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The Medicine Forum: Volume 22

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 22, 2020-2021

TABLE OF CONTENTS

Clinical Images

Case Reports

• Cardiology
• Gastroenterology and Hepatology
• General Medicine
• Hematology and Oncology
• Pulmonary Medicine

Resident Reflection

Serum Ammonia And Folate Levels: Opportunities For High Value Care, R. Benson Jones Jr., Md, Sean Dikdan, Md, Bracken Babula, Md

The Medicine Forum

High value care encompasses a variety of principles including ordering tests with high diagnostic yield, while reducing low value practice.

Refusing To Be Labeled, Jennifer Perugini

The Medicine Forum

Refusing to be Labeled

Case Report Of E-Cigarette Associated Lung Injury In A Health Female, Mario Fonseca-Paricio, Md, Alan Gandler, Md, Boyd Hehn, Md

The Medicine Forum

This is a case of a woman presenting with four days of diarrhea and dyspenea found to have E-cigarette or vaping-associated lung injury (EVALI)

A Case Report Of Bullous Subconjunctival Hemorrhag In Adenoviral Conjunctivitis, Sean Haynie, Jesse Johnson, Md

The Medicine Forum

A 78-year-old female with a past medical history of optic neuropathy and atrial fibrillation on warfarin presented with two weeks of progressive bilateral eye redness, swelling, pain, and blurry vision.

A Case Report Of Tragaxofusp Causing Severe Tumor Lysis Syndrome In A Patient With Blastic Plasmacytoid Dendritic Cell Neoplasm, Shuwen Lin, Md, Alice Wang, Md

The Medicine Forum

The patient was an 83-year-old male without significant past medical hsitory who presented to his primary care physician with several days of generalized malaise

Exploring The Adverse Effects Of Car-T Therapy: A Cases Report Of Potential Minoca In Car-T, Danielle Verghese, Pgy-1, Adam Binder, Md, Colin Thomas, Md

The Medicine Forum

A 48-year-old man with a history of Stage IV Diffuse Large B-Cell Lymphoma refractory to R-CHOP alternating with high-dose methotrexate and cytarbine, craniospinal irradiation, and haploidentical stem cell transplant, underwent CD 19-directed CAR-T.

A Case Report Of Hemophagocytic Lymphohistiocytosis Secondary To Disseminated Tuberculosis, Shuwen Lin, Md, Christoher Terry

The Medicine Forum

A 72-year-old woman with past medical history of hypertention and type 2 diabsetes presented to the emergency department for one day history of fevers, poor oral intake, and fatigue.

From The Desk Of The Residency Program Director, Emily Stewart, Md, Facp

The Medicine Forum

It has been a historic year for the Nation, City of Philadelphia and teh Jefferson Internal Medicine Residency Program. We have eperienced many health care crises starting with the closure of the historic Philadelphia hospital, Hahnemann. We welcomed residents form this program as part of the Jefferson Family and integrated many patients into our practices.

From The Editors, Eitan Frankel, Md, Guy Katz, Rachel Redfield, Navdeep Sangha, Michael Weintraub, Randi Zukas

The Medicine Forum

We are delighted to present you with the 21st annual edition of The Medicine Forum.Here in the birthplace of our nation, we like to think of The Medicine Forum as being of the housestaff, by the housestaff and for the housestaff. Undeniably, this publication would not be possible without the countless hours dedicated by our residents, students, fellows and faculty.

An Unusual Treatment For Chronic Myelomonocytic Leukemia, Eric Warner, Msiii, Neil Palmisiano, Md

The Medicine Forum

A 76-year-old female with a past medical history of an extraosseous chondrasrcoma status-post-resection thirty years prior, hypertension, hyperlipidemia, and hypothyroidsimm presented to her primary care physicial with fatigue, two weeks of dyspnea on exertion, lightheadedness, and nausea.

Diagnosing Non-Hfe Hereditary Hemochromatosis, Brian Park, Md, Naman Upadhyay, Md, Dina Halegoua-Demarzio, Md

The Medicine Forum

A 63-year-old Caucasian female presented for evaluation of abnormal bile duct appearance on ERCP after being diagnosed with gallstone pancreatitis, duodenal ulcers and gastritis at another hospital.

Pericardial Effusion With Tamponade Physiology In A Patient With Multiple Myeloma, Sairamya Bodempudi, Md, Rukaiya Bashir-Hamidu, Md, Preya Simlote, Md, Shuwen Lin, Md, Philip Margiotta, Md, Tina Boortalary, Md, Gregary D. Marhefka, Md

The Medicine Forum

A 78-yeaer old African American female with a past medical history of IgA Kappa Multiple Myseloma was transfered to the Cardiovascular Intensive Care Unit (CVICU) at Thomas Jefferson University Hospital (TJUH) after being diagnosed with a pericardial effusion with tamponade physiology at an outside hospital.

An Approach To Refractory Hypoxemia, Daniel Garrido, Md, Evan Nardone, Md, Mark Mallozzi, Md

The Medicine Forum

A 74-year-old female with no significant pulmonary history presented as a transfer from an outside hospital for persistent refractory hypoxemia.

Bilateral Intercostal Lung Herniations: A Rare Incidental Finding In A Dyspneic Patient, Jillian Cooper, Md, Christine Kurian, Md

The Medicine Forum

A 63-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD), stage IV sarcoidosis on 3-4 liters of home oxygen and chronic prednisone, moderate aortic stenosis, and a prior aspergilloma for which he had a left upper lobe lung resection presented to the hospital with two weeks of worsening shortness of breath.

The Medicine Forum: Volume 21

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 21, 2019-2020

TABLE OF CONTENTS

Clinical Images

Case Reports

• Cardiology
• Gastroenterology and Hepatology
• Hematology and Oncology
• Infectious Disease
• Pulmonary Medicine

Literature Review

Editorial

No Hard Feelings, Colin Thomas, Md

The Medicine Forum

No abstract provided.

To Those Who Don The White Coat, Cuckoo Choudhary, Md

The Medicine Forum

No abstract provided.

Heart Failure With Preserved Ejection Fraction: A Review Of The Acc/Aha Guidelines And Evidence-Based Management Strategy, Vikas Sunder, Md

The Medicine Forum

Introduction

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome in which a patient has signs and symptoms of heart failure including dyspnea, fatigue, pulmonary rales, peripheral edema and an ejection fraction greater than 50%.1-4 Approximately half of patients with heart failure have a preserved ejection fraction.2-5 HFpEF is considered a distinct clinical entity from other causes of heart failure with a preserved ejection fraction such as valvular heart disease, pericardial disease, and infiltrative cardiomyopathy. HFpEF carries a poor prognosis, with an annual mortality of 29% in patients discharged after an acute decompensated heart failure admission.5 5-year survival …

A Gram-Negative False-Negative: Normal Procalcitonin Level In A Patient With Multiple Klebsiella Pneumoniae Intra-Abdominal Abscesses: A Case Report And Literature Review, Mario Caldararo, Md

The Medicine Forum

Introduction

Despite over 3,000 peer-reviewed articles on procalcitonin (PCT) since 2004, guidance on its usage is sparse.1 An analysis of more than 500 United States hospitals in the Premier Healthcare Database found large differences in utilization exist across regions (115 PCT encounters per 10,000 patients in the Northeast vs. 408 to 576 in other regions) and teaching vs. non-teaching hospitals (345 vs. 530 PCT encounters per 10,000 patients, respectively).2 The purpose of this work is to describe a case that exemplifies the caveats in PCT interpretation and to summarize the current knowledge of the clinical utilization of PCT.

Can Our Hearts Take The New Guidelines?, Eitan Frankel, Md

The Medicine Forum

No abstract provided.

Resident Experiences With Journaling, Tara Sunder, Md, Gretchen Diemer, Md, Vikas Sunder, Md

The Medicine Forum

Background

Each year, medical school graduates don their long white coat for the first time and begin their residency. While residency promises the excitement of learning and increased autonomy, it also brings long duty hours and stressful situations worsened by inexperience. Due to these stressors, burnout affects many residents each year. Studies have been done to see if wellness curricula help decrease resident burnout, and since journaling is a known way to relieve stress and enhance reflection, journaling has become a common intervention in these curricula.1,2 While there are studies evaluating the impact of journaling on mental health and stress …

Pneumatosis Intestinalis In A Patient With Systemic Lupus Erythematosus, Sean Dikdan, Md, Michael Lake, Md

The Medicine Forum

Introduction

Pneumatosis intestinalis (PI) refers to the radiographic finding of gas within the small or large bowel wall. It can be seen in association with gas in the portal venous system. The clinical significance of these findings is variable and depends on the patient's etiology and initial presentation. PI can be seen anywhere in the gastrointestinal tract distal to the stomach and is caused by a myriad of conditions.1 We present a case of a patient admitted to the intensive care unit with PI and portal vein gas.

Hemothorax And Hemorrhagic Ascites: A Rare Presentation Of Endometriosis, Harry Wang, Md

The Medicine Forum

Introduction

Endometriosis is a common diagnosis in reproductive age women characterized by the presence of endometrial tissue outside the uterine cavity.1 Although it is typically confined to the pelvis, rare manifestations involving the thorax, abdomen or pericardium have been documented.2-5 Even more rare is the concurrent presence of endometriosis- associated hemorrhagic pleural effusion and ascites, which can prove a diagnostic challenge. We describe a case of hemothorax and hemorrhagic ascites in a woman with shortness of breath and abdominal pain.

Subacute Onset Hand Clumsiness In A Renal Transplant Patient With A Recent Icu Stay, William Bradford, Md

The Medicine Forum

Introduction

Solid organ transplant recipients carry a high burden of disease and are susceptible to opportunistic infections not seen in other patient subgroups. Signs and symptoms that would not necessarily warrant timely attention in other patient groups may call for an aggressive workup in this subset of patients. Here, we present one case in which a seemingly trivial complaint denoted serious underlying pathology, and timely attention to this minor but unusual concern led to early intervention with appropriate treatment of an uncommon disorder.

Hyperviscosity In Non-Igm Lymphoplasmacytic Lymphoma, Mario Fonseca-Paricio, Md, Sushil Chmire, Md, Adam Binder, Md

The Medicine Forum

The following is a case of how a non-IgM paraproteinemia can present with symptoms of hyperviscosity and coagulopathy, an uncommon occurrence.1-3 As this case demonstrates, this diagnosis must be considered even in patients with relatively normal coagulation laboratory results. Such pathology requires urgent treatment with plasmapheresis.

Worsening Autoimmune Neutropenia After Stopping Ibrutinib In A Patient With Chronic Lymphocytic Leukemia: Case Report And Review Of Literature, Natalie Rosen, Ba, Thomas Klumpp, Md, Sameh Gaballa, Md, Msc

The Medicine Forum

Introduction

Autoimmune cytopenia (AIC) is relatively common in patients with chronic lymphocytic leukemia occurring in 5-10% of patients during the course of their disease.1 Autoimmune hemolytic anemia (AIHA) constitutes the highest prevalence (5-10%) of CLL-associated AIC followed by idiopathic thrombocytopenic purpura (ITP) (2-5%), pure red cell aplasia (PRCA) (<1%), and autoimmune neutropenia (AIN) (<1%).2,3 The prevalence of AIN, however, may in fact be higher than reported due to a lack of awareness of the condition and difficulty in its diagnosis.4 Despite its rarity, autoimmune neutropenia can be a significant clinical challenge in patients with CLL and can increase the risk of infectious complications. Thus, the prompt diagnosis and resolution of CLL-associated AIN is essential to the management of these patients.

Ibrutinib is a selective inhibitor of Bruton tyrosine kinase and induces a durable response in patients with CLL.5 The activity of ibrutinib in CLL-associated AIC is largely unknown as pivotal clinical trials excluded patients with AIC. We report a case of a patient with CLL who experienced worsening of AIN after …

Bilateral Choroidal Metastases As Initial Presentation Of Widespread Follicular Thyroid Cancer, Jennifer Hong, Md

The Medicine Forum

Introduction

Follicular thyroid cancer (FTC) is the second most common malignancy of the thyroid gland and comprise 10-15% of all thyroid tumors; the usual mode of spread is via hematogenous dissemination with the most common sites of metastases being the lungs and bones.4 A case is presented to demonstrate the unusual presentation of follicular thyroid cancer as bilateral choroidal metastases. Although exceptional, a diagnosis of choroidal metastases should be considered in any decline in visual acuity in patients with thyroid cancer.

Complicated Persistent Peritonitis, Lindsey Roth, Ba, Kumar Sarkar, Md

The Medicine Forum

Introduction

Spontaneous bacterial peritonitis (SBP) is a common complication of end-stage liver disease. SBP can present with many symptoms such as abdominal pain, fever and altered mental status.1 The diagnosis of SBP is made when ascitic fluid from a paracentesis has an absolute neutrophil count (ANC) more than 250/uL, there is a positive ascitic fluid culture, and no secondary source of infection can be idenitifed.2 However, nearly 60% of patients with SBP have negative fluid cultures.3 These patients can still potentially have SBP and should be treated as such since in-hospital mortality ranges from 20-40%.1,4 Conventional treatment for SBP includes …

Sealing The Diagnosis Of Celiac Disease In Pregnancy, Ritu Nahar, Md, Avani Aman, Md

The Medicine Forum

Introduction

Celiac disease (CD) is an immune mediated condition that results from a reaction to dietary gluten and primarily affects the small intestine. Genetically predisposed individuals develop a chronic inflammatory state of the small intestine which leads to malabsorption. The disease is mediated by HLA DQ2 or DQ8 haplotypes, which bind the gliadin peptides of gluten, present the peptides to CD4+ T lymphocytes and trigger cytokine and B lymphocyte responses.1

The prevalence of CD in the United States is approximately 1% and can reach up to 4-5% in at-risk groups.2 Serologic study of asymptomatic elderly patients in the United Kingdom …