For more than a year, health systems all over the world have been combating the global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first described in the city of Wuhan in China, presenting as an atypical infection of the lower respiratory tract. COVID-19 is characterized by multisystemic involvement, and mortality is attributed mainly to the respiratory system involvement, which may lead to severe acute respiratory distress syndrome and respiratory failure. Several COVID-19-associated complications are being increasingly reported, including arterial and venous thromboembolic events that may lead to amputation of the affected limbs. So far, a large number of reports have described hypercoagulability crises leading to amputation of the lower limbs. However, a search of the National Library of Medicine (MEDLINE) revealed no cases of urgent upper limb amputation in COVID-19 patients. This article describes a novel case of upper limb ischemia in a COVID-19 patient, with rapid progression to hand necrosis, requiring urgent through-arm amputation of the upper limb. This case emphasizes the need for anticoagulant therapy in COVID-19 patients and to maintain a constant awareness of the possible thromboembolic COVID-19-related sequelae.

Background: Euglycemic diabetic ketoacidosis is an uncommon but life-threatening complication associated with the use of sodium-glucose cotransporter 2 inhibitors that causes lower than expected blood glucose levels typically seen in diabetic ketoacidosis. Case presentation: We present a case of 64-year-old Caucasian male patient previously diagnosed with type 2 diabetes treated with a sodium-glucose cotransporter 2 inhibitor who developed severe ketoacidosis. Serum glucose levels on initial presentation were slightly above normal baseline level. The patient was revealed to have latent autoimmune diabetes in adults. Conclusion: This case highlights the importance of prescribing sodium-glucose cotransporter 2 inhibitors to the correct patient population and the significance of accurately differentiating between various types of diabetes.

Background. Abdominal aortic aneurysm (AAA) and acute coronary syndrome (ACS) share common risk factors. Objectives. To assess the abdominal aortic diameter (AAD) among patients with ACS using transthoracic echocardiography (TTE). Methods. Patients with ACS admitted to our intensive cardiac care unit from December 2013 to June 2014 were screened prospectively for AAA via AAD measurement in the subcostal TTE view. AAA was defined as an aneurysm with a transverse diameter of ≥30 mm. Results. Sixty seven patients were included. The male-to-female sex ratio was 7 : 1. The vast majority of patients were admitted due to STEMI (73%), and the rest were equally divided as NSTEMI and unstable angina. The mean patient age was 58.4 ± 10.4 years. AAD measurements were feasible in 57 patients (85%); among them, AAA was diagnosed in six patients (10.5%). The average additional time required to measure the abdominal aorta was 4 ± 1 min. All patients with AAA were men and had a higher prevalence of smoking (83.3% vs. 60.6%, ) and a lower incidence of diabetes mellitus than those without aneurysm. The prevalence of AAA tended to be related to age (12.5% in those older than 60 years and 18.7% in those older than 65 years). Conclusions. The overall prevalence of AAA is significantly high among patients with ACS and increases with age. AAA screening as a part of routine cardiac TTE can be easily, rapidly, and feasibly performed and yield accurate findings. AAD measurement in the subcostal view should be implemented as a part of routine TTE in patients with ACS.

Coronavirus disease 2019 (COVID-19) is a worldwide pandemic that had emerged in China since December 2019. The disease affects all age groups, with clinical manifestations in the spectrum from asymptomatic to rapidly lethal multi-organ failure, mainly involving the respiratory system. Diagnosis is confirmed mainly by a positive real-time polymerase chain reaction (PCR) nasopharyngeal swab. It is highly recommended to avoid performing invasive procedures in COVID-19 subjects to prevent the potential for dissemination of the pathogen. Treatment consists in particular of respiratory support and symptom relief. Dexamethasone is widely used with encouraging response. There were no cases in the literature that were diagnosed with positive reverse transcription-polymerase chain reaction (RT-PCR) testing only from fluid of involved organs, while repeated nasopharyngeal swabs returned negative for COVID-19. We here describe a case of COVID-19 that presented with moderate-severe pulmonary involvement, diagnosed by RT-PCR testing from broncho-alveolar lavage, while several nasopharyngeal swabs were consistently negative. The patient experienced no improvement under wide-spectrum antibiotics administered initially, and greatly improved after receiving systemic corticosteroids. One can realize from our case that COVID-19 could not be ruled out upon repeated negative RT-PCR nasopharyngeal swabs, and in subjects with highly suspected COVID-19, it is justified to perform invasive procedures, but still using maximal protective measures. J Med Cases. 2021;12(6):217-219 doi: https://doi.org/10.14740/jmc3679

Background: Emergency department shock rooms provide immediate care for critically ill patients requiring life-saving interventions. Rapid diagnosis and treatment are crucial determinants of survival, yet factors predicting outcomes in this population remain poorly understood. This study evaluated factors associated with survival among patients hospitalized after shock room treatment in a tertiary medical center. Methods: In this retrospective cohort study, medical records of patients treated in the emergency department shock room of a tertiary referral center were reviewed. Patients were categorized according to hospital survival. Variables analyzed included age, sex, comorbidities, etiology of the acute event, vital signs at admission and discharge from the SR (including blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation), out-of-hospital mechanical ventilation, and laboratory values including creatinine, hemoglobin, lactate, electrolytes, and coagulation parameters. Results: A total of 101 patients treated over 24 consecutive months were included. The cohort comprised 50 men and 51 women with a mean age of 68± 20 years (range 18– 100). The mean shock room stay was 4.69± 4.3 hours. Sixteen patients (16%) arrived following out-of-hospital resuscitation and were invasively ventilated. Overall, 60 patients (60%) died during hospitalization. Approximately half of all admissions were related to respiratory system morbidity. Mortality was significantly higher among patients aged > 65 years than among those aged ≤ 65 years (75% vs 34%, p=0.046). Oncological disease as a comorbidity was significantly more prevalent in deceased patients (38% vs 10%, p=0.001). Admission creatinine was higher in deceased patients (1.5 vs 0.9 mg/dL, p=0.004) and hemoglobin was lower (11.9 vs 12.9 g/dL, p=0.044). Respiratory rate was significantly higher (18 vs 12 breaths/min, p=0.002) and diastolic blood pressure lower (67.5 vs 79.0 mmHg, p=0.011) in patients who died. Diastolic blood pressure remained significantly lower at shock room discharge in deceased patients (p=0.010). Shock room stay duration (≤ 4 vs > 4 hours) was not significantly associated with mortality (OR 0.66, p=0.320). Conclusion: Age over 65, elevated creatinine, low hemoglobin, high respiratory rate, and low diastolic blood pressure at admission were associated with in-hospital mortality. Persistent diastolic hypotension at shock room discharge was a novel finding. Shock room stay duration was not independently associated with mortality. These findings are exploratory and prospective validation in larger cohorts is needed.