Poster Day 2024: Abstracts: Clinical Vignettes

Gastrointestinal Stromal Tumors (GIST’s) are rare mesenchymal neoplasms of the GI tract that typically arise in the stomach and small intestine but can arise anywhere along the GI tract

GIST’s nearly all express the CD117 antigen, also known as the transmembrane KIT receptor tyrosine kinase

Approximately 80% of GIST’s carry a gain-of-function mutations in the KIT gene

GISTs are thought to originate from the interstitial cells of Cajal, which are in the intramuscular layer of the bowel wall below the epithelium

Clinical presentation varies depending on patient age and the location of the primary tumor, but can include abdominal pain or discomfort, GI bleeding, dysphagia, obstructive jaundice, constipation, or bowel obstruction

Initial diagnostic evaluation includes CT of abdomen and pelvis and upper endoscopy with endoscopic ultrasound

The definitive diagnosis of GIST is established using a combination of histopathology, immunohistochemistry, and identification of disease-specific molecular alterations

62-year-old female with a PMHx of breast cancer (s/p bilateral mastectomy)  presents with diffuse abdominal pain, nausea, vomiting, and constipation, onset 2 months ago, as well as an 80-pound unintentional weight loss over the last year.  Patient reported increasing abdominal pain and constipation over the past few days prompting her to come to the ED. Denies hematochezia or melena. 

Physical exam showed mild epigastric tenderness to palpation but was otherwise unremarkable.

CT A/P was ordered which showed a 13.4 x 12.0 cm x 11.8 cm large multilobulated heterogenous necrotic enhancing LUQ soft tissue mass contiguous with the serosal surface of the stomach with differential considerations including GI stromal tumor as well as a large volume of retained stool throughout the colon. (See images A and B)

Labs on arrival were significant for severe anemia with Hgb of 4.0 and severe hypokalemia with potassium of 2.2. Patient was given 3 units of packed RBCs which improved HgB to 7.8 and was repleted for potassium. 

Patient was admitted to medicine and GI was consulted. 

Esophagogastroduodenoscopy with biopsy was performed which showed the abdominal mass was positive for spindle cell neoplasm consistent with GIST.

The mass was found to be in the top part of the fundus of the stomach at the junction with the cardia, and upon entering the lesion, there was a pocket found inside the GIST where the tumor had eroded through, that was about 6 cm by 8 cm

Immunohistochemistry revealed the mass to be CD117 positive, DOG1 positive, and CD34 positive. Pathology report revealed a mitotic rate of greater than 50 mitoses per 5 mm² and a histological grade of high grade G2 with a 20% extent of necrosis.

Patient was scheduled for exploratory laparotomy and partial gastrectomy with plan for tumor resection with complete margin resection . Ex-lap revealed the GIST was in the posterior stomach along the greater curvature and was severely adhered to the distal pancreas and spleen. Patient underwent a partial gastrectomy, distal pancreatectomy, splenectomy, splenic flexure mobilization of the colon, and J-tube placement. 

Due to the extent of tumor invasion, complete resection was not possible. Further surgical resection was not recommended.

Hematology Oncology was consulted. They recommended patient follow up as outpatient once cleared from hospital stay. Plan to treat with Imatinib. Hematology will also follow up regarding patient’s anemia of chronic disease and iron deficiency.

GIST’s account for only 1-2% of primary gastrointestinal neoplasms, with an average size of approximately 5 cm when diagnosed clinically

Resection is recommended for any GIST’s greater than or equal to 2 cm

This patient presented with 2 months of vague symptoms and was diagnosed late in the disease course, as the tumor had already grown to be 13.4 x 12.0 x 11.8 cm large and had begun to invade adjacent structures

Mitotic rates for GIST’s are classified as “high” if rate is 6 or more mitoses per 5 mm², and the tumor in our case had a mitotic rate of greater than 50 mitoses per 5 mm², making it a highly aggressive GIST

The size, exceptionally high mitotic activity, and extent of tumor invasion of this GIST complicated its resection, necessitating removal of the distal pancreas and spleen and making complete resection not feasible

This case highlights the importance of early identification and management of gastrointestinal stromal tumors

Symptoms are often nonspecific, leading to late diagnosis of the disease

GIST's rarely infiltrate the surrounding structures to the degree that was seen in this case, and tumor-free margins are typically achieved following minimally invasive resection

Further research is needed on GISTs of this size, and earlier recognition and intervention is imperative

Alexander R. Orta, MS, OMS-IV; Guo Qian, OMS-IV; Andrew S. Outlaw, MD

Radial head subluxation (RHS), commonly known as “Nursemaid’s elbow,” typically presents in pediatric patients as acute-onset unilateral arm pain and pseudoparalysis. The classic mechanism of injury is a longitudinal traction force that pulls the radial head through the annular ligament. Bilateral RHS is exceedingly rare, with only a few cases documented in the literature; notably, all cases with a provided history and physical exam presented with the classic mechanism of injury, aiding in diagnosis and treatment. Here, we report the case of a 2-year-old male with bilateral RHS who presented to the emergency department with bilateral upper extremity pain and weakness following an unwitnessed injury. This case required a broad differential diagnosis, including musculoskeletal injury, central cord syndrome, and spinal cord injury without radiographic abnormality (SCIWORA). It underscores the importance of considering RHS in differential diagnoses, even in atypical presentations, to ensure prompt and effective management.

Jeremy Jones, OMS-II Alabama College of Osteopathic Medicine; Dr. Kamran Darabi, Hematology-Oncology BayCare Medical Group

A Caucasian male, age 58, BMI 42.7 presented to the emergency department with history of recurrent DVT starting 10 years prior. On presentation, he complained of pain both in the left popliteal area and left-sided chest that radiated to the neck. Edema of the left lower leg was found on inspection. After a bilateral Doppler study was read as positive for DVT in the left profunda femoris vein, a heparin drip was administered. The following morning, a second Doppler study was read negative in the affected limb, though the pain remained and now included the upper leg. VQ scan, ECG, CBC, electrolytes, kidney function, and INR were all normal.

Arterial study was negative for arterial thrombosis, then venous doppler was and again negative. CT venogram with contrast ruled out iliac vein and inferior vena cava thrombosis. CBC, INR, and creatinine were normal and anti-Xa was consistent with heparin administration. Notably, d-dimer testing was performed at this point, which was negative. Diagnosis was post-thrombophlebitis syndrome; the patient received outpatient follow-up with continued anticoagulation with low molecular weight heparin bridging therapy.

This case demonstrates the importance of d-dimer testing in patients suspicious for DVT. Both the high index of suspicion in the Wells score of pretest probability accompanied by the D-dimer when indicated are important in managing the relatively common but high stakes diagnosis of DVT.

The Ebstein-Barr Virus (EBV) is typically transmitted through close personal contact. It manifests as fever, tonsillar pharyngitis, and lymphadenopathy. It is also rarely complicated as hemolytic anemia, thrombocytopenia, Hemolytic uremic syndrome, and disseminated intravascular coagulation. This case report digs into the complex relationship between EBV infection and hematologic manifestations, with a focus on a patient who acquired cold autoimmune hemolytic anemia as an uncommon sequela of EBV infection. This is a 20-year-old female with a history of iron-deficiency anemia presented to the emergency department with increased fatigue and jaundice. Her labs were significant with a hemoglobin of 5.6 g/dl, a hematocrit of 18.1%, an MCV of 82.2 fl, a total bilirubin of 5.9 mg/dl, a direct bilirubin of 1.02 mg/dl, and an indirect bilirubin of 4.88 mg/dl. The haptoglobin level was less than 30, the reticulocyte count was 8.55%. EBV serology was positive, with EBV IgM greater than 160 units/mL. Direct Coombs test was positive for C3 and negative for IgG. Her cold agglutinin titer was positively suggestive of cold autoimmune hemolytic anemia. We re-emphasize the importance of checking for the evaluation of hemolytic anemia in patients with EBV infection to avoid potentially fatal consequences.

Ectopic pregnancies occur when a fertilized egg implants outside the uterus, with the majority occurring in the fallopian tube. Other sites include interstitial, cervical, ovarian, or abdominal locations. In rare cases, a fertilized egg can implant in the uterine wall, separate from the uterine cavity and fallopian tubes. This rare pregnancy is known as an intramural pregnancy and is considered unsustainable and potentially life-threatening. Confirmation of an intramural pregnancy is challenging, and management strategies differ with severity of presentation, average gestational age, and viability. In this case study, we present a case of intramural pregnancy found in a 35-year-old woman in which there was difficulty reaching the correct diagnosis but through collaborative team efforts, which included the patient herself, was finally diagnosed and managed.

Rheumatoid arthritis (RA) is a chronic autoimmune disease that can affect various organ systems, including the lungs. Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a serious extra-articular manifestation that can significantly impact morbidity and mortality. We present the case of a 61-year-old female with a history of congestive heart failure, former smoker, and advanced pulmonary fibrosis, who was on 2-5 liters of home oxygen. She presented to the hospital with worsening shortness of breath and increased work of breathing. On admission, her oxygen requirements escalated to 7-10 liters per minute to maintain a SpO2 greater than 92%. The patient had known seropositive RA but had been lost to follow-up before initiating treatment. During her hospital stay, she was treated with empiric antibiotics, diuretics, steroids, and immunomodulator treatment was started with Mycophenolate. Despite these interventions, her oxygen needs remained unchanged, reflecting end-stage ILD. This case highlights the severe consequences of untreated autoimmune disease, particularly in patients with RA. Early diagnosis and treatment of RA are critical to preventing irreversible lung damage. The progression to end-stage RA-ILD in this patient underscores the importance of regular follow-up and timely intervention. Untreated RA can lead to life-threatening complications, severely affecting the quality of life and long-term outcomes. This case serves as a reminder of the need for vigilance in managing autoimmune diseases to prevent such debilitating outcomes.

Guillain-Barré syndrome (GBS) is becoming a more prominent sequelae of COVID-19 infection with different subtypes manifesting with distinct clinical features and development of specific anti-ganglioside antibodies in serum. Here we present a rare case of double seropositivity in an 86-year old male with a history of recently treated small bowel obstruction who developed worsening quadriparesis with diminished sensation and hyporeflexia. Upon workup, labs and imaging and history of COVID-19 infection four weeks prior with his neurological symptoms suggested the development of acute inflammatory polyneuropathy (AIDP) subtype of Guillain-Barré syndrome. CSF analysis demonstrated albuminocytological dissociation consistent with AIDP or GBS, and he was treated with intravenous immunoglobulin (IVIG) with minimal improvement of his symptoms. Antibody titers were measured, finding positive Anti-GM1 IgG and Anti-GD1b IgG titers. His hospital course was complicated by the development of encephalopathy and hyponatremia likely related to course of IVIG that with stabilization and correction, along with involvement of physical and occupational therapy, did not improve his bilateral upper and lower extremity weakness and sensory deficits, thus requiring outpatient long-term acute care. We review current literature of cases with double seropositivity and their possible implications on patient prognosis as well as avenues for further research into this rare yet growing potential outcome of COVID-19 disease.

A 51-year-old female presented to the clinic with worsening persistent and involuntary spasm of head and neck muscles that included a right head tilt, decreased cervical rotation and rhythmic twisting of the chin to the right laterally. The patient presented with significant medical history for anxiety, tremors, and depression. She stated her biological mother has had a similar presentation of symptoms for several years. Our patient was prescribed medications to treat her comorbid conditions. These included Fluoxetine, Gabapentin and Mirtazapine. It appears the use of Prozac and gabapentin exacerbated her symptoms of cervical dystonia. To alleviate the persistent symptoms, this case report aims to discuss how several drugs can worsen dystonia as well as how the use of onabotulinumtoxinA (Botox) or Botolinum toxin A can alleviate cervical dystonia symptoms.      

A 67-year-old male presented to our clinic with a history of severe pain, persistent involuntary spasm of neck and upper back muscles with accompanying forward head tilt and decreased cervical range of motion bilaterally. His past surgical history was significant for anterior cervical spine fusion C6-T1 and posterior spine fusion C4-T3 to correct his medical history of cervical myelopathy and degenerative disc degeneration. Botox was used to help the history of spasm, anterior head tilt, decreased cervical rotation and severe pain. This report aims to analyze the background behind anterior and posterior cervical spine fusion surgery, its potential complications, and offer an insight on how Botox can help solve similar clinical cases.

We present a case of a 64-year-old male who developed Guillain-Barré syndrome (GBS) following a recent COVID-19 infection. Eighteen days after contracting COVID-19, the patient began experiencing progressively worsening bilateral upper and lower extremity paresthesia, numbness, and significant gait instability. Despite empirical supplementation with B12 and thiamine, his neurological symptoms persisted without improvement. A detailed neurological evaluation, including lumbar puncture, revealed albuminocytological dissociation, consistent with GBS. The patient was started on intravenous immunoglobulin (IVIG) therapy. Initially, he was admitted to our hospital for chest pain secondary to multivessel coronary disease and subsequently transferred to UAB for urgent coronary artery bypass grafting (CABG). However, given the severity of his weakness due to post-COVID GBS, the cardiothoracic surgeons deemed him too debilitated for surgery at that time and referred him for intensive physical therapy rehabilitation to improve his mobility and optimize him as a future surgical candidate. This case highlights the far-reaching effects of COVID-19, with complications extending beyond the respiratory system to involve the peripheral nervous system. It also underscores the critical need to recognize and manage post-infectious syndromes like GBS, which can significantly alter a patient’s overall treatment plan and recovery trajectory.     

Drug-induced liver injury (DILI) has a relatively low incidence, and it is considered to be a diagnosis of exclusion. Amoxicillin-clavulanic acid (Amoxiclav) is one of the most prescribed antibiotics worldwide because of its large spectrum of action. It is known to cause DILI in some patients. We report a case of a 68-year-old female with a past medical biopsy Non-alcoholic steatohepatitis (NASH) was prescribed a 7-day course of Amoxiclav for tooth infection. She developed generalized weakness and generalized jaundice while on her antibiotics. On admission, her total bilirubin was elevated at 6.7, direct bilirubin of 2.9, alkaline phosphatase 239, Alanine transaminase 182, and Aspartate transaminase 201. Her bilirubin and liver enzymes trended down after the discontinuation of antibiotics. This case highlights the importance of monitoring liver function in patients prescribed Amoxiclav, particularly those with underlying liver conditions such as NASH. This case contributes to the growing literature on DILI and underscores healthcare providers need to consider the patient history, especially regarding liver health when prescribing common medications. Given the widespread use of Amoxiclav, further research is warranted to understand its hepatotoxic potential better and to develop guidelines for safer prescribing practices in patients with pre-existing liver conditions.       

Pasteurella multocida is a gram-negative coccobacillus typically transmitted to humans through bites or scratches from cats and dogs. While it is uncommon, this organism can cause serious conditions such as osteomyelitis, sepsis, meningitis, and septic arthritis, particularly in immunocompromised patients. The most common pathogens associated with prosthetic joint infections include coagulase-negative Staphylococcus, Staphylococcus aureus, Streptococcus, and anaerobes, with an incidence rate of approximately 1%. In this context, Pasteurella multocida represents an even rarer cause. We report a case involving a 73-year-old male who developed a knee prosthetic infection due to Pasteurella multocida, which was further complicated by bacteremia. This case underscores the need for awareness among patients with prosthetic joints about the potential risks associated with animal interactions, emphasizing the importance of seeking urgent medical care following bites or scratches. Additionally, recognizing the potential for infections caused by Pasteurella multocida is critical for guiding appropriate antibiotic therapy and preventing clinical deterioration.         

Greeshma Thomas MD, Nabeel Siddique MD, Benjamin Easow MD, Tijin Mathew MD, Lydia George MD       

Tijin Mathew MD, Mohamad A Khedari MD, Lydia George MD, Benjamin Easow MD, Greeshma Thomas MD, Namitha Thotli MD, Rowan Bandaranaike MD, Tehmina Zafar MD 

Primary retroperitoneal non-Hodgkin lymphoma (NHL) is considered sporadic, difficult to diagnose, and has atypical presentation. NHL typically presents with non-tender peripheral lymphadenopathy. Very uncommonly it may present with abdominal swelling and obstructive symptoms of the respiratory and GI tracts. However, there are only a few reported cases of primary retroperitoneal lymphoma and among them most of them were diffuse large B cell lymphoma Here we present a 54-year-old male who presented to the emergency department with abdominal swelling for the past 4 months. The CT abdomen and pelvis were concerned for massive retroperitoneal and mesenteric adenopathy with some volume ascites. He underwent an IR-guided retroperitoneal lymph node biopsy. Given his pleural effusion on the CT abdomen and pelvis a CT chest was ordered which showed loculated left-sided pleural effusion and trace pleural effusion on the right side. His biopsy results of the lymph nodes revealed Follicular lymphoma. This case highlights the atypical presentation of follicular lymphoma, and that lymphoma should be considered in the differential diagnosis when a patient presents with pleural effusion or ascites even though the patient might not have any B symptoms. Because of the indolent, follicular lymphoma is often diagnosed when a patient presents with obstructive symptoms and other complications like peritoneal carcinomatosis. Early diagnosis and treatment will offer good clinical outcomes.

Median arcuate ligament syndrome (MALS) is a rare but significant condition that severely impacts the quality of life of affected patients, often presenting with symptoms such as nausea, vomiting, and postprandial abdominal pain. The syndrome arises when the median arcuate ligament, a continuation of the posterior diaphragm passing over the aorta, compresses the celiac artery if positioned too low. This compression can lead to abdominal pain, particularly after eating. Despite the clear association between celiac artery compression and symptoms, MALS is frequently overlooked as a diagnosis in patients with unexplained abdominal pain. It should be considered in the differential diagnosis, especially when other causes of postprandial pain have been ruled out. We present the case of a 54-year-old female patient with a 6-year history of nausea, vomiting, and abdominal pain after meals. The patient underwent multiple extensive workups over the years but remained undiagnosed until an interventional radiology (IR) angiogram confirmed MALS. She was  managed with successful laparoscopic celiac artery decompression, currently the preferred treatment method. Early recognition and surgical intervention for MALS can significantly improve patient outcomes and quality of life.  

Diabetic ketoacidosis (DKA) is a life-threatening complication of both type 1 and type 2 diabetes, often exacerbated by stress, infections, and other factors. Managing DKA in end-stage renal disease (ESRD) patients undergoing hemodialysis presents unique challenges, particularly in anuric patients, as standard DKA management protocols such as aggressive fluid resuscitation and potassium supplementation can be hazardous for these patients and must be avoided. These patients do not lose fluids through osmotic diuresis as typical DKA patients do, so their management focuses more on correcting acidosis and maintaining cardiac stability. This case highlights the distinct pathophysiology and management of DKA in a 53-year-old female, hemodialysis-dependent patient with a history of type 2 diabetes mellitus, who developed DKA following a hemodialysis session. Treatment included a slower rate of insulin infusion, cautious fluid replacement, and bicarbonate infusion to correct acidosis. While treatment recommendations for this patient cohort are less established, they follow logically from an understanding of the fascinating underlying pathophysiology. This case highlights the complexity of DKA management in hemodialysis patients, emphasizing the need for personalized strategies and further research to optimize care.             

Hyperglycemia is known to lead to poor outcomes in hospitalized patients, especially those who are critically ill. Propofol, a common anesthetic used in the ICU (intensive care unit), may cause hyperglycemia by inducing insulin resistance, reducing insulin-stimulated glucose uptake in muscles, and attenuating insulin-mediated suppression of hepatic glucose. We presented a case of a 58-year-old female who was admitted for sepsis secondary to cellulitis but required intubation for respiratory failure; she was provided propofol for sedation and went on to develop propofol-induced hyperglycemia. This is one of the few documented human cases that demonstrates the association between propofol and hyperglycemia. There are animal-based studies that demonstrate this effect as well. This case report highlights the fact that propofol-induced hyperglycemia should be a consideration when deciding sedation strategies in critically ill patients.

A large, mobile, right atrial (RA) thrombus is a medical emergency requiring timely management. The optimal therapeutic approach for patients with intracardiac thrombi with high risk of embolization, especially asymptomatic pediatric patients, remains unclear. 

An 8-year-old, 24.2 kg male with Hodgkin’s lymphoma was found to have a large, mobile RA thrombus associated with port-a-cath on routine pre-chemotherapy echocardiogram. Given the risk of catastrophic pulmonary embolization, he was emergently admitted to the pediatric cardiac intensive care unit and started on heparin and alteplase but developed anaphylaxis to alteplase. He was then referred for thrombectomy. Transthoracic echocardiogram (TEE) demonstrated a large, mobile, echogenic mass measuring 15 x 21 mm attached to the RA free wall via a narrow stalk. The large mobile portion of the thrombus was removed using the novel ONO retrieval system while a significantly smaller portion of the thrombus remained and was revealed to be strongly adherent to the Eustachian valve. This remaining portion was deemed unlikely to embolize and treated with medical management.

The novel ONO retrieval system offers an improved approach for transcatheter thrombectomy. Partial percutaneous thrombectomy using the ONO retrieval system successfully prevented fatal consequences of embolism and need for invasive cardiac surgery. Although the entirety of the patient’s thrombus was not removed, the patient went from high to low risk of embolization following the procedure. This case describes the youngest and smallest patient to date to safely undergo thrombectomy using the ONO device.

Authors:

Catatonia is a very serious neuropsychiatric syndrome, including a wide range of behavioral and motor symptoms. Traditionally, it is associated with schizophrenia, though currently, it is perceived as a potential manifestation of various psychiatric disorders and substance-induced disorders. A subtype, clozapine withdrawal-induced catatonia, is recognized in the literature but is not well-researched. In this subtype, there is a partial comprehension regarding the pathophysiology, and treatment options are not well validated. This case report describes a 49-year-old male patient with a history of schizophrenia who developed catatonia following abrupt cessation of clozapine medication. Initial treatments by risperidone and lorazepam did not improve his condition, while re-establishment of clozapine medication significantly improved the patient’s condition. This case illustrates the importance of medication adherence to prevent severe neuropsychiatric sequelae and further highlights a need for further research into the treatment methodology of this condition.

This case emphasizes the importance of recognizing atypical presentations in autoimmune diseases, particularly when hallmark symptoms like Raynaud’s phenomenon are absent. The patient’s significant gastrointestinal involvement and overlapping fibromyalgia required a comprehensive and multidisciplinary management strategy. Ongoing surveillance for systemic complications, such as pulmonary hypertension and malignancies, remains critical for long-term care. This case demonstrates the necessity for clinicians to maintain a broad differential when assessing patients with vague and overlapping symptoms, and the need for individualized treatment approaches in complex autoimmune disorders.          

Single coronary arteries are rare anatomic phenomena that have the potential for serious consequences. An 18-year-old female was referred to our institution for further evaluation following a computed tomography angiogram that was concerning for a single coronary artery. Selective coronary angiography demonstrated a single, large caliber right coronary artery (RCA) arising from the right sinus of Valsalva that followed a normal course in the right atrioventricular groove and wrapped posteriorly to supply both a rudimentary posterior descending artery and a rudimentary left anterior descending (LAD) artery, which arose from the proximal portion of the RCA and followed a transseptal course. The LAD appeared to travel intraseptally, diving into the conal septum but not becoming epicardial, with its territory being supplied by collateral arteries from a large conal branch of the RCA. Notably, a small circumflex artery was seen filling retrograde from collateral vessels originating from the RCA. The left and noncoronary sinuses demonstrated no evidence of a coronary os or remnant.

Given the lack of evidence-based guidelines, the optimal therapeutic approach for patients with single coronary arteries remains unclear. Clinical presentation is highly variable, and management is complicated by the limited literature reporting all anatomical variations of single coronary arteries. In 1979, Shirani and Roberts established a classification scheme to account for every possible anomalous coronary artery anatomy. Although many of these patterns have been reported, some have not. This case describes the youngest patient reported to have a Shirani-Roberts type IIC3 single right coronary artery.

Reminders of mortality result in subconscious behavioral strategies that help us cope with the emotional discomfort of our own mortality. These behavioral changes involve an individual increasing adherence to their own world views while rejecting alternative views. In a medical setting where mortality reminders are common, this effect could lead to ineffectual team dynamics and negatively affect patient care. In this study, we sought to investigate the effect of mortality cues on healthcare students’ perceptions of their interprofessional colleagues during a clinical training event. 

This study supports prior research on the mortality priming effect and extends it into the realm of interprofessional healthcare education. These findings suggest that mortality cues often present in healthcare settings could affect medical team member perceptions of each other and alter team dynamics. Students training for healthcare professions should be provided with curricular content on mortality topics which has been shown to decrease the non-conscious behavioral effects of mortality cues.

Adenoid cystic carcinoma (ACC) is an exceptionally rare malignant tumor, representing less than 0.1% of all breast cancers. Characterized by glandular proliferation, stromal involvement, and a prominent basement membrane, ACC typically arises in salivary glands and is often classified as low-grade and triple negative. This case report discusses a 68-year-old female who presented with an abnormality detected during routine mammography. Following the identification of the lesion, she underwent mastectomy with sentinel lymphadenectomy. Pathological evaluation confirmed a diagnosis of invasive adenoid cystic carcinoma of the solid basaloid variant. Due to the rarity of this malignancy, treatment approaches vary widely, complicating standardization of care. This report aims to highlight the current treatment protocols while also discussing recent advances in the management of ACC, contributing to the understanding of this uncommon breast cancer variant and informing clinical practice. Our findings underscore the importance of early detection and tailored treatment strategies for optimizing outcomes in patients with this unique malignancy.      

A 51-year-old woman presented with severe abdominal pain and nausea, prompting a diagnosis of acute pancreatitis, supported by elevated pancreatic enzymes and imaging. During the workup, critical thrombocytopenia was incidentally discovered, leading to a diagnosis of thrombotic thrombocytopenic purpura (TTP), confirmed by low ADAMTS13 activity. She was treated with plasmapheresis, steroids, rituximab, and caplacizumab, leading to clinical improvement. The pancreatitis is thought to be due to microvascular ischemia from TTP. This case highlights the rare but serious complication of TTP-induced pancreatitis and underscores the importance of early recognition and aggressive management of this serious and life-threatening condition.

Arginine vasopressin deficiency (AVP-D), previously known as central diabetes insipidus (CDI), arises from the impairment or absence of vasopressinergic neurons in the hypothalamus and posterior pituitary, leading to inadequate synthesis and/or secretion of arginine vasopressin (AVP, also known as vasopressin or antidiuretic hormone (ADH)). This results in renal water loss and an inability to concentrate urine. Diagnosis can be challenging and requires a combination of clinical and laboratory findings. Management involves pharmacological interventions such as desmopressin (dDAVP), carbamazepine, and fluid regulation. We present the case of a 26-year-old female who developed AVP-D following surgical excision of a suprasellar tumor. She initially presented with symptoms of headache, nausea, vomiting, visual disturbances, and unintended weight loss. Imaging revealed a large sellar and suprasellar mass, leading to panhypopituitarism. Despite successful tumor resection, she developed polyuria and hypernatremia, with an unusual absence of thirst response, indicative of adipsia. This case underscores the importance of prompt recognition and tailored management of AVP-D post-surgery, particularly in patients with complications such as adipsia, and emphasizes the ongoing need for careful postoperative care to minimize complications and enhance patient outcomes.

Immune checkpoint inhibitors are widely used as targeted therapies for advanced malignancies. Nivolumab, an anti-programmed cell death-1 (PD-1) receptor monoclonal antibody, is commonly prescribed for metastatic renal cell carcinoma, advanced melanoma, and non-small cell lung carcinoma, etc. While these therapies have improved outcomes, they are associated with immune-related adverse events (irAEs). We present a case of a 69-year-old female with metastatic renal carcinoma who developed secondary adrenal insufficiency after receiving nivolumab. The patient had a history of long-standing hypertension, which had previously required multiple antihypertensive agents for optimal control. Following her first infusion of nivolumab, she was noted to have hypotension. Her hypotensive episodes led to multiple Emergency Department visits and hospitalizations. Endocrinologic evaluation revealed suboptimal adrenal function, confirmed by adrenocorticotropic hormone (ACTH) and corticotropin-releasing hormone (CRH) testing. Given evidence of adrenal insufficiency, nivolumab was subsequently discontinued, and the patient was started on fludrocortisone, and hydrocortisone which stabilized her blood pressure and improved her symptoms. This case underscores the potential for immune-mediated inflammation, such as adrenalitis, in patients receiving immune checkpoint inhibitors. The resulting damage to the adrenal glands can lead to adrenal insufficiency, impairing cortisol production. These rare but potentially life-threatening side effects of Nivolumab must be considered when initiating patients on this therapy.

A seven-year-old female presented with a purpuric rash, painful joints, and a recent history of streptococcal pharyngitis. Initial symptoms included fever, throat pain, and vomiting, which were treated with amoxicillin. Following treatment, the patient developed a rash and joint pain, leading to further evaluation. Physical examination revealed erythematous, edematous, and purpuric lesions on the extremities, along with periarticular swelling in the knees and ankles. Laboratory findings were significant for hematuria, prompting a differential diagnosis that included IgA vasculitis, acute urticaria, acute glomerulonephritis, and idiopathic thrombocytopenic purpura. Treatment included switching antibiotics to azithromycin and initiating prednisolone. Despite initial treatment, the patient returned with worsening symptoms, including new lesions, fatigue, and abdominal pain. Hospital admission for close monitoring and treatment was recommended but declined by the patient's mother, who opted for care at a different facility. This case highlights IgA vasculitis in pediatric patients and the management and treatment of this rare condition.

A comprehensive medical and drug history is critical for identifying potential causes of pulmonary toxicity, particularly with long-term nitrofurantoin use. Chronic pulmonary toxicity, although rare, typically occurs in older women prescribed nitrofurantoin for urinary tract infection (UTI) prophylaxis. This case report presents an 85-year-old female with a history of atrial fibrillation and recurrent urinary tract infections (UTIs), who was admitted for worsening shortness of breath (SOB) and a non productive cough over two weeks. She had been on prophylactic nitrofurantoin for five weeks due to frequent UTIs. Initial evaluation revealed moderate hypoxemia with bilateral interstitial infiltrates on imaging, suggestive of interstitial lung disease or pneumonia. A diagnosis of nitrofurantoin-induced pneumonitis was made based on a negative infectious workup, clinical presentation and radiographic findings. Despite appropriate management with IV steroids, antibiotics, and Optiflow, the patient’s respiratory status deteriorated, leading to development of a spontaneous pneumothorax. The patient then developed right arm weakness, brain MRI revealed diffuse bilateral infiltrates in the frontoparietal and occipital lobes. The patient had been on xarelto without lapse in treatment. The family opted for comfort care measures and the patient passed away shortly after discontinuing oxygen support. This case highlights the importance of early diagnosis and prompt cessation of nitrofurantoin to prevent progression of the disease.

Benjamin M Easow, MD, Abinaya Sivakumar, MD, Motunrayo Adeleye, MD, Fnu Anshul, MD, Chandra Kodavanti, MD

Nasogastric (NG) tube insertion, first introduced by Dr. Levin in 1921, is a widely used procedure for stomach decompression in cases of obstruction or ileus, or for delivering nutrition and medications in patients unable to tolerate oral intake. Though minor adverse effects like discomfort, sinusitis, and epistaxis are common, severe complications are rare. This report highlights a life-threatening complication following NG tube placement.  An 81-year-old female developed pneumomediastinum and soft tissue emphysema after the NG tube perforated the left piriform sinus, leading to air leakage into the central mediastinum. A chest X-ray revealed mediastinal air and neck soft tissue emphysema, which were confirmed by a chest CT scan. An esophagogastroduodenoscopy (EGD) showed esophageal webs in the distal esophagus. The NG tube was promptly removed, and the patient was managed conservatively with broad-spectrum antibiotics. A multidisciplinary team, including intensivists, gastroenterologists, and general surgeons, was involved in her care. This approach led to significant clinical improvement.  This case underscores the potential dangers of NG tube insertion, particularly in elderly patients, whose anatomical or functional vulnerabilities may heighten the risk of complications. It emphasizes the importance of meticulous technique during tube placement and the need for immediate evaluation and imaging when complications arise, as untreated pneumomediastinum can be fatal. Early recognition and appropriate management are essential to improving patient outcomes.

Chronic Lymphocytic Leukemia (CLL) and Chronic Myeloid Leukemia (CML) are commonly diagnosed in the elderly, with CML patients being more susceptible to secondary malignancies. While CLL is characterized by mature lymphocyte proliferation, CML is a myeloproliferative disorder driven by the BCR-ABL gene. The coexistence or sequential occurrence of these diseases is rare. We present a 64-year-old male with a history of stage 2a squamous cell carcinoma, prostate cancer on Eligard, and leukocytosis. He was initially diagnosed with CML, confirmed via positive BCR-ABL rearrangement on FISH, and managed with bosutinib. After two years, a colonoscopy revealed an ascending colon mass positive for CLL. Treatment with Dasatinib led to a major molecular response and significant improvement in leukocytosis. He remains under monitoring for CLL. This case underscores the importance of considering coexisting or subsequent malignancies in patients with CML.

Mixed connective tissue (MCTD) is a rheumatic disease syndrome with clinical features of rheumatic disease, systemic lupus erythematosus (SLE), scleroderma, and polyangiitis. Scleroderma is not only a rare multi-system immune disorder but also a severe complication that can occur in MCTD. Here we present a case of MCTD with chronic features of rheumatoid arthritis, pulmonary embolism, and recent dysphagia complicated with scleroderma renal crisis. Patient is a 45 year old hispanic male with a recent diagnosis of MCTD 3 months back and dysphagia with PEG tube placement who presented with complaints of worsening abdominal pain, nausea and vomiting for 1 week. Labs were remarkable for BUN of 64 mg/dL, S. creatinine of 4.19 mg/dL, potassium of 3.6, sodium of 127, hemoglobin 11 g/gl, wbc of 4200 cells/uL with left shift. Urinalysis showed 1+protein, 1+blood, RBC count 1/HPF and trace ketones. Urine protein creatinine ratio was 3373 mg/g, urine creatinine was 49 mg/dL and urine sodium was 59 mmol/L. FeNA was 4.2% suggesting intrinsic renal injury. He was initially started on iv fluids and antibiotics. However his condition deteriorated and he subsequently had to be started on SLED. His serology was remarkable for MPO and anti-PR3 antibodies, p-ANCA of 1:640 and c-ANCA 1:80. Renal biopsy was carried out once the patient stabilized which showed thrombotic angiopathy. He was subsequently started on captopril for scleroderma renal crisis.    

This case involves a 70-year-old female with a history of triple-negative breast cancer (TNBC) diagnosed in March 2018, who developed chronic esophagitis and mucosal inflammation as a result of her cancer treatment. After undergoing neoadjuvant chemotherapy, left mastectomy, and radiation therapy, the patient achieved remission. However, in early 2020, a metastatic liver lesion was detected, and she was treated with Abraxane (nab-paclitaxel) and the immune checkpoint inhibitor Tecentriq (atezolizumab). Although initially effective, the immunotherapy led to severe gastrointestinal immune-related adverse events (irAEs), including esophagitis, mucositis, and dysphagia.  Endoscopic evaluation revealed grade 3 esophagitis with multiple strictures, necessitating frequent balloon dilations and long-term immunosuppressive therapy with corticosteroids and infliximab. Despite treatment, the patient continues to experience intermittent swallowing difficulties and requires ongoing dietary modifications and steroid therapy. Her case demonstrates the complexity of managing irAEs in patients receiving ICIs, particularly when compounded by multiple comorbidities such as chronic obstructive pulmonary disease (COPD) and chronic renal failure.  This case emphasizes the importance of balancing the efficacy of oncologic treatments with managing the significant toxicities they can induce. For this patient, immune-mediated esophagitis remains a chronic and challenging condition that requires multidisciplinary care. Close monitoring and individualized management strategies are critical to maintaining quality of life in patients facing both cancer recurrence and irAEs.

This case report describes a patient presenting with abdominal pain and distension, whose workup revealed markedly elevated triglyceride levels and an underlying diagnosis of non-Hodgkin lymphoma localized to the abdomen. While hypertriglyceridemia can be caused by various conditions, its association with blood cancers, including lymphomas, is becoming increasingly recognized. Current research suggests that patients with certain hematologic malignancies may exhibit elevated triglyceride levels due to complex mechanisms, including increased lipoprotein lipase activity in cancer cells and cancer-induced metabolic disruptions. This case highlights the importance of considering the possibility of blood cancers in patients presenting with severe hypertriglyceridemia, even in the absence of typical cancer-related symptoms. Further research is warranted to elucidate the underlying mechanisms of hypertriglyceridemia in malignancy, explore its potential as a diagnostic marker, and determine its prognostic significance in the context of hematologic cancers.

Amiodarone is a critical medication used to manage various arrhythmias, but it can lead to a range of side effects, including rare cases of neurotoxicity that may arise unexpectedly. This abstract presents a case of a patient suspected of experiencing neurotoxicity related to amiodarone use.  We describe a 69-year-old male with a complicated medical history, including atrial fibrillation treated with amiodarone, end-stage renal disease on hemodialysis, diabetes mellitus, and hypertension. He was admitted with palpitations and fatigue that began three days prior to hospitalization. Upon evaluation, the patient exhibited atrial fibrillation with rapid ventricular response (RVR) at a rate of 131 BPM and was hypotensive. Rate control was achieved with low-dose Cardizem. The patient had also been taking amiodarone 200 mg daily at home. A neurological consultation was initiated due to the presence of ataxic gait and tremors, which reportedly developed after the initiation of amiodarone two months earlier, following cardioversion. After amiodarone was discontinued, a follow-up neurological assessment the next day indicated the absence of ataxia or tremors.  This case underscores the potential neurotoxicity associated with amiodarone, a risk that, while documented, is infrequently reported in the literature. The sporadic nature of these cases complicates the identification of specific risk factors for neurotoxicity, highlighting the need for increased awareness and monitoring among healthcare providers. 

ERCP is a fundamental procedure in gastroenterology for diagnosing and managing biliary and pancreatic conditions. Despite its established utility, ERCP carries the risk of rare complications, including intestinal, perforation, pancreatitis, or hemorrhage. we present a case of a 90-year-old female who, after undergoing ERCP for suspected Choledocholithiasis, experienced a delayed complication involving a migrated pancreatic stent, causing hematochezia, revealing and undetected cecal adenocarcinoma. This case underscores ERCP complications while also highlighting the diagnostic challenges posed by concomitant pathology.

Trousseau’s syndrome (cancer-associated thrombosis) is considered to be the second leading cause of death in cancer patients. The cancer contributes to hypercoagulable condition which can result in stroke and could be the initial presentation and has received relatively little attention to the date. Arterial thromboembolism is more common in pancreatic, gastric, and lung adenocarcinoma. Gastric cancer could present with multifocal ischemic and hemorrhagic stroke. Strokes are usually seen in poorly differentiated gastric adenocarcinoma. Here we present a very well-differentiated gastric adenocarcinoma presenting with recurrent strokes.     

A 65-year-old male was recently discharged and re-admitted with new stroke-like symptoms. During his last hospitalization, he was diagnosed with a pontine stroke and DVT for which he was placed on Eliquis however he developed GI bleeding after which an IVC filter was placed. He was discharged on dual-antiplatelet agents with aspirin and Plavix. He developed another stroke-like symptoms one month later however his MRI was unremarkable for any new stroke. However, the patient developed GI bleed for which he underwent EGD which showed abnormal mucosa in the body off the stomach. The cold biopsy performed was consistent with invasive-well differentiated gastric adenocarcinoma. He was referred to oncology services and he is currently undergoing 14 cycles of FOLFOX.

Trousseau’s syndrome must be considered in those presenting with recurrent strokes with an otherwise negative embolic work-up.          

Post- ERCP pancreatitis (PEP) is the most frequent significant complication of endoscopic retrograde cholangiography (ERCP). While pancreatic duct stenting if effective in reducing PEP by ensuring pancreatic drainage, it is costly, time-consuming, and requires follow up imaging. Recently, rectal indomethacin has emerged as a promising, more affordable alternative to stenting for preventing PEP. A landmark randomised controlled trial demonstrated that rectally administered indomethacin significantly reduces the incidence of PEP. Indomethacin, an anti-inflammatory medication, works by inhibiting cyclooxygenase enzymes, thus preventing inflammatory responses that contribute to pancreatitis. It also offers better bioavailability when administered rectally. We present the case of a 50-year-old female who received pre-ERCP rectal indomethacin and underwent laparoscopic cholecystectomy without developing PEP. This case highlights the importance of indomethacin in reducing PEP and offers a safer, cost-effective preventive option.

Since the 1920s, when the flavobacterium genes were first described, there have been only 53 reported cases of Myroides infections. We present what is to our knowledge the 17th case of Myroides species causing a cutaneous infection. Our patient, a 53-year-old male with multiple comorbidities including coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), current tobacco use, poorly controlled insulin-dependent diabetes mellitus (IDDM), and hypertension, developed severe gas gangrene of the left foot, confirmed via X-ray. While blood cultures were negative, non-surgical wound cultures yielded positive results for Myroides and methicillin-resistant Staphylococcus aureus (MRSA). The patient underwent left below-knee amputation and hardware removal from previous fracture by orthopedics. He received intravenous vancomycin and ciprofloxacin during hospitalization, later transitioning to oral doxycycline and ciprofloxacin for a total of four weeks, per infectious disease recommendations. Given the multidrug resistance of Myroides and its potential for fatal infections, particularly in cases of pan-resistance, it is crucial for physicians to remain vigilant about this rare pathogen.              

Dr. Li Wenliang, an ophthalmologist, was among the first in China to raise concerns about COVID-19 and tragically succumbed to the virus, possibly contracted from an asymptomatic glaucoma patient. Numerous reports have since linked COVID-19 with ocular manifestations, initially identifying conjunctivitis as the most common. However, recent findings have connected the virus with more severe conditions, including uveitic, retinovascular, and neuro-ophthalmic diseases. We present the case of a 54-year-old female with a history of hypertension, hyperlipidemia, and restless leg syndrome, who experienced sudden, painless vision loss in her left eye two weeks after testing positive for COVID-19. Notably, she reported no ocular pain, headaches, or jaw claudication. Her visual field deficit, more prominent in the lower left quadrant, initially raised concerns for giant cell arteritis (GCA). Despite an extensive workup—comprising ESR, CRP, platelets, CTA head, and MRI head—no abnormalities were detected. Ophthalmological evaluation revealed a left temporal field defect, relative afferent pupillary defect (RAPD), and mild disc swelling with flame hemorrhages, leading to a diagnosis of non-arteritic ischemic optic neuropathy (NAION), likely associated with COVID-19. She was safely discharged on aspirin and prednisone, with instructions for outpatient ophthalmology follow-up. Although the precise mechanism remains unclear, literature suggests that COVID-19 may induce complement-mediated endothelial dysfunction and microvascular damage, affecting ocular circulation through ACE-2 expressing pericytes. This case highlights the importance of recognizing neuro-ophthalmic complications in COVID-19 patients, even without severe systemic symptoms, and stresses the need for vigilance regarding potential ocular involvement.     

Metastatic cancer of unknown primary is a rare clinical entity, accounting for only 10-20% of all adenocarcinomas, where the primary tumor site cannot be identified. We present the case of a 58-year-old male diagnosed with metastatic adenocarcinoma favoring a lung origin, despite having no thoracic symptoms or radiological findings. The patient was initially hospitalized following a motor vehicle accident caused by a questionable seizure. Subsequent brain imaging revealed three right frontal lobe and cerebellar lesions, which led to a craniotomy and biopsy. Pathology confirmed poorly differentiated adenocarcinoma, with immunohistochemistry favoring a lung origin (TTF-1 and CK7 positive, Napsin positive). However, staging CT of the chest, abdomen, and pelvis was unremarkable, with no lung lesions or mediastinal abnormalities. Despite the absence of lung findings, the patient was diagnosed with metastatic adenocarcinoma of unknown primary, likely of lung origin, based on histopathology and tumor marker profiling. This case highlights the diagnostic complexity of cancer of unknown primary and underscores the importance of integrating pathological findings and tumor markers in establishing a diagnosis, even when imaging studies are noncontributory. Given the rarity of such presentations, this case adds to the limited literature on metastatic adenocarcinoma of unknown origin, particularly of lung primary, and emphasizes the challenges in early identification and management.                     

Pembrolizumab, a monoclonal antibody targeting PD-1, has revolutionized cancer treatment by enhancing anti-tumor immunity. Despite its effectiveness, pembrolizumab can induce immune-related adverse effects (irAEs), including rare cutaneous reactions such as lichenoid dermatitis. This report presents a case of a 67-year-old female with stage IV lung adenocarcinoma who, after receiving carboplatin, pemetrexed, and pembrolizumab, developed a pruritic rash that evolved into nodular, scab-forming lesions. A biopsy confirmed lichenoid dermatitis. The rash responded to treatment with systemic prednisone, topical triamcinolone, and antihistamines. Following imaging that revealed disease progression, pembrolizumab was discontinued, and the patient was switched to docetaxel and ramucirumab. This case highlights the need for timely recognition and management of lichenoid dermatitis as an irAE of pembrolizumab, emphasizing that while corticosteroids are often effective, alternative treatments may be necessary for steroid-resistant cases.

GDF is a rare endoscopic finding that is associated with congenital abnormalities, H. pylori, and peptic ulcer disease. Acquired GDF is treated with anti-ulcer therapy. Surgical intervention is indicated for refractory symptoms like recurrent ulcers and bleeding despite adequate medical therapy.   

Adult epiglottitis is a potentially life-threatening condition characterized by inflammation and swelling of the epiglottis, often leading to airway obstruction. This case underscores the importance of early recognition of epiglottitis symptoms, timely airway management, and appropriate antibiotic therapy. There are reported incidences ranging from 0.1 to 1.3 cases per 100,000 people annually. 

The increased incidence of infections due to non-typeable strains of Haemophilus influenzae, as well as other pathogens like Streptococcus pneumoniae and Staphylococcus aureus, highlights the need for heightened awareness among healthcare providers. This emphasizes the need for increased awareness of this condition in adults, particularly in the context of atypical presentations and underlying risk factors, to prevent serious complications.

Male breast cancer is a rare disease, accounting for approximately 1% of all breast cancers diagnosed in the United States. The most common histological types in men include invasive ductal carcinoma and ductal carcinoma in situ. Here, we report the case of a 45-year-old male who presented with discoloration and pain in the left nipple. Subsequent evaluation and surgery revealed invasive grade 2 ductal carcinoma with a minor component of ductal carcinoma in situ. The patient underwent left mastectomy with sentinel lymph node biopsy, confirming the absence of nodal metastasis (pT1c pN0). All surgical margins were free of carcinoma by over 5 mm. Immunohistochemical analysis showed estrogen receptor (ER) positivity (>95%), progesterone receptor (PR) positivity (20%), HER2/neu negativity (1+), and a Ki-67 index of 10%. Although chemotherapy was recommended, the patient opted to decline. Genetic testing identified mutations in the RET and WRN genes. The patient was subsequently started on adjuvant tamoxifen therapy. This case underscores the importance of early diagnosis and individualized treatment in male breast cancer, emphasizing the role of hormone receptor status and genetic profiling in guiding management decisions.           

Candida auris is an emerging multidrug-resistant yeast that poses a global health threat, particularly in critically ill patients with prolonged hospital stays, multiple comorbidities, and prior exposure to antibiotics or antifungal medications. We present a case of a 78-year-old male who was readmitted following a 44-day stay in the ICU for septic shock. He presented with excessive bleeding from the right lower extremity, which was managed with epinephrine injection and supportive care, including blood transfusion for a hemoglobin level of 6.5 g/dL. His clinical course was complicated by persistent fevers, and blood cultures later revealed Candida auris fungemia. Infectious Disease (ID) specialists were consulted, initiating micafungin and recommending further evaluation, including transthoracic echocardiography (TTE) and ophthalmology assessment. A non-diagnostic TTE prompted a transesophageal echocardiogram (TEE), which confirmed tricuspid valve vegetation consistent with Candida-related endocarditis. Given the patient’s advanced age, multiple comorbidities—including atrial fibrillation, intellectual disability, and a recent colon perforation with colostomy—he was deemed unfit for surgical valve replacement. The ID team recommended lifelong antifungal therapy with micafungin. Despite aggressive management, the patient’s condition deteriorated, leading to intensive care unit (ICU) admission for MRSA pneumonia. He was also initiated on IV Vancomycin and Cefepime. Due to poor prognosis, following discussions with the family, he was transitioned to comfort measures and subsequently passed away.  This case underscores the rare but severe presentation of Candida auris fungemia complicated by endocarditis and highlights the challenges in its management, especially in high-risk, comorbid patients.    

Labile hypertension, characterized by unpredictable fluctuations in blood pressure, can be challenging to diagnose and manage. This case report presents a 65 years-old male with persistent labile hypertension unresponsive to conventional antihypertensive therapy. Biochemical evaluation revealed normal plasma metanephrines; however, normetanephrines were significantly elevated, prompting further investigation. Imaging studies identified an adrenal adenoma, raising the likelihood of intermittent catecholamine secretion as the underlying cause of the patient’s blood pressure variability. This case highlights the importance of considering adrenal adenomas in the differential diagnosis of labile hypertension, even in the presence of normal metanephrines but significantly elevated normetanephrines. Early detection and appropriate management are essential in preventing adverse cardiovascular outcomes associated with labile hypertension. 

Propionic acidemia, caused by a deficiency of propionyl-CoA carboxylase, is typically diagnosed in the neonatal period, with an incidence of 1 in 100,000 newborns. However, rare cases, such as our patient’s, present later in life.  This report describes a 33-year-old female with propionic acidemia admitted with altered mental status after multiple episodes of vomiting following a recent flu infection. A multidisciplinary team involving specialists in gastroenterology, nephrology, neurology, and critical care managed her care. Upon admission, she presented with significant high anion gap metabolic acidosis (HAGMA) and hyperammonemia. She was started on a bicarbonate drip with D10. Her condition worsened with non-convulsive seizures and encephalopathy, requiring intubation for airway protection. A thorough workup, including transthoracic echocardiogram (TTE) and lumbar puncture (LP), was unremarkable. EEG showed nonspecific toxic-metabolic/hypoxic encephalopathy without epileptiform activity. MRI revealed diffuse gyral swelling, restricted diffusion, and T2 hyperintensity in the cortex and basal ganglia. She was started on a 40-60 g protein diet supplemented with propimex formula. L-carnitine 1500 mg TID was initiated to enhance the excretion of toxic acylcarnitine conjugates. Lactated Ringer’s (LR) solution was avoided due to her organic acidemia. Despite these interventions, her condition declined, and a follow-up CT scan revealed diffuse cerebral edema, effacement of sulci and basal cisterns, cerebellar tonsil herniation, and suspected pseudo-subarachnoid hemorrhage. The patient eventually passed away after being transitioned to comfort measures, as surgical intervention was not viable.  This case emphasizes that less severe forms of propionic acidemia can present later in life, with metabolic crises triggered by stressors, leading to severe neurological outcomes, coma, and death, as seen in this patient.            

Human Immunodeficiency Virus positive patients have a compromised immune system normalized through highly active antiretroviral therapy (HAART). Immune reconstitution inflammatory syndrome (IRIS) is a complication that may result in autoimmune diseases. Though the occurrence of Graves disease in such circumstances is well recognized, we will look at a rare case of an HIV-positive patient testing positive for both Hashimoto’s thyroiditis and Graves disease after therapy. We present a case of a 36-year-old male, is HIV positive and consistently on HAART. Routine evaluation in August 2023, revealed undetectable TSH levels less than 0.01, free T3/ free T4 were not checked at the time. Though scheduled, extensive testing was not done. The patient was asymptomatic at the time but has since developed several symptoms consistent with hyperthyroidism including easy fatigability, generalized weakness, palpitations, tremors, and 20-pound weight loss since December 2023, along with obvious goiter and bulging of his eyes. Extensive testing revealed positive for both Graves disease and Hashimoto’s Thyroiditis. The case highlights the complex relationship between HIV, antiretroviral therapy, and autoimmune thyroid disorders. The successful immune reconstitution brought on by HAART resulted in autoimmune responses due to IRIS. Though rare, the combination of the emergence of Hashimoto’s thyroiditis and Graves's disease shows how immune recovery can make individuals more prone to multiple thyroid disorders simultaneously, indicating the need for careful monitoring of thyroid function in HIV patients undergoing therapy.  

Shprintzen Syndrome is a type of 22q11.2 deletion syndrome also known as velocardiofacial syndrome, characterized by combination of craniofacial anomalies including cleft palate, facial dysmorphism associated with various congenital heart defects.  We present a case of 37 year old female with elevated BMI 52 and PMH of Shprintzen Syndrome, ASD, PDA s/p repair, atrial flutter s/p ablation, cleft palate, sleep apnea, COPD, chronic hypocalcemia, hypothyroidism presented with concerns for seizure-like activity. A CT head and EEG was done which had no acute findings. On admission, she was found to have electrolyte dysfunction with corrected calcium levels 5.5 which was not adequately replaced. Few hours after admission a code blue was called and the patient was found to be potentially seizing and was intubated for airway protection. As per neurology the patient’s history and eeg was consistent with non epileptic seizures. On additional investigation, the mother reported that the patient had severe diarrhea at the time of admission which could have led to severe electrolyte depletion. During the hospital course the patient’s ionized calcium levels remained persistently low and was repleted daily. Further workup included TSH, PTH, vitamin D levels, phosphate, urine calcium/creatinine levels were within normal limits. The patient had no repeated seizure-like episode and later on discharged on appropriate calcium supplements.  So we conclude that healthcare providers must remain vigilant in replacing calcium levels in patients with a history of Shprintzen Syndrome even if the PTH levels are normal. Especially in stressful situations like infection as they are more prone to developing hypocalcemic symptoms compared to normal individuals.        

Benzocaine (ethyl aminobenzoate) is widely used as a topical oropharyngeal anesthetic during transesophageal echocardiography (TEE). Although generally safe, benzocaine has been rarely associated with methemoglobinemia, a potentially life-threatening condition. We report the case of a 31-year-old female with a complex medical history, including morbid obesity, asthma, diabetes mellitus, and hypertension, who presented with a draining left gluteal abscess, fever, and shortness of breath. Blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA), and chest CT revealed scattered septic emboli in both lungs. She was admitted to the ICU and started on IV cefepime, vancomycin, and metronidazole. After undergoing abscess debridement, a transthoracic echocardiogram (TTE) was performed but was non-diagnostic, prompting a TEE. Following TEE, the patient developed asymptomatic severe hypoxemia, requiring 100% oxygen via a non-rebreather mask. Arterial blood gas (ABG) revealed a methemoglobin level of 31%, likely secondary to benzocaine exposure. Her oxygen saturation improved after administration of methylene blue. This case highlights the importance of considering benzocaine-induced methemoglobinemia in patients undergoing TEE who develop unexplained hypoxemia, especially when high-risk comorbidities are present. Early recognition and treatment are essential to prevent life-threatening complications.

It’s important to determine FUO especially if caused by immunological disease. The earlier HIV is detected and treated, the better the outcome for the patient

Salicylate toxicity is a rare but serious cause of pulmonary disorders, including acute respiratory distress syndrome and pulmonary edema. We report the case of a 39-year-old female who presented with a 3-day history of shortness of breath and productive cough and was subsequently found to have hypoxia and chest imagining that revealed diffuse bilateral ground-glass infiltrates. Upon further inquiry, it was discovered that the patient had been consuming excessive amounts of BC Goody Powder, an over-the-counter salicylate, to manage her chronic musculoskeletal pain. This history, combined with the rapid improvement of pulmonary infiltrates following hospital stabilization, pointed towards salicylate toxicity as the underlying cause. The patient was advised to discontinue all salicylate use. This case highlights the rare but serious potential for salicylates to cause pulmonary complications and emphasizes the necessity of considering this etiology in patients with a history of over-the-counter analgesic use.

Breast cancer treatment and prevention utilizes tamoxifen, a nonsteroidal nonselective estrogen receptor modulator. Long-term use of tamoxifen has been documented to be associated with various hepatic dysfunctions such as fatty liver, steatohepatitis, cirrhosis, and rare instances of acute liver injury.

We present a 41 year old female with a past medical history of Stage II Ductal Breast Cancer, which was diagnosed in November 2023. The patient subsequently underwent a bilateral mastectomy and was given tamoxifen plus triple negative cancer prophylaxis. Positron emission tomography showed no recurrence following above treatment. Following nausea, vomiting, scleral icterus due to an elevated bilirubin level, and a negligible gallstone, tamoxifen treatment was discontinued in July 2024. In August 2024, the patient presented with recurrent nausea and vomiting, pruritus, worsening jaundice, weight loss, right upper quadrant pain, and back pain. Hence, she was admitted. Her bilirubin levels were found to be 16.20. Following subsequent labs and scans such as HIDA scan, MRCP, liver biopsy, anti-smooth muscle antibody test, CT L spine, MRI L spine/bilateral hips, etc., it was determined that the patient was suffering from drug induced liver injury. After initiation of steroids and ursodiol, her bilirubin measurements decreased. Patient reported resolution of symptoms a month later, with her bilirubin stabilized at 2.3. As tamoxifen-induced acute liver injury is reversible, patients on tamoxifen need frequent comprehensive labs during treatment in order to preemptively detect possible liver injury so as to proactively withdraw medication.

Introduction:

Aspergilloma is a clump of aspergillus, mucus, fibrin inflammatory cells, blood, and epithelial cells that grow in preexisting cavitations (1). Its presentation can range from asymptomatic to fatal hemoptysis (2). Aspergilloma can be often overlooked especially in cases with chronic pulmonary conditions.

Case Presentation:

A 63-year-old male with a history of pancreatic cancer, diabetes, recurrent sinusitis, recurrent pneumonia, and a lifelong smoker presented to the hospital floor in 2022 for an amputation of the right big toe due to a diabetic ulcer. During this encounter, a left upper lobe consolidation was found incidentally on a chest CT. In February 2024, the patient developed symptoms of pneumonia such as chest tightness and flu-like symptoms after not wearing his respirator mask at work as a fume technician. He was subsequently diagnosed with pneumonia and treated. Concurrently, the left upper lobe consolidation was diagnosed as Aspergilloma.

Discussion:

In a patient with multiple comorbidities such as pancreatic cancer, COPD, recurrent sinusitis, recurrent pneumonia, pulmonary aspergilloma can be a consequence due to weakened immune system and multiple lung scars. However, aspergilloma can often be overlooked and put lower on the differential in patients who show minimum respiratory symptoms. Additionally, aspergilloma may also be missed by clinicians due to failing to consider risk factors (3).

Conclusion:

Aspergilloma is a fungal infection caused by aspergillus. Lung scars, and weakened immune system are risk factors for aspergilloma. This case demonstrates the importance of being apprehensive of the development of aspergilloma in the course of patients' comorbidities treatment.

We present a case of a 60-year-old male with a history of hypertension, diverticulitis, and status post-colonoscopy with polyp removal who arrived at the ED with worsening confusion over several days. His altered mentation had persisted for weeks, leading to multiple hospitalizations, during which he was diagnosed with Cushing’s disease. His wife reported personality changes over several months, with paranoia developing about a month prior. On this admission, the patient exhibited agitation, paranoia, hypomania, and active suicidal ideation. Elevated ACTH, serum cortisol, and urinary cortisol were noted in a recent admission to an outside facility.  At our facility, a CT head was unremarkable, and a CT abdomen showed mild thickening of the adrenal limbs bilaterally, suggesting nonspecific adrenal hyperplasia. EEG showed no active seizures. Persistent leukocytosis, likely due to hypercortisolism-induced neutrophilia, was noted, with urinalysis, blood cultures, and GI panel all negative.  Cushing’s psychosis was suspected, and metabolic encephalopathy was ruled out through normal ammonia, urine toxicology, vitamin B12, BUN, copper, and B1 levels. Serum cortisol was elevated at 77, free cortisol at 4995, and ACTH at 112. MRI revealed a 3 mm pituitary lesion, likely a microadenoma.  This case highlights the unique presentation of neuropsychiatric symptoms in Cushing's disease, underscoring the diagnostic challenges in differentiating organic psychosis in hypercortisolism, which is rare and adds to the understanding of its clinical spectrum.  

We present a case of a 43-year-old female with an extensive past medical history including, but not limited to, chronic hypertension, recurrent tachycardia, recurrent syncope, relapsing-remitting multiple sclerosis, dysautonomia, and postural orthostatic tachycardia syndrome (POTS) who presented to the emergency department with hypertensive emergency and headache associated with acute visual changes. This patient had a history of multiple emergency department visits for symptoms related to hypertension, tachycardia, and syncope. However, these symptoms were often isolated and not present together, further complicating the diagnosis. These episodes were initially thought to be due to dysautonomia secondary to multiple sclerosis, POTS, or a combination of both. While POTS is typically associated with hypotension, it was thought that dysautonomia from her multiple sclerosis was likely contributing to her labile blood pressure considering the intermittent nature of her symptoms. This patient's hypertensive emergency prompted a work-up for other potential causes of her symptoms including pheochromocytoma. The initial work-up including urinary 24-hour urinary fractionated metanephrine was unremarkable, however, further investigation revealing elevated plasma free metanephrines confirmed the diagnosis of pheochromocytoma. The patient was subsequently started on phenoxybenzamine and is currently awaiting follow-up with an endocrinologist. This case report serves to raise awareness of key differentiating symptoms in the patient history such as hypertension in differentiating pheochromocytoma from other conditions with similar overlapping symptoms such as multiple sclerosis and POTS. This case also emphasizes the importance of the more sensitive test for plasma tree metanephrine in identifying pheochromocytomas.

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is characterized by increased intracranial pressure without a clear cause and in the absence of structural or obstructive abnormalities. This condition is most frequently observed in obese women of childbearing age, though it can affect others as well. Common symptoms include headaches, transient visual disturbances, and sounds within the head, with cranial nerve involvement, particularly cranial nerve VI, occurring in some cases. We present a unique case of IIH in a 31-year-old woman who displayed isolated complete unilateral abducens nerve palsy as her only neurological symptom. This presentation is notably rare and adds to the existing literature on IIH, highlighting the diverse ways this condition can manifest. Understanding these atypical presentations is essential for accurate diagnosis and management, as they may lead to delays in recognizing IIH and implementing appropriate treatment strategies.

Primary cardiac tumors are rare, and their incidence is less than 0.02 percent, with myxoma being the most common. Approximately 80% of the tumors are located in the left atrium, 7 to 10% in the right atrium, and up to 10% of cases are found as bi-atrial or in the left and right ventricles. Patients with right atrial myxoma can remain asymptomatic or may present with some constitutional symptoms, pulmonary embolism (PE), pulmonary hypertension, and or Budd-Chiari syndrome. We present a case of a 69-year-old male who was initially admitted with stroke-like symptoms. However, the patient developed tachycardia and hypoxia after the admission. His CTA chest showed moderate to large pulmonary embolus. His transthoracic echocardiography revealed an irregular isoechoic mass in the right atrium.  His mechanical thrombectomy led to the diagnosis of the right atrial myxoma. To avoid complications from atrial myxoma, early diagnosis, and surgical intervention are necessary. Clinicians should consider right atrial myxoma in their differential diagnosis of a patient presenting with pulmonary embolism and stroke.                 

This case report describes a 77-year-old female with a history of hypertrophic obstructive cardiomyopathy (HOCM) who underwent elective right and left cardiac catheterization for further evaluation. During the procedure, she experienced sudden onset of severe mitral regurgitation (MR) resulting in flash pulmonary edema, which could not be explained by her underlying physiology. Notably, she had no known risk factors, such as coronary artery disease or valvular heart disease. The occurrence of severe MR and flash pulmonary edema in this patient is not fully attributable to HOCM alone. This case highlights the need for further investigation into mechanisms by which HOCM may precipitate acute severe MR, with the potential to improve management strategies for similar presentations in the future.      

Introduction:

Case Presentation:

Discussion:

Conclusion:

This case of TTP illustrates the urgency of early recognition and treatment in preventing severe morbidity and mortality. Ongoing education about the signs and symptoms of TTP among healthcare professionals is essential to facilitate timely diagnosis.          

Introduction:

Case Presentation:

Discussion:

Conclusion:

Staph scalded skin syndrome should be included in the differential for any patient - whether pediatric or adult - who develops an acute desquamative rash and systemic symptoms. Clinical suspicion should be increased in adults with impaired kidney function.

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) is a rare but serious hypersensitivity reaction, with an incidence of 0.9 to 2 cases per 100,000 annually. While often linked to antiepileptics and allopurinol, reports associated with vancomycin have risen, likely due to its increased use in hospitals. DRESS is mediated by T-cells, typically presenting with facial edema, fever, rash, eosinophilia, and multi-organ involvement, with renal complications occurring only in 8-11% of cases and pulmonary involvement only in 30% of cases, as seen in our patient. We present a 63-year-old female who developed DRESS following two weeks of vancomycin therapy, with symptoms including high fever (>101.3°F), eosinophilia, a rash across her lower extremities, trunk, and upper extremities, acute renal failure requiring slow low-efficiency dialysis (SLED), and severe acute respiratory distress syndrome (ARDS). A RegiSCAR score of 6 confirmed her diagnosis. Additional evaluations, including TTE, ANA, ANCA, and bronchoscopy, were unremarkable. Vancomycin was promptly discontinued, and she was treated with methylprednisolone 125 mg every 12 hours for two days, followed by 60 mg daily to manage persistent ARDS. Though her kidney function has returned to baseline, her severe ARDS continues to complicate extubation, and tracheostomy with PEG is anticipated in the coming days. This case underscores the importance of recognizing DRESS early in patients on prolonged vancomycin therapy, as timely intervention is crucial to prevent severe outcomes.      

An 80-year-old male with paroxysmal atrial fibrillation and myelodysplastic syndrome,  developed transfusion-dependent anemia while on Eliquis, and was referred for percutaneous left atrial appendage closure (LAAC) device evaluation. Atrial transseptal catheterization was performed with intracardiac echocardiography and fluoroscopy. During the procedure, ST elevations appeared in lead II, accompanied by hypotension, mildly decreased systolic function, and atrioventricular dissociation. Treatment with IV ephedrine and epinephrine stabilized his blood pressure, resolving ST elevations and improving ventricular function. An echogenic area in the left ventricular apex, suspected to be a thrombus or air embolism, prompted the procedure's termination. The patient, admitted to the ICU, later experienced a witnessed generalized tonic seizure, treated with Ativan. Intubation was performed for airway protection, with head CT revealing no acute abnormalities, while chest CT confirmed a small air volume in the left ventricular apex. Prophylactic phenytoin was initiated and later tapered off without recurrence of seizures. The patient was extubated and returned to baseline, with no residual neurological deficits at discharge. LAAC complications often include pericardial effusion, bleeding, stroke, and thromboembolism, with air embolism being rare. In this case, a coronary-cameral fistula (CCF), an anomaly between the right coronary artery and left ventricle, may have contributed to air embolism and resulted in ST-segment elevation and seizure—a rare presentation for left ventricular air embolism. Increasing awareness and establishing structured protocols are essential for timely recognition and management of such events.

This is a case of 73-year-old female with diagnosis of stage IV lung adenocarcinoma was recently started Sotorasib presented to emergency department with episodic shortness of breath and palpitations.  At the time of admission, patient was found to have hyponatremia and hypokalemia along with new onset atrial fibrillation.  Sotorasib, a novel chemotherapy agent is found to be associated with electrolyte abnormalities including hyponatremia, hypocalcemia and rarely hypokalemia. Atrial fibrillation is not a well-established association with use of Sotorasib. In our patient, her electrolyte abnormalities notably hyponatremia and hypokalemia likely potentially trigger the atrial fibrillation. We have to be very vigilant for monitoring electrolyte in patient who are started on Sotorasib to prevent potential rhythm problem.