Unusual Presentation of Atrial Flutter With Slow Ventricular Response.

Atrial flutter is usually associated with tachycardia with a ventricular rate of 150 beats per minute. Less commonly, it may be associated with a slow ventricular response (SVR). This is typically seen in patients taking atrioventricular (AV) nodal blocking agents such as beta-blockers. In the absence of these drugs, atrial flutter with SVR may suggest intrinsic AV nodal disease, electrolyte disturbances, or atrial disease. We present a case of atrial flutter with SVR in a patient who was not receiving AV nodal blocking agents.

Lactobacillus Discitis/Osteomyelitis in an Intravenous Drug Abuser.

Vertebral osteomyelitis is usually secondary to hematogenous seeding from direct inoculation during spinal surgery or from adjacent soft tissue infection; the most common organism being Staphylococcus aureus. We present a case of a 31-year-old male who was found to have vertebral osteomyelitis secondary to Lactobacillus species. The patient with a past medical history significant for hepatitis C, intravenous (IV) drug use, and nicotine dependence presented with severe back pain that started one month ago. His pain was located in the middle and lower back, radiating to his abdomen, and both lower extremities. The patient admitted to abusing IV heroin daily and sharing needles with his fiancée. CT of the abdomen and pelvis with contrast revealed marked irregularity of the endplates at the L3-L4 level and mild irregularity of the endplates at the L4-L5 level suggestive of osteomyelitis/discitis with no evidence of a paraspinal fluid collection. Core biopsy of the superior endplate of L4 and adjacent disc material was done and sent for microbiology and pathology review. His bone culture came back positive for Lactobacillus species; however, blood cultures remained negative. Clinical improvement was noted after starting antibiotics, and the patient was discharged on six weeks of oral clindamycin. When thinking of Lactobacillus, a simple probiotic comes to mind, clinicians need to be more vigilant in recognizing its different strains as possible infectious microorganisms. As described in our case, and other cases of bacteremia secondary to Lactobacillus, Lactobacillus should no longer be regarded as merely a contaminant.

Operator-Controlled Comparison Between 5 French and 6 French Guiding Catheters for Percutaneous Intervention Using Transradial Approach.

Objective To compare 5 French (Fr) and 6 Fr guiding catheters regarding the volume of contrast administered, fluoroscopy time, and total procedure time during transradial percutaneous coronary intervention (PCI). Background Previous studies had compared 5 Fr and 6 Fr catheters and deemed 5 Fr catheters safe and effective. In this study, we retrospectively compared the 5 Fr catheter to 6 Fr catheter with an attempt to eliminate the effect of inter-operator skill level variability. Methods In a single-center, retrospective cohort study, we randomly selected patients who had received PCI through transradial access using 5 Fr or 6 Fr catheters. The study involved two groups of 100 patients each. These groups were comprised of an equal number of cases from each operator. The primary endpoint was contrast medium volume. Secondary endpoints were fluoroscopy time and procedure time. Results Less contrast was used in the 5 Fr group vs. 6 Fr catheter group (140.2 ± 45.7 mL vs. 158.2 ± 66.7 mL, p=0.004). PCI using 5 Fr catheters was associated with shorter fluoroscopy time (13.7 ± 7.3 mins vs. 15.2 ± 8.2 mins, p=0.584) and shorter procedure time (43.7 ± 22.2 mins vs. 46.5 ± 19.7 mins, p=0.890), but this was not statistically significant. Conclusion Transradial PCI using 5 Fr guiding catheters was associated with less contrast medium usage, but there was no advantage regarding procedure time or fluoroscopy time when compared to 6 Fr catheters. Similar to 6 Fr catheters, 5 Fr catheters achieved high PCI success rates through radial access when compared in the treatment of coronary lesions with the same level of complexity.

Tracheolaryngeal Squamous Cell Carcinoma with Extensive Mucosal Spread Without Metastasis in a Female.

Tracheal tumors remain one of the most interesting and challenging respiratory tumors. Usually, with the more invasive histologic subtypes, cancer has already invaded surrounding structures at the time of diagnosis. We present an unusual case of primary tracheal squamous cell carcinoma with an extensive mucosal spread at the time of diagnosis without any invasion of surrounding organs or distant metastasis. We discuss the unique features and our treatment approach to this unusual presentation. We also discuss the various epidemiologic, diagnostic and treatment aspects of upper airways tumors of the hypopharynx, larynx, and trachea that can help patients achieve more favorable outcomes.

Paroxysmal Sympathetic Hyperactivity in a Young Male with Glioblastoma Multiforme.

Paroxysmal sympathetic hyperactivity (PSH) is a rare syndrome that is a recognized complication of severe brain injury. It is characterized by episodic hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, and specific posturing. It is prevalent in an intensive care unit (ICU) setting where high acuity illnesses can mask the symptoms of PSH. Herein, we report a case of PSH in a patient with a past medical history significant for glioblastoma multiforme (GBM) status post hemicraniectomy, radiation, and chemotherapy.

Elastofibroma Dorsi: A Rare Connective Tissue Tumor.

Elastofibroma dorsi (ED) is a benign connective tissue tumor that most commonly occurs on the inferior pole of the scapula. It can be found incidentally on radiologic imaging or due to clinical symptoms. Patients may become apprehensive due to it mimicking new malignancy or recurrence of prior malignancy. Treatment is only recommended in symptomatic cases and biopsy is usually unnecessary. We present a case of a 70-year-old female status-post lung cancer resection who was found to have a lump at the inferior pole of her right scapula. She was seen by multiple different specialties and subsequently, a biopsy confirmed her mass to be consistent with ED. Since ED is a benign soft tissue tumor, educating physicians is of utmost importance to avoid pursuing unnecessary diagnosis and to thereby decrease the cost of care to the patient. Therapeutic excision should only be performed in symptomatic patients and observing these lesions in asymptomatic patients would be sufficient.

Is It Really SUMP Syndrome? A Case Report.

Sump syndrome is a rare, long-term complication with a prevalence ranging from 0% to 9.6% in patients with a history of side-to-side choledochoduodenostomy. Choledochoduodenostomy was originally performed to achieve drainage of the common bile duct in high-risk patients with low morbidity, which was commonly done in the pre-endoscopic retrograde cholangiopancreatography era. "Sump" comes from the segment of the common bile duct between the anastomosis and the ampulla of Vater, which acts as a stagnant reservoir for debris, stones, and static bile. This predisposes patients to changes in the biliary tree with signs and symptoms in relation to that area. If left untreated, cholangitis, pancreatitis, hepatic abscesses, and secondary biliary cirrhosis can develop. Here, we have a case of a 77-year-old male with a history significant for choledochoduodenostomy, who presented with the clinical signs and symptoms of pancreatitis, choledocholithiasis, and urinary tract infection. Computed tomography (CT) scan findings revealed choledocholithiasis and an enlarged common bile duct with smaller adjacent calculi along with pneumobilia consistent with sump syndrome. The patient's clinical status improved without invasive measures being taken, i.e. endoscopic retrograde cholangiopancreatography. He was subsequently discharged home after improving clinically and no invasive measures were pursued.

Virchow's node: a case report of an extremely rare presentation of metastasis of adenocarcinoma with mucinous features from the colon.

Colon cancer is one of the most common causes of cancer-related mortality. Adenocarcinoma with mucinous features accounts for 10-15% of colon carcinoma. Distal nodal metastatic colorectal cancer is uncommon, and metastasis of colorectal cancer to the left supraclavicular lymph node is extremely rare without signs of metastatic organ involvement. We present a case of a 54-year-old Caucasian male with colonic adenocarcinoma that presented initially as a left-sided neck mass that had progressively increased in size over 9 months. On physical exam, a left supraclavicular soft tissue mass 6 cm in diameter was appreciated, it was non-tender with no submandibular lymphadenopathy. Soft tissue mass was palpable on the anterior abdominal wall in the epigastric region. Open excisional tissue biopsy of the left supraclavicular mass revealed metastatic adenocarcinoma with mucinous features and colonoscopy revealed a 6 cm obstructing mass in the transverse colon with biopsy revealing primary adenocarcinoma of the mucinous type. Palliative care with comfort measures was agreed upon. Typically, the most common sites of colon cancer metastasis are regional lymph nodes, liver, lung, bone and brain, and ours demonstrated an extremely rare pattern of colon cancer metastasis. The presentation to metastasize to the left supraclavicular node without solid end organ involvement makes this case even more novel.

A Challenging Case of Coexisting Type A and Type B Lactic Acidosis: A Case Report.

The etiology of lactic acidosis can potentially be misleading, especially in a critically ill patient with malignancy. Type B lactic acidosis represents a rare and often lethal complication of malignancy. When differentiating the types of lactic acidosis, Type A is due to marked tissue hypoperfusion and Type B is due to causes in the setting of a normal perfused state. We report the case of a 56-year-old male with newly diagnosed poorly differentiated neuroendocrine metastatic carcinoma and renal cell carcinoma who presented with a decreased level of consciousness and appetite. The patient was started on a sepsis protocol from an initial intensive care unit (ICU) admission. Broad spectrum antibiotics were initiated, and despite management, his mentation and respiratory status worsened, leading to intubation and mechanical ventilation. The patient continued to have elevated lactic acid and white count levels throughout the hospital course. After extensive workup and an ICU stay of 16 days, a decision was made to pursue comfort care measures and the patient passed away shortly thereafter. The patient's persistently elevated lactic acidosis may have resulted from the inherent malignancy. The literature mentions glycolysis with enhanced metabolism as a proposed mechanism. One theory states that these changes enable cancer cells to acquire and metabolize nutrients in a way that favors proliferation over efficient adenosine triphosphate (ATP) production, resulting in elevations of lactate production. Patients presenting to the ICU with elevated lactic acid levels need to be thoroughly worked up for all potential causes. In our case, the underlying malignancies likely caused the persistently elevated lactic acidosis, despite subtherapeutic treatment and resuscitative measures.

Tumefactive Multiple Sclerosis, A Rare Variant Presenting as Multiple Ring-enhancing Lesions in an Immunocompetent Patient: A Case Report.

Tumefactive multiple sclerosis (TMS) is a rare entity which can be difficult to diagnose unless definitive diagnostic measures are taken. TMS is characterized by solitary or multiple lesions that are sized > 2 cm, with/without mass effect, edema, and ring enhancement on magnetic resonance imaging (MRI). The demyelinating lesion can mimic infections, vascular lesions, and inflammatory lesions. The clinical presentation is highly dependent on the area of the brain which is affected, and this can lead to a variety of signs and symptoms. Herein, we present the case of a 40-year-old immunocompetent female with a history of right-sided numbness of her face, arm, and leg associated with muscle weakness for about a week. Workup included an MRI showing ring-enhancing lesions in the white matter of the brain, zero oligoclonal bands in the CSF, a normal immunoglobulin G (IgG) index, and an elevated myelin basic protein (MBP) in the CSF. A biopsy was obtained that showed predominant macrophage infiltrate with loss of myelin but the preservation of axons. Suspecting a demyelinating pathology, the patient was informed that she would be started on intravenous dexamethasone for an eight-day course. With subsequent completion of this course in the hospital, the patient was discharged on oral prednisone daily for a month and a referral leading to a definitive diagnosis of TMS. The patient was started on interferon beta-1a and subsequently relapsed due to noncompliance. However, further workup showed a reduction in the mass-like lesions and a response to therapy. If suspicion for TMS is high despite workup, steroids can be used with immunomodulators in the interim to combat symptoms and potentially reduce lesions and potentially subvert the need for biopsy.