Case Reports

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Copper Deficiency Myeloneuropathy: An Atypical Presentation of Guillain-Barré Syndrome

Eric Lisznyai, Stephanie Phillips, Kajali Mishra, and Sean Drake

Copper (Cu) deficiency myeloneuropathy due to acquired Cu deficiency is both rare and debilitating. More women than men are affected, involving patients aged 32-80 years. Cu itself is a key component of the nervous system, involved in electron transport, oxidative phosphorylation, antioxidant defense, catecholamine synthesis, and iron homeostasis. Afflicted patients usually present with anemia and leukopenia, along with subacute gait disorder with prominent sensory ataxia/spasticity, impaired vibration/position sense, and... Read More
An Unexpected Cause of Small Bowel Obstruction in an Elderly Gentleman

Ana Lozano, Shyamal Pansuriya, and Shivanhalli Prakash

Introduction: When compared to children, intussusception is rare in adults. It comprises only 5% of all intussusceptions and represents only 1% of all bowel obstructions. The mean age in adults is 50 years of age with no gender predominance. It typically presents with nonspecific symptoms and clinical findings. Thus, it is important to maintain a broad differential in order to avoid delay in diagnosis and treatment.

Case presentation: We... Read More
Tumefactive Multiple Sclerosis, an Uncommon Variant with Several Mimics

David Macon

Tumefactive multiple sclerosis is a rare variant of multiple sclerosis that poses both diagnostic and therapeutic challenges for medical providers. This variant occurs infrequently, with an incidence of approximately 1-3 per 1000 cases of multiple sclerosis, with clinical features that make it difficult to distinguish from CNS neoplasm, infection, or infarction. Symptoms are highly variable, depending on areas of the brain affected, possibly impacting sensory, motor, and cognitive function.... Read More
Nocardia farcinica: No Farce Bacteremia

Georgiana Marusca, Smitha Gudipati, Hind Hadid, and Mayur Ramesh

Nocardia species are gram-positive, aerobic, partially acid-fast organisms with a beaded branching growth pattern. This species is commonly found in soil, dust, decomposing vegetation, salt and fresh water. Nocardia species are opportunistic bacteria, acquired either through inhalation of airborne spores or direct skin inoculation. The typical patient population includes cases of neoplasms, solid organ and hematopoietic stem cell transplant on immunosuppression, HIV infection, and long-term steroid use. Of all... Read More
Development of Hepatocellular Carcinoma after Achieving Sustained HCVVirologic Response and Regression of Cirrhosis

Harshita Mehrotra, Beena U. Ahsan, and Mohammad Raoufi

Hepatocellular carcinoma (HCC) is the fastest growing cause of cancer mortality. Interferon/ribavirin and direct acting antiviral (DAA) therapy have successfully treated HCV infection and may halt the progression of fibrosis. It is generally believed that HCC primarily occurs in the background of HCV- related cirrhosis; theoretically, achieving sustained viral response (SVR) could decrease the incidence of HCC by slowing down fibrosing process; hence preventing progression of cirrhosis. Here, we... Read More
Three Lives At Stake: A Case of Acute Myocardial Infarction in a Patient with Twin Pregnancy

Anthony Michaelis, Satheesh Gunaga, Tyson McKechnie, Brandon Baroff, and Qaiser Shafiq

An acute myocardial infarction (AMI) is a rare complication of pregnancy. The incidence ranges between 3 to 100 per 100,000 live-births. Risk factors include common comorbidities such as smoking, hypertension, hyperlipidemia, diabetes mellitus, sedentary life-style, and obesity. Pregnancy carries additional unique AMI risk factors including advanced maternal age, preeclampsia, thrombophilia, postpartum infection/sepsis and hemorrhages. We describe the unique case of an acute ST-elevation myocardial infarction (STEMI) in a 37... Read More
Rare case of gout manifesting as bilateral eyelid lesions

Shravani Mikkilineni and Dianne M. Schlachter

Gout is a systemic disease characterized by monosodium urate crystal deposition triggering inflammation throughout the body. The authors present a case of a 37-year-old female who presented with bilateral eyelid and canthal lesions. The patient had a tan spherical lesion on her left upper lid, a circumscribed flesh-colored nodule at her left medial canthus, and a more pigmented lesion at her right lateral canthus. Following complete excisional biopsy of... Read More
Persistent hypogammaglobulinemia in CVID secondary to protein losing enteropathy

Sunjay Modi, Alex Horbal, Jasmine F. Alsukhon, and Haejin Kim

Case Presentation: Patient is a 40 year old male with PMH of B cell Lymphoma s/p R-CHOP and radiation in remission, Common Variable Immunodeficiency (CVID) diagnosed prior to the hospital admission after IgG levels were found to be/dL (reference range of 700-1600 mg/dL) and recurrent Clostridium Difficile (C. Difficile) admitted to the ICU for left hip abscess and Acinetobacter pneumonia causing septic shock. Patient had a chronic history of... Read More
Thoracoacromial Artery Injury After Tube Thoracostomy for Pneumothorax

Adhnan Mohamed, Shravan Leonard-Murali, Ann Woodward, and Dione Blyden

In this case, a patient presented in a delayed fashion after blunt trauma. He was found to have a large left-sided pneumothorax without any associated traumatic injuries, such as rib fractures. A tube thoracostomy was performed. After placement of the apically-oriented tube, he developed a hemothorax. Computed tomography imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His hemothorax was... Read More
An Unusual Presentation of Recurrent Squamous Cell Carcinoma

Tasneem F. Mohammad, Aaron Tisack, Mark R. Balle, and Joseph McGoey

Introduction: Cutaneous squamous cell carcinoma (cSCC) is the second most common type of skin cancer with excellent outcomes after surgical removal in most cases. However, local recurrence occurs in about 4.6% of cases and is a sign of aggressive biologic behavior. Here, we present a case of recurrent SCC with unusual clinical features.

Case Presentation: A 65-year old male with past medical history of untreated prostate cancer and anal... Read More
Interesting Presentation of Statin-induced Necrotizing Myopathy

Mustafa Mohammed, Omar Sallam, and Ahmed Elbanna

Introduction: It is well know that statins can be associated with myopathy, myalgias and elevation in CPK. These aforementioned events resolve on discontinuation of statins. One unique presentation is autoimmune myopathy that persists despite discontinuation of statins. This entity requires immunosuppression following the insult in addition to statin discontinuation to help with symptoms.

Case description: 67-year-old male with past medical history of hepatitis C, type 2 diabetes mellitus, hypertension... Read More
Right coronary artery spasm following anastomotic leak status post-esophagectomy

Yogita Mosalpuria

MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) is a syndrome defined as MI with normal or near normal coronary arteries on angiography. Although the prevalence is estimated to be between 1-14%, its incidence in patients undergoing non-cardiac surgery, is not established. Etiologies such as coronary artery vasospasm, acute thrombosis at site of a non-obstructive eccentric plaque thrombus, takotsubo cardiomyopathy, coronary microvascular dysfunction, viral myocarditis, thrombophilia, and coronary artery embolism,... Read More
Disseminated Histoplasmosis after Vedolizumab Treatment for Ulcerative Colitis

Ivanna O. Murskyj

Case: A 41-year-old male from Michigan with a past medical history significant for ulcerative colitis presented to the emergency department with fevers and chills in November 2019. He had been experiencing recurrent daily fevers at home, reaching temperatures of 102-103 F. Previously, the patient had been experiencing abdominal pain and loose, bloody stool since January 2019. A colonoscopy in June 2019 showed pancolitis and biopsy was consistent with ulcerative... Read More
An Unusual Case of Urban Actinomyces Pyogenes Infective Endocarditis

Maher Musleh, Anita Ukani, Zain Tariq, and Erica Herc

Actinomyces pyogenes is a gram positive bacillus known to cause pyogenic infections in animals with rare reports in humans with farm animal exposure. A 52-year-old male who was an active injection drug user presented to the emergency department with right-sided weakness, expressive aphasia, and altered mental status. He was found to be tachycardic and febrile. The patient was admitted two weeks prior for bilateral pneumonia and blood cultures grew... Read More
Not Every Rash is an Allergy

Sashi N. Nair

A 61-year-old HIV+ male presented for regular follow up and complained of a rash. Past history was notable for myelofibrosis, and a solitary renal nodule. He had been on cART since 1996 and was on FTC/TAF/Dolutegravir with CD-4 greater than 200 and an undetectable viral load. Three months prior to evaluation he began to develop intermittent fevers with drenching night sweats. Subsequently one month prior to evaluation he developed... Read More
An Intraneural Ganglion Cyst causing Foot Drop: A Case Report

Preyantha Navaratnarajah, Rohit R. Goel, and Danielle Heidemann

A 46 year old male with a past medical history of HTN and chronic pancreatitis presented to clinic with a chief complaint of right leg weakness and numbness/tingling that developed suddenly two months prior to presentation. He denied history of trauma or surgery to the right lower extremity. Physical exam revealed a right foot drop on ambulation with slight circumduction of right leg. Further neurological exam was remarkable for... Read More
$Low Dose Ketamine for Opioid Refractory Cancer Pain by Michelle Nguyen and Anthony S. Grech$
Low Dose Ketamine for Opioid Refractory Cancer Pain

Michelle Nguyen and Anthony S. Grech

Background: Sub-anesthetic ketamine is used in the hospice and palliative setting to provide analgesia for opioid refractory cancer pain. While there are case reports supporting its use for this indication, results from the few studies done are mixed. Additionally, there are no widely agreed upon guidelines for dosing. The heterogeneous results may be attributed to small sample sizes and differing doses and routes of administration of ketamine. The objectives... Read More
Budd-Chiari Syndrome Leading to Cirrhosis in a Young Woman

Hailey Olds and Eric Scher

Introduction: A young woman with a past medical history of hepatic steatosis and polycystic ovarian syndrome on oral contraceptive pills presents with ascites and diffuse hepatocellular disease of unknown etiology. Advanced liver disease is rather unusual in young adults because cirrhosis typically develops gradually after years of persistent liver injury. Cirrhosis is commonly caused by alcohol abuse, viral hepatitis, or nonalcoholic fatty liver disease. Other potential etiologies include autoimmune,... Read More
A Medical Red Herring: Cardiomyopathy presenting as Acute Liver Injury

Dylan T. O'Reilly and Rachel Karmally

Introduction: Heart failure secondary to cardiomyopathy is a known cause of acute liver injury and in severe cases even progression to liver failure. In the setting of severe transaminase elevation, patients may often be misdiagnosed with primary liver injury secondary to acute viral hepatitis, or drug-induced liver injury.

Case Presentation: 32-year-old female 5 months post-partum with no past medical history presented with a 2-week history of nausea, vomiting, abdominal... Read More
The Role of Transcatheter Aortic Valve Replacement in Heyde Syndrome

Keval Patel, Joseph Abbo, Imtiaz Ali, and Rajika L. Munasinghe

This is a case of a pleasant 81 year-old male who presented to the ED complaining of chest pain with activity for the past 3-4 weeks. He reports of chest pain with minimal exertion of walking across the parking lot to the car. This has been a substantial change from his baseline, he currently works as a mason. He was referred to the ED by his primary care physician... Read More
New Onset Back Pain in a Young Patient with Undiagnosed Inferior Vena Cava Atresia

Parth M. Patel, Satheesh Gunaga, Gale Darnell, Gehring Sauter, and Benjamin Glasener

We describe the emergency department (ED) and hospital course of a young male patient that came in with a chief complaint of lower back pain and was ultimately diagnosed with an acute deep venous thrombosis (DVT) precipitated by an underlying congenital abnormality of the Inferior Vena Cava (IVC). Often lower back pain in young patients can be dismissed as musculoskeletal back pain. It is for this reason, that doing... Read More
Ventricular Entrapment Due To Isolated Intraventricular Aspergillus Infection

Parth Y. Patel, Suresh C. Patel, Daniel Noujaim, John Corrigan, and Brent Griffith

Introduction: Intraventricular aspergillus infections are a rare manifestation of fungal infections of the central nervous system (CNS). Intraventricular aspergillus infections have most commonly been identified in immunocompromised patients. Spread to the central nervous system is thought to occur hematogenously (usually from pulmonary infection) or directly from the paranasal sinuses. Clinical diagnosis is difficult, as symptoms are nonspecific, but imaging can be used to create a more accurate differential. This... Read More
A Case of Triglyceride-Induced Pancreatitis

Shama Patel and Omar Francis

The incidence of acute pancreatitis has increased over the years, with gallstones and alcohol abuse being the leading causes of pancreatitis. Seven-percent of the cases of pancreatitis are attributed to hypertriglyceridemia. The diagnosis is often missed secondary to coexisting factors such as medications and alcohol abuse1. Treatment options include bowel rest, intravenous fluids, insulin drip, and plasmapheresis. A 55-year-old female presented to the ED with epigastric abdominal pain radiating... Read More
Psychotic Features and Behavioral Dysregulation in a Patient with Tumefactive Multiple Sclerosis

Shivali Patel, Mohan Gautam, and Bassem Krayem

Tumefactive multiple sclerosis (TMS) is a rare variant of multiple sclerosis (MS), mimicking features of infectious, inflammatory, neoplastic, and vascular neurological phenomena1-3. TMS can present asymptomatically, as well as with higher cortical, motor, sensory, cerebellar, and brainstem symptoms4-6. However, there have not been reported TMS cases presenting with psychiatric features. We describe the case of a 42-year-old woman with a chart reported history of schizoaffective disorder who was first... Read More
Aortic pseudoaneurysm - An unusual presentation

Chinmayee Potti, Scott Bendix, Ali Rteil, Themistokles Chamogeorgakis, Brian Lace, Ann Woodward, and Loay S. Kabbani

Introduction: The esophagus is a frequent site of foreign body impaction, but esophageal perforation and subsequent aortic pseudoaneurysms, and aorto-esophageal fistulas are very rare but potentially life-threatening complications. We present a case of foreign body ingestion, complicated by erosion into the aorta causing a mycotic aneurysm.

Case description: We introduce the case of a 60 year-old male with abdominal pain, nausea, fatigue and fevers. Blood cultures grew out gram-positive... Read More