Prevalence and Risk Factors of Distal Symmetric Polyneuropathy Among Predominantly Non-Hispanic Black, Low-Income Patients.

BACKGROUND AND OBJECTIVES: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. METHODS: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. RESULTS: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DISCUSSION: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Spinal Solitary Plasmacytoma With Minimal Marrow Involvement Presenting With Epidural Spinal Cord Compression.

Solitary plasmacytoma (SPC) is a rare type of plasma cell dyscrasia characterized by the proliferation of neoplastic monoclonal plasma cells. It can involve bone or soft tissue without signs of systemic disease. The solitary bone plasmacytoma typically involves the axial skeleton, most commonly the vertebrae. This article presents a 58-year-old male with a history of Parkinson's disease, hypertension, and cervical spine degenerative joint disease. He arrived at the emergency department with severe thoracic and lumbar back pain, accompanied by numbness and weakness in both legs, which worsened with movement and deep breathing. Magnetic resonance imaging (MRI) findings revealed a sizable mass in the T11 vertebra, leading to thoracic spinal cord compression. Treatment included high-dose dexamethasone, and surgical intervention was undertaken. Subsequent pathology confirmed plasma cell dyscrasia. Radiotherapy and chemotherapy (lenalidomide and dexamethasone) were administered, resulting in no recurrence or new masses after two years. Solitary plasmacytoma is a rare disease with limited clinical trials due to the inability to accrue larger cohorts. Prompt diagnosis and staging of plasmacytomas, involving robust histopathological and radiographic methods, are needed to prevent further complications and possible progression to multiple myeloma. Radiation therapy is the primary treatment, with some studies showing the benefits of lenalidomide and dexamethasone. Further studies are needed to improve treatment options for these patients. This case report adds to the current literature the importance of a multidisciplinary approach to the treatment of SPC.

Left Ventricular Noncompaction in Concomitance With Heroin Use Disorder.

Left ventricular noncompaction (LVNC) is a rare congenital condition defined by the presence of prominent trabeculations in the myocardial layer of the left ventricle. The clinical presentation is varied as some patients are asymptomatic and others have symptoms of decompensated heart failure, arrhythmias, or thromboembolism. We present the case of a 42-year-old female with a past medical history of asthma and substance use disorder who presented to the Emergency Department following a syncopal event. The patient had used heroin intranasally, following which she became unresponsive for several minutes. Her husband witnessed the event and initiated chest compressions. When examined by emergency medical services (EMS), she had a palpable pulse and was given naloxone. The patient underwent further evaluation and was admitted for the treatment of aspiration pneumonia. Throughout her hospital stay, she complained of chest pain with musculoskeletal characteristics, likely secondary to chest compressions. However, due to the persistence of pain, she had further cardiac evaluation done. Her electrocardiography (EKG) revealed a normal sinus rhythm with no acute ischemic changes. Her echocardiography revealed left ventricular apical trabeculations with normal systolic and diastolic function, in line with the diagnosis of LVNC. Upon discharge, she was extensively counseled to abstain from substance use and to follow up with cardiology for a cardiac event monitor. Given her initial syncopal event and high-risk substance use behavior, she would benefit from close follow-up for the presence of arrhythmias.

Retroperitoneal Hematoma: A Sequela of Acute Hemorrhagic Pancreatitis Post Endoscopic Retrograde Cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic tool for pancreaticobiliary diseases. Like every other procedure, ERCP can lead to complications that include pancreatitis, cholecystitis, perforation, and rarely, retroperitoneal hematoma. We present a case of post-ERCP acute hemorrhagic pancreatitis resulting in retroperitoneal hematoma and sequelae of unilateral hydronephrosis and ileus. The patient was treated supportively and had good clinical improvement with resolution of hydronephrosis, ileus and more importantly tolerating oral diet without further episodes of abdominal pain. LEARNING POINTS: The most common complications of endoscopic retrograde cholangiography are acute pancreatitis and hemorrhage. In high-risk patients, acute pancreatis can be prevented with rectal non-steroidal anti-inflammatory suppository before the procedure.Occurrence of Grey-Turner or Cullen sign should prompt immediate search for retroperitoneal hematoma especially in the setting of acute hemorrhagic pancreatitis.Apart from hemodynamic instability or compressive symptoms, retroperitoneal hematoma can also cause complications due to inflammatory reactions resulting in hydronephrosis or ileus.

Protein S Deficiency and COVID-19: A Brutal Combination Leading to Acute Submassive Bilateral Pulmonary Embolism.

Protein S deficiency is a form of inherited thrombophilia that occurs due to low levels of or improper function of protein S. The role of protein S is to inactivate procoagulant factors, and a deficiency results in an increased risk of thrombotic events. The coronavirus disease 2019 (COVID-19) infection has also been studied to increase the risk of venous thromboembolism (VTE) due to an interplay of several mechanisms. However, the risk of VTE in patients affected by both of these disease processes simultaneously has not been thoroughly studied, and so recommendations regarding routine screening and prophylaxis of VTE have also not been established. We discuss the case of a 46-year-old woman with a past history of protein S deficiency and a recent COVID-19 infection who presented with complaints of shortness of breath. Upon examination, she was found to be hypoxic and tachycardic. A computed tomography angiography of the chest was done and revealed acute submassive bilateral pulmonary embolism with right heart strain and pulmonary infarcts. She was initially treated with intravenous heparin and later transitioned to oral anticoagulation for a minimum of six months.

A Fatal Case of Systemic Calciphylaxis in the Gastrointestinal Tract: A Case Report and Literature Review.

Calciphylaxis is an infrequent yet lethal disease often associated with end-stage kidney disease (ESKD). The most common sites include proximal and distal extremities and the trunk, with few reported in the penis and very few as gastrointestinal (GI) disease. We report a case of systemic calciphylaxis in a middle-aged male, presenting with a colostomy leak and parastomal abscess. Workup revealed severe calcification of the intestinal arteries and ischemic colon necrosis. The patient underwent colectomy, antibiotic therapy, regular hemodialysis (HD), and sodium thiosulphate infusion with clinical stability. Histopathology of the colon revealed ischemic necrosis and pericolonic vessel calcification suggestive of calciphylaxis. It is an important differential to be considered in patients with risk factors presenting with symptoms of gastrointestinal hemorrhage and necrosis with perforation.

Constipation in transverse myelitis.

Transverse myelitis is an extremely rare neuroinflammatory disorder. About half of the affected patients develop paraplegia associated with urinary and bowel dysfunction. The bowel dysfunction is thought to be benign and is usually managed with dietary management and laxatives. We report a case of a man in his 60s presenting with transverse myelitis and the acute disease course complicated with treatment refractory intestinal dysfunction resulting in intestinal perforation, eventually leading to his death. Thus, this case helps us weigh the fact that intestinal dysfunction in the case of transverse myelitis is not always benign but can lead to deadly outcomes as well.