MERF 2019 - Case Reports

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Case Study: Type B Aortic Dissection in a Petitioned Patient (SI)

Gary Mikhjian and Omar Francis

Aortic dissection occurs after a tear in the intima allows blood to enter the media and dissect between the intimal and adventitial layers, creating a false lumen which may extend anterograde or retrograde - Incidence: 2.6-3.5 per 100,000 person, bimodal age distribution - Risk factors: long-term HTN or connective tissue disorders (most common), preexisting aneurysm, bicuspid aortic valve, aortic coarctation, cocaine use - Classic presentation: tearing/ripping sensation, severe pain,... Read More
Nasolacrimal Duct Obstruction Caused by Primary Lacrimal Sac Adenocarcinoma

Shravani Mikkilineni, Daniel Brill, Taylor Fields, Mariam Hamid, and Christian George

Background: Primary lacrimal sac tumors are a group of rare, highly malignant group of orbital neoplasms. Early diagnosis is critical, but often delayed, as these tumors are commonly mistaken for comparatively benign conditions. To our knowledge, there are less than 15 published cases of primary lacrimal sac adenocarcinoma. Purpose: To report a rare case of primary lacrimal sac adenocarcinoma with surgical removal and reconstruction by oculoplastics, orthopedic surgery and... Read More
An Atypical Presentation of Disseminated CMV in an Immunocompromised Patient

Krishna Modi, Ali Omari, and Odaliz Abreu-Lanfranco

Discussion: We present a case of disseminated CMV manifesting as cutaneous eruptions, viremia, retinitis, and encephalopathy in an immunocompromised patient. This patient was admitted for multifocal pneumonia, but continued to spike fevers and remained encephalopathic even after resolution of the pneumonia. Despite extensive evaluation for other infectious etiologies he failed to improve until he was placed on ganciclovir. Encephalopathy in HIV patients requires evaluation for Toxoplasma, primary CNS lymphoma,... Read More
JC Virus Induced Longitudinally Extensive Transverse Myelitis in Immunocompromised Patient

Ghada A. Mohamed, Gamal el Din Osman, Hassan Abd El Noor, Daniel Newman, and Angelos Katramados

Introduction: John Cunningham virus (JCV) is a human polyomavirus that causes a fatal demyelinating disease of the central nervous system (CNS) called progressive multifocal leukoencephalopathy (PML). Primary JCV infection usually occurs asymptomatically in childhood and may result in a chronic asymptomatic carrier state. It remains usually dormant in the kidneys, lympho-reticular system, or brain tissue. Seventy to ninty percent of adults are seropositive for the JC virus and the... Read More
Allergic Contact Dermatitis Due to Benzoyl Peroxide from an Unlikely Source

Tasneem F. Mohammad, Madeline Adelman, and Holly Kerr

Although irritant contact dermatitis secondary to BPO is common, allergic contact dermatitis is rare. Here, we present a baker who developed allergic contact hand dermatitis to BPO in the bleached flour he used at work. Case Presentation: A 64-year-old man presented with a pruritic dermatitis involving the hands. Treatments had included triamcinolone 0.1% ointment and fluocinonide 0.05% ointment without resolution. Given the lack of improvement, the patient was referred... Read More
A Cutaneous Case of Checkpoint Inhibitor-Induced Sarcoidosis

Hadi Mohammed and Sharmeen Mahmood

Introduction: Sarcoidosis is a granulomatous T-cell-mediated disease with an incidence of 10.0 cases per 100,000 citizens per year in the U.S. Cutaneous involvement is seen in at least 33% of cases. The earliest case of tattoo-induced sarcoidosis was described in 1939. Now, predilection for tattoos is seen in primary Sarcoidosis and drug-induced sarcoidosis (DIS). DIS can occur in response to immune checkpoint inhibitors (ICIs), highly active antiretroviral therapy, Interferon... Read More
Occult Breast Cancer Metastasis Presenting as Acute Liver Failure

Saara Mohammed, Keerthana Sankar, Zaid Al Saheli, and David E. Willens

CASE: A 45 year-old-female with history of clinically stage IA ER/PR/Her-2 Negative moderately differentiated ductal carcinoma of right breast presented with abdominal pain, abdominal distension, jaundice, and scleral icterus three weeks after laparoscopic cholecystectomy due to acute cholecystitis. Intraoperatively her liver was noted to be cirrhotic and an intraoperative biopsy was done. Upon discharge after surgery her total bilirubin remained elevated. On presentation she showed signs of acute liver... Read More
When Street Drugs Stop at Hospital Doors: A Closer Look at Kratom and Phenibut Withdrawal

Monique Mun, Vanessa Patel, and Cathrine Frank

The use of synthetic psychotropics is rapidly increasing across America, sometimes recreationally, sometimes as prescribed medicine. Medical literature systematically discusses Kratom, a synthetic opioid used for opioid dependence, withdrawal and mood enhancement. However, the research gap remains wide when faced with treating individuals using Phenibut, a GABA derivative used for its anxiolytic effect, and also known to have a synergistic effect with Kratom to produce euphoria. We present the... Read More
Idiopathic Chylothorax: Is it a Benign or Malignant Diagnosis?

Sandra Naffouj and Jasmine-Yasmine Omar

Background:Chylothorax is the presence of chyle in the pleural space with triglyceride (TG) level>110 mg/dl or evidence of chylomicrons in the pleural fluid. The two main etiologies for chylothorax are traumatic (thoracic surgery) and non-traumatic (malignancy). We present a case of idiopathic chylothorax in which the etiology could not be identified after an extensive work-up and resolution occurred after operative intervention. Case: A 29-year-old male presented with acute onset... Read More
Navigating a Request for LVAD Termination in the Context of Depression

Suchi Nagaraj, Kristin Chasteen, Kelly Bryce, and Karen Smith

Objectives: 1)Describe an approach to assessing capacity for end-of-life decision making in apatient with depression 2)Recognize the Interdisciplinary Team’s (IDT)approach to navigating a patient’s request to discontinue a Left Ventricular Assist Device (LVAD) 3)Define the ethical principles that are involved inthedecision to withdraw LVAD therapy. Background: There is ethical consensus that patients with capacity have the right to stopany life-extendingmedical treatment, includingan LVAD. When a patient with depression requests... Read More
An Atypical Response to Epinephrine

Niren Naidoo, Adithya Peruri, Alan Mundakkal, and Jayanthi Chandrasekaran

Epinephrine and epinephrine related medications have been widely studied and their side effect profiles have been well documented. Rare reactions can occur due to administration of EpiPen and it is critical to document and explore the cause of such reactions. We present a case report on a patient experiencing a unique reaction to EpiPen administration which we suspect is due to vasospasm. A 38-year-old caucasian female presented after a... Read More
Hemolytic anemia with mutations SPTA1 c.6531-12C>T and SLC4A1 Pro868Leu

Vidhya Nair, Diego Cabrera-Fernandez, and Vijayalakshmi Donthireddy

Learning Objective: Novel phenotype of hemolytic anemia with simultaneous mutations of SPTA1 c.6531-12C>T and SLC4A1 Pro868LeuCase: A 33-year-old male with no prior medical history presented with dizziness, diaphoresis and near syncope. On evaluation, hemoglobin was noted to be 6.1, Ultrasound of the abdomen showed splenomegaly measuring 18 cm. Anemia work up revealed a low haptoglobin <30, reticulocytosis, hyperbilirubinemia and high LDH. Coombs test was negative. Peripheral smear showed elliptocytosis... Read More
Invasive aspergillosis of the liver in an immunocompetent patient

Varidhi Nauriyal and Erica Herc

Introduction: Invasive aspergillosis is most often seen in immunocompromised patients, although there are rare case reports of infection in immunocompetent hosts. We present a case of an immunocompetent patient with isolated hepatic aspergillosis. Case presentation: A 77-year-old male with chronic kidney disease stage III and history of Whipple procedure for a benign pancreatic mass 12 years prior presented with 1.5 months of fatigue, decreased appetite, chills, nausea, vomiting and... Read More
Gluteus Maximus Transfer for Trendelenburg Gait Following Total Hip Arthroplasty

Karen Nelson, Melissa Martinez, Fremont Scott, JJ Goldman, and K Chaiyasate

Introduction: Lateral approach total hip arthroplasty (THA) accounts for 12% of the total hip reconstructions performed annually. Approximately 4.4% of these patients experience postoperative rupture of the gluteus medius (routinely take down and repaired during the surgery), resulting in loss of abduction and a contralateral hip drop with a Trendelenburg gait. While functional muscle transfer has been proposed for use at the time of implant revision surgery, to our... Read More
Dupilumab Induced Psoriasiform Dermatitis

Karlee Novice, Jesse Veenstra, Dana Siegel, and Holly Kerr

Atopic dermatitis (AD) is a common inflammatory skin condition that affects up to 20-30% of children and 2-10% of adults. In the past, therapeutic options were limited to emollients, topical glucocorticoids and calcineurin inhibitors, phototherapy, and systemic corticosteroids and anti-inflammatory therapies (e.g., methotrexate, mycophenolate mofetil, azathioprine, cyclosporine). The newly FDA approved biologic dupilumab has demonstrated significant improvement in the signs and symptoms of AD, including pruritus as well as... Read More
Progressive Multifocal Leukoencephalopathy Presenting as Transverse Myelitis

Ifeoma Onwubiko, Kanika Taneja, Nilesh Gupta, and Abir Mukherjee

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease caused by reactivation of JC virus affecting typically subcortical and periventricular white matter of immunocompromised hosts (HIV infection, hematologic malignancies). We present an unusual case of PML predominantly affecting cervical spinal cord and brainstem in an immunocompetent host. A 65-year-old female presented with vertigo, hemiparesis and right sided weakness. MRI of the brain without contrast showed T2 signal abnormality involving... Read More
Evaluation of Dental Abscesses Using Ultrasound

Timothy Otto, Scott Craver, Gale Darnell, and Satheesh Gunaga

Facial swelling due to a dental abscess is a relatively common presenting complaint in emergency departments. The condition is distressful for the patient and may have very serious and potentially life-threatening complications if allowed to progress. This report describes the use of bedside ultrasound and compares it to the gold standard of CT imaging for accurately differentiating normal intraoral structures and the areas of soft tissue infection involved with... Read More
Mixed Histocytosis Manifesting as Suprasellar Mass with Aortic Involvement

Hayk Papukhyan, Connor Kerndt, Gurinder Gakhal, and Prashant Patel

Introduction: Histiocytoses are a group heterogeneous diseases of unknown cause affecting myeloid progenitor cells. Erdheim-Chester disease (ECD) is a subclassification of Non-Langerhan cell Histiocytosis (LCH). ECD has characteristic lesions of the skeletal, cardiac, and vascular systems. There are many instances when LCH and ECD occurs concurrently, called mixed Histiocytosis. Fewer than 500 cases of ECD have been reported and even fewer of mixed histiocytosis. Case: 42 year old caucasian... Read More