Iatrogenic Cushing's From Celiac Plexus Blocks for Chronic Pancreatitis: A Case Report.

Chronic pancreatitis and pancreatic malignancies can result in chronic pain that is difficult to treat with traditional regimens. Various pain management strategies have been implemented to improve the quality of life for patients with these conditions, but these strategies are limited by their efficacy and side effects, including opiate dependence. Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) were implemented to decrease opiate dependency and treat chronic pain for pancreatitis and pancreatic malignancy. Numerous approaches are used to facilitate CPB/CPN, including percutaneous, surgical, and endoscopic, guided as computerized tomography (CT), fluoroscopy, ultrasound (US), or endoscopic ultrasound (EUS) techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method; however, it is highly efficacious and associated with minimal complications and/or risks. With endoscopic CPB/CPN, overall mortality improves. Despite the various complications associated with other techniques, no case report or current literature has documented the development of iatrogenic Cushing's disease from the use of steroids during CPB via any approach. Herein, we report the first case of iatrogenic Cushing's disease from CPB in the treatment of chronic pancreatitis. Future studies are warranted to examine the agents used in the chemical destruction for CPB/CPN, to avoid complications such as this.

A rare case of tophaceous gout manifesting as an osteolytic lesion of the acromioclavicular joint.

An osteolytic lesion on imaging can be considered malignancy until proven otherwise. However, advanced stages of gout have presented with sclerotic rims and lytic lesions thought to be due to overexpression of osteoclasts. Patients have been found to demonstrate osteolytic lesions in patellar regions, which are common locations for gout to manifest; however, to our knowledge, no other cases of osteolytic gout in the acromioclavicular joint have been reported at this time. We report a rare case of a 56-year-old male who presented with acute-on-chronic left upper extremity pain and was found to have an osteolytic lesion of the shoulder on imaging. This lesion was later biopsied and found to be histologically consistent with gout. This case report aims to elucidate further understanding of the various ways that gout can present, to diagnose and treat these patients more effectively.

How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts.

Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.

Atypical Stroke-Like Presentation in a Critically-Ill Patient With Serratia marcescens Bullous Cellulitis.

Skin and soft-tissue infections are common in critically ill patients, especially with gram-positive bacteria such as Streptococcus or Staphylococcus species. However, it is imperative to consider gram-negative infections in atypical presentations of bullous cellulitis, where patients do not initially respond to common empiric therapy for skin infections. Serratia marcescens is a gram-negative organism that manifests in nosocomial settings due to its affinity for moisture-rich environments. This bacteria is often difficult to treat due to extensive antibiotic resistance, and thus treatment is generally catered towards culture sensitivity. Rarely, this bacteria is an infective agent of infective endocarditis. We present a case of a 44-year-old gentleman who presented with stroke-like symptoms and was found to have bullous cellulitis with deep wound cultures growing S. marcescens. This case report highlights an atypical, severe presentation, and aims to provide a literature review of this rare manifestation of S. marcescens in skin and soft-tissue infections. We intend to improve rapid diagnosis and proper treatment for future critically-ill patients with skin and soft-tissue infections.

The great invasion, a case of lung mass invading the heart through the pulmonary veins.

The heart is a rare site of metastatic lesions of malignancies. Cardiac metastasis may go unrecognized till autopsy, and about half of all newly diagnosed lung cancer patients have metastasis to another organ. Due to the absence of early symptoms, the clinical diagnosis of cardiac metastasis is challenging. Even when they are symptomatic, these symptoms may be masked by the clinical features of primary cancer. Noncardiac neoplasms may spread to the heart through lymphatic or hematogenous dissemination, local extension, or a transvenous route. Here, we report a case of a 56-year-old male with lung mass extending from the right upper lobe to the left atrium was associated with mass effect on superior vena cava and left brachiocephalic vein.

A Case Report of Recurrent Glomerulonephritis 27 Years After Renal Transplant.

Herein we present the case of a patient who was diagnosed with membranoproliferative glomerulonephritis and underwent renal transplant 27 years prior to presentation with new kidney failure. Although our patient did not undergo renal biopsy, it is our thought that she developed recurrent membranoproliferative disease, as she was well maintained on immunosuppressants and steroids for many years. This case is unique, because she was outside of the typical window for both chronic rejection and recurrent disease. This case also raises awareness of the utility of renal biopsy to differentiate these two conditions, which allows physicians to treat accordingly.