ResearchPad - Internal Medicine https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Spontaneous Coronary Artery Dissection in a Healthy Male: A Case Report and Literature Review]]> https://www.researchpad.co/article/elastic_article_11606 Spontaneous coronary artery dissection (SCAD) is a rare presentation of acute coronary syndrome (ACS) and can potentially lead to sudden cardiac death. SCAD is particularly seen in young females and/or patients with relatively few cardiovascular risk factors which further makes it a diagnostic conundrum. This article aims to highlight the causes, clinical presentation, treatment options, and complications of SCAD in addition to a case report of a young gentleman who was found to have SCAD.

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<![CDATA[An Atypical Presentation of Formic Acid Poisoning]]> https://www.researchpad.co/article/elastic_article_11602 Although formic acid (FA) poisoning is rare, it is usually fatal. Many FA poisoning cases commonly involve rubber plantation workers in which these workers ingest FA accidentally or with suicidal intentions. This is a case presentation of FA poisoning by a 73-year-old man. Additionally, the patient’s old age likely contributed to his severe prognosis.

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<![CDATA[A Hemodialysis Patient with Severe COVID-19 Pneumonia]]> https://www.researchpad.co/article/elastic_article_11601 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a novel coronavirus that has spread rapidly, resulting in a worldwide pandemic. Even though end-stage renal disease (ESRD) patients are particularly susceptible to COVID-19 infection and can develop severe to critical disease, there are limited studies and case reports about COVID-19 in ESRD patients. We report a case of a 63-year-old gentleman with ESRD on regular hemodialysis. We describe the clinical presentation of this patient, the diagnostic process, the laboratory and imaging investigations, as well as the course of treatment. He positively responded to a 14-day course of Lopinavir-Ritonavir, Ribavirin, Azithromycin, and Hydroxychloroquine.

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<![CDATA[Migration of Over-the-scope Clip Resulting in Anal Pain and Obstructed Defecation]]> https://www.researchpad.co/article/elastic_article_11595 Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonoscopy. Specific locations in the gastrointestinal tract, such as the jejunum, have a higher risk of perforation owing to its difficult anatomical position. Over-the-scope clips have recently been used for the management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®, Ovesco Endoscopy AG, Tübingen, Germany) clips for an iatrogenic postpolypectomy perforation with subsequent anal pain and inability to evacuate stool occurring as a result of the migration of the clip, followed by a review of the literature.

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<![CDATA[Recurrent Venous Thromboembolism in a Patient with Klippel-Trenaunay Syndrome Despite Adequate Anticoagulation with Warfarin]]> https://www.researchpad.co/article/elastic_article_11582 Klippel-Trenaunay syndrome (KTS) is a rare genetic condition defined by capillary malformation, venous malformation, and soft tissue and bony overgrowth. Due to venous malformations, individuals are predisposed to intravascular coagulopathy leading to thrombosis and thromboembolism. However, anticoagulating these patients long-term remains a challenge because of the presence of capillary malformations that increase bleeding risk. We present a rare case of a 30-year-old Caucasian male with KTS and history of gastrointestinal bleeding who has been on anticoagulation since the age of 7 and has had three different inferior vena cava filters placed during his lifetime. At presentation, he had dyspnea with stable vital signs. His prothrombin time/international normalized ratio was 37.3 and 3.2, respectively and chest computed tomography showed bilateral segmental pulmonary embolism (PE). He was treated with heparin drip and his home anticoagulation was switched from warfarin to apixaban at the time of discharge for better anticoagulation optimization. KTS is a condition associated with venous thromboembolic complications that can be difficult to manage. PE should remain on the top of the list of differential diagnoses in patients with KTS presenting with dyspnea even if laboratory findings suggest an alternate diagnosis.

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<![CDATA[Argatroban Treatment and Decreased Fibrinogen in a Septic Patient]]> https://www.researchpad.co/article/elastic_article_11578 Disseminated intravascular coagulation (DIC) is a consumptive coagulopathy associated with multiple conditions. Diagnosis is based upon clinical and laboratory findings with assessment of fibrinogen, platelets, D-dimer, prothrombin time/international normalized ratio and activated partial thromboplastin time. Herein, we report a case of a 39-year-old female patient diagnosed with endocarditis complicated by pulmonary septic emboli. For anticoagulation, the patient initially was treated with a heparin drip, but the patient remained subtherapeutic despite increasing dosage. The patient was transitioned to argatroban and developed an acute drop in the fibrinogen level. With concern for possible DIC, argatroban was held with a repeat panel six hours later revealing a significantly improved fibrinogen level. It was discovered that the Clauss method, which measures the capability of fibrinogen to form a clot after a high concentration of thrombin is added to diluted plasma, was used to measure fibrinogen at our institute. Argatroban may falsely reduce measured fibrinogen levels in vitro, caused by this method.

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<![CDATA[Right Ventricular Perforation Presenting as Tingling of the Left Breast]]> https://www.researchpad.co/article/elastic_article_10714 Pacemaker lead-associated cardiac perforation is a rare phenomenon. Lead perforations can be acute, subacute, or chronic following lead placement. Symptoms are typically nonspecific and depend on the location of the displaced lead. Diagnostic workup requires interrogation of the pacemaker and imaging studies. Management of lead displacement is dependent on multiple risk factors such as age, gender, corticosteroid use, and anticoagulation therapy.

A 74-year-old female with a history of myosin light chain kinase (MYLK) 2 hypertrophic cardiomyopathy, Sjogren’s syndrome, Raynaud’s disease, and sick sinus syndrome was evaluated for an abnormal finding on pacemaker interrogation. The patient’s only symptom was tingling of her left breast. Imaging studies confirmed pacemaker lead perforation. Right ventricle perforation due to a pacemaker lead displacement can cause severe complications. Early identification and treatment by physicians can reduce the risk of mortality.

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<![CDATA[Successful Conservative Management of Acute Appendicitis in a Coronavirus Disease 2019 (COVID-19) Patient]]> https://www.researchpad.co/article/elastic_article_10711 Appendectomy is the gold standard of treatment for acute appendicitis; however, recent evidence suggests conservative management with intravenous antibiotics may provide similar outcomes and can be used as an alternative in selected patients. Performing appendectomy in acute appendicitis patients with 2019 novel Coronavirus Disease (COVID-19) is challenging, as it involves considerable operative risks for the patients and risks for health care professionals (HCPs) exposed to COVID-19. Medical management eliminates the morbidity and mortality associated with surgery but involves significant risks of treatment failures that, in turn, may lead to perforation, peritonitis, and death. We are reporting a case of a middle-aged man with multiple co-morbidities, who was diagnosed with COVID-19 and acute appendicitis. Our patient received intravenous antibiotics for seven days with a significant improvement in symptoms. Our case report illustrates the implementation of successful conservative treatment for acute appendicitis in COVID-19 patients.

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<![CDATA[SMARCB1/INI1-Deficient Extrarenal Rhabdoid Tumor: A Case Report of a Rare and Aggressive Soft Tissue Sarcoma]]> https://www.researchpad.co/article/elastic_article_10708 Malignant SMARCB1/INI1-deficient extrarenal rhabdoid tumors are aggressive tumors that are extremely rare in adults. A 56-year-old male presented with the chief complaints of unilateral lower abdominal and pelvic pain. He underwent urgent surgical intervention and mass resection with tissue sampling. After pathology confirmed the diagnosis, systemic chemotherapy with vincristine, doxorubicin plus ifosfamide, and mesna was administered. Following treatment, he experienced a durable and long-lasting response to therapy for this aggressive and rare soft tissue sarcoma. To date, the patient remains in complete remission following the cessation of chemotherapy. Malignant SMARCB1/INI1-deficient extrarenal rhabdoid tumors are aggressive neoplasms that are extremely rare in adults. We report a rare case of such a tumor and review the literature for its molecular, clinical, and imaging features.

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<![CDATA[Embolic ST-elevation Myocardial Infarction from Candida Endocarditis]]> https://www.researchpad.co/article/elastic_article_10706 Infective endocarditis in intravenous drug users is uncommon in left-sided native valves. Adding to the rarity, in this case, is endocarditis from Candida species complicated by ST-elevation myocardial infarction. Embolic myocardial infarction has worse outcomes as compared to other etiologies, and the management of septic embolic myocardial infarction is rather challenging. The management of embolic myocardial infarction from Candida endocarditis vegetation includes antifungal therapy. The use of anti-thrombotic therapy and anticoagulation carries a significant risk of fatal neurologic complications and has been controversial, with limited observational data available. Among percutaneous coronary interventions, balloon angioplasty and stenting have been associated with multiple complications while aspiration embolectomy appears to be a safer option. Surgical management is considered if medical and interventional therapies fail or if there is an indication for valve replacement.

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<![CDATA[Severe Lower Extremity Cellulitis Caused by an Unusual Pathogen: Haemophilus Influenzae Type F]]> https://www.researchpad.co/article/elastic_article_10545 We present a case of unusual cellulitis of the lower extremities caused by Haemophilus influenzae (HI). A 64-year-old female with human immunodeficiency virus (HIV) with a suppressed viral load on treatment, presented with severe, very painful cellulitis of her lower extremity. CT scan did not show any gas or collections; however, she was taken to the operating room for concern of necrotizing fasciitis but no evidence of deep tissue involvement was found. Blood culture and wound culture were positive forHI type F (HiF), a newly emergent pathogenic capsulatedHI that has emerged post-HI type B (HiB) vaccination.

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<![CDATA[Breast Cancer Metastasis Masquerading as a Primary Gynecological / Colonic Malignancy: A Rare Diagnostic Conundrum]]> https://www.researchpad.co/article/elastic_article_10540 Breast cancer is the most common malignancy affecting women. Metastatic involvement of the gastrointestinal (GI) tract secondary to a primary breast malignancy is rare. Here, we describe the case of a 60-year-old woman with a history of right lobular breast cancer (diagnosed and treated five years prior to presentation) who presented with fatigue, generalized abdominal pain, distension, weight loss, and vomiting. Her initial imaging was suspicious for a primary gynecological malignancy; however, subsequent workup showed a colonic mass. Total colonoscopy revealed colon metastases, and an immunohistochemical profile favored invasive lobular carcinoma of breast. Most cases of gastrointestinal metastases from breast cancer have lobular histology; however, colonic involvement is rare.

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<![CDATA[Guillain-Barre Syndrome, Neuroborreliosis, or Both]]> https://www.researchpad.co/article/elastic_article_10529 Guillain-Barre syndrome (GBS) is an acute paralytic neuropathy. Limited reports of GBS caused by tick-borne pathogens exist. Lyme disease is a tick-borne infectious disease that is commonly caused by Borrelia burgdorferi. The nervous system may be involved and is called neuroborreliosis.

In this case, we report a 30-year-old female who presented to the emergency department with one week of diffuse, increasing weakness in the upper/lower extremities and face after a recent gastrointestinal illness and travel to the Northeastern United States. Areflexia was noted in bilateral lower extremities. Lumbar puncture results together with clinical presentation were consistent with a diagnosis of GBS. Lab results later revealed a possible Lyme infection in cerebrospinal fluid, which along with recent travel to endemic area gave high suspicion for Lyme disease. The patient was treated for both diseases with significant improvement.

Taking a good history is an essential first step in diagnosis, as travel history was key in testing for Lyme.

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<![CDATA[Pneumonia Caused by Three Separate Microorganisms Simultaneously in a Patient Infected with Human Immunodeficiency Virus]]> https://www.researchpad.co/article/elastic_article_10519 Community-acquired pneumonia (CAP) is usually caused by a single microorganism. Streptococcus pneumoniae is the most common organism associated with CAP. However, in immunocompromised patients, especially those infected with human immunodeficiency virus (HIV), pneumonia may be caused by multiple organisms simultaneously. This report describes a previously healthy 29-year-old man who presented with acute CAP. Blood tests showed that he was positive for HIV antigen/antibody, and urinalysis showed that he was initially positive for pneumococcal antigen. Although blood cultures showed growth of Streptococcus pneumoniae, he did not respond to invasive anti-pneumococcal treatment with ceftriaxone and vancomycin. Rather, his pneumonia worsened, and he was intubated for hypoxic respiratory failure. His bronchoalveolar lavage fluid was positive for Pneumocystis pneumonia and methicillin-resistant Staphylococcus aureus. These findings indicate that pneumonia in immunocompromised patients may be caused by multiple organisms. Patients who fail to respond to treatment for a single identified organism should be suspected of being infected with other pathogenic organisms.

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<![CDATA[Cardiac Dysrhythmia Associated With Opioid Toxicity]]> https://www.researchpad.co/article/elastic_article_10517 Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder involving abnormal motility. The patients are commonly started on symptom control management for IBS - diarrhea subtype by prescribing antimotility agents, usually having opioid agonist activity, and newer medications have been emerging for this as well. Patients sometimes self-medicate themselves to exceedingly high doses of these medications to achieve symptoms control. There are only a few cases of opioid-induced arrhythmia in the literature, primarily loperamide being used as a drug substitute by substance abusers. Still, it has been rarely reported to cause arrhythmia in a patient with IBS.

We present a case of a 33-year-old female with a past medical history of hypertension and depression who presented to the emergency department for evaluation of syncope. She had wide complex tachycardia on electrocardiogram (EKG) with prolonged rate-corrected QT interval (QTc). Her medications, including eluxadoline, Lomotil, and loperamide, were held and she was discharged on mexiletine with normal QTc. She did not have any more incidences of arrhythmia.

This case highlights the importance of not overdosing on opioid agonist medications prescribed to treat IBS as these can lead to potentially fatal complications. Physicians have to be judicious in promptly determining that the cause of arrhythmia can also be over-the-counter (OTC) medications.

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<![CDATA[Out of the Blue: A Case of Blue Subungual Discoloration Associated with Prolonged Tetracycline Use]]> https://www.researchpad.co/article/elastic_article_10504 Tetracycline derivatives are antibiotics such as minocycline and doxycycline that have been commonly utilized for inflammatory dermatological conditions such as acne and rosacea. Hyperpigmentation of the skin, nails, thyroid, oral mucosa, teeth, and bones is a known but rare side effect of prolonged tetracycline use. The hyperpigmentation typically takes months to years to develop. There may also be residual changes to the skin after discontinuation of the medication. For this reason, the time tetracyclines are used should be minimized and patients should be monitored for the skin findings. Subungual discoloration carries a broad differential including infectious, inflammatory, metabolic, malignant or systemic diseases. Knowledge of this side effect is crucial in order to avoid unnecessary testing in determining the etiology of the subungual discoloration. We report on a case of a patient who has been on long-term minocycline use for adult acne management. He was initially on minocycline for six years, but due to minocycline-induced hyperpigmentation of his ears and fingernails, he had switched to doxycycline. One year later, the skin hyperpigmentation of the ears regressed; however, the blue subungual hyperpigmentation of his hands progressively become more prominent without any other significant symptoms. 

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<![CDATA[Infective Endocarditis Caused by Rhodococcus equi in an Immunocompetent Patient]]> https://www.researchpad.co/article/elastic_article_10502 Rhodococcus equi (R. equi) is a rare zoonotic organism that is found in the feces of grazing animals and in farm soil. It typically causes pulmonary disease, but it can also cause extrapulmonary disease. Immunocompromised patients are at a higher risk of developing the infection, but it has been reported in individuals with competent immune system as well. We present a unique case of infectious endocarditis (IE) due to a R. equi infection in an immunocompetent patient.

A 77-year-old male with a history of coronary artery disease, prior myocardial infarction, systolic heart failure, hypertension, hyperlipidemia, aortic stenosis, and benign prostatic hypertrophy was evaluated by cardiothoracic surgery for coronary and valvular heart disease. His transesophageal echocardiogram and cardiac catheterization demonstrated severe aortic stenosis and multivessel coronary artery disease. The patient underwent coronary artery bypass grafting and simultaneous aortic valve replacement. Intraoperatively, there was exudative material covering his aortic valve, which was sent for tissue culture. Tissue culture was positive for R. equi and Enterococcus faecium. 

R. equi endocarditis is a rare presentation of this organism. R. equi endocarditis is a very challenging diagnosis due to its varying presentation compared to typical IE. Detailed history taking and physical exam are extremely important to determine if further evaluation is needed. Prolonged oral and intravenous antibiotics are recommended for effective treatment. 

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<![CDATA[A Case of a COVID-19-positive Patient]]> https://www.researchpad.co/article/elastic_article_9472 The coronavirus (COVID-19), discovered in 2019, has been creating havoc since it first emerged in China and is now spreading worldwide. Its presentation is somewhat similar to influenza. We hereby discuss the salient features of the coronavirus and present the case of a 33-year-old male who was tested positive for COVID-19. 

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<![CDATA[Readmission Risk Factors and Complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis]]> https://www.researchpad.co/article/elastic_article_9460 Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are mucocutaneous hypersensitivity reactions that cause necrosis of the epidermis, often at multiple sites. This process is frequently caused by medications and is associated with significant complications and mortality during hospitalization. However, increasing attention has been drawn to the less studied area of post-hospitalization complications leading to multiple readmissions. We present a patient diagnosed with trimethoprim-sulfamethoxazole induced SJS/TEN, who was readmitted within one week with sepsis. We also discuss the readmission risk factors and post-hospitalization features and complications of SJS/TEN.

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<![CDATA[Elevated C-reactive Protein and Role of Steroids in Cocaine-associated Levamisole-induced Vasculitis]]> https://www.researchpad.co/article/elastic_article_9459 Levamisole is a common contaminant in cocaine and has led to the emergence of an entity known as levamisole-induced vasculitis (LIV). There is no consensus on the management of this condition. We describe a patient who presented with acute on chronic LIV who was treated with pulse dose steroids. We aim to discuss the diagnosis and current management options for LIV. We have compared seven case reports that have measured C-reactive protein (CRP) and compared the CRP levels, site involved, dose, and mode of steroid administration. We postulate that elevated CRP may warrant steroid therapy over conservative management and could lead to a possible decreased hospital stay.

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