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Chromogenic Factor X Assay for Monitoring Warfarin Anticoagulation in a Child With a Prosthetic Mitral Valve
Mechanical mitral valve replacement in infants and young children is associated with substantial morbidity and mortality. Lifelong anticoagulation is required, with all the accompanying challenges of maintaining levels in infants and children whose dietary input continually changes. Even with careful control of all aspects that can perturb the coagulation cascade, these patients have a substantial lifelong risk of thrombotic and hemorrhagic complications that can also affect the durability of the valve.Successful Treatment of Pembrolizumab-Induced Severe Capillary Leak Syndrome and Lymphatic Capillary Dysfunction
Although capillary leak syndrome has a high mortality rate, its trigger, diagnosis, and treatment remain a challenge to clinicians because of the poor understanding of its mechanism and lack of treatment guidelines. With the extended use of immune checkpoint inhibitors in modern oncology, immune checkpoint inhibitor–associated immune-related adverse events have also expanded. We present a case of pembrolizumab-induced capillary leak syndrome and lymphatic capillary dysfunction in which the patient had an excellent clinical response to a tailored treatment strategy.Glycemic Outcomes of Second-Line Diabetes Drug Choice in a Real-World Population
Hypoglycemia and acute metabolic complications (AMCs; ketoacidosis, hyperosmolarity, and coma) are glycemic outcomes that have high cost and high morbidity; these outcomes must be taken into consideration when choosing initial second-line therapy after metformin. We conducted a retrospective cohort study analyzing national administrative data from adults with type 2 diabetes mellitus who started a second-line diabetes medication (sulfonylureas [SFUs], thiazolidinediones [TZDs], glucagon-like peptide 1 [GLP-1] agonists, dipeptidyl peptidase 4 [DPP-4] inhibitors, basal insulin, or sodium-glucose contransporter 2 [SGLT-2] inhibitors) between April 1, 2011 and September 30, 2015 (N=43,288) and compared rates of hypoglycemia and AMCs.Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient
Treatment strategies for hypertriglyceridemia-induced acute pancreatitis are not well defined in the current literature or guidelines. One therapeutic option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic woman treated with a reduced-dose insulin infusion that was complicated by hypoglycemic episodes requiring dextrose infusion titrations.EVALI: A Mimicker of COVID-19
E-cigarette or vaping product use–associated lung injury (EVALI) is a respiratory illness that has significant overlap with the symptoms of coronavirus disease 2019 (COVID-19). In the current pandemic, diagnosis of EVALI may be delayed because of anchoring bias when patients present with symptoms consistent with COVID-19. We present 3 cases of patients who were hospitalized with a presumed diagnosis of COVID-19 but were later diagnosed with EVALI.The Impact of COVID-19 on Volume of Inpatient Hospitalization Through General Medicine and Medicine Subspecialty Services at US Medical Centers
As the coronavirus disease 2019 pandemic continues to impact hospital systems both in the United States and throughout the world, it is important to understand how the pandemic has impacted the volume of hospital admissions. Using the Vizient Inc (Chicago, IL) clinical databases, we analyzed inpatient hospital discharges from the general medicine service and its subspecialty services including cardiology, neonatology, pulmonary/critical care, oncology, psychiatry, and neurology between December 2019 and July 2020.Refractory Left Focal Motor Status Epilepticus as Initial Clinical Presentation of Acute Basilar Artery Thrombosis
Seizures are uncommon with posterior circulation strokes. They are more often associated with anterior circulation strokes, with only a limited number of cases of status epilepticus reported to be related to brain stem ischemia. The literature includes case reports of generalized tonic-clonic seizures and associated status epilepticus as an initial presentation of acute basilar artery thrombosis. However, there are only rare cases reporting focal motor seizure as status epilepticus in the setting of acute basilar artery thrombosis, an important clinical presentation that should prompt evaluation for acute brain stem ischemia.Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient
Hypertriglyceridemia-induced acute pancreatitis treatment strategies are not well defined in current literature or guidelines. One therapy option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic female patient treated with a reduced-dose insulin infusion, complicated by hypoglycemic episodes requiring dextrose infusion titrations.Prosthetic Joint Infections Due to Histoplasma capsulatum: A Report of 3 Cases
Histoplasma capsulatum causes pneumonia and multisystemic disease in humans. Musculoskeletal involvement in histoplasmosis is most often tenosynovitis and rarely septic arthritis. Even more uncommon is the involvement of prosthetic joints. Here, we report a series of 3 cases of prosthetic joint failures caused by infection due to H capsulatum. Together with a review of 4 previously reported cases, we summarize host characteristics, clinical presentation, surgical approaches, antifungal management, and outcomes of this rare orthopedic joint infection.Efficacy of 177Lu-Dotatate Therapy in the Treatment of Recurrent Meningioma
A 62-year-old man presented with a history of atypical meningioma (World Health Organization grade II) and recurrent as anaplastic meningioma (World Health Organization grade III). His previous treatments included multiple surgical resections, fractionated radiation therapy, stereotactic radiosurgery, everolimus/octreotide long-acting release, bevacizumab, and hydroxyurea. Magnetic resonance imaging revealed rapid volumetric progression over the prior 9 months, with a near tripling in size from 29.9 cm3 to 80.4 cm3.Pulmonary Vascular Disease Due to Plasma Cell Dyscrasia
Pulmonary hypertension (PH) has been described in myeloproliferative disorders; monoclonal plasma cell disorder such as polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome; and plasma cell dyscrasias such as multiple myeloma and amyloidosis. We describe 4 cases of PH likely due to pulmonary vascular involvement and myocardial deposition from light chain deposition disease, amyloidosis, and multiple myeloma. On the basis of our clinical experience and literature review, we propose screening for plasma cell dyscrasia in patients with heart failure with preserved ejection fraction, unexplained PH, and hematological abnormalities.Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis
Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion.Progressive Monoarticular Inflammatory Arthritis Following Influenza Vaccination
Musculoskeletal injury is an uncommon but usually self-limited complication of vaccine administration. We present a case of progressive inflammatory monoarthritis of the shoulder characterized by bone erosion, bursitis, and severe synovitis caused by an influenza vaccine administered to the ipsilateral deltoid region. Clinical symptoms began within 2 hours of vaccination, with progressive decline in function over 6 weeks. Magnetic resonance imaging examinations performed 5 months apart demonstrated progressive erosive changes of the greater tuberosity, rotator cuff injury, and extensive enhancing synovitis of the glenohumeral joint and subacromial/subdeltoid bursa.Hereditary Angioedema Attack in Utero and Treatment of the Mother and Fetus
Hereditary angioedema (HAE), an inherited deficiency of functional C1 esterase inhibitor (C1-INH), is characterized by unpredictable recurrent episodes of painful and often disabling swelling in subcutaneous and/or submucosal tissues. We report the case of a 23-year-old woman with type I HAE who had abdominal, facial, and peripheral attacks throughout her first pregnancy. A facial HAE attack occurred at week 38 of her pregnancy, and symptoms improved after self-administration of 50 U/kg of recombinant human C1-INH (total dose, 3500 U), but soon after she had an unusual abdominal sensation.A Rare Case of Prostate-Specific Antigen–Producing Metastatic Parotid Adenocarcinoma Developing Androgen Receptor Resistance
A 62-year-old man presented with a rising serum concentration of prostate-specific antigen (PSA) to 53.3 ng/mL (to convert to μg/L, multiply by 1) and a PSA doubling time of 2.6 months. Computed tomography, fluorodeoxyglucose–positron emission tomography, and C-11 choline positron emission tomography demonstrated a parotid mass with innumerable lytic bone lesions and diffuse metastatic disease to the neck and mediastinal lymph nodes. Mediastinal lymph node biopsy revealed salivary ductal adenocarcinoma that produced PSA and demonstrated androgen receptor sensitivity.Acute Herpes Zoster Radiculopathy of the Lower Extremity With Dermatomal Rash and Lumbar Nerve Enhancement on MRI
Herpes zoster is a frequent cause of neuralgia and dermatomal vesicular rash secondary to reactivation of latent varicella zoster virus. However, it rarely presents with acute lumbar radiculopathy and the diagnosis can be quite challenging in such cases. Nerve signal abnormalities on magnetic resonance imaging are well recognized in herpes zoster neuropathy or plexopathy affecting the extremities, although gadolinium enhancement is characteristically absent. In this article, we describe a case of acute herpes zoster lumbosacral radiculopathy with characteristic vesicular dermatomal rash and second ever reported finding of gadolinium enhancement of the lumbar nerve on magnetic resonance imaging.The Many Faces of Itraconazole Cardiac Toxicity
Itraconazole is well known for carrying a black-box warning for new or worsening congestive heart failure. Single cases of other cardiac- and fluid-related disturbances have been reported periodically since its issuance. We describe a large cohort of patients on itraconazole experiencing a breadth of cardiac- and fluid-related toxicities, ranging from new-onset hypertension to cardiac arrest. A retrospective, single-center, large case series at a large tertiary medical center was conducted. Patients with itraconazole and cardiac toxicity—including hypertension, cardiomyopathy, reduced ejection fraction, and edema—in medical record between January 1, 1999, and May 21, 2019, were identified and assigned a Naranjo score; 31 patients were included with a Naranjo score of 5 or higher.Magnetic Resonance Imaging–Guided Focused Ultrasound Ablation of Lumbar Facet Joints of a Patient With a Magnetic Resonance Image Non-Conditional Pacemaker at 1.5T
To provide an initial report that patients with magnetic resonance imaging (MRI) non-conditional cardiac implanted electronic device (CIED) can undergo state-of-the-art magnetic resonance imaging–guided focused (MRgFUS) ablation procedures with careful planning and integration of the procedure into an established CIED MRI practice.Mobile Mitral and Aortic Valvular Masses in Patients With Hereditary Hemorrhagic Telangiectasia Receiving Intravenous Bevacizumab
Bevacizumab is now an emerging treatment option for severe hereditary hemorrhagic telangiectasia–related bleeding including epistaxis and gastrointestinal tract bleeding. The impact of long-term intravenous bevacizumab therapy on cardiac structure and function is unknown. We describe 3 patients receiving intravenous bevacizumab therapy for severe hereditary hemorrhagic telangiectasia–related bleeding who were found to have abnormal mobile masses on the mitral valve (n=2) and aortic valve (n=1). The clinical impact of these findings is unknown and requires further study.Migratory Polyarthralgias and Skin Rash: Rat Bite Fever with a Positive Anti–Cyclic Citrullinated Peptide
Rat bite fever is a rare, underdiagnosed disease caused by Streptobacillus moniliformis in the United States, and is typically characterized by leukocytosis, elevated C-reactive protein, migratory polyarthralgias, and pustular skin rash. Rat bite fever is frequently misdiagnosed as either a viral illness or a rheumatologic disease and carries a high mortality risk if untreated. We report the first case of rat bite fever associated with positive anti–cyclic citrullinated peptide. The patient initially presented with low back pain and developed a pustular rash as well as severe asymmetric polyarthralgias.Approaching Acute Vertigo With Diplopia: A Rare Skew Deviation in Vestibular Neuritis
Evaluating the patient with acute constant vertigo or diplopia can be a daunting task for clinicians, who recognize that such symptoms can be the manifestation of potentially devastating disorders like stroke but may be uncomfortable eliciting and interpreting the key symptoms and subtle signs that distinguish dangerous from benign causes. We present a novel and highly instructive case of a patient with acute vertigo and binocular diplopia from a large skew deviation due to vestibular neuritis. As the case unfolds, text and video commentary guide the clinician through the important elements of the history, bedside examination, and laboratory evaluation necessary for accurate diagnosis in the acute vestibular syndrome.Removal of a Large Stone in the Upper Thoracic Esophagus
Ingestion of a foreign body is a common occurrence. Flexible endoscopy is most commonly used for treatment, but certain large foreign bodies are more easily retrieved with rigid endoscopy. We present a technically challenging case of intentional ingestion of a large stone that required retrieval from the upper thoracic esophagus using rigid endoscopy. This case highlights the importance of alternative methods to manage large foreign bodies and of collaboration of medical subspecialties.Improved Treatment Response Following Magnetic Resonance Imaging–Guided Focused Ultrasound for Lumbar Facet Joint Pain
Magnetic resonance imaging–guided focused ultrasound (MRgFUS) is a noninvasive modality that allows for precise tissue ablation with sparing of surrounding structures. Early reports of the use of MRgFUS for the treatment of facet joint osteoarthritis are promising. We present a case of facet joint pain treated successfully by MRgFUS at our institution. Magnetic resonance imaging–guided focused ultrasonography may be a useful modality for patients with facet joint–mediated low back pain, particularly in the setting of limited or refractory response to conventional treatments.Rebound Vertebral Fractures in a Patient With Lung Cancer After Oncology-Dose Denosumab Discontinuation: A Cautionary Tale
We describe a 55-year-old woman with lung cancer complicated by bone metastases. Treatment with denosumab (120 mg monthly) was interrupted after 9 doses because of concern for potential osteonecrosis of the jaw during upcoming dental work. Fifteen months after receiving the last dose of denosumab, the patient presented with 7 atraumatic spinal compression fractures requiring kyphoplasty for symptom relief. No malignancy was found in pathology specimens. Evaluation for secondary causes of osteoporosis was negative.Thiamine and Heart Failure: Challenging Cases of Modern-Day Cardiac Beriberi
Cardiac beriberi, or heart failure due to thiamine deficiency, is considered rare in the developed world. The diagnosis is often only considered in limited populations such as those with chronic alcoholism. Alternatively, the disease can be mislabeled as “alcoholic cardiomyopathy” or “nonischemic cardiomyopathy.” The following 2 cases illustrate the need to expand our vigilance to other at-risk populations.
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