Internal Medicine Commons^™

Lyme Disease Presenting As A Dermal Hypersensitivity Reaction, William T. Snider, Ian Depew, Rebecca Hicks, Shane Cook

Marshall Journal of Medicine

Background:

Lyme disease is a well-recognized illness commonly associated with skin manifestations such as erythema migrans. However, atypical presentations can complicate diagnosis, particularly when they deviate from classic clinical and histological findings.

Methods:

We report a potential case of Lyme disease presenting as a dermal hypersensitivity reaction (DHR), with clinical findings resembling urticaria rather than urticarial vasculitis. Skin biopsy findings were reviewed, and Lyme serology testing was performed.

Results:

The biopsy did not demonstrate the characteristic superficial perivascular lymphocytic infiltrate typically seen with erythema migrans. The patient's history included prior tick exposures, but while Lyme IgM was positive, the Lyme …

Cancer Of Unknown Primary With Squamous Cell Carcinoma Phenotype Presenting As Isolated Axillary Mass, Nicole Liang, Mohamed Ashal, Lynne J. Goebel

Internal Medicine

Cancer of unknown primary (CUP) is a rare metastatic malignancy where no primary tumor can be found. We report the case of a 71-year-old female with a strong family history of breast cancer presenting with isolated axillary lymphadenopathy after a tick bite. A biopsy of the axillary mass revealed poorly differentiated squamous cell carcinoma and after extensive evaluation, she was diagnosed with metastatic squamous cell carcinoma with unknown primary tumor. We present this case because of the role of confounding history complicating her initial diagnosis and bringing awareness to a rare disease.

In Vivo Evaluation Of Novel Nanoparticles And Repurposed Pharmaceuticals To Combat Antimicrobial Resistance, Sarah E. Evans

Theses, Dissertations and Capstones

In a 2019 report by the Centers for Disease Control and Prevention (CDC), infections resistant to antibiotic treatment amount to about three million infections and 48,000 deaths. Antimicrobial resistance is an escalating global threat as existing antibiotics lose efficacy over time. The project described is focused on partnering with pharmaceutical researchers and producers to test new nanoparticle-based or repurposed compounds. The central hypothesis of this thesis is that pharmaceutical formulations such as nanoparticles may provide a cost-effective means of combating the emerging antimicrobial resistance. The nanoparticle compounds allowed for a wide range of customization for the pharmaceutical design, since the …

Musical Hallucinations In An Elderly Female With Hearing Loss, Jacqueline Cavendish, Lynne J. Goebel

Internal Medicine

Musical hallucinations (MH) are rare auditory phenomena in which patients perceive music without a known source. Risk factors for MH include hearing loss, older age, female gender, epilepsy, and certain medications. This case report details the presentation, diagnosis, and treatment of an 82-year-old woman who developed MH following the onset of hearing loss. Despite treatment attempts with gabapentin, quetiapine, and donepezil, the symptoms persisted, demonstrating the difficulty in treating this condition.

A Case Of Herpes Zoster In An Immunocompetent 19-Year-Old Female, Martin Nguyen, Jennifer Read, Emma Filary, Aaron Mcguffin

Marshall Journal of Medicine

This case report describes the unusual presentation of herpes zoster in a fully vaccinated teenage patient and highlights management considerations. The patient is a 19-year-old female who presented with pain in her left lower back, side, and upper thigh for approximately 3 days, which was then followed by the eruption of a vesicular rash along the L2 dermatome consistent with herpes zoster. Herpes zoster is predominantly observed only in elderly and immunocompromised individuals, primarily due to the widespread use of the varicella-zoster virus vaccine for children since 1995, when it became part of the routine immunization schedule. However, this case …

Atypical Lyme Disease Rash: A Case Report, Selena Khanna, Lynne J. Goebel

Internal Medicine

Lyme disease (LD), caused in the United States primarily by Borrelia burgdorferi sensu lato, is a tick-borne illness characterized by a spectrum of clinical manifestations depending on the stage of illness. Most clinicians are familiar with the classic bullseye appearance of the erythema migrans (EM) rash that occurs inthe early stage of the disease. However, many providers may not be aware of alternate appearances for the rash. This paper reports the case of a 69-year-old female with LD, exhibiting an atypical rash with purplish discoloration that was devoid of an outer ring or central clearing. In geographic areas with a …

Ogilvie's Syndrome: Acute Colonic Pseudoobstruction. A Review For Residents., Tyler Bayliss, Caleb Clark, Errington C. Thompson

Marshall Journal of Medicine

Ogilvie's syndrome (acute colonic pseudoobstruction) was first described in 1948. Acute colonic pseudoobstruction can occur in a variety of clinical settings, including postsurgical, obstetrics, pelvic surgery, critical care and sepsis. Clinicians need to recognize the syndrome early. Colonic distention without evidence of obstruction can be seen on plain films of the abdomen or CT scan. Successful therapies, including bowel rest, neostigmine and colonoscopic decompression, have been used. Avoiding respiratory compromise from abdominal distention and colonic perforation of the primary goals of treatment. Surgical intervention should be reserved for patients who are refractory to medical treatment or develops signs and symptoms …

Written Communication From Pharmacy Benefit Managers: Is It Helpful?, Lily G. Cessna, Lynne J. Goebel

Internal Medicine

Introduction: Physicians are experiencing greater burnout due to excessive time spent on paperwork. Pharmacy benefit managers (PBMs) are adding to this problem by sending excessive mail to physicians. This study examined these mailed communications to determine their frequency and if the physician acted upon them. We hypothesized that few of these mailings would be helpful to the physician.

Methods: From July 2021 to May 2023, we collected all written communications from PBMs to a single geriatrics outpatient physician. We sorted this information by specific PBM, by communication category, if it resulted in an intervention, and if communications were repeated.

Results: …

Management Of Asymptomatic Hypertension In The Inpatient Setting., Charles Meadows, Mehiar Elhamdani, Dial Larry, Murad Kheetan, Khaled Al-Baqain

Marshall Journal of Medicine

Hypertension is common in hospitalized patients and is most often asymptomatic. While there are no guidelines for management of such patients, aggressive blood pressure treatment, including the use of intravenous antihypertensives, is often undertaken. While evidence of benefit is lacking, emerging data suggest that treatment of asymptomatic hypertension in the inpatient setting is associated with adverse outcomes, including acute kidney injury and ischemic stroke. In addition, the intensification of a preexisting antihypertensive regimen at hospital discharge significantly increases the risk of readmission without significant improvement in outpatient hypertension control. Such a combination of a common problem with the demonstrable benefit …

Neonatal Abstinence Syndrome: An Update On The Cost And Length Of Stay Associated With Treatment During The Hospital Stay, Kimberly Stanfield, Kylie Day, Sarah M. Clemente, Alberto Coustasse

Management Faculty Research

Neonatal Abstinence Syndrome (NAS) has been costly for the healthcare system; every 19 minutes, a newborn was diagnosed in 2021. Medically Assisted Treatment (MAT)) for expecting mothers has been shown to decrease costs and length of stay for newborns NAS. This study utilized a literature review and a semi-structured interview. The research showed that medically assisted treatment with methadone or buprenorphine during pregnancy decreased costs, LOS, and severity of symptoms for newborns diagnosed with NAS. The findings showed a positive association between lower costs for the initial stay of infants whose mothers received MAT. MAT during pregnancy has been shown …

A Rare Metastatic Primary Rectal Melanoma In A Geriatric Male, Onyinye Ugonabo, Mujtaba Mohamed, Ebubechukwu Ezeh, Joseph Simmons, Jonathan Cuda, Shima Ghavimi

Internal Medicine

Primary rectal melanoma (PRM) is an uncommon malignancy whose etiology remains unknown. Most patients present with rectal bleeding. Distant metastasis is commonly seen in the lung and liver. The incidence rates for locoregional lymph node metastases on initial presentation are almost 60%. Histology and immunochemistry are useful and are the gold standard for diagnosis. The prognosis is very poor due to the late presentation of patients. Optimum surgical treatment remains controversial. Abdominoperineal resection was considered traditionally but over time, has been found to have no survival benefit. Current literature and studies, therefore, recommend wide local excision. The beneficial effects of …

Sclerosing Mesenteritis: A Rare Cause Of Abdominal Pain, Said Sharawi, Vincent A. Graffeo, Lynne J. Goebel

Internal Medicine

Sclerosing mesenteritis (SM) is a rare inflammatory fibrotic disease of the small intestine mesenteric fat often discovered incidentally on a CT scan. Clinical manifestations depend on the mass effect on the viscera and vessels. The most common symptoms are abdominal pain, bloating, and nausea. SM occurs predominantly in Caucasian men, during the fifth to seventh decades of life. We present a 69-year-old woman with SM whose symptoms were thought to be from irritable bowel syndrome. A 69-year-old female with a history of fibromyalgia presented with recurrent bouts of abdominal pain across her mid-abdomen lasting 30 minutes to an hour associated …

A Novel Backward Stepwise Logistic Regression And Classification And Regression Tree Model To Predict 180-Day Clinical Outcomes In Hepatitis B Virus-Acute-On-Chronic Liver Failure Patients, Shima Ghavimi

Internal Medicine

As the era of precision and personalized medicine is gaining exponential positive gain in the field of medicine, there is a positive shift towards a more evidence-based patient care approach for patients with hepatological diseases. One factor that is crucial in any physician’s decision-making efforts involves the application of novel innovative approaches that can enhance predicting survival outcome. Acute-on-chronic liver failure (ACLF) is a perfect example of how liver can rapidly deteriorate, and the hepatitis B virus (HBV) is one crucial culprit. Patients can experience organ failure that leads to their mortality, and in this article the authors clearly described …

A Randomized Open-Label Study Of Two Methods Of Proton Pump Inhibitors Discontinuation, Emily Hendricks, Aman Ajmeri, Monider M. Singh, Milliejoan Mongalo, Lynne J. Goebel

Internal Medicine

Background: Proton pump inhibitors (PPIs) are effective in treating gastroesophageal reflux disease (GERD). Unfortunately, they are often inappropriately prescribed and long-term use has potential adverse effects. A single best method for discontinuation of PPIs does not currently exist. The objective of this study was to determine if there is a significant difference in successfully discontinuing PPI use at 12 months between patients discontinuing abruptly or tapering first.

Methodology: We conducted a randomized trial with 38 patients diagnosed with GERD. We collected six weekly and then monthly surveys of symptoms based on the Dyspepsia Symptom Severity Index. Chart review at 12 …

Can Charcoal Improve Outcomes In Covid-19 Infections?, Zeid J. Khitan, Imran Khawaja, Maurice A. Mufson, Juan R. Sanabria, Nader G. Abraham, Stephen J. Peterson, Uma Sundaram, Joseph I. Shapiro

Internal Medicine

COVID-19 infection causes considerable morbidity and mortality, especially to those who are aged, have impaired renal function and are obese. We propose to examine the potential utility of oral activated charcoal with the hypothesis that such treatment would lower absorption of microbiome derived toxins and ameliorate systemic oxidant stress and inflammation.

Post-Influenza Vaccine Subdeltoid Bursitis, Marenda Jenkins, David Rupp, Lynne J. Goebel

Internal Medicine

A 61-year-old female presented three months following an influenza vaccination with ongoing pain since the injection and was diagnosed by MRI with subdeltoid bursitis. The patient received a short course of prednisone and several months of physical therapy before returning to pain-free function. The primary reason for injection-related subdeltoid bursitis is improper administration. It is a preventable issue, and improved training of healthcare workers on proper vaccine administration may decrease its occurrence.

When Treating Sick Joints Harms Lungs, Ixekizumab Induced Pleural Effusion, Rami Batarseh, Kyle Smith, Mohammed Al-Ourani, Amro K. Al-Astal

Marshall Journal of Medicine

Immunological therapies have provided a multitude of new and effective treatment strategies for various disease states. While monoclonal antibody therapy benefits many patients, side effects are widely variable. here we present a case of pleural effusion complicating psoriatic arthritis treatment.

Modern Ventilator Management In Surgical/Trauma Patients, Errington C. Thompson

Marshall Journal of Medicine

Physicians have a lot to consider when they place a patient on the ventilator. This article reviews the literature and provides the physician with a clear guide to managing the ventilator in the ICU. This manuscript is meant to be a practical guide to managing the ventilator at the patient's bedside.

Geriatric Hepatology: The Hepatic Diseases Of The Elderly And Liver Transplant, Shima Ghavimi, Hamed Azimi, Neel Patel, Oleg Shulik

Internal Medicine

Introduction: With the aging US population, chronic liver diseases are becoming more commonly diagnosed in the geriatric population. Advanced age leads to changes in liver blood flow, volume, morphology and normal physiology. This predisposes elderly patients to develop certain chronic liver diseases. Also, the clinical course and management differ in an older patient when compared to a younger patient. Some causes of chronic liver disease in the geriatric population include Hepatitis A, B, C, Non-Alcoholic Fatty liver disease, prolonged alcohol use and inflammation. Many chronic liver diseases are characterized by a slow, indolent course of progression with non-specific symptoms and …

Duodenal Variceal Bleeding With Large Spss Treated With Transjugular Intrahepatic Portosystemic Shunt And Embolization: A Case Report, Rohit Anand, Saad Emhmed Ali, Driss Raissi, Wesam M. Frandah

Internal Medicine

Background: Duodenal variceal bleeding is a rare cause of gastrointestinal bleeding. The most common site is the duodenal bulb. It is usually detected endoscopically but it can be very challenging to diagnose if it is located distal to the second part of duodenum. The pre- transjugular intrahepatic portosystemic shunt (TIPS) presence of SPSS was found to be associated with an increased risk of early morbidity and mortality after TIPS placement. Case Summary: A 43-year-old cirrhotic male presented with melena for three days. Upper endoscopy was performed and showed active blood oozing from the distal duodenum concerning for ectopic duodenal varix. …

Pulmonary Alveolar Microlithiasis Diagnosed With Radiography, Ct, And Bone Scintigraphy, Emad Alkankan, Hasan Yamin, Hazim Bukamur, Fadi Alkhankan, Yousef Shweihat, Fuad Zeid

Internal Medicine

Pulmonary alveolar microlithiasis is rare disease characterized by accumulation of calcium phosphate microlithis in the alveoli. The pathogenesis relates to mutation in the gene SLC34A2 (solute carrier family 34 member 2) located on chromosome 4p15.2, which produces a defective sodium-phosphate cotransporter in alveolar epithelial type-2 cells, making these cells unable to clear phosphorus released during recycling of surfactant.

Should A Fully Covered Self-Expandable Biliary Metal Stent Be Anchored With A Double-Pigtail Plastic Stent? A Retrospective Study, Saad Emhmed Ali, Wesam M. Frandah, Leon Su, Cory Fielding, Houssam Mardini

Internal Medicine

Background: The migration rate of fully covered self-expandable metal stents (FCSEMSs) has been reported to be between 14% to 37%. Anchoring of FCSEMSs using a double-pigtail plastic stent (DPS) may decrease migration. Aim: To compare stent migration rates between patients who received FCSEMS alone and those who received both an FCSEMS and anchoring DPS. Methods: We conducted a retrospective analysis of endoscopy reporting system and medical records of 1366 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS placement at the University of Kentucky health care. Between July 2015 and April 2017, 203 patients with FCSEMS insertion for the treatment …

Rare Sarcomatoid Carcinoma Of The Liver In A Patient With No History Of Hepatocellular Carcinoma: A Case Report, Kevat B. Patel, Rita H. Hawarny, Elizabeth Saunders, Marc Hettlinger, Niru Nahar

Marshall Journal of Medicine

Sarcomatoid carcinoma is a rare malignant tumor of unknown pathogenesis characterized by poorly differentiated carcinoma tissue containing sarcoma-like differentiation of either spindle or giant cell and rarely occurs in the gastrointestinal tract and hepatobiliary-pancreatic system.¹ Primary hepatic sarcomatoid carcinoma accounts for only 0.2 % of primary malignant liver tumors, and 1.8% of all surgically resected hepatocellular carcinomas.² The majority of hepatic sarcomatoid carcinoma cases appear to occur simultaneously with hepatocellular or cholangiocellular carcinoma.³ The preferred treatment for hepatic sarcomatoid carcinoma is surgical resection and the overall prognosis is poor.⁴ This case depicts a 62-year-old female whom …

Using The Ebus Scope In The Esophagus, Yousef Shweihat, Shantanu Singh

Internal Medicine

This chapter aims at introducing the interested Pulmonologist/Interventional Pulmonologist to the esophageal ultrasound. In this chapter, we give short descriptions of some technical aspects of the endobronchial ultrasound (EBUS) scope and explain in detail why we believe the EBUS scope is well suited to be an esophageal scope in the hands of the trained pulmonologist. The chapter then explains indications and benefits of this procedure that we consider central to the practice of chest physicians. We also describe in steps how to reach each lymph node station using the EBUS scope as a EUS scope (EUS-B) from our own experience. …

Eus-B For The Interventional Pulmonologist Using The Ebus Scope In The Esophagus, Yousef Shweihat, Shantanu Singh

Internal Medicine

This chapter aims at introducing the interested Pulmonologist/Interventional Pulmonologist to the esophageal ultrasound. In this chapter, we give short descriptions of some technical aspects of the endobronchial ultrasound (EBUS) scope and explain in detail why we believe the EBUS scope is well suited to be an esophageal scope in the hands of the trained pulmonologist. The chapter then explains indications and benefits of this procedure that we consider central to the practice of chest physicians. We also describe in steps how to reach each lymph node station using the EBUS scope as a EUS scope (EUS-B) from our own experience. …

Massive Hemoptysis Due To Recurrence Of Bronchial To Pulmonary Vascular Malformation: A Case Report, Chelsey White, Pedro Ottaviano, Nancy Munn, Yousef Shweihat, Fuad Zeid

Internal Medicine

Bronchial dieulafoy lesions are quite rare with relatively few case reports in the literature. Symptoms may vary but the lesion is often associated with hemoptysis and may present as massive hemoptysis. We present a case of a 69-year-old male with a recurrent episode of hemoptysis three years after treatment for a bronchial dieulafoy lesion. The bronchoscopy done three years prior during an initial episode of hemoptysis showed a visible dieulafoy deep within a subsegmental branch of the right lower lobe. This case is unique because there are no other reports within the literature of a delayed recurrence several years after …

Percutaneous Transluminal Balloon Venoplasty: A Less Invasive Technique For Implantation Of Cardiac Leads In Patients With Limited Venous Access To The Heart, Waiel Abusnina, Zachary O. Curtis, Emilia C. Leigh, Eric Y. Auyoung, Dr. Mehiar El-Hamdani, Esam Baryun

Marshall Journal of Medicine

Since its inception, cardiac pacing has made a significant advancement in cardiology. As new therapies and devices emerge, the number of implantations is steadily increasing which requires up-to-date clinical guidelines for management. Although advanced, these mechanical devices often require maintenance and revisions to achieve optimal performance. One of the most common deteriorations is the lead failure.

In the case of lead failure requiring revision, new lead implant, or upgrading to a more advanced pacing system, venous stenosis resulting in partial or complete obstruction of the vessel can pose a real problem. This case series report introduces the technique of percutaneous …

Case Report: Steroid Responsive Mesothelioma-Related Pleural Effusion, Mena Shehata, Fouad Zaid, Peter Ottaviano, Yousef Shweihat, Nancy Munn

Internal Medicine

Malignant pleural mesothelioma (MPM) is an asbestos-related tumor arising in the pleural cavity. Symptoms reflect extension of disease and include shortness of breath and chest pain. Unexplained pleural effusion and pleural pain in patients exposed to asbestos should raise the suspicion of MPM. The most common radiologic presentation is ipsilateral pleural effusion with or without pleural thickening or a mass. Thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis of mesothelioma. Despite advancement in diagnostic procedures and biomolecular research, this tumor nevertheless has poor prognosis. Mesothelioma remains a diagnostic and therapeutic challenge and is likely to remain one in …

Clostridium Sporogenes Bacteremia In An Immunocompetent Patient, Waiel Abusnina, Mena Shehata, Emhemmid S. Karem, Zeynep C. Koc, Elie Khalil

Internal Medicine

Of the 200 Clostridium spp. known to exist, approximately 30 have been associated with human disease. Commonly found in soil, marine sediment and mammalian intestinal tracts, these gram-positive bacilli are known to cause infections ranging from cellulitis to septicemia. Isolates that are identified by clinical microbiology laboratories include Clostridium perfrigens species in 20–40% of cases. However, when Clostridium sporogenes is identified, is rarely considered to be pathogenic. We present a case of Clostridium sporogenes bacteremia secondary to lower limb cellulitis and osteomyelitis in an immunocompetent patient.

A Rare Case Of Metastases From A High-Grade Astrocytoma To The Pleura, Bones, And Liver Within Six Months Of Diagnosis, Jennifer L. Dotson, Ala Nijim, Krista L. Denning, Yousef R. Shweihat, Yehuda Lebowicz

Internal Medicine

High grade astrocytomas such as anaplastic astrocytoma and glioblastoma multiforme are aggressive central nervous system malignancies with a poor prognosis. Due to shortened survival times, their devastating effects are usually localized intracranially and rarely metastasize outside of the central nervous system. When metastases occur, they usually present in patients with longer survival times and they typically coincide with a primary site recurrence. We present a rare case of metastases from a high-grade astrocytoma/glioblastoma to the pleura, bones and liver within six months of diagnosis, without primary site recurrence.