General Medicine

Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/32079

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Adult-Onset Still’s Disease Masquerading as Candida Sepsis
(2023) Lee, Jessica; Khoncarly, Bilal; Patel, Riddhi; Koldstad, Rebecca; Khan, Ammad; Van, Nga; Upadhyay, Bishwas
Background: Adult Onset Still’s Disease (AOSD) is a rare systemic inflammatory disorder characterized by daily fever, polyarthritis, and transient salmon-pink rash typically at the peak of fever. It is hypothesized to be a reactive syndrome triggered by an infectious process. However, the etiology is still unknown. The Yamaguchi diagnostic criteria is commonly used to classify AOSD. Although there is not a specific laboratory or imaging study used to diagnose AOSD, a serum ferritin > 1000 ng/mL is typically seen. Case presentation: Here we present a case about a 66 year old male with a past medical history of hypertension, hyperlipidemia, uncontrolled type II diabetes mellitus (DMT2), atrial fibrillation, hypothyroidism, chronic knee pain, and tobacco abuse who presented to the hospital with subjective fevers, myalgias, and generalized weakness for 2 weeks. The patient also had a pruritic, erythematous rash in the bilateral lower abdominal region which extended to the inguinal folds over the last 15 days. Physical exam revealed oral thrush covering his tongue. The patient also had chronic, bilateral knee swelling, erythema, and warmth without formal diagnosis of arthritis in the past. The patient was febrile, tachycardic, and hypotensive on admission. Complete blood count was remarkable for leukocytosis with a white blood cell count of 12.35 K/mm3. Based on his initial presentation, the patient was diagnosed with sepsis secondary to candida infection. The patient’s history of DMT2, Jardiance use, and tobacco abuse further elevated suspicion of candidiasis. However, his fever was non-responsive to antifungals, antibiotics, or antivirals. Given his bilateral knee, elbow, and wrist swelling, we investigated possible rheumatologic processes. Further workup revealed an elevated erythrocyte sedimentation rate (ESR) of 106 mm/Hr, elevated C-reactive protein (CRP) of 353 mg/L, and elevated ferritin of 29125 ng/mL suggestive of severe inflammation. The patient’s daughter later revealed he had an erythematous rash most notable at the height of his fever. The Yamaguchi criteria were used to diagnose AOSD. Patient presentation was positive for four major criteria and two minor criteria. His elevated ferritin > 1000 ng/mL solidified the diagnosis. His fever ultimately improved after corticosteroid treatment. Discussion: Diagnosis of AOSD still remains a challenge because it is a diagnosis of exclusion. Although the Yamaguchi criteria are the most sensitive criteria for identifying AOSD, cases do not always present classically. Sepsis is an exclusion criteria for AOSD. The patient’s initial presentation was highly suggestive of sepsis, which initially delayed identification of AOSD. Also the salmon-pink rash that is classically presented with AOSD masqueraded as candida infection in addition to his oral thrush. This case illustrates the diagnostic challenges of AOSD. Delay in diagnosis remains a problem with AOSD, because delay can lead to increased risk of complications including disseminated intravascular coagulopathy (DIC), thrombotic thrombocytopenic purpura (TTP), macrophage activation syndrome, pulmonary hypertension, and diffuse alveolar hemorrhage. Further investigation is critical for understanding the etiology of AOSD as well as diagnostic protocols to expedite management and prevent life-threatening complications.
Case Report: Infective Endocarditis With Pulmonary Emboli, Effusion, and Pneumonia (Last Methamphetamine Abuse 15 Years Ago)
(2023) Patel, Salman; Charolia, Samita; Ahmed, Affan; Kasim, Chaitanya
Background: Infective endocarditis of the right-sided native valve involves the tricuspid or pulmonic valve; isolated right-sided IE accounts for approximately 10 percent of all IE cases. Methamphetamine use is known to cause cardiac complications including vasospasms and damage to the myocardial surface. Case Presentation: Patient is a 51-year-old Caucasian male presented to the ED with cough, fever, shortness of breath and wheezing for the last 2 weeks. Past medical history significant of COPD, hypertension (not on home medications), history of skin cancer of unknown type 10 years ago status postresection, methamphetamine use 15 years ago, current tobacco use disorder, and marijuana use disorder. Patient reported that his symptoms started with fever and a cough that is productive with yellow-colored sputum. He also lost about 15 to 20 pounds in the last 2 to 3 weeks. Patient also noticed hemoptysis and had a couple episodes of bloody sputum. He also reported worsening shortness of breath associated with wheezing and has been using albuterol nebulizer up to 4 times a day without much relief in symptoms. He denies sick contacts. He has been experiencing left upper quadrant abdominal pain worse with breathing/deep inspiration. Patient denies family history of blood clots. Work-up in the ED showed elevated leukocytosis with hyponatremia and mild hyperkalemia. Initial troponin was 0.06 and elevated BNP at 460. Urine analysis was only positive for marijuana. Patient's chest x-ray showed left sided pleural effusion. CTA chest with PE protocol was done and showed numerous cavitary consolidate to masses suspicious for septic emboli and left lower lobe pulmonary embolus with left lower lobe pneumonia and moderate pleural effusion. Day 1 he had a left thoracentesis showing exudative effusion. Day 3-5 PPD skin test, quant gold and AFB sputum cultures x3 are negative. BCX show initially MSSA and then repeat BCX show corynebacterium and staph capitis likely skin contaminant. Patience was placed on oxacillin for MRSA coverage. Day 5 TEE shows 1 cm vegetation in tricuspid valve confirming infective endocarditis. CT surgery is following outpatient for improvement of vegetation in 4 weeks with OP cardiology f/u. Heparin drip switched to Argatroban for heparin resistance and possible HIT. Argatroban bridged to warfarin. PT is now therapeutic. ANA is elevated 1:640, but further work up is negative. Patient will need continued IV antibiotic with oxacillin for at least 6 weeks. Will follow up echo with Cardiology in 4 weeks then revaluate with ID and CT surgery. Order heparin resistance antithrombin III evaluate OP after acute treatment. Conclusion: This case illustrates a unique presentation of infective endocarditis with pulmonary effusion, embolus, and pneumonia. Not certain what caused this patient case if it was his current use of marijuana or is methamphetamine use 15 years ago that just started presenting now.
A Case Report of Multiple Myeloma in a Middle-Aged Male Patient
(2023) Frangenberg, Alexander; Warner, Amanda; Lafonte-Nunez, Eric; Desai, Shivani
Background Multiple Myeloma is a neoplastic plasma cell disorder that results in proliferation, and thus overactivity, of plasma cells to produce immunoglobulin light chains, causing end-organ damage due to proteinemia. Clinical symptoms commonly manifest as renal insufficiency, with hypercalcemia and high blood creatinine, bone marrow dysfunction, such as anemia and osteolytic bone lesions or severe osteopenia, and infection due to suppression of humoral and cell-mediated immunity. While a majority of patients affected are older than 60, younger patients can also be affected; however, clinical factors such as reversibility of renal function, response to chemotherapy, molecular markers, and the need for hemodialysis show greater clinical correlation to differences in outcomes. Case Information This patient is a 42 y.o. male with no past medical history who presented to the ED after his PCP informed him that he had "abnormal labs.” Patient reported back and chest pain for 3 months, which he attributed to a motor vehicle accident, as well as increased fatigue and weight loss ~25 lbs in past 2.5 months. Labs were remarkable for anemia, of Cr 26 (previous baseline of 0.7 1 year ago), BUN 136, Ca 17.8, and K 6.7. CT CAP revealed multiple lytic lesions throughout and was admitted to ICU for continuous renal replacement therapy (CRRT) and evaluation of acute kidney failure in the setting of lytic bone lesions. At this time, nephrology, hematology/oncology and palliative services were consulted for management of patients’ renal function, concerning lab findings with lytic lesions, and pain, respectively. Serum protein electrophoresis (SPEP) was ordered and indicated a kappa light chain myeloma, later confirmed by bone biopsy. He completed 5 days of plasmapheresis and was started on chemotherapy treatment for multiple myeloma, consisting of the CyBorD therapy regimen (cyclophosphamide, bortezomib, dexamethasone). Patient was transferred out of the ICU and began conventional hemodialysis (HD). At time of discharge, patient would follow with Oncology and undergo HD on an outpatient basis. Patient was also treated with Denosumab given his hypercalcemia with plan to continue as outpatient after dental clearance as well as EPO in the outpatient setting given his anemia. Conclusions Multiple Myeloma is a disease primarily affecting older patients, with rates peaking in the seventh decade, and as is common with multiple types of cancer, was commonly thought to have been more severe when presenting in younger patients, as a higher proportion may have cytogenetic abnormalities and physical manifestations of disease on imaging. There does not seem to be any defining presenting clinical features that may differentiate between younger and older patients presenting with signs of Myeloma. Regardless of age, certain presenting clinical factors have been associated with poor outcomes, some of the main ones being creatinine on presentation, platelet count, and serum albumin. In regards to the patient mentioned in this case, creatinine on presentation and maintenance of renal function on hemodialysis are risk factors relating to his disease prognosis, although individual patient factors and treatment options should not be overlooked.
A case of inclusion body myositis masquerading as statin-induced myopathy
(2023) Fatima, Fariya; Quresh, Zehratul; Ansari, Mahira; Moizuddin, Mohammed; Quresh, Quretul
Background: Inclusion body myositis (IBM) is a common acquired myopathy in individuals older than 50 years of age. This idiopathic inflammatory myopathy carries an insidious progression with frequent delays in diagnosis and a high incidence of misdiagnosis resulting in significant morbidity and disability for affected individuals. Clinical features include asymmetric weakness predominantly affecting the quadriceps and/or finger flexors, and a slow, progressive course leading to loss of ambulation and dysphagia. Creatinine kinase (CK) levels are usually less than 10 times normal and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) fall within normal limits. Myositis-specific autoantibodies are typically absent in patients with IBM; however, highly specific positive cytoplasmic 5'-nucleotidase 1A (cN1A) autoantibodies can help distinguish IBM from other forms of myositis, such as polymyositis. There is an association of IBM with autoimmune diseases, such as Sjögren's syndrome, sarcoidosis, and some lymphoproliferative disorders. Unlike many other autoimmune diseases, the condition typically affects males more frequently with a male-to-female ratio of approximately 3:1. Mean age of symptom onset ranges from 61 to 68, with over 20% of patients developing symptoms in their forties. Case presentation: A 71-year-old male patient with a long-standing history of hypertension and dyslipidemia was evaluated for complaints of progressively worsening proximal muscle weakness, fatigue, and dyspnea for more than 2 years in duration. He had been prescribed 40 mg of atorvastatin and was presumed to have statin-induced myopathy after taking the drug for 1 year. Physical examination revealed an otherwise healthy male with proximal muscle weakness with stable vital signs. CK was within normal limits and CRP was 6.6. He was noted to have a negative ANA screen extensive myositis and HMGCR antibody, but was found positive for cytoplasmic 5'-nucleotidase 1A (cN1A) autoantibodies, thus confirming suspicion of IBM. MRI of the thigh demonstrated generalized muscular atrophy with no active inflammation. Given the prolonged nature of the disease in the patient, no active inflammation was noted. He is responding well to tapering doses of steroids and other immunomodulatory options being discussed with him. Conclusion: This case illustrates the importance of appropriate recognition of IBM, and the challenges associated with diagnosis and management. This acquired myopathy may be mistaken for other conditions such as statin-induced myopathy and should be considered in the evaluation of progressive muscle weakness in individuals over 50 years of age. Appropriate intervention is essential to prevent progressive disability with rapid loss of strength and function in affected individuals.
Iatrogenic Ureter Injury and Repair: Comparing Suture Versus Suture and Glue in Ureter End-to-End Anastomosis
(2023) Iloani, Nwamaka Amy; Wade, Michael; Joseph, Matthew; Martinez, Maria; Ntekim, Nedeke; Mallet, Robert T.; Yurvati, Albert
Funding: Dallas Southwest Osteopathic Physicians The ureter is a delicate structure due to its size and anatomical location. It is found deep within the retroperitoneal space and the lower third of the ureter lies adjacent to numerous pelvic structures such as the uterine artery, cervix, vagina, colon, and iliac vessels, and due to its proximity, the ureter is subject to unintentional accidental injury during diagnostic or medical procedures, termed iatrogenic. This paper and associated aim to explore the odds of iatrogenic ureteral injuries (IUI) when comparing different surgical methods, discuss the best preventative options and review the current repair measures, as well as any associated complications. The aim of this study focused on ureter transection that require surgical repair using a ureterouretal anastomosis, a procedure that ligates the free ends of the transected ureter together. Ureters were obtained from anesthetized Yorkshire pigs via standard laparotomy [protocol: IACUC-20-0011]. Ureters were transected laterally midway along the length of the harvested ureter. In Group A ureters, 2 standard stay sutures were placed 180˚ degrees opposite one another to anchor the ureter and ligated using a simple continuous running suture technique. In Group B, ureters were anchored in a similar fashion with stay sutures and ligated using glue to perform the anastomosis. 500 mL saline was then flushed through the ureter to assess the structural integrity of the ureterouretal anastomosis. Group A ureters showed less stricture formation and fluid leakage at the site of anastomoses, indicating that the standard suture technique used in ureter repair is a safe and reasonable gold standard. In contrast, Group B ureters showed stricture formation and some fluid leakage at suture/glue line, indicating the method of ureter anastomoses was inferior. When IV saline was pushed in Group B ureters, the fluid often exited the ureter at both the suture site and the end portion of the ureter, more so than the Group A ureters. Future study needs to be conducted in suture/glue method as it is promising. However, it is not at the level where it can replace current ureter repair end to end anastomoses gold standard. *These authors are solely listed in alphabetical order Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R25HL125447. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Aggressive Fibromatosis of the Quadratus Lumborum in A 28-Year-Old-Female: A Case Report
(2023) Gattu, Tejashwini; Ngo, Wayne; Martinez, Maria; Schultz, Steven
Background: Desmoid tumors (aggressive fibromatosis/desmoid-like tumors) are rare neoplasms that consist of proliferations of clonal fibroblastic proliferation that are aggressive and locally invasive. While the exact cause of desmoid tumors is unknown, they are associated with hereditary conditions such as Gardner’s syndrome and familial adenomatous polyposis both of which arise due to inactivating mutations of the APC gene. On the other hand, fibromatosis that arise sporadically generally has an activating mutation of the CTNNB1 gene which encodes beta-catenin. A history of trauma such as injuries and previous surgeries has also been associated with the development of desmoid tumors. Desmoid tumors are rare with an estimated incidence of 2-4 per million people per year and make up 0.03% of all neoplasms. Early diagnosis and treatment of desmoid tumors are crucial in minimizing morbidity and mortality. Fibromatosis primarily arise in the extra-abdominal setting which comprises approximately 58% of all cases. Among this, most arise in the shoulder or pelvic girdle region. Here, we report an uncommon site of origin for desmoid tumors. Case Presentation: A 28-year-old female with no previous history of trauma presented with lower back pain with radiculopathy radiating to her right hip. An MRI of the lumbar spine revealed a mass in the right iliac fossa and an abdominal and pelvic MRI showed a large circumscribed posterolateral right intra-abdominal wall mass extending up from the right iliac fossa with low signal bands on T1W and T2W imaging. There were intermediate signal areas elsewhere with islands of enhancement. Subsequent abdominal and pelvis CT showed a right posterior pelvic mass measuring 19x13x10 cm concerning for a neoplasm with fibrotic components. The mass originated from the right quadratus lumborum muscle. It involved the posterior distal transversus abdominis and internal oblique abdominal muscle anteriorly. Distally, it involved the iliacus muscle. Differential diagnoses were abdominal wall aggressive fibromatosis/desmoid tumor, solitary fibroid tumor, sarcoma, unusual GIST tumor, neuroectodermal tumor versus nerve sheath tumor, metastasis, lymphoma. A biopsy was performed and results were consistent with aggressive fibromatosis. Conclusion: Desmoid tumors are rare tumors with a locally aggressive and variable course and high risk of local recurrence. The diagnostic workup often includes imaging with MRI and CT and which allows for determining the origin and involvement of adjacent structures to guide possible interventions. Diagnosis can only be confirmed through biopsy which will reveal a monoclonal proliferation of fibroblasts. Treatment ranges from observation, radiotherapy, surgery, and various medications. Because this case presents a desmoid tumor originating from an uncommon site of origin in the quadratus lumborum region, we hope to provide a better clinical picture for the screening and diagnosis of similar aggressive fibromatosis.
The one where all paths point to ITP
(2023) Cruz, Krystal; Hasan, Aya
Background: Immune Thrombocytopenic Purpura (ITP) is an autoimmune condition where antibodies against platelets can eventually lead to sequestration by the spleen and liver inducing a thrombocytopenia. Although primary idiopathic ITP is most common, secondary ITP associated with a trigger such as malignancy, infection, and drugs have also been reported. Case Description: We report a case of a 66 year old male status post two years of chemoradiation for invasive squamous cell carcinoma of oropharynx. This is a unique case where our patient presented to the ED with vomiting, generalized weakness, and a low grade fever. Initial physical exam was negative for mucosal bleeding and petechial rash. Initial labs indicated severe thrombocytopenia with platelets as low as 36,000/UL, AKI with creatinine of 3.73, and elevated LFTs. There was concern for TTP vs. ST-HUS vs Tick borne illness given the extent of thrombocytopenia and subsequent upper extremity petechiae appearing a few days into the patient's admission. However ADAMTS13 and coagulation function were normal, our patient was shiga-toxin negative, and Rickettsia serology negative. The patient was found to have coagulase negative staphylococcus bacteremia which was successfully treated with 7 days of doxycycline. Bone marrow biopsy was notable for schistocytes suspicious for a low grade hemolytic process with no evidence of hematopoietic neoplasia or myelodysplasia. Platelets did not initially improve with blood transfusions remaining 30,0000-50,000. In concordance with the transfusions oral prednisone was given, however thrombocytopenia was refractory to this therapy as well. Lastly plasma exchanges were continued and Rituximab once weekly for three weeks was started; after the first dose our patients' platelets began to improve. Platelet count rose above goal of 150,000 and the patient was discharged with plan for once weekly Rituximab infusions for four weeks outpatient and oral Prednisone 40 mg daily. Discussion: ITP is usually found in females and is mostly asymptomatic. When symptoms appear they are characterized by things such as petechiae, purpura, gingival bleeding. The diagnosis is one of exclusion where patients present with thrombocytopenia and no other abnormalities. Treatment options for first line refractory ITP involve identifying and treating the underlying cause as well as interventions with thrombopoietin receptor agonists, Rituximab, and even splenectomy. These solutions can prove to be expensive and each provides their own risks. Cases such as this emphasize the importance of broadening differential diagnosis when presentation is not typical and initial treatments seem to be refractory.
How did we get here? A historical look at the early clinical trial data investigating Covid-19 monoclonal antibody therapy and implications for the future
(2023) Healy, Jack; Finkenstaedt, Samantha; Frangenberg, Alexander; Tandon, Saloni; Chou, Eric
BACKGROUND: The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic to mild, moderate, severe, and clinical illness. Current recommendations for the use of monoclonal antibody (mAb) therapy - including Ritonavir-boosted Nirmatrelvir, Remdesivir, and Molnupiravir - for the treatment of SARS-CoV-2 infection include use in patients who are at risk of progressing to severe COVID-19. Given the unprecedented process and speed of research conducted on the use of antibody therapies, beginning with polyclonal antibodies developed from patients recovered from COVID-19 to the development of monoclonal antibodies targeting the spike protein(s) of various COVID-19 variants, it is important to reflect on early data to better understand the early challenges pertaining to mAb and early COVID 19 research. METHODS: Articles published between January 1, 2019 and October 1, 2021 were identified from keyword search of Medline (via PubMed). Clinical trials evaluating the outcomes of monoclonal antibody (MAB) therapy for the treatment of Covid-19 infection were included. This study was IRB-exempt. RESULTS: Initial search results yielded 493 papers. After title and abstract screen, full articles were read in their entirety. A total of 21 articles were included in this analysis, representing 7833 patients. Eight studies found a statistically significant benefit to MAB use, 12 found no benefit, and one study did not perform formal statistical hypothesis testing. Primary outcomes varied between studies and included mortality rate, ICU admission, mechanical ventilation requirements, Covid-related hospitalization, supplementary oxygen use, clinical composite scores, and viral load. DISCUSSION: Early clinical trial data was inconclusive but suggested that monoclonal antibody therapy may have reduced hospitalizations and provided a mortality benefit in some populations with COVID-19. However, several important factors may have influenced treatment response. These factors included antibody type, dose, route, therapy initiation relative to symptom onset, and disease severity, varying COVID-19 treatment protocols throughout the pandemic, possible interactions between early vaccinations and mAb, and disease severity-dependent treatment response . It is important to look back at the early data to understand the progression to current management protocols. Previously, biologics were analyzed for approval independently of other drug applications, and could be given priority as an "orphan drug” with accelerated status for patients with rare diseases needing treatment now, allowing for rapid market mobilization. The COVID-19 pandemic sped up the process even further. The FDA was able to issue Emergency Use Authorizations (EUA) to companies with promising pharmaceuticals and biologics for direct care of patients with COVID-19, without the confirmatory trials and tests previously required. Although the healthcare system benefited from greater access to approved biologic treatments for COVID-19, many of the biologics were revoked due to concerns about both efficacy and safety. In the end, it remains to be seen if the proper avenues for the ethical development of pharmaceuticals were neglected in favor of the streamlined approval process by the pharmaceutical companies, and thus should be considered in future international medical events.
Presentations of Cutaneous Disease in Various Skin Pigmentations: Atopic Dermatitis
(2023) Thompson, Jordan; Nguyen, Cecilia; Nguyen, Daniel; Wong, Christopher; Scheufele, Christian; Carletti, Michael; Weis, Stephen
Background Atopic dermatitis (AD), commonly known as eczema, is a chronic inflammatory skin disorder classically affecting flexural areas of the body. It presents in any age group, but commonly develops during infancy and early childhood and morphologic subtypes exist due to varying skin tones. Children with darker skin were approximately six times more likely to develop atopic dermatitis in comparison to children with lighter skin. African American and Asian patients more frequently have atopic dermatitis compared to Caucasian patients. Presentations of atopic dermatitis vary due to duration, age and color of skin. Acute lesions are clinically characterized as ill-defined pruritic, erythematous plaques (raised, >1cm) while chronic lesions are dry, hyperpigmented plaques (raised, >1cm) with lichenification and prurigo nodules. Differential diagnosis includes scabies, seborrheic dermatitis, ichthyoses, and psoriasis. This review article will showcase clinical images with varying presentations of atopic dermatitis in ranging age groups and skin color according to the Fitzpatrick scale. Case Information The Fitzpatrick scale provides a classification system for an individual’s skin type based on the ability to burn and/or tan when exposed to ultraviolet light. It is used to approximate the degree of skin pigmentation. This review article focuses on 5 distinct cases of varying ages and skin types to present 5 atypical presentations of atopic dermatitis. Case 1 presents a 40-year-old, Fitzpatrick I, with chronic atopic dermatitis. Case 2 presents a 6-month-old, Fitzpatrick III, with acute atopic dermatitis. Case 3 presents a 11-year-old, Fitzpatrick IV, with subacute atopic dermatitis. Case 4 presents a 21-year-old, Fitzpatrick IV, with chronic atopic dermatitis. Case 5 presents a 3-year-old, Fitzpatrick V, with chronic atopic dermatitis. Discussion In the United States, atopic dermatitis affects approximately 11.3 – 12.7% and 6.9 – 7.6% of children and adults, respectively. Presentations of atopic dermatitis can vary due to duration, age and color of skin. Post inflammatory dyspigmentation is observed more in African American patients due to decreased healthcare access and different clinical manifestations, notably with erythema. Atopic dermatitis can have a significant quality of life impairment and disease burden in diagnosed individuals, especially those with darker skin pigmentation. The disease can progress to a systemic disorder, "atopic march” causing allergic conditions including asthma, allergic rhinitis and food allergies. Pruritus, a hallmark symptom of atopic dermatitis, may lead to increased sleep disturbances, fatigue, and mental health symptoms which ultimately affects growth, school performance, attention, and accident rates in children. Atopic dermatitis has been linked to attention-deficit hyperactivity disorder in children and increased rates of depression and anxiety in teengagers and adults. The purpose of this review article is to outline atypical presentations of atopic dermatitis to allow practitioners to gain a better understanding to aid in diagnosing patients with different skin tones.
Assessing Postural Sway Among Older Adult Females with Hypertension
(2023) Bautista, Trissha Belle; Adams, Aminah; Kennedy, Shawn; Camp, Kathlene E.; Patterson, Rita
Purpose: Hypertension and use of antihypertensive medications have been generally suggested as risk factors for falls; however, supporting evidence remains unclear on the link between hypertension and balance. With minimal research assessing postural control using a force plate among older adults with hypertension, the purpose of this study is to evaluate the relationship between postural sway and blood pressure status and identify variables that contribute to falls. Methods: This study is a retrospective, matched case-control analysis incorporating Quiet Stance Test data from the UNTHSC Human Movement Performance Lab for a case group of older adult females aged 55 to 94 with hypertension (n=100) and an age-matched and gender-matched normotensive control group (n=44) generated from previous studies conducted through the UNTHSC HMP Lab. The Quiet Stance Test involved participants standing barefoot with disposable foot covers, on pre-marked footprints on a force plate (Bertec, Columbus, OH and BioSway, Shirley, NY), both arms relaxed on the sides while looking at an eye-level target for three 10-second trials each in eyes open (EO) and eyes closed (EC) conditions. Twenty sway variables were analyzed using Paired Samples t-Test. Data were also stratified for age and height for One-Way ANOVA and Pearson Correlation tests. Tables were generated to compare mean differences between case and control groups in the EO and EC conditions. (UNTHSC IRB# 2013-102) Results: Participants’ ages ranged from 55 to 90 (M=70.7, SD=9.3) and height from 1.45m to 1.78m (M=1.62, SD=0.07) in the case group. In the control group, participants’ ages ranged from 57 to 89 (M=68.8, SD=6.0) and height from 1.47m to 1.73m (M=1.62, SD=0.06). Roughly 80% of all participants identified as White. The Paired Samples t-Test comparing EC and EO conditions revealed significant mean differences (p<.001) for thirteen of twenty sway variables in the case group. Meanwhile, the control group showed no significant mean differences in any variable. The mean differences for four of twenty sway variables were significant (p<.001) for at least one of the height subgroups in the case group (EC condition), while the control group had no significant mean differences. The only variable that was found to have significant (p<.001) mean differences for at least one of the age subgroups is rotational frequency for the case group (EC condition). For the same group and condition, a significant positive correlation was found between rotational frequency and age (r=0.404, p<.001). The center of pressure’s (COP) position is dynamic. Rotational frequency is a measure of COP instability and is the mean velocity of the COP traveling over a circular path defined by the mean displacement from the center position of the COP stabilogram. Conclusion: These findings suggest there may be differences in balance between normotensive and hypertensive older adult females related to age and height. A limitation of this study is that the sampling of convenience included hypertensive subjects that also have back pain concerns. Further studies should include male participants, create more racially diverse research cohorts, and consider comorbidities as variables that may provide insight into other influences on sway.
Evaluating a Nail-Plate Combination Implant in Treatment of Distal Femoral Fractures: A Case Series
(2023) Ngo, Wayne; Dutta, Arpam; Benage, Timothy
Distal femur fractures are severe injuries that have varying management among orthopedic surgeons. These fractures are thought to be caused by high-energy trauma in younger patients and low-energy injuries in older patients. These fractures account for approximately 6 to 7% of all fractures and the gender distribution is estimated to be 33.4% male and 66.6% female. Additionally, there is increase in distal femoral fracture incidence after the age of 60 in both genders. Therefore, these fractures require optimal treatment to prevent disability and improve patient quality of life. Current treatment for distal femur fractures can vary broadly but in this study, we focus on intramedullary nailing and plating. Intramedullary nailing has been championed as less invasive as it offers minimal disruption of soft tissues and endosteal arterial supply. Nailing of extremely distal periarticular fractures is becoming more common because of better load sharing and minimal soft tissue stripping compared to plating. In comparison, submuscular locking plates have become standard in these fractures and offer several advantages. These include more flexibility in periprosthetic fractures, preservation of blood supply to the periosteum, decreased time under anesthesia, and lower blood loss. The purpose of this case series is to qualitatively examine the outcomes of patients who received a nail-plate combination for their distal femoral fracture. A chart review of 10 patients who received a nail and side plate combination at JPS Hospital was conducted. These patients underwent surgery from August 2021 to May 2022. They consisted of 4 males and 6 females with a mean age of 63 years (range of 36 to 89 years). For each patient, an outcome of union or nonunion was recorded along with time since surgery. The nailing system used was the Synthes Retrograde Femoral Nailing System. When examining results, only 6 patients had follow up visits. 4 of the 6 patients achieved union at times of 3, 4, 6, and 8 months since date of surgery. Meanwhile, the remaining 2 patients had nonunion. One of these nonunion patients required hardware removal and has not achieved union at 5 months. The other nonunion patient has yet to achieve union at 7 months. When compared to current literature, two studies have shown promising results with the nail-plate combination. The first had 8 patients with 100% union rate while the second had 15 patients with 93% union rate. The union rate in this study is relatively lower at 66%. However, this can be attributed to variables such as severity of initial injury, patient compliance, comorbidities affecting healing, and implant manufacturer. The rationale behind the combination technique is creating a stable and balanced fixation that allows for immediate weight bearing and mobilization post-surgery. While it shows promising results, more research in larger cohorts need to be done before the nail-plate combination can be evaluated against traditional methods.
Factor VII Deficiency: A Diagnostic Dilemma
(2023) Nguyen, My; Nguyen-Pham, Amy; Nguyen, Khanh; Wang, Jonathan
Background/Introduction: Factor VII deficiency is a rare bleeding disorder, estimated to affect 1 in 300,000 to 500,000 individuals in the general population. The disease is associated with autosomal recessive inheritance or could be acquired. Clinical manifestations range from asymptomatic to severe, life-threatening bleeds. There is poor correlation between the level of factor VII and the severity of symptoms, thus making diagnosis and management a challenge. Here we present a case of incidental finding of elevated international normalized ratio (INR) and found to have factor VII deficiency. Description of Case: Patient is a 74 year-old male with a history of CREST, pulmonary fibrosis, Raynaud's Disease, COPD, referred by his cardiologist for recurrent, unresolved pericardial effusion. Compared to his previous echocardiogram, the pericardial effusion is now circumferential and enlarged, leading to an immediate need for pericardiocentesis. Due to the urgency of the patient’s condition and lack of bleeding history, we proceeded with the procedure without obtaining INR. CT scan taken during the course of hospitalization revealed a cavitary lesion of the lung, which prompted planning of a CT biopsy with Interventional Radiology. At this time, INR was 1.8 (Ref 0.8-1.1) with normal PTT and there was no reported anticoagulants use. Due to increased INR, ultrasound of the liver was done and showed no features of fibrosis. Vitamin K was preemptively administered without improvement of INR. Mixing study resulted in correction for PT and the ensuing factor assay revealed a deficiency of factor VII. FFP was administered prior to other procedures. Discussion/Conclusion: Factor VII deficiency is an extremely heterogeneous disorder with regard to clinical presentation, sites, and severity of bleeding. Symptoms exist on a continuum of severity, ranging from epistaxis, gum bleeds, easy bruisability, and menorrhagia to hemarthrosis, gastrointestinal and intracranial bleeds (3). Despite being a prime protein in the coagulation system, patients mostly present with mucocutaneous bleeding, which sometimes can be confused with platelet-related bleeding and hence require thorough evaluation (2). Most patients with Factor VII deficiency are diagnosed incidentally with abnormal PT, which can then be confirmed by one-stage PT-based assay for factor VII level. However, PT and factor VII levels do not correlate with the severity of bleeding symptoms and future risk of bleeding (3). In addition, previous studies have shown a marked phenotype-genotype disparity among patients (4). This could be attributed to various genetic polymorphisms of the gene or environmental factors, such as pregnancy, increasing age, obesity, underlying disorders, and vitamin K deficiency. The lack of correlation also poses a challenge for management strategies. Treatment cannot depend on the level of Factor VII alone, but also on severity of disease, risk of certain medications or procedures, and patient’s age and comorbidities. Several modalities have been used as treatment, such as recombinant activated factor VII (rFVIIa), plasma-derived factor VII, fresh frozen plasma, and IV prothrombin complex concentrates (5).
Tibial Plateau Fracture Treated with ORIF and Tibia Strut in a 37-year-old Male: A Case Report
(2023) Ngo, Wayne; Craddock, Germain; Frangenberg, Alexander
Tibial plateau fractures (TPFs) are orthopedic challenges that have multiple injury modalities and clinical presentations. These fractures can be caused by high energy or low energy trauma. Epidemiological studies estimate peak incidence in the third and sixth decade of life for males and between the fourth and fifth decade for females. TPFs are often classified using the Schatzker classification system which can dictate management. Case presentation: this is a 37-year-old male who complained of right knee pain after sustaining a fall from a truck ramp. The patient heard a pop and had severe, sharp pain in his right knee. In the emergency room, CT imaging demonstrated a comminuted tibial plateau fracture involving the medial and lateral tibial plateau as well as the metaphysis. The lateral tibial plateau was depressed by 5 mm. The patient was placed in a knee immobilizer, made non-weight bearing, and scheduled for surgical planning in 2 weeks. Unfortunately, the patient never followed up and opted for non-operative management. 6 months later, he came to our clinic because of significant pain and instability in the knee. X-rays demonstrated a chronic, incompletely healed fracture of the medial tibial metaphysis extending to the tibial eminence. Chronic fracture deformities of the medial femoral condyle and lateral tibial plateau were also observed. The patient agreed to surgery at our clinic. The surgical technique was a proximal tibial osteotomy. An incision was made centered over the medial aspect of the gastrocnemius. The medial soft tissue sleeve was elevated off the proximal tibia in subperiosteal fashion while maintaining the MCL insertions. Next, a sagittal saw was used to make an osteotomy. The proximal tibia was elevated to correct for varus deformity. Afterwards, a fibula strut was placed followed by plate and screws. After biplanar x-ray verified adequate reduction and hardware replacement, bone filler was used to fill the void. Post operatively, the patient was made non-weight bearing for 3 months. Range of the motion was encouraged as tolerated. At the first month follow up, the patient’s pain was well controlled and range of motion exercises were done regularly. No paresthesia, numbness, or wound dehiscence were noted. Repeat x-rays demonstrated intact hardware with evidence of healing fracture lines compared to immediate post-operative images. Fragments and the knee were appropriately aligned. No significant soft tissue or joint effusion were appreciated on imaging. Conclusion: after failing nonoperative treatment, this patient with comminuted bicondylar tibial plateau fracture has received definitive treatment with open reduction and internal fixation. Higher rates of unacceptable results from nonoperative treatment is inline with Schatzker’s series in which operative treatment resulted in more acceptable outcomes. Because the fracture in this patient is more consistent with a Schatzker IV or V classification with intra-articular displacement more than 2 mm, the patient’s choice for nonoperative treatment was not appropriate. This led to a malunion and non-union that necessitated surgery. Perhaps greater warning should have been given to the patient about the risks of nonoperative treatment at their initial encounter.
HASHIMOTO'S THYROIDITIS ASSOCIATED WITH RHABDOMYOLYSIS AFTER INFECTION WITH COVID19
(2023) Park, Daniel; Mebane, Nova; Mebane, Neva; Salloum, Cynthia
This case study discusses the care of a 74-year-old female with three hospital admissions over the year 2022. There will be a detailed focus on the second admission. Her chief complaint for her second admission was generalized weakness and fatigue with an initial creatinine kinase of greater than 50,000 Units/L (reference range 25-192) and a thyroid stimulating hormone level of 178. She was initially treated with intravenous fluids, IV levothyroxine, and IV hydrocortisone. During the middle of her second hospitalization, intravenous immunoglobulin was added to her treatment regimen. The patient was discharged from her second hospitalization and readmitted one day later due to severe blood loss secondary to a muscle biopsy hematoma. The patient was discharged with baseline ambulation and mentation after receiving multiple blood transfusions in addition to the continuation of oral levothyroxine and oral steroids. Conclusions: This case study represents another contribution to scientific literature towards the suggestion that Hashimoto’s Thyroiditis is associated with severe rhabdomyolysis. In addition, this case study suggests a possible association between people developing autoimmune thyroiditis and rhabdomyolysis post-infection with COVID-19. In patients with rhabdomyolysis, physicians should consider ordering a TSH with close outpatient follow-up. Investigation into the use of intravenous immunoglobulin for severe Hashimoto’s Thyroiditis may prove beneficial for patients.
The One Where Hepatic Encephalopathy Presented in the Setting of Normal Ammonia Levels
(2023) Hasan, Aya; Cruz Escobar, Krystal
Background: Ammonia has long been used as an independent predictor of hospitalization with liver-related complications and mortality as well as directly linked to hepatic encephalopathy. Ammonia is able to cross the blood-brain barrier and employ toxic neuroinflammation and alterations in neurotransmission. Case Presentation: A 67 year-old-male with a history of cirrhosis status post TIPS, varices with multiple upper and lower GI bleeding episodes presented to the Emergency Department with abdominal pain, fever, and altered mental status. Vital signs were notable for fever and tachycardia. The initial consideration for the patient's altered mental status involved infectious vs metabolic concern. He was started on empiric antibiotic treatment while awaiting blood cultures. Upon examination, the patient was disoriented with abnormal coordination, inattentive and impaired cognition. Initial labs shown were notable for a WBC of 6.31, Hemoglobin (Hgb) of 10.4, Hematocrit (Hct) of 30.2, MCV of 98.1, and Platelets (plt) of 56. His ammonia levels were 30, in the high normal range.** Given immunocompromised state, a lumbar puncture was obtained, revealing 97 protein and 4 WBC (insignificant). CT and Ultrasound of the abdomen revealed occlusion of TIPS shunt, along with MRI revealing hepatocellular carcinoma. GI was consulted and based on clinical suspicion of hepatic encephalopathy S/P TIPS occlusion, he was started on Rifaxmin 550 mg BID and Lactulose 20 g q2 hours. After 9 bowel movements, the patient had a surprising improvement in his mentation, considering his normal ammonia levels. On exam, he had returned to baseline mentation, AO x3. Following changes in mentation, labs revealed IgG AB reactive to Treponema Pallidum, and the patient was started on Penicillin. It is important to note that the improvement in the patient’s mentation was prior to the initiation of the penicillin. Conclusion: Hyperammonemia in cirrhosis involves interactions amongst many different organs as it may arise due to declining liver synthetic function, portosystemic shunting, or renal dysfunction. Ammonia, a neurotoxic metabolite, is believed to play a central role in the abnormal brain function that is seen in hepatic encephalopathy. It is important to note that inflammation has been shown to play a role in the encephalopathic symptoms of liver disease, as the liver is inflamed and the gut leaks bacteria, cytokines produced from these processes can reach the brain, inducing further inflammation of the CNS. This case demonstrates the importance of not ruling out Hepatic Encephalopathy as the cause of abnormal brain function in the setting of normal ammonia levels, as there are many other inflammatory processes that are taking place as a result of hepatic dysfunction. Treatment options involve the use of Rifaximin, an antibiotic that targets ammonia-producing bacteria in the gut, and lactulose which aids in creating an acidic intestinal environment converting ammonia to ammonium for excretion. Our patient provides a unique example where all of the mechanisms and solutions imply rising levels of ammonia leading to hepatic encephalopathy, in the rare setting of a normal-ranging blood ammonia level.
Major Musculoskeletal Injuries and the Menstrual Cycle: A Case Study
(2023) Prado, Cynthia; Maddux, Scott D.
Background: There is a clear difference between males and females in the incidence of certain sports injuries. For example, females are about 9 times more likely to experience anterior cruciate ligament (ACL) tears, while males are about 7 times more likely to experience calcaneal (Achilles) tears. These discrepancies warrant further evaluation into the core differences between males and females, one of which is the menstrual cycle. During the first 15 days of the of the menstrual cycle, estrogen levels rise. There is discussion in medical literature about estrogen’s effects on the musculoskeletal system, which may begin to correlate these injury rates and menstruation. One study measured estrogen levels and presynaptic inhibition in males and females during day 1 and day 15 of the menstrual cycle, and found that both measurements were significantly different on day 15. This suggests that as estrogen concentration increases in the first half of the menstrual cycle, gamma-aminobutyric acid (GABA) in the spinal cord is attenuated, decreasing pre-synaptic inhibition, resulting in altered skeletal motor control. Another study evaluated estrogen’s effect on failure load, which is the force necessary to break or tear a certain object. It analyzed two groups of ovariectomized rabbits, administering estrogen supplementation to one and not the other. It found a reduction in failure load in the hormonal substitution group, implying that tendons and ligaments under estrogen’s influence could rupture at a lower applied force. Another study analyzed the extracellular matrix (ECM) enzyme lysyl oxidase (LOX), which oxidizes lysin in collagen and elastin, mediating the cross-linking between these ECM fibrils. It showed that estrogen inhibits LOX activity in engineered ligaments, implying that the increased estrogen in vivo may decrease the stiffness of tendons/ligaments in women, leading to increased risk of injury. This case illustrates two major musculoskeletal injuries in a young female patient that both occurred within the first fifteen days of her menstrual cycle. Case information: 17-year-old female sustained a right ACL tear during a track meet on day 5 of her menstrual cycle. The same female at age 27 sustained a left Achilles tear during a recreational volleyball game on day 6 of her menstrual cycle. In both occurrences, the patient had no previous injury to the area, no medical conditions, and was not taking any medication. Conclusions: The fact that both of this patient’s major musculoskeletal tears occurred during the first week of her menstrual cycle suggests that changing hormones may have influenced these injuries. The studies that support this conclusion have evaluated estrogen’s effects on the musculoskeletal system and concluded that estrogen has been shown to 1) decrease presynaptic inhibition, 2) reduce failure load, and 3) decrease the stiffness of tendons/ligaments. This research together may begin to explain the correlation between this patient’s injuries and her menstrual cycle. More research is needed on this topic, so that we can definitively identify all risk factors for these kinds of injuries and begin to take steps toward prevention for the appropriate athletes.

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