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“A Hemolytic Quandary”—WINNER, 1st Place
Nathanael Gay, MD
G6DP deficiency is a known cause of acute oxidative hemolysis. In this case this seemed to be triggered by fava bean ingestion inducing oxidative stress that patients system could not compensate for. The differential in this case was broad and included toxin/infection mediated hemolysis, hereditary spherocytosis along with pyruvate kinase and hexokinase deficiencies. G6PD deficiency is an x-linked recessive condition and it is atypical for females to become symptomatic however her fava bean consumption could given her enough oxidative stress her into hemolysis even in the setting of her mild to moderate G6PD deficiency. In the acute phase reaction her initial G6PD screen was negative which is known to be the case acutely and only after repeat reference lab G6PD testing was her deficiency and the diagnosis of favism revealed.
The Deadliest Cancer “Cure”
Michael Hendricks, MD
No longer marginalized to the realm of medical sideshow, among the historical likes of phrenology and snake oils, alternative therapies now represent a viable adjunct to conventional medicine. New diagnostic challenges spawn from this rise in popularity, however, as many of these nostrums are manufactured and sold with minimal Food and Drug Administration (FDA) safety oversight. We present a case of near fatal toxicity in a patient taking a homeopathic remedy marketed online as a benign, and universally effective, cancer treatment.
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Extramedullary Multiple Myeloma Associated with Reduced Overall Survival: A Retrospective Single-Center Study
Ido Barkay, MD; Richard T. Maziarz, MD; Andy Chen, MD, PhD; William Dibb; Yiyi Chen, PhD; Emma Scott, MD
Multiple Myeloma (MM) is an incurable neoplasm, however recent advancements in therapies have led to median overall survival of 7-10 years in standard risk patients. High risk patients still succumb to the disease within 3 to 5 years. Traditionally used clinical prognostic markers such as the International Staging System (ISS), the Durie-Salmon (DS) staging system, and cytogenetics do not adequately predict response to novel agents or overall prognosis. We previously presented data identifying high risk sub-groups that succumb to shorter progression free survival (PFS) and overall survival (OS) after hematopoietic stem cell transplant (HSCT). Extramedullary disease (EMD) was a highly significant risk factor for poor survival.
Cost Conscious Utilization of Diagnostic Tests—WINNER, 1st Place Quality Improvement
Lawrence Huan, MD; Michael Hendricks, MD; Erin Fender, MD; Alan Hunter, MD; Sima Desai, MD; Sudhakar Karlapudi, MBBS
In 2011, national health care expenditure was $2.7 trillion, up from $253 billion in 1980 and accounted for 17% of the Gross Domestic Product. It is estimated that one third of these costs are wasted on unnecessary tests, approximately $810 billion dollars per year. Efforts to stem this unsustainable growth have focused on educating practioners about cost-conscious care, particularly residents. Thus, we implemented an educational intervention and studied its impact on the utilization of laboratory tests and phlebotomy in an academic institution.
Defining Cultural Competence
Qian Leng, MD, MPH; Somnah Saha, MD; Martha Gerrity, MD
In the past 2 decades, there has been increasing awareness of the diversity of the US population and the demands of providing care to such a wide group. This has led to interest in cultural competence. Many health care professionals view cultural competence as the ability to work effectively with a wide group of patients, including those from an ethnicity different than that of the provider. New medical school and undergraduate courses have been designed to teach cultural competence. However, there still lacks a cohesive definition cultural competence. In order to answer this question, a review of the literature is being conducted.
QTc Monitoring in Patients on Methadone at a Federally Qualified Health Center—2nd Place Quality Improvement
Methadone is an opioid agonist used in the treatment of opioid addiction and chronic pain, with an FDA-issued black box warning cautioning the risk of serious arrhythmias due to QTc prolongation. Ventricular arrhythmia and cardiac arrest are the most frequent methadone attributed adverse events reported to the FDA. Two separate guidelines recommend that patients prescribed methadone undergo annual ECG screening. The aim of this study was to examine the adherence to screening recommendations in patients on methadone at a federally qualified health center (FQHC) in Portland, Oregon.
The presenting signs and symptoms prompting physicians to order a colonoscopy for patients under age 50 years old are unclear. Our study evaluates signs and symptoms in patients age 40 to 49 years old to identify clinical predictors of advanced neoplasia at colonoscopy.
Rifaximin is a non-absorbable antibiotic used for the treatment of hepatic encephalopathy (HE). Given its limited systemic absorption and antibacterial spectrum, rifaximin is an intriguing candidate medication for spontaneous bacterial peritonitis (SBP) prophylaxis as well. The potential effect of rifaximin on the incidence of SBP in patients with cirrhosis and ascites is unclear. The aim of this study was to assess the association of rifaximin with SBP in cirrhotic patients.
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The Masquerader: Pulmonary Actinomycosis, a Rare Etiology of Empyema in Developed Countries
Reyhaneh Akhavein, MD; Kyle Kent, MD
Thoracopulmonary Actinomycosis is rare and commonly misdiagnosed as it mimics a wide variety of lung pathologies particularly bronchogenic carcinoma, pleural effusion, tuberculosis, and pneumonia. It constitutes 15–20% of Actinomycosis cases and is highly treatable when detected early.
A Rare Etiology of Back Pain: Solitary Plasmacytoma of Bone Resulting in Pathologic Vertebral Fracture
A 73 year-old man with history of monoclonal gammapathy of undetermined significance that had remained stable for the past 9 years presented with progressive back pain over the course of few months in the absence of neurologic symptoms or trauma.
When is a Tumor…Not? A Treatable Diagnosis Not to Be Missed.
Ashvin Baru, MD; Ryan Clay, MD; Dean Peterson, BA; Alan Hunter, MD
A cecal mass with terminal ileitis has a broad differential of both neoplastic and non-neoplastic etiologies. We present a case of a large Yersinia enterocolitica cecal abscess mimicking a tumor, complicated by bacteremia in a transplant recipient.
Relapsing Polychondritis Mimicking Orbital Cellulitis
Katie Camilleri, MD; Kacy Church, MD; Jake Lenington, MD; Devan Kansagara, MD
Relapsing Polychondritis is a rare autoimmune condition characterized by episodic, progressive inflammatory destruction of cartilaginous structures, including the eye, which can mimic orbital cellulitis. This case presented the question of using high dose steroids in a patient with orbital cellulitis that was not responsive to antibiotics.
SMV Thrombosis in a Patient with Chronic C. difficile Infection
Elizabeth Cathcart-Rake, MD; Qian Leng, MD, MPH
Warfarin-related Nephropathy: When CKD and Anticoagulation Collide
Erin Chamberlain, MD; Sima Desai, MD
Progressive Neurologic Decline Provides Strokes of Insight
Cherry Chen, MD; Renee Dversdal, MD
Aspirin: Friend or Masked Killer? A Rare Case of a Penetrating Gastroduodenal Ulcer
Carlene Chun MD, PhD; Ryan Childers, MD; Brian Fennerty, MD
Dapsone Hypersensitivity Syndrome as a Presentation of DRESS
Kacy A. Church, MD; Reyhaneh M. Akhavein, MD; Andre Mansoor, MD
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a drug-induced hypersensitivity that typically occurs two to six weeks after the initiation of an offending medication. It is a multi-systemic syndrome that causes a constellation of signs and symptoms that may include rash, lymphadenopathy, hematologic abnormalities of eosinophilia and atypical lymphocytosis, and inflammation of the lungs, liver, and kidneys. Dapsone hypersensitivity syndrome, unlike DRESS caused by most other medications, also often elevates the methemoglobin level. Management of DRESS is primarily supportive with removal of the offending agent. In patients with severe organ involvement, particularly in those with pulmonary or renal involvement, the use of systemic corticosteroids is recommended. Most patients will have complete recovery weeks-months after removal of the offending drug.
Erythema ab igne is considered a type of a thermal burn injury akin to infrared radiation. Similar to actinic keratosis, neutrophil-derived proteolytic enzymes may be responsible for the histopathologic changes which include squamous atypia in the epidermis. Removal of the inciting cause is the mainstay of therapy. Following removal of the stimulus, the discoloration gradually lightens after several months to years, although long standing pigmentations have been reported. If the rash is severe or becomes ulcerated, there is increased risk for squamous cell carcinoma and a biopsy may be indicated if the lesion does not heal.
Kathleen Drago, MD; Elizabeth Eckstrom, MD
Delirium occurs in ~20% of inpatients and ~50% of terminally ill cancer patients, costing the healthcare system upwards of $30 million per year for management. The following case describes the successful management of severe hyperactive delirium in the absence of pharmacologic therapy.
Hiding in Plain Sight: Discovery of Chronic Hepatitis B in an Inflammatory Bowel Disease Patient in Need of Urgent anti-TNF Therapy
Jeffrey M. Dueker, MD, MPH; Stephanie Halvorson, MD
Persistent Kidney Injury in a Transplant Patient: A Case of Xanthrogranulomatous Pyelonephritis
Melissa Hayden, MD; Suzanne Watnick, MD
Moans, Groans, Stones, and STEMI overtones
Lawrence Huan, MD; Peter Sullivan, MD
A 68 year old with a history of schizophrenia and nephrolithiasis with subsequent pyelonephritis requiring nephrectomy, presents to the emergency room for a witnessed syncopal event. Serum calcium was 17.6 mmol/L with an ionized calcium 1.96 mmol/L. Electrocardiogram showed 3mm ST-elevations in leads v3-v6, without active chest pain. Literature review does indicate several case reports that suggest severe hypercalcemia has the ability to mimic ST-elevation myocardial infarction, which is the most probable etiology here.
DRESS Associated Myocarditis: What Every Internist Needs to Know
Briana Jelenc, MD; Peter Sullivan, MD
Drug related eosinophilia and systemic symptoms (DRESS) is a rare but potentially fatal syndrome consisting of a cutaneous drug reaction and varying organ system involvement. Although the liver is the most frequently affected organ, DRESS-related myocarditis is a fairly common but under-recognized manifestation that can occur weeks to months after initial rash and can progress to acute necrotizing eosinophilic myocarditis (ANEM), which is fatal in >50% of patients. We present a case of DRESS-related myocarditis from exposure to vancomycin,
A Rare Case of Decompensated Heart Failure and Transient Ischemic Attack with a “Compact” Unifying Diagnosis
Brian Jeppesen, MD
Although LVNC is a rare clinical entity, the incidence is expected to rise with growing recognition given the increasing ubiquity and sensitivity of cardiovascular imaging. For general providers, LVNC is a consideration for patients presenting with new onset heart failure, dysrhythmia or thromboembolic disease.
Parvovirus B-19 Pure Red Cell Aplasia Complicating Concurrent Lupus-Associated Autoimmune Hemolytic Anemia.
Andrew Lawton, MD; Aaron Spaugy, MD; Alan J. Hunter, MD
This case illustrates how parvovirus infection with resultant aplastic crisis can cloud the clinical presentation of AIHA. While reticulocytopenia in the setting of suspected AIHA may represent intramedullary destruction of reticulocyte precursors or nutritional deficiencies, clinicians should also consider marrow suppression and red cell aplasia due to a separate clinical entity, including parvovirus infection.
Breathing Easily at Eighty Five Percent: Sudden Oxygen Desaturation after Rasburicase Administration
Elizabeth C Lee, MD; Jennifer LeTourneau, DO
Adult Onset Autoimmune Enteropathy
Sarah Lee, MD; Zibing Woodward, MD; Ellen Flatley, MD; M. Brian Fennerty, MD
Peritoneal Mesothelioma in a Young Woman
Qian Leng, MD, MPH
Anti-N-methyl-d-aspartate Receptor Encephalitis: an Under-recognized Cause of Altered Mental Status
Katherine Mackey, MD; Marissa Maier, MD; Kimberly Hutchison, MD
Stephanie Mittelstaedt, MD, MPH; Kyle Kent, MD
Serositis – A Not So Unusual Presentation of Late-Onset Systemic Lupus Erythematosus
Emily Ames Morgan, MD; Joseph C. Chiovaro, MD
A Diagnosis of Malignancy from Simple Urinalysis
Srini V. Mukundan, MD; Sharon Anderson, MD; Kirstin Woolf, MD
Shiga Toxin-producing Escherichea Coli Hemolytic Uremic Syndrome (STEC HUS) Evolving to Atypical HUS
Go Nishikawa, MD; James Bordley, MD; Thomas Deloughery, MD, PhD
Atypical hemolytic syndrome is a newly recognized entity with a similar clinical presentation to STEC induced HUS. They both present with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Atypical HUS is differentiated by the absence of shiga toxin and has a different pathopyhsiology involving decreased regulation of alternative complement pathway.
The Wrong Arthritis—WINNER, 1st Place Clinical Vignettes
Andrew Oehler, MD; Ellen Flatley, MD; James Bordley, MD
Secondary Raynaud’s Phenomenon
Amirala Pasha, DO
This illustrates a case of secondary Raynaud’s phenomenon, risk factors associated with secondary causes and the importance of thorough and complete workup and follow up for diagnosis of underlying disease.
A Case of Suspected Paraneoplastic Pemphigus
Veena Patel, DO; Akram Khan, MD
Paraneoplastic pemphigus (PNP) is a rare autoimmune disease characterized by painful mucocutaenous lesions most commonly associated with lymphoproliferative disorders, carcinomas and thymomas (6 % of patients). Diagnosis is made with a combination of clinical features, laboratory and histopathological findings. PNP can predate the recognition of malignancy in approximately one third of patients and our case illustrates the importance of evaluation for malignancy in an elderly patient presenting with new onset pemphigus. Muco-cuntaenous lesions of PNP can lead to complications that have high morbidity and mortality such as dehydration, infection and airway compromise with respiratory failure therefore these patients should be monitored closely. In cases of PNP associated with thymoma resection can often result in resolution of muco-cutaneous lesions.
What can PET do for you? – Use in Fever of Unknown Origin—2nd Place Clinical Vignettes
Sriram Ravi, MD; Kerry Rhyne, MD
Fever of Unknown Origin (FUO), first defined in 1961 by Petersdorf and Beeson, continues to be a formidable challenge, and requires a very extensive differential diagnosis. Over the years, laboratory and technological advances have helped identify many pathologic causes. However, despite these advancements, roughly 20-30% of FUO remain undiagnosed. As a result, newer diagnostic modalities are being incorporated in solving these diagnostic dilemmas.
A Hematologic Trifecta in a Sickle Cell Patient
Matthew H. Richards, MD; Lynn Boshkov, MD
Though sickle cell disease is not an uncommon disease, it is underrepresented in Oregon. As we are not exposed to this disease as frequently it is important to be aware of the potentially lethal as well as the common manifestations. Acute chest syndrome is a severe complication of sickle cell disease at its variants with a 3% mortality rate. Additionally common manifestations and complications including vaso-occlusive phenomenon, infections, and transfusion related complications are common entities to be able to manage.
Lumps and Bumps, Could it be Cancer?
Matthew H. Richards, MD; Renee Dversdal, MD
Syphilis is a disease described in the medical literature for centuries with a variety of presentations and complications. Even since the arrival of penicillin, the rates of syphilis continue to rise. Recently, the rates in Oregon, especially Portland, have had a dramatic increase. Due to is multiple forms and varied presentation, it becomes an important component of the differential diagnosis for a number of symptoms.
Weakness in a Myasthenic Patient: Avoiding Early Closure and Anchoring
Hannah Rose, MD; Joseph Hardman, MD
This patient's first words to the admitting team were "Docs I'm tired. I have myasthenia and need plasmapharesis." A thorough physical exam helped the team avoid diagnostic pitfalls, ultimately distinguishing between a myasthenic crisis and a more grave etiology.
SIRS and Acute Painful Nodular Rash in a Patient with Leprosy
Sarah Soltman, MD; James Clements, MD
Abrupt Osmotic Shifts followed by Unexplained Neurologic Phenomena: A Case of Reversible Cerebral Vasoconstriction Syndrome
Aaron Spaugy, DO; Andrew Lawton, MD; Alan J. Hunter, MD
This case highlights a rare, but increasingly recognized cerebrovascular syndrome which providers should consider when evaluating patients with neurologic findings either following severe thunderclap headaches, or whose occurrence and/or evolution cannot be explained. While there is no definitive therapy, early diagnosis will allow withholding of potentially risky therapeutic anticoagulants, and cessation of known vasoactive triggers.
Chronic Norovirus in an Immunocompromised Host
Brad Stauber, MD
Lithium Related EKG Changes Despite Dialysis
Leah M. Wilson, MD; Melissa Weimer, DO, MCR
Lithium has historical medicinal use dating back to the 1800s. It has been FDA approved for use in mania since 1970. In 2011, 6,737 reports of lithium toxicity were reported to the American Association of Poison Control Centers’ National Poison Data System.