Journal of Community Hospital Internal Medicine Perspectives最新文献

Sclerosing mesenteritis (SM) is a rare idiopathic fibroinflammatory disorder of the bowel mesentery adipose tissue. While the use of rituximab has been documented in IgG4-related SM, its effectiveness in idiopathic, IgG4-unrelated SM remains unknown. We present a case of idiopathic SM successfully managed with rituximab, suggesting that this treatment may be an option for patients who either have contraindications to or have not responded to current first-line therapies.

Liver cirrhosis is commonly diagnosed with etiologies such as viral hepatitis, alcohol-related liver disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). However, less common causes should be considered, especially in atypical presentations or suboptimal treatment responses. A 67-year-old man presented with massive bilateral pedal edema unresponsive to furosemide. He had well-controlled diabetes and hypertension but no history of alcohol use. Laboratory tests showed normal renal function, mild transaminitis, and mild thrombocytopenia. Imaging revealed liver morphology suggestive of cirrhosis, which prompted the presumptive diagnosis of metabolic-associated steatohepatitis (MASH). Despite diuretic therapy, the patient's edema worsened, necessitating repeated hospital admissions for intravenous diuresis. Measurement of transhepatic pressures showed findings consistent with portal hypertension, but the degree of edema was disproportionate to the hepatic venous pressure gradient. Liver biopsy showed sinusoidal congestion suggesting cardiac causes of portal hypertension. Subsequent cardiac evaluation, including left and right heart catheterization and cardiac MRI, revealed constrictive pericarditis. The patient then underwent pericardiectomy, leading to substantial improvement in symptoms allowing cessation of diuretic therapy. The overlap of symptoms between cardiopulmonary and hepatic diseases can complicate diagnosis. Cardiac cirrhosis, though often asymptomatic, should be considered in patients with unexplained peripheral edema. Diagnostic challenges include normal echocardiograms and the need for advanced imaging. Careful evaluation and consideration of atypical presentations are crucial, with gastroenterologists playing a vital role in identifying cardiac conditions masquerading as primary liver disease.

Background: The COVID-19 pandemic caused a major burden on the healthcare system. Since the beginning of the pandemic, the timing of intubation in patients with COVID-19 induced acute respiratory distress syndrome (ARDS) remained an area of debate.

Research question: Does a trial of non-invasive ventilation (NIV) in COVID-19 patients worsen mortality in patients intubated due to ARDS?

Study design and methods: A single-center, retrospective cohort study of all adult patients (n = 161) with COVID-19 admitted to the ICU between March 2020 through September 2022 with acute hypoxic respiratory failure were included. The group was divided into patients intubated after a trial of NIV (N = 100) and patients intubated without a trial of NIV (N = 61). The primary outcome was to compare the mortality rates between the two groups.

Measurements and main results: ICU mortality (defined as death during ICU admission) was higher in patients intubated after a trial of the NIV group compared to those without a trial of NIV (69% vs 52%, p = 0.044). Patients initially treated with a trial of NIV had an odds ratio (OR) of 2.17 for mortality compared to those intubated without a trial of NIV (95% CI 1.04-4.54). ICU length of stay was higher in the intubation after a trial of the NIV group, 11.9 vs 7.7 days (p = 0.001). Patients intubated after a trial of NIV had a longer hospital Length of stay (LOS) (IRR 1.39, 95% CI 1.05-1.85, p = 0.022). However, the duration of mechanical ventilation was similar in the two groups (IRR 1.23, 95% CI 1.93-4.68, p = 0.35). The incidence of pneumothorax, ventilator associated pneumonia (VAP), and venous thromboembolism (VTE) were similar in the two groups.

Conclusion: In ARDS, a lung protective strategy with low TV has been proven to improve patient outcomes. The use of a trial of NIV prior to intubation is associated with an increase in mortality.

Right atrial thrombus is a rare complication of hemodialysis catheter with an incidence of <6 %. New-onset atrial fibrillation can be the first symptom of catheter-related right atrial thrombus (CRAT) in a patient with long-term dialysis catheter. Therefore, evaluation for CRAT is justified in such scenario. We highlight a case report where a new-onset atrial fibrillation led to the discovery of a right atrial thrombus in a patient with long-term dialysis catheter.

Ibrutinib, a Bruton's tyrosine kinase inhibitor, has transformed the management of various hematological malignancies. However, its association with cardiovascular toxicities, particularly atrial fibrillation (AF), hypertension, and heart failure (HF), has raised clinical concerns. Pericardial effusion, though rare, is an emerging complication warranting attention. We present the case of a 62-year-old male with lymphoplasmacytic lymphoma, initially treated with Bendamustine and Rituximab, which was discontinued due to significant neutropenia. Ibrutinib therapy was initiated, leading to a partial response at three months. Approximately ten months into ibrutinib treatment, the patient developed new-onset dyspnea, palpitations, and dizziness. ECG revealed AF with rapid ventricular response, and transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction of 40 % and a moderate pericardial effusion. Baseline assessments prior to ibrutinib had indicated normal cardiac function. Given the development of heart failure with reduced ejection fraction and pericardial effusion, ibrutinib was discontinued. The patient was initiated on guideline-directed medical therapy for heart failure. Over six months, the patient exhibited significant cardiac recovery, with normalization of ejection fraction and resolution of the pericardial effusion. While atrial fibrillation and heart failure are recognized as adverse effects of ibrutinib, pericardial effusion is less commonly reported. Given the increasing use of ibrutinib, clinicians should maintain vigilance for cardiovascular complications. Early recognition and management are crucial to mitigate morbidity and mortality associated with these adverse effects. This case highlights the importance of comprehensive cardiovascular monitoring in patients receiving ibrutinib and contributes to the growing body of literature on its cardiotoxic profile.

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors arising from adrenal medulla and extra-adrenal paraganglia. Metastatic pheochromocytomas, pose diagnostic and therapeutic challenges due to their atypical presentations and potential for malignant transformation years after primary tumor resection. We report a case of 61-year-old woman who presented with intermittent cough, shortness of breath, and elevated blood pressure 6 years after resection of primary adrenal pheochromocytoma. Imaging revealed bilateral pulmonary nodules, a retroperitoneal mass, and L4 vertebral involvement, raising suspicion for metastatic pheochromocytoma. Elevated serum meta-nephrines and normetanephrines, alongside tissue biopsy and MIBG imaging, confirmed diagnosis. Germline genetic testing did not reveal any pathogenic mutations. The patient underwent CT-guided cryoablation for retroperitoneal lymph nodes and scheduled for radiofrequency ablation (RFA) of metastatic lesions. This case underscores evolving understanding of PPGLs, challenging "10 % rule" regarding metastasis and inheritance. While mutations in genes such as SDHB are associated with increased metastatic risk, sporadic cases like this highlight need for lifelong surveillance in all patients' post-resection of primary tumor. Ablative techniques, EBRT, and emerging systemic therapies are promising methods for managing metastatic disease. This case highlights importance of long-term follow-up and genetic testing in patients with PPGLs, even in absence of hereditary mutations, to detect and manage late-onset metastatic disease efficiently.

Background: Blastomycosis is a fungal infection caused by Blastomyces species, which are thermally dimorphic fungi endemic to the midwestern, south-central, and southeastern United States (US). Organ transplant patients are at risk of infection due to long-term immunosuppressive therapy. We present a unique case of blastomycosis in a renal transplant patient residing in a non-endemic region of Appalachia.

Case report: A 67-year-old patient with history of tobacco use, atrial fibrillation, type 2 diabetes, hyperlipidemia, and bilateral deceased donor kidney transplantation (DDKT) in 2021, presented to Charleston Area Medical Center's (CAMC), Charleston WV, Emergency Department (ED) for fever and night sweats. Initial workup revealed 39.4 °C temperature with remaining vital signs normal. Corona, parainfluenza, influenza, metapneumovirus, mycoplasma pneumonia, RSV were negative, GI PCR panel was negative for C. difficle, yersinia, campylobacter, giardia, vibrio, norovirus, salmonella, rotavirus. Chest X-ray showed a 2.1 × 1.6 cm nodular density in the left upper lobe (LUL) lobe. White blood cell (WBC) count was elevated at 13000/mcl with a left-sided shift. Subsequent computed tomography (CT) of the chest without contrast demonstrated a 2.7 × 2.1 cm LUL mass. Urine Blastomyces antigen tested positive, prompting the initiation of empiric therapy for blastomycosis. Aspergillus was ruled out initially.

Conclusion: Blastomycosis is a rare occurrence in the US, with annual incidence reported at 1 to 2 cases per 100,000. While transplant recipients are predisposed to acquiring blastomycosis, it remains an infrequent occurrence. In transplant patients presenting with persistent infectious symptoms, blastomycosis and other rare etiologies should be considered to prevent severe complications.

Introduction: Synonymous with the American film industry, Hollywood wields considerable influence on public health through its vast global reach and engaging media. This paper explores Hollywood's role and its impacts on public health, primarily driven by its portrayal of healthcare services, illnesses, and related beliefs and provides recommendations to improve "education entertainment" for the future.

Methods: PubMed was searched using keywords such as hollywood, healthcare, medical dramas, health education, smoking, suicide, and many more. Relevant literature up to June 2024 has been examined and summarized, which consisted of 37 articles with data from various clinical trials, meta-analyses, and literature reviews.

Discussion: Medical dramas like "Grey's Anatomy" and "E.R." have educated audiences on medical knowledge, healthcare structures, and inspired healthcare career aspirations. By depicting the realities of medical practice, these shows have enhanced public support for healthcare reforms. Similarly, films like "Contagion" have fostered awareness and empathy by positively portraying healthcare professionals during crises. However, Hollywood's glamorization of certain lifestyles has also contributed to body dissatisfaction and unhealthy behaviors, with increased cosmetic procedure rates and eating disorders linked to media portrayals. Furthermore, the depiction of smoking and vaping, as well as the sensationalized portrayal of suicides, has been shown to elevate risky behaviors and suicide rates among impressionable viewers.

Conclusions: Hollywood's impact on healthcare is thus dual-faceted, necessitating responsible media practices and preventive measures to mitigate adverse outcomes while leveraging its potential for public health education.

Background: Colonic varices (CV) remain an extremely rare condition, the usual cause of which is portal hypertension due to liver disease, chronic pancreatitis or malignancy. Here we present a case of familial idiopathic CV in a middle-aged female, complicated by a polyp removal during colonoscopy.

Case presentation: A 57-year-old female with a past medical history of 5 months of melena, polyps and hemorrhoids diagnosed with idiopathic CV during diagnostic colonoscopy. She had no prior history of liver disease, pancreatic disease, non-steroidal anti-inflammatory drugs (NSAID) use, or blood thinner use. She was later found to have a family history of the condition.

Conclusion: The rarity of this case is of particular concern for clinicians due to its life threatening complication of severe lower gastrointestinal bleed - a true medical emergency. This is particularly difficult in the absence of usual predisposing triggers. Differential diagnoses should be considered in patients that present with rectal bleeding of unknown cause.