ResearchPad - internal-medicine https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Iron Deficiency Anemia: An Unexpected Cause of an Acute Occipital Lobe Stroke in an Otherwise Healthy Young Woman]]> https://www.researchpad.co/article/elastic_article_14324 A 29-year-old caucasian woman who presented to the hospital with an acute onset of right eye visual disturbance and headache was found to have an acute left occipital lobe infarction. Past medical history was significant for iron deficiency anemia (IDA) secondary to menorrhagia. Her initial hemoglobin level was 7.8 G/DL, and her symptoms improved after iron and blood transfusions. Hypercoagulable studies were completed in the outpatient setting, and the results were unremarkable. Her acute stroke was most likely related to IDA as she had low cardiovascular risk factors along with a negative complete stroke workup.

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<![CDATA[What Do We Need to Know to Improve Diagnostic Testing Methods for the 2019 Novel Coronavirus?]]> https://www.researchpad.co/article/elastic_article_14263 There is widespread agreement that reliable, fast, and easy-to-produce diagnostic testing methods that have high sensitivity and specificity are essential for guiding appropriate responses to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak. At the present time, there are important unanswered questions about testing methods for SARS-CoV-2. This review article interprets recent findings related to the principal testing methods used to diagnose SARS-CoV-2, including reverse-transcription polymerase chain reaction (RT-PCR), chest imaging, and immunoassay. We discuss the value and limitations of these approaches and suggest directions for future research that can advance the understanding of diagnostic methods. Addressing areas of uncertainty will improve clinical outcomes and allow more effective policies to be implemented to control the disease.

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<![CDATA[Late-onset Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like Episodes (MELAS) Syndrome in a 63-year-old Patient]]> https://www.researchpad.co/article/elastic_article_14258 Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) usually manifests in early life. Clinical hallmarks of the disease are mitochondrial myopathies, encephalopathy with stroke-like episodes, seizures, and lactic acidosis. It rarely manifests in late adulthood. Here we present the case of a 63-year-old female patient who developed recurrent stroke-like symptoms with typical resolving and remitting pattern of findings on imaging. Later on, it was confirmed as a case of MELAS upon genetic analysis.

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<![CDATA[Abdominal Pain, an Atypical Presenting Symptom of Granulomatosis with Polyangiitis]]> https://www.researchpad.co/article/elastic_article_14216 Granulomatosis with polyangiitis (GPA) formerly known as Wegener’s granulomatosis, is an anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). It is an uncommon disease with an estimated prevalence of 3 in 100,000 individuals with an equal distribution in both sexes. It is characterized by necrotizing granulomatous vasculitis that primarily affects the upper and lower respiratory tracts and the kidneys. 

Our patient's initial presentation was abdominal pain with no typical pulmonary or renal manifestations. Along the course of her hospitalization, she had multiple episodes of drop in hemoglobin and a steady increase in serum creatinine which was thought to be due to IV contrast nephropathy. With this case, we project the need for a high index of clinical suspicion to make an early diagnosis, especially in patients with atypical symptoms such as abdominal pain, and acknowledge the fact that IV contrast can possibly act as a second hit in underlying GPA, unmasking the active renal symptoms of the disease.

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<![CDATA[Tingles, Tetany, and Electrolyte Derangements]]> https://www.researchpad.co/article/elastic_article_14193 We report a patient who presented with anxiety, hyperventilation, perioral paresthesia, and tingling in the fingers associated with hypomagnesemia, hypocalcemia, and hypokalemia. We discuss the possible mechanistic basis for sequence of events that may have led to this presentation.

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<![CDATA[Young-onset Amyotrophic Lateral Sclerosis with Rare Skin Manifestation: Case Report and Literature Review]]> https://www.researchpad.co/article/elastic_article_14179 Amyotrophic lateral sclerosis (ALS) is one of the most common motor neuron diseases (MND), which presents as muscle weakness, atrophy, spasticity, and, in extreme cases, may result in death due to respiratory failure. ALS has been reported with dermatological conditions such as bullous pemphigoid and decreased collagen. Hyperpigmentation usually occurs due to underlying adrenal or metabolic disorder, but no case of hyperpigmentation has been associated with MND. We report a case of a 25-year-old man who presented with signs of young-onset ALS (progressive weakness of both upper limbs) with hyperpigmentation of limbs. The patient did not have any other underlying etiology, which could have led to the development of hyperpigmentation Biopsy was negative for polymyositis and dermatomyositis. The patient was counseled about the nature of the disease and was advised regular follow-ups.

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<![CDATA[Impact of Diabetes-related Self-management on Glycemic Control in Type II Diabetes Mellitus]]> https://www.researchpad.co/article/elastic_article_13985 Introduction: Self-care activities are behaviors adopted in order to enhance one’s health. Self-care behaviors and activities are studied in their role to enhance glycemic control, reduce diabetes-related complications, and contribute to enhancing overall quality of life in people with diabetes. The aim of this observational study was to evaluate the impact of diabetes self-care activities and behaviors on glycemic control in people with diabetes.

Methods: This observational, cross-sectional study was conducted at the outpatient department of a secondary care hospital in Karachi, Pakistan from 1st September 2019 till 30th November 2019. Patients with known type II diabetes of age ≥45 years visiting the hospital for routine follow-up visit were included. Diabetes Self-Management Questionnaire (DSMQ) in Urdu version was used to assess their status of self-management. For data entry and statistical analysis SPSS for Windows version 21.0 was used.

Results: There were 174 (54.9%) males and 152 (47.9%) were of age 45-60 years. Glycemic control was good (HbA1c <7%) in 125 (39.4%) and poor (HbA1c ≥7%) in 192 (60.6%) patients. Patients with good glycemic control scored significantly better on DSMQ overall (5.53 ± 0.35 vs. 4.32 ± 0.61; p<0.0001), and on three sub-scales - dietary control (4.24 ± 1.04 vs. 3.63 ± 0.98; p<0.0001), physical activity (4.16 ± 0.56 vs. 3.47 ± 1.17; p<0.0001), and healthcare use (4.22 ± 0.78 vs. 3.98 ± 0.65; p=0.003). 

Conclusions: The self-care activities that impact glycemic control in patients with diabetes include dietary control, physical activity, and healthcare use.

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<![CDATA[Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator]]> https://www.researchpad.co/article/elastic_article_13907 Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the highly infectious novel SARS-CoV-2 coronavirus spread by droplet transmission. Consequently, the use of respiratory devices that may potentially promote aerosolization like non-invasive positive pressure ventilation (NIPPV) for diseases such as obstructive sleep apnea (OSA), advanced chronic obstructive lung disease, pulmonary hypertension (PH), and neuromuscular respiratory disease has been called into question. We present a case of a patient with history of OSA and PH convalescing from refractory acute respiratory distress syndrome (ARDS) secondary to COVID-19 who was successfully extubated to average volume-assured pressure support (AVAPS).

A 74-year-old male with medical history notable for OSA on NIPPV, PH, and hypertension presented with respiratory failure secondary to COVID-19 confirmed on polymerase chain reaction (PCR) test. His respiratory status worsened leading to ARDS requiring intubation. He was initially extubated to high flow nasal cannula (HFNC) due to hospital policy to avoid NIPPV due to concerns of viral dissemination. He did not tolerate HFNC and required re-intubation for prolonged period. He was then medically optimized for a second attempt and extubated two days later to AVAPS with an anti-viral filter and negative pressure room with a goal of optimizing his critical illness myopathy and pre-existing OSA and PH. He tolerated extubation well, and over the next five days was weaned from alternating AVAPS/HFNC to eventually requiring two liters nasal cannula in the day and AVAPS mode at night.

This case highlights a potential therapeutic option for patients with severe respiratory failure secondary to COVID-19. This patient’s pre-existing comorbidities of OSA and PH markedly increased his risk for extubation failure on HFNC. The use of AVAPS after his second extubation attempt helped ensure ventilation and oxygenation non-invasively. COVID-19 can lead to prolonged dependence on mechanical ventilation. This pandemic has the potential to create medical resource scarcities, especially in rural areas where ventilators and trained personnel are already in short supply. By using AVAPS mode, this patient was able to rehabilitate his myopathy and participate in intermittent weaning of HFNC to ultimately simple nasal cannula.

AVAPS is useful tool to facilitate extubation, as it allows non-invasive support of respiratory dynamics, particularly in those with co-morbidities such as OSA and PH. Further, larger scale studies are needed to determine its exact role during the COVID-19 pandemic.

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<![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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