Internal Medicine Commons^™

Medetomidine As A Fentanyl Adulterant: Pharmacology, Detection, Clinical Presentation, And Management, Kory S. London, Phil Durney, Brendan Hart, Ashish Thakrar, Dennis Goodstein, Alex J. Krotulski, Daniel Teixeira Da Silva, Joseph D’Orazio, Lara Weinstein, Jeanmarie Perrone, Michael J. Lynch

Division of Internal Medicine Faculty Papers & Presentations

Purpose of Review Medetomidine is a veterinary α2-adrenergic agonist that has been an adulterant of illicitly manufactured opioids since 2022. We review its pharmacology, detection, intoxication, withdrawal, and management, and assess why severe withdrawal has emerged in some regions but not others. Recent Findings Medetomidine has spread through North American drug markets yet evades most toxicology testing. Roughly two hundred times more potent than xylazine, with greater α2 selectivity and imidazoline-1 activity, it causes intoxication resembling other α2 agonists: sedation and bradycardia. The dominant clinical problem is withdrawal: autonomic dysregulation, intractable vomiting, and encephalopathy frequently requiring intensive care. Treatment requires …

Responding To Medetomidine In Philadelphia: Narrative Summary Of The Public Health Response To A New Psychoactive Substance, Tareva Warrick-Stone, Serge-Emile Simpson, Phil Durney, Dennis Goodstein, Catherine Abrams, Raymond Bobb, Kory London, Daniel Teixeira Da Silva

Division of Internal Medicine Faculty Papers & Presentations

BACKGROUND: Despite the emergence of medetomidine as the dominant adulterant in Philadelphia's illicit opioid supply, coordinated public health responses are limited or non-existent in the literature. Thus, we summarize a recent Summit in Philadelphia of outpatient and inpatient service providers who specialize in the care of persons who use drugs to discuss medetomidine response readiness and building ongoing community readiness for potential destabilizing drug supply changes.

PURPOSE: Describe a public health intervention that distributed information about practices across health care settings and mobilized key informants to identify and address barriers to treatment.

METHODS: Descriptive summary of the in-person Summit organized …

Metastatic Large Cell Neuroendocrine Carcinoma: A Rare Cause Of Hypopituitarism, Smriti Nair, Taskeen Ahmed, Jessica Watari

Division of Internal Medicine Faculty Papers & Presentations

Pituitary metastases from pulmonary large cell neuroendocrine carcinoma (LCNEC) are exceedingly rare but should be considered in patients presenting with arginine vasopressin deficiency and panhypopituitarism in the context of known or suspected metastatic lung cancer. Early recognition and prompt initiation of hormonal replacement therapy are essential to prevent life-threatening endocrine crises and to improve symptom burden. We describe a case of a 43-year-old male who presented with dyspnea, weight loss, and weakness who was found to have metastatic LCNEC involving the liver. Endocrine evaluation revealed central hypothyroidism, central adrenal insufficiency, and later arginine vasopressin deficiency manifested by polyuria and hypernatremia. …

Transjugular Intrahepatic Portosystemic Shunt (Tips) Outcomes For Variceal Hemorrhage During And After Covid-19: Racial, Payer, And Income Disparities - A National Retrospective Cohort Study With Stratified Sensitivity Analyses, Nakul Ganju, Shubham Gupta, Sahak Hovsepian, Samay Shah, Shaunak Ganju, Farshad Aduli

Student Papers, Posters & Projects

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) reduces mortality in esophageal variceal hemorrhage. Whether the COVID-19 pandemic worsened existing disparities in outcomes among patients undergoing TIPS remains unclear. We aimed to characterize racial, payer-based, and income-based disparities in post-TIPS outcomes before and after the COVID-19 pandemic.

METHODS: Using the 2016-2022 National Inpatient Sample, we conducted a retrospective cohort analysis of 31,860 weighted hospitalizations of adults with cirrhosis and esophageal variceal hemorrhage who underwent TIPS. Admissions were stratified as pre-COVID (2016-2019) and post-COVID (2020-2022). Primary outcomes were in-hospital mortality, length of stay, and total hospital charges. Multivariable regression models with …

The Medicine Forum Crossword, Youssef Elfatatry, Md

The Medicine Forum

ACROSS
1 One leading cause of ACS in young women

DOWN
1 A.O.A. alternative

The Parts They Don’T See, Alexis Notarianni, Md

The Medicine Forum

People think they know what resident doctors do.

They know the obvious parts: we examine patients, prescribe medications, and write notes. We diagnose infections, perform procedures, and coordinate care with nurses. We work long hours and rarely have days off. From the outside, it looks familiar enough to understand.

But there is a large portion of this job that is invisible, even to the people closest to us. It is difficult to explain, and harder still to feel understood unless you are living it.

More Than Medicine: How Advocacy, Education, And Loss Shape The Physician Within, Sheraz Qamar, Md

The Medicine Forum

Illness rarely unfolds in a linear or predictable way. Instead, it emerges through uncertainty – shaped by fragmented symptoms, gaps in access, and the limits of medical knowledge. Reflecting on three deeply personal experiences within my family, I have come to understand my role as a resident physician not only through clinical training, but through lived experience: as an advocate, an educator, and, at times, as someone profoundly affected by loss.

Holding Hands, Alexis Notarianni, Md

The Medicine Forum

My patient had already received the medications we reach for when patients are in pain and afraid — antiemetics, analgesics, and anxiolytics. The nasogastric tube was in place. What remained was not another intervention, but the simple act of being there.

My patient had been healthy until just months earlier, when his life changed abruptly. In the two hundred days since, illness had altered nearly every part of his body. Now he lay in bed in pain, breathing through a tracheostomy, receiving nutrition from a feeding tube. Tears streamed down his cheeks as he reached out and took my hand. …

Good Enough, Anne Leone, Md

The Medicine Forum

(Verse 1)
Coming out the gate a little too fast
This is not sustainable, it won’t last
Can’t turn around, I can’t backtrack
Where do I go from here
How can I maneuver this current

Ripping through and pulling me with it
Going under, air’s running out quick
but the shoreline is near

(Chorus)
Never knew that I could get through a patch so rough,
Never knew before that I was good enough,
The only thing holding me back was my own self doubt,
But I’ll let go now

(Verse 2)
hard to plan what steps to take next now …

An Examination Of Generative Ai In Medicine, J. Marco Cipriaso, Md, Trishya Srinivasan, Md

The Medicine Forum

The age of artificial intelligence (AI) is upon us. Specifically, generative AI has been transforming how we interface with the world by directly generating its own novel output.¹ Medicine is not immune to this change. AI search tools such as OpenEvidence have shown promise by providing evidence-based recommendations, already proven to perform well in primary care settings, with additional promise for future applications.² AI tools have taken over the note-writing process through ambient software, allowing physicians to dedicate more time to face-to-face interaction with their patients.³ These and other developments show clear reason to be excited about …

The Emotional Labor Of Clinicians And The Need For Reflective Support, Benedicta Olonilua, Bs, Evan Nardone, Md

The Medicine Forum

Physicians who work in Palliative Care or adjacent fields like Oncology often bear a unique emotional weight in addition to the typical responsibilities that come with the job. The nature of their work puts them in frequent contact with serious illness, dying, and grief. Additionally, they are often required to engage in conversations that are not only medically complex but also deeply personal and, at times, emotionally charged. While this emotional labor is an inherent part of the job, it can become especially heavy when there is no space to process it. Over time, this can build up and eventually …

Coping As A Team, J. Marco Cipriaso, Md

The Medicine Forum

“Medicine is the only job where someone can die, and you’re expected to go back to work, business as usual.” - Rachael Grosso MD

Methylene Blue As An Adjunctive Therapy In Refractory Septic Shock: A Case-Based Review Of Emerging Evidence, Warda Naqvi, Md, Paulina Lowery, Do, Enad Haddad, Md, Muneeba Ali, Md, Prerana Sevella, Md, Sudeep Nugooru, Md, Richard Friedenheim, Md

The Medicine Forum

Septic shock is associated with high mortality, particularly in patients who develop refractory vasoplegia despite guideline-directed therapy. Excess nitric oxide mediated vasodilation contributes to catecholamine resistance and persistent hypotension. Methylene blue (MB), an inhibitor of nitric oxide synthase and soluble guanylate cyclase, has emerged as a potential adjunctive therapy targeting this pathway. We report a case of a 36-year-old female presenting with severe septic shock secondary to aspiration pneumonia, complicated by profound hypoxemia requiring mechanical ventilation and veno-venous extracorporeal membrane oxygenation. Despite aggressive fluid resuscitation, broad-spectrum antibiotics, corticosteroids, and maximal vasopressor support, she remained hemodynamically unstable. Administration of intravenous MB …

The Intersection Of Ventilator Support And Hospice In Late Als Diagnosis, J. Marco Cipriaso, Md, Kenna Hawes, Md, Margot Noyelle, Md, Megan Cecchine, Md

The Medicine Forum

Amyotrophic lateral sclerosis (ALS) often leads to respiratory failure that can be treated with respiratory support in the form of tracheostomy plus invasive mechanical ventilation. It typically occurs late in the disease course, often allowing patients to adequately prepare by discussing their goals of care. We describe a case of a patient whose ALS was diagnosed after he had TMV initiated. As a result, the patient and family faced a daily decision on when to withdraw ventilator support, and he was unable to achieve his ultimate wish to die at home. We highlight this to recognize that serious illnesses with …

The Back Burn: A Case Report Of Mollaret’S Meningitis In A Young Male, Muneeba Ali, Md, Lubaba Mukhtar, Md, Warda Naqvi, Md, Joseph Hassey, Md, Muhammad Ayub, Md

The Medicine Forum

Mollaret’s syndrome, or benign recurrent aseptic meningitis, is a rare condition characterized by recurrent, self-limited episodes of aseptic meningitis. We present the case of a 49-year-old male with a past medical history of herpes meningitis as a teenager, who presented to the emergency department (ED) with a headache, and whose initial lumbar puncture results were consistent with viral meningitis. HSV-2 was detectable in cerebrospinal fluid (CSF) DNA by PCR but not detected on quantitative PCR. He was diagnosed with Mollaret’s meningitis, and all intravenous antiviral therapy was discontinued, with the patient making a full recovery. This case highlights the important …

Refractory Autoimmune Encephalitis In Metastatic Thymoma, Michael Predi, Do, Anna Bondonese, Md, Anish Vora, Md, Sarah W. Gordon, Do

The Medicine Forum

Thymoma-associated autoimmune encephalitis (TAAE) is a rare paraneoplastic neurological syndrome occurring in approximately 8% of thymoma patients. The condition results from thymic dysfunction leading to impaired T-cell selection and production of autoantibodies against neuronal antigens. Autoimmune encephalitis represents a severe but underrecognized complication with heterogeneous clinical presentations. Thymectomy has been shown to be the most effective treatment for TAAE.

Fever, Cytopenias, And Splenomegaly: A Hematologic Approach To Suspected Hlh In Autoimmune Liver Disease, Reed Firestone, Md, Ms

The Medicine Forum

Fever with cytopenias and splenomegaly raises concern for hematologic malignancy and hyperinflammatory syndromes such as hemophagocytic lymphohistiocytosis (HLH). Distinguishing these entities is critical, as management strategies differ significantly. In this report, we describe a 19-year-old male with autoimmune hepatitis–primary sclerosing cholangitis overlap who presented with one year of recurrent fevers, cytopenias, and splenomegaly. Extensive infectious and malignant workup, including PET imaging and bone marrow biopsy, were negative. HLH was considered; however, laboratory findings were inconsistent, including ferritin of 191 ng/mL and fibrinogen of 683 mg/dL. His course remained chronic and stable. The presentation was attributed to autoimmune liver disease with …

Delayed Immune-Related Ophthalmoplegia After Pembrolizumab Therapy: A Case Report, Mohammed Shah, Md, Smriti Nair, Md, Sarah Sulkowski, Md, Maheen Imran, Bs

The Medicine Forum

We present a case of Pembrolizumab-associated ophthalmoplegia in a patient with HNSCC who previously developed an immune checkpoint inhibitor associated hepatitis. Immune checkpoint inhibitor– associated ocular toxicities are rare, occurring in approximately <1% to 1.1% of treated patients.^1,2 This case highlights the diagnostic challenges of neuroophthalmic immune-related adverse events and the importance of prompt evaluation and immunosuppressive therapy.

Brain On Fire: A Case Of Severe Ifosfamide Encephalopathy And Utilization Of Methylene Blue, Nicholas Spyropoulos, Do, Michelle Joyner, Do

The Medicine Forum

Ifosfamide is a commonly used chemotherapeutic agent indicated for a variety of malignancies; however, given its well-documented complications including Ifosfamide induced encephalopathy (IFE), its overall use is limited. Neurotoxicity secondary to ifosfamide can range from mild confusion to severe neurologic deterioration, with the primary treatment being focused on supportive care. This clinical case highlights a 41-year-old patient with BRAF positive ameloblastic carcinoma who developed acute neurotoxic symptoms following ifosfamide chemotherapy induction. His symptoms, ranging from altered mental status, restlessness, severe headache, and peripheral neuropathy, began shortly after chemotherapy initiation. Both his lab work and imaging could not explain the acute …

Radiographic Imaging Of Power Injectable Medical Access Ports As A Supplemental Identification Tool, Nikhil Goyal, Md, Huy M. Do, Md, Alexandra P. Toscano, Bs, Lillian G. Spear, Bs Georgetown University, Lindsey A. Hazen, Rn, Les R. Folio, Do

The Medicine Forum

Medical access ports (MAPs) are implanted devices often used for intravenous administration of chemotherapeutic agents or contrast agents for CT or MR imaging. Improper MAP usage poses risk of catheter rupture; hence, proper identification and usage are essential. We demonstrate an approach for MAP identification based on their unique radiographic imaging features.

Large Language Models For Detecting Extraprostatic Extension In Free-Text Prostate Mri Radiology Reports, Nikhil Goyal, Md, Satvik Tripathi, Krishnan R. Patel, Md, Mhs, Hyun Tae Kim, Md, Mph, Tessa S. Cook, Md, Phd

The Medicine Forum

Extraprostatic extension (EPE) is a prognostically important pathologic feature of prostate cancer that is difficult to predict preoperatively. Because EPE may be microscopic, it may not be detected with conventional imaging. Several magnetic resonance imaging (MRI) features associated with EPE risk are routinely described in radiology reports and may be detectable by large language models (LLMs). This study evaluated the performance of five commercial LLMs (GPT-3.5-turbo, GPT-4, GPT-4o-mini, GPT-4o, and o3-mini) in classifying pathologic EPE from free-text prostate MRI reports for patients with confirmed prostate cancer. Among the models tested, o3-mini achieved the highest accuracy (66.3%) and positive predictive value …

Reconsidering The Clinical Implications Of Albumin In Severe Acute Pancreatitis, Alexis Notarianni, Md, Jacqueline Krieger, Md

The Medicine Forum

In this single-center pilot trial of 60 ICU patients, early administration of 5% albumin in addition to crystalloid did not significantly improve Systemic Inflammatory Response Syndrome (SIRS) remission at Day 3 nor reduce 60-day mortality.¹ However, a statistically significant reduction in sepsis was observed in the albumin group compared with crystalloid alone (10% vs. 36.7%, P = 0.01). Although the study concludes that albumin did not improve prognosis, we believe the observed difference in sepsis merits further consideration.

Infection and persistent organ failure are well-established determinants of mortality in acute pancreatitis, particularly in the later phases of disease progression. …

Accounting For Sex-Specific Physiology In Wearable Devices Identifying Inflammatory Bowel Disease Flares, Sonali Shah, Md

The Medicine Forum

The study “Physiological Data Collected from Wearable Devices Identify and Predict Inflammatory Bowel Disease Flares” evaluates how the use of wearable devices to collect physiological data can help identify inflammatory bowel disease (IBD) flares.1 The study found significant differences in longitudinal heart rate (HR), heart rate variability (HRV), as well as resting heart rate (RHR) during periods of both inflammatory (measured by elevation in CRP, ESR, or fecal calprotectin) and symptomatic flares. Additionally, the authors found that these variables were often different up to 7 weeks prior to a flare, suggesting that the use of wearable devices could aid clinicians …

When It’S Not Gastroparesis: Isolated Idiopathic Acth Deficiency Presenting With Recurrent Gastrointestinal Symptoms, Navya Pendyala, Md, Ramya Pendyala, Md, Anna Mathew, Md, Beatriz Torre, Md, Christopher Henry, Md

The Medicine Forum

Adrenal insufficiency is an uncommon but important cause of nonspecific gastrointestinal symptoms. We present a 33-year-old male with recurrent nausea, vomiting, and presumed gastroparesis who was ultimately found to have isolated idiopathic ACTH deficiency after discordant diagnostic findings prompted further evaluation. His symptoms resolved rapidly with glucocorticoid replacement. This case highlights the importance of considering adrenal insufficiency in patients with unexplained gastrointestinal symptoms and systemic features despite negative structural work up and underscores the role of diagnostic anchoring in delayed diagnosis.

Squamous Cell Carcinoma Of The Sigmoid Colon: A Rare Late Presentation Of Metastatic Urothelial Cancer With Squamous Differentiation Of The Bladder, Hamzah Shariff, Md, Ghazal Ghafari, Do, Mph, Zachary Hoffer, Md, Phd, Danyall Saeed, Anila Mahesh, Md, Kishore Kumar, Md

The Medicine Forum

Urothelial cell carcinoma (UCC) with squamous differentiation (SqD) is a subtype of bladder cancer with high metastatic potential. Metastasis of muscle-invasive UCC to the GI tract, with complete transition to squamous cell carcinoma (SCC), is rare, particularly in females. We present a female patient with high grade UCC with SqD treated with radical cystectomy and immunotherapy who presented with hematochezia 1 year after her cancer treatment. Imaging and colonoscopy revealed an annular, obstructing mass in the rectosigmoid region prompting sigmoid colectomy and partial proctectomy. Histopathology revealed invasive SCC. New gastrointestinal (GI) symptoms with prior invasive bladder cancer should prompt evaluation …

Radiation-Induced Biliary Strictures Leading To Recurrent Pyogenic Liver Abscesses: A Case Report, Rhea Ratan, Md, Beatriz Torre, Md, Rishi Pawa, Md

The Medicine Forum

Introduction

Radiation-induced biliary damage, including strictures, stenosis, cholangitis, and posthepatic cholestasis, is a rare complication of radiation therapy reported most frequently in the context of hepatobiliary cancers and other upper abdominal mal ignancies.^1-3 This complication often occurs with a delayed presentation, with a variable latency period ranging from months to as late as decades after treatment.^1-4 Histologic examination demonstrates segmental bile duct wall thickening, cholestasis, fibrosis, and features consistent with radiation injury.^1,5 Most reported cases involve the common bile duct and major hepatic ducts, where endoscopic and percutaneous interventions remain feasible. These are identified during surveillance imaging, …

Occupational Hydrocarbon Exposure Presenting As Acute Hepatocellular Injury With Atypical Mitotic Figures On Liver Histopathology In An Oil Rig Worker: A Case Report, Hamzah Shariff, Md, Maria Averbuch, Do, Leanna Rucker, Md, Madison Force, Md, Dina Halegoua-De Marzio, Md

The Medicine Forum

Occupational exposure to hydrocarbons and aromatic solvents in the petroleum industry has been somewhat associated with hepatotoxicity, though the clinical manifestations and histologic features remain incompletely characterized. We present the case of a 33-year-old oil rig worker with prolonged occupational exposure to benzene and hydrocarbon compounds who presented with acute hepatocellular liver injury and concurrent biliary pathology. The patient presented with right upper quadrant pain, jaundice, and pale stools. Laboratory evaluation demonstrated marked hepatocellular injury with alanine aminotransferase (ALT) elevation to 1183 U/L and total bilirubin of 6 mg/dL. Extensive infectious, metabolic, and autoimmune evaluation was unrevealing. ANA and ASMA …

Gastric Nodules As A Rare Presentation Of Diffuse Large B Cell Lymphoma, Hamzah Shariff, Md, Ghazal Ghafari, Do, Mph, Anila Mahesh, Md, Kishore Kumar, Md

The Medicine Forum

Diffuse large B-cell lymphoma (DLBCL) commonly involves the gastrointestinal tract, though typical endoscopic findings include ulcerations or masses. We report a 79-year-old woman with iron deficiency anemia found to have multiple small gastric nodules on endoscopy. Biopsy demonstrated DLBCL, with imaging confirming disseminated disease and secondary gastric involvement. This presentation is atypical, as nodular morphology is rarely described. Importantly, such findings may mimic other malignancies, particularly neuroendocrine tumors. This case highlights that gastric nodules may be an atypical manifestation of secondary DLBCL and underscores the necessity of adequate tissue biopsy to establish diagnosis and guide management.

Diet And Dysphagia: Balancing Aspiration Risk With Quality Of Life, Margot Noyelle, Md, Kenna Hawes, Md, J. Marco Cipriaso, Md, Megan Cecchine, Md

The Medicine Forum

Nil per os (NPO) diets are often prescribed for patients who have dysphagia to prevent aspiration pneumonia, but recent studies have questioned the efficacy of such strict recommendations. This case report describes the care provided to a 73-year-old woman with chronic dysphagia who described her inability to eat or drink as the “single greatest agony” of a months-long hospitalization. This report highlights the ethical challenges of determining diet orders for patients with dysphagia.

Lost In Stratification: The Underutilization Of Fib-4-Guided Masld Screening In The Primary Care Setting, Sanjna Shelukar, Md, Ananya Venkatesh, Md, Breanne Mcdermott, Bs, Julietta Gervase, Ba, Maria Winte, Md, Rebecca Loh, Md, Dina Halegoua-De Marzio, Md

The Medicine Forum

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading contributor to chronic liver disease worldwide. Early identification of MASLD and hepatic fibrosis in the primary care setting is essential for timely and effective management. The Fibrosis-4 (FIB-4) index is recommended as a first-line, non-invasive tool to screen at-risk patients for advanced fibrosis. This study aims to determine FIB-4 screening rates in at-risk patients in an urban resident-led primary care clinic.

A retrospective chart review was conducted in a single Internal Medicine resident-led primary care clinic. Patients aged 36 to 65 years were included, and FIB-4 scores were calculated. Patients were …