Internal Medicine Commons^™

Refractory Abdominal Pain In A Patient With Chronic Lymphocytic Leukemia: Be Wary Of Acquired Angioedema Due To C1 Esterase Inhibitor Deficiency., Abdullateef Abdulkareem, Ryan S D'Souza, Joshua Mundorff, Pragya Shrestha, Oluwaseun Shogbesan, Anthony Donato

Reading Hospital Internal Medicine Residency

Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented …

Agranulocytosis Associated With Topiramate: A Case Report And Review Of Published Cases., Saroj Lohani, Niranjan Tachamo, Salik Nazir, Anthony Donato

Reading Hospital Internal Medicine Residency

A 41-year-old female presented to the hospital with sore throat and shortness of breath. She was hypoxic with an oxygen saturation of 87% in room air. Physical examination revealed swollen uvula with exudates. She had been started on topiramate for treatment of migraine few months ago. The dose of topiramate was increased to 100 mg twice daily 2 weeks ago. Complete blood count revealed an absolute neutrophil count (ANC) of 8 c/mm

Pulmonary Mucormycosis In Chronic Lymphocytic Leukemia And Neutropenia., Izza Mir, Sijan Basnet, David Ellsworth, Elan Mohanty

Reading Hospital Internal Medicine Residency

Pulmonary mucormycosis is a rare life-threatening fungal infection associated with high mortality. We present the case of a 61-year-old man with history of chronic lymphocytic leukemia who presented with fever and cough, eventually diagnosed with pulmonary mucormycosis after right lung video-assisted thoracoscopic surgery. The patient was successfully treated with amphotericin B and right lung pneumonectomy; however, he later died from left lung pneumonia.

A Case Of Probable Amiodarone-Induced Pancreatitis In The Treatment Of Atrial Fibrillation: A Literature Review And Case Report., Christopher J. Mercogliano, Muhammad Khan, Mussaber Ahmad

Reading Hospital Internal Medicine Residency

Amiodarone is an effective medication used in the treatment of several different arrhythmias. Its most well-known adverse effects include pulmonary fibrosis, thyroid dysfunction, and hepatotoxicity. A less common side effect is acute pancreatitis. A 67-year-old male being treated for atrial fibrillation in rapid ventricular response with Amiodarone developed acute epigastric abdominal pain 24 hours after initiation of therapy. He was diagnosed as having acute pancreatitis based on characteristic findings seen on an abdominal CT scan. Commonly encountered etiologies of pancreatitis were ruled out through a combination of the history, laboratory values, and imaging results. Based on the temporal association of …

Pharmacomechanical Catheter-Directed Thrombolysis For Deep-Vein Thrombosis., Suresh Vedantham, Samuel Z Goldhaber, Jim A Julian, Susan R Kahn, Michael R Jaff, David J Cohen, Elizabeth Magnuson, Mahmood K Razavi, Anthony J Comerota, Heather L Gornik, Timothy P Murphy, Lawrence Lewis, James R Duncan, Patricia Nieters, Mary C Derfler, Marc Filion, Chu-Shu Gu, Stephen Kee, Joseph Schneider, Nael Saad, Morey Blinder, Stephan Moll, David Sacks, Judith Lin, John Rundback, Mark Garcia, Rahul Razdan, Eric Vanderwoude, Vasco Marques, Clive Kearon

Reading Hospital Interventional Radiology

BACKGROUND: The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.

METHODS: We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up.

RESULTS: Between 6 and 24 …

Acquired Von Willebrand Disease Associated With Monoclonal Gammopathy Of Unknown Significance, Sijan Basnet, Catherine Lin, Rashmi Dhital, Izza Mir, Elan Mohanty, Biswaraj Tharu, Sushil Ghimire, Dilli Ram Poudel

Reading Hospital Internal Medicine Residency

We present a case of a 79-year-old male who presented with retroperitoneal hematoma a week after motor vehicle accident. Prior history and family history of bleeding were nonsignificant. His activated partial thromboplastin time was found to be prolonged in the emergency department. Further workup with coagulation studies showed decreased factor VIII, vWF antigen, and vWF:ristocetin cofactor assay, and negative Bethesda assay, indicating acquired von Willebrand disease. Immunofluorescence to find an underlying etiology was suggestive of MGUS. Management of AvWD depends on controlling active bleeding and treating the underlying cause. He was treated with factor VIII, haemate-p, rituximab, two cycles of …

An Extensive Chronic Aortic Dissection Presenting With Acute Embolic Stroke., Sijan Basnet, Naba Raj Mainali, Biswaraj Tharu, Rashmi Dhital, Dilli Ram Poudel

Reading Hospital Internal Medicine Residency

Herein, we present a rare case of extensive chronic aortic dissection with extension to bilateral subclavian arteries, bilateral common carotid arteries, right internal carotid artery, bilateral proximal external iliac arteries and simultaneous presentation of acute embolic stroke and seizure. The rarity of this case presentation and the presence of neurological features necessitated a high index of clinical suspicion to reach the definitive diagnosis. This study also demonstrates a unique situation requiring correlation between chronic aortic dissection and multi-organ system dysfunction from chronic ischemia.

Gastrointestinal Involvement Of Testicular Germ Cell Tumor: A Case Report And Literature Review., Oluwaseun Shogbesan, Abdullateef Abdulkareem, Asad Jehangir, Sunila Byreddy, Sharon Swierczynski, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Testicular germ cell tumors (GCT) are the commonest solid tumors in young men. Typical presentation is with painless scrotal swelling; however, symptoms related to complications or metastasis may be the initial presentation. Gastrointestinal (GI) metastasis is seen in about 5% of patients with germ cell tumors and presentation is commonly with GI bleed. It is important to have GCT as a differential diagnosis of GI bleed in young men presenting with unexplained anemia as direct questioning about scrotal swelling and genital examination when appropriate will guide further investigation and facilitate prompt diagnosis. We present a case of a 26-year-old man …

A Case Of Rituximab-Induced Necrotizing Fasciitis And A Review Of The Literature., Abdullateef Abdulkareem, Ryan S D'Souza, Anthony Donato, Oluwaseun Shogbesan

Reading Hospital Internal Medicine Residency

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to

Pembrolizumab-Associated Hypothyroidism: Case Report And Review Of Literature, Niranjan Tachamo, Saroj Lohani, Salik Nazir, Rishikesh Joshi, Mrunalini Deshmukh

Reading Hospital Internal Medicine Residency

Pembrolizumab is a Programmed Death 1 (PD-1) inhibitor used to treat advanced malignant melanoma and metastatic non-small cell lung cancer. It causes various endocrinological side effects including immune mediated thyroiditis. Thyroiditis caused by Pembrolizumab can mimic other immune mediated thyroiditis like Hashimoto thyroiditis and Grave’s disease.

Hypersensitivity Pneumonitis: An Overlooked Cause Of Cough And Dyspnea., Ryan S. D'Souza, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Hypersensitivity pneumonitis (HP) is an immune-mediated pulmonary disorder involving inflammation of the lung interstitium, terminal bronchioles, and alveoli caused by the immune response to the inhalation of an offending environmental airborne agent. It can manifest as exertional dyspnea, fatigue, weight loss, and progressive respiratory failure if left untreated. Because of its protean features, it can be misdiagnosed as other common obstructive lung conditions such as asthma. If triggers are not avoided, it can progress to irreversible pulmonary fibrosis. In this article, we present the case of a 51-year-old male who presented to our hospital with recurrent bouts of dyspnea and …

Acute Intermittent Porphyria: A Test Of Clinical Acumen., Rashmi Dhital, Sijan Basnet, Dilli Ram Poudel, Khema Raj Bhusal

Reading Hospital Internal Medicine Residency

Acute intermittent porphyria (AIP) is a rare autosomal dominant hepatic porphyria due to deficiency of hydroxymethylbilane synthase (HMBS), also known as porphobilinogen deaminase leading to accumulation of porphyrin precursors. However, gene defect alone is usually not sufficient to cause an acute attack, and many extrinsic factors play a role. Diagnostic tests are defined, but clinical suspicion is often delayed as symptoms mimic other common conditions. We report a case of a 18-year-old male with severe, persistent, and generalized abdominal pain along with marked hyponatremia, with subsequent development of altered mentation needing intensive care. He improved after infusion of intravenous dextrose. …

Shigella Sonnei Bacteremia Presenting With Profound Hepatic Dysfunction, Oluwaseun Shogbesan, Andrew Rettew, Bilal Shaikh, Abdullateef Abdulkareem, Anthony Donato

Reading Hospital Internal Medicine Residency

Worldwide, Shigellosis is a significant public health issue, associated with nearly one million deaths annually. About half a million cases of Shigella infection are reported annually in the United States. Shigella bacteremia is uncommon and generally seen in children and immunocompromised adults. We present a case of a Shigella sonnei bacteremia with marked hepatic derangement in a 27-yearold previously healthy homosexual male with history of Roux-en-Y gastric bypass, who presented to the emergency room with a 4-day history of loose watery stool, abdominal cramps, nausea and vomiting, and yellow skin of 2-day duration. He reports similar diarrhea illness in two …

Design Of A Clinical Competency Committee To Maximize Formative Feedback., Anthony A. Donato, Richard Alweis, Suzanne Wenderoth

Reading Hospital Internal Medicine Residency

BACKGROUND: As the next phase in the roll-out of Next Accreditation System, US residency programs are to develop Clinical Competency Committees (CCCs) to formally implement outcome-based medical education objectives in the resident assessment process. However, any changes to an assessment system must consider balancing formative and summative tensions, flexibility and standardization tensions, fairness and transparency to learners, and administrative burden for faculty.

OBJECTIVES/METHODS: In this article, one program discusses the approach one internal medicine residency took to create a developmental model CCC. In this model, a learner's mentor presents the argument for competence to the CCC, while a second reviewer …

Effectiveness Of Iterative Interventions To Increase Research Productivity In One Residency Program., Richard Alweis, Suzanne Wenderoth, Anthony A. Donato

Reading Hospital Internal Medicine Residency

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residency programs to expose residents to research opportunities.

OBJECTIVE: The purpose of this study was to assess the impact of a series of iterative interventions to increase scholarly activity in one internal medicine residency.

METHODS: Retrospective analysis of the effectiveness of a series of interventions to increase resident and faculty scholarly productivity over a 14-year period was performed using quality improvement methodology. Outcomes measured were accepted regional and national abstracts and PubMed indexed manuscripts of residents and faculty.

RESULTS: Initially, regional meeting abstracts increased and then were supplanted by national meeting …

Post-Polypectomy Electrocoagulation Syndrome: A Rare Cause Of Acute Abdominal Pain., Asad Jehangir, Kyle M. Bennett, Andrew C. Rettew, Opeyemi Fadahunsi, Bilal Shaikh, Anthony A. Donato

Reading Hospital Internal Medicine Residency

While generally safe, the most feared complication of colonoscopy is perforation of the colon, occurring in nearly 1 in 1,000 procedures, and is more common when polypectomy is performed and electrocautery is used. Less commonly known is the post-polypectomy electrocoagulation syndrome, a transmural burn of the colon which mimics the signs and symptoms of perforation as well as the time course, but follows a benign course and can be treated conservatively.

Rater Perceptions Of Bias Using The Multiple Mini-Interview Format: A Qualitative Study, Anthony A. Donato, Richard L. Alweis, Caroline Fitzpatrick

Reading Hospital Internal Medicine Residency

The Multiple Mini-Interview (MMI) format appears to mitigate individual rater biases. However, the format itself may introduce structural systematic bias, favoring extroverted personality types. This study aimed to gain a better understanding of these biases from the perspective of the interviewer

Primary Cutaneous Peripheral T-Cell Lymphoma Not Otherwise Specified: A Rapidly Progressive Variant Of Cutaneous T-Cell Lymphoma., Kimberly Aderhold, Lisa Carpenter, Krysta Brown, Anthony Donato

Reading Hospital Internal Medicine Residency

Primary Cutaneous Peripheral T-Cell Lymphoma NOS (PTL-NOS) is a rare, progressive, fatal dermatologic disease that presents with features similar to many common benign plaque-like skin conditions, making recognition of its distinguishing features critical for early diagnosis and treatment (Bolognia et al., 2008). A 78-year-old woman presented to ambulatory care with a single 5 cm nodule on her shoulder that had developed rapidly over 1-2 weeks. Examination was suspicious for malignancy and a biopsy was performed. Biopsy results demonstrated CD4 positivity, consistent with Mycosis Fungoides with coexpression of CD5, CD47, and CD7. Within three months her cancer had progressed into diffuse …

Factors Supporting And Inhibiting Adherence To Hiv Medication Regimen In Women: A Qualitative Analysis Of Patient Interviews., Oluwakemi Fagbami, Adetokunbo Oluwasanjo, Carrie Fitzpatrick, Rebecca Fairchild, Ann Shin, Anthony Donato

Reading Hospital Internal Medicine Residency

Adherence to antiretroviral therapy reduces morbidity and mortality; however rates of non-adherence are variable among women for unclear reasons. This study was a single-center qualitative analysis of interviews with 18 female HIV-positive non-adherent patients (defined by virologic failure) to explore psychosocial factors impacting adherence. Factors identified were categorized as promoting, inhibiting or having no effect on adherence. Three themes, characterized as social factors, illness factors and other societal pressures, were identified. Medical systems support, family support and compliance for children were most commonly identified as promoting adherence, while psychiatric comorbidities, lack of medical systems support and side effects were identified …

A Gut Gone To Pot: A Case Of Cannabinoid Hyperemesis Syndrome Due To K2, A Synthetic Cannabinoid., Anene Ukaigwe, Paras Karmacharya, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Cannabinoid Hyperemesis Syndrome (CHS) was first described in 2004. Due to its novelty, CHS is often unrecognized by clinicians leading to expensive workup of these patients with cyclical symptoms. It may take up to 9 years to diagnose CHS. CHS is characterized by cyclical nausea and vomiting, abdominal pain, and an unusual compulsion to take hot showers in the presence of chronic use of cannabinoids. Cannabicyclohexanol is a synthetic cannabinoid, popularly known as K2 spice. It is a popular marijuana alternative among teenagers and young adults since it is readily available as herbal incense. Unlike marijuana, many users know that …

Mesenteric Vein Thrombosis In A Patient Heterozygous For Factor V Leiden And G20210a Prothrombin Genotypes., Paras Karmacharya, Madan Raj Aryal, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Mesenteric venous thrombosis (MVT) is a rare but life threatening form of bowel ischemia. It is implicated in 6%-9% of all cases of acute mesenteric ischemia. The proportion of patients with primary (or idiopathic) MVT varies from 0% to 49%, with a decrease in frequency secondary to more recent availability of newer investigations for hypercoagulability. The presence of factor V Leiden (FVL) and prothrombin G20210A mutations (PGM) have been well documented in these cases. However, there have been scarce case reports describing MVT in heterozygotes of both these mutations occurring simultaneously and its implications on long term management. Our case …

Reliability And Acceptability Of A Five-Station Multiple Mini-Interview Model For Residency Program Recruitment., Julian Diaz Fraga, Adetokunbo Oluwasanjo, Thomas Wasser, Anthony Donato, Richard Alweis

Reading Hospital Internal Medicine Residency

BACKGROUND: Standard interviews are used by most residency programs in the United States for assessment of aptitude of the non-cognitive competencies, but variability of interviewer skill, interviewer bias, interviewer leniency or stringency, and context specificity limit reliability.

AIM: To investigate reliability and acceptability of five-station multiple mini-interview (MMI) model for resident selection into an internal medicine residency program in the United States.

SETTING: One independent academic medical center.

PARTICIPANTS: Two hundred and thirty-seven applicants and 17 faculty interviewers.

PROGRAM DESCRIPTION: Five, 10-min MMI stations with five different interviewers blinded to the candidate's records and one traditional 20-min interview with the …

Improving The Tracking And Removal Of Retrievable Inferior Vena Cava Filters., Anthony D Goei, Shellie C Josephs, Thomas B Kinney, Charles E Ray, David Sacks

Reading Hospital Interventional Radiology

Therapeutic and prophylactic inferior vena cava (IVC) filters should be placed based on currently accepted indications to prevent a fatal pulmonary embolism (PE). The protective effect of filters is offset by the potential for lower extremity deep venous thrombosis (DVT), caval thrombosis, and possible otherwise unnecessary life-long anticoagulation (AC). The duration of treatment for most DVTs or PEs is 3 to 6 months of AC/filter. Filters should be retrieved when duration of treatment for a DVT/PE has been met, the risk of a PE is no longer high, and/or there is no longer a contraindication to AC. An effective system …

Tips And Tricks For The Trauma Patient., Anthony D Goei, Brian H Ching, Mark W Meyermann, Timothy Nunez, David Sacks

Reading Hospital Interventional Radiology

Interventions on the trauma patient are an essential component of the complete scope of care that is provided to the multiply injured patient today. The active participation by the interventional radiologist along the entire spectrum of clinical care is very important to optimize patient outcomes. Suggestions on how to establish a clinical presence are presented. A few of the newer concepts and terminology applicable to trauma care are reviewed. Tips useful in the trauma room, in the interventional radiology suite, and during the postprocedural period are discussed.