion abnormalities indicative of stress-induced cardiomyopathy. Detailed investigations revealed normal coronary arteries, prompting further exploration into the intricacies of the ATAK complex. Notably, the administration of intravenous rather than intramuscular epinephrine was identified as a contributing factor. This case underscores the critical importance of recognizing and managing the ATAK complex promptly, emphasizing the need for refined diagnostic and treatment guidelines. The interplay between adrenaline, takotsubo, anaphylaxis, and Kounis syndrome necessitates a nuanced approach, urging healthcare professionals to exercise caution and adhere to recommended administration routes. Increased awareness of the ATAK complex is imperative for optimizing patient outcomes and guiding therapeutic interventions in similar clinical scenarios. Further research is warranted to elucidate the underlying mechanisms and refine strategies for the effective management of this intricate syndrome.

Histoplasmosis is usually self-limiting in healthy individuals but often fatal in immunocompromised patients. It can mimic primary lung malignancy and liver metastasis, causing a delay in appropriate therapy. We report a case of a 58-year-old male, with a 20 pack-year smoking habit, who presented with a three-week history of persistent fevers and productive cough with night sweats. Computed tomography (CT) scan of chest, abdomen and pelvis showed findings suggestive for primary lung malignancy associated with liver metastasis. Liver biopsy showed budding yeast. Bronchoalveolar lavage (BAL) fluid grew fungal organisms. Urine and serology were positive for histoplasmosis. Patient was pancytopenic, hence, we decided to evaluate further with a bone marrow biopsy which revealed underlying hairy cell leukemia. In the case of disseminated histoplasmosis, a high degree of suspicion towards any immunosuppressive condition should be entertained and any signs should be promptly investigated.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease marked by high cytokine levels, uncontrolled lymphocyte, and macrophage proliferation. It is generally a systemic disorder with varying degrees of central nervous system (CNS) involvement, with the vast majority of cases affecting children. We report a case of CNS-HLH in a 51-year-old male who initially presented with fevers, night sweats, fatigue, bilateral arthralgia, and altered mental status. Computed tomography (CT) of the chest, abdomen, and pelvis showed hepatosplenomegaly. Magnetic resonance imaging (MRI) of the brain showed enhancing lesions mainly in the right frontal lobe with a small hemorrhagic focus. An extensive workup for infectious, autoimmune, and neoplastic and genetic etiologies was only significant for cytopenia with markedly elevated C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH), in addition to mild triglyceridemia. Bone marrow and liver biopsy revealed hemophagocytosis. Brain biopsy revealed no evidence of malignancy or infection. The patient was treated with high-dose dexamethasone and etoposide and fully recovered with resolution of all of HLH parameters and decrease/resolution of brain lesion. Clinicians should have a high index of suspicion for CNS-HLH in adults who present with sepsis-like illness with fevers, altered mental status, and cytopenia but negative cultures and unusual radiographic cerebral abnormalities so that early diagnosis and treatment can be initiated to prevent end-organ failure and death.Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease marked by high cytokine levels, uncontrolled lymphocyte, and macrophage proliferation. It is generally a systemic disorder with varying degrees of central nervous system (CNS) involvement, with the vast majority of cases affecting children. We report a case of CNS-HLH in a 51-year-old male who initially presented with fevers, night sweats, fatigue, bilateral arthralgia, and altered mental status. Computed tomography (CT) of the chest, abdomen, and pelvis showed hepatosplenomegaly. Magnetic resonance imaging (MRI) of the brain showed enhancing lesions mainly in the right frontal lobe with a small hemorrhagic focus. An extensive workup for infectious, autoimmune, and neoplastic and genetic etiologies was only significant for cytopenia with markedly elevated C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH), in addition to mild triglyceridemia. Bone marrow and liver biopsy revealed hemophagocytosis. Brain biopsy revealed no evidence of malignancy or infection. The patient was treated with high-dose dexamethasone and etoposide and fully recovered with resolution of all of HLH parameters and decrease/resolution of brain lesion. Clinicians should have a high index of suspicion for CNS-HLH in adults who present with sepsis-like illness with fevers, altered mental status, and cytopenia but negative cultures and unusual radiographic cerebral abnormalities so that early diagnosis and treatment can be initiated to prevent end-organ failure and death.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several cardiovascular complications of COVID-19 have been described in clinical studies. While those with pre-existing cardiovascular disease seem to have worse outcomes, growing evidence suggests that COVID-19 itself can cause myocardial injury, arrhythmia, and heart failure. We report a case of a 27-year-old male with no known comorbidities who presented with nausea, vomiting and non-radiating substernal chest pressure without respiratory symptoms in May of 2020. Laboratory findings showed elevated cardiac biomarkers and electrocardiogram showed diffuse ST-segment elevation. Coronary angiography revealed normal coronaries but findings suggestive of cardiogenic shock. Reverse transcription polymerase chain reaction for SARS-CoV-2 returned positive. He was treated for fulminant myopericarditis and cardiogenic shock with remdesivir, steroid, inotropes and vasopressors but rapidly deteriorated and went into cardiac arrest and was unable to be resuscitated despite multiple rounds of cardiopulmonary resuscitation. Fulminant myopericarditis is a rare complication of COVID-19 with high mortality that requires early recognition, treatment and a transfer to a tertiary facility with advanced cardiac services.

Immunoglobulin A vasculitis is a small vessel vasculitis which is usually common in the pediatric group. It is rare in adult population but more severe than in children. Proposed triggers include infections, malignancy and medications. For most part, the association is made when immunoglobulin A vasculitis develops within two weeks after starting the implicated medication. A 66-year-old male who was treated with amoxicillin/clavulanate for presumed right fourth toe infection but returned to the emergency department 48 hours later with palpable purpura of lower limbs, arthralgia with swollen hands and colicky abdominal pain with nausea. Abdominal computed tomography (CT) scan showed mildly dilated small bowel. Skin biopsies showed leukocytoclastic vasculitis with IgA deposit on immunofluorescence. The patient was treated with a short course of steroid and the rash was significantly reduced during subsequent follow-up. Although amoxicillin/clavulanate is widely prescribed, clinicians need to be aware of this risk and immediately stop it if signs of drug-induced vasculitis develop.Immunoglobulin A vasculitis is a small vessel vasculitis which is usually common in the pediatric group. It is rare in adult population but more severe than in children. Proposed triggers include infections, malignancy and medications. For most part, the association is made when immunoglobulin A vasculitis develops within two weeks after starting the implicated medication. A 66-year-old male who was treated with amoxicillin/clavulanate for presumed right fourth toe infection but returned to the emergency department 48 hours later with palpable purpura of lower limbs, arthralgia with swollen hands and colicky abdominal pain with nausea. Abdominal computed tomography (CT) scan showed mildly dilated small bowel. Skin biopsies showed leukocytoclastic vasculitis with IgA deposit on immunofluorescence. The patient was treated with a short course of steroid and the rash was significantly reduced during subsequent follow-up. Although amoxicillin/clavulanate is widely prescribed, clinicians need to be aware of this risk and immediately stop it if signs of drug-induced vasculitis develop.

Spontaneous splenic rupture is a rare but potentially life-threatening condition. More common infectious causes include infectious mononucleosis, cytomegalovirus (CMV), human immunodeficiency virus (HIV), and malaria. We present a case of a 42-year-old male who was admitted with persistent fevers, myalgia, and a recent ulcerative lesion on the base of his left thumb after a cat bite. He developed abdominal and back pains, left axillary lymphadenopathy, and near syncope. Abdominal computed tomography (CT) scan showed splenomegaly with subcapsular splenic rupture and large hematoma requiring emergent splenic embolization. Infectious work-up revealed tularemia as a cause which was successfully treated with oral doxycycline. Though not a common cat zoonoses, tularemia should be considered in a patient with splenomegaly or spontaneous splenic rupture in the setting of cat bite.