Neutrophilic Dermatosis in a Patient with Myelodyplastic Syndrome that was not so Sweet

Jessica J. Dreicer, MD

Faculty Mentor: Stephanie Halvorson, MD 

A diagnosis of a rare form of neutrophilic dermatosis called pyodermatitis/pyostomatitis vegetans (PD-PSV) was rendered based on neutrophilic necrotic lesions involving the skin and mucosa. His steroids were increased to 1 mg/kg. PD-PSV is reportedly almost exclusively in patients with inflammatory bowel disease (IBD) so the patient underwent colonoscopy with biopsies which were negative for inflammation. At a follow-up visit five months later, the patient’s lesions were completely resolved.

DisCORDant Symptoms Simplified

Kristy T. Duggan, MD

Faculty mentors: Alan J. Hunter, MD, Mary E. Pickett, MD

The evaluation of respiratory distress requires a systematic approach to arrive at an accurate diagnosis. For patients with unexplained dyspnea and characteristics of VCD, consider referral for videolaryngoscopy. Achieving this diagnosis early can limit further costs and fruitless investigations, as well as minimize exposure to invasive and non-beneficial interventions.

The Cupric Culprit: A Case of Copper Deficiency Myelopathy

Jane Babiarz MD, 

Copper deficiency is a rare complication of peptic ulcer or bariatric surgeries, malabsorptive disorders, and excess zinc ingestion. A mimicker of subacute combined degeneration seen in cobalamin (B12) deficiency, copper deficiency myelopathy most commonly presents with ataxic gait, paresthesia, anemia or neutropenia, and dorsal column enhancement on cervical spine magnetic resonance imaging.

One HIT Wonder

Jeffrey Bien, MD, Luai Al Rabidi, MD

Faculty Mentor: Tom DeLoughery, MD

Heparin Induced Thrombocytopenia (HIT) is one of the most thrombogenic processes known. While uncommon, its consequences can be devastating, as it predisposes patients to both pro-thrombotic and high-bleeding-risk states simultaneously. It is most often diagnosed by first calculating a 4T score, for which a low or intermediate score confers a low pre-test probability of the condition.

Retention attention: small cell prostate cancer presenting with SIADH and urinary retention

Joel Burnett, MD, Adam Kittai, MD

Faculty Mentor: Jia Luo, MD

The syndrome of inappropriate antidiuretic hormone (SIADH) is associated with multiple etiologies including CNS disorders, pulmonary diseases, and malignancies. SIADH is classically associated with small cell carcinoma of the lung (SCLC) but can be present in non-pulmonary small cell cancers and other malignancies. We present a rare case of SIADH as the initial manifestation of small cell carcinoma of the prostate (SCPC).

Butterfly effects: a tremor as the proximate cause of empyema

Joaquin Chapa, MD

Faculty Mentor: Avital O’Glasser, MD

The classic complications associated with cataract surgery are ocular and infrequent. Here we describe a severe pulmonary complication attributed to a specific patient preoperative risk factor: severe essential tremor requiring the administration of deep sedation and bag-mask ventilation, with a resultant MRSA empyema as a complication

An expected systemic reaction with unexpected costs to the system

Joaquin Chapa, MD

Faculty Mentor: Avital O’Glasser, MD

The acute phase response (APR)—characterized by fevers, fatigue and myalgias—is a well-known adverse effect of intravenous zolendronic acid administration, affecting 40-60% of patients.  We report a case of a severe APR, requiring a 4-day hospitalization and temporary move to a SNF.

"The Prognosis for Life and Vision is Good, for Hearing, Poor"

Jessica J. Dreicer, MD; Sonam Kiwalkar, MD; Timothy Boyce, MD

Faculty Mentor: Leslie E. Kahl, MD

Cogan's syndrome is a rare disease characterized by non-syphilitic inflammatory eye disease and sudden onset sensorineural hearing loss. Patients typically present with either ophthalmologic or vestibuloauditory symptoms. By definition, patients must develop both symptoms within two years of onset. 

Mind your Language: Dangers in Documentation

Cate Edgell, MD

Faculty Mentor: Andrew Seaman, MD

Autoimmune hepatitis is a disease with a >3:1 female predominance and often diagnosed in middle age, consistent with this patient. Progression to end stage liver disease can qualify a patient for transplant, but alcohol/substance abuse within the past 6 months usually excludes transplant listing.  Factors which delayed appropriate treatment and transplant listing included early anchoring bias on alcoholic hepatitis based on chart history of alcohol abuse without completely corroborating history and cultural stereotyping of Native Americans as being at high of AUD.

Wandering Spleen with a Twist

Cate Edgell, MD, Michael Loudin, MD

Per our review, this is only the fifth report of the association of gastric volvulus with wandering spleen in adults reported in the literature to date. Furthermore, as the standard treatment is surgical fixation by simultaneous gastropexy and splenopexy, this is the first case that has been treated with endoscopic therapy alone. Though this case is rare, it does represent a promising non-surgical endoscopic intervention that could be considered in these and other, less-rare conditions including gastric volvulus alone.

A Grave Complication:  Reactivated Thyrotoxicosis with Concurrent Diabetic Ketoacidosis
Daniel Feng, MD

Faculty Mentor: Robert Klein, MD

Graves' thyrotoxicosis (GT) is a potentially life-threatening condition characterized by autonomic instability due to autoantibody-mediated excess production and secretion of thyroid hormone. Early recognition, treatment, and appropriate secondary prevention are key to ensuring a favorable prognosis in GT.

Granulomatosis with polyangiitis: When Tissue is not the issue

Michael Gardner, MD, Stephanie Cobb, MD

Faculty Mentors: Alan J. Hunter, MD, Atul Deodhar, MD

Granulomatosis with polyangiitis (GPA) is characterized by the classic triad of respiratory tract granulomatous inflammation, systemic small vessel vasculitis, and necrotizing glomerulonephritis. The gold standard for diagnosis of GPA is tissue biopsy involving the skin, lung, or kidney; however the diagnosis of GPA can be made without tissue biopsy when a patient presents with the classic symptoms for GPA and are found to be positive for cytoplasmic-ANCA (c-ANCA) and anti-proteinase 3 (anti-PR3) antibody.

A sCurveball on the Wards: Uncovering the Cause of Ecchymosis and Anemia

Richard Hegarty MD; Jeffrey Bien, MD

Faculty Mentor: Brian Chan, MD

Scurvy is a pathologic deficiency of vitamin C, a necessary cofactor for collagen synthesis. It is the only known acquired, non-autoimmune connective tissue disorder. In the developed world, it is rare given the presence of vitamin C in most common foods. As a result, it has become increasingly difficulty to recognize. Nevertheless, scurvy is a potentially lethal but treatable condition with diagnosis based on a careful history and physical exam, prior to a complex hematologic workup.

The Leading Suspect: Hemothorax due to myocardial perforation by pacemaker lead

Joel Horton MD, Jane Babiarz MD

Faculty Mentor: Alan J. Hunter MD

Perforation of the right ventricular wall is a recognized but uncommon complication of intracardiac device and pacemaker implantations. Pacemaker lead migration may present with hemodynamic instability due to hemopericardium or with abnormal pacing parameters, but it is rarely associated with hemothorax.

White Water Rafting: Navigating the Lymph Rapids

Bruce Kaufman, DO, MPH

Faculty Mentor: Mary Pickett, MD

Chylous ascites is a rare form of ascites in which lymph accumulates in the peritoneal cavity after lymphatic flow is disrupted. Clinical manifestations range from abdominal pain to malnutrition and immunologic deficits. A diagnostic paracentesis demonstrating triglyceride-rich milky-appearing ascites is confirmatory. Lymphangiography usefully identifies the source and severity of a chylous leak. Many lymphatic leaks seal spontaneously if a low-flow state is present, but such leaks are challenging to manage when conservative therapy fails. 

Back to Basics: The Limits of pH

Bruce Kaufman, DO, MPH; Justine Hum, MD; Sami Amjad, MD

Faculty Mentor: Jeffrey Gold, MD

Extreme metabolic alkalosis (EMA) is a rarely encountered acid-base disturbance characterized by muscle spasms, hypoventilation, and fatal cardiac arrhythmias associated with a markedly elevated serum bicarbonate. Optimal management of EMA is challenging and the upper limit of human pH tolerance remains controversial.

Painless Jaundice: A Rare Case of Nivolumab Induced Hepatitis

Kaleb Keyserling, MD; Bruce Kaufman DO, MPH; Adam Kittai, MD

Faculty Mentor: Armarpit Bains, MD

The class of drugs known as immune checkpoint inhibitors (ICIs) are revolutionizing the treatment of malignancies and are rapidly being approved by the FDA for new treatment indications.  Nivolumab, a monoclonal antibody against programmed death ligand-1 (PD-1), is an ICI that unmasks tumor cells from immune system evasion, activating the T-cell to attack the malignant cells. This T-cell activation may also lead to adverse autoimmune reactions. 

Antipsychotic-induced hypothermia

Elise Larson, MD; Julien Chirouze, MD

Faculty Mentor: Joseph Chiovaro, MD

In elderly patients with concurrent dementia and agitation, hypothermia represents a clinically significant reaction to APDs. Dose-dependent hypothermia and ECG changes (J-waves) are clues to this diagnosis. In this patient, rapid withdrawal of the APD after full diagnostic work-up resulted in resolution of hypothermia.

Hyponatremia Haze: Ipilimumab and Steroid Tapers

Melissa Rae LeBlanc, MD

Hypophysitis due to Ipilimumab has been previously described as a complication of therapy. Manifestations include panhypopituirism or secondary adrenal insufficiency due to decreased ACTH secretion. The hormone insufficiency induced by hypophysitis is not always reversible while exogenous steroid induced adrenal insufficiency is

Where did the blood go? Anchoring bias on the assurance of haptoglobin

Sophia Li, MD

G6PD deficiency is a well-known condition in which extravascular and intravascular hemolysis occurs in patients with the X-linked deficiency who are exposed to oxidizing stress. The diagnosis is not difficult when given the right clinical clues such as patient ethnicity, history of exposure to oxidizing agents, and supportive labs. Cases may prove more  challenging in patients with multiple acute illnesses and ambiguous laboratory findings which illustrates the power of anchoring bias.

Acute on Chronic DIC in Metastatic Prostate Cancer

Joshua Liu, MD

Faculty Mentor: Jason A. Taylor, MD, PhD

Acute DIC is often seen in life-threatening settings such as sepsis or diffuse trauma. However, chronic DIC occurs much less frequently and often involves an indolent process such as occult malignancy. This case emphasizes the diagnostic workup for chronic DIC as well as the challenging management issues that arise in the setting of severe, persistent consumptive coagulopathy.

The Wide Spectrum of Infections in the Age of Novel Monoclonal Antibody Therapies: A Case of Pulmonary Tuberculosis

Eric Lu, MD

Faculty Mentor: Stephen Hall, MD

In recent years, there has been an increasing use of monoclonal antibodies in the treatment of hematologic malignancies. Alemtuzumab, is one such antibody which targets CD52 antigens and is used as a therapy for T-cell lymphomas and chronic lymphocytic leukemia. Herein, we describe a case of pulmonary tuberculosis which developed while on therapy with this drug.

Seeing Is Believing: Diffuse Large B-cell Lymphoma Presenting as Horner Syndrome and Syncope

Ayako Mayo, MD

Faculty Mentor: Scott Stroup, MD

Diffuse large B-cell lymphoma (DLBCL) has a varied clinical presentation, but commonly presents in the form of a mass or obstruction due to its aggressive nature and rapid growth. Here we illustrate an example of mass effect secondary to DLBCL manifesting as Horner syndrome and syncope.  Horner syndrome (HS) is a constellation of findings including miosis, ptosis, and anhidrosis and can be caused by a lesion anywhere along the sympathetic chain.  Swift recognition of these clinical signs is essential to provide a thoughtful workup of the underlying process.

An atypical chest pain: Acute chest syndrome, pericarditis and cardiac tamponade

Austin Perlmutter, MD

Faculty Mentor: Avital O’Glasser, MD

In sickle cell patients presenting to the emergency department with chest pain, vaso-occlusive crisis and acute chest syndrome account for the majority of diagnoses. Here, we describe a sickle cell patient presenting with chest pain and found to have concurrent diagnoses of acute chest syndrome, pericarditis and associated cardiac tamponade.

Altered Mental Status Takes a New Form

Alina Plavsky, MD

Faculty Mentor: Bailey Pope, MD

Unregulated supplements pose a risk to the general public, and there is little information available about the harms associated with taking various forms of supplements. By describing this case, our goal is to not only report another case of Phenibut intoxication, but to highlight the unexpected effects of changing supplement modalities. This case illustrates the unexpected consequence of increasing the dose of a supplement by changing the form of consumption.

Palmoplantar Keratodemra Associated with Peripheral T-cell Lymphoma

Jack Shuler, MD, MD, Daniel Guy, MD

Faculty Mentor: Sima Desai, MD

Pseudohyperchloremia in salicylate toxicity: the value of misinformation

Aaron Smith, MD, Joaquin Chapa, MD

Pseudohyperchloremia refers to a spuriously elevated blood chloride level.  A rare finding, it can be associated with marked hyperlipidemia, bromide ingestion, and, in this case, salicylate toxicity.  Although of no intrinsic clinical significance, as a clinical sign and a confounder of gap acidosis calculations, it can have important clinical implications.

A curious case of Moyamoya disease in an adult

Namisha Thapa, DO

Faculty Mentor: Hormozd Bozorgchami, MD

Moyamoya disease is a rare disease with chronic, progressive, non-inflammatory occlusion of Circle of Willis arteries resulting in a unique pattern of collateral vessels described as “puff of smoke” in Japanese.  It presents in children and adults differently, and commonly in Asian population. It is associated with conditions such as neurofibromatosis-1 and sickle cell disease, but has few reported association with polycystic kidney disease.

Wernicke’s Encephalopathy in a Morbidly Obese Patient With Infrequently Suspected Risk Factors

Joel VanderSchuur, MD, Jack Shuler, MD

Faculty Mentor: Avital O’Glasser, MD

Wernicke’s encephalopathy is a neurologic disease characterized by thiamine deficiency and characteristic neurologic deficits that may include altered mental status, ophthalmoplegias and cerebellar deficits. It has classically been associated with long-standing alcohol abuse, but it is also increasingly recognized in other various states of nutritional deficiency including bariatric surgery. If gone unrecognized, it may lead to irreversible neurologic deficits.

A Hemoglobin-Based Oxygen Carrier as a Last Resort for a Jehovah’s Witness With Severe Aplastic Anemia

Riana Wurzburger, MD, MPH

Faculty Mentor: Bart Moulton, MD

Hemoglobin-based oxygen carriers (HBOCs) were developed for improving oxygenation in situations where blood products are not readily available or cannot be used. Hemopure, composed of acellular bovine hemoglobin, is one such HBOC that was developed in South Africa in 2001. In concept, HBOCs seem a promising therapy for Jehovah’s Witnesses, a population well known to routinely decline blood products on religious grounds. However their use remains quite limited after a 2008 meta-analysis found an increased risk of mortality associated with their use. 

A Diagnostic Dilemma: Venturing into the Gray Zone with Lupus Myelitis

Celine Zhou M.D., Jenna McGoldrick M.D.

Faculty Mentor: Atul Deodhar M.D
 
Systemic lupus erythematosus is a clinically heterogeneous autoimmune disease more common in females with variable manifestations affecting up to 150 per 100,000. Notably, transverse myelitis is 1000 times more prevalent in SLE compared to the general population and can be the primary manifestation of lupus.

Just Breath

Dr. Stephen Cohen

A Breath of Fresh Care

Dr. Hayden Oldham

Labile Labs and Late Results

Dr. Mario Padilla