2022: Vol 9 No 3

2022: Vol 9 No 3
  • Hardik Fichadiya, Muhammad Atif Masood Noori, Harshwardhan Khandait , Latika Patel , Shruti Jesani

    The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6–10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol. 
    We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion.

  • Zouheir Bitar, Ossama Maadarani, Mohamad Abdelfatah, Hadeel Alothman, Adnan Hajjiah

    The main ultrasound criterion for diagnosing pulmonary infarction is the presence of triangular/wedge-shaped or rounded, hypoechogenic, homogeneous, pleura-based lesions. When used in point-of-care, ultrasonography of several organs can facilitate the diagnosis of pulmonary embolism in a patient presenting with chest pain. We describe a case of chest pain which we thought was due to angina, but point-of-care ultrasonography directed us to a diagnosis of pulmonary embolism.

  • Sara Seife Hassen, Gawahir A Ali, Ashraf Ahmed, Wael Goravey

    A cholesterol granuloma is a benign lesion that can occur in various organs, mimicking other pathologies. We present the case of a 35-year-old man presenting with asymptomatic lung and pleural lesions which were suspected to be pulmonary tuberculosis but found to be cholesterol granuloma on biopsy. Cholesterol granulomas are a rare mimic of common lung pathology and should be considered in the differential diagnosis if the initial investigations are not informative.

  • Nouraldeen Manasrah, Chandima J Herath, Ali Al Sbihi, Sarah Alqasem, Andrew S Kao, Ahmed J Chaudhary, Rana Ismail

    Obesity has become a major public health problem with increased prevalence. It is associated with cardiovascular mortality. Phentermine is approved for short-term obesity treatment in conjunction with lifestyle modifications. Palpitation is a well-documented side effect of phentermine. However atrial fibrillation (AF) is rarely reported. We present a case of new-onset AF in a healthy woman who was recently started on phentermine for weight loss.

  • Asnia Latif , Hardik Fichadiya, Fareeha Abid, Gerardo Capo

    Immune thrombocytopenia (ITP) is a bleeding disorder characterized by a decreased number of platelets. It is an immune system-mediated condition, with formation of antibodies against a structural platelet antigen. Although the pathogenesis remains elusive, primary disease is idiopathic and comprises 80% of cases. However, quite a few secondary causes have been established including Helicobacter pylori, varicella-zoster virus and cytomegalovirus. A few cases with an incidental association with herbal medications have been reported, but this causality has not been studied in detail.

    Here we present the case of 38-year-old African-American woman who presented with symptomatic thrombocytopenia, with a platelet count of 5 K/µl 1 week after she had consumed herbal tea containing Rumex crispus (yellow dock) and Arctium lappa (burdock). The association between unstudied herbs and ITP needs further research, given the widespread use of these substances and ongoing public uncertainty about their benefits.

  • Inês de Sousa Miranda, Joana Ferreira, Sara Rocha, Marta Monteiro, José Guilherme, Raquel Domingos

    The authors present the case of a 79-year-old woman who presented with chronic secretory diarrhoea and severe electrolyte imbalance. A large rectal tubulovillous adenoma was discovered, leading to surgical resection of the tumour with complete resolution of the diarrhoea and electrolyte imbalance. The diagnosis of McKittrick-Wheelock syndrome was made.

    We hope this case report will contribute to a greater awareness among health professionals about this clinical condition. A multidisciplinary approach is essential for the best outcome.

  • Joshua Winston, Kale Munien

    Penile Mondor’s disease is a rare condition characterised by superficial thrombophlebitis of the penis which is usually self-limiting. The cause is often unknown. The AstraZeneca ChAdOx1-S vaccine has been found to cause a hypercoagulable state, which is well documented. This case report describes a man who presented with Mondor’s disease following ChAdOx1-S vaccination with no other risk factors.

  • Miki Hamashoji, Kotaro Kunitomo, Taro Shimizu, Takahiro Tsuji

    Introduction: Carbon monoxide (CO) binds to haemoglobin with a much higher affinity than oxygen, forming carboxyhaemoglobin (COHb), which impairs oxygen transport and utilization. As CO concentrations can easily peak in closed environments, non-fire-related CO poisoning can also occur. However, because CO poisoning is often a nonspecific clinical finding, it can result in a diagnostic error. This report details the misdiagnosis of a 42-year-old male patient with psychiatric disorders.

    Case description: The patient presented to the hospital with dizziness, abdominal pain and nausea on multiple occasions. His symptoms were ascribed to his psychiatric conditions. On his fifth visit, we diagnosed the patient with CO poisoning.

    Discussion: It is apparent that this patient was misdiagnosed because of his medical history, and standard analysis was overlooked. When patients with psychiatric disorders have nonspecific symptoms, it is important to check for urgent underlying conditions during diagnosis.

  • Ashraf OE Ahmed, Gawahir A. Ali, Wael Goravey

    Pulmonary tuberculosis (TB) is a common infection in developing countries and is associated with low socioeconomic status. It is considered a serious infection due it its long-term sequelae. Post-TB lung disease decreases life expectancy and increases the risk of recurrent TB infection. It also significantly increases the risk of other bacterial and fungal infections. Aspergillosis develops in the cavitary lesions of TB, worsening them and resulting in a deteriorating clinical situation. Concomitant pulmonary TB (PTB) and invasive aspergillosis is uncommon, particularly in the absence of factors that suppress the immune system. In this report, we describe the case of a healthy young adult without previous structural lung damage who presented with primary PTB and acute invasive aspergillosis infection, discuss the treatment dilemma and provide a literature review.

  • Adnan Hajjiah, Ossama Maadarani, Zouheir Bitar, Boutros Hanna, Ragab Elshabasy, Mohamed Abdelfatah, Mohammad Gohar

    Hypotension in patients with heart failure is much more frequent in daily clinical practice than the 10–15% reported in clinical trials. In patients with heart failure with reduced ejection fraction (HFrEF), hypotension frequently limits the initiation and up-titration of guideline-directed medical therapy (GDMT). Midodrine is a peripheral alpha-1 agonist and a vasopressor anti-hypotensive agent approved for the treatment of orthostatic hypotension. We describe two cases where midodrine was prescribed in patients with HFrEF and hypotension.

  • Moayad Alqurashi, Badr Madani, Mohamed Mursi, Nazik Eltayeb

    Extra-colonic Clostridioides difficile infection is rare. Here we describe a sickle cell disease patient with avascular necrosis who presented with persistent bacteraemia due to C. difficile and septic arthritis in a native knee joint, which responded very well to medical and surgical treatment but recurred multiple times within weeks of the cessation of antibiotics.

  • Payal Rath, Hardik Fichadiya, Sherif Elkattawy, Shruti Jesani, Melissa Messalti, Harshil Fichadiya, Clark Sherer

    The growing prevalence of obesity in the USA has resulted in increased consumption of weight loss products that promote fat metabolism. Dietary supplements used for weight loss contain a wide variety of ingredients but the amount of scientific information available on these ingredients varies considerably. Such supplements have documented and undocumented adverse effects. Although the FDA frequently issues health advisories, the health consequences of consuming supplements are often overlooked by the general public. A common supplement used for weight loss is Hydroxycut. The ingredients used in the different forms of Hydroxycut products vary but generally include caffeine and green tea extract, which are responsible for a wide range of adverse effects. We present the case of 41-year-old man with a medical history of polysubstance abuse who developed acute compartment syndrome in the setting of rhabdomyolysis from prolonged immobilisation and the use of Hydroxycut. This case demonstrates the possible adverse effects of consuming weight loss herbal supplements like Hydroxycut. Healthcare professionals and consumers are encouraged to report serious adverse events or product quality problems with the use of these supplements to the FDA's MedWatch adverse event reporting program.

  • Ana Milena Mejía Sanjuanelo, Maria Carolina Manzur Barbur, Maria Cristina Martinez-Ávila, Juan Camilo García Dominguez

    The Amplatzer septal occluder is one of several percutaneous devices used for the closure of secundum atrial septal defects. The main complications are related to the procedure, with infection being the least common. We present the case of a 67-year-old woman with a secundum atrial septal defect, who, 3 years after repair with an Amplatzer occluder, was admitted with sepsis and bacteraemia following recent hospitalization in an intensive care unit. Transoesophageal echocardiography showed the presence of a mobile echogenic structure in the left atrium suggestive of a vegetation. Few cases of late endocarditis involving the Amplatzer device have been reported, even though partial endothelization is one of the risk factors. There are no guidelines for the prevention, diagnosis or management of this complication.

  • Inês Miranda, Leonor Ávila, Luís Castro, Sara Rocha, Marta Monteiro, Raquel Domingos

    Small bowel tumours are rare, representing about 0.5% of all tumours and about 3% of gastrointestinal tract tumours . The low prevalence contrasts with the vast surface area of the small intestine, which accounts for over 90% of the surface area of the digestive tract. The frequency of small tumours decreases from proximal to distal, and therefore from the duodenum to the ileum. The histological types differ in terms of prevalence according to the affected segment, with adenocarcinoma being the most frequent in the duodenum and jejunum and carcinoid tumour in the ileum. Diagnosis is challenging due to clinical non-specificity, low prevalence and a low level of suspicion.

    Schwannomas are typically benign tumours that arise from Schwann’s cells and are rarely found in the small intestine. It is even more rare to find them together with another histological type, namely adenocarcinoma. No cases have been reported in the literature of these lesions occurring in the small intestine simultaneously. Further studies are needed to clarify the underlying pathophysiology of these synchronous tumours.

    The authors present the case of an 86-year-old female patient admitted for high intestinal subocclusion, with refractory vomiting and involuntary weight loss. Two synchronous lesions in the digestive tract were identified: an adenocarcinoma in the duodenum and a schwannoma in the ileum. The patient underwent surgical resection of both lesions.

    A high level of suspicion combined with a multidisciplinary approach is necessary for timely diagnosis and surgical resolution.

  • Abeline Kapuczinski, Sammy Place, Oliver Filleul, Christine Villers

    Infectious sacroiliitis is a rare disease that can occur in conjunction with other osteoarticular infections. Furthermore, it is very unusual for Listeria monocytogenes to be identified in an osteoarticular infection, with spondylodiscitis being the most frequent such infection. We report a case of spondylodiscitis with infectious sacroiliitis due to infection with L. monocytogenes treated successfully with meropenem as salvage therapy.

  • Maria Lume, Marisa Couto, Luís Lemos, Ana Monteiro, José Carlos Martins

    Acrometastasis, referring to metastases located distal to the elbow and knee, is a rare observation. The most common primary cancer site is the lungs, followed by colorectal, breast and genitourinary tract locations.

    We present a case of a 54-year-old woman with a 25-pack-year smoking history, chronic obstructive pulmonary disease and squamous cell carcinoma of the lung diagnosed at age 50. Upon physical examination, in the distal phalanx of the fourth finger of the right hand, there was a hypervascularized swelling, purplish and painful. Distal amputation of the fourth finger was performed with pathological anatomy compatible with acrometastasis of primary squamous cell carcinoma of the lung. Clinicians should be aware of this type of metastasis because it is sometimes difficult to distinguish from tuberculous dactylitis and other types of osteomyelitis in patients with undiagnosed cancer. The presence of acrometastasis confers a poor prognosis.

  • Deeba Ali, Yilmaz Gorur , Benoît Cardos , Jean Bosco Masabarakiza , Anne-Christine Stilmant, Michèle Yerna, Noel Lorenzo-Villalba

    We report the case of an 86-year-old female patient with chronic neck pain who presented with an initial misleading clinical picture suggesting an ischaemic stroke. No recent or previous anticoagulation treatment or fall history was reported. The patient developed a paraplegia of the upper limbs needing magnetic resonance imaging which revealed a compressive cervical haematoma. The patient benefitted from cervical laminectomy and evacuation of the cervical haematoma. Motricity in upper extremities was recovered but paresis in the lower extremities persisted 1 week after surgical intervention.

  • Ali Al Sbihi, Nouraldeen Manasrah, Dahlia Sano

    We present a case series of three multiple myeloma (MM) patients on lenalidomide for maintenance therapy who were at high risk of coronavirus disease 2019 (COVID-19) complications and mortality. However, our patients had minor symptoms after testing positive for COVID-19 although they were unvaccinated. We think that lenalidomide might have a protective effect against severe COVID-19 symptoms.

  • Monther Ghunaim, Ali Someili, Mohammad Mawardi

    Candida is a rare cause of purulent pericarditis. Oesophago-pericardial fistula is an uncommon and potentially life-threatening complication of both benign and malignant oesophageal tumours. Here we report the case of 40-year-old woman who presented with symptoms and signs suggestive of acute pericarditis complicated by cardiac tamponade which required acute management with paracentesis. Pericardial fluid analysis was positive for Candida albicans. Oesophagogastroduodenoscopy was performed and revealed a small fistula in the proximal oesophagus extending into the retrocardiac space. Multiple biopsy specimens of the fistula site and oesophageal stricture were obtained. Histopathological findings were consistent with poorly differentiated squamous cell carcinoma of the oesophagus complicated by fistulation to the retrocardiac space.

  • Soroush Rouhani, Nikesh Adunuri

    Introduction: Complications of peritoneal dialysis (PD) such as exit-site infections and PD peritonitis are common reasons for admission to General Internal Medicine wards. Culprit organisms range from typical skin flora to rarer complicated atypical organisms such as non-tuberculous mycobacteria. Encapsulating peritoneal sclerosis (EPS) is a rarer complication of PD characterized by peritoneal inflammation, ileus and fibrosis with high morbidity, few management options, and poor prognosis.

    Case Description: We report the case of a patient with a history of end-stage renal disease on peritoneal dialysis who presented with undifferentiated peritonitis and ileus refractory to standard antimicrobial therapy. Subsequent ascitic cultures were positive for Mycobacterium abscessus, and CT imaging was consistent with EPS. To date, EPS secondary to M. abscessus peritonitis has not previously been described.

    Discussion and Conclusion: This report describes the diagnostic process and treatment offered to this patient and his treatment outcomes over 8 months. It highlights the importance of prompt identification of patients at risk, timely eradication of high-risk pathogens, and transition to haemodialysis to limit morbidity and improve patient prognosis.

  • Murtaza Hussain, Katherine Boyer, Anoosha Ponnapalli, Dominic Awuah, Sina Khaneki, Smit Deliwala, Ghassan Bachuwa

    Escitalopram is a commonly prescribed medication that has infrequently been implicated in drug-induced thrombocytopenia (DITP) but has never been associated with aplastic anaemia in the literature. We present an extremely rare case of hypoproliferative pancytopenia due to self-administered intravenous (IV) injection of escitalopram. The crux of this case is the unusual trilineage cytopenia. Our patient was managed with steroids and supportive care with subsequent clinical and blood count recovery. This case sheds light on this uncommon but important association.

  • Omer Yousaf, Arisha Carreon, Ibrahim Mohsin

    Introduction: Strongyloidiasis is a systemic disease caused by the nematode Strongyloides stercoralis. Strongyloides is unique among parasites in that it can remain undetected for decades. Although patients may present with the typical symptoms of a skin rash, cough or diarrhoea, a rare manifestation of infection is pseudopolyposis in the colon. This case highlights the unique finding of pseudopolyposis in a patient with strongyloidiasis with negative stool studies.

    Case description: We present the case of an 81-year-old man with a delayed diagnosis of strongyloidiasis. The patient initially presented to the clinic for evaluation of productive cough and was treated empirically for bronchitis. He subsequently developed vomiting and diarrhoea with imaging revealing circumferential wall thickening of the ascending colon, consistent with colitis. Although stool tests were negative, the patient was treated with antibiotics, and then underwent a colonoscopy which revealed multiple polyps. Biopsy results confirmed Strongyloides infection. The patient was treated with ivermectin and improved.

    Discussion: This case describes the unique finding of colonic pseudopolyposis in a patient infected with Strongyloides in rural southwest Virginia. Strongyloidiasis is often misdiagnosed due to its non-specific gastrointestinal symptoms and the chronic nature of the disease. Although stool studies are routinely negative for parasitic infection, CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context. Determining the definitive diagnosis in a timely manner is crucial for establishing the specific treatment and for resolution of the disease.

  • Vinit Singh , Dhairya Gor, Rana Prathap Padappayil , Ali Jaffery , Patrick Lee

    Venous thromboembolism is a common cause of morbidity and mortality in cancer patients. Given the bleeding risks, determining treatment for malignancy-related thrombosis is challenging, especially in the case of submassive pulmonary embolism (PE) because the risk-benefit ratio in terms of bleeding risk is uncertain. Here we discuss the case of a 53-year-old man with Kartagener syndrome with situs inversus totalis and stage IV non-small cell lung cancer with a recent brain mass resection, presenting with dyspnoea and palpitations. The patient was diagnosed with a submassive PE and only underwent suction thrombectomy through the left internal jugular vein with excellent response. In conclusion, when treating submassive PE, aspiration thrombectomy without thrombolysis is preferable to thrombolysis, which may be contraindicated due to the higher risk of bleeding.

  • Filipa David, Joana Rodrigues Morais, Francisca Beires, Helena Greefield, Gonçalo L Fernandes

    COVID-19 emerged in China in late 2019 and quickly spread worldwide. The severe immunomodulation and depletion of lymphocytes caused by the virus and its therapy led to an increase in the incidence of superinfections. COVID-19-associated pulmonary aspergillosis (CAPA) is a new entity with increasing incidence and high associated mortality.

    We present the case of a 68-year-old patient admitted to our ward after recovering from severe COVID-19 pneumonia. Due to worsening of her clinical condition, chest computed tomography was performed and a lung abscess was documented with the identification of Aspergillus niger. Despite therapy with voriconazole, the patient’s condition deteriorated, culminating in her death.

    COVID-19 emerged in China in late 2019 and quickly spread worldwide. The severe immunomodulation and depletion of lymphocytes caused by the virus and its therapy led to an increase in the incidence of superinfections. COVID-19-associated pulmonary aspergillosis (CAPA) is a new entity with increasing incidence and high associated mortality.

    We present the case of a 68-year-old patient admitted to our ward after recovering from severe COVID-19 pneumonia. Due to worsening of her clinical condition, chest computed tomography was performed and a lung abscess was documented with the identification of Aspergillus niger. Despite therapy with voriconazole, the patient’s condition deteriorated, culminating in her death.

  • Muhammad Atif Masood Noori, Kalpesh Shah, Hardik Fichadiya, Mofe Adeosun, Shruti Jesani, Edmund Appiah-Kubi, Hasham Saeed, Sherif Elkattawy, Meherwan Joshi

    Aortic dissection is a relatively uncommon, although catastrophic, disease which requires early and accurate diagnosis and treatment for patient survival. Aortic dissection can be difficult to diagnose due to the diverse symptom presentation, which can lead to later diagnosis, resulting in a higher mortality rate. Here we present a case of type A aortic dissection with a varied symptom presentation, highlighting the importance of early detection and the Bentall procedure for management of such cases. A 50-year-old man with no known medical history presented with bilateral lower extremity swelling and fatigue for 2 weeks. The patient denied any chest pain or dyspnoea. Vital signs showed blood pressure of 160/76 mmHg, pulse of 103 bpm, respiratory rate of 18, and temperature of 36.7°C. Laboratory findings indicated a BNP of 1901 pg/ml and troponin of 0.5 ng/ml. An initial diagnosis of decompensated heart failure was made, and IV Lasix was started. Subsequently, an echocardiogram indicated an EF of 50–55% and ascending dissection of the aorta. A CT angiogram of the chest and abdomen confirmed this diagnosis. This patient presented with unusual symptoms of aortic dissection without the typical presentation of chest pain. It is important to consider aortic dissection in a cardiac-related case as prompt imaging can help confirm the diagnosis. We explore the risks and benefits of the Bentall procedure for the management and early detection of aortic dissection.