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P-16: Immunohistochemical Staining To Differentiate An Inflamed Atypical Nevus, Madeline Adelman, Alexis B. Lyons, Lauren Seale, Ben J. Friedman

Case Reports

In the monitoring of patients who have had metastatic melanoma, repeat skin exams at specific intervals is a crucial screening tool to prevent recurrence. At many of these visits, suspicious melanocytic lesions are biopsied to determine if they represent a return of the patient’s melanoma. Here, we present a case of a suspicious atypical melanocytic nevus discovered during a skin exam following diagnosis of metastatic melanoma to a lymph node from an unknown primary lesion. To determine whether this lesion was melanoma, p16 immunohistochemical staining was performed of both the lymph node biopsy and the nevus, and provided a reliable …

Retinal Detachment With Vitreous Hemorrhage Causing Acute Angle Closure Glaucoma, Michael B. Holbrook, Daniel Kaitis, Lily Van Laere, Jeffrey Van Laere, Christopher R. Clark

Case Reports

A 90-year-old female with past medical history of trigeminal neuralgia presented with a four-day history of a left-sided headache, nausea, vomiting, and vision loss in her left eye and one month of intermittent flashes of light in her left eye. Her left eye was diffusely injected with a cloudy cornea and fixed, mid-dilated, and non-reactive pupil. The vision in her, right eye was 20/200 with an intraocular pressure (IOP) of 16 mm Hg; her left eye was no light perception (NLP) with an IOP of 56 mm Hg. She was started on dorzolamide, brimonidine, and latanoprost eye drops. A bedside …

An Atypical Case Of Hemolytic Anemia, Hussna E. Abunafeesa

Case Reports

Introduction: Tumor lysis syndrome (TLS) is a well-known oncologic emergency that can cause significant morbidity and mortality in highly proliferative tumors such as Lymphomas or Leukemias(1). Rasburicase is a recombinant urate oxidase enzyme that converts uric acid to allantoin, which is 5 to 10 times more soluble in urine than uric acid. It is recommended by the 2008 American Society of Clinical Oncology (ASCO) Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome as the initial management of patients with a high risk of developing TLS and in patients with intermediate-risk if hyperuricemia occurs despite allopurinol prophylaxis(2). G6PD-deficient …

Taking Abdominal Pain Seriously: A Case Of Aggressive Dedifferentiated Liposarcoma, Sally Fk Askar, Hiba Jabbour, Philip Kuriakose

Case Reports

Case Description: A 64 year-old female with history of PE on Eliquis with IVC filter placement, tobacco dependence, and class III obesity presents with abdominal discomfort and bilateral leg swelling. Physical examination showed a distended abdomen and bilateral leg edema and tenderness. Doppler ultrasound of the lower extremities showed extensive bilateral lower extremity deep vein thromboses (DVT). Patient developed oliguria and acute kidney injury, and ultrasound of the kidney was obtained. Kidney U.S. showed two large masses in the abdomen and pelvis. CT of the abdomen/pelvis demonstrated a mesenteric mass measuring up to 26 cm in the right mid-abdomen with …

Broken Heart, Broken Mind, Taha Ashraf, Ivan M. Columbus Morales, Avi Cohen

Case Reports

Introduction: Takostubo Cardiomyopathy (TCM) is a unique condition of reversible cardiac dysfunction precipitated by emotional or physical stress. Studies are emerging noting an association with Amyotrophic Lateral Sclerosis (ALS). This is hypothesized to be secondary to baseline elevation of catecholamines in these individuals.

Case Presentation: A 53-year-old female with background of anxiety, presented with acute onset chest pain. Initial evaluation revealed elevated troponins without ST changes on EKG. Echocardiogram showed EF 28% with apical ballooning and left heart catheterization was unremarkable. Her echocardiogram improved 2 weeks later, consistent with TCM. During this evaluation it was noted she was significantly dysarthric. …

A Novel Endoscopic Treatment For Blue Rubber Bleb Nevus Syndrome, Khaled Almadhoun, Diana Kakos, Georgi Fram, Anas Kutait

Case Reports

Introduction: Blue Rubber Bleb Nevus Syndrome (BRBNS), also known as Bean Syndrome, is a rare congenital disorder characterized by numerous, cutaneous and internal venous malformations, most commonly involving the skin and gastrointestinal tract (GI). Patients with GI manifestations present with iron deficiency anemia due to recurrent GI hemorrhage from the oozing venous malformations. Due to the rarity of the condition, there are no defined guidelines for the management of BRBNS, further highlighting the need for case reports to dictate therapy.

Case Presentation: We present a case of an 83-year-old male who presented with a GI bleed due to an unknown …

Bilateral Segmental Optic Disc Edema In Vitamin B1 Deficiency, Andre Aung, Sachin Gandhi, Poonam Bansal

Case Reports

Introduction: Thiamine is an important vitamin that serves as a crucial cofactor for glucose metabolism. As a result, thiamine deficiency affects many organ systems and can lead to significant morbidity and mortality. The brain heavily relies on glucose metabolism and is thus particularly susceptible to thiamine deficiency. Consequently, thiamine deficiency can lead to Wernicke’s encephalopathy (WE), a clinical syndrome consisting of the triad of ataxia, confusion, and ophthalmic abnormalities (Wei-Yi et al. 2013). At times, ophthalmologic manifestations, which include optic neuropathy, ophthalmoparesis, and nystagmus, provide the first clue of a thiamine deficiency. Optic neuropathy is the rarest presentation, only present …

Eagle Syndrome Presenting In A Patient As Dysphagia And Failed Intubations, Alison Bradley, Natalie Stec, Sean Drake

Case Reports

Eagle syndrome is a rare elongation of the styloid process or calcification of the stylohyoid ligament. Most cases are asymptomatic but compression on head and neck structures can result in dysphagia and neck pain. Etiology may be related to surgical scar tissue but is unclear due to limited case presentation. A 52 year-old male with surgical history of tonsillectomy presented to the hospital with shortness of breath. He developed sudden onset dyspnea and pink frothy sputum. He desaturated and was put on BiPaP in the ED. Chest X-ray revealed flash pulmonary edema and he was admitted for hypoxic respiratory failure. …

Case Report: Four Extremity Compartment Syndrome Fasciotomy Resulting From Influenza A Viral Myositis; A Rare Complication, Eric Chen, Arion Lochner, Robert Cesaro

Case Reports

Influenza A and B commonly cause benign respiratory disease in humans but can cause more severe illness in higher risk populations. From 2009-2015 there was only one reported case in the English literature with the formal diagnosis of compartment syndrome as a complication from influenza. We report an unusual case of a previously healthy adult patient who presented with myocarditis and severe rhabdomyolysis secondary to influenza A infection, which resulted in atraumatic compartment syndrome of all four extremities each requiring emergent fasciotomy. The patient was subsequently managed with delayed primary closure and skin grafting in the operating room. Prompt recognition …

Advanced Systolic Heart Failure In Undiagnosed Cardiac Amyloidosis, David Gelovani, Zachary Demertzis, Gillian Grafton

Case Reports

Introduction: Transthyretin (TTR) amyloidosis is a life-threatening disease characterized by extracellular deposition of hepatocyte derived TTR with hereditary and acquired variants. Although there are over 120 genetic mutations in the (TTR) gene, only a few are responsible for hereditary TTR amyloidosis. The most common mutation in African-Americans is Val142Ile substitution, occurring with a frequency of 3.5%. Accumulation of misfolded TTR within the myocardium results in cardiac restriction and dysfunction, most commonly presenting as heart failure with preserved ejection fraction. Delay of diagnosis is associated with elevated cardiac biomarkers, worsening patient outcomes, and an unfavorable prognosis in a potentially treatable and …

Terson’S Syndrome: An Underdiagnosed Complication Of Subarachnoid Hemorrhage, Danielle Gabe, Hisham Alhajala, Mariam Hamid, Bradley Howell

Case Reports

Background: Terson Syndrome refers to an intraocular hemorrhage in patients with severe subarachnoid hemorrhage (SAH), traumatic brain injury or intracerebal hemorrhage. The mechanism of injury is due to increased intracranial pressure which transmits into the optic nerve sheath and causes rupture of the retinal vessels. Despite its relatively common incidence, the syndrome remains under diagnosed or delayed because it usually occurs in severely ill patients with depressed level of consciousness. Early recognition of the intraocular hemorrhage on head CT and treatment can be significant to patient's outcome.

Case Description: We present a 46-year-old man with a past medical history of …

Hypertriglyceridemia Induced Pancreatitis: A Cost-Effective Management Approach, Sonika Gill

Case Reports

Hypertriglyceridemia (HTG) induced pancreatitis causes up to 15% of cases of acute pancreatitis, typically occurring in patients with triglyceride levels >1,000 mg/dL. HTG occurs in primary(genetic) and secondary disorders of lipoprotein metabolism. Secondary causes include diabetes, pregnancy, medication, alcoholism, and thyroid disorders. Our case involves a 45-year old male former alcohol user who presented with acute epigastric abdominal pain and bilious emesis. On exam, he severe epigastric tenderness with guarding, normoactive bowel sounds. When obtaining labs, his blood was turbid. Labs were significant for elevated Lipase (1,534IU/L), total cholesterol (915mg/dL), triglycerides (>5,250mg/dL),and incalculable LDL and HDL. He was hypocalcemic(7.7 …

Splenic Artery Embolization For Idiopathic Warm Autoimmune Hemolytic Anemia Refractory To Medical Therapy, Mohamad O. Hadied, Riyad Y. Kherallah, Mariam Salman, Khalid Eteer, Scott Schwartz

Case Reports

Purpose: While Partial Splenic Artery Embolization (PSAE) is a useful procedure that has been performed for a variety of indications including trauma and hypersplenism, it has been rarely described as a treatment for Idiopathic warm Autoimmune Hemolytic Anemia (AIHA). Previous reports in the literature are limited to case reports in situations that include the patient being a poor surgical candidate, the inability to transfuse blood during surgery because of autoantibodies, and a patient's refusal of blood products on religious grounds. The purpose of this study is to demonstrate the utility of PSAE in the acute management of AIHA refractory to …

Rasburicase-Induced Reds And Blues, Zakaa Hassan, Tanya Belle, Gina Hurst

Case Reports

Introduction: G6PD deficiency (G6PDD) is a genetic disorder resulting in low levels of the G6PD enzyme which plays a key role in preventing cellular damage from oxidative stress. We report a case of newly diagnosed G6PDD manifesting as methemoglobinemia (MetHb) and non-autoimmune hemolytic anemia (NIHA) following Rasburicase administration in an elderly male.

Case: A 78-year-old male with a history of untreated chronic lymphocytic leukemia (CLL), congestive heart failure and hypertension presented with altered mental status and acute kidney injury. Initial labs revealed a creatinine of 6.89 mg/dL, potassium of 5.2, phosphate of 6.1, calcium of 9.0, uric acid of 13.9, …

Sinam: A Rare Case Leading To Respiratory Failure, D. Christine Hermiz, Patrick Bradley

Case Reports

Introduction: Statins are commonly prescribed in primary care offices daily; however, they are not exempt from adverse effects. Statin-induced myopathies are best described on a continuum, as patients can range widely in presentation. The most extreme of cases displaying respiratory distress, quadriparesis, dysphagia, and rhabdomyolysis. Cases on the severe end of the spectrum with respiratory failure are exceedingly rare and should be shared with the medical community in order to gain more insight into the types of statins most at risk for causing complications, most effective treatments based on disease severity, as well as characteristics and objective findings among affected …

Case Report: Hypersensitivity Mediated St-Elevation Myocardial Infarction—“Kounis Syndrome With Cronovich Phenomenon”, Joseph Jabour, Heather Cronovich

Case Reports

Introduction: ST elevation myocardial infarction in concurrence with angioedema, anaphylaxis, hypersensitivity, or platelet activation is an event well published in literature known as Kounis-Syndrome. Classically, these events are linked by the administration of epinephrine either intravenously or intramuscularly for the treatment of the acute immunologic response.

Case Report: This particular case is a 78 year old male with history of c1 esterase inhibitor deficiency, angioedema, and hypertension presenting with angioedema. His symptoms started the previous night and were managed in the ED with methylprednisolone, diphenhydramine, and famotidine. The patient was intubated for airway protection and extubated about 24 hours later. …

Recurrent Benign Lymphocytic Meningitis In A 66-Year-Old Male Diagnosed With Mollaret Syndrome. Is Suppressive Therapy Necessary?, Khaled Jamoor, Rita Kassab, Niluka Weerakoon

Case Reports

Mollaret syndrome is a rare form of recurrent lymphocytic meningitis. It is defined as recurrent episodes of acute attacks that last usually few days and separated by symptom free periods that can last months to years. Herpes simplex virus 2 (HSV-2) is responsible for the majority of cases. Diagnosis is usually made by isolating the virus DNA from the CSF. Treatment with antivirals as a herpetic infection has been used and showed some success. Here we present a 66-year old male with past medical history of genital herpes who presented with his third episode of meningitis. Patient presented with low …

You See, I See, We All See Uc, Katherine Joyce, Jody S. Chou, Zachary Hanna

Case Reports

A 21 year old male with a six month history of biopsy-proven ulcerative colitis presented to Henry Ford with worsening abdominal pain and rectal bleeding despite steroid therapy. Upon CT evaluation, the patient was found to have a significant mass of the descending colon. Biopsy was completed and showed EBV+ B-cell lymphoma. The patient’s clinical course was complicated by bowel perforation, but he was ultimately able to receive chemotherapy and treatment.

Chicken Coop-Induced Hemophagocytic Lymphohistiocytosis, Ahmed Kazem, Odaliz Abreu-Lanfranco

Case Reports

Introduction: Hemophagocytic lymphohistiocytosisis (HLH) is a rare and often fatal condition characterized by an overactive but ineffective response of the immune system. There have been several documented causes, which include genetic predisposition, malignancy, infection, autoimmune disease, and chronic immunosuppressive therapy.

Case Presentation: A 42 year-old woman with a two year history of ankylosing spondylitis, who was recently initiated on Infliximab, presented with abdominal pain, fevers, and jaundice. She had a temperature of 104F and a leukocytosis. She was suspected to have acute cholangitis and was initially treated with antibiotics, however, several imaging studies, including ultrasound, HIDA, and MRCP did not …

Morphea Affecting Bilateral Ankles, Katherine Kloberdanz, Chris Olenech

Case Reports

Clinical Presentation: 65-year-old female with past medical history of diabetes, hypothyroidism, and arthritis presented to the podiatry clinic on 12/21/2018 complaining of increased swelling, pain, and skin darkening to bilateral dorsal ankles and stiffening of her ankle joints for two months. Patient also had multiple hyperpigmented firm plaques on her back, neck, and all four extremities. Patient had recently been seen by her rheumatologist. Lab work from that visit revealed she was ANA+ and SSA+. The lesion on her neck was also biopsied and showed dermal sclerosis consistent with morphea (localized scleroderma). Therefore, she was diagnosed with morphea and Sjogren’s …

Case Report: New Onset Of Febrile Episodes On Low Doses Of Clozapine In Sicu Setting, Adan Khan, Christopher Busuito, Aimee Dereczyk

Case Reports

Clozapine, a tricyclic dibenzodiazepine derivative, is an antipsychotic used in treatment resistant Schizophrenia to treat positive and negative symptoms of psychosis (1). It is also used for reduction in the risk of suicidal behavior in individuals with Schizophrenia and Schizoaffective disorders (1). However, it is a medication that is often used after trials of other antipsychotics have failed due to the concerns related to side effects. Some common side effects of Clozapine include agranulocytosis, seizures, cardiovascular and pulmonary effects, neuroleptic malignant syndrome, hepatitis, anticholinergic toxicity and fever (3). The prevalence of febrile episodes range from 0.5% - 55% (depending on …

A Tale Of Two Nets: A Pheochromocytoma Masquerading As A Pancreatic Net, Adam A. Kudirka, Nino Balanchivadze

Case Reports

Introduction: Neuroendocrine tumors (NETs) are rare endocrine neoplasms with myriad of clinical manifestations. We present a case of two different NETs in a patient to increase physician awareness and highlight the importance of prompt multidisciplinary approach to avoid catastrophic complications.

Case Presentation: A 58-year-old female with history of hypertension, diabetes mellitus and gastroesophageal reflux was referred to an oncology office for systemic therapy regarding suspected metastatic pancreatic neuroendocrine tumor based on abdominal imaging demonstrating a 1.6 cm pancreatic lesion and a 1.2 cm hypervascular right adrenal nodule. Endoscopic ultrasound with fine needle aspiration/biopsy of the pancreatic lesion was consistent with …

Pembrolizumab (Keytruda®) Associated Diabetic Ketoacidosis In A Previously Nondiabetic Patient, Han Lam, Jason Rosner, Misha Masumy, Ashish Verma

Case Reports

Immune checkpoint inhibitors have been shown to be an essential part of cancer treatments, however there have been reported immune related adverse events. Type 1 diabetes was reported in only 0.1% of the patients in clinical trials of Pembrolizumab, a programmed cell death 1 (PD-1) inhibitor. We present a case of pembrolizumab associated DKA in a previously nondiabetic. Patient is a 75yo male with a history of carcinoma in situ of the bladder, prostate cancer, carcinoma of unknown primary (had been on Atezolizumab, Taxotere), CKD presents to the hospital with fatigue, weakness and diarrhea. Of note, the patient was recently …

An Unexpected Cause Of Small Bowel Obstruction In An Elderly Gentleman, Ana Lozano, Shyamal Pansuriya, Shivanhalli Prakash

Case Reports

Introduction: When compared to children, intussusception is rare in adults. It comprises only 5% of all intussusceptions and represents only 1% of all bowel obstructions. The mean age in adults is 50 years of age with no gender predominance. It typically presents with nonspecific symptoms and clinical findings. Thus, it is important to maintain a broad differential in order to avoid delay in diagnosis and treatment.

Case presentation: We discuss the case of a 93-year-old male with surgical history of open appendectomy who presented to the emergency department with intermittent episodes of diffuse abdominal cramping. On physical exam, abdomen was …

Management Of Traumatic Coracoid Fracture And Anterior Shoulder Instability With A Modified Arthroscopic Latarjet Technique, Shariff Bishai, Colby Ward, Melissa Martinez, Cameron King, Jonathan Hinz

Case Reports

Abstract: Coracoid fractures are an uncommon injury and typically occur in the setting of high energy trauma. Isolated injury to the coracoid is rare therefore a high suspicion for concomitant shoulder injury should exist. These associated injuries have been shown to be acromioclavicular dislocations, clavicular and acromial fractures, scapular spine fractures, rotator cuff tears, and anterior shoulder dislocations. While the majority of these shoulder injuries respond to non-surgical treatment, there are case reports and literature reviews that present more complicated injuries requiring surgical intervention. Shoulder dislocations with associated coracoid fractures can also manifest glenoid bone loss resulting in continued instability. …

Tumefactive Multiple Sclerosis, An Uncommon Variant With Several Mimics, David Macon

Case Reports

Tumefactive multiple sclerosis is a rare variant of multiple sclerosis that poses both diagnostic and therapeutic challenges for medical providers. This variant occurs infrequently, with an incidence of approximately 1-3 per 1000 cases of multiple sclerosis, with clinical features that make it difficult to distinguish from CNS neoplasm, infection, or infarction. Symptoms are highly variable, depending on areas of the brain affected, possibly impacting sensory, motor, and cognitive function. Serum labs may not reveal any specific abnormality, though CSF studies often contain oligoclonal band cells. Typical radiologic features identified in tumefactive MS may include the following; singular or multiple contrast …

Three Lives At Stake: A Case Of Acute Myocardial Infarction In A Patient With Twin Pregnancy, Anthony Michaelis, Satheesh Gunaga, Tyson Mckechnie, Brandon Baroff, Qaiser Shafiq

Case Reports

An acute myocardial infarction (AMI) is a rare complication of pregnancy. The incidence ranges between 3 to 100 per 100,000 live-births. Risk factors include common comorbidities such as smoking, hypertension, hyperlipidemia, diabetes mellitus, sedentary life-style, and obesity. Pregnancy carries additional unique AMI risk factors including advanced maternal age, preeclampsia, thrombophilia, postpartum infection/sepsis and hemorrhages. We describe the unique case of an acute ST-elevation myocardial infarction (STEMI) in a 37 year old woman at 24 weeks gestation with a dichorionic/diamniotic (DCDA) pregnancy. Through serial EKGs and echocardiography, a diagnosis was able to be made despite an atypical clinical presentation of AMI …

An Unusual Case Of Urban Actinomyces Pyogenes Infective Endocarditis, Maher Musleh, Anita Ukani, Zain Tariq, Erica Herc

Case Reports

Actinomyces pyogenes is a gram positive bacillus known to cause pyogenic infections in animals with rare reports in humans with farm animal exposure. A 52-year-old male who was an active injection drug user presented to the emergency department with right-sided weakness, expressive aphasia, and altered mental status. He was found to be tachycardic and febrile. The patient was admitted two weeks prior for bilateral pneumonia and blood cultures grew Actinomyces pyogenes. Infectious Diseases was not consulted during that admission. On this admission, CT head showed a large left MCA ischemic stroke. Further imaging was concerning for septic emboli to the …

A Case Of Suspected Delirious Mania Treated With Benzodiazepines, Hala Katato, Mohan Gautam, Esther Akinyemi

Case Reports

Delirious mania is a life-threatening syndrome characterized by rapid onset of delirium, mania, psychosis, and catatonia. It is crucial to include this in a differential as this condition responds poorly to traditional pharmacotherapeutic management of delirium or mania. Here, we present the case of a 71-year-old African American woman who was hospitalized with symptoms presenting as hyperactive delirium. She was found to have a UTI, which was treated, and she was discharged. However, due to the persistence of her psychiatric symptoms, she was brought back to the hospital. To target symptoms of hyperactive delirium, haloperidol was utilized as needed. However, …

Low Dose Ketamine For Opioid Refractory Cancer Pain, Michelle Nguyen, Anthony S. Grech

Case Reports

Background: Sub-anesthetic ketamine is used in the hospice and palliative setting to provide analgesia for opioid refractory cancer pain. While there are case reports supporting its use for this indication, results from the few studies done are mixed. Additionally, there are no widely agreed upon guidelines for dosing. The heterogeneous results may be attributed to small sample sizes and differing doses and routes of administration of ketamine. The objectives of this case presentation is to describe the successful use of sub-anesthetic ketamine in the management of high dose opioid refractory cancer pain and to propose a new area of study …