Acute Coronary Syndrome Presenting With Hiccups.

Acute coronary syndrome can present with atypical symptoms. Hiccups, generally considered benign and self-limiting, can be an indicator of myocardial ischemia if persistent. We present the case of a 62-year-old gentleman with a past medical history significant for hypertension, type II diabetes mellitus, and ischemic stroke who presented with persistent hiccups. Coronary angiogram revealed severe triple vessel disease and he underwent coronary artery bypass graft surgery, following which his hiccups resolved. There are very few cases that report the association of hiccups and myocardial ischemia. To our knowledge, this is the first reported case in which hiccups were a part of the primary symptoms associated with severe triple vessel coronary artery disease. This could be due to irritation of the phrenic nerve from the infarcted myocardium resulting in activation of the hiccup reflex arc. Our case highlights the association between these two common entities and stresses the importance of having a high index of suspicion, especially among high-risk and elderly patients.

Cardiac Tamponade Secondary to Influenza B Infection.

Every year, Influenza infection contributes to significant morbidity and mortality carrying a huge economic burden. Extra-pulmonary manifestations are increasingly being recognized. We present a 29-year-old woman with acute pericarditis and cardiac tamponade requiring emergent pericardiocentesis secondary to Influenza B infection. Although very rare in relation to Influenza B infection, the pericardial disease can occur during the acute infection or as a post-viral syndrome. Considering pericardial disease in patients with chest pain and any viral infection may facilitate timely diagnosis and prevent unnecessary life-threatening complications.

Diagnostic Reboot: A Proposal to Improve Diagnostic Reasoning.

Background Diagnostic errors contribute to the morbidity and mortality of patients. We created and utilized a novel diagnostic tool (Diagnostic Reboot) and assessed its practical efficacy in the inpatient setting for improving diagnostic outcomes. Design This was a prospective sequential controlled study that involved University Hospitalist Adult Teaching Service (UHATS) teams. Senior residents were instructed to use the Diagnostic Reboot (DxR) tool whenever a patient aged 19-99 years was identified who had an uncertain diagnosis 24 hours into their admission.  Results Participating residents identified a total of 32 patients as meeting the criteria of uncertain diagnosis after at least 24 hours of hospitalization during the six months of the study period. Of these, seven were during the intervention (DxR) period. The leading diagnosis was excluded in 3/7 (43%) patients in the DxR period and 13/25 (52%) in the control period. A new leading diagnosis was made in 6/7 (86%) cases in the DxR period and in 13/25 (52%) people in the control period. A new diagnostic plan was made in 100% of the patients in the DxR group and in 80% of patients in the control group. A new consultation was requested in 4/7 (57%) patients in the DxR group and in 9/25 (36%) patients in the control group. The Residents spent an average of 20 minutes on the DxR tool. Conclusions This study demonstrated that the use of DxR may help to improve analytical thinking in residents. It may also play a role in improving outcomes in medically challenging cases, but the use of the tool during the study period was not sufficient to draw concrete conclusions. The primary barrier to the use of such a diagnostic aid was identified as time pressure on a busy hospitalist service.

Multiple Drug-Resistant CLABSI from an Extremely Rare Bacterium, Chryseobacterium gleum.

Chryseobacterium gleum is a lactose nonfermenting Gram-negative bacillus (NFGNB) found in soil, plants, and some water sources but rarely implicated as a human pathogen. Its scarcity in the medical literature and resistance to numerous broad-spectrum antibiotics such as carbapenems, cephalosporins, and beta-lactam/lactamase inhibitors pose a diagnostic and therapeutic challenge. We present the first reported case, to the best of our knowledge, of sepsis from central line-associated blood stream infection from Chryseobacterium gleum in the United States.

Hemorrhagic Stroke in Relapsing Polychondritis: A Rare Complication of a Rare Disease.

BACKGROUND: Relapsing Polychondritis is a rare rheumatologic condition with multisystem involvement. Common presenting symptoms are auricular and nasal chondritis. Common complications include hearing loss and cardiac involvement. An extremely rare complication is neurological involvement. Case report. We present a case of relapsing polychondritis resulting in stroke and discuss the current literature on this condition. CONCLUSION: To our knowledge, only 6 previous documented cases of stroke secondary to relapsing polychondritis exist in the current literature. This case represents a rare but important complication of relapsing polychondritis.

Ipilimumab- and Nivolumab-Induced Colitis Causing Severe Hypokalemia and QTc Prolongation.

Immune-mediated colitis is an uncommon but well-documented adverse event in patients receiving nivolumab or ipilimumab therapy. In this report, we present a 69-year-old man who developed severe hypokalemia and colitis with significant corrected Q-T segment (QTc) prolongation as a result of combination nivolumab-ipilimumab immunotherapy for clear cell renal cell carcinoma.

Multiple Hepatic Abscess from Parvimonas micra: An Emerging Gastrointestinal Microbe.

Parvimonas micra is an obligate anaerobic bacterium and a known commensal of the human oral cavity and gastrointestinal tract. It is rarely associated with infections outside the oral cavity. Recently it has been isolated as a causative agent in a variety of systemic infections, but it has never been previously identified to cause a hepatic abscess. We report a 90-year-old woman with multiple hepatic abscesses caused by P. micra.

Pyridostigmine induced heart block requiring ICU admission.

Myasthenia gravis is an autoimmune disorder that effects an estimated 20 people per 100,000 in the USA per year. Pyridostigmine is a common drug used in the symptomatic treatment of myasthenia gravis. While generally safe and effective, a rare set of patients treated with pyridostigmine encounter cardiac conduction disorders. Here, we report a rare presentation of an adverse drug reaction due to pyridostigmine, which is important for its implications in the acute care setting.

AGEP from a dog bite treated with Ibuprofen.

BACKGROUND: Acute Generalized Exanthematous Pustulosis (AGEP) is a rare dermatologic reaction characterized by an erythematous rash with pustular erosions, fever and leukocytosis. Although most often secondary to antibiotic use, AGEP has also been associated with many drugs. A thorough literature search showed only four previously documented cases of ibuprofen-associated AGEP, and one case of dog bite-associated AGEP. CASE REPORT: We present the case of a 46 year old Caucasian female who developed AGEP after self-treating with ibuprofen for a dog bite. CONCLUSION: In the clinical setting this rash is often dramatic and illuminating the causative agent can be a diagnostic challenge. Our case represents a rare cause of AGEP and an important finding for current practitioners.

Angioedema Secondary to IV Tissue Plasminogen Activator Administration for Treatment of Acute Ischemic Stroke.

BACKGROUND: IV tissue plasminogen activator (tPA) is the treatment of choice for ischemic strokes that present within the treatment window. In the majority of patients, this offers an effective and often life-prolonging treatment in the acute setting. In a rare set of patients treated with IV tPA, side effects can be seen. One rare and potentially dangerous side effect is angioedema. CASE REPORT: We present the case of a patient treated for ischemic stroke who developed angioedema and discuss the etiology and risk factors for this rare, but dangerous side effect. CONCLUSION: Given the frequent and widespread use of tPA, awareness of the rare life-threatening side effects is paramount. This is of particular importance for practitioners in the acute care setting.

Nivolumab-Induced Encephalitis in Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome.

The treatment of cancer is a rapidly evolving field. As more chemotherapeutic agents become available, reporting the side effects of these agents in clinical practice becomes increasingly important. Nivolumab is one of the chemotherapeutic agents commonly used for treatment of renal cell carcinoma, metastatic melanoma, and metastatic non-small cell lung cancer. While common side effects are known and well documented, encephalitis is documented as an extremely rare side effect. We present the case of an extremely rare side effect to a common chemotherapeutic agent.

Uterine Perforation with Intra-Abdominal Clostridium perfringens Gas Gangrene: A Rare and Fatal Infection.

Background:Clostridium perfringens gas gangrene is an extremely rare and fatal infection. Necrosis of the myometrium is rarely seen and has only been recorded in 18 cases to date. Of these 18 reported cases, only 5 have occurred in nonpregnant women. This article presents the 6th case of myometrium necrosis from C. perfringens.Case: A 72-year-old woman, gravida 2, para 2, presented with abdominal pain and vaginal bleeding. After examinations, laboratory testing, and several surgical interventions, she was found to have C. perfringens infection and advanced high-grade serous adenocarcinoma of the endometrium with >50% invasion into the myometrium. Results: Despite the surgical interventions and use of several antibiotics, this patient did not improve. She was weaned from treatment per her advance directive and died after weaning. Conclusions: Awareness of the many etiologies for peritonitis is of great importance when a fatal infection may be the cause of the condition. Correct diagnosis and proper treatment is essential for the survival of patients infected with C. perfringens. (J GYNECOL SURG 32:182).

Dasatinib-Induced CMV Hepatitis in an Immunocompetent Patient: A Rare Complication of a Common Drug.

Dasatinib is a common anticancer drug used in the treatment of leukemia. Several side effects have been reported, the most common being myelosuppression, diarrhea, edema, and nausea. Three papers have been published reporting hepatic side effects of dasatinib treatment. A rare side effect of dasatinib treatment is reactivation of latent cytomegalovirus (CMV) infection. Never before has dasatinib therapy shown to be the cause of CMV hepatitis in an immunocompetent patient. We present a case of an immunocompetent patient who was treated with the standard dose of dasatinib therapy and subsequently developed CMV hepatitis. Well-known side effects of dasatinib therapy are understood and documented; unknown adverse drug reactions can occur and should be monitored for. This is a significant finding given the high rate of CMV seropositivity in the general population.

Aerococcus urinae associated aortic and tricuspid valve infective endocarditis.

Aerococcus urinae is a rare bacteria usually associated with urinary tract infection. It is unusually associated with endocarditis. To date only 18 cases have been reported. Among these cases, the majority had aortic valve involvement. Three had mitral and aortic valve involvement, and two had mitral and tricuspid valve involvement. We present the first reported case of A. urinae associated aortic and tricuspid valve endocarditis. Timely recognition and appropriate treatment of this fatal infection is essential to decrease morbidity and mortality.

Identification Bracelet Precipitated Acute Compartment Syndrome during Intravenous Infusion in an Obtunded Patient.

Acute compartment syndrome is a serious condition requiring immediate medical care. A lack of urgent medical treatment can result in serious complications such as loss of function and even amputation. While the pathophysiology of acute compartment syndrome is well understood, numerous potential causes are still being discovered. A rare cause of acute compartment syndrome is IV infiltration. We present a case of acute compartment syndrome resulting from intravenous infusion due to proximal placement of a patient identification bracelet. We conclude that both routine evaluation for IV infiltration and proximal placement of IV lines are essential for prevention of acute compartment syndrome.

Behcet's disease in acquired immune deficiency syndrome.

HIV/AIDS patients often present with orogenital ulcers. In the immunocompromised patient diagnosis of these ulcers pose a challenge, as there is a myriad of etiologies. We present a case of an HIV/AIDS patient with recurrent orogenital aphthosis that was confirmed to have concomitant diagnosis of Behcet's disease. Proper awareness of the causes of these ulcers is essential for prompt and effective treatment. While rare causes may be at the bottom of a differential list in an immunocompetent host, when HIV/AIDS is involved these rare causes often percolate to the top.