Double Trouble Research Articles

Ocular myasthenia gravis and thyroid eye disease: double trouble.

A 60-year-old male patient with a previously unremarkable medical history presented with unilateral eyelid ptosis and binocular diplopia in the past year. Clinical and laboratory workup confirmed the diagnosis of ocular myasthenia gravis. In addition, further workup with orbital MRI performed due to exophthalmos and unilateral ophthalmoplegia demonstrated findings compatible with thyroid eye disease, which were further verified by antibody testing. The unusual concurrent appearance of ocular myasthenia gravis and thyroid eye disease is presented while illustrating the hallmark clinical, laboratory, and imaging findings relevant to both diseases.

Double Trouble: A Rare Case of Dual Esophageal Stenosis in a 4-month-old

ABSTRACT Esophageal stenosis is an uncommon clinical condition defined as a fixed narrowing of the esophagus. It can be congenital or acquired. The incidence of congenital esophageal stenosis (CES) is 1 in 25,000–50,000 live births. Most of these patients present in early infancy and many of them require surgical intervention. We report a very interesting case of a 4-month-old child with esophageal stenosis involving two different segments of the esophagus who was successfully treated surgically. This is one of the rarest variants of CES which involves two different segments of the esophagus.

Double Trouble: Metabolic Dysfunction-Associated Fatty Liver Disease in Fraternal Twins

Pediatric cases of metabolic dysfunction-associated fatty liver disease (MASLD, formerly termed non-alcoholic fatty liver disease (NAFLD) are a troubling new outcome of the pediatric obesity epidemic. Advising patients and families with this condition is challenging considering the nutrition needed to sustain developmentally appropriate growth in youth. Describing risk factors, comorbidities, management, and referrals for MASLD could improve surveillance and outcomes for this condition. MASLD is commonly seen with other comorbidities such as dyslipidemia, obstructive sleep apnea, type 2 diabetes, hypothyroidism, anxiety, and depression. Considerations of epigenetics, diabetes, and adverse childhood experiences will be explored as additional underlying contributors to MASLD. Screening patients for this condition in conjunction with other comorbidities is essential to preventing the progression to non-alcoholic steatohepatitis (NASH) and cirrhosis, as well as lowering the risk for hepatocellular carcinoma. This fraternal twin case report describes pertinent diagnostics, recommendations for referrals, follow-up consultations, and red flags for more advanced liver disease.

Double Trouble: A Rare Case of Cephalosporin-Induced Myeloperoxidase Glomerulonephritis with Acute Interstitial Nephritis

Double Trouble: A Rare Case of Cephalosporin-Induced Myeloperoxidase Glomerulonephritis with Acute Interstitial Nephritis

Double Trouble in the Basement! A Case of Phospholipase A2 Receptor (PLA2R)-Associated Membranous Nephropathy with Atypical Anti-glomerular Basement Membrane Disease

Double Trouble in the Basement! A Case of Phospholipase A2 Receptor (PLA2R)-Associated Membranous Nephropathy with Atypical Anti-glomerular Basement Membrane Disease

Crescentic Glomerulonephritis (GN) with Anti-glomerular Basement Membrane (GBM) Antibodies and ANCA: Double Trouble

Crescentic Glomerulonephritis (GN) with Anti-glomerular Basement Membrane (GBM) Antibodies and ANCA: Double Trouble

S3059 Double Trouble: A Rare Case Of Primary Rectal Adenocarcinoma Complicated By Synchronous Prostate Cancer

S3059 Double Trouble: A Rare Case Of Primary Rectal Adenocarcinoma Complicated By Synchronous Prostate Cancer

622P An unusual case of double trouble of facioscapulohumeral dystrophy (FSHD) and coexisting congenital myopathy uncovered by whole genome sequencing

622P An unusual case of double trouble of facioscapulohumeral dystrophy (FSHD) and coexisting congenital myopathy uncovered by whole genome sequencing

Double Trouble: Pulmonary Nontuberculous Mycobacteria (Mycobacterium fortuitum) Unveiled in a Successfully Treated Tuberculosis Survivor: A Case Report

Double Trouble: Pulmonary Nontuberculous Mycobacteria (Mycobacterium fortuitum) Unveiled in a Successfully Treated Tuberculosis Survivor: A Case Report

Double trouble: adipsic diabetes insipidus and panhypopituitarism in isolated hypothalamo-pituitary langerhans cell histiocytosis

Double trouble: adipsic diabetes insipidus and panhypopituitarism in isolated hypothalamo-pituitary langerhans cell histiocytosis

Double Trouble: A Case of Synchronous Breast and Renal Malignancies Associated with ATM Gene Mutation in a 41-Year-Old Filipino Female

Double Trouble: A Case of Synchronous Breast and Renal Malignancies Associated with ATM Gene Mutation in a 41-Year-Old Filipino Female

Double trouble: an unusual case of Klebsiella pneumoniae invasive syndrome with liver abscess, gallbladder empyema and infective endocarditis

BackgroundKlebsiella pneumoniae invasive syndrome (KPIS) is characterized by primary pyogenic liver abscess associated with metastatic infections. Although rare, Klebsiella endocarditis carries a high mortality risk.Case presentationA 60-year-old lady with type II diabetes mellitus presented with fever, malaise, right hypochondriac pain and vomiting for two weeks. Ultrasound abdomen revealed a collection within liver, and distended gallbladder with echogenic debris within. 3 days after ultrasound guided pigtail drainage of gallbladder empyema, newly presence murmur detected. Pus, urine, and blood cultures obtained were positive for Klebsiella pneumonia. Echocardiogram exhibited oscillating mass attached to anterior mitral valve leaflet. After 6 weeks of intravenous ceftriaxone, follow-up echocardiogram and ultrasound showed complete resolution of mitral valve vegetation, hepatic and gallbladder collection.ConclusionConcomitant extrahepatic infective endocarditis (IE) should raise concerns in daily practice for patients with Klebsiella pneumoniae liver abscesses, despite the rarity of Klebsiella endocarditis. In the absence of diagnostic suspicion, antibiotic treatment regimens may be shortened, and adverse effects from IE infection may ensue.

Double trouble: Co-infection of Angiostrongylus vasorum and Dirofilaria immitis in golden jackal (Canis aureus) in Friuli Venezia Giulia, Italy

This study reports the first co-infection of Angiostrongylus vasorum and Dirofilaria immitis, two nematodes affecting canid cardiopulmonary systems, in golden jackals (Canis aureus) in Italy. Data on golden jackal carcasses, recovered in Friuli Venezia Giulia (Italy) from 2020 to 2023, were recorded using InfoFaunaFVG wildlife monitoring network. Out of 60 necropsied golden jackals, 24 tested positive for either pathogen, with 3 animals displaying co-infection. Pathological findings included verminous pneumonia, abdominal and thoracic bleeding, and adult individuals in the heart and pulmonary arteries. The recent expansion of the golden jackal in northern Italy may favour the establishment and spread of these nematodes, posing challenges for disease containment and surveillance. Given the increasing prevalence of angiostrongylosis and cardiopulmonary dirofilariosis in Europe, health monitoring of wild canids is essential to reduce their potential impact.

Double Trouble: Malunited Distal Radius Fracture and Scapholunate Ligament Injury

Abstract Background Combinations of distal radius fractures with scapholunate ligament (SL) injuries are hard to diagnose, and amalunited fractures with ligament damage are rarely discussed. Methods Here is presented a case of a 40-year-old man with history of a malunited distal radius fracture and a scapholunate rupture with a time difference of over a decade between assumed traumatic incidents. We present the results of a simultaneous treatment of both conditions with corrective osteotomy and osteosynthesis of the distal radius combined with SL tenodesis. Results At 2 years after the surgery, there was a significant improvement in the results of the patient's questionnaire on subjective scales, a slight improvement in the range of motion in the wrist joint. Conclusion Despite the lack of publications on the topic in the literature, isolated problems of malunion of the distal radius fractures and the consequences of scapholunate injuries are still open for discussion. Our results suggest that when these two problems are combined, one-stage treatment can have excellent results.

Double Trouble! Do Workplace Supports Mitigate Lost Productivity for Young Workers with Both Severe Rheumatic Diseases and Depressive Symptoms?

The objectives of this longitudinal study were to understand how comorbid rheumatic disease and depression symptoms were associated with at-work productivity among young adults, and to examine whether workplace support modified this association. Seventy-six Canadian young adults who wereemployedand living with a rheumatic disease were surveyed three times over 27months. Morbidity was defined by whether participants reported severe rheumatic disease symptoms and/or depressive symptoms. Participants were asked about presenteeism, absenteeism, and whether the workplace support needs (accommodation and benefit availability and use) were met. Generalized estimating equations were used to address study objectives. Seventeen participants experienced neither severe rheumatic disease nor depressive symptoms (no morbidity), 42 participants experienced either severe rheumatic disease or depressive symptoms (single morbidity), and 17 participants reported comorbidityat baseline. Participants with comorbidity reported greater presenteeism scores and were most likely to report absenteeism, compared to the other two morbidity levels. Having workplace support needs met was associated with decreased presenteeism over the 27-month period among participants with no and a single morbidity. Conversely, unmet support need was associated with greater presenteeism for participants with comorbidity. Having workplace support needs met did not modify the association between morbidity and absenteeism. Comorbid rheumatic disease and depression burden reduce productivity among young adults. A supportive work environment has the potential to address at-work productivity challenges. Additional research is needed to understand how workplace supports coupled with clinical interventions may tackle challenges at work for young adults living with rheumatic disease and depression.

Double Trouble: COVID-19 Infection Exacerbates Sickle Cell Crisis Outcomes in Hospitalized Patients-Insights from National Inpatient Sample 2020.

Background: This study investigated the impact of COVID-19 on patients with sickle cell crisis (SCC) using National Inpatient Sample (NIS) data for the year 2020. Methods: A retrospective cohort analysis was conducted utilizing International Classification of Diseases (ICD-10) codes to identify adults who were admitted with a principal diagnosis of sickle cell crisis. The primary outcomes examined were inpatient mortality, while the secondary outcomes assessed included morbidity, hospital length of stay, and resource utilization. Analyses were conducted with STATA. Multivariate logistic and linear regression analyses were used to adjust for confounding variables. Results: Of 66,415 adult patients with a primary SCC diagnosis, 875 were identified with a secondary diagnosis of COVID-19 infection. Unadjusted mortality rate was higher for SCC patients with COVID-19 (2.28%) compared to those without (0.33%), with an adjusted odds ratio (aOR) of 8.49 (p = 0.001). They also showed increased odds of developing acute respiratory failure (aOR = 2.37, p = 0.003) and acute kidney injury requiring dialysis (aOR = 8.66, p = 0.034). Additionally, these patients had longer hospital stays by an adjusted mean of 3.30 days (p < 0.001) and incurred higher hospitalization charges by an adjusted mean of USD 35,578 (p = 0.005). Conclusions: The SCC patients with COVID-19 presented higher mortality rates, increased morbidity indicators, longer hospital stays, and substantial economic burdens.

Double Trouble: Co-occurrence of Langerhans Cell Histiocytosis and Rosai Dorfman Disease in a Toddler

The coexistence of Rosai-Dorfman disease (RDD) with Langerhans cell histiocytosis (LCH) is very rare, as to date only a handful of cases have been reported. Though both the entities come under the spectrum of histiocytic disorders, the patient outcomes are very different for each one of them. RDD is a benign disorder with often a self-limiting course; whereas LCH has a more aggressive outcome. The pathobiology of this rare co-occurrence is still unknown and the topic of several theories. Case presentation: We report a case of a 2-year-old female patient who presented with fever, pallor, lymphadenopathy and neck pain. X-ray radiograph and Computed Tomography (CT) scan chest showed multiple lytic lesions on vertebra. The biopsy finding of lymph node and bone marrow were consistent with a combined RDD-LCH disease. Conclusion: Combined RDD-LCH presentation is very rare and it’s pathophysiology is still elusive and a topic of numerous conjectures.

Double Trouble: A Case of Secondary Evans Syndrome from Systemic Lupus Erythematosus with May-Thurner Syndrome

Double Trouble: A Case of Secondary Evans Syndrome from Systemic Lupus Erythematosus with May-Thurner Syndrome

Double trouble: Implications and management of twinning in lactating dairy cows

Over the past 4 decades, twinning increased concurrently with milk production in dairy cattle, but recently appears to have plateaued, likely from the adoption of hormonal synchroniza­tion protocols. Approximately 95% of Holstein twins are dizy­gotic, making double ovulations the primary mechanism for twinning. Decreased progesterone (P4) concentrations dur­ing preovulatory follicle growth increases double ovulations. Increased hepatic catabolism of P4 because of increased feed intake associated with increased milk production provides a physiological mechanism for decreased P4 concentrations and increased double ovulations. Cows with unilateral twins have more pregnancy losses than cows with bilateral twins which were similar to cows with singletons. Selective embryo reduction followed by P4 treatment did not increase the risk of pregnancy loss for cows with unilateral twins, but increased the risk of loss for cows with bilateral twins. Twinning will likely increase concurrently with milk production over time but can be decreased using 2 approaches: 1) submitting cows to hormonal synchronization protocols that increase P4 dur­ing growth of the preovulatory follicle before timed AI; and 2) identifying twins by laterality and allowing cows with bilateral twins to continue through gestation with extra assistance at calving, while selective reduction can be attempted for cows with unilateral twins.

381 Double Trouble: Two cases of “double-seropositive” ANCA and Anti-GBM Disease

381 Double Trouble: Two cases of “double-seropositive” ANCA and Anti-GBM Disease