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Haemophagocytic lymphohistiocytosis (HLH) is a rare condition of uncontrolled immune activation as a result of an inherited genetic defect or in response to malignancy, autoimmune disease, rheumatological disease, AIDS infection or post-transplant immunosuppression. Described here is the case of a 19-year-old Caucasian man who presented with complaints of worsening fever, new-onset jaundice and lethargy after failing treatment for suspected infectious mononucleosis. Physical examination was significant for fever and splenomegaly while laboratory results revealed transaminitis, cytopaenia, indirect hyperbilirubinaemia and elevated ferritin, raising the likelihood of both autoimmune haemolytic anaemia and HLH. He tested positive for Epstein-Barr virus (EBV), and bone marrow biopsy revealed hypercellular marrow with haemophagocytosis and no evidence of malignancy. High dose steroids were initiated with significant improvement in haemoglobin, resulting in a final diagnosis of HLH secondary to acute EBV infection. The patient was discharged on continued high-dose prednisone with planned taper and consideration of outpatient rituximab therapy for 4 weeks. High clinical suspicion and prompt evaluation were critical to early treatment and decreased morbidity.

Alexandra Halalau,1,2 Fadi Odish,3 Zaid Imam,4 Aryana Sharrak,2 Evan Brickner,2 Paul Bumki Lee,2 Adam Foglesong,1 Adrian Michel,1 Inayat Gill,1 Lihua Qu,2,5 Amr E Abbas,2,6 Christopher F Carpenter1,2,7 1Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA; 2Oakland University William Beaumont School of Medicine, Rochester, MI, USA; 3Section of Gastroenterology and Hepatology, Department of Internal Medicine, Wright State University, Dayton, OH, USA; 4Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA; 5Outcome Research Department, Research Institute Beaumont Health, Royal Oak, MI, USA; 6Cardiovascular Department, Beaumont Health, Royal Oak, MI, USA; 7Infectious Disease Section, Beaumont Health, Royal Oak, MI, USACorrespondence: Alexandra HalalauWilliam Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI, 48073, USATel +1 248 551-3481Email Alexandra.Halalau@beaumont.orgBackground: Most outpatients with coronavirus disease 2019 (COVID-19) do not initially demonstrate severe features requiring hospitalization. Understanding this population’s epidemiological and clinical characteristics to allow outcome anticipation is crucial in healthcare resource allocation.Methods: Retrospective, multicenter (8 hospitals) study reporting on 821 patients diagnosed with COVID-19 by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs and discharged home to self-isolate after evaluation in emergency departments (EDs) within Beaumont Health System in March, 2020. Outcomes were collected through April 14, 2020, with a minimum of 12 day follow-up and included subsequent ED visit, admission status, and mortality.Results: Of the 821 patients, mean age was 49.3 years (SD 15.7), 46.8% were male and 55.1% were African-American. Cough was the most frequent symptom in 78.2% of patients with a median duration of 3 days (IQR 2– 7), and other symptoms included fever 62.1%, rhinorrhea or nasal congestion 35.1% and dyspnea 31.2%. ACEI/ARBs usage was reported in 28.7% patients and 34.0% had diabetes mellitus. Return to the ED for re-evaluation was reported in 19.2% of patients from whom 54.4% were admitted. The patients eventually admitted to the hospital were older (mean age 54.4 vs 48.7 years, p=0.002), had higher BMI (35.4 kg/m2 vs 31.9 kg/m2, p=0.004), were more likely male (58.1% vs 45.4%, p=0.026), and more likely to have hypertension (52.3% vs 29.4%, p< 0.001), diabetes mellitus (74.4% vs 29.3%, p< 0.001) or prediabetes (25.6% vs 8.4%, p< 0.001), COPD (39.5% vs 5.4%, p< 0.001), and OSA (36% vs 19%, p< 0.001). The overall mortality rate was 1.3%.Conclusion: We found that 80.8% of patients did not return to the ED for re-evaluation. Sending patients with COVID-19 home if they experience mild symptoms is a safe approach for most patients and might mitigate some of the financial and staffing pressures on healthcare systems.Keywords: COVID-19, infectious disease, epidemiology, SARS-CoV-2, demographics, outpatient

Pancreatic ganglioneuromas occur mostly in children and rarely in young adults, with no cases reported in adults older than 60 years. An 86-year-old-woman, with active advanced multiple myeloma, presented with epigastric pain for 2 days. Abdominal and pelvic computed tomography demonstrated a distended gallbladder, mildly dilated biliary tree, and a 13 × 8-mm hypodense mass in pancreatic body, without extrapancreatic invasion at endoscopic ultrasound. Fine-needle endoscopic ultrasound–guided core biopsy revealed characteristic histopathology of ganglioneuroma, as confirmed by immunohistochemical positivity for S100, SOX-10, and synaptophysin. This demonstrates novel finding of pancreatic ganglioneuroma occurring in the elderly. Lesion inclusion in the differential diagnosis may mandate tissue for pathologic diagnosis and complete lesion resection.

Radiation esophagitis is a serious complication occurring in patients receiving radiotherapy for head and neck cancers. Current treatment with proton pump inhibitors and mucosal protectants provides symptomatic relief with few studies showing improvement in erosive esophagitis or ulceration. Use of self-expandable metal stents (SEMS) in cases of erosive radiation esophagitis refractory to medical therapy has not been studied. We report a case of a patient presenting with recurrent hematemesis from late (chronic) radiation esophagitis with bleeding esophageal ulceration successfully treated with SEMS placement after failure of conservative medical management, proposing a possible utility for SEMS in this setting.

INTRODUCTION: Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States. DESIGN: Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h. RESULTS: The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h. CONCLUSION: Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.

This article documents the increasing use of the English curse word fuck worldwide, as well as its degree of adaption into the host language, its syntactic function, and its meaning and its strength as taboo. Comparing the use of fuck with a special focus on the Nordic countries (Norway, Denmark, and Iceland) with its use in Eurasia and Africa (with different alphabets, namely Cyrillic in Russia, Devanāgarī in India and Ge’ez script in Ethiopia), we found some similar developmental patterns, but also differences, for example to what degree the English loan word has replaced local curses and in what ways among social groups within a country. Comparing the terms used for the same concept was challenging because some countries have better text corpora and more research on written languages and especially on taboos, and those without such resources required additional minor investigations for a baseline. Findings revealed that fuck has spread worldwide from English, and it is commonly used in Nordic languages today. In Russian fuck is also adopted into the heritage language to a relatively high degree, and it has further gained importance in the vocabulary of India, where English has become the most used language by the higher and middle classes, but less so by lower classes. In contrast, the study of Amharic language in Ethiopia shows that the f-word is rarely used at all, and only by youngsters. We found a pattern starting from the outer North with Icelandic having adapted and adopted the word fuck the most, a slight decline in use in Norwegian and Danish, with less adaption and use in Russian, even less in Indian-English or Hindi, and being more or less absent in the African language Amharic. Formally though it is used conceptually both in Hindi and Amharic.