Internal Medicine Commons^™

Acute Bilateral Pyelonephritis In The Setting Of Newly Diagnosed Diabetes Mellitus: A Case Report, Jessenia Ariana Contreras, Satwinder Singh, Ramesh Alwarappan

HCA Healthcare Journal of Medicine

Introduction

Acute pyelonephritis is a bacterial infection that starts in the bladder and ascends to the kidneys, causing inflammation of the renal parenchyma. Women are more likely to get infected compared to men, with diabetics being at higher risk. The pathophysiology of how diabetics are more prone to getting urinary tract infections/pyelonephritis has been studied, particularly the difference between bilateral pyelonephritis and unilateral pyelonephritis.

Case Presentation

This case presentation follows a 51-year-old Spanish-speaking woman with a past medical history of prediabetes, bilateral tubal ligation, and perimenopause. She presented to the hospital for abdominal and back pain, fevers, and weakness that …

Mpox-Induced Proctitis, Saif Ghias, Niyati Joshi, Dzenana Cabaravdic, Ramesh Nathan, Jasprit Takher

HCA Healthcare Journal of Medicine

Introduction

Mpox, formerly known as monkeypox, is a zoonotic virus in the genus Orthopoxvirus, which has a variable incubation period and an extensive array of symptoms. While those infected with Mpox have displayed generalized viral prodromal symptoms, atypical symptoms such as proctitis have also been seen. Proctitis associated with Mpox is a relatively infrequent initial presenting symptom with a reported incidence of 14-32.9% that has seen an uptick in prevalence since the 2022 global endemic.

Case Presentation

We present a confirmed case of Mpox in a 27-year-old male who presented with 3 days of intermittent anorectal bleeding and various forms …

Presentations Of Cutaneous Disease In Various Skin Pigmentations: Chronic Atopic Dermatitis, Cecilia Nguyen, Jordan Thompson, Daniel A. Nguyen, Christopher M. Wong, Christian J. Scheufele, Michael Carletti, Stephen E. Weis

HCA Healthcare Journal of Medicine

Atopic dermatitis is a chronic inflammatory skin disorder classically affecting flexural areas of the body. It is present in children and adults, including those with darker skin pigmentation. Chronic lesions are hyperpigmented plaques that are dry, cracked, and/or scaly often with lichenification. Differential diagnoses include psoriasis, seborrheic dermatitis, ichthyosis, and pityriasis rosea. This article will showcase clinical images with varying presentations of chronic atopic dermatitis in a range of age groups and skin colors according to the Fitzpatrick scale.

Percutaneous Endoscopic Gastrostomy: A Possible Trigger For Dieulafoy's Lesion, Ali Tariq Alvi, Elsa Tchouambou, Murali Shankar

HCA Healthcare Journal of Medicine

Introduction

Upper gastrointestinal (GI) bleeding is a medical condition commonly seen in clinical practice due to variable etiologies and a multitude of presentations. The patients can present with hematemesis, melena, or hematochezia in case of severe bleeding. The initial evaluation should involve assessing the hemodynamic status with adequate resuscitation followed by diagnostic tests to identify the source and potentially treat it. Dieulafoy's lesion, sometimes referred to as Dieulafoy's disease, is a rare cause of upper GI bleeding with no clear risk factors, which makes it a diagnostic conundrum. Here we describe an unusual case of Dieulafoy's lesion developing following percutaneous …

Characteristics And Hospital Outcomes Of 1403 Patients Hospitalized At Community Hospitals With Ankylosing Spondylitis, Se Won Lee, Carol Elsakr, Jonathan Holt, Napatkamon Ayutyanont

HCA Healthcare Journal of Medicine

Background

In this study, we aimed to assess the hospital course, outcomes after hospitalization, and predictors of outcomes in patients with ankylosing spondylitis (AS).

Methods

We included 1403 patients with AS between 2016 and 2021 who were identified using International Classification of Disease (ICD) codes from a large for-profit healthcare system database. Demographics and clinical characteristics were compared between those who had a favorable outcome, defined as being discharged to home without readmission within 3 months of discharge, versus those who had an unfavorable outcome. A stepwise logistic regression was used to identify demographic and clinical characteristics associated with home …

On The Discontinuation Of Enteral Feeding In Head And Neck Cancer: A Case Report, Kyle Fisk, Ana Sanchez

HCA Healthcare Journal of Medicine

Introduction

The goal of palliative care is to preserve the quality of life or patient “comfort” in patients with serious diseases. Palliative care providers serve a wide range of patients: from those who seek curative treatment to those who are actively dying. Given this range, palliative care must mirror the dynamic goals of the patient at different stages of life and treatment. Throughout these stages, a goal of the palliative care provider would be to avoid hastening death; however, this often leads to clinical decisions that directly pit the patient’s comfort against the patient’s life span. This is most salient …

A Rare Case Of Candida Glabrata Cervical Spondylodiscitis, Angelina Hong, Lily Hyungjung Lim, Ali Tariq Alvi, Pallavi Aneja

HCA Healthcare Journal of Medicine

Introduction

Invasive candidiasis can lead to numerous life-threatening sequelae. Candida glabrata is the second-most common causative species of invasive candidiasis. This species possesses a high risk for persistent infection and candidemia. An uncommon complication of invasive candidiasis is spondylodiscitis and can rarely affect the cervical spine.

Case Presentation

The patient is a female in her late 50s with a complex medical history inclusive of chronic obstructive pulmonary disease, chronic pain, multiple abdominal surgeries, prolonged intensive care unit admission, and administration of total parenteral nutrition and broad-spectrum antibiotics who presented with complaints of worsening neck pain. She was last hospitalized 3 …

Ciprofloxacin-Induced Peripheral Neuropathy: A Case Report, Alexander Refaeian, Eric L. Vest, Michael Schmidt, Jorge D. Guerra, Mohd N. Refaei, Michael Refaeian, Ryan A. Floresca, Manouchehr Refaeian

HCA Healthcare Journal of Medicine

Introduction

Fluoroquinolones, a class of antibiotics, are commonly employed in the treatment of a wide array of bacterial infections. Recognized for their effectiveness against a broad spectrum of pathogens, fluoroquinolones have played a pivotal role in managing conditions like urinary tract infections and respiratory diseases. Nevertheless, their usage is not without contention due to their association with a variety of adverse effects, including tendon rupture and the less frequently reported issue of peripheral neuropathy.

Case Presentation

We present the case of a 42-year-old male who developed peripheral neuropathy several days after completing a 10-day course of ciprofloxacin for gastroenteritis. The …

Who Left The Hospital Against Medical Advice During The Early Covid-19 Pandemic?, Bryan Werner, Se Won Lee

HCA Healthcare Journal of Medicine

Background

Patients leaving against medical advice (AMA) presents a challenge to hospitals as they try to manage costs and improve patient outcomes in an ever-increasing competitive market. Investigating AMA discharges that occurred during the early COVID-19 pandemic presents a unique opportunity to better understand this phenomenon and be better prepared for the future.

Methods

This retrospective analysis of 34 379 patients from a nationwide private healthcare system across 20 states analyzed patients during the early stages of the pandemic who chose to leave against medical advice (AMA) after being admitted with COVID-19 infection and identified several patient characteristics associated with …

An Unusual Presentation Of Infective Endocarditis, Ethan J. Peterson, Jordan Jackson, Syed M. Zaidi, Jorge Perez

HCA Healthcare Journal of Medicine

Introduction

Leukocytoclastic vasculitis is the inflammation of small blood vessels due to leukocyte migration that comprises a wide range of differentials. It can be caused by autoimmune disorders, infections, neoplasms, or certain medications and warrants prompt recognition and therapy for optimal patient outcomes.

Case Presentation

Here we present a case of a 37-year-old male who presented with a painful, petechial rash on his torso and extremities. Skin biopsy revealed leukocytoclastic vasculitis, thereby prompting a comprehensive investigation into the underlying etiology leading to the diagnosis of Pseudomonas aeruginosa infective endocarditis.

Conclusion

Pseudomonas aeruginosa is a rare cause of infective endocarditis with …

Adenocarcinoma Of The Transverse Colon Presenting As Anterior Abdominal Wall Abscess, Jenn Klein, Nima Avin, Sunil Gandhi

HCA Healthcare Journal of Medicine

Introduction

Locally invasive colon carcinoma comprises a small fraction of the incidence of colon carcinoma. Complications, such as perforation and obstruction, can occur in less than 0.5% of cases and often present differently based on location.

Case Presentation

We present a case of an 85-year-old woman who presented with an acute abdominal wall abscess which was caused by perforation of transverse colon carcinoma.

Conclusion

En-bloc resection increases 5-year survival, and adjuvant chemotherapy reduces the risk of recurrence in patients with stage II resectable colon carcinoma.

Accidental Extravasation Of Mitomycin C Into The Subcutaneous Tissue, Johnathon Chung, Brooke Walterscheid, Jose Lopez-Vera, Hytham Rashid, Mike K. Liang

HCA Healthcare Journal of Medicine

Introduction

Mitomycin C (MMC) is a common chemotherapeutic agent used to treat a variety of solid tumors. Cutaneous adverse events are rare, but MMC is a known vesicant reported to cause tissue necrosis and sloughing, erythema, and ulceration if incorrectly infused into the subcutaneous tissue. Definitive treatment of extravasation injuries due to MMC depends on the severity of the cutaneous manifestation, which includes stopping the infusion, removing the catheter, or possible debridement.

Case Presentation

We present the case of a 70-year-old female with extensive soft-tissue injury secondary to extravasation of MMC that required hospital admission and surgical intervention to remove …

Death Due To Drug Reaction With Eosinophilia And Systemic Symptoms (Dress) Syndrome: A Case Report, Samantha P. Sternad, Jane Pangburn, Chad Johnston, David Rowe

HCA Healthcare Journal of Medicine

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening, multi-organ adverse drug reaction with an incidence of 1 in 1000 to 1 in 10 000 highrisk drug exposures.

Case Presentation

An elderly female presented to the hospital with progressive weakness and a diffuse erythematous macular rash covering most of her body that started 3 days prior. Over the next 3 days, the patient quickly deteriorated, developing disorientation with acute onset left-sided weakness, leukocytosis, thrombocytopenia, eosinophilia, liver and kidney failure, and hypoxia. Clinical and histological changes supported the diagnosis of DRESS syndrome caused by intravenous (IV) ampicillin …

Suspected Anaphylactic Reaction Following Second Dose Of The Pfizer-Biontech (Bnt162b2) Coronavirus Vaccine In A Geriatric Female, Angelina Hong, Giezy Sardinas

HCA Healthcare Journal of Medicine

Anaphylaxis is a rare but serious adverse reaction that can occur following mRNA-based vaccination against coronavirus (COVID-19). This is a case of a geriatric patient presenting with hypotension and an urticarial rash with bullous lesions following a syncopal episode with incontinence. She received the second dose of the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine three days prior, and first developed the skin abnormalities the morning after receiving the vaccine. She had no past history of anaphylaxis or allergies to vaccinations.

Her presentation met the diagnostic criteria for anaphylaxis, according to the World Allergy Organization: she had acute onset illness involving the skin …

Covid-19 And Lung Cavitation: A Clue To Pathogenesis?, Tanner W. Norris, Blake M. Snyder, Patryk Purta, Ryan P. Spilman, Vanessa J. Craig

HCA Healthcare Journal of Medicine

Lung cavitation as a complication of COVID-19 is rare. A 56-year-old male presented with lung cavitation, small volume hemoptysis, and violaceous discoloration of the right great toe, 5 weeks after diagnosis with COVID-19 pneumonia. The digital changes were consistent with previously described microvascular changes called "COVID toe." CT angiography of the chest was negative for pulmonary embolism but showed a 2.5 x 3.1 x 2.2 cm cavitation within the right lung. Extensive evaluation for commonly implicated infectious and autoimmune causes was negative. We concluded that the cavitary lung lesions were likely a complication of COVID-19 pneumonia and may implicate microangiopathy …

Doctors And Disability: Improving Inclusion In Medical Education, Mary Alice Keller

HCA Healthcare Journal of Medicine

Disability is extremely common in the United States with 26% of adults identifying as having some type of disability. Oftentimes, people with disabilities need to access health care services frequently in order to receive adequate care and support. However, despite this need, medical students receive limited, if any, education about people with disabilities and how to appropriately provide medical care and interact with them. This lack of education exacerbates health care disparities experienced by people with disabilities. This article highlights these disparities as well as the history of disability and health care. Current advancements in medical education regarding people with …

Presentations Of Cutaneous Disease In Various Skin Pigmentations: Inverse Psoriasis, Daniel A. Nguyen, Henry Lim, Christopher M. Wong, Christian J. Scheufele, Ashleigh E. Hermann, Jean Elizze M. Charles, Michael Carletti, Stephen E. Weis

HCA Healthcare Journal of Medicine

Inverse psoriasis is a clinical variant of psoriasis involving flexural or intertriginous areas of the body. Inverse psoriasis may be present in 3 to 36% of psoriasis patients. Lesions are clinically characterized as smooth, well-demarcated, erythematous plaques (raised, >1 cm) without the typical silvery scales of classic psoriasis. Differential diagnosis includes tinea infection, candidiasis, seborrheic dermatitis, or bacterial streptococcal infection. The clinical images in this review focus on identifying inverse psoriasis along the full spectrum of skin tones.

Is There A Bias Toward Unvaccinated Covid-19 Patients?, Abbas B. Jama, Anwar Khedr, Hisham Mushtaq, Nitesh K. Jain, Thoyaja Koritala, Syed Anjum Khan

HCA Healthcare Journal of Medicine

With more than 22% of the United States still not vaccinated for COVID-19, we are trying to shed some light on whether there is any bias when treating unvaccinated COVID-19 patients. We highlight several reports where some individuals or organizations displayed possible bias, whether implicit or explicit. We examine the legal and ethical implications of these biases and offer a general overview of how to tackle them.

An Assessment Of The Diagnostic Value In Syncope Workup: A Retrospective Study, Ashan T. Hatharasinghe, Kayvon Etebar, Ryan Wolsky, Hossein Akhondi, Napatkamon Ayutyanont

HCA Healthcare Journal of Medicine

Background

Patients with syncope often undergo costly testing, despite current guidelines and data supporting the contrary.

Objective

To determine the diagnostic value through positivity rate of electrocardiogram (EKG), computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, transthoracic echocardiogram, nuclear and pharmacologic cardiac stress test, tilt table test and carotid ultrasound in patients diagnosed with syncope.

Methods

This is a retrospective study of 10,036 adults presenting to the emergency department or hospitalized with a primary diagnosis of syncope at 8 acute care facilities in the southwest United States from January 1, 2019, to December 31, 2019. …

A Rare Presentation Of An Acute Type A Aortic Dissection Obscured Due To The Simultaneous Presence Of Acute Pancreatitis, Amrin M. Kharawala, Nirav Brahmbhatt, Huzefa Bhopalwala, Nakeya Dewaswala, Adnan Bhopalwala, Waqas Ghumman, Robert Dean Chait

HCA Healthcare Journal of Medicine

Introduction

Acute pancreatitis (AP) and acute aortic dissection (AAD) are medical emergencies that must be promptly recognized to avoid the development of life-threatening complications. Both of these diseases can present with chest or epigastric pain which can radiate to the back, thus, early suspicion based on clinical presentation and risk factors is essential. We present the case of a 56-year-old patient initially diagnosed with AP who was later found to have an AAD.

Clinical Findings

A 56-year-old man with a history of alcohol abuse presented with 1 day of diffuse abdominal pain, nausea and vomiting. His lipase was 3,909 U/L …

Utilization Of Patient-Controlled Analgesia Reduces Length Of Stay Of Sickle Cell Crisis Hospitalizations, Brett M. Prestia, Talha Ramzan, Catherine Waldron, Ameer Malik, Robert M. Pallay, Candace R. Murbach, Mike Flynn, Eric Shaw Phd, Abdullah Kutlar, Daniel Lowe

HCA Healthcare Journal of Medicine

Background

Sickle cell crisis hospitalizations are emotionally and financially burdensome to patients and healthcare systems, and processes to decrease the frequency or length of stay of these crises should be examined.

Methods

This is a multicenter retrospective hospital record review of sickle cell crisis hospitalizations as defined by ICD-10 codes (D57.1-4), from January 2016 through December 2019, examining inpatient medication administration records and length of stay among admitted adults aged 18–65 years. Patient controlled analgesia orders using morphine, hydromorphone, fentanyl and/or merperidine at any point of an admission (n=188) were compared to admissions without any patient-controlled analgesia orders (n=2,159). The …

A Retrospective Study Of Admission Nt-Probnp Levels As A Predictor Of Readmission Rate, Length Of Stay And Mortality, Kunjan Udani, Dveet Patel, Andrew Mangano

HCA Healthcare Journal of Medicine

Introduction

Serum levels of pro-B-type natriuretic peptide (BNP) and N-terminal (NT) proBNP are measured at admission to assess the likelihood of acutely decompensated heart failure (ADHF). Elevated NT-proBNP levels on initial presentation are a reliable marker of ADHF. However, the prognostic significance of NT-proBNP levels measured on admission remains unknown. With a better understanding of how admitting NT-proBNP levels impacts readmission rates, length of stay and mortality, future prospective studies with specific interventions can be developed to reduce all-cause readmissions, shorten length of stay and reduce mortality.

Methods

In this retrospective study, we evaluated heart failure with reduced ejection fraction …

May-Thurner Compressive Syndrome Unmasked By Rapid Weight Loss, Hesham A. Hassan, Jan-Paul Sambataro, James C. Abraham

HCA Healthcare Journal of Medicine

May-Thurner Syndrome (MTS) is an anatomical syndrome characterized by a predisposition to clot formation when there is compression of the left iliac vein by the right iliac artery. In this case, we discuss an atypical presentation of MTS in a young male after rapid weight loss. The patient was admitted for an unprovoked massive proximal deep vein thrombosis (DVT) after a two-hundred-pound weight loss during the preceding six-month period. Treatment involved mechanical thrombectomy by interventional radiology, initiation of apixaban and recommended follow up with vascular surgery for angioplasty instead of immediate stent placement.

Guillain-Barré Syndrome In A Patient With Sickle Cell Anemia, Kunjan Udani, Pooja Patel, Dveet Patel, Hajra Awwab, Nino Balanchivadze

HCA Healthcare Journal of Medicine

A 24-year-old African American male with a history of sickle cell anemia (Hb S/S) presented to an outside hospital with acute colitis, acute renal failure and sickle cell crisis and was treated with supportive measures. On day 3 of hospitalization, he developed bilateral ascending paralysis with sacral numbness. Magnetic resonance imaging (MRI) demonstrated epidural lipomatosis, which was attributed as the cause of his paralysis. He was transferred to our facility for neurosurgery evaluation. Based on the physical examination, Guillain-Barré Syndrome (GBS) was suspected. This conclusion lead to a lumbar puncture with cerebrospinal fluid (CSF) analysis that confirmed the diagnosis. He …

Methamphetamine Associated Cardiomyopathy In Pregnancy: The Distinctions And The Implications, Ashan Hatharasinghe, Hossein Akhondi

HCA Healthcare Journal of Medicine

Introduction

Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process.

Clinical Findings and Outcomes

This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean …

Acute Ischemic Stroke As The Presenting Feature Of Covid-19 In The Young And Pregnant, Nermila A. Ballmick, Jiri F. Kubac, Hossein Akhondi

HCA Healthcare Journal of Medicine

Introduction: Coronavirus disease (COVID-19) is an emerging and rapidly evolving public health issue that has become globally widespread and an overwhelming pandemic. Clinical manifestations of the disease include asymptomatic carrier states, acute respiratory distress syndrome, and even multiorgan dysfunction. Here, we present a unique and rare case of an acute ischemic stroke (AIS) in an asymptomatic pregnant woman with no predisposing medical illnesses.

Discussion: An 18-year-old G2P1 African American woman at 7 weeks gestational age with no significant medical or family history presenting to the Emergency Department during the initial phases of the pandemic with complaints of new onset left …

A Case Of Plesiomonas Bacteremia Without Reported Freshwater Exposure, Abigail E. Mcdonald

HCA Healthcare Journal of Medicine

Introduction: Plesiomonas shigelloides is a member of the Enterobacteriaceae family generally found in freshwater. There is little substantive data about the prevalence or distribution of Plesiomonas within the United States. Plesiomonas are most commonly associated with mild, self-limited watery diarrhea among healthy individuals followed by infective colitis. Bacteremia is the most common extraintestinal manifestation of Plesiomonas. Few cases of Plesiomonas bacteremia can be found in the literature.

Clinical Findings: An elderly female with multiple comorbidities was admitted to our hospital for evaluation of generalized cramping abdominal pain of several days duration. She denied any freshwater or saltwater exposure. The …

Flash Pulmonary Edema: A Case And Review Of Left Ventricular Non-Compaction Cardiomyopathy, Paula J. Watts, Oliver S. Garbo, Wendy Barrett, Michael Kopstein, Ryan Maybrook, Dmitriy Scherbak

HCA Healthcare Journal of Medicine

Left ventricular non-compaction cardiomyopathy is an uncommon type of cardiomyopathy caused by malformation of the myocardium during embryogenesis. This results in trabeculations within the ventricular wall that can affect the left and, less commonly, right ventricles. Presentation ranges from clinically asymptomatic to life-threatening arrhythmias. It is a rare and relatively unknown form of cardiomyopathy, though thought to be underdiagnosed. Prevalence is increasing due to improvements in imaging and awareness. Management is similar to that of other cardiomyopathies including angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, beta-blockers, diuretics, automatic implantable cardioverter defibrillator placement and cardiac transplantation. We present a case of a …

Low Dose Clenbuterol Toxicity: Case Report And Review Of Literature, Kenneth Lan, Adarsh Saheba, Paul Mathew

HCA Healthcare Journal of Medicine

Clenbuterol is a long-acting β-agonist used in oral and inhaled form for asthma treatment outside the U.S. and in veterinary medicine within the U.S. It is also used off-label for anabolic effects worldwide. Toxicity with clenbuterol is increasingly seen in U.S. hospitals, primarily in younger individuals using the drug for competitive athletics or bodybuilding. We present a case of a young patient who presented after an intentional overdose and discuss the relevant literature. Presentations do not correlate with the dosage ingested. Signs and symptoms can range from simple nausea to myocardial ischemia, rhabdomyolysis and cardiogenic shock. Treatment of overdose is …

Acute Disseminated Encephalomyelitis, Ashan Hatharasinghe, Hossein Akhondi, Don Pepito

HCA Healthcare Journal of Medicine

Introduction: Acute Disseminated Encephalomyelitis (ADEM) is a rare autoimmune demyelinating disorder of the central nervous system. Clinical manifestations include encephalopathy, motor deficits, ataxia, and meningeal signs. In most cases, ADEM is preceded by either vaccination or viral illness. Here, we present a case with neither of the two predisposing elements.

Discussion: A 28-year-old Hispanic female presenting with substance use and suicidal ideation was placed on an involuntary psychiatric hold, started on olanzapine and scheduled for a psychiatric facility transfer. The following day, she was noted to have neurological deficits when ambulating. Computed tomography of the brain showed a right frontal …