Persistent Relapsing Immune Thrombocytopenia Following COVID-19 Infection.

Immune thrombocytopenia (ITP) is a rare autoimmune disease that presents along a spectrum of disease severity, ranging from asymptomatic thrombocytopenia to potentially life-threatening bleeding complications. Recent case reports and case series suggest that a COVID-19 infection can trigger secondary ITP and may be associated with higher rates of bleeding and lower nadir platelet counts compared to patients with ITP of other etiologies. Multiple ITP relapses have also been described in some COVID-19 patients. We report the case of a 30-year-old otherwise healthy woman who presented to the hospital with fatigue, easy bruising, and a platelet count of 11 x 103/µL. She responded well to our initial treatment with prednisone and intravenous immunoglobulin (IVIG) but experienced a persistent disease course with nine ITP relapses (defined as platelet count <30 x 103/µL) over the next 10.5 months, requiring six additional hospital admissions for acute management as well as long-term maintenance medication adjustments. It is important for clinicians to recognize ITP as a potential complication of a COVID-19 infection and to initiate early therapy to prevent serious bleeding in these patients. Further studies will be needed to understand the natural history, optimal treatment, and prognosis for patients with relapsing COVID-19-associated ITP.

Steroid-Induced Diabetic Ketoacidosis: A Case Report and Review of the Literature.

It has been well documented that corticosteroid treatment can precipitate hyperglycemia and may lead to new diagnoses of type 2 diabetes mellitus. However, steroid-induced diabetic ketoacidosis (DKA) has rarely been reported in the literature. We report the case of an obese 73-year-old man with no known history of diabetes mellitus who presented with DKA after two months of treatment with high-dose steroids. Our patient's presentation and clinical course were consistent with ketosis-prone type 2 diabetes (KPDM-2). A literature review revealed three other reports of patients with steroid-induced DKA, two of whom also had clinical and biochemical features that were consistent with KPDM-2. We postulate that high-dose steroid treatment can trigger DKA in a subgroup of obese, middle-aged patients with risk factors for KPDM-2. Physicians should suspect steroid-induced KPDM-2 in obese patients who present with new-onset DKA after initiation of steroid treatment.

False-Negative 18F-Fluorodeoxyglucose PET/CT in Malignant Pleural Mesothelioma.

We report a diagnostically challenging case of a 77-year-old man who presented with shortness of breath and was found to have a large right hydropneumothorax with collapse of the right lung. A malignancy was suspected, but pleural fluid cytology and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging were negative. He then underwent video-assisted thoracoscopy with biopsies of the pleura and chest wall which revealed malignant pleural mesothelioma (MPM). Older patients with early stage MPM are more likely to have false-negative FDG PET/CT results. Pleural biopsy is essential when there is clinical suspicion for mesothelioma, even with negative initial FDG PET imaging.

Epistaxis Complicated by Hemolacria: A Case Report.

Hemolacria is a rare complication of epistaxis treated with nasal compression or tamponade. We report the case of a man, aged 81 years, with end-stage renal disease who developed hemolacria after insertion of a "Rhino Rocket" nasal tamponade device to treat persistent epistaxis. The hemolacria resolved after treatment with intranasal oxymetazoline. In the setting of epistaxis with nasal tamponade, hemolacria is thought to be caused by retrograde flow from the inferior nasal turbinates via an anatomic connection with the lacrimal system, with passage through the valves of Hasner and Rosenmüller to the lacrimal ducts. Hemolacria is very rare even in severe cases of epistaxis; we postulate that only patients with either congenital absence or acquired incompetence of the lacrimal valves are predisposed to hemolacria after treatment of epistaxis with a tamponade device. Physicians should be aware that hemolacria in the setting of epistaxis is usually a self-limited condition that can be treated with conservative measures to control nasal hemorrhage.

Evaluation and Treatment of Severe Rhabdomyolysis in a Patient with Legionnaires' Disease.

A 53-year-old man with alcoholism and a three-day history of diarrhea and abdominal pain was hospitalized with mild acute kidney injury (AKI) and rhabdomyolysis after a fall where he was down for a short duration. Subsequent testing revealed patchy right lower lobe infiltrates on chest X-ray and a positive urinary Legionella antigen test. Creatinine phosphokinase (CPK) peaked at 85,780 U/L (normal 0-250) on hospital day two and remained markedly elevated for five days despite aggressive intravenous (IV) hydration and appropriate antibiotic treatment. When the patient defervesced and showed clinical signs of resolution of pneumonia, the CPK level declined rapidly, and renal function returned to baseline. Rhabdomyolysis with AKI is a rare but serious complication of Legionella pneumonia, with most patients requiring dialysis. Our patient's complete recovery without renal replacement therapy can probably be attributed to his normal baseline renal function, timely diagnosis of his Legionella-associated rhabdomyolysis, and prompt treatment with aggressive IV hydration and appropriate antibiotics. Legionella infection should be considered in acutely ill patients with rhabdomyolysis of unclear etiology.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey.

BACKGROUND: Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE: To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN: National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES: The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS: The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS: Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

Submassive Pulmonary Embolism: A Re-evaluation of Hemodynamic Instability.

Current medical management of pulmonary embolism (PE) is driven by risk stratification, with thrombolytic treatment reserved for patients with hemodynamic instability. We describe a case of a man with acute submassive bilateral pulmonary emboli and a right popliteal deep vein thrombosis (DVT), who had persistent shortness of breath, tachycardia, and hypoxemia but remained normotensive and was therefore not treated with thrombolytics until he suffered a fatal cardiac arrest on hospital day six. We examine the indications, risks, and potential benefits of thrombolytic treatment in patients with submassive PE who exhibit signs of instability but do not meet current indications for thrombolytic treatment with persistent hypotension or shock.

Analysis of Medical Error Contributing to Missed Acute Myeloid Leukemia Diagnosis.

Hospitals and physicians attempt to minimize medical error by putting systems checks and balances in place at multiple levels. The effectiveness of these hospital-specific strategies to thwart error is called into question, as medical error remains a leading cause of death in the United States. This case report outlines the course of a 62-year-old man with a history of non-small cell lung cancer and right tongue squamous cell carcinoma, who had been admitted to an outside hospital for possible pneumonia. On initial presentation, the patient was pancytopenic with an absolute neutrophil count of 598. As his counts continued to downtrend and his conditioned worsened, oncology saw the patient and attributed the pancytopenia to "transient myelosuppression from pneumonia". This statement impacted the trajectory of the patient's care, delaying his ultimate diagnosis and treatment for acute myeloid leukemia. This case emphasizes the power of framing and anchoring biases in medical decision making and the need to evolve practice models from the current method of closed-door inquiry towards a more inclusive system of error reporting and analysis.

Norovirus-induced Gastroparesis.

Postviral gastroparesis can result from a variety of viral infections and may cause severe, persistent gastrointestinal symptoms. We report the case of an 85-year-old man with one year of persistent nausea, epigastric pain, early satiety, and 25-pound weight loss after an episode of viral gastroenteritis contracted on a cruise ship. The patient reported that he had tested positive for norovirus shortly after the onset of symptoms. Esophagogastroduodenoscopy revealed no abnormalities, and his symptoms persisted despite treatment for a positive serum H. pylori IgG antibody. Lab workup, including hemoglobin A1c, was otherwise normal, and computed tomography (CT) angiography was unremarkable. A gastric emptying study performed one year after the onset of illness revealed moderate gastroparesis. While most cases of postviral gastroparesis resolve within a year or less, there are a few reports of gastroparetic symptoms lasting two to three years or longer. The pathophysiology might involve a slowly reversible injury to gut neuromodulator cells. Antiviral treatment has not been shown to be effective; symptomatic treatment with antiemetic and prokinetic drugs may be helpful in some cases.

Zinc Deficiency-induced Hypogeusia in a Patient with Refractory Iron-deficiency Anemia: A Case Report.

Zinc deficiency is a relatively common condition in various American populations but is frequently unrecognized and under-diagnosed. It typically presents with nonspecific symptoms, including lethargy, immune dysfunction, dermatitis, diarrhea, and decreased taste sensation (hypogeusia). Zinc deficiency often occurs concurrently with iron deficiency and has been linked to more severe clinical manifestations of iron deficiency anemia. We describe a 66-year-old man who presented with weakness and fatigue and was found to have persistent iron-deficiency anemia attributable at least in part to malnutrition caused by zinc deficiency-induced hypogeusia. The hypogeusia rapidly improved and nutritional intake normalized with zinc supplementation.

Validity Evidence for a Brief Online Key Features Examination in the Internal Medicine Clerkship.

PURPOSE: Medical educators use key features examinations (KFEs) to assess clinical decision making in many countries, but not in U.S. medical schools. The authors developed an online KFE to assess third-year medical students' decision-making abilities during internal medicine (IM) clerkships in the United States. They used Messick's unified validity framework to gather validity evidence regarding response process, internal structure, and relationship to other variables. METHOD: From February 2012 through January 2013, 759 students (at eight U.S. medical schools) had 75 minutes to complete one of four KFE forms during their IM clerkship. They also completed a survey regarding their experiences. The authors performed item analyses and generalizability studies, comparing KFE scores with prior clinical experience and National Board of Medical Examiners Subject Examination (NBME-SE) scores. RESULTS: Five hundred fifteen (67.9%) students consented to participate. Across KFE forms, mean scores ranged from 54.6% to 60.3% (standard deviation 8.4-9.6%), and Phi-coefficients ranged from 0.36 to 0.52. Adding five cases to the most reliable form would increase the Phi-coefficient to 0.59. Removing the least discriminating case from the two most reliable forms would increase the alpha coefficient to, respectively, 0.58 and 0.57. The main source of variance came from the interaction of students (nested in schools) and cases. Correlation between KFE and NBME-SE scores ranged from 0.24 to 0.47 (P < .01). CONCLUSIONS: These results provide strong evidence for response-process and relationship-to-other-variables validity and moderate internal structure validity for using a KFE to complement other assessments in U.S. IM clerkships.

Vancomycin-resistant Enterococcus faecium Empyema in an Asplenic Patient.

Enterococcal empyema is a rare complication of pneumonia. We report the case of a 67-year-old asplenic man with pneumonia complicated by respiratory failure and empyema requiring decortication and prolonged chest tube drainage. Cultures of the empyema were initially negative, but later grew vancomycin-resistant Enterococcus faecium (VRE), which was successfully treated with linezolid. To our knowledge, this is only the second reported case of an empyema caused by VRE that was not associated with an intra-abdominal infection. We suspect superinfection due to airway or chest tube contamination as the most likely mechanism of infection. Physicians should consider multi-drug resistant organisms such as VRE in patients with empyema that fail to resolve with chest tube drainage and broad-spectrum antibiotics.

Staphylococcus caprae: A Skin Commensal with Pathogenic Potential.

Staphylococcus caprae (S. caprae) is a catalase-positive, coagulase-negative organism that was first isolated from goat milk, and was later found to colonize healthy human skin, nails, and nasal mucosa. Rarely, this commensal organism can become pathogenic in humans. S. caprae has been implicated in a variety of human infections, with the highest incidence being in bone and joint infections. We describe a man who, after receiving facet joint injections for back pain, developed native vertebral discitis, vertebral osteomyelitis with phlegmon, and bilateral psoas abscesses, from which S. caprae was isolated.

Herpes Simplex Virus Hepatitis: A Presentation of Multi-Institutional Cases to Promote Early Diagnosis and Management of the Disease.

OBJECTIVE: To compare three cases of Herpes simplex virus (HSV) hepatitis to increase early diagnosis of the disease. Case 1. A 23-year-old man with Crohn's disease and oral HSV. HSV hepatitis was diagnosed clinically and he improved with acyclovir. Case 2. An 18-year-old G1P0 woman with transaminitis. Despite early empiric acyclovir therapy, she died due to fulminant liver failure. Case 3. A 65-year-old woman who developed transaminitis after liver transplant. Diagnosis was confirmed by biopsy and she had resolution of acute liver failure with acyclovir. CONCLUSION: It is imperative that clinicians be aware of patients at high risk for developing HSV hepatitis to increase timely diagnosis and prevent morbidity and fatality.