Journal of Brown hospital medicine最新文献

Anti-glomerular basement membrane (anti-GBM) disease is a rare autoimmune disorder causing rapidly progressive glomerulonephritis. Early recognition is crucial to prevent irreversible damage. We present a 70-year-old female with hypertension and COPD who had elevated creatinine without respiratory symptoms. Workup revealed elevated anti-GBM antibodies (59 U/mL), anti-MPO antibodies (168 AU/mL), and p-ANCA positivity with kidney biopsy confirming crescentic glomerulonephritis. She was treated with plasmapheresis, corticosteroids, and cyclophosphamide. Her antibody titers declined, and she was discharged on hemodialysis and immunosuppressive therapy. At her 4-week follow-up, renal function had not recovered, and she continued to require hemodialysis. This case highlights the need to consider anti-GBM disease even in isolated renal presentations and emphasizes challenges in managing dual-positive cases. Long-term considerations include maintenance immunosuppression and infection prevention.

This article reviews pearls and pitfalls in managing hyperkalemia associated with Bactrim use for PJP prophylaxis, as well as strategies for addressing hypercalcemia induced by immune checkpoint inhibitors.

Reno-duodenal fistulas are an extremely rare complication of radiotherapy in patients with metastatic lung cancer. Here we describe the case of a 60-year-old man with metastatic non-small cell lung cancer treated with chemoradiation who presented with fever, chills, and flank pain and was found to have septic shock with polymicrobial bacteremia and fungemia. Subsequent imaging showed evidence of a reno-duodenal fistula. After a failed attempt at endoscopic closure, the patient was not deemed a surgical candidate due to poor performance status and advanced metastatic disease and was transitioned to home hospice care. This report highlights the importance of considering reno-alimentary fistulization in the differential diagnosis of emphysematous pyelonephritis, especially in the setting of radiation therapy and malignancy.

Erythromelalgia is a rare condition characterized by severe paroxysmal pain in the extremities and erythema that leads to significant morbidity and incapacity. We report on the case of a female with a history of erythromelalgia, presenting with worsening bilateral leg pain and purple discoloration of her feet following a surgical procedure. After ruling out secondary causes, a diagnosis of atypical erythromelalgia flare was established. A multimodal pain management strategy was instituted, and the patient improved upon follow-up. The clinical presentation of erythromelalgia presents diagnostic and therapeutic challenges, and atypical presentations highlight our poor understanding of the disease.

The inpatient setting is fraught with emotional challenges for patients and healthcare providers due to unexpected illnesses, procedural delays, diagnostic uncertainties, suboptimal treatment responses, and prolonged hospital stays. These stressors often manifest in patient demands, behaviors, and questions, necessitating difficult conversations. The rise in misinformation, unrealistic expectations, and complex psychosocial dynamics has further increased the frequency of such interactions. Avoiding these conversations can exacerbate issues, erode trust, and harm therapeutic relationships. Hospitalists must cultivate skills to address these challenges effectively, fostering clarity, shared goals, and patient-centered care. A structured approach to navigating difficult conversations includes preparation, creating an appropriate setting, active listening, reflecting on perspectives, and collaborative action. Tools such as the Awareness-Understanding Matrix can guide understanding and resolution. By prioritizing open, empathetic, and purpose-driven communication, hospitalists can align with patients, strengthen relationships, and achieve meaningful outcomes in care.

Peritoneal tuberculosis (PTB) is a diagnostic challenge due to its nonspecific presentation, low sensitivity of ascitic fluid microbiologic tests, and possible resemblance to peritoneal carcinomatosis. We describe a case of 51-year-old woman with long-term tumor necrosis factor alpha (TNF-α) inhibitor exposure presented with fever and abdominal distension after returning from the Philippines. Initial tests, including microbiological studies, were inconclusive, despite imaging findings suggestive of carcinomatosis with elevated CA-125. Diagnostic laparoscopy revealed miliary white nodules; however, omental biopsy showed non-necrotizing granulomas without AFB. High clinical suspicion prompted excision of an enlarged axillary lymph node, which demonstrated necrotizing granulomas with rare AFB-positivity and ultimately grew Mycobacterium tuberculosis. The patient experienced rapid symptomatic relief and near-complete radiological resolution within four months of tuberculosis (TB) treatment. PTB should remain on the differential for unexplained ascites or peritoneal nodularity - particularly in immunosuppressed travelers from endemic regions - even when early microbiologic tests are negative. Timely invasive sampling and, when warranted, empirical anti-TB therapy is critical. Clinicians must recognize that patients on TNF-α inhibitors remain at heightened risk for extrapulmonary TB despite negative baseline screening.

Malaria is a common febrile illness that can sometimes present as an acute potentially fatal disease if left undiagnosed or untreated. It is caused by an intra-erythrocytic infection from the Plasmodium parasite and transmitted by the female Anopheles mosquito. Symptoms are nonspecific, ranging from fevers, headache, malaise, myalgia, gastrointestinal distress to confusion, seizures or coma. Fever is the most characteristic feature of the illness and periodic febrile responses correspond to rupture of mature schizonts from erythrocytes. Diagnosis should be considered with anyone with fever of unknown origin regardless of travel history. Plasmodium falciparum is the most likely to cause severe malaria. Severe malaria is defined by the Centers for Diseases Control (CDC), when there is high burden of parasitemia and evidence of end organ dysfunction spanning across central nervous, cardiovascular, respiratory, renal and hematological systems. This entity needs prompt diagnosis and treatment. Despite recommendations and approval by the FDA, IV artesunate is not readily available at most hospitals in the United States.

Calciphylaxis is a rare and life-threatening condition characterized by vascular calcification and thrombosis, typically seen in patients with end-stage renal disease but also associated with long-term warfarin use in non-uremic patients. We present the case of a 78-year-old woman with a mechanical aortic valve on chronic warfarin therapy who developed progressive, painful necrotic skin ulcerations over ten months. Skin biopsy confirmed warfarin-induced non-uremic calciphylaxis. Following shared decision-making, warfarin was discontinued and replaced with low molecular weight heparin, and intravenous sodium thiosulfate was initiated. This case underscores the importance of recognizing non-uremic calciphylaxis in warfarin-treated patients and highlights the need for early diagnosis, multidisciplinary management, and shared decision-making to balance the risks of anticoagulation against serious complications like calciphylaxis.

Resident project winners at the Warren Alpert Medical School of Brown University annual research forum.