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ACP Michigan Chapter Residents Day 2021

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ACP Michigan Chapter Residents Day 2021 ACP Michigan Chapter Residents Day 2021 Poster #1 Category: Clinical Vignette Program: Ascension Macomb Hospital Director: Deborah Jo Levan, DO Presenter: Aye Thet Additional Authors: Stephen Kehres, DO, FACOI Transient Enophthalmos in NF1 Complicated by Lumbar Puncture Neurofibromatosis type-1 (NF1) is an inherited autosomal dominant disorder, affecting 1 in 3000 population. NIH diagnostic criteria of NF1 includes distinctive bony lesions which are sphenoid dysplasia and pseudoarthrosis. They can occur with enlargement of the middle fossa resulting in herniation of the intracranial contents into the orbit and proptosis. Here, I present a case of a NF1 patient experiencing enophthalmos from decreased intracranial pressure status post lumbar puncture (LP). A 19 year old female with a history of NF-1 presented to ED with the complaints of blurred vision, right-sided headache and eye pain about 30 hours post LP. As a part of work ups, LP was performed in her previous admission. The physical exam was significant for right enophthalmos, tearing, right eye pain with extraocular movement and vision 20/50 right, 20/25 left. CT Head and Orbit revealed right globe migrated 12.4 mm posteriorly and new right lacrimal gland enlargement compared to pre-LP scan in addition to right sphenoid wing dysplasia and right orbit deformity with absence of medial and superior orbital wall posteriorly. The patient was given IV methylprednisolone along with ampicillin/sulbactam for possible dacryoadenitis. Day 3 repeat MRI Orbit demonstrated a slightly proptotic right globe. Her headache and eye pain improved and she was discharged home with ophthalmology follow up. This case is a rare presentation of transient enophthalmos complicated by LP in the setting of absence of greater wing of sphenoid occurring at a frequency of about 4% in NF1. References Mink, Jonathan W. "Congenital, developmental, and neurocutaneous disorders." Goldman's Cecil Medicine. WB Saunders, 2012. 2386-2391 DeBella K1, Szudek J, Friedman JM. Use of the national institutes of health criteria for diagnosis of neurofibromatosis 1 in children. PMID: 10699117 DOI:10.1542/peds.105.3.608 ACP Michigan Chapter Residents Day 2021 Poster #2 Category: Clinical Vignette Program: Ascension St. John Hospital Director: Raymond Hilu, MD, FACP Presenter: Rami Arabo Additional Authors: Kootaybah Al Sheikhly, Raymond Hilu Severe Hypothermia Requiring Modified ACLS and Venous- Arterial Extracorporeal Membrane Oxygenation ( VA ECMO) Introduction: Hypothermia is defined as a core temperature less than 95 F. It can be classified as mild (90- 95 F), moderate (82-90 F), or severe ( < 82 F). Hypothermia causes almost 1500 deaths in the United States. Presentation and management differs depending on the severity. Etiologies include outdoor cold exposure, cold water submersion, and medical conditions such as hypothyroidism, sepsis, and medications. We present a case of hypothermia requiring advanced life-saving measures and benefiting from VA ECMO. Case Presentation: A 40 years old male was found down with a core temperature of 77 F. At presentation, the patient was unresponsive, hypothermic, and in PEA arrest. He was intubated, and ACLS protocol was initiated. Hypothermia protocol was also initiated including chest tubes placement, warm IV fluid resuscitation, and external warming. Patient did not respond to initial management and developed ventricular fibrillation. Per modified ACLS for hypothermia, CPR was continued by mechanical CPR machine and shocks were delayed until rewarming was achieved. Pertinent labs noted venous pH 7.01, PCO2 76, lactate 11.5, creatinine 1.8, and troponin of 1.03. Patient was then started on VA ECMO requiring cardiac shocking for ventricular fibrillation. Patient was maintained on VA ECMO for 2 days and exhibited a full cardiac and neurologic recovery. seven days later, he was discharged home walking without assistance. Discussion: This case illustrates the importance of early recognition of severe hypothermia, the application of modified ACLS guidelines, and the benefit of VA ECMO in severe hypothermia treatment. Moreover, national guidelines for the management of hypothermia are needed in order that all patients with severe hypothermia would benefit from VA ECMO. ACP Michigan Chapter Residents Day 2021 Poster #3 Category: Clinical Vignette Program: Ascension St. John Hospital Director: Raymond Hilu, MD, FACP Presenter: Zoheb Backer Additional Authors: Reynald John MD, Elizabeth Bankstahl MD FACP Unusual case of a Loculated Pleural Effusion Due to Chronic Pancreatitis Introduction: Large exudative pleural effusions are most commonly caused by infections and malignancy. Less commonly, other etiologies such as pancreatitis, or chronic Boerhaave's syndrome should be considered. Case description: A 65-year-old male with a history significant for prior retroperitoneal fluid collection and alcohol abuse presented with left sided chest pain of 2 weeks duration. He denied abdominal pain, fever, cough, vomiting, or shortness of breath. Physical exam was significant for decreased breath sounds on the left lung base, he had no abdominal tenderness. Chest X-ray showed a large left sided pleural effusion. Two sets of blood cultures were sent, and the patient was started on broad spectrum antibiotics. Thoracentesis revealed exudative fluid with elevated amylase>6000. Repeat CXR showed persistent effusion. Bronchoscopy and VATS were performed without evidence of a bronchial lesion, or mass. Loculated cloudy fluid was drained and a chest tube was placed. Blood and pleural fluid cultures were negative. CT scan suggested possible pancreatic pseudocysts with fluid seen near the tail of pancreas. Serum Lipase was mildly elevated at 146. EGD with EUS was performed to evaluate for pancreatitis versus Boerhaave’s syndrome. EGD revealed normal esophagus, however, fluid and debris was seen around the tail of pancreas, suggestive of acute pancreatitis. Pleural fluid analysis showed elevated lipase>20000. Patient was discharged and was advised outpatient follow up for repeat CT and possible ERCP in 2 weeks. Discussion: Massive pleural effusion is a rare complication of chronic pancreatitis. Large effusions are likely due to the presence of a pancreaticopleural fistula which has an incidence of 0.4%. Another mechanism is through transdiaphragmatic lymphatic blockage. This case aims to increase awareness of these rare etiologies of massive pleural effusion and possibly help establish better guidelines for diagnosis and treatment which appear underexplored currently. ACP Michigan Chapter Residents Day 2021 Poster #4 Category: Clinical Vignette Program: Ascension St. John Hospital Director: Raymond Hilu, MD, FACP Presenter: Anmar Dalati Additional Authors: Thomas Loss, MD, Saif Affas, MD COVID-19 Vaccination. A Stressful Conundrum Introduction Adrenal crisis is a life-threatening condition which can be precipitated by internal or external factors. We present a case of adrenal crisis following administration of the COVID-19 vaccine. Case Presentation A 33-year-old male with history of adrenal insufficiency following TBI presented with hypotension, syncope and hypoglycemia after administration of COVID-19 vaccination. The first dose was well-tolerated. Following the second dose he reported fevers, generalized weakness and syncopal episodes. He presented to the emergency department with a BP of 93/46, fever of 101.9 °F, tachypneic and tachycardic. Laboratory findings revealed a blood glucose level of 63 mg/dL and lactic acidosis. No electrolyte abnormalities were noted. He received 3 L of IV fluids, 1 amp of dextrose and 100 mg dose of IV hydrocortisone. Vital signs improved and hypoglycemia resolved with dextrose. He was discharged the following day on his usual steroid regimen and educated of the importance of doubling his home steroid regimen with future vaccinations or illnesses. Discussion The hallmark presentation of adrenal crisis is shock. Patients also present with significant electrolyte derangements including hyponatremia, found in 70 to 80% of patients, and hyperkalemia secondary to mineralocorticoid deficiency. Acute infectious processes may often be the precipitant of adrenal insufficiency. However, reportings of adrenal crises precipitated by vaccinations appear under reported. A previous report revealed severe adrenal crisis triggered by administration of 3 vaccines in a single healthcare appointment. Conclusion Routine vaccinations are known to cause systemic symptoms. This is no more evident than with the administration of COVID-19 series. Injection site pain remains the most commonly reported reaction. Systemic symptoms nearly double in reporting following the second dose, likely owing to the more robust second immune response. It may be reasonable to suggest patients with adrenal insufficiency receive stress dose steroids with administration of the 2 part COVID-19 vaccine to avoid adrenal crisis. ACP Michigan Chapter Residents Day 2021 Poster #5 Category: Clinical Vignette Program: Ascension St. John Hospital Director: Raymond Hilu, MD, FACP Presenter: Mohamed Issa Additional Authors: Issa Mohamed, MD, Cherri Mujtaba, MD, Benjamin Huber, DO Humoral Hypercalcemia of Malignancy , An Unusual Presentation of Paraneoplastic Syndrome of invasive Urothelial Cell Carcinoma Ascension St. John Hospital Introduction: Hypercalcemia is a common feature of malignancies. The cause of hypercalcemia includes bony metastasis or endogenous hormone production. Humoral hypercalcemia is a well-known paraneoplastic
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