A Rare Case of Metastatic Poorly Differentiated Neuroendocrine Tumor Arising From the Sigmoid Colon in an Active Duty Service Member.

Neuroendocrine tumors (NET) are rare malignancies that contain neural and endocrine cells with a median age of diagnosis of 63 years. NETs are typically located in the gastrointestinal (GI) tract, the pancreas, or the lungs. Within the GI tract, the most common locations for NETs are the small bowel, appendix, or rectum. They are often asymptomatic and found incidentally on imaging or during procedures. NETs arising from the left side of the colon are very uncommon. While most NETs are well-differentiated by histology and are slow growing, 7% are poorly differentiated and usually progress rapidly. While rare, it is vital to be vigilant for this reason We present such a case of poorly differentiated metastatic NET of the sigmoid colon in a young active duty service member.

Underreporting Supplements: A Case of Drug-induced Liver Injury Due to a Testosterone Booster.

Acute liver injuries (ALIs) are caused by a wide range of etiologies, and determining the cause can often be challenging. Detailed history taking is essential in patients with liver injuries to promptly determine the underlying source of injury and for timely treatment and prognosis. A 27-year-old active duty man presented to the emergency department (ED) with jaundice. On medication reconciliation, he only reported taking acetaminophen for a recent upper respiratory infection. The patient had an ALI and was treated with N-acetyl cysteine for presumed acetaminophen toxicity. Initially, his liver-associated enzymes (LAEs) improved, but 2 weeks after discharge, he returned to the ED upon referral from ship medical for jaundice and worsening liver injury. Repeated query into the patient's history revealed that he was using a testosterone booster supplement for 6 months preceding initial hospitalization. After evaluation of other etiologies for liver injury returned negative, drug-induced liver injury from the testosterone booster was determined to be the underlying etiology. With discontinuation of the supplement, his liver injury improved. Hepatotoxicity is a major concern in supplement use; however, it is largely underreported. Supplements are often not recognized or reported as medications by patients, leading to failure to identify them as potential toxicants. This case highlights the importance of including supplement education and questioning in the evaluation of ALI and maintaining a high index of suspicion when other common etiologies of liver disease are negative.

A Case of Refractory Eosinophilic Gastrointestinal Disease Successfully Treated With Dupilumab.

Eosinophilic infiltration of the gastrointestinal (GI) tract beyond the esophagus is a rare condition in adults with limited data on treatment. Current treatments with steroids and diet modifications have shown benefit, but when these treatments fall short, there is little research-driven guidance for further recommendations. We present a case of eosinophilic GI disease with extensive involvement of the GI tract successfully treated with dupilumab after failure of traditional treatment occurred.

Paroxysmal Supraventricular Tachycardia.

Supraventricular tachycardia is a common emergency department (ED) pathology that frequently leads to hospital admission, but this may not be necessary in all cases. Here, we present a supraventricular tachycardia patient who was discharged from the ED after vagal maneuvers. This case demonstrates evidence that judicious emergency physicians can discharge supraventricular tachycardia patients home safely and gives impetus for a data-driven protocol for discharging these patients.

Aortic Bifurcation Saddle Thrombus.

Acute aortic pathology demands a high index of suspicion and frequent reevaluations during emergency department (ED) stay for proper diagnosis. This high index of suspicion is crucial to avoid missing the potentially devastating aortic diagnosis. Here, we present a 59-year-old male who presented with chest pain and was ultimately diagnosed with a rare aortic bifurcation saddle thrombus causing acute aortic occlusion. This diagnosis, although rare, highlights a more common point that all patients should be reevaluated for an acute aorta, especially when diagnostic clues are present. The diagnosis was found only because of a thorough reevaluation. Missing the diagnosis would have resulted in death or lifetime dependence on hemodialysis.

Loperamide Overdose.

In light of the opioid epidemic, cardiac complications following a loperamide overdose are a growing concern for patients presenting to the emergency department (ED). Here, we present the case of a 35-year-old male with long QT syndrome who presented following a loperamide overdose and was receiving multiple shocks because of the resulting arrhythmias and electrolyte disturbances. It is necessary for emergency physicians to be aware of loperamide overdoses because cases have been increasing over the past several years and the cardiac complications can be life-threatening.