MERF 2019 - Case Reports

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Disseminated Cryptococcal Disease in Liver Cirrhosis

Tommy Parraga Acosta and Indira Brar

Introduction: Cryptococcus is an environmental yeast that is typically associated with human immunodeficiency virus (HIV), and transplant recipients. Invasive disease has been described in patients with liver disease, however it is not a common occurrence. We describe a case of disseminated Cryptococcus neoformans infection in a patient with liver cirrhosis. Case presentation: 53-year-old male, with history of Hepatitis C infection, liver cirrhosis, Sjogren’s syndrome, venous thromboembolism (VTE), was admitted... Read More
Diffuse idiopathic skeletal hyperostosis causing progressive dysphagia

Parth Y. Patel and Odaliz E. Abreu Lanfranco

Background: There are a multitude of extrinsic and intrinsic etiologies of dysphagia, including mechanical obstruction, infections, neuromuscular conditions, and malignancies. Diffuse idiopathic skeletal hyperostosis (DISH) of the cervical and upper thoracic spine, a relatively common finding in spinal imaging, is rarely associated with upper esophageal pathology. We present a case of progressive dysphagia due to DISH. Case Presentation: A 64-year-old male presents to the emergency department with a three-day... Read More
A Case of Diffuse Alveolar Hemorrhage

Shama Patel and Scott Sipp

Diffuse alveolar hemorrhage (DAH) is the process of bleeding into the alveolar spaces of the lungs due to disruption of the alveolar-capillary basement membrane. It can be caused by many disease processes, including rheumatic diseases, vasculitis, infection, drugs, etc4. DAH is a rare, but a serious pulmonary complication of systematic lupus erythematosus1. Cough, hemoptysis, fever, and dyspnea are common initial symptoms, however, hemoptysis can be absent in up to... Read More
Case Study: Unilateral Vocal Cord Paralysis

Michelle Powers and Megan Cahill

Patient is an 89-year-old female with a PMH of lung cancer, COPD, AAA, thyroid nodule, bladder cancer, HTN, hypothyroidism presenting to the Emergency Department with a complaint of hoarse voice. Her symptoms started five days prior. She was seen at an urgent care and diagnosed with laryngitis. The shortness of breath is worse when speaking. She denies fever, chills, chest pain, cough, recent URI symptoms, nausea, or vomiting.Vital signs... Read More
Takotsubo Cardiomyopathy - More Than Just a Broken Heart?

David Ragbeer and Heather Cronovich

Takotsubo Cardiomyopathy also known as stress cardiomyopathy is a heart condition in which a type of stress physical or emotional can cause severe weakness of the heart musculature. A 71 y/o F with a history of polycythemia vera, HTN, HLD, and DM presented to the emergency department with a chief complaint of diarrhea x1 week. The diarrhea was associated with two episodes of nausea and vomiting, abdominal cramping, and... Read More
A Teenage Girl with a Spreading Violaceous Birthmark

Gabrielle Robinson, Samantha Schneider, Jesse Veenstra, Marla Jahnke, and Margaret Douglass

CASE REPORT: A 17-year-old healthy Latina female presented with an asymptomatic slowly enlarging birthmark. A purplish patch had been present over her left chest since birth and over time had gradually spread to involve her left shoulder and arm. She notes that sometimes the lesions will become darker red with paler colored skin at the periphery. There was no family history of similar findings.Over the left chest, shoulder, and... Read More
Significant Improvement in Pain and ASES Scores After Partial Thickness Rotator Cuff Repair with Augmentation Using a Xenograft Collagen Bioinductive Implant

Paul Rodenhouse and Shariff Bishai

Introduction: Rotator cuff tears (RCT) range from partial thickness to full thickness tears and are common problems creating significant pain and morbidity among sufferers. Even with the increasing prevalence of partial thickness RCTs, much of the literature focuses on full-thickness RCTs and treatment. Partial thickness RCTs are unique and affect a wide range of patients. Furthermore, a significant percentage of partial thickness RCT’s, up to 35%, propagate to full-thickness... Read More
Peri-stomal Fat Grafting to Enhance Parastomal Contour and Improve Ostomy Care

Ihab Saab, Hassan Ahmad, Tommy Ivanics, Andrew Worten, Daniel Yoho, Megumi Asai, Katherine Zimnicki, and Aamir Siddiqui

BACKGROUND: Stomas are common surgical procedures with predictable outcome. When the operation is done properly there can still be a spectrum of morbidities from poor appliance fitting to chronic skin breakdown. Irregularities in parastomal skin contour secondary to scarring, wound contraction, and change in weight and body habitus are major culprits. In cases where revising the stoma of relocating it are not options, other solutions are necessary. We report... Read More
A Man with Multiple Ulcerated Papules on His Face: A Muir-Torre Story

Ethan Sagher, David M. Oberlin, and Ellen N. Pritchett

HISTORY: A 61 year-old Caucasian man with a history of cardiac transplant in 2014 secondary to non-ischemic cardiomyopathy (on tacrolimus and mycophenolate), sebaceous adenomas, and sebaceous carcinomas presented for full body skin exam. His previous sebaceous carcinomas were on his right neck and right buttock, and were treated with wide local excision and Mohs micrographic surgery, respectively. He denied any specific lesions of concern since his last visit 3... Read More
Acute portal venous thrombosis caused by severe sepsis and not associated with liver disease

Nicole Saghy and Jillian Davis-Baumann

Background: Portal venous thrombosis (PVT) can be generally classified into three categories- acute non cirrhotic PVT, chronic PVT (also called extrahepatic portal venous occlusion), and PVT in cirrhosis. PVT is usually seen in those with liver disease and it is rare in patients without. Management is usually with anticoagulation and finding and treating the etiology of the PVT. If untreated, patients can develop portal hypertension. This patient presented a... Read More
Congenital Supravalvular Pulmonic Stenosis, Maybe or Maybe Not

Ashraf Saleh, Theistokles Chamogeorgakis, Marvin Eng, Firas Yazigi, Chad Stone, and Karthik Ananthasubramaniam

Introduction: It is extremely rare for leiomyosarcomas to affect the cardiovascular system. High degree of suspicion is required to diagnose this tumor in patients presenting with symptoms suggestive of a cardiac etiology. Because of the high mortality associated with this malignancy, early and aggressive intervention is crucial. Furthermore, imaging modalities may not adequately identify this tumor, as will be presented in this case leading challenges in diagnosis. Case: We... Read More
Stimulant-Induced Chorea

Carrie Schmitt, Imran Tarrar, and Alicja D. Wasilewski

Dextroamphetamine/levoamphetamine salt (Adderall), is a widely used stimulant medication commonly used to treat attention deficit hyperactivity disorder (ADHD) in children, adolescents, and adults. It works through a mechanism of increasing the release of both norepinephrine and dopamine in the central nervous system, thereby enhancing cognitive effects of increased wakefulness, improved focus and concentration, and decreasing hyperactivity, impulsivity and inattentiveness. At higher doses, or through abuse, it can cause impaired... Read More
Hemophagocytic Lymphohistiocytosis

Saumeet Shah, Jay Patel, and Omokayode Osobamiro

Hemophagocytic Lymphohistocytosis is a rare, aggressive and life threatening condition characterized by excessive immune activation. In view of a variable clinical presentation, lack of specificity of the clinical and laboratory findings and outcomes limited by delay in identification warrants discussion to help in this challenging diagnosis. A 57 year old female initially presented for a CT of the chest after failed outpatient treatment for pneumonia; imaging denoted diffuse lymphadenopathy,... Read More
Rare Case of CYP2D6 and CYP2C19 Poor Metabolizer: A Pain Management Dilemma

Amna Shaikh and Murali Patri

Introduction: Cytochrome P450 enzymes are essential for the metabolism of many medications. Genetic variability (polymorphism) in these enzymes may influence a patient's response to commonly prescribed drug classes. CYP2D6 and CYP2C19 enzymes are part of the CYP450 enzyme. CYP2D6 is responsible for the metabolism of most of the commonly prescribed opiate medications, including codeine, tramadol, hydrocodone, and oxycodone while CYP2C19 primarily affects the metabolism of diazepam and carisoprodol, as... Read More
Hyperammonemic Encephalopathy: A Tale of an Innocent Liver

Shivani Sharma, Yaser Alkhatib, and Thushara Paul

Introduction: We describe a rare case of Multiple Myeloma presenting with hyperammonemic encephalopathy.Case: A 76 year-old Caucasian lady was admitted with sudden onset altered mental status. Initial work up included normal Computed Tomography of the head and diffuse background slowing on EEG consistent with metabolic etiology. Her CSF analysis was normal. Ammonia level was elevated at 180 mcg/dL despite the lack of underlying liver disease as evidenced by normal... Read More
Colonic Prolapse of Efferent Stoma in Patients with Cecal Bascule

Tushar Shetty, Tommy Ivanics, Hassan Nasser, and Amalia Stefanou

Cecal bascule, initially described in 1899 by Treves, is the rarest form of cecal volvulus and represents a phenomenon when a redundant and distended cecum folds anteriorly over the ascending colon causing an intestinal obstruction. Patients with cerebral palsy are at increased risk for this condition. We present a 28-year-old male with cerebral palsy, fully functionally dependent in activities of daily living, who presented to the emergency department with... Read More
A Rare Manifestation of Sarcoidosis: A Case of Laryngeal Infiltration

Mohammad Shukairy, Sunjay Modi, Ahmad Murad, and Sarah Gorgis

Background: Sarcoidosis is a multisystem, immune-mediated inflammatory disease characterized histologically by noncaseating granulomas. The underlying etiology favors a multifactorial origin with genetic predisposition, however it remains largely unknown. Presenting symptoms commonly include dyspnea, cough, and chest pain, as more than 90% of individuals with sarcoidosis have pulmonary involvement. Laryngeal involvement is rare and most frequently accompanies diffuse disease, with a reported incidence of 0.33-2.1%. Clinical manifestations of laryngeal sarcoidosis... Read More
Perniotic Lupus

Rasnik Singh, Karlee Novice, and Tor Shwayder

A 9-year-old African American female was referred to dermatology for a history of recurring painful, red-purple bumps and blisters on her hands, feet and nose in the winter. She tried topical hydrocortisone 1% cream without improvement, though noted that the previous year she had similar lesions that resolved in the summertime. Family history was notable for lupus and Sjogren’s disease on her maternal side. On the nose and fingertips... Read More