Medicine and Health Sciences Commons^™

Recurrent Unilateral Pleural Effusion From Constrictive Pericarditis Of Unknown Etiology Requiring Pericardiectomy, Aishah Ali, Md, Gina Keiffer, Md

The Medicine Forum

Introduction

Constrictive pericarditis is an uncommon cause of unilateral pleural effusion. In patient’s who have repeated thoracenteses with no obvious cause for the pleural effusion, constrictive pericarditis should be considered. Right and left heart catheterization is used to diagnosis constrictive pericarditis by measuring filling pressures of the heart.

Case Report

A 52-year-old man with a history of hepatitis C, hepatocellular carcinoma (HCC), status post liver transplant in July 2013, chronic kidney disease, gastroesophageal reflux disease and hypothyroidism presented with increasing dyspnea with minimal exertion and was found to have recurrent pleural effusion. Patient had been worked up as an outpatient …

A Rare Case Of Tumor Lysis Syndrome, Anne Mainardi, Ms4, Daniel Okamoto, Md, Jianqing Lin, Md

The Medicine Forum

INTRODUCTION

Tumor lysis syndrome (TLS) is a metabolic disturbance caused by the destruction of rapidly dividing cancer cells following administration of cytotoxic chemotherapy. The subsequent release of intracellular material results in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.1 The clinical presentation of TLS, including acute kidney injury, results from these electrolyte abnormalities and can be life-threatening.2 Here we present the second reported case of TLS in a woman with endometrial cancer.

CASE PRESENTATION

A 63 year old woman with newly-diagnosed endometrial cancer (International Federation of Gynecology and Obstetrics, FIGO, stage IVB) who received her first dose of carboplatin and paclitaxel four days …

Anomalous Left Main Coronary Artery Originating From The Right Sinus Of Valsalva, Silpa Yalamanchili, Ms4, Kevin M. Curl, Md

The Medicine Forum

Introduction

An anomalous left main coronary artery is a rarely seen clinical entity, particularly when it arises from the right sinus of Valsalva. This case report highlights this uncommon finding and how it affects the care of a patient with significant coronary artery disease.

Case Presentation

A 66 year-old male with a history of hypertension, hyperlipidemia, and type II diabetes presented with progressive exertional mid-epigastric and mid-chest discomfort. The patient stated that he had been feeling this “heaviness” with various activities and occasionally at rest for the past nine months. When it occurred with activity, the pain was generally relieved …

Interventricular Septum Rupture In The Catheterization Laboratory, Xing Zhang, Md, Loheetha Ragupathi, Md

The Medicine Forum

Introduction

This is a case of acute ventricular septal defect (VSD) that was diagnosed while a patient with an acute ST-elevation myocardial infarction (STEMI) was being treated in the cardiac catheterization laboratory. Post-MI VSD is a well-recognized complication of STEMI, and this case was particularly interesting given the circumstances of its diagnosis.

Case Presentation

A 75 year-old female with a history of well-controlled hypertension presented with 3 days of substernal chest pain radiating down her left arm. The pain was severe, unremitting, associated with shortness of breath, nausea, vomiting, and was not relieved by simethicone or by changes in position. …

Fever In A Man With Hiv: An Unusual Case Of An Immune System Gone Wrong, Emily Sutton, Md, Aishah Ali, Md

The Medicine Forum

Introduction

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome of immune dysregulation that is often recognized as secondary to an underlying immune activating state, such as malignancy, rheumatologic disorders, and infections. This case highlights an association between HLH and human immunodeficiency virus (HIV) infection. Although HLH is a rare complication of HIV, it presents a difficult challenge for treatment. Without treatment, HLH is invariably fatal, but the consequence of the immunosuppressive treatment regimen in the setting of an underlying opportunistic infection can also have fatal outcomes.

Case Presentation

A 38 year-old man with a history of HIV infection with a CD4 …

Hiv Screening: A Review Of Nationally Recommended Guidelines And Specific Instances In Which Hiv Screening Is Often Overlooked, Anusha Ganesh, Md

The Medicine Forum

INTRODUCTION

According to the Centers for Disease Control and Prevention (CDC), one in five human immunodeficiency virus (HIV)-infected individuals are currently living without knowledge of their diagnosis.1 In 2006, the cost of a rapid HIV test with pre/post-test HIV counseling was anywhere between 48-64 US dollars (USD). The majority of the cost incurred was for HIV counseling, with the cost of the rapid HIV test being between 8-25 USD.2 Research looking at the cost-effectiveness of HIV screening shows that it is more cost-effective than routine screening for breast cancer with mammography yearly or even routine screening for diabetes mellitus with …

A Case Of Fibrosing Mediastinitis, Esther Molnar, Md

The Medicine Forum

Introduction

Fibrosing mediastinitis (FM) is a rare disease of slowly progressive fibrosis that encases major mediastinal structures. Complications include obstruction of mediastinal vasculature, including main pulmonary arteries, which may lead to life-threatening hemodynamic compromise. In North America, the disease is usually a sequela of histoplasmosis. Because Histoplasma capsulatum (H. capsulatum) is found in the Ohio River Valley, physicians in Pennsylvania must be able to recognize and diagnose the disease.

Case Presentation

The patient is a 59 year-old female who was seen for follow-up in April 2013. She originally presented to the outpatient office in 2008 with chronic chest pain and …

A Speedy Recovery With Medical Management In A Patient With Emphysematous Gastritis, Tanvi Khurana, Md

The Medicine Forum

INTRODUCTION

Emphysematous gastritis is a rare and serious condition characterized by evidence of intramural air and inflammation of the gastric wall as well as systemic toxicity. It is generally caused by local infection by gas-forming organisms through a mucosal defect or via hematogenous spread from a distant focus.1 Since emphysematous gastritis has a fulminant course with a mortality rate of 60%, prompt recognition as well as early treatment are crucial.2 Here, we present a case of a 65 year-old male who presented with abdominal pain and had CT findings consistent with emphysematous gastritis. He was treated with antibiotics and had …

A Case Of Dengue Hemorrhagic Fever And The Use Of Supportive Therapy, Aishah Ali, Md, Emily Sutton, Md

The Medicine Forum

Introduction

Dengue fever is a mosquito-bound viral illness that occurs in tropical climates. It is endemic in 110 countries.1 Fifty to three hundred and ninety million people are infected worldwide every year,2 leading to ~25,000 deaths.3 It is often an asymptomatic self-limited illness, which can present with myalgias, arthralgias, and hemorrhagic manifestations such as petechiae. In a fraction of cases, dengue fever can proceed to dengue hemorrhagic fever (DHF), which can be life threatening causing thrombocytopenia, bleeding and increased vascular permeability. Dengue shock syndrome (DSS) can then ensue, if hypotension occurs, and is fatal in >10% of patients.4

Here we …

Recurrent Cryptococcosis In A Human Immunodeficiency Virus-Negative Patient, Lillian C. Man, Md

The Medicine Forum

Introduction

Idiopathic CD4+ lymphocytopenia (ICL) is a rare disorder that can predispose otherwise immunocompetent individuals to life-threatening opportunistic infections. We present a case of a human immunodeficiency virus (HIV)-negative patient with ICL who presented with recurrent cryptococcosis.

Case Presentation

A 39-year-old Caucasian, HIV-negative male with a past medical history of stroke 13 years prior to admission and an episode of cryptococcal meningitis 18 months prior to admission presented to the hospital with generalized weakness for 7 days. The patient had a 10 pack-year smoking history and no significant environmental or occupational exposures. On admission, vital signs were significant for a …

Congenital Absence Of The Pericardium, Lillian C. Man, Md, Jaehee Kim, Md, Rakesh Gupta, Md

The Medicine Forum

Introduction

Congenital absence of the pericardium (CAP) is an uncommon finding previously recognized only post-mortem or during surgery. However, its incidence has been on the rise with the use of multiple contemporary imaging techniques. CAP can present with paroxysmal, left-sided chest pain and should be considered in the differential diagnosis of atypical causes of chest pain. We present the case of a 50-year-old male who presented with chest pressure, symptoms of heart failure, and was found to be in atrial fibrillation in whom partial absence of the left pericardium was diagnosed.

Case Presentation

A 50 year-old African-American male presented to …

A Case Of Bilhemia: A Rare Complication Of Transjugular Intraheptic Portosytemic Shunt, Michael Zhang, Ms3, Michael Valentino, Md, Phd

The Medicine Forum

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a common procedure used to alleviate the secondary effects of portal hypertension including uncontrolled variceal bleeding, refractory ascites, and hepatic pleural effusion (hydrothorax). There are several well-known complications of TIPS, including portosystemic encephalopathy, hemolytic anemia, hepatic ischemia, and stent thrombosis.1 In this case report we present a rare but serious complication of TIPS – bilhemia - in which bile escapes into the bloodstream through a fistula between the biliary tree and the hepatic venous system.

Case Presentation

A 56 year-old female with cirrhosis due to chronic hepatitis C presented to the hospital for …

An Uncommon Presentation Of Amyloidosis, Brandon Kujawski, Ms3, Drew Johnson, Ms3, Kushan Radadia, Ms4, Eric Feduska, Md, Robert Ford, Md, Guldeep Uppal, Md, Mariam Kabir, Md, Phd, John Stewart, Md

The Medicine Forum

Introduction

AL amyloidosis is a rare disease, with only 1200-3200 new cases in the US per year.1 Two-thirds of patients are male; presentation typically occurs after age fifty.1,2,3 Amyloid can involve the kidneys (74%), heart (60-90%), liver (27%), peripheral nervous system (22%), and carpal tunnel (20%).3 We describe an atypical presentation of AL amyloidosis and highlight the importance of recognizing this disease in patients with systemic signs.

Sustained Achromobacter Xylosoxidans Bacteremia In A Patient With Adenocarcinoma Of The Colon, Matt Enriquez, Ms4, Andi Favini, Ms4, Kevin Curl, Md

The Medicine Forum

Introduction

Achromobacter xylosoxidans is a rare cause of bacteremia; however patients with underlying illness, especially malignancies, are at increased risk of infection. Antibiotic therapy against this pathogen can be difficult owing to its inherent resistance to multiple common antibiotics.

Case Presentation

A 69-year-old male with adenocarcinoma of the colon status post right hemicolectomy and chemotherapy presented with fever and fatigue 10 days following endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for new liver metastases. The patient had undergone partial hemicolectomy and had completed 12 cycles of adjuvant FOLFOX (leucovorin, 5-fluorouracil, and oxaliplatin) at the time of initial diagnosis. Two …

Table Of Contents, The Medicine Forum, Volume 15, 2013-2014

The Medicine Forum

Table of Contents, The Medicine Forum, Volume 15, 2013-2014

From The Editors, Harkirat Singh, Md, Michael A. Valentino, Md, Phd

The Medicine Forum

We are proud to publish the 15th issue of The Medicine Forum. Since its inception, this journal has provided a medium for medical students and housestaff to share their scholarly pursuits and clinical experiences with the Jefferson community. It has served as a platform both for those pursuing careers in academic medicine as well as those wishing to share their personal experiences with a larger audience. This year we are introducing a new section called Clinical Images which will showcase interesting physical exam findings and radiographic images accompanied by brief patient vignettes. We have been fortunate to have received numerous …

From The Desk Of The Residency Program Director, Gretchen Diemer, Md, Facp

The Medicine Forum

Welcome to the Forum!

We have experienced another wonderful year in the Jefferson Internal Medicine Residency Program! Our program continues to attract the best and brightest medical students who over three years become outstanding clinicians, accomplished researchers and compassionate physicians. Residency training is increasingly complex, with competing demands compressing their work into fewer hours. I am consistently impressed with the camaraderie among our housestaff—they not only take care of patients, but they take care of each other. It is something that sets our program apart from others and is something of which I am incredibly proud.

Download Entire Issue Of The Medicine Forum, Volume 16, 2014-2015

The Medicine Forum

Download entire issue of The Medicine Forum, Volume 16, 2014-2015

Pneumothorax Ex Vacuo In A Patient With Malignant Pleural Effusion After Pleurx Catheter Placement, Meera Bhardwaj, Ms4, Loheetha Ragupathi, Md

The Medicine Forum

Introduction

Pneumothorax ex vacuo (“without vaccuum”) is a type of pneumothorax that can develop in patients with large pleural effusions. Unlike spontaneous or tension pneumothoraces, pneumothorax ex vacuo does not require chest tube placement. Careful recognition of this type of pneumothorax may save patients and physicians from an unnecessary procedure, and limit patient risk of infection, bleeding and further lung injury.

Hemorrhagic Bullous Dermatosis, Bhuvanesh Govind, Md, Luis Eraso, Md, Esteban Gnass, Md, Geno Merli, Md

The Medicine Forum

Introduction

The patient is a 64 year old man with active primary central nervous system B-cell lymphoma who was hospitalized for management of a right lower extremity traumatic injury complicated by a calf hematoma. During the hospital stay, the patient was diagnosed with a provoked left lower extremity deep vein thrombosis (DVT) and treated initially with therapeutic dosing of enoxaparin. Five days after low molecular weight heparin (LMWH) initiation, gradual development of tense, well-circumscribed bullae were noted to appear on his arms and hands bilaterally, ranging from 0.5 cm to 1.5 cm in diameter. These lesions were both nonpruritic and …

Tumor Lysis Syndrome In Light Chain Multiple Myeloma Treated With Bortezomib Combination Therapy, Hasmik Minasyan, Md, Meaghan Henrici, Md

The Medicine Forum

Introduction

Tumor lysis syndrome (TLS) is a potentially life threatening complication of cancer treatments that typically occurs in highly proliferative malignancies. It is rare in patients with multiple myeloma (MM) given the disease’s indolent nature and is estimated to occur in less than 1% of cases.1 Increasing reports of TLS have been described in MM, particularly in treatment regimens containing bortezomib, the first available proteasome inhibitor. Here we describe a case of a newly diagnosed light chain multiple myeloma resulting in tumor lysis syndrome following the first dose of combination therapy with bortezomib, cyclophosphamide and dexamethasone.

CASE REPORT

A 68 …

The Rare Case Of Streptococcus Pyogenes Pneumonia And Its Sequelae, Fern Martin, Md, Gloria Francis, Md

The Medicine Forum

Introduction

Group A Streptococcus (GAS) or Streptococcus pyogenes is an aerobic gram-positive coccus that causes a multitude of infections that range in severity. GAS most commonly infects the soft tissues, which results in infections such as cellulitis, erysipelas, necrotizing fasciitis and myositis. These deep soft tissue infections are also the most common source of GAS bacteremia. Other common infections caused by GAS include pharyngitis, rheumatic fever and glomerulonephritis.1 The lower respiratory tract is an uncommon site for GAS infection and it is the least common source of GAS bacteremia; however, in adults with GAS pneumonia, the incidence of bacteremia is …

Sudden Vision Loss During Hemodialysis, Andrew W. Panakos, Md

The Medicine Forum

Introduction

Catheter-related blood stream infections (CRBSIs) are a common and unfortunate consequence of prolonged vascular access in hemodialysis patients. Metastatic infections are feared sequelae of bacteremia, and include endocarditis, osteomyelitis, septic arthritis, epidural abscess, and endophthalmitis.1 The following is a case of Serratia endophthalmitis originating from a tunneled-dialysis catheter.

Case Presentation

A 47 year-old Caucasian female with a history of end stage renal disease on hemodialysis, Type 2 diabetes mellitus, and hypertension was undergoing her routinely scheduled hemodialysis session when she experienced “flashes of hot pink” in her left eye. The hemodialysis session was terminated, and the patient returned home. …

Sinus Histiocytosis: An Uncommon Presentation Of An Uncommon Condition, Allison Greco, Md, Gregory Kane, Md

The Medicine Forum

Introduction

Rosai–Dorfman Disease (RDD), also known as Sinus Histiocytosis with Massive Lymphadenopathy (SHML), is a rare, benign, proliferative disorder of macrophages and monocytes that was first described by Rosai and Dorfman in 1969. The vast majority of patients present with painless bilateral cervical lymphadenopathy during childhood or young adulthood. The condition is self-limited and rarely requires medical treatment. Involvement of extranodal sites such as eyelids, eye sockets, skin and subcutaneous tissue, gastrointestinal tract, upper airways and central nervous system have been infrequently described. Mediastinal involvement is extremely rare, and there are few cases reported in the literature.

Here, we present …

Rising Prevalence Of Pneumocystis Jirovecii Pneumonia Amongst The Non-Hiv Immunosuppressed, Zachary Jones, Md, Anusha Ganesh, Md

The Medicine Forum

INTRODUCTION

Fungal Pneumonia caused by Pnemocystis Jirovecci (PCP) has long been associated with morbidity and mortality in HIV-positive patients. With the widespread use of high dose corticosteroids and biologic therapies, the prevalence of PCP infection in the non-HIV immunosuppressed population has increased significantly. A lack of formalized prophylaxis guidelines in these specific populations has lead to increasing rates of preventable infection and death.

CASE PRESENTATION

The patient is a 63-year-old man, admitted to the hospital for persistent shortness of breath following a seven-day course of Levofloxacin taken as an outpatient. Two months prior, the patient was found by his hematologist …

A Retinal Tear Induced By Pazopanib Therapy: A Case Report, Raza Hasan, Md

The Medicine Forum

Introduction

The management of renal cell carcinoma has undergone major transformation in recent years. With the onset of innovative surgical treatments and systemic medications – there has been an overall decrease in mortality.1 The systemic medications that target the vascular endothelial growth factor (VEGF) protein have created the most potent effects, especially when treating metastatic renal cell carcinoma. These prove to be important treatments since renal cell carcinoma has become the seventh most common cancer in men, with a general prevalence of 2-3%.2 With more advancement in knowledge about renal cell carcinoma, research has shown the utility of pazopanib (Votrient), …

Pulmonary Mucormycosis In A Patient With Acute Myeloid Leukemia, Jonathan Pan, Md, Margaret Kasner, Md, Sheel Patel, Md, Gretchen Diemer, Md

The Medicine Forum

Introduction

Mucormycosis is a rare fungal infection that is common amongst uncontrolled diabetics and immunocompromised patients. The most common clinical presentation is rhino-orbital-cerebral infection, which typically affects diabetics with ketoacidosis.1 Less commonly, pulmonary mucormycosis can occur in patients with hematologic malignancy, solid organ transplant and patients taking steroids or deferoxamine.1 The following report describes a 25-year-old male with Acute Myeloid Leukemia (AML) who developed a pulmonary mucormycosis infection. With a mortality rate of about 87%, this case represents a favorable outcome for a rare and often lethal diagnosis.

Case Description

A 25-year-old male with no past medical history presented to …

Persistent Fever And Pancytopenia: Lupus Flare Vs Macrophage Activation Syndrome, Amy Mcghee, Md

The Medicine Forum

Introduction

Macrophage activation syndrome (MAS), first named in 1993, is a subcategory of hemophagocytic lymphohistiocytosis (HLH), characterized by prolonged fever, hepatosplenomegaly, pancytopenia, liver dysfunction, and most notably hyperferritinemia. MAS, in particular, is the term used to describe secondary HLH, or HLH caused by rheumatologic conditions. Secondary HLH can also be associated with other systemic autoimmune diseases, underlying malignancy, infection, or medications and can be a life-threatening complication. MAS is characterized by unwarranted proliferation and stimulation of T cells and benign macrophages leading to an excessive inflammatory state with hypersecretion of cytokines. This, in turn, leads to phagocytosis of normal blood …

Nephrotic Syndrome: Is Hiv Associated Nephropathy On Your Differential?, Jad Al Danaf, Md, Jeffrey Marbach, Md, Sharon Li, Ms4, Emily Stewart, Md

The Medicine Forum

Case Description

A 30-year old African American female with no significant past medical history initially presented to our emergency department with three days of sore throat, dysphagia, fever, fatigue, nausea and vomiting. She denied ear pain, rhinorrhea, shortness of breath or any sick contacts. Her social history was negative for tobacco, alcohol and illicit drug use. She works as a security officer, lives with her family and is sexually active only with her husband. On initial examination she was febrile to 101.9° F, with a heart rate of 100 beats per minute, blood pressure of 143/99 mmHg, respiratory rate of …

Metformin Associated Lactic Acidosis, Jinyu Zhang, Md, Ravi Sunderkrishnan, Md, Samantha Brackett, Ms4, Maham Qureshi, Md, Keithe Shensky, Md, Rakesh Gulati, Md

The Medicine Forum

Introduction

Metformin is a first line oral medication for diabetes mellitus shown to decrease cardiovascular morbidity and mortality. Though the prevalence of metformin-associated lactic acidosis (MALA) is low, mortality is high, ranging from 25-50%. Therefore, it presents a diagnostic challenge that is critical to identify, particularly in patients with renal impairment at baseline. Traditionally patients with creatinine greater than 1.5 mg/dL have been excluded from using metformin; however, metformin might be acceptable in some patients with chronic kidney disease (CKD).

Case Presentation:

A 69 year old female with a past medical history of diabetes mellitus, hypertension, breast cancer, and no …