Medical Specialties Commons^™

An Exceedingly Rare Case Of Bilateral Synchronous Germ Cell Testicular Tumors Of Different Histological Types, Joseph Kim, Ray Page, Gregory Moses, Rod Carlo Columbres

North Texas GME Research Forum 2023

It is exceedingly rare to find a case of bilateral synchronous germ cell testicular tumors of different histological types, and there have been only a handful of cases because of a lack of connections through lymphatic or vascular pathways between the testes. Here we present a unique case of a 43-year-old man who initially presented to the primary care physician for increasing right testicular swelling. He had a testicular sonogram that showed a large right testicular mass as well as a 1.7 cm left testicular mass suspicious of malignancy. Pre-surgical laboratories showed PSA 0.97, alpha-fetoprotein 1875, quantitative hCG 2508, and …

Case Of Shiga-Toxin Producing E. Coli Dysentery In Adult Patient In The Absence Of Diarrhea, Diana Roy

North Texas GME Research Forum 2023

This is a unique case of a 38 year old Caucasian female with no significant medical history who presented to the hospital with complaint of 3 days of abdominal pain, nausea/vomiting, dark red formed stool, and fever (TMax 102F), as well as dizziness, body aches and throat pain. She reported eating meatloaf with her daughter two days before symptom onset, and daughter was reported to be ill as well. Upon initial exam, patient was found to have temp 100F, was hypotensive and tachycardic with lactate of 4.2. FOBT was positive. Significant lab values include creatinine 3.39 (baseline normal), hemoglobin of …

Presentations Of Tumor Recurrence Of Non-Melanoma Skin Cancer After Treatment With Low-Energy Superficial Radiation Therapy, Marshall Hall, Henry Lim, Christian Scheufele, Christopher M. Wong, Daniel A. Nguyen, Michael Carletti, Stephen Weis

North Texas GME Research Forum 2023

Background: Basal cell carcinoma and squamous cell carcinoma are the most common types of non-melanoma skin cancers.1 Superficial radiation therapy (SRT) is a treatment modality that utilizes low-energy x-rays to disrupt cell mitosis.2 While this technique has been used for over a century, it has recently gained favor in clinical practice.3,4 This method of treatment offers favorable outcomes and advantages for select patients. Although the incidence of cancer recurrence after superficial radiation therapy is low, relatively little is known regarding predictive patterns. The frequency and timing of cancer recurrence is not well defined using SRT delivered technology with an image-guided …

Euglycemic Diabetic Ketoacidosis Secondary To Sglt2 Inhibitors In Combination With A Low-Carbohydrate Diet, George Yeung, Nhi Duong, Akshaj Pole, Benjamin Larsen, Syed Ahmed

North Texas GME Research Forum 2023

Euglycemic diabetic ketoacidosis (EuDKA) is a rare complication of type 2 diabetes mellitus (T2DM) characterized by normoglycemia in the presence of anion gap metabolic acidosis and blood ketone. EuDKA has been associated with the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) but the reported adverse events are scarce. We present a case of a 68-year-old gentleman with T2DM and coronary artery disease, who developed EuDKA after starting empagliflozin (Jardiance) with a low-carbohydrate diet for a few days. SGLT2i block proximal tubule glucose reabsorption, resulting in a state of carbohydrate starvation and subsequent ketosis. The combination of SGLT2i with a low-carbohydrate diet …

Covid-19 Masking An Atypical Presentation Of Hairy Cell Leukemia, Kahmalia-Kalee Sada

North Texas GME Research Forum 2023

Hairy cell leukemia is a rare lymphoid neoplasm of small mature B cell lymphoid cells. Hairy cell leukemia only accounts for about 1 to 2 percent of adult leukemia cases. Early diagnosis of Hairy cell Leukemia is important, it is proven that without treatment the median survival of this cancer is four years. After numerous studies the age-adjusted risk of death with proper diagnosis and treatment has decreased by 85%. The greatest outcomes are seen in individuals who are younger with earlier diagnosis. Hairy Cell Leukemia is a rare leukemia seen with the classic triad of splenomegaly, pancytopenia, and “hairy” …

51-Year-Old Female With Epistaxis And Generalized Weakness For 2 Months Diagnosed With Rpgn, Meihuan Lin

North Texas GME Research Forum 2023

Rapidly progressive glomerulonephritis (RPGN)’s clinical presentation including acute onset of macroscopic hematuria, decreased urine output, acute onset of hypertension, and edema. Other clinical findings include nephritis presentation on urine analysis with proteinuria, micro and macroscopic hematuria, red blood cells, dysmorphic RBC and RBC casts. Pathological findings characterized extensive crescent formation. Untreated patients can rapidly progress to end-stage kidney disease over a very short periods (days to months). Renal biopsy can further differentiate the types of crescentic glomerulonephritis. There are three major types of RPGN: 1. Anti-glomerular basement membrane (GBM) disease cause by anti-GBM antibodies. It is also associated with pulmonary …

A Case Of Erythema Nodosum, Mahmood Ahmad, Sunitha Valayil

North Texas GME Research Forum 2023

Background: Erythema nodosum (EN) is characterized as a delayed hypersensitivity reaction to subcutaneous adipose tissue. This panniculitis process presents as erythematous, tender nodules and plaques most commonly located on the pretibial areas. EN may be idiopathic or may be caused by a number of factors such as infection, chronic systemic inflammatory processes, drugs or malignancy.

Case presentation: A 29-year-old male with no significant past medical history presented with a 2-week history of worsening bilateral lower extremity erythema, nodules and pain. This patient was initially seen in the emergency department after a 4-day history of his symptoms. At this time, he …

Extraintestinal Salmonellosis Unmasked In A Parotid Mass, Kahmalia-Kalee Sada

North Texas GME Research Forum 2023

Salmonella infection can cause a wide range of presentations, predominantly gastrointestinal but occasionally with cardiovascular or other extraintestinal manifestations. The diagnosis of extraintestinal salmonellosis requires a high degree of clinical suspicion and should be considered in patients with deep-seated abscesses. [1]. Typically, these types of infections, are extremely rare, and when revealed are typically seen in the immunocompromised patient with chronic illness, HIV, or Hepatitis. While the incidence of nontyphoid salmonellosis is estimated at over 2 million cases annually, extraintestinal manifestations account for less than 1% of cases. Studies have revealed that individuals with diabetes have risk for salmonellosis due …

Does Brief Intervention In The Form Of A Lecture Improve Resident Knowledge About Hep C Screening?, Mary Dacosta, Evelyn Chicas, Kiana Clem, Shelby Collymore

North Texas GME Research Forum 2023

The prevalence for hepatitis C during 2013-2016 was about ~2.4 million. Screening helps to prevent chronic hepatitis C or start early curative treatment. USPSTF recently changed their guidelines in 2021 for Hepatitis C screening to now include all asymptomatic patients from ages from 18-79 years old without liver disease. Screening usually includes the Hepatitis C Antibody test. Further testing includes Hepatitis C mRNA PCR if screening test is positive. High risk patients should have periodic screening. Since the change, this project was done to ensure the appropriate screening and testing thereafter was done, as well as appropriate communication and documentation. …

A Case Of Viral Pneumonia And Acute Respiratory Distress Syndrome During The Covid-19 Pandemic, Mark Cheneler, Khizir Qureshi, Carlos Bahrami

North Texas GME Research Forum 2023

Acute respiratory distress syndrome (ARDS) remains a major cause of morbidity and mortality in the ICU setting and a continued source for investigation to improve outcomes. It is characterized by acute respiratory failure with an identifiable insult, bilateral infiltrates on imaging, and a PaO2/FiO2 ratio (PF ratio) of less than 300 mmHg. It can be further classified into mild, moderate, and severe ARDS with a PF ratio of less than 300, 200, and 100 mmHg respectfully. Treatment requires elucidation of the underlying insult to the pulmonary system and prompt treatment. Presented here is a case of ARDS secondary to herpes …

Monitoring Concordance In The Management Of Transfusing Blood Components In Cirrhotic Patients For Paracentesis With Evidence-Based Guidelines, Joseph Kim, Gregory Moses

North Texas GME Research Forum 2023

Initiative to decrease unnecessary hemostatic agent transfusion in cirrhotic patients undergoing paracentesis: a resident-led approach quality improvement project to prevent transfusion overuse. Currently, there is no official guideline placed in the hospital for the administration of a hemostatic agent such as fresh frozen plasma in the setting of an elevated international normalized ratio, which paradoxically is an anticipated finding in cirrhotic patients. This process leads to unnecessarily prolonging the duration of the hospital course due to delays in performing the interventional procedures and interruptions in scheduling. The goal of this project is to educate and provide physicians with the most …

An Interesting Case Of Suppurative Thrombophlebitis And Perivascular Abscesses As A Cause Of Complicated Mrsa Bacteremia, Ramya Ramachandran, Punjan Patel, Nasima Mehraban, Win Leth Shwe Yee

North Texas GME Research Forum 2023

Methicillin resistant staph aureus (MRSA) Bacteremia has become a serious re-emerging infection. As per the Centers of Disease Control (CDC), the worsening opioid epidemic has created a snowballing effect, in that there is not only an increase in invasive MRSA infections but also in complications from MRSA. Early source control through the form of early foci identification, obtaining serial blood cultures, decolonization and hygiene measures, appropriate antibiotic stewardship are used to eradicate this bacteria and prevent its spread. There are multiple challenges in treating injection drug users with MRSA bacteremia is not only in medical management but also in trying …

Rare Presentation Of Primary Malignant Peripheral Nerve Sheath Tumor Of The Femur In Neurofibromatosis-1, Akshaj Pole, Danielle Ford, Elizabeth Pollard

North Texas GME Research Forum 2023

Malignant peripheral nerve sheath tumors (MPNSTs) are rare sarcomas, most commonly seen in patients with Neurofibromatosis type 1 (NF1), that are characterized as aggressive with high rate of local recurrence. Among NF1 patients, the risk of developing MNPSTs is approximately 8-13% over a lifetime. Primary MPNST is exceedingly rare, of which the vast majority are concentrated in the head and neck region. Here, we present a case of a 40-year-old male with NF1 who presented with a giant MPNST that originated in the right proximal femur. The mass was treated with complete surgical resection with right hip disarticulation. In a …

The Domino Effect: Spontaneous Abortions As A Sequela Of Eisenmenger Syndrome, Riddhiben Patel, Anas Hamadeh, Laura Montoya, Senthil Thambidorai

North Texas GME Research Forum 2023

Background: Eisenmenger's syndrome (ES) is a congenital cardiac abnormality in which a significant chronic left-to-right shunt results in pulmonary arterial hypertension and a reversal of the shunting direction. A woman with ES should ideally avoid conception given the increased risk of unexpected fetal demise and maternal mortality. Case: We present a case of a 35-year-old female patient G3, P0, at 9 weeks gestation with reported PMHx of erythrocytosis and spontaneous abortions who presented to the hospital with complaints of vaginal bleeding and worsening SOB. She was noted to have a Hct of 70 and a Hb of 23.8, with SaO2 …

A Rare Case Of Persistent Left Superior Vena Cava Discovered During An Intracardiac Echocardiography Procedure, Riddhi H. Patel, Bilal Ayub

North Texas GME Research Forum 2023

Background: Isolated persistent left superior vena cava (PLSVC), also known as persistent left superior vena cava (SVC) with absent right SVC, affects 0.09-0.13% of the population. Right SVC is present in the majority of people with left SVC. Rarely, the right SVC may be missing. Here, we discuss a rare case of PLSVC found incidentally in a patient with paroxysmal atrial fibrillation (PAF).

Case: A 63-year-old female patient with a history of Paroxysmal Atrial flutter (AFL) and atrial fibrillation (AF) on apixaban, HTN, and HLD was brought to the electrophysiology lab for electrophysiology study (EPS) and AF/AFL ablation due to …

A Rare Case Of Von Gierke Causing Severe Aortic Stenosis, Srujana Dasari, Akhil R. Gade, Nethuja Salagundla, Chandralekha Ashangari, Rashonda Carlisle

North Texas GME Research Forum 2023

Von Gierke disease is an inherited Glycogen Storage disease - type 1 resulting from deficiencies in the specific enzymes glucose 6 phosphatase(1a), and/or glucose 6 phosphate translocase(1b) glycogen metabolism pathway. Von Gierke disease is commonly seen in the pediatric population and is known for his hepatic and renal manifestations. Here we discuss a rare case of Von Gierke’s disease causing some rare cardiac manifestations. 41yo M with PMHx significant for Von Gierke type 1a, HFrEF complicated by VT s/p ICD, HTN who presented for complaints of continued SOB with new muscle soreness. On arrival, lactic acid was elevated at 5.2, …

Electrolyte Abnormalities And Seizure Like Activity Unmasking An Underlying Rare Genetic Disorder, Riddhiben Patel, Andrew Cushing, Amnah Andrabi, Sathish Karmegam

North Texas GME Research Forum 2023

Fahr's syndrome, or idiopathic basal ganglia calcification, is a rare neurological disorder that runs in families as an autosomal dominant trait. It is associated with a variety of other diseases, especially Parkinson’s disease, but the etiology remains a mystery. On imaging, it presents as abnormal calcium deposits found primarily in the basal ganglia and cerebral cortex, both of which are areas responsible for controlling movement. A 73-year old woman with a past medical history of hypertension and seizures presented to the emergency department due to altered mental status. The patient was indulged in a conversation with her daughter when all …

An Interesting Twist: An Adult Midgut Volvulus Presenting As A Transverse Colon Volvulus, Both Rare Phenomena, Allison Walworth, Danielle Ford

North Texas GME Research Forum 2023

Introduction and Case Presentation: We report an unusual case of an adult midgut volvulus presenting first as a transverse colon volvulus. A 62-year-old man with no significant past medical history presented to the emergency department with complaints of intractable nausea, vomiting, and abdominal pain for twenty-four hours. He had been evaluated at an outside hospital where an abdominal and pelvis computed tomography was read as a transverse colon volvulus, a vanishingly rare medical condition. A CT reimaging of the abdomen and pelvis illustrated a whirlpool sign in the region of the small bowel, consistent with a small bowel volvulus. In …

An Interesting Occurrence Of Bell’S Palsy With Atypical Presentation After Contracting Covid-19 Infection, Yen-Chung Wang, Yen-Hsiang Wang, Christian Sanchez

North Texas GME Research Forum 2023

Introduction: COVID-19 has been identified as primarily a respiratory illness, however, with its clinical manifestation of involvement with multiple organs, it is now considered a systemic illness. In particular, it also can elicit a broad spectrum of neurological symptoms. One of the proposed manifestations is Bell’s Palsy, an acute idiopathic facial nerve palsy that affects the lower motor neuron. Here we have a patient with recent COVID infection who presents with a unilateral facial droop along with unilateral weakness/tingling of extremities and was diagnosed with Bell’s Palsy.

Case Description: Patient is a 47-year-old male with a past medical history of …

Low-Grade Adenosquamous Carcinoma Of The Breast In A Pregnant Patient: Case Report And Literature Review, David Bassa, Makenzie Morrissey, Adewuni Ojo, Adeel Raza

North Texas GME Research Forum 2023

Low-grade Adenosquamous Carcinoma of the Breast: Case Report and Literature Review Authors: David Bassa DO, MaKenzie Morrissey MD, Adewuni Ojo MD, Adeel Raza MD Abstract: Introduction: Low-grade adenosquamous carcinoma (LGASC) is a rare variant of metaplastic carcinomas of the breast. It is characterized by its clinical indolence and low-grade cytomorphology. Presentation is typically asymptomatic with indeterminate imaging characteristics with diagnosis dependent solely on histopathology findings. We herein describe a case of LGASC presenting in a young premenopausal female, an extremely rare occurrence. Case presentation: A 23-year-old woman presented to the breast clinic with a left breast ultrasound demonstrating a heterogeneous …

Lesion Size Inclusion On Dermatopathology Requisition Forms: A Quality Improvement Project, Christopher M. Wong, Henry Lim, Christian Scheufele, Daniel A. Nguyen, Ashleigh E. Hermann, Michael Carletti, Stephen Weis

North Texas GME Research Forum 2023

Introduction: Dermatopathology requisition forms (RFs) are a critical communication tool between dermatologists and dermatopathologists. Including detailed information on RFs improves the diagnostic accuracy of the consulting dermatopathologist. However, the diameter of the biopsied lesion is often omitted on RFs. This study aimed to increase the rate of reporting lesion diameters on RFs from an academic outpatient dermatology clinic to greater than 65% through education, reinforcement, and evaluation. Methods: This quality improvement project retrospectively and prospectively analyzed the inclusion rate of lesion diameters on dermatopathology RFs from a single institution. In Phase 1, data was collected from all skin biopsies performed …

A Case Of Unilateral Jerking Movements In A Patient With Uncontrolled Type 2 Diabetes Mellitus, Mark Cheneler, Tapannita Padhi, Khizir Qureshi, Carlos Bahrami

North Texas GME Research Forum 2023

Hemichorea-hemiballismus (HCHB) syndrome is a syndrome characterized by choreic movements which are irregular, nonrepetitive, and random movements and ballismus which are spontaneous, violent movements. HCHB syndrome is a rare presentation which can be precipitated by uncontrolled diabetes and is thought to have multiple plausible mechanisms. One mechanism of HCHB with uncontrolled diabetes is ischemic injury in the basal ganglia causing impaired gross motor control. Presented here is a case of HCHB syndrome initially seen on imaging and later correlated with physical examination. This patient presented for nonspecific complaints of fatigue, generalized weakness, and lower extremity weakness. On evaluation by EMS …

Post-Thrombotic Syndrome: Assessing Medical City Weatherford Resident Physicians’ Knowledge In Diagnosis, Treatment, And Prevention, Hiral Thakkar, Aaron Kolar

North Texas GME Research Forum 2023

Post-thrombotic syndrome (PTS) is a relatively understudied sequelae of deep vein thrombosis (DVT). PTS typically presents with similar signs and symptoms as chronic venous insufficiency (CVI) and treatment modalities also mirror each other with the use of compression therapy, emollients, and topical steroids. The contrast is PTS is a direct result of a DVT, and DVTs can be prevented. Thus, it is essential that physicians are able to differentiate and effectively treat both PTS and CVI. Since PTS is widely understudied, the goal of our project is educate residents and other medical professionals on the full scope of PTS including …

Capnocytophaga Canimorsus Infection In A Hispanic Male After A Dog Bite, Ahmad Ahsen, Shin Kang, Jack Lee, Jose Sanchez, Fadi Albahra, Stephen Chabot, Tariq Zain, Ranjit Nair

North Texas GME Research Forum 2023

Here we present a unique case of a 38-year-old Hispanic male with a history of alcohol abuse and multiple sexual partners, who presented with fulminant sepsis with shock, multiorgan failure, and livedo racemosa after a dog bite a week prior. Patient was intubated on arrival and started on vasopressors and antibiotics. He later developed gangrene of all of extremities, due to the severity of hypoperfusion and disseminated intravascular coagulation (DIC). Eventually, the patient’s clinical status improved, and he was transferred out of the intensive care unit (ICU). Peripheral blood smear showed gram-negative intracellular rods. Blood cultures tested positive for gram-negative …

Platelets In Preeclamptic Pregnancies Fail To Exhibit The Decrease In Mitochondrial Oxygen Consumption Rate Seen In Normal Pregnancies, Joseph Kim, Andrew Malinow, Rosemary Schuh

North Texas GME Research Forum 2023

Cellular oxygen consumption and lactate production rates have been measured in both placental and myometrial cells to study obstetrics-related disease states such as preeclampsia. Platelet metabolic alterations indicate systemic bioenergetic changes that can be useful as disease biomarkers. We tested the hypothesis that platelet mitochondria display functional alterations in preeclampsia. Platelets were harvested from women in the third trimester of either a healthy, non-preeclamptic or preeclamptic pregnancy, and from healthy, non-pregnant women. Using Seahorse respirometry, we analyzed platelets for oxygen consumption (OCR) and extracellular acidification (ECAR) rates, indicators of mitochondrial electron transport and glucose metabolism, respectively. There was a 37% …

West Nile Virus Encephalitis With Status Epilepticus Treated With High-Dose Steroids: A Case Study, Sherwin Thomas, Sawroop Sandhu

North Texas GME Research Forum 2023

West Nile virus (WNV) is a flavivirus endemic in the United States. WNV infection can present with a variety of non-neurologic and neurologic symptoms. Patients who present with WNV neuroinvasive disease have significant morbidity and mortality, with about 10% of cases resulting in death. There is currently no evidence-based treatment for WNV infection. Management is typically with supportive care. Some limited data shows corticosteroids as a possible treatment for neuroinvasive disease. This case report discusses a 55-year-old female patient who presented with altered mental status. She was found to be septic overnight and was found to be in status epilepticus …

Decreasing Rate Of Clabsi At Medical City North Hills With Implementation Of A “Central Line Cart”, William Mangin, Hong Lou, David Maldonado

North Texas GME Research Forum 2023

Central line associated blood stream infections (CLABSI) impart both a significant increase in mortality but also a substantial financial burden onto hospitals. Several processes have been shown to reduce the rate of CLABSIs, most of which have already been implemented at Medical City North Hills (MCNH) Hospital. Key areas of improvement are in those of compliance; namely, the implementation of a dedicated central line cart and a reminder check list to help staff. The project involved implementation of a dedicated line cart at MCNH Hospital. The cart contains supplies for placement of central lines, including trialysis catheters, and arterial lines. …

A Rare Case Of Gigantic Ascending Aortic Arch Thrombus, Srujana Dasari, Akhil R. Gade, Nethuja Salagundla, Chandralekha Ashangari, Rashonda Carlisle

North Texas GME Research Forum 2023

An ascending aortic arch thrombus (ACT) is a rare finding in an anatomically normal aorta. It can be seen with aortic dissection or aneurysm. Complications of large thrombus like stroke or systemic emboli are less likely when found in normal aorta. Even with the low risk embolic events, it is even less likely if patients are on therapeutic anticoagulation. Here we discuss this rare case in detail. 49 y/o with PMHx of HTN, HLD, COVID19, DVT s/p thrombectomy, noncompliant with warfarin, ICH from fall presents with left-sided weakness and blurry vision. MRI head showed scattered acute infarction along right PCA …

Early Diagnosis Of Purulent Pericarditis Secondary To Methicillin-Sensitive Staphylococcus Aureus In An End-Stage Renal Disease Patient, Stephen Shey, Alejandro Espinosa-Tello, Amnah Andrabi

North Texas GME Research Forum 2023

Introduction Purulent pericarditis is a rare illness in the modern age of medicine due to the increased usage of antibiotics. Unfortunately, diagnosis of this disease is often delayed due to its nonspecific symptoms. Without treatment, the mortality is nearly one hundred percent due to major complications such as cardiac tamponade and constrictive pericarditis. As a result, most cases of purulent pericarditis are discovered post-mortem. This case report details an early diagnosis of purulent pericarditis secondary to methicillin-sensitive Staphylococcus aureus (MSSA) in an end-stage renal disease (ESRD) patient. Case Presentation A 66-year-old female with past medical history of ESRD initially presented …

Head And Neck Tumor Histopathological Image Representation With Pre- Trained Convolutional Neural Network And Vision Transformer, Ranny Rahaningrum Herdiantoputri, Daisuke Komura, Tohru Ikeda, Shumpei Ishikawa

Journal of Dentistry Indonesia

Image representation via machine learning is an approach to quantitatively represent histopathological images of head and neck tumors for future applications of artificial intelligence-assisted pathological diagnosis systems. Objective: This study compares image representations produced by a pre-trained convolutional neural network (VGG16) to those produced by a vision transformer (ViT-L/14) in terms of the classification performance of head and neck tumors. Methods: W hole-slide images of five oral t umor categories (n = 319 cases) were analyzed. Image patches were created from manually annotated regions at 4096, 2048, and 1024 pixels and rescaled to 256 pixels. Image representations were …