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The Medicine Forum: Volume 24

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 24, 2022-2023

TABLE OF CONTENTS

• Case Reports
• Ultrasound Education

Steroid Responsive Idiopathic Calcitriol Induced Hypercalcemia: A Case Report And Review Of The Literature, Omar El Fadel, Anshel Kenkare, Jingjing Zhang

Division of Internal Medicine Faculty Papers & Presentations

BACKGROUND: Idiopathic Calcitriol Induced Hypercalcemia is a rare cause of a common condition of hypercalcemia. Hypercalcemia is most commonly the result of hyperparathyroidism and together with hypercalcemia of malignancy accounts for over 95% of cases. Idiopathic Calcitriol Induced Hypercalcemia can mimic hypercalcemia secondary to granulomatous diseases like sarcoidosis, but with apparent absences of both imaging and physical exam findings consistent with the disease. We report here a 51-year-old man who presented with recurrent nephrolithiasis, hypercalcemia, and acute kidney injury.

CASE PRESENTATION: A 51-year-old man presented with severe back pain and mild hematuria. He had a history of recurrent nephrolithiasis over …

The Role Of Bispecific Antibodies In Relapsed Refractory Multiple Myeloma: A Systematic Review, Razwana Khanam, Omer S. Ashruf, Syed Hamza Bin Waqar, Zunairah Shah, Saba Batool, Rameesha Mehreen, Pranali Pachika, Zinath Roksana, Mohammad Ebad Ur Rehman, Faiz Anwer

Abington Jefferson Health Papers

Multiple myeloma is a heterogeneous clonal malignant plasma cell disorder, which remains incurable despite the therapeutic armamentarium's evolution. Bispecific antibodies (BsAbs) can bind simultaneously to the CD3 T-cell receptor and tumor antigen of myeloma cells, causing cell lysis. This systematic review of phase I/II/III clinical trials aimed to analyze the efficacy and safety of BsAbs in relapsed refractory multiple myeloma (RRMM). A thorough literature search was performed using PubMed, Cochrane Library, EMBASE, and major conference abstracts. A total of 18 phase I/II/III studies, including 1283 patients, met the inclusion criteria. Among the B-cell maturation antigen (BCMA)-targeting agents across 13 studies, …

Apolipoprotein E Dyslipidemia And Nephrotic Syndrome: A Rare Connection, Sahana Tito, Avica Atri, Shivaraj Patil, Saima Dean, Sweta Carpenter

Einstein Health Papers

Severe hyperlipidemia warrants an extensive evaluation. We report a case of a 25-year-old man of Chinese descent seen in the cardiology-lipid clinic. He was found to have a serum low-density lipoprotein cholesterol of 12.12 mmol/L (468 mg/dL) and serum triglycerides of 2.29 mmol/L (203 mg/dL) during routine screening. Work-up revealed nephrotic-range proteinuria, and renal biopsy showed dilated glomerular capillary loops with lipid deposits, pathognomonic of lipoprotein glomerulopathy. Genetic studies showed apolipoprotein E3/E4 phenotype. He was treated with a high-intensity statin and fibrate therapy, which resulted in a marked improvement in dyslipidemia and proteinuria.

A Rare Case Of Autopsy Proven Achromobacter Xylosoxidans Endocarditis Involving Tricuspid Valve: A Case Report, Chaitra Janga, Mackenzie Kramer, Ifrah Naeem, Lucy Checchio, Md, Zahra Qamar

Abington Jefferson Health Papers

Infective endocarditis refers to infection of one or more valves of the heart, with Achromobacter xylosoxidans (A. xylosoxidans) being a rare cause. So far, 24 cases of A. xylosoxidans endocarditis were reported, with only one case describing tricuspid valvular involvement. Despite the rarity of A. xylosoxidans endocarditis, it is important for clinicians to be aware of atypical presentation and the high mortality associated with it. We present an autopsy-proven case of tricuspid valve endocarditis in the setting of A. xylosoxidans bacteremia in a 43-year-old female.

Covid-19 Related Biliary Injury: A Review Of Recent Literature, Sujani Yadlapati, Simone A. Jarrett, Daniel Baik, Adib Chaaya

COVID-19 Papers, Posters, and Presentations

Since its emergence in 2019, it has become apparent that coronavirus 2019 (COVID-19) infection can result in multi systemic involvement. In addition to pulmonary symptoms, hepatobiliary involvement has been widely reported. Extent of hepatic involvement ranges from minor elevation in liver function tests (LFTs) to significant hepatocellular or cholestatic injury. In majority of cases, resolution of hepatic injury or improvement in LFTs is noted as patients recover from COVID-19 infection. However, severe biliary tract injury progressing to liver failure has been reported in patients requiring prolonged intensive care unit stay or mechanical ventilation. Due to the timing of its presentation, …

An Unusual Case Of Hemophagocytic Lymphohistiocytosis Associated With Mycobacterium Chimaera Or Large-Cell Neuroendocrine Carcinoma, Tejaswi Venigalla, Sheila Kalathil, Meena Bansal, Mark Morginstin, Vinicius Jorge, Patricia Perosio

Einstein Health Papers

Hemophagocytic lymphohistiocytosis (HLH) is a rare and very dangerous condition characterized by abnormal activation of the immune system, causing hemophagocytosis, inflammation, and potentially widespread organ damage. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity, is most commonly seen in children. Secondary HLH is commonly associated with infections, malignancies, and rheumatologic disorders. Most current information on diagnosis and treatment is based on pediatric populations. HLH is a disease that should be diagnosed and treated promptly, otherwise it is fatal. Treatment is directed at treating the triggering disorder, along with symptomatic treatment with dexamethasone and etoposide. We present a 56-year-old …

Impact Of End Stage Renal Disease On The Clinical Outcomes Of Diabetics Admitted For Heart Failure: Analysis Of National Inpatient Sample, Muhammad Usman Almani, Yaqi Zhang, Muhammed Hamza Arshad, Muhammad Usman, Muhammad Talha Ayub

Einstein Health Papers

Introduction: Patients with diabetes and heart failure (HF) can have varying outcomes depending on whether they also have End Stage Renal Disease (ESRD). This study aimed to compare the outcomes of patients with diabetes and HF with and without ESRD.

Methods: Data from the National Inpatient Sample (NIS) 2016-2018 was analyzed to find hospitalizations for patients with HF as the main diagnosis and diabetes as a secondary diagnosis, with and without ESRD. Multivariable logistic and linear regression analysis was used to adjust for confounding factors.

Results: In the total cohort of 12215 patients with a principal diagnosis of heart failure …

Risk Of Coronary Artery Disease In Patients With Gout On Treatment With Colchicine: A Systematic Review And Meta-Analysis, Muhammad U Siddiqui, Joey Junarta, Swaminathan Sathyanarayanan, Kirpal Kochar, Waqas Ullah, D L Fischman

Division of Cardiology Faculty Papers

Background: Colchicine has anti-inflammatory properties, but its utility in improving cardiovascular outcomes has been disputed. Here, we study the impact of colchicine on cardiovascular outcomes in patients with gout with and without coronary artery disease (CAD).

Methods: Medline, Web of Science and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Primary outcomes included myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Secondary outcomes included stroke and all-cause mortality.

Results: We included 4 observational studies comprising 10,026 patients with gout on treatment with colchicine. There was no significant difference in the …

The “Evolving” Role Of Intravascular Imaging In Myocardial Infarction With Nonobstructive Coronary Arteries, D L Fischman, Vaikom S. Mahadevan, Eric R. Bates

Division of Internal Medicine Faculty Papers & Presentations

No abstract provided.

Point And Counterpoint: Polatuzumab Vedotin In The Front-Line Therapy For Diffuse Large B- Cell Lymphoma, Colin Thomas, Sameep Thapa, Connor Mclaughlin, Molly Halloran, Porcu Pierluigi

Department of Medical Oncology Faculty Papers

No abstract provided.

Functional Assessment Data: Current Status Of Federal Initiatives To Support Interoperability Among Post Acute Care Settings, Edgar Chou

Division of Internal Medicine Faculty Papers & Presentations

Health information needed along the transitions in care includes functional status such as self-care abilities assessments. Despite current federal efforts to support interoperability of functional status data, gaps still exist. Functional status assessments are included in data collection instruments widely used in four post acute care (PAC) settings, with each type of setting using a different standard instrument. These various instruments lack a shared standard for the content (meaning) of functional assessment items, necessitating mapping to a standard data terminology. Analysis indicates complete LOINC representation and incomplete SNOMED representation among functional status items and instruments. The new U.S. Core Data …

An Unexpected Case Of Non-Uremic Calciphylaxis In A Patient With Multiple Risk Factors, Shannon Nugent, Fred Karaisz, Maisa Elbadawi, Andrew Touati, Neda Nikbakht, Jason B. Lee, Hasan Arif

Division of Internal Medicine Faculty Papers & Presentations

A 58-year-old woman with a history of morbid obesity, asthma, and prior warfarin use presented to the hospital with shortness of breath and a three-month history of painful, ulcerated ulcers with retiform purpura of her bilateral distal extremities. A punch biopsy specimen demonstrated focal necrosis and hyalinization of the adipose tissue with subtle arteriolar calcium deposition, findings consistent with calciphylaxis. We discuss the presentation of non-uremic calciphylaxis and review the risk factors, pathophysiology, and interdisciplinary management approach of this rare disease.

Comprehensive Review Of Cardiovascular Disease Risk In Nonalcoholic Fatty Liver Disease, Kevan Josloff, Jacob Beiriger, Adnan Khan, Richard J. Gawel, Richard S. Kirby, Aaron Kendrick, Abhinav K. Rao, Roy Wang, Michelle Schafer, Margaret Pearce, Kashyap Chauhan, Yash B. Shah, Gregary D. Marhefka, Dina Halegoua-De Marzio

Department of Medicine Faculty Papers

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising …

Cardiogenic Shock Due To Atrial Arrhythmia As The Initial Presentation Of Transthyretin Cardiac Amyloidosis, Svenja M. Schneider, Kirpal Kochar, Max Ruge, Stefanie Marek-Iannucci, Tanuka Datta, Alexander Hajduczok, Waqas Ullah, Indranee Rajapreyar, Yevgeniy Brailovsky

Jefferson Hospital Staff Papers and Presentations

Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.)

Cannabidiol, ∆9 -Tetrahydrocannabinol, And Metabolites In Human Blood By Volumetric Absorptive Microsampling And Lc-Ms/Ms Following Controlled Administration In Epilepsy Patients, Federica Pigliasco, Sara Malaca, Alfredo Fabrizio Lo Faro, Anastasio Tini, Giuliana Cangemi, Alessia Cafaro, Sebastiano Barco, Antonella Riva, Angelica Pisati, Elisabetta Amadori, Pasquale Striano, Adriano Tagliabracci, Marilyn A. Huestis, Francesco Paolo Busardò

Institute of Emerging Health Professions Faculty Papers

Cannabidiol (CBD) exhibits anti-inflammatory, anxiolytic, antiseizure, and neuroprotective proprieties without addictive or psychotropic side effects, as opposed to Δ9-tetrahydrocannabinol (THC). While recreational cannabis contains higher THC and lower CBD concentrations, medical cannabis contains THC and CBD in different ratios, along with minor phytocannabinoids, terpenes, flavonoids and other chemicals. A volumetric absorptive microsampling (VAMS) method combined with ultra-high-performance liquid chromatography coupled with mass spectrometry in tandem for quantification of CBD, THC and their respective metabolites: cannabidiol-7-oic acid (7-COOH-CBD); 7-hydroxy-cannabidiol (7-OH-CBD); 6-alpha-hydroxy-cannabidiol (6-α-OH-CBD); and 6-beta-hydroxycannabidiol (6-β-OH-CBD); 11- Hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC) and 11-Nor-9-carboxy-Δ9-tetrahydrocannabinol (THCCOOH). After overnight enzymatic glucuronide hydrolysis at 37°C, samples underwent acidic …

Risk Prevention And Health Promotion For Non-Alcoholic Fatty Liver Diseases (Nafld), Adnan Khan, Do, Heather Ross, Natali Salinas, Sarah Chen, Kashyap Chauhan, Makala Wang, Brian Yan, Ba, John Magagna, Jacob Beiriger, Yash Shah, Taha Shahzad, Dina Halegoua-De Marzio, Md

Division of Internal Medicine Faculty Papers & Presentations

Non-alcoholic fatty liver disease (NAFLD) is a serious clinicopathological condition that is recognized as the most frequent chronic liver disease, affecting 14%-30% of the world’s population. The prevalence of NAFLD has rapidly grown and is correlated with the growth in obesity and type 2 diabetes, among other factors. NAFLD often results in long-term complications including cardiovascular disease, liver cirrhosis, and liver fibrosis. This paper provides an updated overview of NAFLD with a focus on epidemiology, etiology, pathophysiology, screening, complications, and pharmacological therapies to identify effective risk prevention and health promotion.

The Laws Of The Dead, Gillian Naro, Md, Med, Marie-Laure Flamer, Md

The Medicine Forum

George Washington suddenly fell ill with a sore throat and labored breathing at his estate in 1799. Initial management consisted of a "mixture of molasses, vinegar and butter," that was followed by “sage, tea and vinegar.” With no signs of clinical improvement, his doctors were called to his bedside. As was standard medical care at the time and thought to be beneficial in various afflictions, he was “bleed” more than 2L of blood in an attempt to restore his good health. The three doctors overseeing the bleeding process noticed the General become weaker despite their best efforts. His breathing became …

Internal Medicine Residents’ Experience With Using Handheld Ultrasound Machines In Point-Of-Care Ultrasonography, Michael Dong, Md, Tudor Sturzoiu, Md, Fred Karaisz, Max Ruge, Md

The Medicine Forum

Point-of-care ultrasonography (POCUS) is defined as the acquisition and interpretation of ultrasonographic images generated by the clinician at the bedside. The advent of handheld machines has increased access and practical application of ultrasound technology in internal medicine training and medical education. The most common system involves a single portable ultrasound probe that connects to a smartphone or tablet, and storage of images are stored via cloud-based technology. We discuss our experience with POCUS using handheld ultrasound machines in the Thomas Jefferson University Hospital academic setting.

Pulmonary Metastases Of Basal Cell Adenocarcinoma Presenting As Hemoptysis, Matthew Dimeglio, Do, Mba, Mark Mallozzi, Md, Prarthna Kulandaisamy, Md, Julie Barta, Md, Jennifer Johnson, Md

The Medicine Forum

Basal Cell Adenocarcinoma (BCAC) is a rare malignancy, only accounting for approximately 2% of all salivary neoplasms. Considered the malignant counterpart of basal cell adenoma, it most commonly presents at 60 years of age without gender predilection. Sites of involvement frequently includes the parotid gland, but sites in the minor salivary glands, nasopharynx, buccal mucosa, and tongue have also been reported. Often regarded as an indolent malignancy, BCAC can occasionally cause invasive disease and infrequently, metastatic disease. Among all solid tumors, endobronchial metastases is quite a rare occurrence, contributing to approximately 4% of endobronchial biopsies4. Most common sites of metastases …

Spontaneous Tumor Lysis Syndrome In Undifferentiated Pelvic Solid Tumor With Associated New Onset Atrial Flutter: A Case Report, Sameep Thapa, Md, Max Ruge, Md, Tamar Wolinsky Md

The Medicine Forum

Tumor lysis syndrome (TLS) is an oncologic emergency that is caused by electrolyte derangements from the lysis of malignant tumor cells. The syndrome consists of several laboratory abnormalities including hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia1,2. When these lab findings are associated with end-organ damage such as acute renal failure, seizures, or cardiac dysrhythmias amongst others, it is known as clinical TLS3. TLS is more commonly associated with hematological malignancies given their tendency of rapid cellular turnover. The most common culprits include acute lymphocytic leukemia and Burkitt’s lymphoma. It is, however, quite rare for TLS to occur secondary to a solid malignancy4. …

A Case Report Of Methemoglobinemia And Hemolytic Anemia In The Setting Of Covid-19 Pneumonia And G6pd Deficiency, Grant W. Jirka, Md, Travis Hunt, Md, Sushil Ghimire, Md, Rakhshanda Akram, Md, Urvashi Vaid, Md, Ms

The Medicine Forum

It is well known that hereditary or acquired methemoglobinemia can cause hypoxia due to the oxidation of heme, which impairs its ability to offload oxygen (Figures 1 & 2), and that acquired methemoglobinemia is most often caused by exposure to drugs and toxins that oxidize hemoglobin to methemoglobin, directly or indirectly1. Recently, a few case reports have highlighted methemoglobinemia in patients with COVID-19 pneumonia. Some of these reports were due to treatment with hydroxychloroquine and others from unidentifiable causes2-4. We present a case in which a patient with COVID-19 pneumonia was diagnosed with methemoglobinemia and acute hemolysis from G6PD deficiency …

A Case Of Acute Pancreatitis Associated With Empagliflozin, Tudor Sturzoiu, Md, Sameep Thapa, Md, Ellen Solomon, Suchit Bhutani, Md

The Medicine Forum

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are being prescribed increasingly more often for type 2 diabetes mellitus as well as heart failure. They have not typically been associated with acute pancreatitis, but there has been a steady flow of case reports implicating them in acute pancreatitis over the years since they were initially approved. Here, we present the case of an 82-year-old woman with a past medical history of T2DM, COPD, hyperlipidemia, a remote stroke, peripheral arterial disease, and remote breast cancer now with recurrent localized breast cancer on treatment with ademaciclib and letrozole who presented to the emergency department with …

A Confounding Case Of Acute Hepatitis A, Andrea Molin, Md, Michael Cheung, Md, Timothy Kuchera, Md

The Medicine Forum

Hepatitis A (HAV) is a picornavirus transmitted via fecal-oral route that disproportionately affects homeless persons, men who have sex with men, and individuals who use intravenous drugs. Acute HAV typically presents with nausea, vomiting, abdominal pain, and fever. It is most commonly self-limited but can progress to fulminant hepatic failure in less than 1% of cases. The following case is a unique presentation of acute HAV infection requiring diagnostic dexterity and critical thinking.

Shocked But Not Surprised: The Philly Cardioversion, Gillian Naro, Md, Med, Naman Upadhyay, Md, Emilie Thompson, Md, Tudor Sturzoiu, Md

The Medicine Forum

Neuromuscular incapacitating devices, colloquially known as ‘tasers’, are typically used by police and security personnel as a non-lethal way to subdue combative assailants. Unfortunately, there are times in the hospital when patients can become assailants, thus potentially necessitating the use of tasers to ensure the safety of staff and other patients. Tasers come in several varieties. However, those typically used by law enforcement have a 50,000-V capacity and deliver 0.36 - 1.76 Joules of energy per pulse, at a rate of ~20 pulses per second, via two barbed projections. This leads to incapacitation of the assailant via the induction of …

A Case Of Patent Foramen Ovale As A Cause Of Persistent Hypoxia, Jaya Janadhyala, Md, Jonathan Foster, Md

The Medicine Forum

Patent foramen ovale (PFO) is a congenital cardiac variant caused by failure of the closure of a passage in the atrial septum. It is quite common, occurring in as much as 27% of the population based on autopsy studies. Most cases of PFOs are incidentally discovered or found during work-up of cryptogenic strokes as a potential cause of the stroke.1 New research is being conducted on the role PFOs play in hypoxia from intracardiac right-to-left shunting, including in patients with co-existent cardiovascular and pulmonary disease

Cardiac Amyloidosis: A Known Disease With An Unknown Presentation, Svenja Schneider, Md, Tudor Sturzoiu, Md, Tanuka Datta, Md, Yevgeniy Brailovsky, Do, Facc, Sung-Hae Cho, Md, Facc, Paulina Gorodin-Kiliddar, Md

The Medicine Forum

Cardiac amyloidosis is an increasingly recognized entity that causes significant morbidity and mortality. Transthyretin amyloidosis (ATTR) is present in about 16% of patients with severe aortic stenosis and up to 17% of patients with heart failure with preserved ejection fraction9,10. Though the screening test of choice, echocardiography is not highly sensitive or specific, and it should not be relied upon to rule out cardiac amyloidosis, especially if clinical suspicion is high.

We present a case of a 58-year-old woman with a history of bilateral carpal tunnel syndrome who presented with paresthesia and syncope. Extensive workup for neurologic, infectious, and malignant …

Another Case Of Takotsubo Syndrome: Excluded By The Presence Of Significant Coronary Artery Disease, Or Caused By Significant Coronary Artery Disease?, Bharaniabirami Rajaram, Md, Neveda Murugesan, Md, Gregary D. Marhefka, Md

The Medicine Forum

Takotsubo syndrome (TTS) is a reversible condition of abnormal myocardial contraction that was first given this name in Japan by Dr. Sato in 1991. The name comes from the Japanese word for “octopus trap,” which has a similar shape to that of the left ventricle on ventriculography during Takotsubo syndrome. It is also known as broken heart syndrome, stress-induced cardiomyopathy, or apical ballooning syndrome. The first descriptions of this phenomenon date as far back as the 1960s.

TTS typically presents with symptoms and clinical signs suggestive of acute coronary syndrome (ACS). It may include ST segment elevations on electrocardiogram (ECG) …

Challenges Of Managing Giant Cell Myocarditis: A Case Report On The Mechanical Support Perspective, Abdul W. Kazi, Md, Mba, Harsh Doshi, Md

The Medicine Forum

Giant cell myocarditis is a rare and fatal disease which may result in heart failure, complete heart block, or ventricular arrhythmias. We describe a patient who previously had been discharged from our institution with a left ventricular assist device and immunosuppressive therapy for management of his giant cell myocarditis. His subsequent course was complicated by further deterioration of heart function which required multiple mechanical circulatory support devices. He successfully received a heart transplant which later had recurrence of giant cell myocarditis. This case highlights the challenges of left and right sided mechanical assist devices in managing giant cell myocarditis.

AG …

From The Chief Residents, Cristina Angelo, Md, Katherine Duffey, Md, Evan Nardone, Md, Michelle Perkons, Md

The Medicine Forum

The four of us have had the unique opportunity to work alongside you and watch you grow throughout the last three years. During an extremely turbulent time at Jefferson, in the city of Philadelphia, and the larger healthcare landscape you all have been the constant presence that has kept the Jefferson IM residency culture alive. Jefferson residents are: Compassionate, intelligent, dedicated, fun, and resilient. But most of all, Jefferson residents look out for each other and have each other’s backs. This is the culture that brings people to our program and the culture that makes residency training which would otherwise …