Aung Naing Lin

A Rare Thermophilic Bug in Complicated Diverticular Abscess

Actinomycosis is a form of painful abscess in the gastrointestinal tract or in deep tissue caused by actinomyces species. They are one of the commensal bacteria in the oral cavity and gastrointestinal tract of humans but can opportunistically cause infection in immunosuppressive hosts through invasion of breached mucosa or necrotic tissue while mimicking malignancy, gastrointestinal tuberculosis, and inflammatory bowel disease. Actinomyces israelii is, by far, the major and most common human pathogen throughout literatures. By virtue of rarity and diagnostic confusion with masquerading malignancies, only 10% of the cases have been diagnosed preoperatively, so as to be able to verge patients from undergoing unnecessary surgical intervention. Herein, we present a rare case of complicated diverticular abscess manifested by Actinomyces meyeri after postoperative tissue diagnosis.

Cocaine-induced pseudo-Wellens’ syndrome: a Wellens’ phenocopy

Wellens’ syndrome represents critical occlusion of the proximal left anterior descending coronary artery. Electrocardiographic changes similar to Wellens’ wave are not exceptional to acute coronary occlusion and can also be seen in cardiac and non-cardiac conditions, such as left ventricular hypertrophy, persistent juvenile T wave, bundle branch blocks, cerebral haemorrhage, pulmonary oedema, pulmonary embolism, pheochromocytoma, Takotsubo syndrome, digitalis and cocaine-induced coronary vasospasm. Cocaine-induced pseudo-Wellens’ syndrome should be considered as one of the differentials, since cocaine is used frequently by young adults and can cause left anterior descending coronary vasospasm mimicking Wellens’ syndrome. Initiation of the beta-blocking agent in pseudo-Wellens’ syndrome as a part of acute coronary syndrome management can be disastrous. We illustrated a case of cocaine-induced pseudo-Wellens’ syndrome presented with typical chest pain associated with Wellenoid ECG.

State of diagnostic quandary solved by modern technology: a rare case of Madelung's disease.

Madelungs disease is a neglected metabolic disease characterised by generalised multiple fatty tissue deposits. A 64-year-old Caucasian woman presented with generalised weakness and symptomatic hypoglycaemia with altered mental status. Physical examination showed very distinct physical characteristics with multiple lumps distributed over the upper body. Her neurological symptoms were solved by giving intravenous glucose and optimisation of medical treatment. Even though she had unique characteristics of Madelungs disease, many physicians, on several occasions, failed to recognise her ‘hidden diagnosis’. This diagnostic uncertainty was able to be solved by searching the Internet for similar clinical features and images. This case demonstrates characteristics and unique features of a rare disease that can be seen in a female patient even though it is mostly found in males.

A Rare but Fetal Complication of PEG: Buried Bumper Syndrome (BBS)

Buried Bumper Syndrome (BBS) is defined as migration of inner bumper (fixating internal part of PEG) along the stoma channel. The bumper may be partially covered by over-growth mucosa or completely dislodged outside the gastric wall. Complete BBS without visible part of inner pumper can be a challenge for endoscopic management. Here, we present a 72yearold nursing home resident with complete BBS.

A Mild Version of Danon Disease Caused by a Newly Recognized Mutation in the Lysosome-associated Membrane Protein-2 Gene

We present the case of a patient with dilated cardiomyopathy caused by a novel mutation in the lysosome-associated membrane protein-2 (LAMP-2) gene. Patients with pathogenic mutations of this gene typically suffer from Danon disease – a condition that leads to cognitive decline, severe skeletal myopathy, and severe hypertrophic cardiomyopathy. Our patient’s presentation and clinical course, however, is different and much less severe than other patients with this disease. He did not suffer from neurologic and musculoskeletal complications. He is also possibly the longest-known survivor of this disease without a heart transplant. This disease is unfamiliar to many physicians, and our case highlights the importance of an awareness of this disorder, particularly because of its implications for both the patient and his family.

An Unusual Presentation of Acute Abdomen Pain: Splenic and Renal Emboli from Left Ventricular Thrombus

Splenic infarction is an unusual cause for a patient to present with left upper abdomen pain. A 47-year-old woman presented to the emergency department with left upper abdomen pain. She reported that she stopped taking warfarin two days prior to presentation. A physical examination revealed fine crackles within the left lower lobe and significant tenderness within the left upper abdomen. Computed tomography of the abdomen showed mild cardiomegaly with a 2.3 cm calcified thrombus in the left ventricular apex. We noted infarction in the spleen and right kidney with bilateral renal scarring. The patient was initially started on a heparin drip and later bridged to warfarin on the third day. She was discharged after seven days with complete resolution of the abdominal pain. The decision to prescribe an anticoagulant should include a consideration of underlying causes, comorbidities, an assessment of risks and benefits, and chances of recurrence. In our patient, her new splenic infarct and renal infarction were most likely embolic in origin due to her left ventricular apical aneurysm with thrombus and nonadherence to her prescribed anticoagulation medication.

Staphylococcus Lugdunensis Endocarditis and Cerebrovascular Accident: A Systemic Review of Risk Factors and Clinical outcome

Infective endocarditis (IE) secondary to Staphylococcus lugdunensis has been increasingly recognized since 1988. IE-related thromboembolism represents an associated complication of the disease and carries a dismal prognosis. However, the incidence of cerebrovascular accident secondary to S. lugdunensis IE is relatively uncommon and its treatment has not been clearly elucidated yet. We performed an extensive literature search using Pubmed, Medline, Scopus, and Google Scholar to identify the articles using the following keywords: ‘Staphylococcus lugdunensis’, ‘infective endocarditis’, ‘stroke’, and ‘cerebrovascular accident.’ Patient characteristics, risk factors, severity of neurological deficit, echocardiographic findings, medical management, required surgical intervention, complications and mortality rate were reviewed in detail. Eighteen cases (mean age of 47.8 years, 55% male) from 17 publications with S. lugdunensis-related cerebrovascular accident (CVA) were identified. Of these, 16 (87%) cases were left-sided endocarditis and 10 (61%) cases experienced right-sided neurological deficit. The source of infection was documented in eight cases (50%) in which four cases (50%) were related to groin-related procedures and the mitral valve (52.5%) was mostly infected followed by aortic valve (37%). Surgical valve replacement was done in 61% of patients and overall mortality rate was 22%. S. lugdunensis endocarditis is associated with high mortality and morbidity, including a higher prevalence of CVA. Early disease identification with aggressive intervention is crucial for better outcomes.

A Myth Still Needs to be Clarified: A Case Report of the Frank's Sign

Despite advancements in diagnostic tools, physical signs such as xanthelasmata, arcus corneae, facial wrinkles, and gray hair are useful indicators of underlying diseases. The presence of bilateral diagonal earlobe creases (DELCs), also known as Frank’s sign, correlates with a myriad of cardiovascular diseases such as coronary artery disease, cerebrovascular disease, and peripheral vascular disease. The use of Frank’s sign as a bedside predictor of underlying coronary artery disease is controversial among clinicians. We report a case of a patient with bilateral DELCs found to have significant coronary artery disease during diagnostic coronary angiography for recurrent chest pain.

Ginseng-Related Drug-Induced Liver Injury

Ginseng is commonly used as a medicinal herb for memory and concentration and general well-being. Drug-induced liver injury (DILI) is one of the most challenging disorders and trending events in the United States which are related to body building and weight loss supplements. Currently, herbal and dietary supplementation is the second most common cause of DILI. Here, we report on a 45-year-old healthy Chinese woman who presented with dull intermittent left upper quadrant abdomen pain for a month. Upon thorough history taking, she had been taking ginseng tea and supplementation for her menopausal symptoms for almost 3 months. Physical examination was unremarkable except mild tenderness in left upper quadrant of the abdomen. Liver function test showed aspartate transaminase (AST) 717 U/L, alanine transaminase (ALT) 343 U/L, total bilirubin 5 mg/dL, direct bilirubin 3.3 mg/dL, alkaline phosphatase 182 U/L, with international normalized ratio (INR) 1.2. Prior liver enzymes (6 months earlier) showed AST 21 U/L, ALT 18 U/L, total bilirubin 0.8 mg/dL, direct bilirubin 0.3 mg/dL, alkaline phosphatase 34 U/L, with INR 0.7. Viral serology for acute hepatitis B, C, E, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus was negative. She was immune to hepatitis A. Her antinuclear antibody was positive. Her anti-Smith antibody, anti-smooth muscle antibody, HFE gene mutation, ceruloplasmin, alpha-1 antitrypsin serologies were within normal references. An abdomen sonogram showed fatty infiltration. Liver biopsy showed moderate to severe portal inflammation and marked lobular disarray. Portal and lobular inflammatory infiltrates consisted of a mixture of histiocytes, lymphocytes, plasma cells, eosinophils, and neutrophils with centrilobular necrosis and focal bridging necrosis, and necro-inflammation. After 6 weeks of follow-up, the patient improved physically, and the abdomen pain resolved. Ginseng has been widely used in the Chinese community as medicinal herb for a variety of conditions for decades. However, proper research has never been done regarding its pharmacokinetics, efficacy, and safety issues. In our case report, the idiosyncratic DILI resulted from ingestion of ginseng as herbal supplementation for premenopausal symptoms. Physicians should be aware of and suspect DILI in any patient with acute liver injury, and patients should be reminded that all medications and supplements have a potential to cause DILI.

Hypothermia-Related Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disease presenting from mild localized inflammation to severe infected necrotic pancreatic tissue. In the literature, there are a few cases of hypothermia-induced AP. However, the association between hypothermia and AP is still a myth. Generally, mortality from acute pancreatitis is nearly 3–6%. Here, we present a 40-year-old chronic alcoholic female who presented with acute pancreatitis induced by transient hypothermia. A 40-year-old chronic alcoholic female was hypothermic at 81°F on arrival which was improved to 91.7°F with warming blanket and then around 97°F in 8 h. Laboratory tests including complete blood count, lipid panel, and comprehensive metabolic panels were within the normal limit. Serum alcohol level was 0.01, amylase 498, lipase 1,200, ammonia 26, serum carboxyhemoglobin level 2.4, and β-HCG was negative. The entire sepsis workup was negative. During rewarming period, she had one episode of witnessed generalized tonic-clonic seizure. It was followed by transient hypotension. Fluid challenge was successful with 2 L of normal saline. Sonogram (abdomen) showed fatty liver and trace ascites. CAT scan (abdomen and pelvis) showed evidence of acute pancreatitis without necrosis, peripancreatic abscess, pancreatic mass, or radiopaque gallstones. The patient was managed medically and later discharged from the hospital on the 4th day as she tolerated a normal low-fat diet. In our patient, transient hypothermia from chronic alcohol abuse and her social circumstances might predispose to microcirculatory disturbance resulting in acute pancreatitis. Early and aggressive fluid resuscitation prevents complications.