Journal of Brown hospital medicine最新文献

Granulomatosis with polyangiitis (GPA) is a medium- and small-vessel necrotizing vasculitis that affects the upper and lower respiratory tracts, resulting in symptomatic and radiographic similarities with pulmonary tuberculosis (TB). We discuss the case of a 45-year-old previously healthy male who recently immigrated from India that presented after three weeks of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy for presumed TB prior to receiving the GPA diagnosis. Previous admission to a community hospital yielded negative Mycobacterium tuberculosis polymerase chain reaction (MTB PCR) and acid-fast bacillus (AFB) sputum cultures, prompting repeat testing and broad autoimmune/infectious workup. Chest computed tomography redemonstrated cavitary lesions with interval enlargement. Dermatopathology of bilateral lower extremity palpable purpura that erupted during admission demonstrated findings consistent with small-vessel vasculitis. Cytoplasmic-antineutrophil cytoplasmic antibodies was positive (1:80), and serine proteinase-3 IgG was 546 AU/mL (ref<19 AU/mL). Bronchoalveolar lavage samples produced a negative MTB PCR and AFB culture. This case highlights the importance of differentiating clinically similar diseases that can be symptomatically detrimental and require potentially competing therapeutics. Some evidence, including in vitro studies and acute care patients, suggests low risk of harm to initiate GPA treatment with possible concomitant TB. We hope this case informs providers to avoid diagnostic bias and consider early steroid treatment for patients suspicious of GPA in the absence of an unequivocal TB diagnosis.

Rapid changes in healthcare payment models and increasing regulatory scrutiny have driven many physician groups to be absorbed by healthcare systems, fueling "forward" vertical integration. This strategy-acquiring physician practices to control the care continuum aims to improve efficiency, quality, and market share. While integration offers potential benefits, it introduces significant challenges, including regulatory constraints, market volatility, internal tensions, and substantial investment in infrastructure and human capital. Successful integration depends on deliberate alignment between newly acquired physician groups and hospital operations. Key elements include preserving functional clinical and academic systems, fostering goal congruence, accommodating organizational culture, and establishing trust-based strategic relationships. Operational excellence requires balancing individual productivity with institutional priorities, coordinating inpatient and outpatient care, and sustaining core academic and community missions. Misalignment can lead to inefficiencies, reduced quality, physician dissatisfaction, and labor disputes.

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent histologic subtype of non-Hodgkin lymphomas. It usually presents with nodal involvement (cervical, mediastinal, or abdominal), but approximately 30% of patients will exhibit extranodal involvement, with 2-4% presenting as a primary cardiac mass. Multimodal imaging is essential to distinguish these masses from other common benign lesions and to assist in surgical planning. Here, we report a case of DLBCL manifested as a right atrial mass, pericardial effusion, and cardiac tamponade. Transesophageal echocardiogram (TEE) and cardiac magnetic resonance imaging (CMR) were complementary to transthoracic echocardiogram in diagnosing the cardiac neoplasm, with positron emission tomography (PET-CT) aiding in staging and localizing the primary tumor. Biopsy of the cardiac mass or extracardiac involvement confirms the histopathological subtype and guides the treatment. Although primary and secondary cardiac tumors have poor outcomes, early diagnosis and aggressive treatment can influence prognosis.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a T cell mediated, drug-specific immune response associated with end-organ damage. We present the case of a 65 year old woman presenting with a confluent rash, fever, and abdominal pain. Two months prior, she noted a finger lesion which progressed to cellulitis, requiring two debridements with culture growing Mycobacterium marinum. In this time, she was treated with several known triggers for DRESS. The most likely culprit drug was ethambutol and this is the only described case in M. Marinum. This report highlights the challenges of diagnosing and managing DRESS in a patient with concurrent M. marinum cellulitis and multiple high-risk antibiotic exposures.

Pott's puffy tumor (PPT) is a rare complication of frontal sinusitis, characterized by subperiosteal abscess formation and frontal bone osteomyelitis, with potential for severe intracranial spread. An 18-year-old male presented with forehead swelling and periorbital edema following recent sinusitis. Imaging revealed bilateral frontal epidural abscesses, osteomyelitis, and pachymeningitis. Surgical intervention included bicoronal craniotomy, frontal sinus cranialization, and abscess debridement. The presence of bilateral epidural abscesses and pachymeningitis represented an unusually severe presentation of PPT. In contrast to typical cases, systemic signs were absent, resulting in delayed diagnosis. Imaging findings and surgical management aligned with current literature and support these approaches in complex cases. Clinicians should suspect PPT in adolescents presenting with forehead swelling in the setting of sinusitis. Early imaging, prompt surgical management, and prolonged antibiotic therapy are essential to prevent life-threatening complications.

Manganese is an essential trace element necessary for various physiological functions, but excessive exposure or impaired elimination can result in neurotoxicity. We report a 50-year-old patient with chronic liver disease and worsening confusions, who on imaging was shown to have T1-hyperintensities in the globi pallidi consistent with manganese accumulation. However, the patient did not demonstrate Parkinsonian features raising the possibility of a biphasic presentation in which neuropsychiatric symptoms precede motor deficits. This case underscores the importance of recognizing manganese neurotoxicity as a potential contributor to neuropsychiatric symptoms in patients with hepatic dysfunction.

Hypothyroidism is an endocrine disorder that causes widespread systemic effects, but its impact on vascular tone is often under-recognized. We present a case of severe, longstanding hypothyroidism leading to bilateral lower extremity vasospasm and failure to thrive in a complex patient with significant psychiatric and medical comorbidities. A 46-year-old male with a history of type 2 diabetes, chronic DVT, bipolar disorder, and recent untreated hypothyroidism presented with progressive bilateral leg pain, weakness, and inability to ambulate. He had been discharged a week prior with a TSH of 101 mIU/L and newly initiated levothyroxine 50 mcg. On return, symptoms had worsened, and his mother reported cognitive slowing. Workup revealed stable chronic DVT and new arterial duplex findings showing diffuse high-resistance waveforms consistent with vasoconstrictive physiology in both lower extremities, without stenosis. Creatinine was elevated, likely due to vasomotor nephropathy. Neurological and rheumatological causes were previously excluded. Severe hypothyroidism is known to increase systemic vascular resistance and reduce endothelial-mediated vasodilation, potentially contributing to vasospastic phenomena. In this patient, no other etiology for bilateral vasoconstriction was found. With no history of Raynaud's, vasoactive drug use, or active thrombosis, hypothyroidism remained the most plausible cause. Although rare, such vascular manifestations can lead to functional decline, especially in vulnerable patients. This case highlights the importance of considering hypothyroidism in the differential diagnosis of unexplained vasospasm and functional decline. Timely thyroid hormone replacement may reverse vascular dysfunction and prevent further complications.

Neutrophilic dermatosis of the dorsum of the hand (NDDH) is a rare skin condition characterized by acute onset painful erythematous and violaceous papules localized to the dorsum of the hand with histological evidence of dense neutrophilic infiltrate without evidence of vasculitis. This condition is most commonly seen in middle aged females and is often associated with fever and an upregulation of inflammatory markers. NDDH is also characterized by its excellent response to corticosteroid therapy. This condition is often the result of an underlying inflammatory condition or malignancy, but it can also be secondary to drug administration. This case report describes a 72-year-old female with a history of collagenous colitis who presented with NDDH following treatment with amoxicillin.

A 29-year-old woman presented to the emergency department with purulent drainage of the left eye, periorbital edema and erythema, conjunctival hyperemia, chemosis, and pain with extraocular movements. Gonococcal conjunctivitis was diagnosed. The patient was successfully treated with a course of ceftriaxone and doxycycline.