Arpan Patel

Polycystic Liver Disease presenting as Acute Abdomen

A 65-year old gentleman came in with an initial complaint of abdominal pain for 2 days. His pain was on the left side at the level of the umbilicus, intermittent, sharp and non-radiating, 10/10. He associated the pain with deep coughing and deep breaths and was not relieved with ibuprofen. His past medical history includes hypertension, surgery was called for suspected acute abdomen and subsequently a computed tomography (CT) scan of abdomen was done with oral contrast which showed a cyst protruding from the liver juxtaposed to the abdominal viscera (Figure 1). Interventional radiology was called to drain the cyst and subsequent to the procedure the patient’s pain was relieved. The abdominal pain was explained by an impressive CT scan for a patient who had no diagnosis of polycystic kidney disease (PKD) with extra renal manifestations.

Hiatal hernia squeezing the heart to flutter

An 80-year-old woman presented to the emergency department with failure to thrive and weakness for 14 days. Medical history was significant for polio. On admission her electrocardiogram showed atrial flutter, and cardiac enzymes were elevated. Echocardiogram revealed a high pulmonary artery pressure, but no other wall motion abnormalities or valvulopathies. Chest x-ray showed a large lucency likely representing a diaphragmatic hernia. Computed tomographic scan confirmed the hernia. Our patient remained in atrial flutter despite rate control, and thereafter surgery was consulted to evaluate the patient. She underwent hernia repair. After surgery, the patient was taken off rate control and monitored for 72 hours; she did not have any episode of atrial flutter and was discharged with follow up in a week showing no arrhythmia. Her flutter was caused directly by the mechanical effect of the large hiatal hernia pressing against her heart, as the flutter resolved after the operation.

Crack lung: cocaine-induced lung injury

A 31-year-old female presented with acute onset shortness of breath and chest pain. She had a past medical history of cocaine abuse and agreed that she used cocaine 2 days prior to presentation. On admission, her vitals …

Powasson virus causing tick-borne encephalitis: a diagnostic dilemma

### Learning Point for Clinicians We strongly recommend that when patients present with encephalitis with a history suggestive of contact with ticks, POWV must be included in the differential diagnosis, especially if they have thalamus/midbrain or cerebellar symptoms. Powassan virus (POWV) is an extremely rare tick-borne agent causing encephalitis in North America. Although only 40 cases have been reported from 1958 to 2000, its virulence in humans appears to be increasing, resulting in severe neurological consequences and mortality. A 44-year-old afebrile male presented with severe occipital headaches associated with nausea and vomiting for 4 days after a hiking trip in Upstate New York. Vital signs and physical exam were normal. Laboratory studies revealed …

Levamisole tainted cocaine :An emerging health issue

### Learning Point for Clinicians Clinicians should suspect levamisole contamination in suspected drug abusers with very low absolute neutrophil count and neutropenia. It should be suspected early as chemical detection will only last 2–4 days. A 52-year-old male presents with complaints of a rash and pain in his perineal area for 4 days. The rash first appeared in his upper right thigh and was purpuric with a central black discoloration. He also complained of general malaise, fever of 103°F and diarrhea for 4 days. His past history includes chronic hepatitis C, alcoholism, liver cirrhosis and substance abuse. Laboratory studies revealed leukopenia (400 per mm3) with an absolute neutrophil count (ANC) of zero. A peripheral blood smear was also taken (Figure 1). Figure 1. Peripheral blood smear showing absence of neutrophils. Differential diagnosis at …

Isolated PTH Renal Resistance Pseudohypoparathyroidism 1b: A Rare Cause of Hypocalcemia.

A case of Pseudohypoparathyroidism 1b is reported, who presented with signs and symptoms of hypocalcemia. Causes, diagnosis and management with new insight into genetic novel mutations in PHP are discussed. The objectives are to provide information regarding problems of Calcium balance, causes and making diagnosis of pseudohypoparathyroidism, learn complexities of PTH cellular interactions and calcium homeostasis and learn the genetic novel mutations of various types of PHP.

Hypercalcemia as a primary manifestation of cryptococcal immune reconstitution syndrome—a rare presentation☆☆☆★★★

• Incidence of immune reconstitution inflammatory syndrome (IRIS) is growing with increasing number of patients on highly active antiretroviral therapy.