Internal Medicine Commons^™

Dietary Fat And Sugar Differentially Affect Β-Adrenergic Stimulation Of Cardiac Erk And Akt Pathways In C57bl/6 Male Mice Subjected To High-Calorie Feeding, Sadia Ashraf, Gizem Yilmaz, Xu Chen, Romain Harmancey

Faculty, Staff and Student Publications

BACKGROUND: High dietary fat and sugar promote cardiac hypertrophy independently from an increase in blood pressure. The respective contribution that each macronutrient exerts on cardiac growth signaling pathways remains unclear.

OBJECTIVE: The goal of this study was to investigate the mechanisms by which high amounts of dietary fat and sugar affect cardiac growth regulatory pathways.

METHODS: Male C57BL/6 mice (9 wk old; n = 20/group) were fed a standard rodent diet (STD; kcal% protein-fat-carbohydrate, 29-17-54), a high-fat diet (HFD; 20-60-20), a high-fat and high-sugar Western diet (WD; 20-45-35), a high-sugar diet with mixed carbohydrates (HCD; 20-10-70), or a high-sucrose diet …

Unique Case Of Anca-Negative Pauci-Immune Necrotizing Glomerulonephritis With Diffuse Alveolar Hemorrhage, Potentially Associated With Midostaurin, Jonathan D Pankow, Guillaume Richard-Carpentier, Naval G Daver, William F Glass, Jaya Kala

Faculty, Staff and Student Publications

We present a 61-year-old male with FLT3-mutated acute myeloid leukemia treated with midostaurin who developed acute kidney injury requiring hemodialysis and pulmonary renal syndrome. Antibodies to proteinase-3, myeloperoxidase, and glomerular basement membrane were negative. Renal biopsy confirmed acute pauci-immune focal necrotizing glomerulonephritis (GN) with fibrin crescents indicating rapidly progressing glomerulonephritis. He improved with pulse methylprednisolone, intravenous cyclophosphamide, and plasma exchange with resolution of hemoptysis. This case highlights the importance of prompt renal biopsy to guide early initiation of life-saving therapies. To our knowledge, this is the first reported case of ANCA-negative pauci-immune necrotizing GN likely secondary to midostaurin.

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.

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 …

Unpainfully Sweet, Khoi Nguyen, Alex Schafir

Providence St. Vincent Internal Medicine 2020

Introduction: Sweet's syndrome (ss), or acute febrile neutrophilic dermatosis, is characterized by sudden onset of fever, leukocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: The diagnosis of Sweet’s syndrome often has a temporal association with the discovery or relapse of cancer as reported in this case.

Case Report: A 64-year-old woman with recurrent breast cancer on targeted and hormonal therapy presented to the ED with acute onset of fever and diffuse non-tender body rash. Vitals suggested sepsis and she was treated with broad spectrum …

Addressing The Social Determinants Of Health In The Clinic Setting, Larissa Sharma, Man Tran

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: It is estimated that clinical care accounts for only 20% of health, while behaviors, physical environment, and social and economic factors determine the rest. The social determinants of health include the basic life needs of housing, food, transport, along with other factors that include employment, education, drug and alcohol use, dental and eye care, etc. Insecurity in these socioeconomic factors are expressed in chronic medical illness, mental health problems, substance use, all leading to high healthcare utilization. Healthcare costs and utilization decrease when when these needs are provided for. In a survey of 6,000 Providence patients, 50% expressed …

Lemierre’S Syndrome, Jennifer Nguyen, Tom Chau

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Lemierre’ssyndrome is a rare and potentially fatal complication of acute pharyngitis most commonly seen in healthy, young adults who present with neck pain and persistent, high-grade fever. It is caused by anaerobic gram-negative organisms, most often Fusobacteriumnecrophorum, spreading into the deep spaces of the neck. This leads to septic thrombophlebitis of the internal jugular vein (IJ) with septic emboli, most frequently to the lungs.

CASE REPORT: A healthy 18-year-old woman presented to the hospital with five days of fever, rigors, sore throat, and left neck pain. She appeared relatively non-toxic but was febrile to 105.6℉ and in septic shock. …

Pulmonary Nocardiosisin An Immunocompetenthost, Leah Grant, Laura Loertscher, Jennifer Marfori

Providence St. Vincent Internal Medicine 2020

Introduction: • Nocardia is known to cause severe pulmonary or disseminated infection in immunocompromised patients, but can cause infection in immunocompetent patients. Providers should consider Nocardiosis in immunocompetent patients with prolonged and unexplained respiratory failure. • The preferred therapy for pulmonary Nocardiosis is a sulfa antibiotic for 3-6 months. Toxicity from prolonged use of alternative agents presents a therapeutic challenge in those with sulfa allergy.

Case Report: • An 85 year-old woman with a history of paroxysmal atrial fibrillation and heart failure with preserved EF presented to her primary care provider with 1 week of cough and progressive dyspnea. Chest …

Catastrophic Antiphospholipid Syndrome, Gabriel Hocum, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Catastrophic Antiphospholipid Syndrome (CAPS) is a rare and extreme manifestation of Antiphospholipid Syndrome (APS) that features widespread thrombotic disease affecting multiple small vessels in a short time frame. CAPS affects only 0.8% of APS patients, but when it occurs it is has a mortality rate of approximately 50%.

CASE REPORT: A 50 year old female with SLE and APS presented with 1 month of cough and fatigue and 2 days of severe confusion after missing doses of rivaroxaban. In the ED she was intubated for airway protection and transferred to the ICU. Her evaluation revealed multi-organ failure with extensive …

Not Just Kids –A Case Of Adult Iga Vasculitis, Heidi Reich, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: IgA vasculitis, formerly known as HenlochSchonleinPurpura, is generally recognized as the most common form of systemic vasculitis in children, with 90% of cases occurring in the pediatric age group. However, the remaining 10% are noted in adult populations, and often has poorer long term outcomes if not identified and treated quickly. IgAVis commonly associated with streptococcal infections, although additional triggers such as drug ingestions, insect bites, and vaccinations have been described. Symptoms can include palpable purpura, acute abdominal pain, arthralgias, and hematuria. Recognizing the constellation of signs and symptoms is key for expediting appropriate therapy, which may reduce long …

Delirium: Delirious Elders, Implementing Reduction Interventions Using Mobility, Michael Silvas, Joe Miller, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: This quality improvement project involved hiring, training, and managing 3 Delirium Mobility Aids to implement a non-pharmacologic delirium prevention bundle package, including early mobility, on hospitalized patients age >65.

Background: Delirium affects 20-30% of older hospitalized patients [1]. Patients with delirium have double the mortality rate [3], which increases with delirium duration [4]. Delirium worsens long term cognitive functioning [9,10,11,12]. Hospital costs increase by $2,500 per patient, totaling $6,900,000,000 in Medicare expenditures [7]. A single delirium episode increases total yearly costs by ~$64,421 [2]. Research suggests the best treatment is non-pharmacologic multicomponent interventions [6], and those with most …

Accidental Botulism Poisoning: A Case Of Pickled Herring, Garrett Spencer, Greg Flick

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Botulism is a rare cause of neuromuscular weakness that presents a diagnostic challenge in the face of respiratory collapse. Pupil and bulbar paralysis aid prompt recognition and treatment, as clinical confirmation can be time intensive and limited by sample integrity. Early treatment can halt paralysis and prevent ICU and ventilator days.

CASE DESCRIPTION: A 74-year-old male with hypertension and DVT presented with acute weakness and respiratory failure after three days of cough and diarrhea. Upon ICU admission for mechanical ventilation, we discovered sluggish pupils, mild ptosis, and proximal muscle weakness. Symptoms then progressed to unresponsive pupils, complete ptosis, and …

Battling The Stigma: Hiv Screening In Resident Primary Care Clinic, Garrett Spencer, Laura Loertscher, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: HIV affects ~1.2 million in the US, with 25% unaware of their statusand annual incidence of 50,000. Early detection and treatment reduces risk of AIDS-related deaths and transmission. Both the CDC and the US Preventative Service Task Force recommend routine HIV screening. The Providence Medical Group at St Vincent (PMG-STV) resident clinic has no routine screening protocol. • 24% (757/3139) of all clinic patients have ever been screened. • Of active clinic patients seen quarterly, 5% are offered screening with only 3% completing screening. We implemented and measured a clinic-wide HIV screening protocol leveraging existing clinic workflows. We aimed …

Ceftriaxone-Induced Immune Hemolytic Anemia From Treatment Of Post-Treatment Lyme Disease Syndrome, Jillian Catral, Emily Hitchcock

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Drug-induced immune hemolytic anemia (DIIHA) is a rare though likely underreported entitythat is associated with significant morbidity and mortality. • Ceftriaxone is a commonly used antibiotics with a well-documented association with DIIHA. The mechanism is a drug-dependent antibody, immune-complex mediated reaction which can be severe, leading to organ failure, shock, and even death. • While the majority of cases are in children, a recent literature review had one-third of cases being adults, with up to 30-40% mortality in all ages. • This case describes an adult patient treated for the controversial diagnosis of post-treatment Lyme disease syndrome (PTLDS) …

Swimming Through Lake Placid: A Major Headache, Elizabeth Severson, Claudia Leonard

Providence St. Vincent Internal Medicine 2020

Introduction: Leptospirosis is caused by Leptospira species, a spirochete bacterium that affects animals and humans. The disease can range from mild flu-like illness to multi-organ failure. While likely underreported, the incidence according to the World Health Organization can range from 0.1 to 10 per 100,000 depending on climate Leptospirosis is commonly associated with occupational or recreational exposures

Case Report: A 43 year-old previously healthy man presented with two weeks of myalgias, fevers, neck pain and throbbing headache. The patient competed in an Iron Man event in upstate New York one month prior to presentation. Initial investigation demonstrated a …

Purpura Fulminans Due To Mssa Toxic Shock Syndrome, Leah Grant, Rachel Plotinsky

Providence St. Vincent Internal Medicine 2020

Introduction: Purpurafulminansis a rare and serious complication of anacute infectious process, characterized by large purpuricskin lesions, fever, hypotension, and DIC. The mostcommon infectious cause of purpurafulminansismeningococcal disease, though few case reports in theliterature describe Staph aureusas a causative organism.

Case Report: •A 53 year-old woman with a history of heart blocks/ppacemaker placement in 2002 presented to the ED withnausea, vomiting, fevers, chills, diffuse muscle pain and asyncopalepisode. •She was found to have multi-organ dysfunction on labs,including AKI and thrombocytopenia.On hospital day 2, shedeveloped acrocyanosis. She became febrile & hypotensive requiring transfer tothe ICU for vasopressor support. Blood cultures were obtained. …

Struck By Lightning Twice, Bao-Ngoc Nguyen, Emily Hitchcock

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: ANCA-associated vasculitides (AAV) refer to a group of disorders causing inflammation of small vessels which include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss). Here I present a case of MPA vasculitis in a patient with alpha-1-antitrypsin (AAT) deficiency, and describe a proposed causal link between these two rare disease processes.

CASE REPORT: • 43-year-old man with history of newly-diagnosed AAT deficiency liver disease. • Chief complaint of subacute shortness of breath associated with hemoptysis and fever for 5 months. • Symptoms had been progressively worsening despite multiple courses of antibiotics and inhalers. …

Beck’S Tetrad? Adding Pocus To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock, Cody Wiench, Benjamin Pedroja

Providence Portland Medical Center Internal Medicine 2020

Beck’s Tetrad?

Adding POCUS To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock

Cody Wiench, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Benjamin Pedroja, MD

Introduction: Obstructive shock due to tamponade is an important, but rare, cause for sudden cardiovascular collapse. Accurate treatment requires prompt (and correct) diagnosis. Bedside echocardiogram can provide rapid and accurate diagnosis, however the physical exam can provide important clues to consider tamponade. In patients with conditions that predispose them to pericardial disease, such as SLE, one must have a high index of suspicion for tamponade when …

A Rare Case Of Metastatic Insulinoma In A Patient With Huntington’S Disease, Olesya Petrenko, Brinton C. Clark

Providence Portland Medical Center Internal Medicine 2020

A Rare Case Of Metastatic Insulinoma

In A Patient With Huntington’s Disease

Olesya Petrenko, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Brinton Clark, MD, FACP

A 49-year-old female with past medical history of Huntington’s disease presents to the ED after being found unresponsive at her assisted-living facility. She was noted to be hypoglycemic with a glucose of 21 and responded to dextrose. For the past several months, patient had symptoms of dizziness, tremors. She has no history of diabetes, and only home medication is Zyprexa. Patient required D10 drip to maintain glucose levels. Given patient’s psychiatric history, …

Chronic Hepatitis B Reactivation: Deadly, But Preventable, Sarah Xie, Jesse Powell, Andrea Roast

Providence Portland Medical Center Internal Medicine 2020

Chronic Hepatitis B Reactivation:

Deadly, But Preventable

Sarah Xie, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Andrea Roast, MD, FACP; Jesse Powell, MD

A 51-year-old Vietnamese male with chronic hepatitis B presents with symptoms of acute hepatitis. 2 months prior, his PCP had discontinued Tenofovir, for which he had been taking for the past decade, based on an undetectable viral load and a negative HBeAg. 1 month later, his viral load soared to 796 million so Tenofovir was restarted. On admission a few days later, the patient had scleral icterus and jaundiced skin. He had severe transaminitis, …