A Rare Presentation of Drug-induced Liver Injury with Fluticasone and Vilanterol Inhaler Use

Drug-induced liver injury (DILI) is a rare and potentially lethal condition associated with the use of many commonly-used medications, including inhaled fluticasone-vilanterol. Therefore, a careful review of medications should always be obtained in the setting of acute onset hepatic dysfunction. We present the first reported case of idiosyncratic drug-induced liver injury associated with the use of this medication

Brucellosis Presenting with Febrile Pancytopenia: An Atypical Presentation of a Common Disease and Review of Brucellosis

Brucellosis is a febrile zoonotic disease caused by one of several species of the Gram-negative coccobacillus Brucella. It is endemic to the Middle East, sub-Saharan Africa, and Central America. However, cases have also been reported in the United States. Infection is most commonly transmitted via unpasteurized dairy products or through occupational exposure to livestock. The clinical presentation is highly variable; symptoms may include fever, myalgias, night sweats, weight loss, nausea, and vomiting. Less common features include orchitis, osteomyelitis, and sacroiliitis. In addition, pregnant women who contract brucellosis face a markedly increased risk of miscarriage. A presumptive diagnosis is typically established through correlation of patient history and classic laboratory findings, which include transaminitis, anemia, and leukopenia with relative lymphocytosis. Definitive diagnosis can only be established through isolation of Brucella species from blood or tissues. Treatment involves a prolonged course of multiple antibiotics; six weeks of combination therapy with aminoglycoside or rifampin and tetracycline represents the most common regimen. Healthy individuals who develop brucellosis have a generally favorable prognosis, as the case fatality rate is less than 2%. Nevertheless, early detection and treatment are essential to reduce the risk of long-term sequelae that may result from chronic, indolent disease

Effect of atrial fibrillation on mortality in SARS-CoV-2 patients: A propensity score-matched analysis of nationwide hospitalizations in the United States

Background: Atrial fibrillation (AF) is one of the most common arrhythmias encountered in patients with SARS-CoV-2 infection. There are racial disparities in the incidence of AF and COVID-19. Several studies have reported an association between AF and mortality. However, it remains to be determined if AF represents an independent risk factor for COVID-19-related mortality. Methods: A propensity score-matched (PSM) analysis was performed using data from the National Inpatient Sample to assess the risk of mortality among patients hospitalized with SARS-CoV-2 infection and incident AF from March 2020 through December 2020. Results: AF was less common among patients who tested positive for SARS-CoV-2 as compared to those who tested negative (6.8% vs 7.4%, p < 0.001). White individuals with the virus had an increased incidence of AF but had lower mortality rates relative to Black and Hispanic patients. After PSM analysis, AF retained a significantly increased odds of mortality among patients with SARS-CoV-2 (OR: 1.35, CI: 1.29–1.41, p < 0.001). Conclusion: This PSM analysis shows that AF is an independent risk factor for inpatient mortality in those with SARS-CoV-2 infection and that White patients, while having a higher burden of SARS-CoV-2 and AF, demonstrate a significantly lower mortality rate as compared to their Black and Hispanic counterparts

Colon Cancer Sidedness, Presentation, and Survival at Different Stages

Background. Several prognostic factors have been used to guide therapy for colon cancer (CC). However, the relationship between CC laterality (sidedness) and prognosis remains under investigation. Objectives. To assess the effect of laterality on CC presentation and survival, using a Surveillance, Epidemiology, and End Results (SEER) population-based cohort. Methods. A retrospective cohort study using data from the SEER program (2007-2015). Results. Of the 163,980 patients with CC, 85,779 (52.3%) presented with right-sided CC (RCC) and 78,201 (47.7%) with left-sided CC (LCC). Stage distributions were as follows: stage I, 24.1%; stage II, 27.3%; stage III, 28.2%; and stage IV, 20.4%. In an adjusted modified Poisson regression approach for risk ratio (RR), patients with LCCs were more likely to be male (RR = 1.14; 95% CI 1.12-1.15, p<0.001). As compared to stage I, stage II cancers (RR = 0.88, 95% CI 0.87-0.90, p<0.001) were less likely to be LCC. Stage IV CC was slightly less likely to be left-sided (RR = 0.98, 95% CI 0.98, 0.96-1.00, p = 0.028). The median overall survival (OS) for RCC was 87 months. The median OS for LCC was not established, as more than half of the patients diagnosed with LCC were still living at the time of the analysis. In adjusted Cox proportional Hazard model, individuals with stage I, III, and IV LCCs had superior OS as compared to those with matched-stage RCC (adjusted HR = 0.87; 95% CI 0.85-0.88, p<0.001). However, OS was worse among those with stage II disease who presented with LCC (adjusted Hazard ratio [aHR] = 1.06; 95% CI 1.02-1.11, p = 0.004). CC-specific survival (CSS) was superior for LCC versus RCC for stages III and IV but worse for II. Conclusions. In this population-cohort study, LCC is associated with superior OS and CSS survival. The overall survival advantage was attributed to stage I, III, and IV disease. Individuals presenting with stage II disease exhibit superior survival if the CC is right-sided

Colorectal Cancer Presentation and Survival in Young Individuals: A Retrospective Cohort Study

Emerging evidence suggests that the incidence of colorectal cancer is increasing among individuals under the age of 50 years. However, the pattern of disease presentation in young patients remains under investigation. This is a retrospective cohort study of patients diagnosed with colorectal cancer (CRC) between 2004 and 2015. Data was acquired from the Surveillance, Epidemiology, and End Results 18 program registries. A total of 269,398 patients who met the inclusion criteria were included in the final analysis. The primary outcomes were the likelihood of metastatic disease at diagnosis and survival. Of the 269,389 patients diagnosed with CRC, 11.8% of the patients were young (20 to 49 years), 45.6% were middle-aged (50 to 69 years), and 42.6% were elderly (70 years or older). Individuals in the middle-aged and elderly cohorts were significantly less likely to present with metastatic disease as compared to the young cohort (middle-aged adjusted odds ratio (aOR) = 0.73, 95% confidence interval (CI) = 0.70 to 0.75, elderly aOR = 0.49, 95% CI = 0.47 to 0.50). However, overall survival was longest in the young cohort. We conclude that young individuals with colorectal cancer have an increased risk of presenting with distant metastases as compared to the middle-aged and elderly, but, nevertheless, exhibit prolonged survival

Basal Cell Carcinoma of the Female Breast Masquerading as Invasive Primary Breast Carcinoma: An Uncommon Presentation Site

Skin cancer as a single entity is the most common malignancy in North America, accounting for half of all human cancers. It comprises two types: melanoma and nonmelanoma skin cancers. Of the nonmelanomas, basal cell carcinoma (BCC) constitutes about 80% of the cancers diagnosed every year. BCC usually occurs in sun-exposed areas such as the face and extremities. Occurrence in the nipple areolar complex is very rare. We present a case of a Caucasian woman who presented with what was initially thought to be invasive carcinoma of the breast involving the nipple areolar complex (NAC); however, the diagnosis was revealed to be a basal cell carcinoma after histopathological examination. The tumor was treated with modified radical mastectomy, with negative margins. The importance of this case lies in the rare site of presentation of basal cell carcinoma and the importance of early detection

The impact of COVID‐19 on mortality, length of stay, and cost of care among patients with gastrointestinal malignancies: A propensity score‐matched analysis

Abstract Background Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and the coronavirus 19 (COVID‐19) pandemic have had a lasting impact on the care of cancer patients. The impact on patients with gastrointestinal (GI) malignancies remains incompletely understood. We aimed to assess the impact of COVID‐19 on mortality, length of stay (LOS), and cost of care among patients with GI malignancies, and identify differences in outcomes based on primary tumor site. Methods We analyzed discharge encounters collected from the National Inpatient Sample (NIS) between March 2020 and December 2020 using propensity score matching (PSM) and COVID‐19 as the treatment effect. Results Of the 87,684 patient discharges with GI malignancies, 1892 were positive for COVID‐19 (C+) and eligible for matching in the PSM model. Following PSM analysis, C+ with GI tumors demonstrated increased incidence of mortality compared to their COVID‐19‐negative (C‐) counterparts (21.3% vs. 11.9%, p < 0.001). C+ patients with colorectal cancer (CRC) had significantly higher mortality compared to those who were C‐ (40% vs. 24%; p = 0.035). In addition, C+ patients with GI tumors had a longer mean LOS (9.4 days vs. 6.9 days; p < 0.001) and increased cost of care ($26,048.29 vs.$21,625.2; p = 0.001) compared to C‐ patients. C+ patients also had higher odds of mortality secondary to myocardial infarction relative to C‐ patients (OR = 3.54, p = 0.001). Conclusions C+ patients with GI tumors face approximately double the odds of mortality, increased LOS, and increased cost of care compared to their C‐ counterparts. Outcome disparities were most pronounced among patients with CRC

Association between Empagliflozin Use and Electrocardiographic Changes

Empagliflozin, a sodium-glucose transporter 2 inhibitor, has been shown to bind to late sodium channels in mice cardiomyocytes. We sought to investigate the electrocardiographic (ECG) features associated with empagliflozin use in patients with diabetes mellitus. We compared ECG features of 101 patients before and after initiation of empagliflozin and found that empagliflozin was associated with a significant increase in QRS duration among diabetes patients with heart failure

Gastrointestinal Bleed from Erosive Gastritis and Duodenitis: A Sentinel Event of Invasive Lobular Carcinoma of the Breast and a Diagnostic Dilemma

Metastasis from breast cancer to the gastrointestinal (GI) tract is uncommon, and such events presenting as GI bleeding are exceedingly rare. In some individuals, the absence of classical findings of primary breast cancer coupled with the non-specific nature of GI symptoms may make early detection and diagnosis challenging. Our patient is a 75-year-old female who presented with symptomatic anemia manifesting as progressive dizziness, weakness, and early satiety that developed eight days after right knee arthroplasty. She had a remote history of acid reflux disease and reported regular use of non-steroidal anti-inflammatory drugs (NSAIDs). Physical examination was notable for pallor and tachycardia the cardiopulmonary examination was otherwise unremarkable and the abdominal examination was normal. A fecal occult blood test was positive. Subsequent esophagogastroduodenoscopy demonstrated significant erosive gastritis and duodenitis that was initially attributed to the patient's NSAID use. However, biopsy showed signet ring carcinoma. No gastric primary tumor was identified on work up. Extensive evaluation ultimately revealed invasive lobular carcinoma of the breast. Notably, no primary breast lesion had been detected on physical examination or breast mammography or magnetic resonance imaging (MRI). Therapy for invasive lobular carcinoma of the breast is substantially different from gastric carcinoma and thus it is important to accurately diagnose the condition early in its course to optimize patient outcomes