Internal Medicine Commons^™

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. …

A Case Of Spontaneous Intercostal Artery Hemorrhage, Chang Min Lee, Veronica Schims, Craig Riley

Providence Portland Medical Center Internal Medicine 2020

A Case Of Spontaneous Intercostal Artery Hemorrhage

Chang Lee, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Veronica Schims, MD; Craig Riley, MD

Introduction: Spontaneous intercostal arterial bleeding is rare and usually related to trauma. We describe a patient with a history of cirrhosis and coagulopathy admitted with sepsis who spontaneously developed an expanding extrathoracic hematoma and subsequent hypovolemic shock requiring arterial embolization.

Case Presentation: 50-year-old male with a past medical history of alcoholic liver disease, esophageal varices, chronic coagulopathy, type 2 diabetes and hypertension on lisinopril was admitted to hospital with decreased urine output, dizziness, …

A Case Of Atypical Pml, Alexander Dreisin, Justin Jin

Providence Portland Medical Center Internal Medicine 2020

No abstract provided.

Be Careful What You Screen For: An Incidental Finding Of Tracheobronchial Amyloidosis, Emma White, Tricia James, Vikram Sahni, Jesse Powell

Providence Portland Medical Center Internal Medicine 2020

Introduction: The 2011 National Lung Screening Trial (NLST) demonstrated a reduction in morbidity and mortality with LDCT compared to CXR. In 2013 the USPSTF began recommending CT scan for lung cancer screening in appropriate patients but, the 2015 National Health Interview Survey (NHIS) demonstrated that less than 5% of eligible patients received screening. The NLST also demonstrated a high rate of false positives, incidental findings, and the need for further invasive testing. When deciding to screen, patients and providers are tasked with reconciling these risks and benefits. In this case, we explore one patient’s incidental findings, and the work-up …

Mixed Signals: A Case Of Hypothyroid-Induced Ogilvie’S, Brieanna Brown, Paul Wichienkeur

Providence Portland Medical Center Internal Medicine 2020

Mixed Signals:

A Case Of Hypothyroid-Induced Ogilvie’s

Brieanna Brown, MD

Providence Portland Medical Center – Portland, OR

Additional Author: Paul Wichienkeur, MD

Ogilve's syndrome, or acute colonic pseudo-obstruction (ACPO), is characterized by acute dilation of the colon, in the absence of a mechanical lesion, which obstructs the flow of intestinal contents. Pseudo-obstruction typically occurs in the critically ill, though the underlying pathophysiology is poorly understood and the etiology is often multifactorial. We present a case of a 51-year-old morbidly obese woman presenting with symptoms of severe hypothyroidism found to have massive acute colonic pseudo-obstruction.

Case presentation:

A 51-year-old African-American …

Hiv-Associated Burkitt Lymphoma: More Than A Starry Sky Appearance, Rahwa Ghebremichael, Amy Dechet

Providence Portland Medical Center Internal Medicine 2020

Introduction: •People with HIV infection are at least 50 times more likely to get lymphoma as compared to the general population. •25-40% of these lymphomas will be Burkitt Lymphoma (BL) – an aggressive B cell malignancy with a high proliferative rate and potentially fatal within months if not diagnosed and treated in a timely manner. •This translates to a 10-20% individual life-time risk of BL for an HIV infected person. •The incidence of BL declined after the introduction of highly active antiretroviral therapy (HAART), but to a lesser extent than other HIV-associated malignancies. •Epidemiologic studies suggest the incidence of BL …

Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia, Kelley Newton, Janan Markee

Providence Portland Medical Center Internal Medicine 2020

Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia

Kelley Newton, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Janan Markee, MD

Patients with chronic lymphocytic leukemia have a 5-10% risk of developing autoimmune complications, the most common of which is autoimmune hemolytic anemia. Here we present a case of AIHA in a patient with suspected CLL that underscores several of the diagnostic and treatment challenges unique to this process. A 79-year old man with a history of hypertension, atrial fibrillation, type 2 diabetes and hypothyroidism was undergoing workup for suspected CLL due to a persistent leukocytosis. He then presented …

Soft Rock – When Blasting It Doesn’T Work, Mark Schneider, Jesse Powell

Providence Portland Medical Center Internal Medicine 2020

Soft Rock – When Blasting It Doesn’t Work

Mark Schneider, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Jesse Powell, MD

Case-History of Present Illness: 68-year-old female presents with several days of malodorous urine and fevers. Brought to the ED by her daughter who diagnosed urinary tract infection (UTI) due to the distinct urine odor. No hematuria, dysuria, retention, or incontinence.

Past Medical History: Recent hospitalization for UTI with culture that grew P.mirabilis, completed course of cefdinir, with follow-up culture ordered by PCP that grew extended-spectrum beta lactamase (ESBL) E.coli.

Physical Exam and Vital Signs: Vitals: 115/48, 101, …

The Dangers Of Gardening – Nocardia Infection In An Immunocompromised Patient, Gerald Hutfles, Justin Jin

Providence Portland Medical Center Internal Medicine 2020

The Dangers Of Gardening –

Nocardia Infection In An Immunocompromised Patient

Gerald Hutfles, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Justin Jin, MD

Introduction: Nocardia is a gram-positive, partially-acid fast, aerobic, branching bacillus that can be found in soil and water. It is typically an opportunistic pathogen, with most infections occurring in the immunocompromised. Disease can be localized or disseminated, preferring pulmonary, nervous, and cutaneous tissues. Optimal antimicrobial therapy depends on speciation of the isolate, as Nocardia may exhibit variable antimicrobial susceptibility. A high clinical suspicion and appropriate empiric antimicrobial therapy is necessary. This clinical case …

A Perplexing Case Of Episodic Abdominal Pain And The Role Of Mast Cells Gastroenteritis, Hayden Smith, Mari Kai

Providence Portland Medical Center Internal Medicine 2020

Here we present a case of chronic intractable vomiting and diarrhea of unknown cause, and introduce the relatively new entity of mast cell gastroenteritis.

Our patient is a 38-year old female with PMH of seronegative rheumatoid arthritis, mixed connective tissue disorder, and several recent hospitalizations over the past 4 months at outside hospitals for suspected colitis with associated vomiting and diarrhea. Current symptoms include 4 days of nausea with intractable vomiting, and 2 days of rectal fullness with mucoid rectal discharge. Previous workup at outside hospitals included multiple abdominal CT scans, flexible sigmoidoscopy, colonoscopy, and exploratory laparotomy. Prior to admission …

When Less-Virulent Becomes Virulent!! An Atypical Presentation Of Streptococcus Viridians., Samreen Khan, Stavan Patel, Mary Anne Nidiry

Providence Portland Medical Center Internal Medicine 2020

When Less Virulent Becomes Virulent!!

An Atypical Presentation Of Streptococcus Viridians

Samreen Kahn, MBBS

Providence Portland Medical Center – Portland, OR

Additional Authors: Stavan Patel MS, MD

Introduction: There are several cardiac and non-cardiac causes and risk factors for the development of infective endocarditis (IE) in young healthy adults. Some risk factors include prior IE, history of valvular or congenital heart disease, IV drug use, indwelling intravenous lines, immunosuppression, or a recent dental or surgical procedure. Most two common sites of IE are mitral and aortic valve. We present a case of a 45-year-old man with no-known risk factors, …

Wrap It Up – Sexually Transmitted Primary Cytologmegalovirus Proctitis In Immunocompetent Host: A Case Report, Vanessa Nwaokocha, Brinton Clark, Ronald Dworkin

Providence Portland Medical Center Internal Medicine 2020

Background: In persons who presents with fever, rectal pain and bleeding, CMV proctitis should be considered if other workup is negative, especially if recent unprotected anal receptive intercourse.

Case Presentation: A 26-year-old bisexual man presented with chief complaints of fever, malaise, rectal pain, and rectal bleeding after anal insertion of foreign body. He initially denied any unprotected sexual intercourse. CBC, CMP, stool pathogen, rectal gonorrhea, and rectal chlamydia were unremarkable. He returned after 1 week with the similar complaints, however admitted to unprotected anal receptive intercourse a month prior. His vitals were notable for temperature of 102 with …

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity, Christopher Bender, Amy Dechet

Providence Portland Medical Center Internal Medicine 2020

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity

Christopher Bender, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Amy Dechet, MD

Introduction: Autonomic neuropathy is known to occur as a side effect of some chemotherapy drugs, including cisplatin. This reports presents a patient with new onset of autonomic instability and orthostatic hypotension after receiving multiple rounds of cisplatin and gemcitabine chemotherapy.

Case Presentation: An 81-year-old man with history of stage III lung cancer presented after a fall at home that occurred while getting out of bed in the middle of the night …

Empiric Treatment For Suspected Malaria In The United States: A Case Report., Jonathan C. Li, Emma Lundsmith

Division of Internal Medicine Faculty Papers & Presentations

Malaria in the United States is rare and most commonly presents among returning travelers from endemic areas. Diagnosis is classically dependent on a positive blood smear or polymerase chain reaction (PCR) test. The objective of this case report is to highlight a case of suspected malaria in a high-risk individual with negative diagnostic testing where a trial of empiric treatment was initiated based on clinical presentation after a thorough discussion of risks and benefits. However, empiric treatment based on a single case is limiting. We present a case of a 56-year-old man with extensive travel history throughout Asia, who presented …

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 …

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, …

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, …