Euglycemic Diabetic Ketoacidosis with a decompensated Hypothyroidism in the setting of a recent Cerebrovascular accident: A case report

Euglycemic diabetic ketoacidosis (EDKA) is an underdiagnosed endocrine emergency. It consists of an increased anion gap metabolic acidosis (pH \u3c 7.3 or serum bicarbonate \u3c 18 mmol/L), moderate ketonuria with a blood glucose levels The Patient is a 73-year-old female with a past medical history of Diabetes Mellitus, Hypertension, Hyperlipidemia, Hypothyroidism and deafness and muteness since birth. Patient had a recent ischemic stroke 5 days prior to the admission and was admitted at a different hospital for management of her stroke. Patient left against medical advice and presented to our ED later that day complaining of rectal prolapse. Of note, the patient is non-compliant with her medications. Upon admission, she is alert, oriented, and in acute distress. On her physical exam, her vital signs were within normal limits. Patient had a significant rectal prolapse with no other abnormalities seen on the exam. Lab values include glucose level of 170, Sodium of 135, HCO3 of 15, Chloride of 103, albumin level of 2.9, Anion Gap of 18, Corrected-albumin anion gap of 20.8. Her lactate level was 0.81. We obtained serum Ketones that resulted in a moderate elevation and her urinalysis showed Ketone +2. She presented no osmolar gap with a serum osmolality of 295. Her Hba1c was 12.9 and her Thyroid studies showed TSH level 32, T3 Uptake of 53.3, Total T4: 4.6 and a Free T4 0.56. Other causes of a high anion gap metabolic acidosis were ruled out and the patient was diagnosed with an EDKA. EDKA is a diagnostic challenge as normal glucose level masks the underlying ketoacidosis. Therefore, a high index of suspicion is warranted. Altogether, our patient carries multiple risk factors for EDKA including poor oral intake, a recent stroke event and poorly controlled Diabetes Mellitus. Patient was hospitalized right before her admission and suspected to have received a long-acting insulin during her stay causing her to be euglycemic. Our patient was also admitted with severe hypothyroidism, it’s effect on development of EDKA is not well studied and suspected to also play a role in this patient’s presentation [2,3]

Candidate Perennial Bioenergy Grasses have a Higher Albedo than Annual Row Crops

The production of perennial cellulosic feedstocks for bioenergy presents the potential to diversify regional economies and the national energy supply, while also serving as climate ‘regulators’ due to a number of biogeochemical and biogeophysical differences relative to row crops. Numerous observational and model-based approaches have investigated biogeochemical trade-offs, such as increased carbon sequestration and increased water use, associated with growing cellulosic feedstocks. A less understood aspect is the biogeophysical changes associated with the difference in albedo (a), which could alter the local energy balance and cause local to regional cooling several times larger than that associated with offsetting carbon. Here, we established paired fields of Miscanthus 9 giganteus (miscanthus) and Panicum virgatum (switchgrass), two of the leading perennial cellulosic feedstock candidates, and traditional annual row crops in the highly productive ‘Corn-belt’. Our results show that miscanthus did and switchgrass did not have an overall higher a than current row crops, but a strong seasonal pattern existed. Both perennials had consistently higher growing season a than row crops and winter a did not differ. The lack of observed differences in winter a, however, masked an interaction between snow cover and species differences, with the perennial species, compared with the row crops, having a higher a when snow was absent and a much lower a when snow was present. Overall, these changes resulted in an average net reduction in annual absorbed energy of about 5 W m -2 for switchgrass and about 8 W m -2 for miscanthus relative to annual crops. Therefore, the conversion from annual row to perennial crops alters the radiative balance of the surface via changes in a and could lead to regional cooling

Newly diagnosed Ulcerative Colitis in a Young Hispanic Mexican Female at South Texas: A Case Report

Introduction: Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by recurring episodes of inflammation limited to the mucosal layer of the colon. Traditionally, this disease has been associated mostly with white Americans, however in recent years, an increase incidence has been reported in minorities in the US and around the world. In Hispanic population, cases are frequently underdiagnosed, and literature is scarse. In this case, we present a young patient without past medical history who presented with what appeared to be an infectious gastroenteritis and found to have a severe UC. Case Presentation: A 22-year old Hispanic female with no known past medical history presented to the emergency department with a 1 month history of right lower quadrant abdominal pain and hematochezia. The abdominal pain was described as episodic, moderate to severe, stabbing-like sensation that was usually associated with episodes of hematochezia and diarrhea. Pain was exacerbated prior to bowel movements and relieved after defecation. She reported having at least 10 or more episodes of diarrhea daily. She denied any other associated symptomatology and had no contributive family history. Upon arrival, her vital signs were T 100.9, HR 136, RR 20, BP 104/80 mm Hg and SPO2 of 96% on room air. Physical examination was consistent with dehydration, abdominal distention with increased tenderness on RLQ and positive rectal exam for blood. Labs upon admission were WBC 18.91, Hb 12, Ht 38, Platelets 593, Na 131, K 3.1, Cl 93, HCO3 23 and Creatinine 1.0. Gastrointestinal (GI) panel was positive for Enteroaggregative E. coli and negative for C. difficile infection. CT abdomen and pelvis without contrast revealed bowel wall thickening of the entire colon, concerning for colitis. She was admitted for sepsis in the setting of lower GI bleed due to E. coli specie. After 2 days of ciprofloxacin, patient persisted with symptoms priory mentioned. Fecal calprotectin was ordered due to concern of underlining IBD and was 1500 ug/g. GI service was consulted and patient underwent immediate colonoscopy, revealing severely inflamed colon with erosions, erythema, and deep ulcerations in a continuous and circumferential pattern from the rectum to the cecum. Patient was placed on IV steroids and after having negative Hepatitis panel and Tb test, she underwent first dose of Infliximab. Patient had improvement on the frequency and consistency of her bowel movements and was able to tolerate diet. She was later discharged with oral steroids and to follow closely with GI for following doses of Infliximab. Discussion: Ulcerative colitis manifestations have been described in specific subgroups of Hispanic population, such as South Americans or Caribbeans (1-2), however not all Hispanic entities groups have the same characteristics and may have differences not applicable to others. In a retrospective cohort analysis done by Mendoza et al in a city located near the US-Mexico Border, they found that UC was significantly more prevalent than Chron´s disease. There was no difference on extent of disease compared between ethnicities, but this population had lower use of immunodulators and biologics, which could be secondary to socioeconomic issues in the area (3). In our case, we present a patient who did not had any contributory past medical or family history with worsening abdominal pain associated with hematochezia, who was treated as GI infection and after 48 hours of poor response, IBD workup was pursued. The perception of IBD within Hispanic population should be modernized, so better medical care may be provided

Jungle Fever: Navigating Malaria in Immigrant Travelers Patient at South Texas: A Case Report

Introduction: Malaria is a severe mosquito-borne illness that can be life-threatening. This infection continues to be a significant global health concern, most prominent in tropical and subtropical regions. Malaria\u27s clinical manifestations exhibit a striking diversity, influenced by geographical variables, the individual\u27s immunity, and age. Diagnosing and treating malaria early is crucial to preventing severe complications and fatalities. This heterogeneity poses unique challenges to its diagnosis and treatment, making it a subject of continuous study and innovation. In this case, we present a case of a patient traveling from an endemic area to a non-endemic area. In this comprehensive examination of malaria, we delve into its intricate tapestry, exploring the wide-ranging symptoms, from uncomplicated to severe forms. This deep dive into the clinical landscape aims to enhance our understanding of this relentless disease, facilitating improved diagnostic techniques and treatment strategies. As we embark on this journey, it becomes clear that tackling malaria demands a multi-faceted approach, integrating epidemiological insights, clinical expertise, and innovative research to combat this enduring global health threat. Case Presentation: A 33-year-old lady with no known past medical history, under border patrol custody, who originally came from Venezuela to the US-border was presented to the emergency department complaining of fever and dysuria. She started with dysuria and urgency 2 weeks ago while she was in the jungle and was on her usual period using pads, and she needed to cross some rivers and stay for long hours with the same pads. Symptoms were associated with vaginal discharge and white/green cottage cheese-like and intense pruritus. Symptoms continued worsening, and 6 days ago she started presenting with regular episodes of fever quantified at 102, chills, headache, decreased appetite, and 1 episode of non-bloody emesis, for which she was started on Macrobid for 2 days with no improvement. She denies flu symptoms, congestion, sore throat, eye pain, cough, sputum production, hemoptysis, dyspnea, palpitations, bleeding from any source, and no new sexual partners. Upon admission, vital signs revealed a BP of 71/46 mmHg, a RR of 23, a pulse of 105 BPM, and a temperature of 99.7°F. Laboratory results showed Hg 11.6, hematocrit 34%, platelets 51, WBC 7.9, Na 133, K 3.1, creatinine 1.1, AST 42, ALT 67, albumin 3, total bilirubin 1.5, lipase 20, Peripheral blood smear positive for malaria-type organisms. UA showing pyuria. A CT of the abdomen revealed no significant abnormalities. She was admitted for sepsis in the setting of a malaria infection, most likely P. vivax. She met Systemic Inflammatory Response Syndrome (SIRS) criteria with 3 of 4 indicators. Mild transaminitis with a hepatocellular pattern and mild anemia were also noted. Fungal vaginitis and suspected uncomplicated urinary track infection not responding to antibiotic therapy In the ED, she received a bolus of LR 1900 mL, doxycycline, ceftriaxone, acetaminophen, and potassium replacement. Infectious disease was consulted and the patient was managed with Atovaquone and Proguanil Discussion: Given the patient\u27s history of travel from a malaria-endemic region and characteristic clinical and laboratory findings of malaria diagnosis, particularly P. vivax, this is highly probable. The patient was managed with combination therapy focusing on P. vivax infection, which aligns with the prevalence of chloroquine-resistant malaria in central and southern America. Monitoring and further treatment will be essential to managing this potentially life-threatening condition. Migration is an important global issue, as poorly managed migration can result in various problems, including increased transmission of diseases such as malaria, and may be largely affected by population movements. 1. It is crucial to consider the potential for localized outbreaks of malaria when infected individuals, such as new immigrants, travel from endemic areas to non-endemic regions. This is due to the possibility of inadvertently introducing the malaria parasite to the local mosquito population, which can then infect the non-immune population. The case emphasizes the importance of recognizing imported malaria cases. It underscores the need for early diagnosis and appropriate treatment, especially in individuals with a history of travel through malaria-endemic areas

Asymptomatic Spontaneous Pneumopericardium in a Young Post-COVID-19 Patient: A Case Report

Background: Pneumopericardium is a rare clinical condition which is defined as the presence of air or gas in the pericardial cavity. Although uncommon to see, it can present after chest trauma, barotrauma, fistula between the pericardium and surrounding structures, gas producing microorganisms and iatrogenic causes. But spontaneous presentations are even more uncommon. Coronavirus Disease 2019 (COVID 19) infection became a large global epidemic and in addition to respiratory symptoms, involvement of other organs such as pericardium was also reported. We here present a young patient post COVID 19 infection with isolated spontaneous pneumopericardium. Case Presentation: A 19 year old patient with a past medical history of ADD and general anxiety disorder presented to the emergency department with worsening abdominal pain of 4 day duration, that started after having lunch at a family gathering. The pain progressed to colicky pain with no radiation and was associated with dysuria. Of note, 2 weeks prior the patient had a COVID 19 infection associated with a non productive cough, for which she received supportive treatment. She denied any shortness of breath, chest pain, paresthesias or paresis, recent trauma, any cannulations, and recent diving. No history of illicit drug use. Vitals were unremarkable. Physical examination showed suprapubic tenderness. Urinalysis included presence of moderate leukocyte esterase, WBC 10 25 and 5 10 RBC. The Urine pregnancy test was negative. Due to the abdominal pain and concern for appendicitis, CT (Computed Tomography) scan of the abdomen and pelvis with contrast was ordered and did not reveal any acute intra abdominal or pelvic process, but there was an incidental finding of air presence in the pericardial space. An immediate CT of the chest without contrast was ordered and it did not reveal any pneumopericardium or pneumomediastinum. Pelvic US was performed later to evaluate for potential causes; and was unremarkable. Patient was admitted under observation for management of UTI (Urinary Tract Infection). She remained stable without any shortness of breath or chest pain and her abdominal pain improved in the first 24 hours. She was later discharged with oral antibiotics for UTI. Conclusion: Pneumopericardium is a rare but potentially life threatening condition. The most common clinical presentation is with chest pain, dyspnea and/or hemodynamic instability if large enough to produce tamponade physiology. In this case, the patient had a recent COVID 19 infection with cough. COVID 19 infection is associated with alveolar rupture and hyperinflammatory response, which could increase the risk of pneumopericardium, but the exact mechanism has not been elucidated. Since most of the patients with COVID 19 have a mild clinical presentation, the incidence of pneumopericardium is difficult to evaluate and the symptoms easily be obscured by the constellation of symptoms these patients present. In this patient, the repeat CT of the chest was unable to find the presence of air, which was consistent with improvement of the patients abdominal pain. This could have been because of migration of air or reabsorption, which correlates to the self limiting nature of this disease

At the Heart of the Diagnosis: A Case of Systemic Lupus Erythematosus Presenting as Cardiac Tamponade

Systemic lupus erythematosus (SLE) is a heterogenous, systemic disease characterized by the production of pathogenic autoantibodies against nuclear antigens. Although the most common cardiac manifestation of SLE is pericardial effusions, their progression to cardiac tamponade is rare and has an incidence between 1-3%. We describe a case of a 42-year-old Hispanic woman who presented with severe shortness of breath, vague chest pain, and hemodynamic compromise secondary to cardiac tamponade. The patient\u27s underlying etiology of cardiac tamponade was attributed to a new diagnosis of SLE based on the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification (EULAR/ACR) criteria for SLE. The patient\u27s treatment consisted of a pericardial window and immunosuppressive therapy with corticosteroids, Mycophenolate, and hydroxychloroquine. This case aims to increase awareness of SLE as a possible differential diagnosis of cardiac tamponade in the appropriate clinical setting

Transient Sinus Node Dysfunction in a Postpartum Female with Sinus Bradycardia: A Case Report

Background: Conduction disorders are common cardiac complications during pregnancy in women with and without structural heart disease. Sinus bradycardia has been described in few case reports secondary to increased vagal tone. Prevalence of newly acquired sinus node dysfunction without structural heart disease is unknown. In this case, we present a post-partum female with symptomatic acquired sinus node dysfunction who presented with severe sinus bradycardia. Case Presentation: A 32-year-old Hispanic lady with a past medical history of obesity and obstetric formula of G4P4, who recently delivered her 4th child via C-section 4 weeks prior, presented to the Women´s Hospital as a transfer due to 4-day history of abdominal pain and subjective fever. Patient stated that her delivery was uneventful, and she was discharged 3 days later with iron pills due to recently diagnosed iron deficiency anemia. She complained of sudden onset episodes of subjective fever, that were associated with chills, diaphoresis, and abdominal pain on the incision site. These episodes were not associated with any foul discharge. She denied any history of heart disease in the past. She presented to an urgent care clinic and CT abdomen and pelvis without contrast revealed a collection anterior to the left uterine wall, suspicious for an abscess. She was later transferred to Women´s hospital and her vital signs were T 98.4, HR 65 BPM, RR 18 and BP 122/87 mm Hg. Her physical exam was remarkable for tenderness at the incision site, with no redness, pus expression, rebound or guarding. She was started on broad spectrum antibiotics and underwent emergent CT guided fluid collection with Fentanyl for pain management. Minimal drainage of dark blood was collected. Four days after procedure, patient suddenly became bradycardic. Her vitals were HR 37 bpm, BP 77/51 mm Hg and EKG was consistent with sinus bradycardia. Labs did not reveal any electrolyte abnormalities, cardiac enzymes, TSH and chest radiograph were within normal limits. Due to lack of response to atropine, the patient was transferred to ICU after placement of transvenous pacemaker. Emergent echocardiogram revealed normal left ventricular function, ejection fraction between 60-70% and normal RVSP. Two days later, her pacemaker was turned off and her baseline was sinus rhythm with a rate in the 60s. Leads of transvenous pacemaker were then removed and she was later discharged with close follow up with Cardiology and OBGYN. Conclusions: Sinus bradycardia can be due to various medical conditions, including secondary to vasovagal response. This is called hypervagotonic sinus node dysfunction (HSND). HSND can be due to intrinsic abnormalities as well as secondary causes such as infections or drugs. Usually, HSND can be treated with conservative management. In our case, four days after the patient underwent interventional procedure, the patient presented symptoms consistent with sinus bradycardia. Holter monitoring and echocardiogram did not reveal significant abnormalities and after 24-48 hours it improved with conservative measures. This is an uncommon and unexpected presentation; however, further studies are required to understand if there is presence of predisposing factors in such population to present this abnormality

A Case of Recently Diagnosed Uncontrolled Hyperthyroidism Associated with Bilateral Pulmonary Embolism

Background: Pulmonary embolism (PE) is a relatively common acute cardiovascular disorder with considerable mortality, despite advances in diagnosis and treatment. In 25 to 50% of first-time cases, no readily identifiable risk factor can be found. Several studies have suggested hyperthyroidism to be a potential hypercoagulable and hypofibrinolytic state. In this case, we present a patient with uncontrolled hyperthyroidism with incidental bilateral PE. Case Presentation: A 47-year-old Hispanic lady with past medical history of recently diagnosed hyperthyroidism who was not compliant with medical therapy, presented to the emergency department with 4-hour history of chest pain. She described it as sudden onset, pressure-like pain that occurred during exertion and radiated to the back. She had associated palpitations, diarrhea, arthralgias and dyspnea that did not improved with rest. She also states having poor appetite and some weight loss for at least 1 year. The patient does mention having been diagnosed with hyperthyroidism one month ago by an endocrinologist in Mexico, who prescribed her propranolol and methimazole, which she was not taking as prescribed. Her vital signs were temperature of 98.1, heart rate of 124, respiratory rate of 18 and blood pressure of 112/84 mm Hg with a SpO2 of 99% on room air. Upon physical examination, she was alert, anxious and in mild distress. She was tachycardic, with no murmur or gallop and lungs were clear to auscultation. She did not have any skin lesions. Laboratory findings were remarkable for elevated D-dimer of 643, alkaline phosphatase of 228 with liver function tests within normal range and troponin I of 0.27. Thyroid function test revealed TSH of 0 uLU/mL, total T3 493 ng/dl, free T3 22.5 pg/ml, T3 uptake of 62.5 %, total T4 24.9 ug/dl and free T4 of 5.06 ng/dl. CT of the chest with contrast revealed subsegmental bilateral lower lobe pulmonary emboli. It also revealed a soft tissue prominence within the anterior mediastinum. Thyroid US revealed an enlarged thyroid gland with heterogeneous echotexture and hyperemic Doppler flow, compatible with active thyroiditis. Burch-Wartofsky score was 35 points. Patient was admitted for uncontrolled hyperthyroidism with impending thyroid storm as well as bilateral PE with possible right heart strain. She was started on Propranolol, Methimazole, potassium iodide and heparin drip. Patient status overall improved and Echocardiogram revealed EF 60-65% without signs of right heart strain. Thyroid workup then revealed TSI of 297, positive ANA with nuclear pattern and TPO of 151 IU/mL. She was later discharged with Eliquis, methimazole and propranolol for close follow up. Conclusions: Hyperthyroidism has well known effects on the cardiovascular system, however, further data suggests that it modifies physiologic processes of hemostasis, leading to bleeding or thrombosis. This is due by upregulating adhesion molecules and endothelial marker proteins. Most studies have shown that hyperthyroidism is related to venous thromboembolism risk, however just a few have focused on specifically its association with PE. There are currently no recommendations in regard to prophylactic anticoagulation in hyperthyroid state, however physicians should be alert for possible thrombotic events with these patients

A Case of Hemorrhagic Myositis Associated With Prophylactic Heparin Use in Dermatomyositis

Dermatomyositis (DM) is a rare systemic autoimmune disease that is associated with inflammation of the skin and muscles. It typically presents with weakness of the proximal muscles along with characteristic skin lesions such as Gottron\u27s papules and heliotrope rash. One of the most feared complications of this disease is the appearance of spontaneous hemorrhagic myositis, as most reported cases are fatal. The mechanism or risk factors of this condition have not been elucidated; however, prophylactic anticoagulation has been correlated with it in previous case reports, although idiopathic hemorrhagic myositis may also be present. We present a case of spontaneous intramuscular hemorrhage (SIH) in a recently diagnosed DM patient. A 59-year-old Hispanic male with a medical history of recently diagnosed prostate cancer and DM presented to the emergency department (ED) due to worsening anemia. His previous hemoglobin (Hgb) was 9 g/dl, but repeated laboratory tests revealed a level of 6.5 g/dl and later 5.5 g/dl at the ED. On admission, the patient was afebrile, tachycardic, and normotensive, with no overt sign of gastrointestinal bleeding. The physical exam revealed an ecchymosis on the right medial aspect of the thigh, and a digital rectal exam was negative. Computer tomography (CT) of the abdomen and pelvis without contrast was ordered due to suspicion of a retroperitoneal hematoma, revealing an interval development of a right groin complex fluid collection of up to 6 cm, concerning a possible hematoma. The patient did not have any previous vascular procedures in the area but was exposed to deep vein thrombosis (DVT) prophylaxis during the previous admission. Vascular surgery was consulted, and the recommendation was made to proceed with conservative management. On the third day, the patient developed new-onset, left-sided pleuritic chest pain. Upon examination, significant swelling and tenderness were noted in his left pectoral region, which was not present on admission. A CT chest without contrast was ordered due to concerns of underlying hematomas, revealing bilateral thickening of the pectoralis muscles, more on the right side, with a fluid collection of 2.5 cm × 1.3 cm. In addition, there was thickening of the right lateral chest wall muscles in the posterior right trapezius or supraspinatus muscles, most likely from intramuscular hemorrhage. The patient was transferred to the step-down unit for close monitoring. Conservative management was continued with as-needed transfusions for three days until hemoglobin stabilized at 9.8 mg/dL. Once stable, the patient was resumed on steroids and immunosuppressive therapy with posterior resolution of the SIH. SIH has been reported in DM, particularly more prominent in those with anti-MDA-5 antibodies. A case series and literature review showed 60.9% mortality within six months in those presenting with SIH, with a poorer prognosis (80% mortality) in those with deep muscle bleeding versus superficial (25%). There is currently no consensus on the treatment approach, and arterial embolization has not been proven effective. In our patient, conservative management with close surveillance and frequent transfusions helped achieve hemodynamic stability. Clinicians should be more aware of these rare but life-threatening complications in patients presenting with DM

Emerging approaches to measure photosynthesis from the leaf to the ecosystem

Measuring photosynthesis is critical for quantifying and modeling leaf to regional scale productivity of managed and natural ecosystems. This review explores existing and novel advances in photosynthesis measurements that are certain to provide innovative directions in plant science research. First, we address gas exchange approaches from leaf to ecosystem scales. Leaf level gas exchange is a mature method but recent improvements to the user interface and environmental controls of commercial systems have resulted in faster and higher quality data collection. Canopy chamber and micrometeorological methods have also become more standardized tools and have an advanced understanding of ecosystem functioning under a changing environment and through long time series data coupled with community data sharing. Second, we review proximal and remote sensing approaches to measure photosynthesis, including hyperspectral reflectance- A nd fluorescence-based techniques. These techniques have long been used with aircraft and orbiting satellites, but lower-cost sensors and improved statistical analyses are allowing these techniques to become applicable at smaller scales to quantify changes in the underlying biochemistry of photosynthesis. Within the past decade measurements of chlorophyll fluorescence from earth-orbiting satellites have measured Solar Induced Fluorescence (SIF) enabling estimates of global ecosystem productivity. Finally, we highlight that stronger interactions of scientists across disciplines will benefit our capacity to accurately estimate productivity at regional and global scales. Applying the multiple techniques outlined in this review at scales from the leaf to the globe are likely to advance understanding of plant functioning from the organelle to the ecosystem