Resident and Medical Student Forum
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Medical Student Clinical Vignette New York Chapter ACP Resident and Medical Student Forum Saturday, November 9, 2013 University of Rochester School of Medicine and Dentistry 415 Elmwood Avenue Rochester, NY 14643 Medical Student Clinical Vignette New York Chapter ACP Resident and Medical Student Forum Medical Student Clinical Vignette 1 Medical Student Clinical Vignette Author: Brett Grobman Author: David Haughey Additional Authors: Daniel Jipescu Additional Authors: Bhardwaj, Rahul MD, Narsipur, Sri MD. Craig Grobman, D.O. Institution: SUNY Upstate Medical School Institution: St. Francis Hospital Title: PRES After Renal Transplantation: A Simple Solution Title: MULTIPLE MYELOMA PRESENTING AS CVA for a Complicated Patient SECONDARY TO MARANTIC ENDOCARDITIS Posterior reversible leukoencephalopathy syndrome (PRES) is characterized by acute neurologic dysfunction coupled with Learning objective: Recognize the importance of completely characteristic findings on brain imaging. PRES occurs in working up CVA. hypertensive emergency, eclampsia and as a neurotoxic effect Case: A 63-year-old male patient with a history of diabetes, of immunosuppressive agents. While overwhelmingly hyperlipidemia and coronary artery disease presented to ER reversible without residual deficits when promptly with right-sided weakness and aphasia. On MRI several acute recognized, vague symptomatology may delay diagnosis. focal infarctions within portions of the left cerebral A 50 year-old male was air-lifted to this institution due to hemisphere were noted. Suspecting cardioembolic event, a multiple episodes of seizure. He had undergone cadaveric transesophageal echocardiography (TEE) was performed. An renal transplant five days prior for end-stage renal disease aortic valve vegetation was found, which was thought to have secondary to focal segmental glomerulosclerosis. He did not most likely led to his thromboembolic event. The patient have a history of seizure disorder or alcoholism. The underwent aortic valve replacement (27 mm Edwards transplantation was without complication; post-transplant Perimount bovine pericardial aortic valve prosthesis) as well urine output was adequate and the patient remained as coronary artery bypass grafting surgery due to multi vessel normotensive. Discharge medications included prednisone, obstructive coronary artery disease (CAD) found on cardiac tacrolimus, mycophenolate, acyclovir, trimethoprim- angiogram. The surgical pathology of the aortic valve revealed sulfamethoxazole, atenolol and enalapril. On the day of aortic valve nodules that were fragments of blood clot and presentation he experienced severe headache, blurred vision calcified material. The patient recovered uneventfully and and tonic-clonic seizure-like activity. In the Emergency followed up in the clinic. Based on the pathology report and Department, IV lorazepam and intubation led to cessation of lack of infectious findings, it was thought that the patient had seizure activity. The patient was afebrile with systolic blood marantic endocarditis due to malignancy or autoimmune pressure in the 170s, heart rate approximately 100 and disease. The workup revealed a very high erythrocyte oxygen saturation 100% while intubated. Neurologic exam sedimentation rate and elevated protein levels. Ultimately, he was limited by sedation, although no focal deficits were was found to have on serum protein electrophoresis (SPEP) evident. Labs evidenced BUN and creatinine of 23 and 1.0 and immunofixation electrophoresis (IFE) an IgG paraprotein mg/dL, the remainder of the BMP was unremarkable. CBC with kappa light chains. Further workup revealed a solitary exhibited no leukocytosis; hemoglobin and hematocrit were focal lytic appearing lesion in L2, positive anti nuclear 9.7 and 28.0 g/dL (unchanged from baseline). Lumbar antibody titer, negative hypercoagulable workup. The patient puncture revealed normal opening pressure, negative Gram was referred to hematology where further diagnostic stain, benign CSF analysis and India ink preparation. CT and procedures were performed including bone marrow biopsy. CTA of the head and neck did not evidence acute pathology. After bone marrow biopsy, 24-hour urine for Bence Jones MRI of the brain revealed prominent bilateral enhancing protein and a skeletal survey, the diagnosis of multiple parietaloccipital lesions on FLAIR sequence. myeloma was made. The aortic valve pathology was Tacrolimus was held, all other medications were continued. retrospectively stained for light chains and was found to be Levetiracetam was begun for seizure prophylaxis. The patient positive. After completing chemotherapy, the patient is remained afebrile and normotensive and was extubated on currently in remission and has undergone stem cell harvest for the second hospital day. Repeat tacrolimus level was 5.0 possible future need. µg/L, a concentration not typically associated with Discussion: The complete work-up of a patient with CVA toxicity. The patient reported no neurologic symptoms and secondary to marantic endocarditis could reveal malignancy, was discharged home on the third hospital day after a full systemic lupus erythematous, antiphospholipid syndrome, or recovery. other diseases that manifest hypercoagulability. Clinically, it While the outcome of PRES is typically benign, delayed resembles bacterial endocarditis. diagnosis may lead to permanent neurologic deficits and misdiagnosis can be lethal. Definitive management involves removal of the offending agent or treatment of the underlying etiology. Given appropriate neuroimaging findings, a clinical picture of headache, visual abnormalities, altered mentation and seizures is sufficient to prompt empiric discontinuation of agents known to cause PRES. Calcineurin inhibitors such as tacrolimus, even at œnormal serum levels, are known to cause PRES and in this patient discontinuation led to complete 2 clinical resolution. Medical Student Clinical Vignette Author: Melissa Hershman Author: Jasmine Kahlon Additional Authors: Jennifer Yeung, M.D., Mark Additional Authors: Harneet Gahley, Niket Sonpal, MD Sonnenschine, D.O., R. Mohan Kilaru, M.D., Robert Graham, MD James O’Donnell, M.D. Institution: Lenox Hill Hospital Institution: Lutheran Medical Center Title: Large Cell Neuroendocrine Cancer of the Title: The Rhino Without It's Sugar Gallbladder: Understanding a Rare Medical Entity BACKGROUND: Rhinocerebral mucormycosis is an acute opportunistic Carcinoma of the gallbladder has a poor prognosis, likely mycosis with broad, non-septate hyphae and right angle attributed to by vague, nonspecific symptoms with late clinical branching classically seen in uncontrolled diabetics. We presentation. Among this cancer, histological classification present a case of a non-diabetic patient with stroke like may indicate disease severity, with the recently identified symptoms that was determined to be due to mucormycosis subclass of Large Cell Neuroendocrine Cancer (LCNEC) invading the sphenoid sinus. described as having perhaps the most invasive and aggressive A 64 year old female was admitted for slurred speech and pattern of growth. Neuroendocrine tumors comprise only 2% right-sided weakness. She was brought to the ER after being of all gallbladder carcinoma, as cells of this origin are not found unresponsive. Family members stated she had been found in normal gallbladder histology. It is believed that the experiencing difficulty speaking, mild right facial weakness, exceedingly rare large cell variant arises as a result of and two months of right arm and lower extremity weakness. metaplastic changes secondary to chronic inflammation such She has been complaining of headaches for the past seven as long-standing gallstone disease. This report aims to further months accompanied by a 15 pound weight loss and disease understanding, including clinical presentation and uncontrollable, shaky movements of the lower extremities. underlying pathophysiology, and to review potential On admission, her temperature was 98.4°F, BP 122/77, management. PR 78, and RR 18. Exam was significant for right-sided facial CASE: asymmetry/droop, expressive aphasia, slurred speech, and A 55-year-old male presented to Lutheran Medical Center jerky movements of bilateral lower extremities. Labs were complaining of acute onset right-sided abdominal pain and significant for an ESR of 72mm/hr. Head CT showed low associated nausea. On CT and subsequent MRCP imaging, the attenuation mass in the left basal ganglia, suspicious for patient was found to have focal thickening at the midportion developing infarct and a partial opacification of the left of the gallbladder, innumerable non-obstructing stones up to sphenoid sinus. The patient was started on aspirin and 4mm, and hypodense lesions in liver segments 8 and 5. The levetiracetam. Carotid Doppler was negative for stenosis. patient underwent uneventful open cholecystectomy after Brain MRI demonstrated a subacute stroke in the left basal which the diagnosis was made of a 3.0 x 2.0 x 1.3 cm ganglia and opacification of adjacent left sphenoid sinus with indurated tumor invading through the muscle and abnormal mucoperiosteal enhancment. Lumbar puncture was perimuscular tissue connective tissue staged as T3. performed and CSF was cloudy, tested nonreactive for VDRL, Histologically the tumor was described as LCNEC, with positive WBC 245/c/mm, and protein 82mg/dl. Culture was negative immunohistochemistry staining for chromogranin and for cryptococcal antigen and no fungus was isolated on India