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Acute encephalopathy is a change in the level of consciousness where the underlying etiology can be difficult to diagnose, and thus, difficult to treat, especially in the context of multi-organ diseases. We report a case of acute encephalopathy in a patient with end-stage renal disease (ESRD) on hemodialysis, chronic hypotension, and a recent diagnosis of colon cancer who presented shortly after initiation of FOLFOX, a chemotherapy regimen for treatment of colorectal cancer comprised of folinic acid (leucovorin), fluorouracil (5-FU), and oxaliplatin (eloxatin). We present a systematic approach to elucidate ambiguous causes of toxic-metabolic encephalopathy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kim et al.)

A twenty-two-year-old woman with a history of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) on rituximab presented with fever, abdominal pain, and worsening shortness of breath requiring supplemental oxygen via nasal cannula one month after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection from which she was minimally symptomatic and had recovered. Radiographic studies revealed bilateral patchy consolidations interspersed with ground-glass opacities (GGO). She was started on antibiotics for presumed community-acquired pneumonia with no improvement. Echocardiography revealed preserved biventricular function and a suspected intracardiac mass. A cardiac magnetic resonance imaging (CMRI) revealed myocarditis and no intracardiac mass. Fever persisted and oxygen requirements increased from FiO2 0.4 to 1.0. Repeat CXR showed subtotal left hemithorax opacification. Bronchoscopic samples showed a negative Gram stain and an unremarkable cell count differential. In view of this and given her lack of response to antibiotics with worsening respiratory status, high-dose steroids were started. She improved rapidly, and six days later she was off oxygen. Transbronchial biopsies showed benign parenchyma with some intra-alveolar fibrin deposition with no definitive evidence of viral cytopathic effect, vasculitis, or diffuse alveolar damage (DAD). Follow-up imaging in the pulmonary clinic revealed improvement of prior airspace disease with some new migratory opacities that completely resolved after 12 weeks. Pulmonary function tests and repeat CMRI were normal three months after discharge. Multisystem inflammatory syndrome in adults (MISA), post-covid organizing pneumonia (OP), and immune reconstitution inflammatory syndrome (IRIS) are rare and potentially steroid-responsive causes of pneumonia, which were in our differential diagnosis. It is imperative to consider the rare possibility of steroid-responsive pneumonia-like MISA, post-COVID-OP, and IRIS in patients with worsening respiratory symptoms following a recent SARS-CoV 2 infection., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Pourshahid et al.)

There has been a recent outbreak of e-cigarette or vaping-associated lung injury (EVALI) but the exact pathophysiology remains unknown. Tetrahydrocannabinol (THC) and vitamin E derivates are the major components in vaping-generated aerosols that are associated with EVALI. So far, there is no standard treatment for EVALI. Most cases are treated with antibiotics and steroids. Counseling for smoking cessation is an integral part of care for EVALI patients. Referral to addiction medicine may be beneficial. Considering the nonspecific presenting symptoms and the growing popularity of vaping devices, providers need to consider EVALI in the differential diagnosis of bilateral patchy ground-glass opacities with respiratory, constitutional, or gastrointestinal symptoms in patients using e-cigarettes. Here, we present four EVALI cases and review the pertinent imaging and pathological findings., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Pourshahid et al.)

Dyspnea is a common symptom and may be due to a multitude of conditions, including cardiopulmonary insufficiency, anemia, neuromuscular disorders, obesity, or deconditioning. It is not uncommon that more than one process contributes to shortness of breath. Here, we present a patient with a complaint of worsening shortness of breath who was found to have two very rare causes of dyspnea simultaneously. The symptoms resolved with treatment of pernicious anemia and myasthenia gravis (MG). The coexistence of pernicious anemia and MG is extremely rare, with only two other cases reported so far., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Khademolhosseini et al.)

Marginal zone lymphoma (MZL) is a relatively uncommon subtype of non-Hodgkin lymphoma consisting of extranodal, nodal, and splenic MZL. Mucosa-associated lymphoma constitutes the majority of extranodal MZL including but not limited to the stomach, lung, salivary gland, ocular adnexa, skin, and thyroid. Depending on the site of origin, maltoma may present with different symptoms. Here we present a patient who presented to the pulmonary clinic for further evaluation of a right middle lobe consolidation. She was treated with a course of antibiotics empirically with no interval change in imaging. She underwent bronchoscopy with biopsy. Pathology was remarkable for extensive lymphoid infiltrates consisting of mixed B and T lymphocytes. Positron emission tomography (PET) CT demonstrated mild uniform uptake in consolidation with no evidence of PET avid distant metastasis. CT-guided biopsy was consistent with extranodal marginal zone lymphoma. She underwent right middle lobectomy with no complications. As mentioned in our case, bronchoscopy is usually nondiagnostic and a lung biopsy is needed in pulmonary maltoma. Treatment is based on the tumor location and extent of the disease. Prognosis is good with an 86-95% five-year survival., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Khademolhosseini et al.)

Pyogenic liver abscess (PLA) is the result of portal vein pyemia, which usually originates from the hepatobiliary system or the gastrointestinal tract. Gram-negative organisms are the most common causative pathogens in PLA. Clostridium tertium is an anaerobic gram-positive, low-virulence organism that most commonly affects neutropenic patients with hematological malignancy and has not been reported to cause PLA. We report an unusual presentation of a C. tertium infection as a PLA in a previously healthy, immunocompetent patient with no identifiable source of portal pyemia.

Fahr's disease, also known as familial idiopathic basal ganglia calcification, is a neurodegenerative disorder affecting cerebral microvessels, mainly the basal ganglia, and presenting with diverse neuropsychiatric manifestations. It is considered to be mainly hereditary, with autosomal dominant inheritance. In light of its various presentations and incomplete penetrance, Fahr's disease is known to be underestimated and underdiagnosed. Here, an early-onset case of Fahr's disease is presented mainly with pure psychiatric symptoms. Given the diversity of the presenting symptoms, and variations in the age of onset, further investigation of organic etiologies in patients presenting with neuropsychiatric symptoms, family members of patients with Fahr's disease, and patients with unexplained cerebral calcification is recommended., Competing Interests: The authors have declared that no competing interests exist.

Seizures is a relatively common presentation with a wide differential diagnosis. However, seizures presenting secondary to underlying pulmonary emboli are rare and, without prompt recognition and management, this easily treatable condition can be potentially fatal. The few available case reports discussing seizures and PE reveal a high mortality rate which underscores the importance of prompt diagnosis. A 38-year-old woman presented to the emergency room having experienced loss of consciousness and a generalized tonic-clonic seizure at home. In the emergency room, her presenting signs and symptoms included tachycardia, worsening dyspnea, mild hypoxemia, and elevated D-dimer. Pertinent history findings revealed she recently received depot hormonal contraceptive treatments. Her initial workup included an EKG which showed sinus tachycardia without evidence of right heart strain. Subsequently a chest CT with angiography revealed massive bilateral pulmonary emboli. DVT studies also revealed a unilateral acute DVT. The patient was promptly started on therapeutic anticoagulation and stabilized. Fortunately, the patient remained symptom-free and eventually was discharged with close follow-up. The goal of this report is to make clinicians more aware of the possibility that seizures, along with the appropriate clinical findings, can be caused by acute PE.