Journal of Community Hospital Internal Medicine Perspectives最新文献

Background: Gastric Adenocarcinoma with enteroblastic differentiation (GAED) is a rare subtype of alpha fetoprotein-producing gastric cancers characterized by a tubulo-papillary pattern resembling fetal gastrointestinal epithelium. It expresses at least one of the following enteroblastic markers (EMs): glypican-3 (GPC3), spalt-like transcription factor 4 (SALL4), and α-fetoprotein (AFP).

Case report: A 78-year-old man with a history of chronic dry cough was found to have multiple lung nodules on Chest X-ray and CT, suspicious for a malignancy. Therefore, percutaneous biopsy of the lung nodule was performed which showed CDX-2 positivity on immunohistochemistry (IHC). Next Generation Sequencing (NGS) and Caris GPSai were inconclusive. Therefore, a search for the primary site was initiated. Endoscopy revealed a fungating mass at the gastroesophageal junction while colonoscopy was unrevealing. Histology revealed well-differentiated adenocarcinoma with mucinous features. IHC was positive for SALL-4 and GPC3. HER2 expression returned a 3+ score. Alpha-fetoprotein (AFP) level was elevated. The patient was started on capecitabine and oxaliplatin in addition to trastuzumab with subsequent clinical and radiological improvement.

Conclusion: Lung malignancy, primary or metastatic, can present as chronic cough. It is imperative for patients to undergo a thorough workup for a timely diagnosis. IHC plays a vital role in delineating the origin of the malignant cells. GPC3 expression is the most sensitive marker for GAED. High serum AFP levels directly correlate with the strength of immunostaining and are associated with a poor prognosis. High HER2 expression and PDL-1 immunostaining is commonly seen in GAED cases with the most common mutation being p53. Currently, there are no set guidelines for management of GAED. Unresectable, metastatic HER2 positive conventional adenocarcinoma is being managed using platinum-fluoropyrimidine doublet therapy with anti-HER2 monoclonal antibody trastuzumab. This case report calls for aggressive IHC staining for prompt diagnosis where necessary as well as proper guidelines for management.

JCHIMP's Editor-in-Chief and a member of the Editorial Board acknowledge the importance of authors and peer reviewers to the success of JCHIMP in 2024. They discuss the value of peer review and how it satisfies ACGME directives for scholarship. Publication costs, and sources for publication funding are also examined.

We present a rare case of Bacteroides fragilis vertebral osteomyelitis, in a 20-year-old female with no underlying medical conditions. She presented with a three-week history of lower back pain, myalgias, rigors, and night sweats. The patient was febrile and tachycardic, with borderline low blood pressures. Her initial labs showed elevated inflammatory markers with no leukocytosis. MRI of the thoracic and lumbar spine demonstrated T12/L1 discitis/osteomyelitis with phlegmonous changes and concerns for epidural abscess, causing mild to moderate spinal stenosis. Bacteroides fragilis grew in an anaerobic bottle, and a CT-guided biopsy of the T12/L1 lesion grew Bacteroides fragilis. E-test sensitivities revealed sensitivity to metronidazole. The source of bacteremia was thought to be from gut translocation thus concerned about possible co-infection with E. coli from the gastrointestinal tract. Another source of E. coli could have been from her recent E. coli urinary tract infection, whose growth from blood cultures could have been suppressed from recent course of cephalexin. She was treated with six weeks of metronidazole for the Bacteroides fragilis and ceftriaxone for possible co-infection with E. coli, resulting in improvement of her back pain and down-trending inflammatory markers on clinic follow-up after six weeks.

Downhill esophageal varices (EVs) were first described in 1964 by Felson and Lessure. They are rare with an incidence rate of 0.5 % in the general population. They usually develop due to an increase in pressure and/or obstruction of the superior vena cava (SVC) and rarely present with hematemesis. SVC syndrome, surgical ligation of the SVC, Castleman syndrome, pulmonary hypertension, and hypercontractile esophageal motility disorders can cause this. We report a case of downhill EVs in an older male with alcohol use disorder with incidental finding of SVC stenosis secondary to an old, unused chemotherapy port.

Intramyocardial dissecting hematoma (IDH), a rare complication of myocardial infarction, was investigated through two unique clinical cases in this study. We demonstrate echocardiography's pivotal role in emergency diagnostics by detailing its critical contribution to rapid identification. Furthermore, we propose a hypothesis regarding the anatomical subtypes of IDH, potentially offering new perspectives and insights into this rare cardiac condition.

Objective: This study aimed to evaluate the impact of contrast-induced nephropathy (CIN) on quality of life (QoL) in patients undergoing percutaneous coronary intervention (PCI) in Pakistan.

Methods: A retrospective cohort study was conducted involving 5325 patients who underwent PCI, divided into CIN (n = 1250) and non-CIN (n = 4075) groups. Demographics, clinical characteristics, and procedural details were recorded. QoL was assessed using a standardized questionnaire before and after PCI, covering physical functioning, pain, mobility, anxiety/depression, and overall health. Statistical analyses compared QoL scores between groups and identified predictors of change.

Results: Patients who developed CIN exhibited a significant decline in post-PCI QoL across all domains compared to the non-CIN group (p < 0.05). CIN, older age, diabetes, lack of hydration protocol use, prolonged hospital stay, and lower baseline QoL were independent predictors of poorer QoL outcomes. Comorbidities were more prevalent in the CIN group, including diabetes (64.0 % vs. 47.8 %), hypertension (68.0 % vs. 60.8 %), and CKD Stage 3 or worse (28.0 % vs. 8.6 %) (all p < 0.05). CIN patients more frequently underwent PCI for acute coronary syndrome, received higher contrast volumes, and had lower use of preventive measures. Post-PCI complications such as heart failure (36.0 %), dialysis requirement (32.0 %), and prolonged hospital stays (60.0 %) were significantly higher in CIN patients.

Conclusion: CIN adversely affects QoL following PCI, particularly in high-risk patients. Preventive strategies and early intervention are essential to mitigate CIN-related complications and improve patient-centered outcomes. Further prospective, multi-center studies are warranted.

Clinicians frequently encounter patients in the hospital with mild-to-moderate COVID-19 who are at high risk for disease progression. Antiviral drugs reduce the rate of progression to severe COVID-19 when given to these patients within 5-7 days of symptom onset. To look at the utilization of antiviral medications in hospitalized patients with mild-to-moderate COVID-19, a detailed chart review was conducted of 500 randomly selected patients from the Charleston Area Medical Center COVID-19 Registry. We identified 124 patients with mild-to-moderate COVID-19 who were eligible for antiviral treatment. Only 41 of the 124 patients (33.1 %) received antiviral treatment. Providers listed mild symptoms as the most common reason (74.7 %) that antiviral treatment was not started. These findings show that antiviral medications are underutilized in treating high-risk hospitalized patients with mild-to-moderate COVID-19 to prevent disease progression.

Bullous Myringitis (BM) is an acute painful infection in which vesicles or bullae form on the tympanic membrane. It is rare in adults and could be present with acute otitis media (AOM) if the middle ear is involved. This case report details a 55-year-old male with a history of recurrent childhood ear infections, chronic military noise exposure, smoking, and Crohn's disease presenting with severe right ear pain, hearing loss, and fever. Examination revealed signs of AOM with perforations in the tympanic membrane and purulent drainage. Initial management included antibiotics and analgesics, but symptoms progressed, requiring further investigation. Imaging showed complete opacification of the R ear structures without bone erosion. Despite initial treatment, the patient's condition worsened with bilateral hearing loss and intermittent peripheral vertigo. Ear, nose and throat (ENT) consultation and advanced diagnostics led to a diagnosis of BM with AOM, and asymmetric sensorineural hearing loss. The treatment was escalated to include high-dose steroids, azithromycin, valacyclovir, and daily aspiration of effusion. His symptoms improved, and he was discharged with oral antibiotics and scheduled follow-up. This case highlights the complexity of diagnosing BM that complicates AOM in an adult and the importance of detailed history, underlying past medical conditions pertinent to early diagnosis, consideration of less common pathogens, and comprehensive treatment.

We report a case of a 55-year-old male with a history of Crohn's Disease who presented for acute on chronic worsening back pain. He was found to have spondylodiscitis with adjacent myositis secondary to an uncommon urinary tract infection pathogen, Actinotignum schaalii. He underwent interventional radiology disc biopsy and open surgical biopsy with culture. He was successfully treated with a six-week course of IV daptomycin and ceftriaxone.

Background: Infective endocarditis (IE) is a rare cause of myocardial infarction (MI). In contrast to other embolic phenomena associated with IE, the incidence of coronary embolism is <1 % with a mortality rate of >65 %. Common risk factors of IE include intravenous drug use (IVDU), hemodialysis and the use of cardiac devices. We present a unique case of multiple coronary artery involvement on 2 separate occasions highlighting the need for increased awareness among healthcare professionals.

Case report: A 38-year-old female with history of IVDU, hepatitis B and C presented with acute chest pain and was found to have NSTEMI and active aortic valve vegetation. Left heart catheterization (LHC) revealed an occlusion of the right coronary artery (RCA), which was treated with stent placement. However, on experiencing ventricular fibrillation on hospital day 2, a repeat cardiac catheterization revealed a re-occlusion of RCA proximal to the stent as well as occlusion of the first obtuse marginal artery (OM1). Subsequent investigations also revealed multiple intraparenchymal hemorrhages and probable renal infarcts. The involvement of multiple systems, as well as the occlusion of multiple coronary arteries on separate occasions distinguishes this case from previously reported cases.

Conclusion: Timely intervention is critical in the management of MI due to septic embolism. A high index of suspicion and immediate action can be lifesaving. Early diagnostic imaging and percutaneous or surgical interventions can improve patient outcomes. Greater awareness of multisystem and multi-coronary artery embolic phenomena is needed.