Transverse colon volvulus in a patient with autism.

Transverse colon volvulus is an extremely rare cause of bowel obstruction with approximately 100 cases reported in literature. Transverse colon volvulus presents with signs and symptoms of large bowel obstruction, but it can become a surgical emergency due to bowel infarction or peritonitis. We present a rare case of transverse colon volvulus in a 36-year-old male patient with severe autism. We hope this case report will raise awareness of this disease.

Invasive Lobular Breast Carcinoma Can Be a Challenging Diagnosis Without the Use of Tumor Markers.

Invasive lobular carcinoma is often challenging to diagnose due to the lack of physical examination findings and macrocalcifications on mammography. The cells of invasive lobular carcinoma form a distinct single file pattern that can be identified on histology slides. Often, when patients present, there is metastasis to the bones, lymph nodes, and gastrointestinal tract. Tumor markers are a valuable tool in identification, especially the loss of E-cadherin protein. However, if E-cadherin protein is not available, epidermal membrane antigen, which inhibits E-cadherin, can prove to be a significant diagnostic tool. Epidermal membrane antigen was the key tumor marker in our patient case. Other tumor markers and histology stains can drive treatment plans and help predict prognosis.

Metoprolol-Associated Central Nervous System Complications.

Metoprolol is a common medication used by the elderly because it is affordable and has proven to decrease mortality in cardiovascular disease. Multiple studies have reported central nervous system (CNS) side effects associated with use of beta-blockers. The risk of beta-blocker CNS side effects is directly associated with the lipophilic property of the drug. We present the case of an 84-year-old male presented to the clinic complaining of increased confusion, fatigue, lightheadedness, nightmares, sleep disturbance, and gait problems for four weeks. The patient was evaluated for neurogenic and cardiogenic causes of his symptoms and both were ruled out. We believe that further review of his medical chart and medication reconciliation will lead us to the underlying cause of his symptoms. Despite being an effective treatment option, there are risks associated with beta-blocker therapy. The most common symptoms are psychiatric conditions, bizarre and vivid dreams, sleep disturbances, delirium, psychosis, and visual hallucinations. Elderly patients who are started on beta-blockers require close monitoring for any adverse neurological symptoms.

Hemorrhagic Cholecystitis in a Patient with Cirrhosis and Rectal Cancer.

Hemorrhagic cholecystitis is a rare presentation of acute calculous cholecystitis which presents with abdominal pain, jaundice, and gastrointestinal bleeding. It is a challenging diagnosis to make because it present similar to other common disorders such as calculous cholecystitis. We present a unique case of hemorrhagic cholecystitis in a patient with cirrhosis and rectal cancer.  A 66-year-old male with a history of rectal cancer, alcohol-induced cirrhosis, esophageal varices, stroke, paroxysmal atrial fibrillation, and hypertension presented to the emergency department with complaints of abdominal pain. Patient's computed tomography (CT) scan revealed bleeding from the gallbladder with hemoperitoneum and thickening of the ascending colon. The patient underwent emergent surgery for hemorrhagic cholecystitis. Hemorrhagic cholecystitis is associated with risk factors, including trauma, malignancy, renal failure, cirrhosis, and anticoagulation therapy. Imaging is not always reliable, but ultrasound and CT scan are the preferred options. Treatment options are surgical or nonsurgical approach depending on patient's hemodynamic stability.

Infective Endocarditis Caused by Rhodococcus equi in an Immunocompetent Patient.

Rhodococcus equi (R. equi) is a rare zoonotic organism that is found in the feces of grazing animals and in farm soil. It typically causes pulmonary disease, but it can also cause extrapulmonary disease. Immunocompromised patients are at a higher risk of developing the infection, but it has been reported in individuals with competent immune system as well. We present a unique case of infectious endocarditis (IE) due to a R. equi infection in an immunocompetent patient. A 77-year-old male with a history of coronary artery disease, prior myocardial infarction, systolic heart failure, hypertension, hyperlipidemia, aortic stenosis, and benign prostatic hypertrophy was evaluated by cardiothoracic surgery for coronary and valvular heart disease. His transesophageal echocardiogram and cardiac catheterization demonstrated severe aortic stenosis and multivessel coronary artery disease. The patient underwent coronary artery bypass grafting and simultaneous aortic valve replacement. Intraoperatively, there was exudative material covering his aortic valve, which was sent for tissue culture. Tissue culture was positive for R. equi and Enterococcus faecium.  R. equi endocarditis is a rare presentation of this organism. R. equi endocarditis is a very challenging diagnosis due to its varying presentation compared to typical IE. Detailed history taking and physical exam are extremely important to determine if further evaluation is needed. Prolonged oral and intravenous antibiotics are recommended for effective treatment.

Right Ventricular Perforation Presenting as Tingling of the Left Breast.

Pacemaker lead-associated cardiac perforation is a rare phenomenon. Lead perforations can be acute, subacute, or chronic following lead placement. Symptoms are typically nonspecific and depend on the location of the displaced lead. Diagnostic workup requires interrogation of the pacemaker and imaging studies. Management of lead displacement is dependent on multiple risk factors such as age, gender, corticosteroid use, and anticoagulation therapy. A 74-year-old female with a history of myosin light chain kinase (MYLK) 2 hypertrophic cardiomyopathy, Sjogren's syndrome, Raynaud's disease, and sick sinus syndrome was evaluated for an abnormal finding on pacemaker interrogation. The patient's only symptom was tingling of her left breast. Imaging studies confirmed pacemaker lead perforation. Right ventricle perforation due to a pacemaker lead displacement can cause severe complications. Early identification and treatment by physicians can reduce the risk of mortality.

Reactivation of Histoplasmosis Disseminated into the Central Nervous System Presenting as a Stroke.

Histoplasmosis is one of the most prevalent endemic mycosis in the United States. Patients with a previous history of histoplasmosis have a risk of reinfection in the future. Individuals with impaired immunity and those who have massive re-exposure to H. capsulatum, their defenses against this organism can be overwhelmed and diseases can recur. We present a unique case of reactivation disseminated histoplasmosis in an immunocompetent patient. We present a case of a 75-year-old male who presented to the ER on two separate occasions for stroke-like symptoms with progressive falls, impaired speech, hand tremor, confusion and generalized weakness. CT of the head without contrast on both occasions showed chronic atrophy and microvascular changes but no acute abnormalities. MRI could not be performed due to pacemaker incompatibility. EKG showed paced rhythm. The only abnormal lab was a creatinine level of 1.6. Neurology was consulted and they ordered an EEG and lumbar puncture during his second hospitalization. EEG showed generalized slowing, suggestive of diffuse brain dysfunction. Lumbar puncture showed WBC: 103, protein: 172, lymphocytes: 88%, neutrophils: 11%, monocytes: 1%. Following the lumbar puncture, Infectious Disease was consulted. On further investigation, it was discovered that the patient was previously treated for oral histoplasmosis with itraconazole for three months. Cerebrospinal fluid (CSF) was positive for histoplasmosis antigen titer 1:64. Serology was positive for histoplasmosis antibody complement fixation titer of 1:32. The patient was treated with liposomal amphotericin B for six weeks. With treatment, his serology titers continued to improve. The patient was discharged home on itraconazole 200 mg for lifetime, due to his previous history of oral histoplasmosis. On his three-month follow-up, his serology titer was <1:8. Histoplasmosis should be considered in the differential diagnosis of patients who present with chronic meningitis, cerebral vascular accident, focal brain or spinal cord lesions, and encephalitis.