Internal Medicine Commons^™

The Role Of Bispecific Antibodies In Relapsed Refractory Multiple Myeloma: A Systematic Review, Razwana Khanam, Omer S. Ashruf, Syed Hamza Bin Waqar, Zunairah Shah, Saba Batool, Rameesha Mehreen, Pranali Pachika, Zinath Roksana, Mohammad Ebad Ur Rehman, Faiz Anwer

Abington Jefferson Health Papers

Multiple myeloma is a heterogeneous clonal malignant plasma cell disorder, which remains incurable despite the therapeutic armamentarium's evolution. Bispecific antibodies (BsAbs) can bind simultaneously to the CD3 T-cell receptor and tumor antigen of myeloma cells, causing cell lysis. This systematic review of phase I/II/III clinical trials aimed to analyze the efficacy and safety of BsAbs in relapsed refractory multiple myeloma (RRMM). A thorough literature search was performed using PubMed, Cochrane Library, EMBASE, and major conference abstracts. A total of 18 phase I/II/III studies, including 1283 patients, met the inclusion criteria. Among the B-cell maturation antigen (BCMA)-targeting agents across 13 studies, …

The Reflection On The Management Of Toxic Epidermal Necrolysis In The Community Setting: An Internist's Perspective, Qian Zhang, Ali Raza Shaikh, Thomas Yoon, Shreeja Shah Shah, James W. Mahoney

Abington Jefferson Health Papers

Toxic epidermal necrolysis (TEN) is a dermatological emergency that is often associated with high mortality. It is differentiated from Stevens-Johnson syndrome (SJS) based on the percentage of the total body surface area affected. There has been an established correlation with certain medications that could trigger the development of such a devastating disease. Despite numerous research studies conducted on aspects of this disease entity, TEN remains foreign to many general Internists situated in a community setting due to the extremely low disease prevalence that leads to a lack of overall experience and medical resources in dealing with this medical condition. Thus, …

Effects Of Left Ventricular Assist Device On Pulmonary Functions And Pulmonary Hemodynamics: A Meta-Analysis, Waqas Ullah, Casey Meizinger, Zain Ali, Ankur Panchal, Rehan Saeed, Donald C. Haas, Eduardo Rame

Abington Jefferson Health Papers

BACKGROUND: Given current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.

AIM: To better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.

METHODS: Electronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.

RESULTS: A total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity …

Medical Therapy Vs Early Revascularization In Diabetics With Chronic Total Occlusions: A Meta-Analysis And Systematic Review, Muhammad Shayan Khan, Farhad Sami, Hemindermeet Singh, Waqas Ullah, Ma'en Al-Dabbas, Khalid Hamid Changal, Tanveer Mir, Zain Ali, Ameer Kabour

Abington Jefferson Health Papers

BACKGROUND: Management of chronic total occlusions (CTO) in diabetics is challenging, with a recent trend towards early revascularization [ER: Percutaneous coronary intervention (PCI) and bypass grafting] instead of optimal medical therapy (OMT). We hypothesize that ER improves morbidity and mortality outcomes in diabetic patients with CTOs as compared to OMT.

AIM: To determine the long term clinical outcomes and to compare morbidity and mortality between OMT and ER in diabetic patients with CTOs.

METHODS: Potentially relevant published clinical trials were identified in Medline, Embase, chemical abstracts and Biosis (from start of the databases till date) and pooled hazard ratios (HR) …

The Difficult Clinical Decision Of Thrombolytic Therapy For Submassive Pulmonary Embolism In A Community Hospital., Qian Zhang, Jonathan Vayalumkal, John Ricely, Daniel L. Gray, Ahmad Raza

Abington Jefferson Health Papers

Submassive or intermediate-risk pulmonary embolism (PE) occurs when an acute PE episode is associated with radiographic evidence of right heart strain without hemodynamic instability. Further risk stratification is important in determining whether systemic thrombolytic therapy should be administered when weighing the risks and benefits. It includes the risk of death from acute PE versus the risk of bleeding. This decision could be further complicated in institutions where there is a lack of complete therapeutic options, which increases the importance of the expertise of a pulmonologist or an intensivist to decide whether rescue reperfusion is needed. We describe the case of …

"Brain Dead" Donor: A Case Of Brain Death Mimic Due To Pentobarbital Overdose, Artem Minalyan, Vincent Chan, Qian Zhang

Abington Jefferson Health Papers

No abstract provided.

A Community Assessment Of Rapid Response Team Events Preceding Cardiopulmonary Arrest: Does It Improve Outcomes?, Vincent Chan, Ahmad Raza, Qian Zhang, Artem Minalyan, Rajesh Patel

Abington Jefferson Health Papers

No abstract provided.

An Unlikely Combination Of Neutrophilic Predominant Pleural Effusion With Acid-Fast Bacilli Positivity, Vincent Chan, Qian Zhang, Ahmad Raza, Artem Minalyan, William Ward

Abington Jefferson Health Papers

No abstract provided.

Rare Cause Of Fatal Liver Disease: A Case Of Acute Liver Failure In A Patient With Recently Diagnosed Metastatic Ovarian Carcinoma, Artem Minalyan, Qian Zhang, Vincent Chan

Abington Jefferson Health Papers

No abstract provided.

A Roller Coaster Ride Of Idiopathic Fibrosing Mediastinitis, Qian Zhang, Khine Shan

Abington Jefferson Health Papers

No abstract provided.

Survival Analysis Based On The Duration Of Cpr After In-Hospital Cardiac Arrest, Ahmad Raza, Nayab Nadeem, Ahmad Arslan, Zain Ali, Qian Zhang, Usama Sadiq, Rajesh Patel

Abington Jefferson Health Papers

No abstract provided.

The Awareness Of Negative Pressure Pulmonary Edema In The Medical Intensive Care Unit., Qian Zhang, Jonathan Vayalumkal, John Ricely, Sarah Elrod, Ahmad Raza

Abington Jefferson Health Papers

Negative pressure pulmonary edema (NPPE) is a noncardiogenic-related rapid onset of bilateral pulmonary edema secondary to various etiologies that lead to upper airway obstruction. Despite the fact that it is more commonly seen in the emergency department (ED), pediatric intensive care unit (PICU), and the postanesthesia care unit (PACU), there is a lower disease prevalence in the medical intensive care unit (MICU) as it sometimes could be overlooked upon. Prompt treatment often leads to favorable clinical outcomes. We detail a 55-year-old lady with a past medical history of nephrolithiasis, obesity, and obstructive sleep apnea presented with right flank pain due …

Hamman-Rich Syndrome: A Diagnosis Of Exclusion In The Covid-19 Pandemic., Qian Zhang, Ahmad Raza, Vincent Chan, Artem Minalyan, John Madara, Md

Abington Jefferson Health Papers

Hamman-Rich syndrome is a rapidly progressive interstitial lung disease with acute respiratory distress syndrome physiology. It carries a grave prognosis and a high early mortality rate. It is often distinguished from other similar pulmonary pathologies based on the clinical course, laboratory findings, bronchoalveolar lavage testing, and pathology report. We detail a 77-year-old lady with no prior pulmonary disease, smoking history, or occupational and environmental exposures present to the emergency department found to be in acute hypoxic respiratory failure with impressive progressive radiographic findings. The presumptive diagnosis of Hamman-Rich syndrome was made based on a combination of factors after ruling out …

A Mysterious Paratracheal Mass: Parathyroid Carcinoma., Qian Zhang, Khine S. Shan, Neethu Gopisetti, Md, Thomas Yoon, Iqra Iqbal

Abington Jefferson Health Papers

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. We detail a 60-years-old gentleman who was otherwise healthy presented to the hospital due to acute encephalopathy. He was subsequently found to have parathyroid carcinoma as the cause of the acute encephalopathy with impressive serum calcium and parathyroid hormone levels. The parathyroid carcinoma was later surgically resected with the diagnosis confirmed via pathology specimen. The patient was safely discharged from the hospital with recommendations of close routine outpatient followup.

A Silent Fatal Presentation Of Pulmonary Embolism: Reflection And Discussion., Qian Zhang, Zain U. Abideen, Khine S. Shan, Thomas Yoon, Muhammad Farooq

Abington Jefferson Health Papers

Acute pulmonary embolism is a common medical condition that clinicians face in practice. It is important to have a prompt diagnosis with proper management as it is associated with high morbidity and mortality. However, a timely diagnosis is often difficult to obtain especially when the presenting symptoms are atypical, but the consequence could be fatal. We present an 80-year-old gentleman who presented with a near-syncope episode who subsequently was found to have acute extensive bilateral pulmonary embolisms after a code blue event.

A Mysterious Paratracheal Mass: Pulmonary Agenesis., Qian Zhang, Khine S. Shan

Abington Jefferson Health Papers

A 35-year-old lady with a history of possible tuberculosis infection 15 years ago presented to the clinic with the chief complaint of cough. Incidental chest CT showed a right paratracheal and medial right apical heterogeneous soft tissue mass with central areas of calcification that warranted further investigation. A routine endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) discovered isolated lobar pulmonary agenesis as the underlying cause of the mass without findings of malignancy on pathology reports.

An Exceedingly Rare Presentation Of Severe Folate Deficiency-Induced Non-Immune Hemolytic Anemia., Qian Zhang, Khine S. Shan, Babatunde A. Ogunnaike, Atsoufi Amewuame-Kpehor, Travis Nace

Abington Jefferson Health Papers

Macrocytic anemia is usually associated with vitamin B12 or folate deficiency. However, folate deficiency was rarely reported as a cause of hemolytic anemia. We present a case of a young man with a history of alcohol abuse who initially presented with an acute on chronic abdominal pain and was found to have jaundice and scleral icterus. His liver enzymes were unremarkable, and his abdominal imaging did not reveal any acute pathology. However, he was found to have a severe non-immune hemolytic anemia secondary to folate deficiency.

Efficacy Of Allopurinol In Cardiovascular Diseases: A Systematic Review And Meta-Analysis, Waqas Ullah, Shristi Khanal, Rozi Khan, Bikash Basyal, Samavia Munir, Artem Minalyan, M. Chadi Alraies, David L. Fischman

Abington Jefferson Health Papers

Background: Given current evidence, the use of allopurinol for the prevention of major cardiovascular events (acute cardiovascular syn-drome (ACS) or cardiovascular mortality) in patients undergoing cor-onary artery bypass graft (CABG), after index ACS or heart failure remains unknown.

Methods: Multiple databases were queried to identify studies com-paring the efficacy of allopurinol in patients undergoing CABG, after ACS or heart failure. The unadjusted odds ratio (OR) was calculated using a random effect model.

Results: A total of nine studies comprising 850 patients (allopurinol 480, control 370) were identified. The pooled OR of periprocedural ACS (OR: 0.25, 95% confidence interval (CI): 0.06 …

Diagnostic Accuracy Of Cardiac Magnetic Resonance Versus Fractional Flow Reserve: A Systematic Review And Meta-Analysis., Waqas Ullah, Sohaib Roomi, Hafez M. Abdullah, Maryam Mukhtar, Zain Ali, Ping Ye, Donald C. Haas, Vincent M. Figueredo

Abington Jefferson Health Papers

Background: Fractional flow reserve (FFR) is considered the gold standard for diagnosis of coronary artery disease (CAD). Stress Cardiac magnetic resonance (SCMR) has been recently gaining traction as a non-invasive alternative to FFR.

Methods: Studies comparing the diagnostic accuracy of SCMR versus FFR were identified and analyzed using Review Manager (RevMan) 5.3 and Stata software.

Results: A total of 28 studies, comprising 2,387 patients, were included. The pooled sensitivity and specificity for SCMR were 86% and 86% at the patient level, and 82% and 88% at the vessel level, respectively. When the patient-level data were stratified based on the FFR …

A Rare Association Of Takotsubo Cardiomyopathy With Neuroleptic Malignant Syndrome, Waqas Ullah, Muhammad Arslan Cheema, Ammar Ashfaq, Maryam Mukhtar, Zain Ali, Mamoon Ur Rashid, Vincent Figueredo

Abington Jefferson Health Papers

Neuroleptic malignant syndrome is a potentially fatal neurological condition secondary toantipsychotic medication. It is characterized by distinctive clinical findings and autonomicdisturbances. NMS has not been associated with Takotsubo cardiomyopathy (TCM).

TCM is an abnormal response to physiological stressors resulting from the autonomicabnormalities which at times can mimic myocardial infarction (MI). We present a unique caseof a 54-year-old female with bipolar disease presenting with lithium and haloperidol-inducedNMS complicated by TCM. The purpose of this case is to make clinicians aware of this rareassociation.

A Rare Presentation Of Coronavirus Disease 2019 (Covid-19) Induced Viral Myositis With Subsequent Rhabdomyolysis., Qian Zhang, Khine S. Shan, Artem Minalyan, Conor O'Sullivan, Travis Nace

Abington Jefferson Health Papers

A 38-year-old gentleman with no significant past medical history but had recent COVID-19 exposure presented to the hospital with the chief complaints of fever, shortness of breath, and generalized myalgia. He was unfortunately found to be severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive. Laboratory findings showed creatine kinase (CK) >42,670 U/L along with elevated inflammatory markers and unremarkable creatinine, cardiac troponin level. The cause of his rhabdomyolysis was discovered to be due to COVID-19 as he had no evidence of other viral infections, strenuous exercise, seizure, or other nontraumatic exertional etiologies. He received aggressive fluid resuscitation while we trended …

A Rare Case Of Coronary Artery Thrombosis In A Patient With Recently Diagnosed Giant Cell Arteritis: Is Anticardiolipin Antibody Involved?, Khine S. Shan, Qian Zhang, Sharmila Bisaria, Anubha Tewary

Abington Jefferson Health Papers

Giant cell arteritis (GCA) is an immune-mediated systemic inflammation of large-sized arteries that predominantly affects elderly women. It may be considered as one of the risk factors for acute coronary syndrome (ACS). Moreover, patients with GCA may have increased anticardiolipin antibodies (aCL). However, its relationship with antiphospholipid syndrome (APS) is not clear. We present a case of a unique presentation of GCA with a connection to both ACS and APS. A 76-year-old woman who initially presented to the hospital with a chief complaint of intermittent unilateral headache, blurry vision along with transient aphasia was found to have a biopsy confirmed …

Novel Coronavirus (2019-Ncov) In Disguise, Qian Zhang, Annyella Douglas, Zain U. Abideen, Shristi Khanal, Stephanie Tzarnas

Abington Jefferson Health Papers

Novel coronavirus (2019-nCoV) pandemic is currently one of the most influential topics as it not only impacts the field of medicine but most importantly, it affects the lives of many individuals throughout the world. We report an interesting 2019-nCoV case in a tertiary community hospital with the initial concern of acute pyelonephritis without respiratory symptoms that ultimately led to the quarantine of a number of healthcare providers. This case emphasizes the importance of radiological evidence in diagnosing 2019-nCoV in the setting of an initial atypical presentation. It also serves as an example of how healthcare providers may need to increase …

Proprotein Convertase Subtilisin/Kexin Type-9 (Pcsk-9) Inhibitors Induced Liver Injury - A Retrospective Analysis., Yousuf Zafar, Yasar Sattar, Waqas Ullah, Sohaib Roomi, Mamoon-Ur- Rashid, Muhammad Shayan Khan, Laura Schmidt

Abington Jefferson Health Papers

Background: Proprotein convertase subtilisin/Kexin type 9 (PCSK-9) inhibitors induced liver dysfunction in patients with or without previous liver injury, and this is not well discussed in the previous literature.

Methods: A total sample of 202 patients were retrospectively reviewed at the University of Missouri, Kansas City, from the year 2015 to 2018 based on predefined selection criteria. Inclusion criteria involved patients with dyslipidemia, with or without PCSK-9 inhibitors, liver function tests and lipid profile at baseline and at a mean of 6-month follow-up. The variables, including age, gender, and confounding factors like other medications (statin, oral antidiabetic, and antihypertensive) induced, …

Role Of Echocardiography In Diagnostic Evaluation Of Patients Admitted To Observation Unit., Muhammad Arslan Cheema, Hafez Mohammad Ammar Abdullah, Waqas Ullah, Yasar Sattar, Shujaul Haq, Khadija Cheema, Asrar Ahmad, Zain Ali, Asoka Balaratna

Abington Jefferson Health Papers

BACKGROUND: Syncope is a transient loss of consciousness due to transient decrease in cerebral perfusion. Syncope accounts for a 3-6% of all emergency department visits. Etiology of syncope can be neural, cardiogenic, or vascular. Previous studies have evaluated the types and management of syncope. Echocardiography is a commonly used test in the evaluation of causes of syncope. Whether the benefit compared to financial burden of this diagnostic study is in all subsets of syncope cases remains unclear.

AIM: To evaluate the impact of echocardiography in the diagnostic evaluation of syncope and to evaluate the subset of patients that would benefit …

Immune-Mediated Colitis From Dual Checkpoint Inhibitors., Nishanth Thalambedu, Yasir Khan, Qian Zhang, Shristi Khanal, Ammar Ashfaq

Abington Jefferson Health Papers

Melanoma is a deadly disease with immunotherapy treatment options that emerged in the last few years and have changed the disease outcome. However, it is associated with immune-related toxic effects despite improving survival. We present the case of a 53-year-old woman who had two weeks of diarrhea after she was treated with dual immunotherapy agents for her advanced melanoma. The final workup revealed pancolitis, possibly due to immunotherapy adverse effects. Initial conservative treatment, unfortunately, did not lead to a clinical improvement until a steroid was introduced. We are reporting this case to alert our fellow physicians about the immune-mediated toxicities …

Sarcoidosis Presenting As Acute Respiratory Distress Syndrome., Bilal Lashari, Ahmad Raza, Vincent Chan, William Ward

Abington Jefferson Health Papers

Sarcoidosis is a multisystem granulomatous disease of unknown origin. It typically involves the lungs and mediastinal lymph nodes in a chronic fashion. However, acute syndrome has been reported possibly in response to systemic release of proinflammatory cytokines. Acute pulmonary manifestations, especially acute respiratory failure or acute respiratory distress syndrome, remain extremely uncommon in individuals without a prior diagnosis. We present the case of a 41-year-old African American female, who presented with ARDS. An extensive workup into the cause of her illness remained negative, and she subsequently succumbed to her illness. A diagnosis of sarcoidosis was made upon autopsy, after exclusion …

Another "D" In Mudpiles? A Review Of Diet-Associated Nondiabetic Ketoacidosis., Waqas Ullah, Mohsin Hamid, Hafez Mohammad Ammar Abdullah, Mamoon Ur Rashid, Faisal Inayat

Abington Jefferson Health Papers

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of "dietary ketosis" in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless "dietary ketosis" can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling …

Posterior Reversible Encephalopathy Syndrome (Pres) After Bevacizumab Therapy For Metastatic Colorectal Cancer., Mohsin Hamid, Ali Ghani, Ida Micaily, Usman Sarwar, Md, Bilal Lashari, Md, Faizan Malik

Abington Jefferson Health Papers

Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognizable neuro-clinical syndrome. Clinical and neurological manifestations of PRES include hypertension, headache, encephalopathy, seizures, and symmetrical white matter changes on brain MRI. Most common precipitants of PRES are acute medical illness, hypertensive crisis, eclampsia, immunosuppressive therapy, and chemotherapy. Bevacizumab is a monoclonal antibody that halts angiogenesis by inhibiting vascular endothelial growth factor. It has gained widespread popularity in oncology world especially for metastatic and recurrent cancers due to its inherent ability to stop angiogenesis; a vital step for tumor growth. Bevacizumab has also been implicated as the cause of PRES due to …

A Deadly Prescription: Combination Of Methotrexate And Trimethoprim-Sulfamethoxazole., Mohsin Hamid, Bilal Lashari, Irfan Ahsan, Ida Micaily, Usman Sarwar, Joseph Crocetti

Abington Jefferson Health Papers

Methotrexate (MTX) is a chemotherapeutic synthetic(s) phase cell cycle inhibitor, and its role has evolved as an immunological agent in autoimmune diseases like rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, etc. Trimethoprim-sulfamethoxazole (TS) is one of the most widely prescribed antibiotics commonly used for urinary tract infections, exacerbations of chronic bronchitis, traveler's diarrhea, and pneumocystis pneumonia. Both MTX and TS can have significantly overlapping side effects involving dermatologic, renal, and hematological systems, and the combination of these can be deadly. Our case is about the combination of MTX and TS that leads to mucocutaneous ulceration, leukopenia, and renal insufficiency. The …