Case Reports

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Life threatening hypercalcemia: An unusual cause

Firdhous A. Abdul Kather and Ashish Verma

Hypercalcemia is commonly seen in patients with primary hyperparathyroidism and malignancy. Rarely, it can be seen in adrenal insufficiency. We report a case of a 42 year old female who presented with altered mental status and weakness. The patient had decreased appetite, nausea and significant weight loss of 60 pounds in the last few months. Laboratory evaluation was significant for hypercalcemia (15 mg/ dL) and acute kidney injury (1.5... Read More
Diltiazem Induced Bullous Leukocytoclastic Vasculitis

Elian D. Abou Asala, David J. Gelovani, Fiona Clowney, Megan Scott, and Jasmine Omar

Diltiazem is a calcium ion cellular influx inhibitor approved by the U.S. Food and Drug Administration for the management of hypertension and chronic stable angina. Diltiazem is commonly used off label for chronic ventricular rate control in atrial fibrillation. Very few cases of widespread cutaneous vasculitis have been described in association with diltiazem since 1988. We report on a patient developing diffuse petechiae with overlying palpable purpura and tense... Read More
Recommendations for phototherapy during the COVID-19 pandemicEnd of Life Considerations in the ECMO Patient - A Case Presentation

Jonathan Abraham and Jonathan Rose

Background: Extracorporeal membrane oxygenation (ECMO) is an emerging life-sustaining intervention for patients experiencing critical cardiopulmonary compromise. Despite the promises of this therapy, studies have shown that over 40% of patients receiving ECMO do not survive their hospitalization.1 In light of this, existing research and protocols for weaning ECMO in the setting of medical futility is extremely limited.2,4 Additionally, research suggests that medications may work differently for patients receiving ECMO3,... Read More
An Atypical Case of Hemolytic Anemia

Hussna E. Abunafeesa

Introduction: Tumor lysis syndrome (TLS) is a well-known oncologic emergency that can cause significant morbidity and mortality in highly proliferative tumors such as Lymphomas or Leukemias(1). Rasburicase is a recombinant urate oxidase enzyme that converts uric acid to allantoin, which is 5 to 10 times more soluble in urine than uric acid. It is recommended by the 2008 American Society of Clinical Oncology (ASCO) Guidelines for the Management of... Read More
p-16: immunohistochemical staining to differentiate an inflamed atypical nevus

Madeline Adelman, Alexis B. Lyons, Lauren Seale, and Ben J. Friedman

In the monitoring of patients who have had metastatic melanoma, repeat skin exams at specific intervals is a crucial screening tool to prevent recurrence. At many of these visits, suspicious melanocytic lesions are biopsied to determine if they represent a return of the patient’s melanoma. Here, we present a case of a suspicious atypical melanocytic nevus discovered during a skin exam following diagnosis of metastatic melanoma to a lymph... Read More
Systemic Sclerosis with Gastrointestinal manifestations: a unique presentation

Beena U. Ahsan, Harshita Mehrotra, and Adrian Ormsby

Systemic sclerosis is a chronic autoimmune disease of unknown etiology. Disease course usually begins with Raynaud’s phenomenon followed by skin sclerosis and internal organ involvement. Diagnosis is made based on the clinical symptoms, presence of antibodies and endoscopy with biopsy. With this background, we present a case of a 60-year female who was followed by GI clinic for treatment resistant dyspepsia, bloating and nausea. Past medical history was significant... Read More
Oh No! PFO!

Yusuf Alalwan, Zaid Al-Saheli, Taha Ashraf, Jerry Yan, and Khaldoon Alaswad

Introduction: Patent foramen ovale is a congenital cardiac lesion with a prevalence of 25% in the adult population. PFO allows passage of oxygenated blood from right to the left atrium during fetal development. It usually closes by age of two. Majority of individuals with PFO are asymptomatic. Some manifestations include cryptogenic stroke, platypnea, migraine and decompression sickness in scuba divers.

Case Presentation: We present an 80 year old female... Read More
Bi-atrial thrombus causing embolic stroke and pulmonary embolisms

Hisham Alhajala, Iyad Isseh, and Daniel J. Miller

Objective: To present a rare case of bi-atria thrombus that caused embolic stroke and PE and was treated with emergent embolectomy.

Background: Right atriumthrombus is labeled as thrombi in transit. It either progresses to the pulmonary arteries causing significant pulmonary embolism, or it straddles through Foramen Ovale leading to impending paradoxical embolism causing ischemic strokes. We are presenting a rare case of right atrial thrombi straddling through PFO and... Read More
A case of vision loss in a patient with Giant Cell Arteritis

Arif Ali

Background: Giant Cell Arteritis (GCA) is the most common large vessel vasculitis (1) and carries the potential for life-changing morbidity manifested as permanent vision loss or other neurological deficit. Despite these well understood complications, literature suggests that a significant delay to diagnosis in GCA exists. (2) Owing to the gradual and non-specific symptoms associated with GCA, patients are likely to present in the ambulatory setting. This case report aims... Read More
A Novel Endoscopic Treatment for Blue Rubber Bleb Nevus Syndrome

Khaled Almadhoun, Diana Kakos, Georgi Fram, and Anas Kutait

Introduction: Blue Rubber Bleb Nevus Syndrome (BRBNS), also known as Bean Syndrome, is a rare congenital disorder characterized by numerous, cutaneous and internal venous malformations, most commonly involving the skin and gastrointestinal tract (GI). Patients with GI manifestations present with iron deficiency anemia due to recurrent GI hemorrhage from the oozing venous malformations. Due to the rarity of the condition, there are no defined guidelines for the management of... Read More
Acute MI After First Sipuleucel-T Infusion for Prostate Cancer

Zaid Al-Saheli, Nino Balanchivadze, Rawan Hammoudeh, Hanan Ibrahim, and Clara Hwang

Introduction: Advances in cancer therapy have improved patient survival statistics; however, treatment related adverse events can lead to significant morbidity and may be life threatening. Sipuleucel-T is the first FDA approved therapeutic cancer vaccine based on improved overall survival in patients with metastatic castration resistant prostate cancer. We describe a case of acute ST segment elevation myocardial infarction (STEMI) in a patient during the first sipuleucel-T infusion. Our aim... Read More
A man with diffuse hyperkeratotic papules and plaques

Harleen Arora, Danielle Yeager, and Alison Tisack-Boucher

HISTORY: A 47-year-old African American man with no relevant past medical history presented to Dermatology with a rash that began 2-3 years prior with a sudden onset on the arms and knees and has since spread diffusely. He endorses oral involvement. Denies any history of hepatitis C, syphilis, or HIV. No family history of similar condition.

EXAMINATION: Diffusely on the body were many hyperkeratotic scaly papules coalescing into plaques... Read More
The Canary in the Coal Mine

Swarn V. Arya, Nitesh Gandhi, and Rawan Hammoudeh

Case: The patient is a 32-year-old Asian male with PMH of ERSD secondary to minimal change disease (diagnosed at age 26) presented for acute onset shortness of breath, lower extremity edema, and abdominal distension. He underwent CTPE which showed large left pleural effusion, moderate pericardial effusion and as well as ascites. Transthoracic ECHO showed moderate to large pericardial effusion with evidence of tamponade physiology. The patient underwent emergent pericardiocentesis... Read More
Broken Heart, Broken Mind

Taha Ashraf, Ivan M. Columbus Morales, and Avi Cohen

Introduction: Takostubo Cardiomyopathy (TCM) is a unique condition of reversible cardiac dysfunction precipitated by emotional or physical stress. Studies are emerging noting an association with Amyotrophic Lateral Sclerosis (ALS). This is hypothesized to be secondary to baseline elevation of catecholamines in these individuals.

Case Presentation: A 53-year-old female with background of anxiety, presented with acute onset chest pain. Initial evaluation revealed elevated troponins without ST changes on EKG. Echocardiogram... Read More
Taking abdominal pain seriously: a case of aggressive dedifferentiated liposarcoma

Sally FK Askar, Hiba Jabbour, and Philip Kuriakose

Case Description: A 64 year-old female with history of PE on Eliquis with IVC filter placement, tobacco dependence, and class III obesity presents with abdominal discomfort and bilateral leg swelling. Physical examination showed a distended abdomen and bilateral leg edema and tenderness. Doppler ultrasound of the lower extremities showed extensive bilateral lower extremity deep vein thromboses (DVT). Patient developed oliguria and acute kidney injury, and ultrasound of the kidney... Read More
Bilateral Segmental Optic Disc Edema in Vitamin B1 Deficiency

Andre Aung, Sachin Gandhi, and Poonam Bansal

Introduction: Thiamine is an important vitamin that serves as a crucial cofactor for glucose metabolism. As a result, thiamine deficiency affects many organ systems and can lead to significant morbidity and mortality. The brain heavily relies on glucose metabolism and is thus particularly susceptible to thiamine deficiency. Consequently, thiamine deficiency can lead to Wernicke’s encephalopathy (WE), a clinical syndrome consisting of the triad of ataxia, confusion, and ophthalmic abnormalities... Read More
Kikuchi's Disease presenting as Lupus Erythematosus

Olabola Awosika and Chauncey A. McHargue

A 34-year-old Bengali man with past medical history of hyperthyroidism presented to Dermatology with a red asymptomatic rash affecting the ears, face, and upper body for 1 year. He endorsed fever prior to onset of his rash as well as chronic muscle aches, joint pain, and fatigue over the past 2 months. Previous treatments, including prednisone taper, triamcinolone ointment, and oral clindamycin, led to no improvement in the appearance... Read More
A Transformation of Prostate Adenocarcinoma to Small Cell Carcinoma

Julia Bachler

Here we describe the case of a 57yo male who was diagnosed with stage IV prostate cancer, which subsequently transformed into small cell carcinoma of the prostate found on histology. He initially presented with fatigue and feeling poor overall for which he was diagnosed with metastatic prostate adenocarcinoma with PSA of 58.4. At that time, CT imaging showed metastatic disease with lymphadenopathy in the retro-peritoneum and pelvis. He was... Read More
Actinomyces Infection Leading to Pseudoepitheliomatous Hyperplasia Within a Tattoo

Victoria Badia, Angela J. Jiang, and Holly Kerr

A Caucasian woman in her 40s presented with a one-year history of raised, dry, pruritic papules on the tattoo on the left medial lower leg she received six months prior. Examination revealed multiple open comedones and pustules coalescing into an edematous plaque, limited to the red portions of the tattoo. Histological examination revealed pseudoepitheliomatous hyperplasia, tattoo ink, and brisk lymphohistiocytic inflammation, suggestive of an infectious process. A wound culture... Read More
Rituximab-induced Procalcitonin Elevation

Zachery Bauer and Junior Uduman

Procalcitonin has been studied as a marker of bacterial lung infection. It frequently guides clinical practice and antibiotic management. However, procalcitonin is known to have false positive results in certain scenarios. This case describes an 86 year old African American woman with mantle cell lymphoma who presented with acute on chronic dyspnea. Diagnostic tests found a white blood cell count of 632 k/uL (95% lymphocytes) and procalcitonin of 1.29... Read More
Management of Traumatic Coracoid Fracture and Anterior Shoulder Instability With a Modified Arthroscopic Latarjet Technique

Shariff Bishai, Colby Ward, Melissa Martinez, Cameron King, and Jonathan Hinz

Abstract: Coracoid fractures are an uncommon injury and typically occur in the setting of high energy trauma. Isolated injury to the coracoid is rare therefore a high suspicion for concomitant shoulder injury should exist. These associated injuries have been shown to be acromioclavicular dislocations, clavicular and acromial fractures, scapular spine fractures, rotator cuff tears, and anterior shoulder dislocations. While the majority of these shoulder injuries respond to non-surgical treatment,... Read More
Eagle Syndrome Presenting in a Patient as Dysphagia and Failed Intubations

Alison Bradley, Natalie Stec, and Sean Drake

Eagle syndrome is a rare elongation of the styloid process or calcification of the stylohyoid ligament. Most cases are asymptomatic but compression on head and neck structures can result in dysphagia and neck pain. Etiology may be related to surgical scar tissue but is unclear due to limited case presentation. A 52 year-old male with surgical history of tonsillectomy presented to the hospital with shortness of breath. He developed... Read More
Acute Onset Shortness of Breath with New Murmur: An ED Case Study

Joseph Broderick and Jerry Greib

Background: Shortness of breath especially acute onset, is an anxiety inducing symptom for both patients and physicians alike, and it accounts for the 6th most common reason for emergency department visits in the United States. Upon initial presentation to ED, it is the job of the ED physician to make critical decisions in the acute management of that patient, but also lay the groundwork further treatment by consultants either... Read More
Perforating folliculitis and hand-foot-skin reaction due to sorafenib

Stephanie Chapman and Anna Axelson

A 62-year-old African American woman presented to dermatology clinic for evaluation of a painful rash on the extremities ongoing for 2 months. She had a past medical history significant for hepatitis c virus treated with Harvoni in 2018, liver cirrhosis, and hepatocellular carcinoma (HCC) diagnosed 7 months prior. Painful, rough, dark bumps erupted on the extremities 3 months after beginning treatment for HCC with sorafenib 400 mg BID. Additionally,... Read More
Metformin Induced Lactic Acidosis

Saad Chaudhry, Michael Ramalia, Alan Mundakkal, and Omokayode Osobamiro

Background: Metformin induced lactic acidosis is estimated to affect less than 10 cases per 100,000 patients. Metformin is the first line treatment for diabetes mellitus II due to its excellent safety profile along with its reasonable efficacy. However, metformin induced lactic acidosis may present, particularly in those with renal or hepatic impairment. Metformin’s mechanism of action is thought to be inhibiting gluconeogenesis in the liver. This impacts lactate metabolism... Read More