Penile Calciphylaxis in an End Stage Renal Disease patient.

Background: Penile Calciphylaxis occurs in about 1–4% of hemodialysis patients worldwide. Associated mortality rates are very high, and hyperparathyroidism is the second most frequently associated disorder. Addressing the resulting metabolic imbalance, and surgical intervention guided by findings of radiological studies may improve quality of life. The pathogenesis is thought to be mediated by vascular smooth muscle cells which differentiate into osteoblast-like cells. Decrease in vascular calcification inhibitory proteins fetuin-A and matrix Gla is found in patients on dialysis causing systemic medial calcification of arterioles, leading to epidermal ischemia, tissue infarction, and ulceration. Case presentation: 47-year-old male with history of coronary arterial disease, type 2 diabetes mellitus, and end stage renal disease on dialysis presented with penile pain. Onset was 1.5 months earlier. Patient was evaluated multiple times, resulting in several antibiotic cycles without much perceived improvement. On presentation patient’s vital signs were unremarkable. Genitourinary exam showed a penis with a necrotic center around the urethral meatus opening and white ischemic patches on the glans. Additionally, darkened penis shaft and ulcerative foreskin lesions were visible. Parathyroid hormone and phosphorus were elevated, 480 pg/mL and 5.1 mg/dL respectively. CT scan of the abdomen showed calcification along the shaft of the penis and glans. The patient started antibiotic therapy, pain management, cinacalcet and a trial of sodium thiosulfate. Total penectomy and suprapubic catheter placement were done successfully. Pathology report confirmed the diagnosis. Conclusion: Because penile calciphylaxis is a metabolically mediated progressive disease, systemic treatment is vital in attempting to slow its progression. These do little to address the pain and urinary retention from necrosis, so the need of a wider and proximal resection, which also helps foster better wound healing. This case illustrates the importance of a prompt and accurate diagnosis of penile calciphylaxis, and management of its systemic manifestation

Euglycemic Diabetic Ketoacidosis in a patient using Sodium-Glucose Cotransporter-2 inhibitor (SGLT 2 inhibitor)

Background: Diabetic Ketoacidosis (DKA) is a life-threatening complication of Diabetes Mellitus type-1 and occasionally type-2 diabetes, associated with high blood glucose levels\u3e250 mg/dl. Normal glucose levels in all diabetic patients may delay diagnosis and management of DKA and result in increased morbidity and mortality. Case Presentation: A 68-year-old male having a medical history of Diabetes Mellitus type-2, atrial fibrillation, aortic stenosis status post total valve replacement, coronary artery disease, gastric bypass surgery, and previous stroke presented with two episodes of hematemesis a few hours prior to admission. The patient denied using drugs or ingestion of methanol, ethylene glycol, and salicylate. His home medications include apixaban (Eliquis), Empagliflozin (Jardiance) SGLT-2 inhibitor, and metformin. Physical exam was unremarkable except for dry mucous membrane. While in the emergency department, the patient suffered shortness of breath with increased respiratory rate 24/min (12-16/min) and use of accessory muscles. IV fluid was administered, and initial laboratory data indicated negative ethanol and salicylate levels, with normal parameters including electrolytes and glucose level of 192mg/dl (\u3c250mg/dl). To eliminate the rare probability of Euglycemic Diabetic Ketoacidosis (EDKA), an extensive lab work showed PH 7.07 (7.35-7.45), bicarbonate 3.5mmol (23-30mmol/L), anion gap 24mmol/L (3-10mmol/L), serum ketone 8mmol/L (0.6-1.5mmol/L), serum osmolality 323mmol/kg (285-295mmol/kg) and osmolar gap 28mmol/kg (\u3c10mml/kg). Euglycemic DKA was diagnosed, and treatment started with insulin drip, IV fluid, discontinuation of Jardiance and Eliquis. Endoscopy showed stomach inflammation with no ulcer. Pathology confirmed mild active gastritis, but no intestinal metaplasia, dysplasia, or malignancy was identified. The patient’s condition improved drastically and was discharged on the third day. Conclusion: Diagnosis of DKA is challenging especially with normal glucose levels. SGLT-2 inhibitor was believed to be the culprit. Ketones should be checked in all admitted diabetic patients with high anion gap metabolic acidosis, regardless of blood glucose level

Metagenomic Sequencing of Monkeypox Virus, Northern Mexico

Monkeypox virus (MPXV) has gained interest because of a multicountry outbreak of mpox (formerly monkeypox) cases with no epidemiologic link to MPXV-endemic regions. We sequenced the complete genome of MPXV isolated from a patient in northern Mexico. Phylogenetic analysis grouped the virus with isolates from Germany