Internal Medicine Commons^™

Typhlitis In A Neutropenic Patient, Alice He Bs, Wern Lynn Ng Md, Lay She Ng Md, Si Yuan Khor Md, Chandi Garg Md

Tower Health Research Day

No abstract provided.

Hiding In Plain Sight; Dermatologic Manifestation Of A Systemic Disease, Christopher Ignatz, David Young Do, Brian Chwiecko Md

Tower Health Research Day

No abstract provided.

The Silent Culprit: Factor V Leiden’S Covert Role In Recurrent Miscarriages And First-Time Thromboembolism, Tanner Aldous, Sarah Almarzooqi, Mingran Yu, Jeremy Ellis

Tower Health Research Day

No abstract provided.

New Onset Dyspnea In A Patient With Pacemaker, What Does The Ecg Tracing Show?, Jakob Nypaver, Robert Libera Do, Arun Kundra, Ravi Choxi

Transformative Medicine (T-Med)

Dual chamber pacemakers are programmed to allow for AV synchrony. Whenever a patient with a dual chamber pacemaker with underlying sinus rhythm presents with AV dissociation, the lack of AV synchrony should be questioned. The authors present a case of new onset dyspnea diagnosed as pacemaker syndrome. The diagnosis was initially delayed due to underlying ventricular paced rhythm as misidentified as normal pacemaker behavior.

A 69-year-old female with a past medical history of 2:1 atrioventricular block status post dual-chamber pacemaker implant presented with complaints of new onset shortness of breath and dyspnea. The ECG showed a ventricular rate of 66 …

When Carbohydrates Are Not Enough: Acute Intermittent Porphyria Treated With Givosiran, Shoja Rahimian, Akanksha Kushwah, Yugandhara Kate, Andrew Rettew

Tower Health Research Day

No abstract provided.

Vitamin C Deficiency In A Food Insecure Patient: A Rare Case Report, Gersham J. Rainone, Tatiana J. Han, Muhammed Rahim, Gregory J. Pirolli, Alina Popa, Jayaram Thimmapuram

Transformative Medicine (T-Med)

Introduction: Scurvy is rarely seen in developed countries and is characterized by deficiency of vitamin C, which can lead to symptoms including wound impairment, bleeding manifestations, and loss of teeth. Case Description: We present a case of a 53-year-old male with a right knee hemarthrosis after a fall. The patient also noted progressively enlarging spontaneous hematomas, denying any recent trauma except for the fall to the knee. He denied family history of bleeding and clotting disorders and endorsed aspirin use in the setting of a prior stroke. He actively resided at a local shelter with limited means of transportation for …

Intelligent Malingering In The Setting Of Porphyria Variegata: A Rare Occurrence On Both Fronts, Gersham J. Rainone, Oleg E. Reznik, Mahrukh Majeed, Alina Popa

Transformative Medicine (T-Med)

Malingering can be a difficult diagnosis to discern, especially in patients with well-crafted stories presenting with signs and symptoms that align directly with the literature. This can further become a challenge when a patient is malingering in the setting of a rare disease, where many complaints can be subjective in nature and not entirely testable by physical exam alone. Malingering is responsible for billions of dollars of healthcare waste every single year, and this report can serve as a guide of history elements, signs and symptoms to look out for with patients malingering in the setting of the porphyrias. It …

Dieulafoy Lesion In The Jejunum: A Rare Cause Of Massive Gastrointestinal Bleeding, Olubunmi Oladunjoye, Adeolu Oladunjoye, Lydia Slater, Asad Jehangir

Reading Hospital Internal Medicine Residency

No abstract provided.

Impact Of Ivig Vs. Scig On Igg Trough Level And Infection Incidence In Primary Immunodeficiency Diseases: A Systematic Review And Meta-Analysis Of Clinical Studies., Pragya Shrestha, Paras Karmacharya, Zhen Wang, Anthony Donato, Avni Y Joshi

Reading Hospital Internal Medicine Residency

Background: Monthly intravenous immunoglobulin (IVIG) and weekly subcutaneous immunoglobulin (SCIG) have been regarded as therapeutically equivalent treatments for primary immunodeficiency diseases (PIDD). Immunoglobulin G (IgG) trough level is used as a monitoring measure for infection prevention.

Objective: A systematic review and meta-analysis were performed to elucidate the relationship between IgG dosing, trough IgG levels with overall infection incidence in patients with PIDD receiving IVIG and SCIG therapy.

Methods: Medline, EMBASE, Cochrane, Central, and Scopus were searched for studies published from Jan 2010-June 2018, fulfilling the inclusion criteria. DerSimonian and Laird random-effects method were used to pool the difference of IgG …

Systematic Review And Meta-Analysis Of The Efficacy And Safety Of Apixaban Compared To Rivaroxaban In Acute Vte In The Real World., Madan Raj Aryal, Rohit Gosain, Anthony Donato, Han Yu, Anjan Katel, Yashoda Bhandari, Rashmi Dhital, Peter A. Kouides

Reading Hospital Internal Medicine Residency

Both apixaban and rivaroxaban have been approved for use in acute venous thromboembolism (VTE). Although indirect comparison through network meta-analyses of randomized trials have been performed to compare the efficacy and safety of these agents, further comparison between these agents was lacking until recently. We sought to systematically review and carry out a meta-analysis of studies to further compare apixaban with rivaroxaban from multiple studies done in the real-world settings. Studies comparing rivaroxaban with apixaban in patients with acute VTE were identified through electronic literature searches of MEDLINE, EMBASE, Scopus, and the Cochrane library up to May 2019. Study-specific risk …

Acute Generalized Exanthematous Pustulosis: A Rare Side Effect Of Clindamycin., Sijan Basnet, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Acute generalized exanthematous pustulosis (AGEP) is a rare adverse effect of clindamycin characterized by widespread papules and pustulosis 1 - 3 weeks of its use. Case description: We present a case of a 71-year-old woman diagnosed with AGEP after clindamycin use for a tooth infection. She had been started on empiric prednisone without benefit. She did not have any systemic involvement and had an unremarkable blood work . Her rash resolved completely in a month.

A Case Of Multisystem Langerhans Cell Histiocytosis Presenting As Central Diabetes Insipidus, P. Daniel Nicholas Iii, Ian Garrahy

Reading Hospital Internal Medicine Residency

Langerhans cell histiocytosis (LCH) is a rare malignancy most commonly characterized by histiocytic infiltration of bone. LCH lesions in the skull place the adjacent central nervous system (CNS) at risk for involvement, which can manifest as central diabetes insipidus (CDI) when there is infiltration of the hypothalamic-pituitary axis. We present a case of a 39-yearold female who presented with polyuria and polydipsia for 1 year and left-sided hearing loss, gait instability, and nystagmus for 5 days. She was found on laboratory evaluation to have CDI and underwent left cortical mastoidectomy for a destructive peripherally enhancing mastoid lesion seen on MRI …

Interventions To Increase Research Publications In Graduate Medical Education Trainees: A Systematic Review., Ryan Zimmerman, Richard Alweis, Alexandra Short, Tom Wasser, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Introduction: Competency-based educational models recommend trainee exposure to research, but the best methods for Graduate Medical Education (GME) programs to accomplish this have not been clarified. The objective of this study was to quantify published interventions to generate resident research and compare effectiveness among those interventions.

Material and methods: A systematic review of English-language articles of studies of GME programs was performed, describing resident research interventions and quantifying the number of publications as an outcome.

Results: The search produced 13,688 potentially relevant articles, and included 47 articles in the final synthesis. Publication effectiveness was calculated as publications per year. The …

Agep Overlap Induced By Hydroxychloroquine: A Case Report And Literature Review., Christopher Mercogliano, Muhammad Khan, Catherine Lin, Elan Mohanty, Ryan Zimmerman

Reading Hospital Internal Medicine Residency

Acute Generalized Exanthematous Pustulosis (AGEP) is a rare drug reaction manifesting as pustular lesions with surrounding erythema following exposure. The disease is often self-limited and treatment is supportive. It may present in an atypical variant with vesicles that desquamate into erosions, which classifies the disease as an AGEP/SJS Overlap. This overlap syndrome can carry a substantial mortality rate and necessitate elevation in the level of care. Hydroxychloroquine has been implicated in cases of AGEP, and we present a case of AGEP/SJS overlap attributed to this common medication. Given the prevalence of drug eruptions, it is critical for the physicians to …

Clinical Outcomes Of Successful Revascularization Of Chronic Total Coronary Occlusions With Bioresorbable Vascular Scaffolds: A Systematic Review., Roman Marchenko, Salik Nazir, Shelina Malla, Anthony Donato

Reading Hospital Internal Medicine Residency

Revascularization of chronic total occlusions (CTO) with percutaneous coronary intervention is associated with favorable long-term clinical and echocardiographic outcomes. Whether bioresorbable vascular scaffolds (BVS) would be advantageous in the treatment of CTO is unknown as patients with these lesions were generally excluded from large BVS randomized trials. We performed a systematic review, which sought to summarize known data on mid- to long-term clinical outcomes for BVS in CTO. We searched MEDLINE, EMBASE, clinicaltrials.gov, and the Cochrane Library through April 2018 to look for studies on implantation of BVS in CTO. Outcomes of interest included myocardial infarction, cardiac death, all-cause mortality, …

Anaplastic Pleomorphic Xanthoastrocytoma Presenting With Musical Hallucination., Oreoluwa Oladiran, Ifeanyi Nwosu, Steve Obanor, Chinyere Ogbonna-Nwosu, Brian Le

Reading Hospital Internal Medicine Residency

Musical hallucinations are a relatively rare form of auditory hallucination characterized by hearing of music in the absence of any external stimuli. This phenomenon has been linked to both psychiatric and structural lesions. We present the case of a previously healthy young male whose presentation with musical hallucinations led to the diagnosis of a rare tumour, anaplastic pleomorphic xanthoastrocytoma.

Perioperative Genitourinary Infection Associated With Sodium-Glucose Co-Transporter 2 Inhibitor Use., Stephen Melnick, Priya Rajagopalan, Theresa Lynn, Anthony Donato

Reading Hospital Internal Medicine Residency

Context: Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a novel treatment approved for type 2 diabetes mellitus to lower hyperglycemia, systolic blood pressure, and promote weight loss. Commonly reported serious adverse events include increased mycotic urogenital infections, orthostatic hypotension, and normoglycemic ketoacidosis. Case report: We present a case of a 47-year old man with a history of type 2 diabetes mellitus initiated on the SGLT-2 inhibitor canagliflozin preoperatively before a penile implant, who presented with late postoperative MRSA bacteremia and scrotal abscess requiring implant extraction. Conclusion: As the SGLT-2 inhibitors are gaining in popularity, prescribers must be aware …

Takotsubo Cardiomyopathy Associated With Polycythemia Vera., Sijan Basnet, Priya Rajagopalan, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Takotsubo cardiomyopathy is characterized by transient apical ballooning with preserved basal ventricular function triggered by physical or emotional stressors. We present a case of a 75-year-old man referred to our facility for the management of acute myocardial infarction later diagnosed as takotsubo cardiomyopathy. We believe platelet-mediated adrenaline release from massive thrombocytosis might have been the precipitating factor for the pathogenesis of takotsubo cardiomyopathy.

A Systematic Review Of The Efficacy And Safety Of Fecal Microbiota Transplant For Clostridium Difficile Infection In Immunocompromised Patients, Oluwaseun Shogbesan, Dilli Ram Poudel, Samjeris Victor, Asad Jehangir, Opeyemi Fadahunsi, Gbenga Shogbesan, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Background: Fecal microbiota transplantation (FMT) has been shown to be effective in recurrent

Methods: We searched MEDLINE and EMBASE for English language articles published on FMT for treatment of CD infection in immunocompromised patients (including patients on immunosuppressant medications, patients with human immunodeficiency virus (HIV), inherited or primary immunodeficiency syndromes, cancer undergoing chemotherapy, or organ transplant, including-bone marrow transplant) of all ages. We excluded inflammatory bowel disease patients that were not on immunosuppressant medications. Resolution and adverse event rates (including secondary infection, rehospitalization, and death) were calculated.

Results: Forty-four studies were included, none of which were randomized designs. A total …

Bevacizumab: A Rare Cause Of Nonischemic Cardiomyopathy., Oreoluwa Oladiran, Salik Nazir

Reading Hospital Internal Medicine Residency

Left ventricular dysfunction is a rare side effect of bevacizumab occurring in 2-4% of cases. We report the case of a 68-year-old woman who presented to the emergency department (ED) with sudden onset of shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. She was tachypneic and in respiratory distress. Physical examination revealed jugular venous distention, diffuse expiratory wheeze, and bipedal edema. She had been started on bevacizumab for the treatment of hereditary hemorrhagic telangiectasia 1 month prior to presentation. Laboratory tests revealed BNP of 1697 pg/ml with slightly elevated troponin 0.05 ng/ml. Chest X-ray showed interstitial edema with cardiomegaly, and …

Immunoglobulin G4 Sclerosing Cholangitis: An Unusual Cause Of Obstructive Jaundice-Case Report And Literature Review., Pragya Shrestha, Brian Le, Brent Wagner, William Pompella, Paras Karmacharya

Reading Hospital Internal Medicine Residency

IgG4-related sclerosing cholangitis (IgG4-SC) is one of the most common extra-pancreatic manifestation of IgG4-related disease (IgG4-RD) and is clinically distinct from primary sclerosing cholangitis (PSC). IgG4-RD is an increasingly recognized immune-mediated fibroinflammatory systemic disease, mostly affecting middle-aged and older male populations that can affect multiple organs. The presence of extra-biliary clinical manifestations of IgG4-RD, such as parotid and lacrimal swelling, lymphadenopathy, autoimmune pancreatitis, and retroperitoneal fibrosis, if present could provide important clues to diagnosis. High serum IgG4 levels, characteristic radiological (e.g., sausage-shaped pancreas or periaortitis) or biopsy findings (high percentage of IgG4+ plasma cells, lymphoplasmacytic infiltrate, storiform fibrosis, or obliterative …

Prevalence Of Chronic Obstructive Pulmonary Disease (Copd) Among Rheumatoid Arthritis: Results From National Inpatient Database., Rashmi Dhital, Sijan Basnet, Prakash Paudel, Yam Prasad Acharya, Dilli Ram Poudel

Reading Hospital Internal Medicine Residency

Rheumatoid arthritis (RA) is being increasingly recognized as an important contributor to chronic obstructive pulmonary disease (COPD). Although smoking is a major risk factor, other factors may play a role. We used National Inpatient Sample (NIS) from 2013 to explore this relationship. We used propensity matching with a 1:3 nearest-neighbor-matching algorithm to match 1 RA hospitalization to 3 age- and-sex-matched comparators. In the age- and-sex-matched population, RA had a higher odds of COPD (OR 1.20, 95% CI: 1.17-1.22,

Recurrent Autoimmune Hemolytic Anemia In Splenic Marginal Zone Lymphoma., Oreoluwa Oladiran, Rashmi Dhital, Anthony Donato

Reading Hospital Internal Medicine Residency

Autoimmune hemolytic anemia (AIHA) is a condition associated with an extensive differential diagnosis that includes lymphoid malignancies. Although AIHA occurs in about 10-25% of patients with chronic lymphocytic leukemia, it is also reported to occur in all of the other lymphoid subtypes. In this article, we report a case of recurrent AIHA in a 67-year-old woman with two acute episodes of hemolysis separated by 3 years of hematologic remission. Both episodes were severe enough to require blood transfusion, oral steroids, and rituximab. Bone marrow biopsy and immunophenotyping using flow cytometry done during both admissions confirmed the presence of splenic marginal …

Novel Stat3 Gene Mutation Related Hyper-Ige Syndrome Misdiagnosed As Hidradenitis Suppurativa., Pragya Shrestha, Geetika Sabharwal, Gisoo Ghaffari

Reading Hospital Internal Medicine Residency

Although Hyper-IgE Syndrome (HIES) is a rare immunodeficiency disorder, presenting symptoms may be as common as lung and skin infections. Symptoms are usually nonspecific such as recurrent abscesses, folliculitis, and pneumonias along with skeletal abnormalities. Careful history of susceptibility to skin and lung infections, thorough family history, and findings on physical exam can guide towards the diagnosis of this often-eluded condition. Early optimization of therapy with prophylactic antibiotics can prevent recurrent infections and future complications and improve quality of life and longevity of survival. We present a case of a young female with Hyper-IgE Syndrome with a novel mutation in …

A Rare Case Of Spontaneous Cardiac Tamponade Induced By Concomitant Use Of Rivaroxaban And Amiodarone., Oreoluwa Oladiran, Jared Segal, Ifeanyi Nwosu, Salik Nazir

Reading Hospital Internal Medicine Residency

Rivaroxaban is a direct oral anticoagulant (DOAC) approved as an important alternative to warfarin in patients with nonvalvular atrial fibrillation. We report the case of an 87-year-old man with past medical history of nonvalvular atrial fibrillation on rivaroxaban and recently started amiodarone for pulseless ventricular tachycardia who presented to our hospital with intermittent chest pain and was diagnosed with spontaneous hemopericardium causing cardiac tamponade. The culprit drugs were discontinued, and the patient was treated with emergent pericardiocentesis. Both rivaroxaban and amiodarone are substrates for the CYP3A4 hepatic pathway, and concomitant use can result in increased plasma rivaroxaban levels causing an …

Primary Hyperparathyroidism In Pregnancy: Successful Parathyroidectomy During First Trimester., Niranjan Tachamo, Bidhya Timilsina, Rashmi Dhital, Theresa Lynn, Vasudev Magaji, Ilan Gabriely

Reading Hospital Internal Medicine Residency

Primary hyperparathyroidism in pregnancy can result in significant maternal and fetal complications. When indicated, prompt parathyroidectomy in the early second trimester is considered the treatment of choice. Pregnant patients with primary hyperparathyroidism who have an indication for parathyroidectomy during the first trimester represent a therapeutic challenge. We present the case of a 32-year-old primigravida who presented with symptomatic hypercalcemia from her primary hyperparathyroidism. She remained symptomatic despite aggressive conservative management and underwent parathyroidectomy in her first trimester with excellent outcomes.

Daptomycin Associated Eosinophilic Pneumonia: Case Report And Differential Diagnoses., Sijan Basnet, Niranjan Tachamo, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Daptomycin is a bactericidal antibiotic approved for treatment of gram-positive skin and soft tissue infections. We present a case of an 89-year-old man who presented with fever, shortness of breath and nonproductive cough on week 4 of starting daptomycin for infective endocarditis. Computerized tomography scan showed bilateral interstitial infiltrates predominantly affecting the lower lobes. He also had peripheral eosinophilia of 6%. He was diagnosed with eosinophilic pneumonia secondary to daptomycin use. His symptoms improved with discontinuation of daptomycin and initiation of corticosteroids. Clinical correlation of pneumonia-like presentation with recent use of daptomycin should make physicians rule out this rare adverse …

Multifactorial Aetiology For Non-Uremic Calciphylaxis: A Case Report., Sijan Basnet, Niranjan Tachamo, Rashmi Dhital, Biswaraj Tharu

Reading Hospital Internal Medicine Residency

Calciphylaxis is commonly associated with end-stage renal disease patients on haemodialysis. We present a rare case of calciphylaxis in a non-uremic patient. The diagnosis was made clinically and confirmed with skin biopsy showing calcification of the dermal and subcutaneous tissues in the von Kossa stain. We believe that the combination of uncontrolled diabetes mellitus, a non-functioning paraganglioma and vitamin D deficiency in a susceptible female patient was responsible for causing calciphylaxis in our patient. An index of suspicion should be maintained by clinicians for calciphylaxis even in patients without uremia.

Closed-Eye Visualizations In The Setting Of Hyponatremia., Travis Peck, Christopher Mercogliano, Eugene York

Reading Hospital Internal Medicine Residency

Purpose: To report a case of closed-eye visualizations and to clarify the different types of hallucinations and their etiologies.

Methods: Retrospective case report of a patient with closed-eye visualizations secondary to hyponatremia. Clinical findings, physical exam, laboratory assessment, treatment, and disease course from the patient's hospitalization were used in creating this report. Follow-up data after discharge were also obtained.

Results: Closed-eye visualizations were diagnosed as secondary to hyponatremia, as they did not occur with the eyes open, and potential alternate causes were excluded. Serum sodium nadir was 119 mEq/L. Symptoms resolved with correction of hyponatremia via fluid resuscitation and electrolyte …

Primary Thyroid Maltoma- A Rare Diagnosis Of An Unassuming Thyroid Nodule., Pragya Shrestha, Kimberly Aderhold, Sharon Swierczynski, Catherine Lin, Ronald Herb

Reading Hospital Internal Medicine Residency

Primary thyroid lymphoma, although a rare malignancy, can arise in common chronic inflammatory conditions such as Hashimoto's thyroiditis. Incidental finding of a thyroid nodule with chronic thyroid inflammation warrants further investigation. Early detection of malignancy can play a vital role in improved outcomes. We report a case of a 60-year-old male who presented to the clinic for a routine visit. An enlarged, firm, non-tender thyroid gland was appreciated on exam with high thyroid stimulating hormone (TSH) level. Fine needle aspiration of the mass revealed nonspecific atypical lymphocytes. The pathology and immunohistochemical stains were consistent with histologic impression of extra nodal …