Internal Medicine Commons^™

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

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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 …

A Clinical Assessment: Counseling Families On Timing Of Colorectal Cancer Screening, Bertilia Tavarez, Md, Hamzah Shariff, Md, Breanne Mcdermott, Bs, Sanjna Shelukar, Md, Limi Jamma, Md, Sonali Shah, Md, Akash Patel, Do, Christopher Henry, Md, Aaron Martin, Md

The Medicine Forum

Colorectal cancer (CRC) remains the second most common cause of cancer mortality in the United States. Current recommendations advise initiating colonoscopy at age 40, or 10 years earlier than the youngest affected first-degree relative (FDR), in individuals with a family history of CRC or advanced polyps (AP). Despite these guidelines, their translation into routine clinical counseling is not well defined. This study examines how often patients with CRC or AP receive guidance about early screening for FDRs.

A retrospective review was performed using electronic health records from an urban academic center. Patients diagnosed with CRC or AP between January 2019 …

Commentary On The Withdrawal-Af Trial And Its Applicability In Select Patient Populations, David Zhang, Md

The Medicine Forum

Segan et al. report that 90% of patients with atrial fibrillation- mediated cardiomyopathy (AFCM) maintained left ventricular ejection fraction (LVEF) ≥50% af ter withdrawing heart failure therapy following successful rhythm control.¹ While these results challenge the current practice of indefinite guideline-directed medical therapy (GDMT) in patients with improved ejection fraction, two important questions remain before these findings can be applied more broadly: which patients are appropriate candidates for withdrawal, and how should they be monitored?

The trial excluded patients with coronary disease, structural heart disease, and AF duration exceeding one year. This approach reveals a fundamental challenge, distinguishing pure …

Sudden Syncope Due To Intra Hisian Block With Severely Prolonged His–Ventricular Interval Diagnosed On Electrophysiology Study, Sheraz Qamar, Md, Meiqi Luo, Md

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Syncope is a common cause of emergency department evaluation in older adults, when sudden loss of consciousness without prodromal symptoms raises concern for cardiac etiology. We present this case of an 80 year old woman with a prior history of vasovagal syncope who presented after a collapse. Initial evaluation, including electrocardiogram, telemetry, echocardiogram, and ambulatory monitoring, was unrevealing. Given the high risk clinical features such as lack of prodromal symptoms and sudden collapse, an inpatient electrophysiology (EP) study was pursued and demonstrated severe intra Hisian conduction disease with split His bundle electrograms and a markedly prolonged His–ventricular interval. A permanent …

A Strain On The Heart: The Hidden Threat Of Ventricular Tachycardia, Sheraz Qamar, Md, Meiqi Luo, Md, Naila Ijaz, Md, Behzad Pavri, Md, Facc, Praveen Mehrotra, Md, Facc

The Medicine Forum

Mitral valve prolapse (MVP) is increasingly recognized to have an arrhythmic phenotype associated with ventricular arrhythmias and sudden cardiac death independent of mitral regurgitation severity. Mitral annular disjunction (MAD) is a key structural abnormality implicated in abnormal myocardial mechanics and myocardial fibrosis. We describe a patient with MVP and MAD who developed recurrent non-sustained ventricular tachycardia in association with markedly abnormal basal lateral wall longitudinal strain and progressive myocardial fibrosis on cardiac magnetic resonance imaging. Surgical mitral valve repair performed for MAD resulted in resolution of annular disjunction, improvement in regional myocardial strain, and elimination of ventricular arrhythmias. This case …

Lvad Patient With Delayed Family Involvement Due To Incarceration, J. Marco Cipriaso, Md, Kathleen Mechler, Md

The Medicine Forum

Left ventricular assist device (LVAD) placement requires an extensive support system for success. Patients who are incarcerated face unique challenges in achieving this due to prison rules. We describe a case in which an LVAD patient suffered a massive intracranial hemorrhage, leaving him unable to make his own decisions. Medical teams did not involve his family in admissions for his slow chronic decline, but family were asked to make decisions for him at this acute change causing them significant distress. We advocate that families of incarcerated patients be more routinely involved in provider communications and education related to their chronic …

Isolated Left Ventricle Apical Non-Compaction- A Diagnostic Conundrum, Trisha Sindhu, Md, Ranjita Sengupta, Md

The Medicine Forum

Left ventricular non-compaction (LVNC) cardiomyopathy is a rare myocardial disorder characterized by abnormal morphogenesis of the left ventricle (LV). It is typically associated with additional cardiac abnormalities and is most often diagnosed in childhood.¹ We present a unique case of isolated LVNC in a 42-year-old, physically active African American police officer. This case highlights an uncommon presentation of LVNC and underscores the variable specificity of current diagnostic criteria across diverse patient populations.³

A Dose Of Trouble: A Case Of Furosemide Exacerbating Amiodarone-Induced Hypothyroidism, Muneeba Ali, Md, Enad Haddad, Md, Warda Naqvi, Md, Ayesha Afzal, Md, Eddy Mizrahi, Md

The Medicine Forum

Heart failure with reduced ejection fraction is a clinical condition that often requires the concurrent use of multiple medications. Unfortunately, cross reactivity between multiple drugs occurs frequently. Today, we present the case of a 79-year-old male with heart failure and atrial fibrillation on long term amiodarone therapy. His furosemide dose was increased from 40 milligrams (mg) to 80 mg after he developed bilateral lower extremity swelling. The patient eventually developed generalized joint pains, weakness, difficulty maintaining balance, and frequent falls. He reported to the Emergency Department (ED), where he was noted to be suffering from severe acute kidney injury (AKI), …

Ascending Aortic Thrombus With Systemic Embolization: Implications For Risk Stratification And Management, Warda Naqvi, Md, Moses Morgan, Md, Muneeba Ali, Md, Enad Haddad, Md, Zaineb Alhassani, Md

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Ascending aortic thrombus is an uncommon clinical finding, particularly in the absence of significant underlying aortic disease, yet it poses a substantial risk for systemic embolization. We describe a 53-year-old woman with a history of cocaine use who presented with acute neurologic deficits and was found to have a left middle cerebral artery occlusion requiring mechanical thrombectomy. Cross-sectional imaging incidentally identified a 1.8 cm thrombus within the ascending aorta. Anticoagulation with intravenous heparin was initiated, however, her clinical course was complicated by recurrent embolic phenomena, including renal infarction and bowel perforation consistent with mesenteric ischemia. Ongoing deterioration with multiorgan failure …