Uroperitoneum as an Atypical Source of Ascites: A Case Report.

Uroperitoneum secondary to spontaneous bladder rupture is a rare cause of ascites associated with significant morbidity and mortality. It can be difficult to detect and is often initially mistaken for other, more common etiologies. We present the case of a 56-year-old female with a history of cervical cancer treated with chemotherapy and radiation, radiation proctitis, and diabetes mellitus who presented with subacute onset abdominal pain and distension, urinary retention, and nausea. She had been diagnosed with cervical squamous cell cancer 12 years prior to presentation and was successfully treated with two months of chemotherapy and radiation, and a presumed recurrence five years later was treated to remission with chemotherapy. The golden-yellow appearance of her ascitic fluid during diagnostic paracentesis raised suspicion for urinary ascites that was confirmed by an elevated ascites-to-serum creatinine ratio and computed tomography (CT) cystography. Subsequent CT cystogram demonstrated leakage of contrast from the bladder with a 0.5 cm irregularity noted at the bladder dome, potentially representing the site of extravasation. A Foley catheter was placed at the time of admission with an immediate output of 1 L of fluid. Subsequently, her abdominal distension significantly improved, and her creatinine began to downtrend. Gynecologic oncology and urology were consulted and determined that she was not a candidate for surgical intervention given the significance of her bladder scarring. Positron emission tomography (PET)/CT was performed and revealed no active cancer. At the time of discharge, she had no episodes of emesis. Additionally, her creatinine had fallen to 1.0 mg/dl. She was discharged with a Foley catheter with plans to follow up with outpatient urology. While relatively uncommon, uroperitoneum should be suspected in patients presenting with new-onset ascites who have risk factors for spontaneous bladder rupture such as pelvic irradiation. Uroperitoneum has a significant rate of mortality and morbidity. Ascites urea and creatinine studies, followed by a CT cystogram if these studies are abnormal, should be performed in any patient with risk factors for uroperitoneum. Patients should be managed with the placement of a Foley catheter and urology consultation for surgical evaluation.

Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease.

Approximately 158,500 adults and adolescents in the United States live with undiagnosed human immunodeficiency virus (HIV). Missed or delayed diagnoses adversely affect disease management and outcomes. This is particularly salient for patients receiving immunosuppressive and immunomodulatory therapy for the management of chronic inflammatory conditions, in which additional immunosuppression may increase the risk and severity of opportunistic infections. Despite this risk, comprehensive HIV testing before the initiation of immunosuppressive therapy is not yet the norm. We describe a case series containing the narratives of three patients recently treated with immunosuppressive agents, who presented with signs concerning for HIV-associated kidney diseases and who were found to have undiagnosed HIV later in the treatment course, which, unfortunately, resulted in poor outcomes. Screening for HIV or related illnesses, such as viral hepatitis or mycobacterial co-infections including tuberculosis, is essential before initiating biologic immunosuppression.

Watery Diarrhea Is Not Always Clostridioides difficile: A Case Report of Aeromonas hydrophila Gastroenteritis.

Aeromonas species can cause acute gastroenteritis but are much less commonly observed in the hospital setting than other bacteria. Most cases of Aeromonas hydrophila gastroenteritis reported in the literature have occurred in pediatric, elderly, and/or immunocompromised patients. We present a case of subacute watery diarrhea due to A. hydrophila infection in an otherwise healthy 48-year-old female patient with prior abdominal surgeries and recent hospitalization for a catheter-associated urinary tract infection (CAUTI) for which she received antibiotics. The patient presented with 10 days of increasingly frequent non-bloody, watery, foul-smelling diarrhea as well as decreased oral intake, cramping bilateral upper abdominal pain, chills, and malaise. Initial diagnoses considered included Clostridioides difficile in the setting of CAUTI and antibiotic use, small intestinal bacterial overgrowth, dumping syndrome related to bariatric surgery, and malabsorption. A computed tomography scan of her abdomen/pelvis, admission labs, and flexible sigmoidoscopy showed no relevant findings. Stool cultures eventually returned positive for A. hydrophila. The case is an uncommon presentation of Aeromonas infection that could be easily missed while other diagnoses are pursued. Early treatment of Aeromonas infection can be crucial in preventing advanced forms of disease such as septicemia and necrotizing fasciitis.

Presentations, Diagnosis, and Treatment of Post-COVID Viral Myocarditis in the Inpatient Setting: A Narrative Review.

While coronavirus disease 2019 (COVID-19) infection rates have declined, and mortality outcomes have improved with vaccines, targeted antiviral therapies, and improved care practices over the course of the pandemic, post-acute sequelae of SARS CoV-2 infection (PASC, also referred to as "long COVID") has emerged as a significant concern, even among individuals who appear to have fully recovered from their initial infection. Acute COVID-19 infection is associated with myocarditis and cardiomyopathies, but the prevalence and presentation of post-infectious myocarditis are unclear. We provide a narrative review of post-COVID myocarditis, including symptoms and signs, physical exam findings, diagnosis, and treatment strategies. Post-COVID myocarditis has a wide range of presentations, from very mild symptoms to severe ones that can include sudden cardiac death. Several studies have noted what appears to be a bimodal distribution of affected patients, with individuals under age 16 (particularly males) most affected, followed by those over age 50. The gold standard of diagnosis for myocarditis is endomyocardial biopsy and cardiac magnetic resonance imaging with a confirmed diagnosis of COVID-19. However, if these are not available, other studies such as electrocardiogram, echocardiography, and inflammatory markers can guide clinicians to diagnose post-COVID myocarditis when appropriate. Treatment is largely supportive and may include oxygen therapy, intravenous hydration, diuretics, steroids, and antivirals. Post-COVID myocarditis is rare but important to recognize as more patients present with this condition in the inpatient setting.

Primary Care Considerations for Elderly U.S. Veterans of World War II and the Korean War: A Narrative Review.

Many of the United States' more than 18 million veterans obtain healthcare through the Department of Veterans Affairs' (VA) Veterans Health Administration system; however, recent legislative changes have expanded veterans' access to non-VA care in their communities, particularly for those who do not live near VA medical centers. Veterans are seen by physicians in outpatient practice across the United States and are admitted to non-VA hospitals; this is particularly salient for older veterans, who may require a more frequent and high level of care. We present a review of characteristics of U.S. veterans from two conflicts: World War II (WWII) and the Korean War. While non-VA clinicians are well equipped to provide care for patients of all different ages, veterans of armed conflicts have a unique constellation of exposures and cultural considerations that must be accounted for when providing them care. In this review, we describe characteristics of the generations of American veterans who served in WWII and the Korean War conflicts in a brief historical context. We then note conflict-specific exposures and potential long-term sequelae to watch for during physical examinations and to monitor thereafter, age-specific health and emotional concerns, and best practices for providing care to this cohort of veterans.

Cannabis-Induced Acute Encephalopathy in a 94-Year-Old Woman Due to Family Administration of Cannabidiol (CBD) Products: A Case Report.

In the United States, cannabis use is rising, including among older adults, as is unintentional ingestion. We describe the case of a 94-year-old woman admitted with altered mental status, diarrhea, and hallucinations. She lived with her family, who had noticed recent confusion with weakness, poor oral intake, and loose bowel movements. In the emergency room, her vital signs revealed mild tachycardia and hypotension. She was lethargic, disoriented, confused, and anxious but could answer simple questions. The attending hospitalist administered the Mini-Cog dementia screening and found that the patient was oriented to herself only and was unable to perform word recall tests or complete a clock drawing. The rest of her physical exam was within normal limits for her age. Despite a workup including urine culture, chest X-ray, and computed tomography scan of her head, no organic source for her mental change was found. After five days of admission, a close relative confessed that they had given the patient cannabis oil (marketed as "pure CBD," i.e., cannabidiol, a nonpsychoactive cannabis derivative widely touted as a remedy for pain, anxiety, and anorexia) in the form of edible brownies to help her with her persistent back pain and poor appetite. We performed a urine drug screen for tetrahydrocannabinol (THC), the psychoactive component of cannabis, which verified cannabis use, as well as exposure to THC. The patient recovered to baseline with supportive care. Currently, there is no governing body or framework for the regulation of cannabis products in the United States. Nonprescription CBD products are not regulated by the US Food and Drug Administration, and these products are not tested for safety, efficacy, or quality. Some producers voluntarily conduct such testing, but there is no regulatory oversight, and consumers may be unaware of the need for testing and/or which testing bodies are credible. Given the rapidly increasing proportion of older adults who are cannabis users, physicians should inquire about outpatient use of cannabis in general and CBD in particular during discussions with patients, even the most elderly.

Presentations and outcomes among sickle cell disease patients with COVID-19 at a large southern healthcare system.

OBJECTIVES: Compared with the general population, patients with sickle cell disease (SCD) typically have substantially reduced life expectancies. It is unclear whether SCD patients who acquire COVID-19 have higher rates of complications and mortality than the general population. We sought to elucidate COVID-19 presentation and outcomes in patients with SCD. METHODS: Using retrospective chart review, we evaluated demographic characteristics, presenting symptoms, chest imaging findings, blood transfusion requirements, need for mechanical ventilation or pressor support, medication administration (including remdesivir and dexamethasone), and survival among individuals with SCD hospitalized with COVID-19 from March 2020 to December 2021. RESULTS: Among 72 SCD patients, increased pain was the most common presenting symptom followed by cough, fever, and dyspnea. Thirty-seven (44%) received simple transfusion and 14 (17%) underwent exchange transfusion. Lung imaging findings suggestive of COVID-19 were observed in 27 (37%) patients; 21 (29%) patients were treated with remdesivir and 26 (35%) received dexamethasone. Three patients (4%) required mechanical ventilation and pressor support; all three died from COVID complications. CONCLUSIONS: Pain is the most common presenting symptom in SCD patients with COVID-19. We observed a mortality rate higher than that among the general population among patients who required mechanical ventilation and pressor support.

Idiopathic Intracranial Hypertension: An Unusual Cause of Headache in a Patient With Sickle Cell Disease.

Idiopathic intracranial hypertension (IIH) is a rare cause of headache and visual disturbance with no known association with sickle cell disease (SCD). We present a patient with SCD with gradual onset of a severe headache and visual changes. Brain magnetic resonance imaging, angiography, and venography were nondiagnostic. Lumbar puncture established a diagnosis of IIH, and the patient had rapid improvement with large-volume lumbar puncture and acetazolamide. To our knowledge, this is the first case of IIH in a nonobese adult with SCD taking hydroxyurea, suggesting an association between SCD or hydroxyurea use and IIH. Furthermore, her clinical course demonstrates the complexities of treating IIH in patients with SCD.

When It's Not Pancreatitis, Don't Brush It Off: A Case Report of Small Bowel Perforation Caused by a Grill Brush Bristle Masquerading As Pancreatitis.

Injuries caused by grill brush bristle ingestion have been documented in the literature, but most existing literature focuses on consumer safety and increasing public awareness of potential injuries. Small bowel perforation is a serious complication and often difficult to diagnose since symptoms are frequently nonspecific and bristle localization can be challenging. We highlight a case where a diagnosis of acute pancreatitis was initially made by computerized tomography (CT) imaging but was later determined to be small bowel perforation with magnetic resonance imaging (MRI).1 Due to its high resolution and excellent anatomic depiction of different pathologies, including inflammation and tumors, MRI is often used as an imaging modality when the cause of pancreatitis is not clear through initial history, physical exam, or imaging modalities like ultrasound and CT scan. MRI provides an opportunity to detect pathologies that cannot be depicted by CT because of its high contrast resolution (though conversely, CT has a higher spatial resolution, so there are some cases in which it can detect things that MRI cannot). This case highlights the importance of considering MRI to diagnose and evaluate complications in suspected cases of wire bristle ingestion prior to endoscopic or surgical extraction.

Copper Deficiency and Polyneuropathy: A Case Report.

Although copper plays a pivotal role in numerous physiological processes, its deficiency is virtually indistinguishable from subacute combined degeneration due to cobalamin deficiency. Moreover, the co-occurrence of deficiencies in other micronutrients and vitamins is common, making the diagnosis even more challenging. Here, we describe a case of copper deficiency in a 50-year-old woman who presented with altered mental status and bilateral upper and lower extremity weakness, numbness, and paresthesia. She was treated for cirrhosis and hepatic encephalopathy secondary to hepatic injury. While her mental symptoms improved, her physical symptoms continued to worsen, and she was transferred for further evaluation. The neurologic examination was positive for sensory neuropathy including decreased vibration/proprioception and ataxia in arms and legs; complete blood count showed pancytopenia; but infectious workup, cerebrospinal fluid analysis, autoimmune studies, and brain/spine magnetic resonance imaging were normal. A nerve conduction study showed generalized, axonal sensorimotor polyneuropathy. Micronutrient/trace element deficiency was suspected in the setting of gastric bypass surgery, and supplementation was successfully initiated. Though uncommon, clinical copper deficiency is increasingly frequently recognized in the inpatient setting, and permanent neurological damage can occur prior to diagnosis and treatment. Physicians should have an elevated clinical suspicion of copper deficiency in cases of polyneuropathy and pancytopenia in patients with a history of bariatric surgery.

Beware the Unexpected Infection: Disseminated Varicella Zoster Virus Mimicking A Drug Eruption.

Adverse cutaneous reactions to medications are not uncommon and may resemble viral infection and vice versa, complicating diagnosis. We describe the case of a 79-year-old male with cholangiocarcinoma with liver and presumed lung metastasis who presented with abdominal pain and was admitted with ileitis with partial small bowel obstruction. He had a widespread papulovesicular rash with hemorrhagic center, mostly on his face, chest, and back. The rash was initially thought to be a drug eruption, but was eventually diagnosed via dermatopathological examination as disseminated varicella zoster virus (VZV) infection. Steroid treatment was discontinued, and airborne precautions were initiated. Polymerase chain reaction for VZV was obtained and intravenous acyclovir treatment was begun. This case of VZV, initially suspected to be an adverse drug reaction, highlights the importance of early identification of a highly infectious lesion and the importance of early infection control measures, given the implications of exposure to VZV for health care personnel.

An Effective Model for Unit-Based Advanced Practice Provider/Physician Collaboration on a Complex Medicine Hospital Unit.

Advanced practice provider care effectively improves outcomes and reduces costs. During COVID-19 challenges and staffing shortages, a team developed and piloted a collaborative advanced practice provider/physician hospital medicine model that resulted in improved outcomes, costs, and quality metrics, including increased productivity and revenue, decreased length of stay, and decreased medical emergency team/rapid response calls.

Family Perceptions of Newborn Cytomegalovirus Screening: A Qualitative Study.

OBJECTIVES: We sought to understand long-term retrospective parental perceptions of the utility of newborn screening in a context where many affected children never develop sequelae but where intensive support services and ongoing healthcare were provided. STUDY DESIGN: Qualitative study. METHODS: Focus groups and interviews among parents (N = 41) of children with congenital CMV who had been enrolled in a long-term follow-up study at a large medical college for a mean of 22 years following diagnosis. Groups included parents whose children were: symptomatic at birth; initially asymptomatic but later developed sensorineural hearing loss; and who remained asymptomatic into adulthood. RESULTS: With proper follow-up support, newborn CMV screening was viewed positively by parents, who felt empowered by the knowledge, though parents often felt that they and healthcare providers needed more information on congenital CMV. Parents in all groups valued newborn CMV screening in the long term and believed it should be embedded within a comprehensive follow-up program. CONCLUSIONS: Despite initial distress, parents of CMV-positive children felt newborn CMV screening was a net positive. Mandatory or opt-out screening for conditions with variable presentations and treatment outcomes may be valuable in contexts where follow-up and care are readily available.

Overview of the United States' Immunization Program.

This manuscript describes the history, background, and current structure of the United States Immunization Program, founded upon public- and private-sector partnerships that include federal agencies, state and local health departments, tribal nations and organizations, healthcare providers, vaccine manufacturers, pharmacies, and a multitude of additional stakeholders. The Centers for Disease Control and Prevention sets the U.S. adult and childhood immunization schedules based on recommendations from the Advisory Committee on Immunization Practices. We review the current immunization schedules; describe the set of surveillance and other systems used to monitor the health impact, coverage levels, and safety of recommended vaccines; and note significant challenges. Vaccines have reduced the incidence of many diseases to historic lows in the US, and have potential to further reduce the burden of respiratory and other infectious diseases in the United States. Though the United States vaccination program has had notable successes in reducing morbidity and mortality from infectious disease, challenges-including disparities in access and vaccine hesitancy-remain. Supporting access to and confidence in vaccines as an essential public health intervention will not only protect individuals from vaccine-preventable diseases; it will also ensure the country is prepared for the next pandemic.

Social and logistical barriers to the use of reversible contraception among women in a rural Indian village.

Women in a small coastal village in western India were asked to explain their preference for female sterilization over modern reversible contraceptive methods. Married women aged 19+ years were interviewed in six focus groups (n=60) and individually (n=15) regarding contraceptive methods and their use and side-effects. Women publicly denied contraceptive use but privately acknowledged limited use. They obtained contraceptive information from other village women and believed that modem reversible methods and vasectomy have high physical and social risks, and fertility goals could be achieved without their use. Women felt that reversible contraception is undesirable, socially unacceptable, and usually unnecessary, although the achievement of fertility goals is likely due to the use of female sterilization with abortion as a back-up method. Economic migration of village men may also play a role. Although women with high social capital can effectively disseminate correct knowledge, the impact on the uptake of reversible method is uncertain.