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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.

Patient: Female, 76-year-old Final Diagnosis: Left hepatic cyst hidatic fistula to gall bladder Symptoms: Biliary colic • icterus • Sepsis Medication: — Clinical Procedure: Multidiscipliner treatment Specialty: Surgery Objective: Rare disease Background: Cholecysto-hydatid fistula is a rare complication of liver echinococcosis; suppurative cholangitis due to cholecysto-hydatid fistula is even rarer. A multidisciplinary approach is required by radiology and surgery departments during the preoperative diagnosis and treatment processes of these cases. In this paper, a patient treated with suppurative cholangitis due to cholecysto-hydatid fistula is presented. Case Report: A 76-year-old female patient was admitted to emergency services due to cholangitis. Abdominal computerized tomography (CT) examination revealed that the common bile duct was dilated through the right liver in a wide and torsional pattern; the gallbladder cleaved into hepatic flexura and its wall became irregular. There was a cystic appearance 10×13×12 cm in size on the lateral segment of the left liver lobe. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and it showed the communication between the hydatid cyst pouch and the bile duct. The patient was taken to open surgery, which confirmed the imaging findings. The gallbladder and the adjacent cyst were excised, and a T-tube was placed in the choledochus. Postoperative recovery was uneventful. Conclusions: We suggest that cholecysto-hydatid fistula is a severe problem that requires close workup with both the radiology and surgery departments. Preoperative ERCP is beneficial for the visualization of the fistulization between gallbladder and hydatid cyst and for the treatment of suppurative cholangitis.

Patient: Female, 5-year-old Final Diagnosis: Granulosa cell tumor of the ovary Symptoms: Abdomen distension • abdominal mass • abdominal pain Medication:— Clinical Procedure: Diagnostic tests, surgical treatment and chemotherapy Specialty: Pediatrics and Neonatology Objective: Rare disease Background: Granulosa cell tumor of the ovary is very rare in childhood; its most common clinical manifestation is isosexual precocious puberty. Clinical presentation as acute abdomen due to pain and ovarian torsion is rare, but a granulosa cell tumor must be suspected in a patient with this acute presentation and signs of early puberty. Adult-type granulosa cell tumor is an even rarer occurrence in children. Case Report: We report a case of torsion of adult-type granulosa cell tumor of the ovary in a 5-year-old patient with acute abdominal pain and ovarian torsion and highlight the importance of histological diagnosis of this tumor for the therapeutic plan and progression of these patients. Conclusion: Precocious puberty, pain, abdominal distension, and an ultrasonography with suspicion of ovarian torsion are warning signs that may indicate the presence of a gonadal stromal tumor in pediatric patients seen at an emergency unit. These patients require long-term follow-up by a pediatrician and gynecologist because of the potential for late recurrence.

Patient: Female, 51-year-old Final Diagnosis: Pneumocephalus • Pneumococcal meningitis Symptoms: Worsening of mental status Medication:— Clinical Procedure: — Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine Objective: Rare co-existance of disease or pathology Background: Pneumocephalus is a rare occurrence without trauma, neurosurgery, or intracranial pathology. It is an uncommon complication of bacterial meningitis, and it is usually diagnosed with a CT head. Bacterial pneumocephalus in the setting of influenza B virus infection is an extremely rare complication; however, vaccination against influenza and early diagnosis and treatment help prevent mortality. Case Report: A 51-year-old woman presented to the Emergency Department in early winter because of worsening mental status over seven days prior to presentation. She was not vaccinated against influenza. Before and upon presentation to our facility, she was diagnosed with influenza B virus infection and was positive for streptococcal meningitis. A CT head revealed pneumocephalus, likely due to Streptococcus infection. She was treated with antibiotics, and a repeat CT head showed resolution of the lesion. Conclusions: Bacterial pneumocephalus in the background of influenza is an uncommon occurrence. Influenza vaccination and early diagnosis with a CT of the head and prompt initiation of antibiotics are essential in preventing mortality.

Patient: Male, 50-year-old Final Diagnosis: Snake bite induce thromotic microangiopathy Symptoms: Coagulopathy • hemolysis • renal failure • snake bite • thrombocytopenia Medication: — Clinical Procedure: Plasma exchange Specialty: Hematology Objective: Unusual clinical course Background: Consumption coagulopathy post envenomation is one the most common complications after a snakebite. It occurs secondary to activation of a coagulation cascade by snake venom and could be followed by a syndrome consistent with thrombotic microangiopathy. The efficacy of plasma exchange for the treatment of thrombotic microangiopathy post envenomation is a matter of debate. Case report: We reported the case of a 50-year-old male who had Arabian saw-scaled viper envenomation. He developed venom induced coagulopathy that improved within 24 hours of antivenom therapy. He subsequently developed micro-angiopathic hemolytic anemia, thrombocytopenia, and renal failure that was consistent with thrombotic microangiopathy. The patient was treated by plasma exchange and hemodialysis. He made a full recovery and was discharged after 4 weeks. Conclusions: This case report supports plasmapheresis as an option for management of a patient who develops thrombotic microangiopathy secondary to snake bite, especially those who do not improve with antivenom and supportive therapy.

Patient: Female, 14-year-old Final Diagnosis: 22q11.2DS with vestibular dysfunction Symptoms: Balance problems Medication:— Clinical Procedure: Comprehensive balance assessment Specialty: Otolaryngology Objective: Challenging differential diagnosis Background: The 22q11.2 deletion syndrome (22q11.2DS) is the most common identified microdeletion in humans. Anomalies of the vestibular system can occur with great frequency and are reported in the radiology literature. Fewer reports exist regarding vestibular function or its clinical features. Case Report: We present a case report of a competitive gymnast with 22q11.2DS who was noted to be having specific issues related to balance under conditions of competition, specifically on the balance beam. Comprehensive balance assessment provided evidence of the absence of lateral semicircular canal function, correlating with computed tomography findings and her symptoms. Counselling and targeted training greatly improved her performance. Conclusions: Comprehensive balance testing correlated with clinical and radiographic findings in a competitive gymnast with 22q11.2DS. Results demonstrated the functional aspect of this anomaly but also displayed the extent to which the complex interactions of all components of balance can work together to overcome balance issues under intense vestibular stress.

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.

Patient: Female, 77-year-old Final Diagnosis: Leukostasis Symptoms: Cough • palpitations • shortness of breath Medication: — Clinical Procedure: Endotracheal intubation • leukapheresis Specialty: Hematology Objective: Unusual clinical course Background: Chronic lymphocytic leukemia (CLL) is a mature B cell lymphocytic neoplasm that has an indolent clinical course. Therefore, not all patients with CLL require treatment at the time of diagnosis. Hyperleukocytosis (white blood cell count, >100×109/L) is present in a large proportion of patients with CLL. However, symptomatic hyperleukocytosis (leukostasis) is an extremely uncommon presentation of CLL. Leukostasis frequently presents with the clinical manifestation of respiratory, neurological, or renal system problems. This is secondary to the decreased tissue perfusion due to the intravascular accumulation of large aggregates of leukemic cells. Leukostasis is a medical emergency requiring intensive care unit (ICU) admission and its management includes aggressive hydration, prevention and treatment of tumor lysis syndrome, cytoreduction, and leukapheresis. Case Report: We report a case of a 77-year-old woman with a long history of untreated CLL who presented with respiratory symptoms with hyperleukocytosis. Her condition rapidly deteriorated, requiring intubation. She required induction chemotherapy with chlorambucil as well as 2 sessions of leukapheresis, to which she responded well. In most reported leukostasis cases in the literature, the white blood cell (WBC) count was >1000×109/L. We present a case of a patient with leukostasis with WBC count 524×109/L who responded to chlorambucil and leukapheresis, with good recovery. Conclusions: Leukostasis, although extremely rare, is a life-threatening complication in patients with CLL. It should be strongly considered in the differential diagnosis of patients with CLL who present with hyperleukocytosis and acute pulmonary symptoms. Clinicians should be aware of this medical emergency, as delayed treatment can increase morbidity and mortality.

Patient: Female, 63-year-old Final Diagnosis: Asthma Symptoms: Wheeze Medication: — Clinical Procedure: — Specialty: Pulmonology Objective: Unusual clinical course Background: Despite the availability of inhaled corticosteroid and the development of various biological treatment agents, severe asthma patients are still at high risk of recurrent and life-threatening exacerbations, which results in morbidity and mortality. In addition to treatment response variability, incorrect inhaler technique, poor adherence, and major psychological problems, environmental factors such as climate change also are contributory factors for worsen symptoms of asthma and acute exacerbation. We present here, a case of a 63-year-old female patient who had oral corticosteroid-dependent severe asthma and recurrent attacks in spring and autumn. Case report: A 63-year-old Chinese female was diagnosed with asthma when she was 3 years old. During 2007–2011, she was admitted to the hospital once a year because of asthma exacerbation; she was on a regular treatment regimen of inhaled corticosteroids (ICS) plus long-acting beta-agonist (LABA). In October 2018, she was admitted to our Department for aggravating symptoms due to “sudden climate change”. She was discharged on tapering doses of oral methylprednisolone from 32 mg once daily, but the reduced methylprednisolone resulted in aggravation of wheezing. However, when the weather warmed up, her symptoms were relieved, and she stopped taking methylprednisolone (after the tapering). Conclusions: This study suggests an association between the common causes of weather changes and acute severe asthma exacerbation. Patients and clinicians should be aware that keeping warm and avoiding exposure to cold air and airborne allergens might reduce the frequency of asthma exacerbations.