Diseases Commons^™

Case Report: Primary Appendiceal Cancer Presenting As Acute Appendicitis, Armeet Singh, Wayne Tamaska, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 46‐year‐old male who presented to the emergency department with right lower quadrant abdominal pain and was initially suspected to have acute appendicitis. Further evaluation and surgical pathology revealed primary appendiceal adenocarcinoma. Appendiceal cancer is rare and often presents with nonspecific symptoms that mimic common abdominal conditions such as appendicitis or diverticulitis. Early diagnosis can be challenging, and many cases are discovered incidentally during surgery or imaging for suspected appendicitis. This case highlights the importance of maintaining a broad differential diagnosis for right lower quadrant pain.

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 …

When Venom Isn’T The Only Threat: Roseomonas Mucosa Bacteremia Following A Snake Bite, Cyrus Davati, Kishan Patel, James A. Espinosa Md, Alan Lucerna

Rowan-Virtua Research Day

Snake bites in the ED  overall are rare in the United States. While mortality is low due to modern interventions, the sequelae - including tissue necrosis, digit amputation, and subsequent infection  remain a significant concern.  Here we present the case of a  presumptively non-venomous snakebite, which  was associated with R. mucosa bacteremia.

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

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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. …

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

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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 …

Arrhythmic Syncope And Brugada Syndrome: Critical Identification Of High-Risk Patterns At The Ed Frontline, Kristine Rubi, Brittany Fera, Kelsey Murray, James Espinosa, Alan Lucerna

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Brugada Syndrome (BrS) is a premier cause of sudden cardiac death (SCD) in structurally normal hearts, particularly in Southeast Asia (SEA) where it is historically recognized as Sudden Unexplained Nocturnal Death Syndrome (SUNDS). We report the case of a 55-year-old male of Vietnamese descent who presented to the emergency department (ED) after a sudden, non-prodromal syncopal episode at rest. The event was significant for urinary incontinence and diaphoresis, classic red flags for arrhythmic syncope. Bedside electrocardiogram (EKG) demonstrated the pathognomonic Type 1 coved ST-segment elevation in leads V1 and V2. This symptomatic presentation following a six-year "follow-up gap" since a …

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, …

Case Report: Acute Cerebrovascular Accident With An Initial Absence Of Infarct Findings On Mri, Alyssa Baldini Md, Brittany Fera

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We report a case of a 42-year-old female whose diffusion-weighted magnetic resonance imaging (MRI) performed 28 hours after symptom onset was negative for acute infarction. Repeat MRI 3 days later demonstrated left-sided corona radiata infarction.

Diffusion-weighted MRI imaging may not be sensitive or specific enough in early stages of acute stroke. Caution should be used in relying on imaging alone to make the diagnosis of ischemic stroke. Clinical assessment likely should be given priority in determining appropriate initial treatment and the need for secondary stroke prevention treatment when imaging is negative. Consideration should be given to the timing of initial …

Myxedema Coma: Recognizing A Silent But Potentially Fatal Emergency, Aashna Chaudhry, Robin Lahr, James Espinosa, James Espinosa, Alan Lucerna

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Myxedema coma is an endocrinologic emergency that requires prompt recognition and treatment. It is described as severe hypothyroidism characterized by life-threatening slowing of metabolic processes, often occurring in the setting of precipitating factors such as trauma, infection, medications, or cold exposure. This case report presents a clinical case in which early suspicion of myxedema coma in an elderly female patient led to prompt treatment and life-saving measures.

An Elusive Diagnosis: Pheochromocytoma Presenting With Hyperglycemia And Hypertensive Crisis, Tucker Ledo

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Pheochromocytoma is a rare catecholamine-secreting tumor that can present with a wide range of nonspecific symptoms, often mimicking more common medical conditions and making early diagnosis difficult. We report the case of a 40-year-old female with a history of hypertension and prediabetes who presented to the emergency department with hyperglycemia following an episode of lightheadedness. This case highlights the diagnostic challenge of pheochromocytoma in the emergency department, where initial symptoms may be subtle and easily attributed to more common conditions such as hypertension, diabetes, or menopause. Recognition of episodic sympathomimetic symptoms and unexplained hypertensive crises should prompt consideration of pheochromocytoma …

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

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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 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

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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

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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 …

High-Intensity Interval Training And Circulating Brain-Derived Neurotrophic Factor In Healthy Young Adults: A Scoping Review, Rikuto Abe, Safe Elhakeem, Mohamed Elhakeem

Rowan-Virtua Research Day

Abstract

Background: Brain-derived neurotrophic factor (BDNF) plays an important role in synaptic plasticity, neuronal survival, and cognitive function (1,2,3). High-intensity interval training (HIIT) has emerged as a time-efficient exercise modality capable of inducing neurotrophic adaptations (4,5). However, the magnitude and consistency of its effects on circulating BDNF remain unclear.

Objective: This scoping review evaluated the current evidence examining the effects of HIIT on circulating BDNF levels measured via enzyme-linked immunosorbent assay (ELISA) in healthy young adults.

Methods: A systematic search of PubMed, Embase, and Scopus was conducted for randomized and controlled clinical trials published between 2020 and 2025. Studies were …

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 …

Gut Microbiota Dysbiosis In Down Syndrome: Implications For Gastrointestinal And Neurological Health, Ashlyn Mcclelland, Jennifer Lecomte, Wendy Aita, Andrea Iannuzzelli

Rowan-Virtua Research Day

Down syndrome (DS) is the most common autosomal aneuploidy and has strong associations with increased gastrointestinal, neurological, and immune disorders. Emerging evidence suggests that gut microbiota dysbiosis may play a prominent role in disorders of gut-brain interaction, including constipation and irritable bowel syndrome affecting over half of individuals with DS. This review examines how gut microbiota alterations can contribute to chronic systemic inflammation and neurological manifestations in DS. Included articles were published between 2014 and 2025 and evaluated microbiota composition, inflammatory markers, and gastrointestinal or neurological outcomes in human or animal models of DS.

Across seven studies, characteristic microbiome shifts …

From Confirmation To Guidance: Making The Case For Intraprocedural Pocus As The Next Developmental Step In Ultrasound-Supported Shoulder Reduction A Conceptual Practice Proposal And Research Agenda, James Espinosa

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Point-of-care ultrasound (POCUS) is well established for the diagnosis of shoulder dislocation and for the confirmation of successful reduction. However, its role during the reduction maneuver itself remains under-described. This conceptual practice proposal argues that intraprocedural POCUS represents the logical next developmental step in ultrasound-supported shoulder reduction. By introducing real-time visualization of humeral head translation during reduction attempts, clinicians may identify ineffective vectors earlier, adjust technique midstream, and potentially reduce repeated attempts or escalation of procedural sedation. This work does not present outcome data but instead proposes a practical framework, workflow model, and research agenda for intraprocedural implementation. Future study …

Rainfall, Air Quality, And Vaso-Occlusive Crisis In Adults With Sickle Cell Disease, James Espinosa

Rowan-Virtua Research Day

.Patients with sickle cell disease (SCD) frequently report that weather changes precipitate vaso-occlusive crises (VOC). While prior investigations have focused primarily on temperature, humidity, and seasonal variation, emerging data suggest that rainfall patterns may represent a more meaningful environmental signal. In a multi-hospital Emergency Department analysis, below-average rainfall days were associated with significantly increased adult VOC presentations (Ahmed et al., 2023). Rainfall may function as an atmospheric clearing mechanism; reduced precipitation may permit accumulation of airborne particulate matter and environmental pollutants, increasing oxidative stress and endothelial activation—mechanisms central to vaso-occlusion. Multiple epidemiologic studies demonstrate associations between particulate exposure and increased …

Designing For Difference: A Systems Approach To Sensory-Adaptive Care In The Emergency Department, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Children with genetic syndromes and other neurodevelopmental conditions frequently present to the Emergency Department (ED) with sensory vulnerabilities that complicate evaluation and treatment in high-stimulus environments. While experienced clinicians often adapt instinctively to meet these needs, such adaptations may be inconsistently applied and may also be highly individual provider dependent. We present a case involving a child with a genetic syndrome affecting auditory and visual systems to illustrate how small environmental, relational, temporal, and cognitive adjustments can prevent escalation and enable routine care delivery without specialized resources.

We propose reframing sensory-adaptive care not as an exceptional accommodation but as a …

The Physics And Biology Of High-Risk Falls: Biomechanical Analysis And Physics Assists In Understanding Why The Threshold For High-Risk Was Lowered To 10 Feet, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Recent revisions to the National Guideline for the Field Triage of Injured Patients lowered the high-risk fall threshold from >20 feet  to >10 feet for all ages. Guideline changes are multifactorial and typically reflect epidemiologic registry data, injury severity trends, and systems-level performance feedback. However, biomechanical analysis assists in understanding the importance of the change.

Objective: To demonstrate that a 10-foot fall generates sufficient kinetic energy and deceleration forces to exceed structural tolerance thresholds in multiple human tissues, and to show that fundamental physics independently supports the recent trauma protocol change.

Methods: Application of gravitational motion equations (v = …

The Epidemiology Of Sledding Injuries: Clinical Patterns And Public Health Prevention Strategies, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Sledding is a widely enjoyed winter recreational activity among children and adolescents. Although commonly perceived as low risk, sledding can result in extremity fractures, head injuries, and collision-related trauma. Emergency Departments frequently encounter sledding injuries during winter months, providing both clinical insight and opportunities for injury prevention counseling. An estimated 20,000–30,000 sledding-related injuries occur annually in the United States, most involving children and adolescents.

Objectives: To describe patterns of sledding injuries presenting to the Emergency Department and highlight practical safety recommendations physicians can communicate to families.

Methods: Conceptual review integrating Emergency Department observational experience with published literature on pediatric …

Obesity Paradox In Post-Cholecystectomy Outcomes: A Bmi Class–Based Trinetx Analysis At 6 Months And 1 Year, Jashanveer S. Johal, Mahmoud Al-Bataineh, Bianca Patel, Archana Salek, Om Patel, Jason Hyman, Yecheskel Schneider, Abdallah Hussein

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Background: Obesity is traditionally associated with higher perioperative risk, yet observational data suggest an "obesity paradox" in which obese patients experience comparable or better outcomes than non-obese peers. We evaluated the impact of obesity (BMI ≥30 kg/m²) and obesity class on post-cholecystectomy outcomes.

Methods: A retrospective cohort study was conducted using the TriNetX global federated network. Adults undergoing cholecystectomy with BMI < 30 kg/m² were propensity score–matched 1:1 to those with BMI ≥30 kg/m², yielding 81,048 patients per group. Primary outcomes included choledocholithiasis, procedural complications, need for ERCP, and ED/inpatient utilization; secondary outcomes included mortality, respiratory and cardiovascular complications, and upgrade of care. Outcomes were assessed at 6 months and 1 year. A prespecified subgroup analysis compared BMI 30–39 versus BMI ≥40 kg/m² (40,238 per cohort).

Results: Obese patients consistently demonstrated lower rates of major outcomes at both timepoints. At 1 year, BMI < 30 had higher risks of choledocholithiasis (9.1% vs. 8.0%; RR 1.13), procedural complications (3.8% vs. 3.1%; RR 1.22), ERCP (5.4% vs. 4.6%; RR 1.19), and ED/inpatient visits (30.3% vs. 28.8%; RR 1.05; all p< 0.001). Mortality was also higher in non-obese patients at 1 year (1.4% vs. 1.2%; RR 1.20). Within the obese subgroup, BMI 30–39 and BMI ≥40 had broadly similar complication and utilization rates, though 1-year mortality was lowest in class I–II obesity (0.8% vs. 1.0%; RR 0.85).

Conclusions: Obesity was associated with better post-cholecystectomy outcomes compared with BMI < 30 kg/m², supporting an obesity paradox in biliary surgery. BMI alone should not deter cholecystectomy, and perioperative risk stratification should incorporate factors beyond weight class.

Sex Differences In Insulin Resistance And Triglyceride/Hdl-Cholesterol Ratio In Human Subjects, Jiyoon Jung, Lakshman Segar, Christine Whitehair, James Bailey, Ashley Coleman, George Scott

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Background: Insulin resistance (IR) plays a major role in dyslipidemia and the associated cardiovascular disease risk. To date, it remains unclear as to how IR alters plasma lipid profile in males versus females. The present study is an initial step to determine sex-specific differences in IR and plasma lipid profile using 40 μL of capillary blood. Methods: 19 adults aged 30-64 were recruited from Rowan Medicine-Sewell clinics, with 13 participants (9 males, 4 females) consenting to the study. After collecting 40 μL of capillary blood via finger prick, the samples were analyzed for glucose, triglyceride (TG), and HDL-cholesterol (HDL-C) using …

Bacteriophage Therapy Vs. Standard Antibiotics: A Review Of Treatment Efficacy For Recurrent Pediatric S. Pyogenes (Gas) Infections, Kartik Kannan Oms-I, Karina Malhotra Oms-I, Gabrielle Coccio Oms-I, Janhavi Belwalkar Oms-I, Jason Rienzo Oms-I, Samay Shukla Oms-I, Valerie J. Carabetta Phd

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Background: Antibiotic resistance poses a growing threat to pediatric infectious disease management, particularly in the treatment of Streptococcus pyogenes (GAS) infections.¹ While β-lactam antibiotics remain the first-line standard of care, their utility is limited by allergy prevalence and rising resistance among alternative antibiotic agents, such as macrolides, lincosamides, and tetracycline.^2,3 Given these trends, bacteriophage therapy has emerged as a promising adjunctive treatment modality, offering targeted bacterial lysis while sparing commensal microbiota.⁴

Methods: A systematic literature search was conducted across PubMed and Embase (2000–2025) using terms related to antibiotic resistance, Streptococcus pyogenes, bacteriophage therapy, and pediatric populations. …

Mental Health Comorbidities And Ibd Outcomes On Anti-Tnf Therapy, Jashanveer S. Johal, Mahmoud Al-Bataineh, Archana Salek, Bianca Patel, Om Patel, Jason Hyman, Yecheskel Schneider, Abdallah Hussein

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Background: Depression and anxiety are prevalent in inflammatory bowel disease (IBD) and may adversely affect biologic therapy outcomes. We evaluated the impact of comorbid mood disorders on clinical outcomes among IBD patients treated with anti-TNF agents.

Methods: Using a global de-identified electronic health record network, adults with Crohn's disease or ulcerative colitis initiating an anti-TNF agent between 2018–2023 were identified. Cohort 1 included patients with a documented mood disorder (depression and/or anxiety) at or prior to anti-TNF initiation; Cohort 2 included those without mood disorders. Propensity score matching (1:1) on demographics and comorbidities yielded 9,605 patients per cohort. Primary outcomes …