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Patient: Male, 29-year-old Final Diagnosis: Acute respiratory distress syndrome (ARDS) • COVID-19 •multi organ failure/septic shock • pneumothorax Symptoms: Cough • dyspnea • fatigue • myalgia Medication:— Clinical Procedure: Mechanical ventilation • thoracentesis Specialty: Critical Care Medicine Objective: Unknown ethiology Background: COVID-19 patients that develop acute respiratory distress syndrome (ARDS) “CARDS” behave differently compared to patients with classic forms of ARDS. Recently 2 CARDS phenotypes have been described, Type L and Type H. Most patients stabilize at the milder form, Type L, while an unknown subset progress to Type H, resembling full-blown ARDS. If uncorrected, phenotypic conversion can induce a rapid downward spiral towards progressive lung injury, vasoplegia, and pulmonary shrinkage, risking ventilator-induced lung injury (VILI) known as the “VILI vortex”. No cases of in-hospital phenotypic conversion have been reported, while ventilation strategies in these patients differ from the lung-protective approaches seen in classic ARDS. Case Report: A 29-year old male was admitted with COVID-19 pneumonia complicated by severe ARDS, multi-organ failure, cytokine release syndrome, and coagulopathy during his admission. He initially resembled CARDS Type L case, although refractory hypoxemia, fevers, and a high viral burden prompted conversion to Type H within 8 days. Despite ventilation strategies, neuromuscular blockade, inhalation therapy, and vitamin C, he remained asynchronous to the ventilator with volumes and pressures beyond accepted thresholds, eventually developing a fatal tension pneumothorax. Conclusions: Patients that convert to Type H can quickly enter a spiral of hypoxemia, shunting, and dead-space ventilation towards full-blown ARDS. Understanding its nuances is vital to interrupting phenotypic conversion and entry into VILI vortex. Tension pneumothorax represents a poor outcome in patients with CARDS. Further research into monitoring lung dynamics, modifying ventilation strategies, and understanding response to various modes of ventilation in CARDS are required to mitigate these adverse outcomes.

Patient: Female, 29-year-old Final Diagnosis: Myocardial bridging Symptoms: Chest pain Medication: — Clinical Procedure: Coronary angiography • CT scan • echocardiography Specialty: Cardiology • General and Internal Medicine Objective: Rare disease Background: Myocardial bridging, although frequent, is often a forgotten cause of angina. It is a congenital anomaly in which the coronary artery tunnels through the myocardium with the overlying muscle, termed a myocardial bridge. The tunneled artery is prone to increased myocardial compression, mechanical load, endothelial damage, and vascular remodeling. During myocardial systole, the tunneled artery undergoes narrowing caused by myocardial compression, which leads to disruption of blood flow, thereby precipitating angina, arrhythmias, infarction, and sudden cardiac death. Case Report: Here, we present a case of a 29-year-old white woman who presented with atypical left-sided achy chest pain, occurring primarily at rest. Further evaluation showed mildly elevated troponins, with normal electrocardiogram, chest x-ray, and CTA chest. She subsequently underwent coronary angiography and was found to have myocardial bridging of her left anterior descending artery, with compression of up to 40% during systole. She was initially treated with diltiazem, but due to adverse effects was transitioned to metoprolol succinate, which she has tolerated well. Conclusions: Myocardial bridging, although benign in nature, carries a vast array of complications requiring these patients to undergo prompt diagnosis and treatment. Vascular spasm, wall stress of the tunneled artery, and intensity of systolic constriction coupled with any delay in management can lead to ischemia, infarction, dysrhythmias, and death. Therefore, it is imperative that patients who have low clinical suspicion for atherosclerosis but who are presenting with anginal equivalents undergo coronary angiography to assess for myocardial bridging and receive immediate treatment.

Patient: Female, 29-year-old Final Diagnosis: COVID-19 Symptoms: Pregnancy Medication: — Clinical Procedure: Cesarian section • spinal anesthesia Specialty: Anesthesiology Objective: Unusual setting of medical care Background: The current COVID-19 pandemic highlights the importance of the mindful use of financial and human resources. Preventing infections and preserving resources and manpower are crucial in healthcare. It is important to ensure the ability of surgeons and specialized interventionalists to function through the pandemic. Until now, no justified protocol has been reported for the anesthetic management in cesarean section (CS). Case Report: A 29-year-old pregnant woman, G2P1 at 37+4 weeks of gestation, was referred to our center on March 28, 2020, after she had tested positive for COVID-19. She was stable and the CS was planned after she reached term. Through spinal anesthesia, CS was conducted. The anesthesia team was protected with full personal protection equipment. The operation was carried out smoothly without complication. A female neonate was delivered and was tested to be negative for COVID-19. No medical staff cross-infection was reported. Conclusions: Special precautions should be considered when pregnant women are undergoing CS. Spinal anesthesia is preferred over general anesthesia.

Case series Patients: Female, 44-year-old • Female, 62-year-old Final Diagnosis: Ectopic liver Symptoms: Asymptomatic Medication: — Clinical Procedure: Laparoscopic excision during cholecystectomy Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Incidental finding of ectopic liver is gaining more attention especially during laparoscopic cholecystectomy. It is reported to be found in different locations as gallbladder, stomach, spleen, umbilical ligament and other intra-peritoneal and intra-thoracic sites. Case Reports: We present 2 cases of ectopic liver found on gallbladder during elective laparoscopic cholecystectomy for 2 Lebanese females. Our findings were consistent with previous reports. The ectopic liver tissues measured 0.9 cm and 0.5 cm respectively, which were smaller than other reports. The liver tissue lacked a biliary system, which was similar to what has been previously reported in the literature. However, no malignant histological signs were seen when excised. Conclusions: These 2 cases highlight the fact that ectopic liver tissue may be encountered on the gallbladder during laparoscopic cholecystectomy. Awareness of this potential entity is beneficial to widen the differential diagnosis when identified on imaging studies pre-operatively or when found incidentally during surgery as in this case.

Patient: Male, 21-year-old Final Diagnosis: Atrioventricular nodal reentrant tachycardia Symptoms: Palpitation Medication: — Clinical Procedure: Radiofrequency catheter ablation Specialty: Cardiology Objective: Rare disease Background: Radiofrequency ablation (RFA) is the criterion standard treatment for patients with atrioventricular nodal reentrant tachycardia (AVNRT). Knowledge about RFA in patients with dextrocardia and situs inversus is limited due to their rare incidence and complexity. The incidence of dextrocardia is reported to be 1 in 12 000 births, with situs inversus occurring in one-third of the cases. The incidence of congenital heart disease is about 5% in these patients. However, data on rhythm and conduction disorders in this group of patients are currently limited, making management more difficult owing to their individual anatomy. Case Report: We report the case of an obese 21-year-old man with complex congenital heart disease (CCHD) (situs inversus dextrocardia, pulmonary atresia, single ventricle, common atrium with single atrioventricular valve), asplenia, and multiple cardiac-corrective surgeries (Fontan repair, bidirectional Glenn anastomosis, and Blalock-Taussig shunt) who underwent successful RFA of recurrent supraventricular tachycardia. Conclusions: Supraventricular arrhythmias are common in the setting of CCHD. Although catheter ablation procedures are technically challenging to perform in patients with CCHD, they remain the best therapeutic option for these arrhythmias. To our knowledge, this case is the first to be described in the literature of successful ablation of AVNRT in a patient with situs inversus dextrocardia, pulmonary atresia, a single ventricle, a common atrium with a single atrioventricular valve, and multiple cardiac-corrective surgeries.