Digital Commons Network^™

A Stemi That Wasn’T: Staphylococcus Aureus Bacteremia Presenting With Troponin Elevation And Pericardial Involvement, Taqi A. Khan, Kelsey A. Murray, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

A 75-year-old female presented to the emergency department (ED) with vomiting, weakness, and altered mental status. Initial evaluation revealed a markedly elevated troponin level and an electrocardiogram (ECG) demonstrating diffuse ST-segment depressions with relative ST elevation in lead aVR, prompting activation of a STEMI alert. After cardiology consultation, emergent catheterization was deferred. Computed tomography (CT) imaging demonstrated an anterior mediastinal fluid collection extending toward the pericardial space with a loculated pericardial effusion. Splenic infarctions were also identified. Blood cultures later grew Staphylococcus aureus. The patient was treated with broad-spectrum antibiotics and transferred to a tertiary care center for further management. …

Case Report: Pott’S Puffy Tumor, A Rare Complication Of Sinusitis, Je Seong Lee, Esai A. Hernandez, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report the case of an 11-year-old female who presented with lethargy and new left upper extremity weakness after a recent Emergency Department visit for fever, rhinorrhea, and head fullness, and was subsequently diagnosed with Pott’s Puffy Tumor(PPT). Pott’s Puffy Tumor is a frontal bone osteomyelitis with an frontal  subperiosteal abscess and represents a rare but potentially life-threatening complication of sinusitis. Prompt imaging and timely clinical intervention are critical, though variable presentations can make diagnosis challenging. This case highlights the importance of early recognition, appropriate imaging, and prompt surgical and antibiotic management given the PPT’s  strong association with intracranial complications. …

Methadone-Associated Qt Prolongation: The Importance Of Early Recognition And Monitoring In The Emergency Department, Uma Murrugappan, Kelsey Murray, James Espinosa Md, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 43-year-old female with cervical cancer and bilateral percutaneous nephrostomy tubes receiving high-dose methadone maintenance therapy who presented to the emergency department with bilateral flank and abdominal pain. She denied cardiac symptoms. Electrocardiogram obtained during evaluation revealed marked QT prolongation (QTc 596 ms) following recent methadone dose escalation. The patient was placed on continuous cardiac monitoring and intravenous magnesium was ordered. While intravenous access was being obtained, she developed polymorphic ventricular tachycardia consistent with torsades de pointes and became pulseless. Advanced cardiac life support was initiated including defibrillation and magnesium administration, with return of spontaneous …

Gram-Negative Infective Endocarditis : A Rare Case Of Escherichia Coli Pulmonic Valve Endocarditis, Caroline Nguyen, Philip Willsie, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Infective endocarditis (IE) is most commonly caused by gram-positive organisms, while Escherichia coli accounts for less than 1% of reported cases. Pulmonic valve involvement is particularly rare, representing fewer than 2% of IE cases. We report a case of E. coli infective endocarditis involving the pulmonic valve complicated by spinal epidural abscess and ascending cholangitis in a patient with intravenous drug use. Blood cultures demonstrated persistent E. coli bacteremia, and further evaluation with echocardiography and MRI revealed pulmonic valve vegetations and epidural abscess. This case highlights the importance of evaluating persistent gram-negative bacteremia for infective endocarditis and metastatic infection.

Case Report: Postpartum Ovarian Vein Thrombosis Without Abdominal Pain, Moshammat Nishu, Russell Mordecai, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 27-year-old woman (2 prior pregnancies: 1 term birth, 1 preterm birth, 2 living children)  who presented with right ovarian vein thrombosis (OVT) in the absence of abdominal pain on postpartum day 5 after spontaneous vaginal delivery. Although OVT is classically associated with abdominal pain, this case illustrates that OVT may present without abdominal pain and should be considered as a differential to prevent a delay of diagnosis in the emergency department. This case also highlights the diagnostic challenge in postpartum fever when an alternative infectious source may lead to premature closure and prevent the …

Case Report: Termination Of Svt Using A Modified Vagal Maneuver With A 10-Cc Syringe, Romina Noormohammadi, Kelsey Murray, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Supraventricular tachycardia (SVT) is a common cardiac arrhythmia encountered in emergency departments and is characterized by a rapid regular rhythm originating above the ventricles. Initial management of hemodynamically stable SVT typically includes vagal maneuvers followed by pharmacologic therapy such as adenosine if non-pharmacologic methods fail. However, vagal maneuvers are frequently unsuccessful due to improper patient execution or insufficient vagal stimulation. We present the case of a 76-year-old female with a history of gastroesophageal reflux disease (GERD), hypertension (HTN), and hyperlipidemia (HLD) who presented with palpitations and was found to have SVT at 156 beats per minute on electrocardiogram. A Valsalva …

Case Report: Acute Encephalopathy Revealing Severe Babesiosis With Lyme Co-Infection, Czarina Gebrelle K. Soriano, James Espinosa, Alan Lucer

Rowan-Virtua Research Day

Acute confusion in older adults is a common emergency department presentation with a broad differential diagnosis. Tick-borne illnesses can cause significant systemic disease and may present with nonspecific neurologic or constitutional symptoms, making early recognition challenging. Babesiosis is a tick-borne parasitic infection transmitted by Ixodes ticks and may occur concurrently with other infections such as Lyme disease, further complicating diagnosis. We present a case of a 67-year-old male who presented with acute confusion and was found to have concurrent babesiosis and Lyme disease. This case highlights the importance of maintaining a high index of suspicion for tick-borne co-infections in patients …

A Neck Too Tight: Emergent Cricothyrotomy For Airway Collapse From Expanding Post Anterior Cervical Discectomy And Fusion (Acdf) Hematoma, Nicole R. Eregha, Kishan Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical procedure used to treat cervical spine pathology including radiculopathy and spinal cord compression. Although generally safe, postoperative complications can occur. One of the most feared complications is expanding neck hematoma, which may lead to rapid airway obstruction due to tracheal compression and soft tissue swelling. The reported incidence of postoperative hematoma after ACDF ranges from 0.2–1.9%, with a subset of patients requiring emergent airway intervention or surgical evacuation [1]. Patients with postoperative hematoma typically present with neck swelling, dysphagia, hoarseness, dyspnea, and inability to tolerate secretions, symptoms that may …

A Pain In The Neck: Lemierre Syndrome Presenting With Retropharyngeal Abscess, Clara Keum, Leo Midure

Rowan-Virtua Research Day

Lemierre syndrome is a rare but potentially life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein following an oropharyngeal infection. It is most commonly associated with Fusobacterium necrophorum,  and typically begins with pharyngitis or deep neck space infections, which can extend into adjacent vascular structures. Retropharyngeal abscesses are among the deep neck infections that may predispose patients to this complication due to their proximity to the internal jugular vein and surrounding fascial planes.

Although Lemierre syndrome classically occurs in otherwise healthy adolescents and young adults, it can also develop in immunocompromised individuals or patients with complex medical conditions. …

Not All That Scratches Is Infection: Sweet Syndrome Mimicking Cat Scratch Disease, Clara Keum, Neelesh R. Parikh

Rowan-Virtua Research Day

Sweet syndrome, or acute febrile neutrophilic dermatosis, is a rare inflammatory condition characterized by painful erythematous skin lesions, neutrophilic dermal infiltration on histopathology, and rapid response to corticosteroid therapy. Although classically associated with fever and leukocytosis, atypical presentations without systemic symptoms are increasingly recognized, often leading to diagnostic confusion.

The clinical presentation of Sweet syndrome frequently overlaps with infectious processes such as cellulitis, particularly when lesions involve the lower extremities. This overlap may result in misdiagnosis and delayed appropriate treatment. Distinguishing between infectious and inflammatory etiologies is critical, as management strategies differ significantly.

We present a case of Sweet syndrome …

The Tensile Gallbladder Sign: A Case Report Of Acute Gangrenous Cholecystitis Diagnosed By A Rare Computed Tomography Finding, Lan D. Ngo, Trent R. Malcolm

Rowan-Virtua Research Day

Acute cholecystitis is one of the most common causes of acute abdominal pain in the emergency department, accounting for approximately 200,000 hospitalizations annually in the United States (Gallagher & Charles, 2022) Ultrasound is the established first-line imaging modality for suspected cholecystitis. However, compute tomography (CT) is increasingly obtained for undifferentiated abdominal pain and offers complementary, operator-independent evaluation.  The tensile gallbladder fundus sign is defined on CT as the absence of fundal flattening by the anterior abdominal wall due to elevated intraluminal pressure.

Case Report: Bilateral Pneumothorax Following T2–T5 Medial Branch Nerve Block, Jenna Rapone Md

Rowan-Virtua Research Day

Bilateral pneumothorax is an uncommon but clinically significant complication of thoracic spinal interventions. We report the case of a 20-year-old female with underlying scoliosis who developed acute pleuritic chest pain, dyspnea, and persistent cough immediately following bilateral T2–T5 medial branch nerve block injections performed in an outpatient pain management setting.  Thoracic medial branch blocks are generally considered low-risk procedures; however, the proximity of the pleura to posterior thoracic elements places patients at risk for iatrogenic pleural injury, particularly in individuals with altered spinal anatomy such as scoliosis. This case underscores the importance of maintaining a high index of suspicion for …

Case Report: Vancomycin-Resistant Enterococcus Faecium Urinary Tract Infection With Stercoral Colitis Presenting In An Elderly Patient, Muhammad Zain Raza, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 76-year-old female who presented with altered mental status characterized by confusion, decreased verbal interaction, and reduced responsiveness noted by her spouse. The patient had a history of chronic constipation and was brought from home for further evaluation. Initial evaluation raised concern for infection or intracranial hemorrhage as a possible cause of altered mental status. Imaging of the CT brain without contrast was unremarkable, however; abdomen and pelvis revealed a large rectal stool impaction with rectal wall thickening and surrounding perirectal fat stranding consistent with Stercoral Colitis. Urine culture subsequently identified vancomycin-resistant enterococcus faecium. The …

Ketamine With Opioids Vs. Ketamine With Non-Opioid Analgesics For Vaso-Occlusive Crisis In Sickle Cell Disease: A Prisma-Style Scoping Review, Akhil Tumpudi

Rowan-Virtua Research Day

Vaso-occlusive crises (VOCs) are the hallmark of Sickle Cell Disease (SCD) and a leading cause of hospitalization. Pain management relies heavily on opioids, but repeated exposure carries risks including tolerance, hyperalgesia, and adverse effects. Ketamine, an NMDA receptor antagonist, has emerged as an adjunctive agent with potential opioid-sparing effects (1–3,7). Systematic reviews suggest ketamine may reduce pain scores and possibly opioid requirements, though pooled results remain inconsistent (5,6,8). While ketamine + opioid regimens have been studied, the feasibility, efficacy, and safety of ketamine combined with non-opioid analgesics for VOC remain largely unknown. Understanding the comparative effectiveness of these approaches is …

Comparative Efficacy Of Intravenous Ketamine And Lidocaine Infusions For Pain Management In Sickle Cell Vaso-Occlusive Crisis (Voc), Akhil Tumpudi Md

Rowan-Virtua Research Day

Sickle cell disease (SCD) is a hereditary hemoglobin disorder characterized by vaso-occlusion and recurrent acute painful crises, which are the leading cause of hospitalization in affected individuals (1,2). Opioids remain the primary treatment for vaso-occlusive crisis (VOC) pain but are associated with adverse effects, tolerance, and risk of dependence, prompting investigation into opioid-sparing adjuncts (1,2). Intravenous ketamine, an NMDA receptor antagonist, has shown modest opioid reduction in randomized and observational studies, though pain score improvements are inconsistent (3–6). Intravenous lidocaine, a sodium channel blocker, has also demonstrated potential opioid-sparing effects in retrospective cohorts with limited evidence of analgesic superiority (7–9). …

Acute Appendicitis With Concomitant Testicular Torsion, Thuc Vu, Clara Keum, Swet Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

This case report presents a 13-year-old male who presented to the emergency department with diffuse abdominal pain radiating to the right lower quadrant, accompanied by nausea and decreased appetite. Diagnostic evaluation revealed right-sided testicular torsion concurrent with acute appendicitis. Although acute appendicitis represents the most common surgical emergency in the pediatric population, clinicians must maintain a broad differential diagnosis to identify potential concomitant acute pathologies, including testicular torsion in this scenario.

Anticipating Animal Ethics Concerns In Islet Xenotransplantation, Sheetal Mohanty, Daniel J. Hurst, Amy Glasofer

Rowan-Virtua Research Day

Type 1 diabetes mellitus (T1D) necessitates life-sustaining insulin therapy or, in select cases, islet allotransplantation, which is limited by donor scarcity. Islet xenotransplantation (XTx; genetically modified pig-to-human transplant) is one potential alternative. Patient perceptions about islet XTx are largely unexplored. This study examined patient support for XTx when T1D patients learned that 25-50 pigs may be needed to treat one adult. Patient viewpoints toward islet XTx suggest animal ethics concerns may extend to the magnitude of animals required to treat a single patient. As clinical trials advance, addressing these values and risk tolerances is essential for developing informed consent frameworks …

The Klatskin Tumor: A Tumor At The Liver’S Crossroads, Asma Zahid, Sergey Medlenov, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We present a 68-year-old female with no significant oncologic history who presented to

the emergency department with a  two –week history of progressive jaundice and diarrhea.

Systematic ED evaluation revealed marked hyperbilirubinemia (total bilirubin 22.3 mg/dL), a

cholestatic laboratory pattern, and multimodal imaging demonstrating multifocal hepatic

masses, a porta hepatis soft tissue mass,  and biliary ductal dilatation consistent with hilar cholangiocarcinoma (Klatskin tumor) with metastatic disease.

A CA 19-9 marker was markedly elevated at 379 U/mL. The patient was admitted and she underwent successful biliary decompression via ERCP with stent placement.  Outpatient oncologic therapy was initiated. This case highlights the …

Heterotopic Pregnancy: A Case Report, Oluwatomi Alade, Robin Lahr, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Heterotopic pregnancy occurs when there is simultaneous intrauterine pregnancy as well as extra uterine ectopic pregnancy.  Historically, this was considered very rare with an estimated incidence of 1 in 30,000 pregnancies however, the incidence has been increased with the use of assisted reproductive  technology.  The most common location is the fallopian tube and less common include the cervix or the ovary. It can be difficult to diagnose because the presence of an intrauterine pregnancy on ultrasound may falsely reassure clinicians and delay evaluation for a concurrent ectopic pregnancy.  These patients usually present with nonspecific symptoms including abdominal pain, vaginal bleeding, …

Acute Ischemic Stroke In Hemoglobin Sc Sickle Disease Requiring Emergent Exchange Transfusion And Neurocritical Transfer, Julian Coz, Trent Malcolm, Andrew Iskandar, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Acute ischemic stroke is a well-recognized complication of sickle cell disease (SCD), with historical estimates suggesting that up to 11% of patients experience an overt stroke by early adulthood. Stroke represents a hematologic and neurologic emergency requiring rapid reduction of the circulating hemoglobin S (HbS) fraction to prevent infarct progression. The American Society of Hematology recommends emergent exchange transfusion within two hours of presentation for patients with acute neurologic deficits [1,3].

Management is particularly nuanced in hemoglobin SC (HbSC) disease. Compared with hemoglobin SS disease, patients with HbSC typically have higher baseline hemoglobin concentrations, increasing blood viscosity and the risk …

Case Report: Ascending Cholangitis Presenting As Sepsis With Encephalopathy In An Older Adult With Choledocholithiasis, David Marconi, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Acute cholangitis is a potentially life-threatening biliary infection usually precipitated by ductal obstruction. In adults ≥80 years, classic right upper quadrant pain and jaundice may be absent and delirium may predominate, increasing the risk of diagnostic delay.¹

An 82-year-old woman presented with generalized weakness and altered mental status. She was febrile (101.9 °F [38.8 °C]) and tachycardic (113 beats/min) without hypotension. Laboratory testing demonstrated leukocytosis and marked cholestatic liver injury (total bilirubin 2.8 mg/dL, alkaline phosphatase 660 U/L) with hyperbilirubinemia and acute encephalopathy consistent with sepsis-associated organ dysfunction. Computed tomography and ultrasound suggested biliary obstruction and cholelithiasis; magnetic resonance cholangiopancreatography …

A Survey-Based Analysis Of The Use Of Lifestyle Medicine In Clinical Practices Of South Jersey, Zehra Jaffri

Rowan-Virtua Research Day

Chronic diseases are the leading cause of death and disability in the United States and are largely driven by modifiable lifestyle factors. Lifestyle Medicine (LM) is an evidence-based medical specialty that uses therapeutic lifestyle interventions—including nutrition, physical activity, stress management, sleep, substance use reduction, and healthy relationships—to prevent, treat, and reverse many chronic conditions. Despite strong evidence supporting lifestyle interventions, LM use in routine primary care remains inconsistent due to barriers such as limited visit time, inadequate clinician training, lack of reimbursement, and difficulty sustaining behavioral change. This study evaluates how often lifestyle counseling is discussed in South Jersey primary …

Surviving Ph 7.0: Rapid Interprofessional Collaboration In Severe Metformin-Associated Lactic Acidosis With Refractory Shock, Karl J. Schlicht Md, Amaani Faizal, Vincent Macolino, Julian Coz

Rowan-Virtua Research Day

Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication with mortality rates of 30-50%. Although metformin is the most widely prescribed antidiabetic medication, severe MALA requiring emergent hemodialysis remains uncommon, with an estimated incidence of 2-9 cases per 100,000 patient-years. Risk factors include acute kidney injury, dehydration, and tissue hypoxia. Early hemodialysis initiation is independently associated with improved survival. This case highlights how rapid interprofessional collaboration from the emergency department to the intensive care unit enabled in a patient presenting with profound acidemia and survival multiorgan dysfunction

A Rare Intervention: Emergency Ultrasound-Guided Pericardiocentesis Using A Central Line Kit, Alec Mirchandani, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Cardiac tamponade is a life-threatening emergency requiring rapid diagnosis and drainage.

Point-of-care ultrasound (POCUS) expedites recognition and guides pericardiocentesis. We report a case of acute large pericardial effusion with hemodynamic collapse in a previously healthy 46-year-old female, managed emergently with ultrasound-guided pericardiocentesis using a central line introducer and subsequent pigtail catheter exchange; the clinical course was complicated by presumed septic pulmonary emboli and death.

Molten Sugar Burn To The Dorsal Foot: A Case Highlighting Unique Thermal And Adhesive Injury Mechanisms, James Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

This brief case report emphasizes injury mechanism and anatomic vulnerability rather than burn management, as treatment of deep partial-thickness burns is well established. The clinical value of this case lies in recognizing molten sugar as a uniquely hazardous thermal agent capable of producing deceptively deep injury, particularly when contact occurs on the dorsal foot.

Brief Review: Quantifying The Risks Of Snow Shoveling: Cardiac, Musculoskeletal, And Environmental Hazards, James Espinosa, Swet A. Patel, James Lee, Alan Lucerna

Rowan-Virtua Research Day

Snow shoveling is a common winter activity in cold-weather regions, yet it uniquely combines intense physical exertion, cold exposure, and environmental hazards. Emergency Departments routinely observe seasonal increases in snow-shoveling–related musculoskeletal injuries, falls, and acute cardiovascular events. Despite this, the cardiovascular risk of snow shoveling is not well emphasized in medical education or patient counseling. Snow shoveling is associated with quantifiable and clinically significant risks, including musculoskeletal injury, falls, and acute cardiovascular events, which are reviewed here.

Ice Water Immersion–Associated Syncope: A Case Report With Mechanistic Review And Public Safety Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Sudden ice water immersion can provoke syncope in otherwise healthy individuals, particularly during first-time exposure. We present a case of a 56-year-old man with mild hypertension and hyperlipidemia who experienced abrupt syncope during entry into cold water at a charitable group immersion event. Emergency department evaluation, including electrocardiography and cardiac biomarkers, was normal. Observation and cardiology consultation supported a diagnosis of provoked, immersion-related syncope. This case highlights the physiologic mechanisms of cold shock and autonomic conflict, the potential drowning risk associated with loss of consciousness during water entry, and the opportunity for improved discharge counseling and public safety messaging.

Refeeding Syndrome In A Person Experiencing Homelessness: A Case Report, James Espinosa, Jose Gerald Aragon, Md Fateha, Alan Lucerna

Rowan-Virtua Research Day

Refeeding syndrome (RFS) is a potentially life-threatening metabolic disturbance that occurs following nutritional reintroduction in severely malnourished individuals. It is characterized by rapid intracellular shifts of electrolytes—most notably hypophosphatemia—driven by insulin-mediated metabolic changes. Although commonly associated with eating disorders and chronic illness, RFS may also occur in socially vulnerable populations.

We report the case of a 64-year-old male experiencing homelessness who presented to the emergency department with weakness, muscle cramps, and confusion after resuming regular meals at a local shelter following prolonged minimal intake. Laboratory evaluation revealed severe hypophosphatemia (0.7 mg/dL), hypokalemia (3.0 mmol/L), and hypomagnesemia (1.2 mg/dL). Electrocardiogram demonstrated …

Shopping Cart–Related Injuries In Children: Brief Clinical Review And Public Health Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Shopping cart–related injuries represent a common yet underrecognized mechanism of pediatric trauma. National estimates suggest approximately 24,000 children annually are treated in U.S. emergency departments for shopping cart–related injuries, with falls accounting for the majority of cases. Younger children, particularly those under 5 years of age, are disproportionately affected, and head and facial injuries predominate.

Objective:

To provide a concise clinical and public health review of shopping cart–related pediatric injuries, with emphasis on epidemiology, injury patterns, and opportunities for prevention within emergency department practice.

Methods

Narrative review of national injury surveillance data, prior epidemiologic studies, and consumer safety guidance addressing …

Effect Of Sauna On Cardiovascular Health In Patients With Heart Failure, Rikuto Abe, Piotr Domaszewski, Safe Elhakeem

Rowan-Virtua Research Day

Abstract

Heart failure (HF) is one of the hallmark diseases that represent a decline of cardiovascular function. Heart failure is characterized by a decrease in the ability of the heart to pump blood throughout the body, leading to symptoms such as fatigue, dyspnea, and swelling. HF is shown to decrease quality of life and increase mortality. Traditional treatments include pharmacology, lifestyle modifications, and surgery. Among the treatments, deliberate heat exposure in the form of dry saunas has been highlighted as a potential treatment option for HF. Dry saunas, especially infrared saunas, are shown to increase body temperature which improves circulation …