Case Presentation

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    Brain Cyst in a Pediatric Patient: Early Diagnosis and Outcome
    (2015-03) Xiong, Yi; Chen, George S.; Nguyen, Bao X.; Bowman, W. Paul; Habiba, Nusrath M.; Honeycutt, John
    Purpose (a): Pediatric macrocephaly can be caused by a variety of medical conditions such as tumors and cysts, as well as hydrocephaly. Because of the pliability of the infant skull, macrocephaly patients rarely exhibit focal neurological deficits or other obvious symptoms. Infants can often times compensate to changes in brain anatomy until the very late stages of the disease before deteriorating rapidly. As a result, early detection, diagnosis and treatment are essential to prevent permanent damage to the brain tissue and subsequent consequences such as disability or even death. Methods (b): An infant presented to the UNT Health Pediatric Clinic for the first time for sick visit due to cough and congestion. She was diagnosed to have a brain cyst. Management, outcome, literature review, as well as educational point are discussed. Results (c): We present the case of a 4 month old female infant who originally presented to UNT Health Pediatric Clinic for the first time for sick visit due to cough and congestion. She had virtually no other symptoms except mild macrocephaly. She was first diagnosed by x-ray and CT scan with a huge intra-ventricular or porencephalic cyst, and then subsequently treated by endoscopic fenestration of the cyst. The patient had a period of post-operative seizures, but has now made an impressive recovery. Conclusions (d): Brain cyst in pediatric patient is a rare but potentially dangerous situation if early diagnosis and treatment is not provided. The case we presented outlined a success recovery of a pediatric patient with brain cyst. Such case provided excellent educational point for medical students and clinicians regarding early detection, diagnosis and treatment of pediatric brain cyst.
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    Mycobacterium Abscessus Infection Post Gastric Band Surgery: A Case Report
    (2015-03) Wicker, Ellen; Eisner, Hailey; Atkinson, Barbara
    Purpose: To describe a patient with resistant Mycobacterium abscessus infection, discuss the clinical features and review treatment. Methods: Information and records were obtained on a 39 year old Hispanic male diagnosed with an abdominal abscess who initially presented to the emergency department with a two week history of fever and chills. He had been prescribed ciprofloxacin and flagyl two days prior to presentation. The patient had a significant past surgical history of laparoscopic adjustable gastric band surgery. Results: The gastric band had eroded through the stomach wall causing an intra-abdominal abscess. The band was completely removed and the abscess was drained. Cultures grew Mycobacterium abscessus. Antibiotic susceptibility testing revealed that it was only sensitive to clarithromycin. Conclusion: Patients that present with fever and chills not responsive to routine antibiotics should be tested for resistant bacteria, such as Mycobacterium abscessus. This is especially important in patients that have foreign bodies in their abdomen. Currently, there are no guidelines on treatment for resistant intra-abdominal infections. The plan is to have this patient on clarithromycin for at least one and a half years to prevent additional resistance.
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    African Tick-Bite Fever: A Case Report
    (2015-03) McCormick, Callum G.; Eisner, Hailey; Atkinson, Barbara
    Purpose: In this report we review the clinical features of African tick bite fever (ATBF) and compare them to domestic rickettsial infections. Methods: Information and records were obtained on a 70 year old female diagnosed with ATBF who initially presented with febrile illness, eschars and a history of recent travel to South Africa. She had been misdiagnosed with a staphylococcus infection and treated with Bactrim prior to presentation. Review of the literature was also conducted to research the presentation of rickettsial spotted fever group (RSFG) infections. Results: Clinical features and history lead to the diagnosis of ATBF and administration of appropriate treatment with doxycycline. Conclusion: African tick bite fever is an acute febrile illness commonly seen in travelers to sub-Saharan Africa and the West Indies. It is a mild illness characterized by fever, lymphadenopathy and multiple eschars. Physicians should consider the diagnosis of ATBF in febrile patients and skin lesions in the appropriate epidemiologic setting.
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    Type I Choledochal Cyst a Case Presentation
    (2015-03) Cordova, Hope; Yurvati, Albert
    Choledochal cysts are cysts of the biliary tree of varying location and quantity with the majority being categorized as Type I showing a fusiform dilation of the common bile duct. They affect 1:100,000 to 1:150,000 individuals in the Western world and are usually diagnosed on abdominal CT or US when looking for a source of right upper quadrant pain. Types I and IV choledochal cysts have an increased likelihood of transforming into cholangiocarcinoma and because of this must be caught early to allow total cyst excision followed by a Roux-en-Y hepatojejunostomy. Following total cyst removal, malignancy is seen in 0.7-6% of patients and for this reason they must be followed up annually for liver enzyme monitoring. The case described here is that of a 43 year old Hispanic male who presented with epigastric pain and was found to have a Type I choledochal cyst on abdominal CT. A brief discussion of presentation, management, and treatment for choledochal cysts will follow.
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    Lung Mass in a Patient with Rheumatoid Arthritis: A Case Report
    (2015-03) Olarte, Neal; Huynh, Minh-Duc; Miranda, Erin; Wong, Long
    Purpose: We present a case of a patient who smokes and has a past medical history of rheumatoid arthritis who presented to clinic with a chief complaint of symptomatic rheumatoid exacerbation. Given the patient's status as a smoker, we investigated whether the patient was presenting with atypical symptoms of lung cancer. Methods: We performed a physical exam on the patient and ordered appropriate labs and imaging. For the purposes of this report, we performed a literature review investigating the correlation between smoking, rheumatoid arthritis, and lung cancer. Results: The patient presented with fatigue and diffuse, symmetrical joint and bone pain. Chest x-ray and CT revealed a lingual lung mass. Smoking is a well-established risk factor for the development of lung cancer. Recent studies have shown smoking also increases the risk for the development of rheumatoid arthritis, while rheumatoid arthritis is correlated with increased risk for the development of lung cancer. Conclusions: Lung cancer typically presents with symptoms of shortness of breath and cough with or without hemoptysis, but non-specific extra-pulmonary symptoms such as fatigue may also be present. This patient presented with symptoms of acute rheumatoid exacerbation, but could also have been presenting atypically for lung cancer. Imaging confirmed the presence of a lung mass, but imaging by itself is inappropriate for making the diagnosis of lung cancer. Still, the presence of a lung mass on imaging in a patient with a history of smoking is highly suspicious for malignancy. Rheumatoid arthritis is correlated with increased incidence of lung cancer, but this correlation is small.
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    Life-Threatening Nocardia Empyema: A Case Report
    (2015-03) Copus, Cristina; Eisner, Hailey; Atkinson, Barbara
    Purpose (a): To highlight a rare presentation of empyema and osteomyelitis of the ribs caused by Nocardia species bacteria. This case discusses the clinical features, imaging, and treatment of this unusual infection. Methods (b): A chart and literature review were performed with emphasis on disease presentation, imaging, cultures obtained, and treatment regimen involved in the management of osteomyelitis of the rib caused by Nocardia infection. The infection initially began as a pneumonia which was untreated due to the patient’s lack of health insurance coverage. The pneumonia then transformed into an empyema and eventually infiltrated the chest wall. This allowed bacteria to colonize in the rib causing an osteomyelitis that presented as a large subcutaneous mass of the chest. Results (c): The unusual clinical presentation of a large, painful, subcutaneous mass prompted a CT scan at the emergency department which identified an empyema in the lung and a rib fracture suggestive of osteomyelitis. Infectious etiology was confirmed with culture of both the rib and empyema aspirate, showing colonization with Nocardia. The patient was treated with aggressive IV Bactrim for 6 weeks followed by 4 weeks of oral Bactrim. At follow up he had complete resolution of symptoms. Conclusions (d): Adults with a history of untreated pneumonia who present weeks later with a large, subcutaneous mass on the thorax should be worked up for possible empyema and osteomyelitis of the ribs. In addition, it is important to obtain cultures and identify the correct infectious organism in order to ensure complete eradication of the infection.
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    Primary Pigmented Nodular Adrenocortical Disease: A Rare Condition of Cushing's Syndrome
    (2015-03) Prakash, Sameer; Maxey, Nicole; Russ, Melanie; Friedman, James; Miller, James; Castro-Silva, Fernando; Wilson, Don P.
    Purpose (a): Cushing’s syndrome (CS) in uncommon in children and may be either ACTH dependent or independent. The most common cause of CS is exogenous administration of glucocorticoids. We present an unusual case of ACTH-independent CS in a 14-1/2 year old Caucasian male. Methods (b): A 14-1/2 year old Caucasian male was referred for accelerated weight gain, which first became apparent at 8 years of age. In the past 2 years he gained ~50 pounds, during which time he reported intermittent fatigue, vague abdominal pain, and pain in his lower back. There was no history of muscle weakness, hypertension or diabetes. Diurnal cortisol and ACTH levels, 24-hour urinary free cortisol, and overnight 0.5 mg dexamethasone suppression studies were performed. To further determine the etiology of Cushing’s syndrome and localize the source of excess glucocorticoids production, additional studies were performed. Results (c): There was no suppression of adrenal steroids following 2 days of high dose dexamethasone. CT scan showed a slight nodular adrenal contour bilaterally. Further workup was consistent with primary pigmented nodular adrenal disease (PPNAD) without evidence of Carney Complex. A bilateral adrenalectomy was performed and the patient maintained on oral adrenal hormone replacement therapy. Conclusions (d): PPNAD accounts for only 2% of ACTH-independent CS. Absence of adrenal suppression following high dose dexamethasone and nodular changes of the adrenal with CT scanning aid in the clinical suspicion of PPNAD. Bilateral adrenalectomy is the treatment of choice and, in the absence of Carney complex, should be curative.
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    An Unusual Second Malignant Neoplasm following Treatment for Childhood Non-Hodgkin Lymphoma
    (2015-03) McConal, Alyson G.; Bowman, W. Paul
    Purpose: This case study aims to describe a patient with a secondary malignant diagnosis of Ewing sarcoma following initial diagnosis of childhood non-Hodgkin lymphoma, to discuss the clinical features based on this case study, and to highlight the steps in the patient’s medical care that led to discovery of his diagnosis. Methods: Information and records were obtained on a 19 year old man who presented to Cook Children’s Medical Center 3 years following his initial diagnosis of childhood non-Hodgkin lymphoma with progressive back pain. Patient was noncompliant with follow-up childhood cancer survivorship program and discovery of a 4 centimeter spinal mass was delayed over six months due to radiology error by an outside institution. Failure to identify the mass early in the course of the disease led to increasing size of the tumor and impingement of the spinal nerves, causing extreme pain, weakness, and paresthesia of the legs. Results: After review of spinal imaging by a Cook Children’s Medical Center radiologist, a progressively enlarging spinal tumor was discovered. Biopsy of the lesion was not wanted by the family and medically risky due to the tumor’s location within the vertebral canal. Although a diagnosis of recurrent non-Hodgkin lymphoma was assumed, biopsy showed a different malignant, small, round, blue cell tumor. A diagnosis of Ewing sarcoma was made, and patient was started on appropriate chemotherapy protocol. Conclusions: Compliance with cancer survivorship programs is extremely important, especially for patients diagnosed with cancer in childhood. These programs maximize the probability of early discovery of recurrences of the original cancer or of second malignancies. It is also important for physicians to realize the importance of biopsies of new tumors in patients with previous cancer diagnoses so that patients will receive appropriate and effective therapy.
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    A Case Presentation of Acute CHF Exacerbation in the Presence of Several Co-mobordities
    (2015-03) Wong, Long; Amlani, Farah M.; Colmenero, Evan
    Purpose: To highlight clinical features and management of congestive heart failure (CHF) exacerbation in a patient with several co-morbidities such as chronic kidney disease (CKD), hypertension (HTN), and diabetes (DM). Methods: A 66 year old African American male with a history of systolic CHF, CKD with anemia, DM, HTN, hyperlipidemia, and tobacco abuse presented to his primary care physician with complaints of fatigue, a cough productive of pink sputum, and intermittent chest pain. For 9 months, he had worsening dyspnea with exertion, cough with chest pain, and orthopnea. On physical exam, lung auscultation revealed 50% rales with diminished breath sounds. 2+ edema was present on the lower extremities bilaterally. An EKG in clinic showed left ventricular hypertrophy. The patient was sent to Plaza Medical for evaluation of CHF exacerbation due to fluid overload while on high dose Lasix and a history of CKD. Results: Labs showed an elevated BUN, creatinine, and BNP. He was anemic with a Hgb of 10.3. Troponins were negative. Initial CXR showed interstitial edema with cardiomegaly and pleural effusions. IV Lasix was started. During his hospital stay, his Hgb dropped to 8.3 and he was started on procrit. Cardiology and nephrology consults were ordered. An echocardiogram showed a dilated left ventricle with an ejection fraction of 25-30% with diffuse hypokinesis. The cardiologist began him on nitrates and digoxin. The nephrologist diagnosed end stage renal disease. A permcath was placed for dialysis. He received 3 treatments of inpatient dialysis. After 6 days, the patient was discharged home and put on outpatient dialysis. Procrit, isosorbide mononitrate, digoxin, hydralazine, and lisinopril were prescribed. The doses of furosemide and simvastatin were increased. Conclusions: Community based studies show that 30-40% of patients die within 1 year of diagnosis of CHF, 60-70% die within 5 years. NYHA class IV patients have a 30-70% annual mortality rate, while NYHA class II patients have an annual mortality rate of 5-10%. Thus, functional status is an important predictor of patient outcome. In our case, the functional status of the patient had deteriorated to the point of hospitalization. In addition, the patient had co-morbidities that affected the functionality of the heart. HTN, CKD, and DM can all play a role in the functional and morphological changes in the heart resulting in CHF. Management of all co-morbidities is imperative to improve patient outcomes.
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    Surgical Management of a Complex Enterocutaneous Fistula with Small Bowel and Gluteal Cleft Involvement Post-Resection of Rectal Adenocarcinoma
    (2015-03) Lee, Jay J.; Yurvati, Albert
    Purpose: The purpose of this case report is to discuss the importance of recognizing the presentation of an enterocutaneous fistula (ECF) as well as its management. Methods: This case report describes a 51 year old African-American male with a past medical history of status post rectal cancer resection performed 9 months ago presented to clinic for follow-up of a persistent perirectal wound with constant drainage. The patient had no complications during the initial hospital stay for the surgery, but later returned to the emergency department 2 weeks later with symptoms of fever and abdominal pain. The patient was found to have a presacral abscess which was drained by interventional radiology. The patient continued to receive wound care, but the perianal wound failed to heal with persistent mucopurulent drainage over many months. Five months later, the patient underwent a fistulogram to visualize the extent of the wound. The fistulogram revealed 2 draining gluteal cleft wounds that converged into 1 tract extending cephalad with small bowel communication. The patient followed up 2 months later, and due to failure of the fistula to heal, it was determined that surgical repair of the ECF was necessary. Results: The patient was taken to the operating room to undergo open repair of the ECF. Due to potential bladder involvement, a urologist performed a cystoscopy but was not able to visualize any obvious fistula involvement. Ureteral stents were placed bilaterally. Afterwards, an open laparotomy was performed and bowel was carefully dissected in order to visualize bowel involvement of the fistula. Once loops of small bowel were freed from the fascia, an obvious opening along the dorsal aspect of bowel was found. There was no obvious visual evidence of an enterovesical fistula. At this point, about 12-14 cm of small bowel was resected with primary anastomosis of the small bowel. Afterwards, 180 cc of methylene blue was injected into the bladder to assess for a leaking fistula, but no leakage was found. The peritoneal cavity was irrigated and the abdominal fascia and skin was closed. The patient tolerated the procedure well. The patient’s postoperative stay was non-eventful and the patient was discharged postoperative day 6 and was instructed to follow-up in clinic. Conclusions: An ECF is a potentially catastrophic complication of surgery, and it continues to remain a significant challenge in its management. While definitive surgical repair is often purposefully delayed for months, it is imperative to recognize the signs of an ECF, as uncontrolled sepsis as well as electrolyte imbalances will result in very poor outcomes. However, this case reveals that it may be rather difficult in definitively diagnosing an ECF, especially when it develops postoperatively outside of the hospital stay. This case hopes to illustrate a presentation of an ECF as well as clinical considerations of its management.
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    Eastern Equine Encephalitis: A Case Report
    (2015-03) Eisner, Hailey; Amlani, Farah M.; Atkinson, Barbara
    Purpose: The purpose of this case report is to discuss a rare case of rapid neurological recovery from eastern equine encephalitis (EEE). Methods: Information and records were obtained on a 53 year old white male diagnosed with eastern equine encephalitis who initially presented to a Fort Worth, Texas emergency department with new onset slurred speech, confusion and weakness upon waking. The patient had a one week history of worsening headaches, waxing and waning fevers, upper back pain, nausea and vomiting. He had been diagnosed with a non-life-threatening viral illness two days prior to presentation. A thorough literature review on EEE was also conducted. Results: Within a few hours of arrival the patient experienced acute flaccid paralysis and a decline in respiratory status requiring emergent intubation. After three days of supportive care in the ICU he was extubated and began rehabilitation therapy. Physical therapy helped to rapidly improve his muscle strength, gait and fine motor skills over the course of one week. At follow-up five weeks later he was able to drive and start working again. He was still in speech therapy twice weekly, but noted improvement. Conclusion: Only 2% of adults infected with the EEE virus develop encephalitis. Of those 2%, 90% become comatose or stuporous. The mortality rate is at least 30%, making it the most severe arboviral encephalitis. Complete recovery among survivors is rare, with the most common sequelae being convulsions, paralysis and mental retardation. This patient was one of the unlucky few to develop encephalitis from the virus. He managed to survive and recover rapidly with no major sequelae.
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    Severe Insulin Resistance and Recurrent Pancreatitis in an 18 year old with Alström Syndrome
    (2015-03) Park, Knoelle; Wilson, Don; Loh, Miranda; Marshall, Jan; Willcutts, Michael
    Background: Alström syndrome (AS) is a rare autosomal recessive disorder caused by a mutation of ALMS1 gene. ALMS1 is located in primary cilia, which serve important sensory roles for the extracellular environment in virtually every organ. Insulin resistance is one of the earliest metabolic changes seen in individuals with AS; and progression of the disease tends to be accelerated. Case report: We describe an 18-year-old female with AS who experienced severe insulin resistance and recurrent pancreatitis. Despite good compliance and multiple combinations and dosing of insulin, including insulin pump therapy, her glycemic control remained inadequate. Over the past 5 years, she has been hospitalized 12 times for treatment of acute pancreatitis. Pancreatitis in AS seems to be related to severe hypertriglyceridemia, the latter caused by hyperphagia and insulin resistance. Discussion: Early onset of obesity with the multi-organ involvement characteristic of ALMS1 may explain the accelerated development and increased severity of insulin resistance. Defective function of ALMS1 also results in reduced numbers of GLUT4 receptors mobilized to adipose cell membranes when stimulated by insulin. Diet modifications and increased physical activity may be beneficial. Recurrent pancreatitis in AS seems to be related to hypertriglyceridemia. Conclusion: Early onset insulin resistance is characteristic of AS and can be severe. The expression of the ALMS1 mutation in the hypothalamus may contribute to hyperphagia, resulting in obesity. An elevated BMI is a significant risk factor for developing diabetes at a young age. A better understanding of the pathophysiology in this disease may help improve glycemic control and offer more effective treatment of multisystem disease in affected individuals.
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    Nerve Hydrodissection for Impingement of the Suprascapular Nerve
    (2015-03) Shah, Neel; Clearfield, Daniel
    Nerve compressions are common clinical presentations. In this case study, the ability for nerve hydrodissection, a non-surgical technique for the release of a compressed nerve, is established. This patient had a compression of the suprascapular nerve in the posterior shoulder. The patient failed traditional non-operative therapies such as physical therapy and corticosteroid injections prior to this procedure. Immediately after the procedure, the patient noticed a significant decrease in pain with an increase in ROM, and was able to complete physical therapy to maintain a pain free ROM. Therefore, this case study demonstrates that nerve hydrodissection can be a viable non-surgical option for compressed nerves refractory to traditional options.
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    Squamous Cell Carcinoma of the Neck with Second Primary Malignancy vs. Metastasis: A Case Study
    (2015-03) Yi, David H.; Jordan, Christopher G.
    Although head and neck squamous cell carcinoma (HNSCC) with a second primary malignancy (SPM) are considered rare, 25-33% of deaths in patients with HNSCC are due to SPMs. This statistic underscores the significance of diagnosing SPMs accurately in the management and treatment of HNSCC. A 56 year old male presents with a large neck mass, dysphagia, and a raspy voice. A magnetic resonance imaging (MRI) of the head and neck displayed a 9x7 cm right neck mass. Therefore, a laryngoscopy with biopsy was performed to assess the severity of the neoplasm. The patient underwent a panendoscopy to exclude any evidence of additional primary malignancies in the neck, larynx, and esophagus. A staging computed tomography (CT) scan of the chest, abdomen, and pelvis revealed two hepatic lesions. These results were inconclusive in defining the lesions as metastases or SPMs, so a triple-phase CT scan of the abdomen was utilized to help explain the origin of the lesions. A liver biopsy was indicated following imaging results of the triple-phase CT. An alpha-fetoprotein level was also measured. The laryngoscopy with biopsy showed evidence of translaryngeal extension and moderately differentiated squamous cell carcinoma (SCC) at the base of the tongue. The CT scan revealed two hepatic lesions: a heterogeneous irregular 6.2x7.1 cm mass within the superomedial right and left hepatic lobes and an ill-defined 4.2x5.4 cm mass at the porta hepatis, which was incompletely visualized. The triple-phase CT scan showed the 6.2x7.1 cm mass as an arterially enhancing lesion with imaging characteristics consistent of hepatocellular carcinoma (HCC) while the 4.2x5.4 cm mass was evaluated as a large necrotic lymph node at the porta hepatis. The liver biopsy’s findings of the 6.2x7.1 cm mass showed a high grade undifferentiated carcinoma favoring HCC and the alpha-fetoprotein was also abnormally high. The patient has undergone induction chemotherapy with cisplatin and 5-fluorouracil followed by concurrent chemoradiotherapy for the HNSCC, while the HCC is stable and remains untreated until the HNSCC is fully addressed. This report provides valuable insight of an uncommon case of HNSCC with a SPM in the liver while illustrating the systematic approach towards a diagnosis based on the results of lab studies to distinguish SPMs from metastases. These types of precise diagnoses are necessary for appropriate treatment of the patient and additional work up is necessary to identify SPMs from metastases.
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    22 year old male trisomy 21 with Syncope and intermittent hyper-production of C-peptide: A Case Report
    (2015-03) Diver, Thomas; Wong, Long
    Purpose: There are multiple causes of syncope, which is a short loss of consciousness and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery. Most of time, it is difficult to figure out the exact reason for syncope in a young adult. Ruling out cardiac, non-cardiac or neurological life-threatening conditions is important. We offer a case report that manifests as syncope in a young adult with multiple intermittent high C-peptide levels upon testing. Methods: A 22-year old white male with Down’s syndrome presented to a family medicine clinic with increased intermittent episodes of syncope. These episodes lasted approximately 3-5 minutes and the patient awoke without recall. The patient presented with two main complaints, seizures and syncope frequently over the last two years. The seizures were consistent with epilepsy and he was given standard anti-convulsants which controlled these symptoms. However, the syncope remained. Further testing was conducted including workups for neurology, cardiology, emergency room evaluation and endocrinology. Results: Neurological causes were ruled out because of a normal brain MRI , Cardiogenic causes were ruled out because of normal results for EKG and echocardiogram. Meanwhile, he went to the emergency room for loss of conscious symptoms and his medication Keppra was increased from 500 milligrams to 750 milligrams controlling his seizures. Repeated blood chemistries indicated that blood glucose levels were normal but C-peptide levels were elevated with each episode of syncope, which could indicate Insulin Hypersecretion Syndrome or a cellular insulinoma. Future testing needs to be conducted at the cellular level, including repeated MRI’s of the pancreas; however, insurance issues are barriers to this process. Conclusions: No other case reports for young adults with a primary complaint of syncope and similar test results have surfaced in the literature thus far. Without further testing, a definitive cause cannot be determined.
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    Ectopic Pregnancy with Unusually High beta-HCG
    (2015-03) Nguyen, Bao X.; Chen, George S.; Xiong, Yi; Lee, Jay; Morse, Steven; Hughes, Natalie; Simonian, Rose S.
    Purpose (a): Ectopic pregnancy is a potentially life-threatening emergency and is usually diagnosed using a combination of clinical symptoms, biochemical markers, and ultrasound studies. However, atypical cases will often present without the classic triad of abdominal pain, amenorrhea, and vaginal spotting. Laboratory and ultrasound studies can also be non-conclusive. Such atypical presentation of ectopic pregnancy is illustrated in this case report. Methods (b): A 32-year-old female, gravida 4, para 2, abortus 1, presented to the obstetrics department with a chief complaint of vaginal bleeding daily for the past two months. She was diagnosed with an ectopic pregnancy, but had an unusual presentation. Management, outcome, literature review, as well as educational point are discussed. Results (c): We report the case of an atypical ectopic pregnancy with initial workup more consistent with an adnexal mass and possible germ cell tumor. The patient denied any lower abdominal pain, had serial beta-hCG levels approaching 60,000 mIU/mL, and a mass of unknown etiology was found on ultrasound. This mass was later discovered to be an intact fetus upon laparoscopy. Conclusions (d): This case illustrates the importance of recognizing ectopic pregnancy in the absence of hemoperitoneum, abdominal pain, confirmatory laboratory or ultrasound studies. Even with extremely high beta-hCG levels, keeping the differential of ectopic pregnancy in mind is crucial and can save the life of the mother.