Medical Specialties Commons^™

Cellular Origins Of Egfr-Driven Lung Cancer Cells Determine Sensitivity To Therapy, Fan Chen, Jinpeng Liu, Robert M. Flight, Kassandra J. Naughton, Alexsandr Lukyanchuk, Abigail R Edgin, Xiulong Song, Haikuo Zhang, Kwok-Kin Wong, Hunter N. B. Moseley, Chi Wang, Christine F. Brainson

Toxicology and Cancer Biology Faculty Publications

Targeting the epidermal growth factor receptor (EGFR) with tyrosine kinase inhibitors (TKIs) is one of the major precision medicine treatment options for lung adenocarcinoma. Due to common development of drug resistance to first- and second-generation TKIs, third-generation inhibitors, including osimertinib and rociletinib, have been developed. A model of EGFR-driven lung cancer and a method to develop tumors of distinct epigenetic states through 3D organotypic cultures are described here. It is discovered that activation of the EGFR T790M/L858R mutation in lung epithelial cells can drive lung cancers with alveolar or bronchiolar features, which can originate from alveolar type 2 (AT2) cells …

A Letter To M, Shifa Gandhi, Md

The Medicine Forum

A Letter to M

An Encounter With “The Difficult Patient”, Rabia Iqbal, Md

The Medicine Forum

On morning pre-rounds during my Methodist rotation, I was rushing to see all the patients in anticipation of the bolus of admissions that would be coming in soon. I spotted the gray and yellow cart near my patient’s door and opened the cart door while simultaneously trying to fit my handoff into a scrub pocket. I was about to knock on the door with my gown and gloves on, but my flimsy gown was falling so I ended up opening the door with my leg as I was retying it around my neck. The nurse down the hall briefly looked …

Evaluation Of Asthma Control In Patients With And Without Sinonasal Polyps Following Treatment With Biologic Agents, Prachi Patel, Chandala Chitguppi, Md, Alan Gandler, Md, Kira Murphy, Md, Tawfiq Khoury, Md, Stephanie Bork, Crnp, Pamela Monostra, Pa, Elina Toskala, Md, Phd, Mindy Rabinowitz, Md, Marc Rosen, Md, Gurston Nyquist, Md, Jessica Most, Md

The Medicine Forum

Background: The effects of biologics on severe asthmatics with chronic rhinosinusitis with sinonasal polyposis (CRSwNP) have not been well established. This study evaluates overall control of asthma in patients with and without sinonasal polyps following initiation of biologics therapy.

Methods: Retrospective review of patients with asthma treated with a biologic agent (benralizumab, omalizumab, dupilumab, mepolizumab) and CRSwNP. Charts were assessed for ACT scores at time of biologic enrollment and at 4-7 months.

Results:82 patients met inclusion criteria; 42 (52.5%) patients with asthma and 40 (47.5%) with concurrent sinonasal polyps. The average ACT score for the non-polyp cohort was 13.16 …

Increasing Patient Confidence In Managing Asthma Using Asthma Action Plans, Pankhuri Jha, Jessica F. Most, Md

The Medicine Forum

Asthma is a common illness affecting 8% of the US population and costing $81.9 billion per year.^1,2 Due to its chronic and variable nature, asthmatics need frequent medication adjustments, making management challenging for both physicians and patients. Studies show that patients can control their asthma using an asthma action plan (AAP), which includes directions for daily self-assessment, baseline medications and steps to facilitate detection and treatment of an exacerbation. Self-management education using AAPs is associated with a reduction in hospital admissions and ED visits by 40% and 20%, respectively.³ Despite evidence that AAPs are efficacious, the underlying reason …

Stemi In A Young Patient With Covid-19; Too Great A Burden?, Naman Upadhyay, Md, Gillian Naro, Md, Med, Gregary Marhefka, Md

The Medicine Forum

Myocardial infarcts (MIs) can be especially devastating when their pathogenesis stems from a coronary artery occlusion by an intracoronary thrombus (ICT). ICTs are most frequently a result of an underlying atherosclerotic plaque rupture, however, can also be a result of emboli, vasospasm, hypercoagulable states, among other etiologies. Patients suffering from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appear to be in both a hypercoagulable and proinflammatory state resulting in an increased risk of clot formation, endothelial damage, and plaque destabilization, thus increasing the ICT burden in infected patients.1 The literature does reflect an increase in ICT ST-segment elevation …

Pancreatic Plasmacytoma: A Rare Extramedullary Manifestation Of Multiple Myeloma, Justin Robbins, Md, Gregory Habig, Md

The Medicine Forum

Multiple myeloma is a plasma cell dyscrasia in which neoplastic plasma cells pathologically produce monoclonal immunoglobulin and infiltrate bone marrow throughout the skeletal system. The disease is classically characterized by bone pain caused by lytic bone lesions, marked increases in monoclonal antibodies in blood or urine, hypercalcemia, and other systemic signs and symptoms of malignancy including weight loss and night sweats. A rare variant of multiple myeloma presents with extramedullary plasmacytomas, or plasma cell tumors, which arise in organs outside of the bone marrow¹. The case presented here exhibits this disease variant, with a woman with severe multiple …

Idiopathic Retroperitoneal Fibrosis, Candace Derenge, Md

The Medicine Forum

Idiopathic retroperitoneal fibrosis (IRF) is a rare and unusual etiology of abdominal pain that is becoming more frequently diagnosed with the use of CT imaging for abdominal pain. Retroperitoneal fibrosis is characterized by the development of extensive fibrosis throughout the retroperitoneum that can encircle the aorta, iliac arteries, and ureters. About two thirds of retroperitoneal fibrosis cases are idiopathic, thought to be due to an autoimmune process of antibodies stimulating desmoplastic reaction. One third of cases are secondary to drugs (methysergide, beta-blockers, hydralazine, ergotamine, LSD) or diseases the stimulate desmoplastic reaction (tumors, infections, radiation, and Erdheim-Chester disease). Histology of IRF …

A Case Of Refractory Gestational Trophoblastic Neoplasia Requiring Hysterectomy After Methotrexate, Ida Micaily, Md, Saveri Bhattacharya, Do, Russell J. Schilder, Md

The Medicine Forum

Gestational trophoblastic neoplasia (GTN) refers to a group of malignant conditions that develop due to abnormal fertilization causing abnormal proliferation of tissue. GTN is primarily treated with surgical evacuation of the underlying proliferative tissue. Approximately half of cases of GTN arise from molar pregnancy¹. GTN include invasive moles, choriocarcinomas, placentalsite trophoblastic tumors and epithelioid trophoblastic tumors. The most common risk factors associated with GTN are prior molar pregnancy, advanced maternal age (>40 years of age), and Asian and Native American ancestry^2-4. Following evaluation of a molar pregnancy, a post-molar GTN is diagnosed based on the …

A Rare Presentation Of A Clear Cell Variant Of Peritoneal Mesothelioma, Nivethietha Maniam, Md, Michael Lee, Md, Mihir M. Shah, Md, H. Richard Alexander, Md

The Medicine Forum

Primary malignant peritoneal mesothelioma with clear cell subtype is a rare malignancy with few previously reported cases. We present a 63-year-old female who presented with abdominal distention and was diagnosed with clear cell mesothelioma of the peritoneum with an isolated metastasis to the liver. The patient underwent surgical resection of a greater than 50 cm mass with en-bloc partial liver and gastric resection with an uneventful post-operative course. There are established prognostic and treatment recommendations for peritoneal mesothelioma based on histological subtype and patient-specific factors, although they do not explicitly incorporate clear cell subtype. This case report describes the presentation, …

A Slow Burning Diagnosis: A Case Report Of Hemophagocytic Lymphohistiocytosis Preceding The Diagnosis Of Subcutaneous Panniculitis-Like T-Cell Lymphoma, Steven Manobianco, Md, William Bradford, Md, Ida Micaily, Md, Adam Binder, Md

The Medicine Forum

HLH is a severe inflammatory syndrome characterized by primary or secondary immune dysregulation causing excess activation of macrophages and cytotoxic lymphocytes, leading to multi-system dysfunction. Diagnosing and managing HLH can be challenging for clinicians, with HLH-2004 criteria for diagnosis requiring a molecular diagnosis or the presence of at least five of the following: fever, splenomegaly, cytopenia involving two or more cell lineages, hypertriglyceridemia and/or hypofibrinogenemia, hemophagocytosis in the bone marrow, spleen or lymph nodes with no evidence of malignancy, low or no NK cell activity, elevated ferritin, or elevated soluble IL-2 receptor¹. These criteria have been utilized to …

Opioid-Induced Secondary Adrenal Insufficiency In A Young Patient With Chronic Pancreatitis, Amry Majeed, Nicholas Noverati, Md, Christine Kurian, Md, Shirin Jaggi, Do

The Medicine Forum

Opioid misuse is a national public health crisis that has contributed to a decrease in life expectancy in men and women in the US. From 1999-2017, the rate of drug overdose deaths tripled, largely due to the rise in opioid use¹. Despite widespread misuse, chronic opioid therapy still has a role in the clinical setting. Adverse effects include dizziness, nausea, vomiting, respiratory depression, and dependence². While these side effects are well- documented, other effects of opioids are less explored, including opioidinduced adrenal insufficiency^3,7. The typical presentation of adrenal insufficiency from any cause can include …

A Severe Case Of Hypertriglyceridemia In Alcoholic Hepatitis, Jillian Cooper

The Medicine Forum

A 53-year-old man with a past medical history of hypertension and alcohol abuse with prior episodes of alcoholic hepatitis presented to the hospital with generalized weakness. He was in his usual state of health until 4 days prior to admission when he began to develop generalized weakness, nausea, and vomiting. Notably, he had had multiple prior admissions with similar symptoms attributed to hyponatremia. He endorsed drinking a few beers daily but denied any other drug use. Review of systems was otherwise negative.

New-Onset Rheumatologic Disease In An Elderly Patient Initially Presenting As Worsening Sequelae Of Longstanding Peripheral Vascular Disease, Peri Levey, Lauren Lally, Md, Xuejun Alice Wang, Md, Vivek Batra, Md

The Medicine Forum

Systemic lupus erythematosus (SLE) is an autoimmune disease that is believed to activate and attack nuclear antigens in genetically susceptible individuals after exposure to environmental factors causing cell damage.^1,2 Although it is most common in females of child-bearing age, initial presentation is not strictly limited to this population, as onset over the age of 50 years is reported in 3-18% of cases.² The common manifestations of SLE affect nearly every system of the body and may include arthralgia, myalgia, fever, rash, hepatosplenomegaly, lymphadenopathy, pleuritis, glomerulonephritis, pericarditis and neuropsychiatric manifestations.^1-3 Common laboratory findings in SLE with varying degrees …

Carbamazepine Induced Bullous Pemphigoid In A 49 Year Old Male, Brendan Gleason, Lisa Matonti, Pharmd, Bcps, Xuejun Alice Wang, Md, Bahar Dasgeb, Md

The Medicine Forum

Bullous pemphigoid is an autoimmune blistering condition mediated by autoantibodies1. It is categorized as an uncommon disorder2-4, with an estimated incidence of 2.4-21.7 cases per million2-6 but carries significant morbidity and mortality, warranting clinical awareness and investigation7,8. A number of medications have been implicated in the development of bullous pemphigoid including loop diuretics, ace inhibitors, and anti-epileptic drugs.

This is a case report of carbamazepine-induced bullous pemphigoid in a 49-year-old male after taking the medication for almost 30 years. Diagnosis of bullous pemphigoid was based on biopsy histology and immunofluorescence, as well as the presence of BP 180 antibody. Clinical …

A Case Of Native Hip Pseudomonas Aeruginosa Septic Arthritis Caused By Vesico-Acetabular Fistula, Tudor Sturzoiu, Md

The Medicine Forum

A 61-year-old man with a past medical history significant for metastatic rectal cancer treated with local resection, chemotherapy, and radiation complicated by vesicocutaneous fistula presented with subacute ambulatory dysfunction secondary to right hip pain. Imaging studies were consistent with a right hip effusion, and fluoroscopyguided hip aspiration revealed septic arthritis caused by Pseudomonas aeruginosa. Resistance patterns identified this strain of Pseudomonas to be the same one that caused pyelonephritis that was treated during the same hospitalization. Although further diagnostic imaging was not pursued, the presentation was most consistent with vesico-acetabular fistula causing native hip septic arthritis. This is a very …

Severely Impaired Gastric Emptying In The Setting Of An Extensive Malignancy History: A Case Of Paraneoplastic Gastroparesis, Gregory Habig, Md, Justin Robbins, Md

The Medicine Forum

Gastroparesis is a disorder of the stomach involving a delay in the emptying of gastric contents that typically presents with nausea, vomiting, early satiety, and weight loss. Though commonly associated with diabetes or as a complication of surgical procedures, etiologies stemming from paraneoplastic processes are important to consider despite often being overlooked. The case presented here describes a patient with a significant malignancy history and evidence of severely impaired gastric emptying concerning for paraneoplastic gastroparesis and highlights the evaluation, diagnosis, and management of the condition.

Acute Mitral Regurgitation Presenting With Right Upper Lobe Opacification, John Wallis, Md, Mark Decaro, Md

The Medicine Forum

We describe a rare entity in which acute mitral regurgitation causes asymmetric findings on chest radiograph. The patient presented with rapid-onset respiratory failure from flash pulmonary edema. She had unilateral infiltrates on chest radiograph, which evoked infectious etiology. However, we identified a flail mitral valve leaflet, for which the patient received an emergent mitral valve replacement. Fortunately, she made a full recovery. We discuss the mechanism of the asymmetric chest radiograph findings, which we were able to confirm using a transesophageal echocardiogram.

Effusive-Constrictive Pericarditis Due To Poorly Differentiated Carcinoma Of The Mediastinum, John Wallis, Md, Naman Upadhyay, Md, Fred Karaisz, Md, Mark Decaro, Md, René Alvarez, Md

The Medicine Forum

A 33-year-old male developed subacute effusiveconstrictive pericarditis with recurrent pleural effusions and mediastinal lymphadenopathy. He was found to have poorly differentiated carcinoma of the mediastinum that led to constrictive physiology not amenable to medical or surgical management, ultimately requiring hospice. This case was remarkable for its rare etiology and presentation.

“Covid Nails”, Gillian Naro, Md, Med, Gregory Kane, Md, Macp

The Medicine Forum

A 73-year-old female presented to an outpatient clinic for management of her COPD. Two months prior, she had experienced a febrile illness with a cough and subsequently tested positive for the SARS-CoV-2 virus, requiring hospitalization and intubation in an intensive care unit. Physical examination revealed transverse white lines extending across the nail plate about 5mm from the base of the nail on multiple nails. These findings were consistent with Beau Lines, a sign of acute systemic inflammation resulting in the sudden interruption of nail keratin synthesis. The location of the line relative to the growth of the nail can reflect …

From The Editors, Xuejun Alice Wang, Md, Nivethietha Maniam, Md, Hillary Landon, Md, Jillian Cooper, Md, Joseph Grogg, Md, Akanksha Arya, Md

The Medicine Forum

It is our honor to present the product of 22 years of resident-run tradition – the 2020-2021 annual edition of The Medicine Forum. In the world of Jefferson traditions, ours is a small one. There is no regalia, pomp and circumstance, or any such fanfare in this marking of the year’s close. Rather than the celebratory release of those other springtime occasions, this publication is a representation of the yearlong dedication and hard work of our residents and fellows in their academic pursuits.

We at The Medicine Forum know that producing scholarly work even during what would constitute a …

From The Desk Of The Residency Program Director, Emily Stewart, Md

The Medicine Forum

The past year has been the most trying many of us have faced as physicians. Despite the challenges, I leave this academic year with hope and gratitude for the future of medicine. The exceptional altruism and dedication portrayed by our colleagues both within and outside the Department of Medicine made this year possible. I've been overwhelmed by the collegiality and dedication of all our colleagues, but specifically our residents. Despite the challenges, they have risen to every encounter with grace and poise working alongside faculty to support the Jefferson mission: We Improve Lives. In the midst of the chaos, our …

Table Of Contents: The Medicine Forum Volume 22, 2020-2021

The Medicine Forum

Table of Contents: The Medicine Forum Volume 22, 2020-2021

The Medicine Forum: Volume 22

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 22, 2020-2021

TABLE OF CONTENTS

Clinical Images

Case Reports

• Cardiology
• Gastroenterology and Hepatology
• General Medicine
• Hematology and Oncology
• Pulmonary Medicine

Resident Reflection

Mycobacterium Avium Pulmonary Infection Disguised As A Urinary Tract Infection, Megan Rolfzen, Allison Ashford

Graduate Medical Education Research Journal

In the United States, Mycobacterium avium complex (MAC) has been found to be the most common isolate in non-tuberculous disease, and pulmonary infection is the most frequent presentation. It is ubiquitous in the environment, particularly in soil and manufactured water supply sources. Worldwide, M. avium infections, both pulmonary and disseminated, are steadily increasing. Due to MAC’s ability to cause non-specific symptoms and its pervasiveness within the environment, it is paramount to incorporate this diagnosis in the differential, especially in those most susceptible. We report a case of a Mycobacterium avium complex pulmonary infection in 72-year-old Caucasian male with history of …

Postoperative Outcomes Of Hip Fracture Surgery In Geriatric Patients On Clopidogrel Or Warfarin At The Time Of Surgery, Josh Locker, Elizabeth Lyden, Justin Siebler

Graduate Medical Education Research Journal

BACKGROUND: The purpose of our study is to evaluate if surgical intervention in the setting of an elevated INR or continued use of clopidogrel lead to elevated post-operative mortality and/or morbidity compared to INR reversal or surgical delay.

METHODS: We retrospectively reviewed 1,007 patients age > 55 undergoing hip fracture fixation at our institution over a 10 year span. We placed patients into four groups based upon their anticoagulation status at the time of surgery. Descriptive statistics were utilized to evaluate for differences in mortality rates, blood loss, time to surgery, and wound complications.

RESULTS: Comorbid conditions occurred at a higher …

Association Of Lung Cancer With Pneumonia And Chlamydia Pneumoniae Infection, Johnny Zakhour Md, Daniel Muller, Alex Glynn, Jose Bordon

The University of Louisville Journal of Respiratory Infections

Introduction: The degree of association and type of causal versus non-causal relationship between pneumonia and lung cancer (LC) are evolving discussions. We reviewed English publications on the degree of association between pneumonia and subsequent LC.

Methods: We searched the PubMed database using key words for pneumonia, LC, and chlamydia infection. We selected peer-reviewed studies of patients with pneumonia and LC. Case reports and other literature reviews were excluded from this review.

Results: Five studies examined the incidence and/or risk of LC for a total of 415,750 patients, and four studies examined cases with Chlamydia pneumoniae chronic infection at the time …

Diabetic Preventative Care In A Resident Clinic: A Quality Improvement Study, Karishma Chopra, Charity Owusu-Asare, Aimee Espinosa, Alexandra Halalau

Conference Presentation Abstracts

Introduction: Studies have shown significant gaps in diabetic preventative care in resident clinics compared to private clinics of practicing physicians. In our medicine-pediatrics resident clinic at Beaumont Hospital, diabetic point of care resources are largely underutilized. We aim to improve the care of patients with diabetes by increasing resident awareness of point of care A1c and retina scan resources. Methods: A team of residents, attendings, and nurses was created. Baseline data looking at use of point of care resources, specifically the number of orders placed in electronic medical record for A1c and retina scan tests, was obtained. A root cause …

Type 1 Cryoglobulinemia Secondary To Primary Plasma Cell Leukemia, Antonio Faieta, Khatoon Tawhida

Conference Presentation Abstracts

Primary plasma cell leukemia (pPCL) is a rare and aggressive form of plasma cell dyscrasia that comprises 1% of the plasma cell dyscrasias. Even more rare is its association with type 1 cryoglobulinemia which management can be challenging. A 63-year-old African American male with no past medical history presented with severe burning pain in his legs, necrotizing rash, constitutional symptoms and severe acute kidney injury (AKI). HIV, hepatitis B and C were negative. Serum electrophoresis revealed an M-spike of 5.67, IgG of 7000, free lambda of 152.10 with a K/L of 0 and cryoglobulin of 81%. CT revealed extensive lytic …

Massive Pulmonary Embolism After Pfizer Vaccine, Samiksha Pandey, Bipin Ghimire, Emma Herrmann, Dilip Khanal

Conference Presentation Abstracts

Introduction Vaccines against COVID -19 have been reported to cause venous thromboembolism (VTE). To our knowledge, this is the first case to report the massive, near-fatal Pulmonary Embolism (PE) associated with BNT162b2 Covid-19 (Pfizer/BioNTech) vaccine and discuss the associated risk factors for PE. Case 41-year-old, non-smoker, female on OCP, presented for syncope and seizure-like activity. Upon presentation, she was obtunded and tachypneic. Initial labs showed leukocytosis, mild anemia, and thrombocytopenia, respiratory and metabolic acidosis. She deteriorated quickly to cardiac arrest requiring Cardiopulmonary Resuscitation and intubation. Tissue Plasminogen Activator administered for possible PE. Computed Tomography Angiography (CTA) pulmonary confirmed sagittal pulmonary …