Overlapping drug-induced vasculitis, ANCA-associated vasculitis, and lupus nephritis caused by low-dose hydralazine

INTRODUCTION

We present a case of drug-induced vasculitis secondary to low-dose hydralazine with overlapping features of antineutrophil cytoplasmic antibody-associated vasculitis and drug-induced lupus nephritis.

CASE PRESENTATION

A 52-year-old Hispanic woman with a medical history of resistant hypertension treated with hydralazine 10 mg twice daily for 1 year presented with generalized weakness, dizziness, nausea, vomiting, and gross hematuria. There was fever, tachycardia, leukocytosis, lactic acidosis, hyperkalemia, renal failure, and anemia. Chest computed tomography and bronchoscopy revealed a left lower lobe infiltrate and diffuse alveolar hemorrhage. Serologic testing was positive for anti-double-stranded DNA, anti-Smith, lupus anticoagulant, anti-histone, anti-cardiolipin IgM antibodies, and antineutrophil cytoplasmic antibodies (myeloperoxidase and proteinase 3). A kidney biopsy revealed crescentic glomerulonephritis with an overlapping finding of membranous nephropathy. Broad-spectrum antibiotics, immunosuppressants, corticosteroids, and plasmapheresis were initiated. The patient survived but required continuous hemodialysis.

CONCLUSIONS

Although a few cases of simultaneous antibody-associated vasculitis and drug-induced lupus nephritis secondary to hydralazine use have been reported, this case is singular. Similar findings were previously reported with doses of 50-100 mg two to three times daily over 1-5 years. In our patient, a dose of only 10 mg twice daily for a year caused a severe disease presentation. This brings to light the combination of different vasculitides that can coexist and the potentially life-threatening adverse effects of low-dose hydralazine that should be kept in mind.

An Acknowledgement to the HCA Healthcare Journal of Medicine's Reviewers and Editors for the First Half of 2023

Description The HCA Healthcare Journal of Medicine would like to thank those behind the scenes who make this publication possible. Our journal would not be possible without the assistance of our peer reviewers, authors, and board members. We also announce our inclusion in PubMed Central.

The Impact of Gender and Race When Using the GRACE ACS Score to Predict Mortality

Background

Acute coronary syndrome (ACS) causes significant global morbidity and mortality and requires early risk stratification. The global registry of acute coronary events (GRACE) score is a well-known, validated risk stratification system that does not include race and gender. We aimed to assess whether the addition of gender and race could add to the predictability of the GRACE score model.

Methods

We performed a retrospective cohort study of 46 764 ACS patients from the files of a national healthcare system. We compared the predictability of the GRACE score in conjunction with gender and race versus the original GRACE score. Different possible associations of predictability were investigated and statistically calculated. The accuracy of the prediction models was assessed using the receiver operating characteristic curve and its respective area under the curve (AUC). We compared the AUC of the 2 models, with the significance set at a P value of less than .05.

Results

Our comparison favored the original GRACE score over the modified prediction model with gender and race added (AUC = 0.838 and 0.839 respectively, P = .008). Although the P value comparing the AUC shows that the original GRACE was superior, due to our large dataset, the actual numbers are similar and may not be clinically significant. Gender and race were significantly associated with in-hospital mortality (P < .001, P = .002, respectively). However, this relationship disappeared in the multivariate analysis. Gender significantly predicted in-hospital mortality, with females 1.167 times more likely to die (P < .001). Non-white racial groups had lower in-hospital mortality than whites (OR: 0.823, P = .03).

Conclusion

The GRACE score was valid in its original form and its ability to predict mortality was not substantially improved by including gender and race.

CO2 Levels Behind and in Front of Different Protective Mask Types

Objectives

Many individuals have difficulty adapting to face mask use and report symptoms while using masks. Our primary objective was to determine whether continuous mask-wearing causes elevated levels of carbon dioxide (CO₂) behind the facemasks.

Methods

CO₂ concentrations were measured behind 3 different types of face masks and were compared to CO₂ concentrations at the mask front in 261 subjects who continuously wore masks for at least 5 minutes. These CO₂ concentrations were also measured in several randomly selected subjects after a 5-minute walk.

Results

There were significantly higher CO₂ concentrations behind the mask (3176 ppm) compared to the front (843 ppm) with an average of 49 minutes of continuous mask use. Of all the subjects, 76.6% had a behind-the-mask CO₂ concentration of more than 2000 ppm (the threshold for clinical symptoms), and 12.2% had a CO₂ concentration of at least 5000 ppm (occupational health exposure limit). The CO₂ level behind the N-95 masks was highest (especially after exertion) and was lowest behind cloth masks. The combination of warm ambient temperature, an N-95 mask, exercise, and young age appeared to induce exceedingly high CO₂ levels that should be avoided.

Discussion

Although masks might be necessary for healthcare workers or to lessen the spread of airborne disease, we found that elevated CO₂ concentrations were present while wearing them. Elevated CO₂ concentrations have historically caused symptoms of CO₂ toxicity. Periodic mask breaks in designated areas may be needed to avoid adverse effects.

Conclusion

The use of masks increased the CO₂ concentration in the air behind them to levels historically associated with toxicity.

An Acknowledgement to the HCA Healthcare Journal of Medicine's Reviewers and Editors for the 1st Half of 2022

Description The HCA Healthcare Journal of Medicine would like to thank those behind the scenes who make this publication possible. Our journal would not be possible without the assistance of our reviewers, authors and board members.

Clinical, Laboratory, and Electrocardiographic Findings in Colchicine Toxicity: 10 Years of Experience

Background:

We aimed to investigate the clinical, laboratory, and electrocardiographic (ECG) findings of colchicine poisoning and to evaluate if there is a correlation between them and the two major outcomes of this toxicity which are respiratory/cardiovascular failure and death.

Materials and Methods

Medical records of 34 colchicine-intoxicated patients that were treated in our center during the past 10 years were retrospectively evaluated. The patient's clinical presentation, vital signs, laboratory tests, ECGs, and outcomes were reviewed.

Results

Abdominal pain, and hypotension at presentation had significant correlation with mortality (p = 0.003, OR: 2.2 [4.1, 7.9], p = 0.029, OR: 13.0 [1.5, 111.8]). Mortality significantly occurred in those with sinus tachycardia, hypokalemia, metabolic acidosis, and impaired liver and kidney function tests (p-values = 0.025, 0.007, 0.04, and 0.008, respectively). All the patients had some ECG abnormalities. Most frequent ECG abnormalities were pathologic ST segment elevation and depression (70%), left atrial enlargement (48%), and sinus tachycardia (37%), PR elevation in aVR lead (37%), and T wave inversion (37%).

Conclusions

Colchicine toxicity is a dangerous entity regarding the cardiovascular events and requires close general and cardiac monitoring.

The Important Factors Applicants Consider When Choosing a Residency: A Survey Study

Background

While medical school graduates compete to get matched into the best residency programs, programs also compete to attract the best applicants. The applicant's decision to rank their programs of interest is determined by several factors, many of which are not always apparent.

Method

This study aimed to evaluate significant factors involved in an applicant's residency program selection. A 12-question survey was sent between June 2020 and September 2020 to all first-year internal medicine residents in the United States (US) through an online national database of residencies using the Survey Monkey platform. We asked them to rank the most significant factors that enticed or deterred them from choosing a specific program. We also compared domestic with international medical graduate (IMG) average ranked responses wherein differences were evaluated using an independent two mean samples t-test. The association between outcomes and predictors was analyzed using Pearson's correlation and chi-square analysis.

Results

Out of 9,127 residents, 102 responded to the survey, which equaled a 1.11% response rate. The findings showed that the location, culture, and organization of a program are high-value factors for applicants. Salary, the number of cases seen, and friends near the residency location were not.There are statistically significant differences between graduates of US medical schools and IMG applicants, with the former placing higher importance on the quality of life during residency. Male and female residents also have different priorities with the latter emphasizing program culture and work environment improvement.Residents who chose programs based on academic competitiveness also placed significance on the prestige of the program (r = 0.418, P < .001), program organization/structure (r = 0.3, P = .006), fellowship match rate (r = 0.307, P = .006) and word of mouth (r = 0.520, P < .001). Residents who chose programs based on program culture also put an emphasis on the perceived happiness of the residents (r = 0.450, P = 0.001), and work-life balance (r = 0.359, P = .004).

Conclusion

Programs can attract stronger applicants if they emphasize modifiable factors that are important to potential residents.

An Acknowledgement to the HCA Healthcare Journal of Medicine's Reviewers and Editors for the 2nd Half of 2021

Description As we celebrate the start of 2022, the HCA Healthcare Journal of Medicine would like to thank those behind the scenes who make this publication possible. Our journal would not be possible without the assistance of our reviewers, authors, and board members.

An Assessment of the Diagnostic Value in Syncope Workup: A Retrospective Study

Background

Patients with syncope often undergo costly testing, despite current guidelines and data supporting the contrary.

Objective

To determine the diagnostic value through positivity rate of electrocardiogram (EKG), computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, transthoracic echocardiogram, nuclear and pharmacologic cardiac stress test, tilt table test and carotid ultrasound in patients diagnosed with syncope.

Methods

This is a retrospective study of 10,036 adults presenting to the emergency department or hospitalized with a primary diagnosis of syncope at 8 acute care facilities in the southwest United States from January 1, 2019, to December 31, 2019. A chi-square analysis was performed for each testing modality to evaluate for a statistically significant difference. The cost of each test was estimated based on published national averages per Medicare.

Results

Of our sample, 903 patients (9%) received a test that yielded any positive finding. The results in the order of highest percent positivity rate to lowest were EKG (5.7%), carotid ultrasound (4.84%), transthoracic echocardiogram (2.56%), tilt table test (1%), MRI brain (0.99%), CT brain (0.82%) and cardiac stress test (0.09%). The total sum spent on testing was estimated at $43,347,332. Only $489,170 of this total was spent on a positive test. If this data is expanded to the 6,146 hospitals across the United States, a yearly $33 billion are wasted on syncope workups.

Conclusion

Costly testing continues to be performed on syncope patients despite guidelines discouraging testing. The necessity of these tests should be carefully evaluated for each patient based on diagnostic value.

An Acknowledgement to the HCA Healthcare Journal of Medicine's Reviewers and Editors for the 1st Half of 2021

Description As we reach the midway point of 2021, the HCA Healthcare Journal of Medicine would like to thank those behind the scenes that make this publication possible. Our journal would not have been possible without the assistance of our reviewers, authors and board members.

Methamphetamine Associated Cardiomyopathy in Pregnancy: The Distinctions and the Implications

Introduction

Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process.

Clinical Findings and Outcomes

This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean section. The patient's course was also complicated by chronic methamphetamine use with a possible withdrawal component, which resulted in rapid sequence intubation and mechanical ventilation. Ultimately the patient's respiratory and cardiac symptoms resolved with appropriate treatment. Resolution of reduced ejection fraction was also demonstrated by repeat echocardiogram.

Conclusions

In this article, we will compare the pathophysiology, diagnostic criteria, treatment and prognosis of MAC, specifically in pregnancy, versus PPCM. We also discuss how we ultimately conclude that a diagnosis of MAC can be made rather than PPCM or stress cardiomyopathy. We also find that studies involving methamphetamine use in pregnancy are limited, and ultimately more longitudinal data is needed to achieve a better understanding of patient outcomes, especially given the increasing prevalence of methamphetamine use in the United States.

An Acknowledgement to the HCA Healthcare Journal of Medicine's Reviewers and Editors for the 2nd Half of 2020

Description As the HCA Healthcare Journal of Medicine reaches the end of our first year in publication, we want to thank those who have provided invaluable support for the journal from July to December 2020. Our journal would not have been possible without the assistance of our reviewers, authors and board members.

Acute Ischemic Stroke as the Presenting Feature of COVID-19 in the Young and Pregnant

Introduction

Coronavirus disease (COVID-19) is an emerging and rapidly evolving public health issue that has become globally widespread and an overwhelming pandemic. Clinical manifestations of the disease include asymptomatic carrier states, acute respiratory distress syndrome, and even multiorgan dysfunction. Here, we present a unique and rare case of an acute ischemic stroke (AIS) in an asymptomatic pregnant woman with no predisposing medical illnesses.

Discussion

An 18-year-old G2P1 African American woman at 7 weeks gestational age with no significant medical or family history presenting to the Emergency Department during the initial phases of the pandemic with complaints of new onset left arm and left leg weakness with National Institute of Health Stroke Scale (NIHSS) of 10. Computed tomography of the brain showed an acutely evolving ischemic infarction in the right middle cerebral artery territory. Other etiologies for causes of her ischemic stroke were ruled out through supporting laboratory testing. Since she did not present early enough due to concerns about the Coronavirus pandemic, tissue plasminogen activator was not administered. COVID-19 was suspected, confirmed and deemed the likely explanation of the cause of her acute ischemic large-vessel stroke. The patient was treated with aspirin and clopidogrel daily and showed significant improvement of her left-sided weakness. She eventually regained her ability to walk and was still pregnant at the time of follow-up.

Conclusions

COVID-19 can be difficult to diagnose since the presentation can vary widely and initial presentation may range from asymptomatic carrier states such as in our patient. In this case, we explain how we reached a diagnosis of AIS likely secondary to COVID-19 and provide further discussion regarding the neurological manifestations and treatment in pregnancy.

SARS-CoV-2 Antibody Positivity and Prevalence in an Outpatient Medical Setting in Las Vegas, NV

Background

SARS-CoV-2 antibody testing shows the prevalence of COVID-19 disease in different communities and has epidemiological significance.

Methods

SARS-CoV-2 IgM and IgG were tested in 319 patients, staff and visitors of a primary care clinic in Las Vegas, NV on a continuous as-requested basis.

Results

Prevalence of SARS-CoV-2 antibodies was 3.76% in a primary care office in Las Vegas, NV. Positivity of IgM was 0.31% and IgG 3.44%. The most common symptoms reported amongst those who tested positive were cough, shortness of breath and loss of smell and taste. The most common comorbidities included hypertension, chronic lung disease, seasonal allergies, and type 2 diabetes mellitus, in that order.

Conclusion

Prevalence was 2.3% in Washoe County, NV in June 2020 and 3.76% in Clark County, NV in April-June 2020. This has important implications for heavily populated urban areas.

Systematic Survey of Creatinine-Based Versus Cystatin C-based Estimated GFR in People with Diabetes

Background

Diabetes is a common cause of kidney failure, and most anti-diabetic agents are excreted through the kidneys. Therefore, it is critical to adjust medication dosage and anti-diabetic agents based on kidney function. There are different methods to estimate kidney function, but the common practice is to use creatinine to estimate the glomerular filtration rate.

Objective

In this systematic review, we identify and review publications in order to assess differences between creatinine-based and cystatin C-based estimated glomerular filtration rates in diabetic patients.

Methods

The articles were identified using 3 databases and were assessed for eligibility. A total of 4 articles were included. Comparisons of the 2 patient groups as well as the patient characteristics were compiled into 2 tables.

Results

Two studies showed significant differences between creatinine-based and cystatin C-based estimated glomerular filtration rates in patients with type 1 diabetes. There were no significant differences in control or type 2 diabetes groups.

Conclusions

Although cystatin C-based estimation of kidney function looks promising, it fails to show superiority over creatinine-based estimation. Most studies included in this systematic review, however, had serious limitations to them. Further research with standardized ways of measuring creatinine and cystatin C is required.

The Coronaviruses: Past, Present, Future

Description The current coronavirus pandemic is unparalleled in recent memory and fundamentally unique. It has been more than a century since humanity fought the Spanish flu pandemic. That widespread disease devastated a World War I-ravaged population when there was a relative paucity of medical knowledge. Coronavirus, on the other hand, is now befalling upon a developed world with advanced infrastructure and health systems; wherein access to medical information and technology is abundant. Yet, it has proven to be a destroyer of economies and populations without geographical partiality. This article is meant to be a broad analysis of the virus, which is causing global disruption from both a historical and clinical perspective. We are receiving new facts and figures daily. Thus, this review is up-to-date as much as it can be and meant to serve as a general knowledge base for all involved in the fight.

Acute Disseminated Encephalomyelitis

Introduction

Acute Disseminated Encephalomyelitis (ADEM) is a rare autoimmune demyelinating disorder of the central nervous system. Clinical manifestations include encephalopathy, motor deficits, ataxia, and meningeal signs. In most cases, ADEM is preceded by either vaccination or viral illness. Here, we present a case with neither of the two predisposing elements.

Discussion

A 28-year-old Hispanic female presenting with substance use and suicidal ideation was placed on an involuntary psychiatric hold, started on olanzapine and scheduled for a psychiatric facility transfer. The following day, she was noted to have neurological deficits when ambulating. Computed tomography of the brain showed a right frontal lesion. Magnetic resonance imaging of the brain was notable for multiple peripherally enhancing white matter lesions. Multiple sclerosis and other etiologies were ruled out through supporting tests and lumbar puncture. ADEM was suspected, and the patient was treated with both a five-day course of intravenous methylprednisolone as well as immune globulins. She continued to have mild expressive aphasia after treatment; however, the majority of her symptoms improved.

Conclusions

Diagnosis of ADEM versus multiple sclerosis can be difficult given there are no current diagnostic criteria for it in the adult population. In this case, we explain how we reached a diagnosis of ADEM and provide further discussion regarding the disease course and treatment.

Periodic Paralysis Syndromes: A T3 Thyrotoxicosis Case and Review of Literature

Description Periodic paralysis is a group of muscle diseases that are related to transmembrane ion channels. Dysfunction of these channels causes an increase in sodium-potassium (Na-K) adenosine triphosphatase (ATPase) activity that pushes potassium into the cells that result in serum hypokalemia that manifests as muscle weakness. Beta-adrenergic stimulation and insulin sensitivity might also play a role. Periodic paralysis is divided into hereditary and acquired forms. Thyrotoxic periodic paralysis is an acquired form of periodic paralysis that manifests as muscle weakness, hypokalemia, and hyperthyroidism. The onset of the symptoms is mainly over the age of 20 and can be triggered by intense physical activity, stress, and excessive carbohydrate intake. This review presents the different types of this disease (hypokalemic, hyperkalemic, thyrotoxic, and Andersen-Tawil syndrome) while presenting a unique case of T3 thyrotoxicosis causing periodic paralysis.

POEMS syndrome complicated by ischaemic stroke and cerebral vasculitis

We present a case of ischaemic stroke in the context of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome associated with cerebral vasculitis as confirmed by imaging. There is little information on the prevalence of cerebral vasculitis in POEMS patients, and we found only one previous report of such case in the literature.

Gerstmann syndrome complicating polycythemia secondary to anabolic steroid use

Anabolic steroid use is prevalent among athletes and bodybuilders. There are known cardiovascular, reproductive, musculoskeletal and neuropsychiatric risks associated with their prolonged use. Although there have been very few documented cases of strokes associated with anabolic steroid use, cardiomyopathy and secondary erythropoiesis can increase the risk of strokes in users with no other risk factors. We present a 49-year-old man with left parietal ischaemic stroke with haemorrhagic conversion resulting in Gerstmann syndrome secondary to a hypercoagulable state from chronic anabolic steroid use.

OR30-2 Efficacy and Safety of Percutaneous Ethanol Ablation of Parathyroid Adenoma

Introduction: Parathyroidectomy is the standard of care for the treatment of primary hyperparathyroidism (PHP). Patients who are not surgical candidates have limited options of treatment. Percutaneous ethanol injection (PEI) for the treatment of parathyroid adenoma was first introduced in the 1980s. Main safety and efficacy data about PEI of parathyroid adenoma comes from the mayo clinic review publication of the treatment of recurrent primary hyperparathyroidism in patient with MEN1. There is no large review of the treatment of PHP. In our practice, we localize the parathyroid adenoma with ultrasound in preparation for surgery. In addition, non-surgical patients who meet the criteria for treatment of hyperparathyroidism get offered the PEI as an option of treatment. All patients who were treated with PEI had FNA from the parathyroid adenoma and PTH level was measured on the aspirate to confirm the diagnosis. Study design: This is a retrospective longitudinal cohort study of calcium and PTH level in patient with PHP after PEI treatment. All patients with PHP who received PEI treatment between 2013 and 2017 electronic chart was reviewed and data was collected about calcium, PTH level before treatment and after treatment up to one year, also side effect and complication of the procedure was collected. Patient who we do not have the 6 months data we assumed treatment failure Result: Baseline characteristic 60 patients, age 34 to 95, 49 female and 11 male, PTH average 136, calcium average 11.2 Normal calcium was achieved in 39 patients (65%) at 1 week after the PEI and 36 patients (58%) at 6 months, also at 6 months the 26 patients who continued to have elevated calcium 17 of them (65%) had improvement in calcium level after the treatment and it was below 11.2. At one year we did not have lab result for all patients, out of the 36 patients who had normal calcium at 6 months we have the result of 29 patients and they continue to have normal calcium Complications from the procedure: pain in the injection site for a few minutes after injection, 4 patients (6%) had hoarseness that resolved in two weeks in 3 patients and one patient had hoarseness that persisted after one year Conclusion: This is the largest cohort of PHP patients treated with PEI and it showed 58% normalization of calcium after treatment. The main significant complication was recurrent nerve injury which was temporary in most cases

Primary Hepatic Follicular Lymphoma Presenting as Sub-acute Liver Failure: A Case Report and Review of the Literature

Sub-acute liver failure is a term that describes the relatively sudden loss of liver function, usually >21 days and <26 weeks, with impaired synthetic function and associated encephalopathy in a person with no pre-existing liver disease or cirrhosis. It is commonly caused by viruses and drugs, less so by malignancy. Our patient is a 71-year-old Japanese man who presented with signs of sub-acute liver failure. A subsequent liver biopsy demonstrated involvement by B-cell non-Hodgkin lymphoma. Evaluation of the bone marrow demonstrated significant marrow involvement by B-cell lymphoma. The fluorescence in situ hybridization (FISH) returned positive for t(14; 18). Noted was the patient's clinical presentation of cholestasis secondary to hepatic lymphoma with no evidence of lymphadenopathy or peripheralized lymphoma. Given the disease distribution, the overall findings are consistent with primary hepatic follicular lymphoma as described in few case reports and small case series in the literature.

Diagnostic approaches and treatment of eosinophilic esophagitis. A review article

Eosinophilic Esophagitis (EoE) is a condition that involves eosinophilic influx into the esophageal epithelium. It affects both children and adults; Adults present with dysphagia whereas children with vague abdominal complaints. The clinical symptoms as well as pathologic features of EoE and gastro esophageal reflux disease (GERD) are similar. Since eosinophilia in the esophagus is a non-specific finding, the clinical presentation in conjunction with endoscopic findings and pathology, is crucial in determining a differential diagnosis. Infections such as parasites, allergic phenomenon, Crohn's disease, malignancies, medication, and chemotherapy are all associated with eosinophilia.

A primary endoscopic difference to note between EoE and GERD is that EoE often involves long segments of the esophagus, could be patchy or focal and frequently involves the proximal esophagus. GERD, however, typically involves the distal much more frequently than the proximal esophagus. Because of the similarity between them, GERD should be excluded by using high dose proton pump inhibitor (PPI) treatment or through evidence of a normal pH by esophageal testing, prior to treatment with an elimination diet or steroids. Until further research establishes different diagnostic tests and criteria, clinical and pathological response to therapy is considered to be the absolute confirmation of this diagnosis. The following is a more detailed discussion of this entity.

•

EoE is an eosinophilic influx into the esophagus epithelium.

•

It is an allergic reaction of esophagus to food particles and allergens.

•

Adults present with dysphagia and reflux-like symptoms whereas children with vague abdominal complaints.

•

Clinical presentation, endoscopic findings and pathology determine the definitive diagnosis.

•

Treatment starts with an elimination diet and followed by orally swallowed inhaled steroids.

Patient with intractable nausea and vomiting

A chest x-ray--followed by further questioning about the patient's medical history--revealed the cause of this woman's symptoms.

Sloughing esophagitis: a not so common entity

BACKGROUND

Sloughing esophagitis, also known as esophagitis dissecans superficialis, is a very rare and underdiagnosed entity with unknown incidence rate. It can be associated with bullous dermatoses and medications such as central nervous system depressants and those causing esophageal injury.

CASE REPORT

A 55-years-old woman was recovering from renal failure due to rhabdomyolysis when she developed dysphagia and odynophagia. Esophagogastroduodenoscopy with biopsy was performed for suspected bullous pemphigus and confirmed sloughing esophagitis. She improved with intravenous steroids.

CONCLUSIONS

Sloughing Esophagitis should enter our differential diagnosis more frequently. It is mostly a benign, self-limiting process but when associated with bullous dermatoses will require steroid treatment.

Choledochoduodenal fistula presenting with pneumobilia in a patient with gallbladder cancer: a case report

Introduction

Spontaneous biliary tract fistulas are rare entities. Most of them are associated with long-standing gallstones (especially common bile duct stones, or recurrent biliary tract infections), some with more uncommon diseases such as gallbladder cancer. Some authors believe that back flow from fistulas predisposes patients to gallbladder cancer and some believe that cancer causes necrosis and fistula formation. Gallbladder cancer has a dismal prognosis and 85% of patients are dead within a year of diagnosis. A common complication of gallbladder cancer is obstruction of the common bile duct, which may produce multiple intra-hepatic abscesses in or near the tumor-laden gallbladder. Fistula formation may further complicate the clinical picture.

Case presentation

We present a case of choledochoduodenal fistula in a 60-year-old diabetic African-American woman with gallbladder cancer. The initial clinical presentation was confusing and complex. Our patient was also found to have a gallbladder fossa abscess that was drained percutaneously as another complicating factor relating to her cancer. She developed myocardial infarction, massive upper gastrointestinal bleeding and respiratory arrest during her stay in hospital. Computed tomography was very helpful in assessing our patient and we discuss how, in a patient with pneumobilia, it can be helpful for detecting fistula, air in bile ducts or to show contractions of the gallbladder.

Conclusions

We believe this case merits reporting as it shows an entity that is not frequently thought of, is hard to diagnose and can be fatal, as in our patient. Careful evaluation, and computed tomography studies and endoscopic retrograde cholangio-pancreatography are helpful in early diagnosis and finding better management options for these patients.

Clinical correlation between effective anticoagulants and risk of stroke: are we using evidence-based strategies?

OBJECTIVES

Despite evidence supporting anticoagulant use in atrial fibrillation, this modality is not fully utilized.

METHODS

Retrospective chart review of 297 patients with nonvalvular atrial fibrillation between 1997 to 2000. 124 patients received warfarin and 166 did not; 91 patients suffered stroke.

RESULTS

Age (P = 0.232) and gender (P = 0.745) were not determinant factors for starting anticoagulation prophylaxis. Whites were more likely to receive anticoagulation therapy than blacks (P = 0.043). Cardiologists were 4.5 times more likely to prescribe warfarin than neurologists and internists (P = 0.035). Neurologists (P = 0.305) and internists (P = 0.770) had similar warfarin prescription patterns and often with patients experiencing the highest rates of stroke.

CONCLUSION

Lack of a uniform pattern in anticoagulant administration, despite multiple guidelines, is disturbing. Continuous physician education and community awareness by local and federal medical agencies is essential and cost-effective.

Hydrocephalus as a presenting manifestation of neurosarcoidosis

We present a case of hydrocephalus as the primary manifestation of neurosarcoidosis. Neurologic involvement is a significant cause of morbidity and mortality in patients with sarcoidosis. Detection and management of neurosarcoidosis remains problematic. Although the typical presentation of facial nerve palsy in a documented case of sarcoidosis is not a diagnostic dilemma, more atypical presentations such as hydrocephalus with increased intracranial pressure in a previously healthy patient can be a challenge.

Haemophilus aphrophilus endocarditis after tongue piercing

Piercing invades subcutaneous areas and has a high potential for infectious complications. The number of case reports of endocarditis associated with piercing is increasing. We studied a 25-year-old man with a pierced tongue, who arrived at Memorial Health University Medical Center with fever, chills, rigors, and shortness of breath of 6 days' duration and had an aortic valvuloplasty for correction of congenital aortic stenosis.