Ramzi Mulki

Lethargy and vision loss: successful management of rhinocerebral mucormycosis.

Rhinocerebral mucormycosis (RCM) is an angioinvasive fungal infection most often caused by Rhizopus oryzae. It is usually associated with an underlying risk factor and is associated with a poor prognosis. There are no consensus guidelines on the optimal management of this aggressive disease; most management decisions are based on case reports and expert opinion. We report a successfully managed case of RCM in an insulin-dependent diabetic, initially presenting with a change in mental status, rapidly progressing to complete right eye blindness and ophthalmoplegia and complicated by multiple cerebral infarctions and abscesses. We describe the diagnostic approach and various therapeutic interventions undertaken to successfully manage our patient.

IgG4-related inflammatory pseudotumour mimicking a hepatic abscess impending rupture

A 50-year-old man presenting with sudden onset right upper quadrant pain and no constitutional symptoms was found to have two necrotic liver masses on imaging, consistent with hepatic abscesses unresponsive to systemic antibiotics and percutaneous drainage. The patient deteriorated and developed symptoms consistent with impending rupture. He therefore subsequently underwent right hepatic segmentectomy. All cultures were negative and histopathology confirmed IgG4 related disease/inflammatory pseudotumour of the liver. Postoperatively, the patient was asymptomatic with no IgG4 disease activity in other organs.

Novel oral anticoagulant and kidney injury: apixaban-related acute interstitial nephritis

Non-vitamin K oral anticoagulants (NOACs) are being increasingly prescribed. These drugs act rapidly, have predictable dose-related anticoagulation effect and require no routine laboratory monitoring, making them attractive for both patients and healthcare providers. All NOACs are at least partially excreted thought the kidneys. Renal injury related to NOAC use is being increasingly reported. NOAC-related acute interstitial nephritis (AIN) has only been reported once and that was in context of dabigatran use. We describe the first case of apixaban-related AIN. This case adds an important differential diagnoses that should be considered for any patient presenting with renal injury while being treated with NOACs.

Non-uremic calciphylaxis in alcoholic hepatitis

Introduction: Calciphylaxis is a rare vasculopathic disorder associated with high morbidity and mortality. Its pathogenesis is poorly understood but likely involves a complex cascade of metabolic interactions culminating in abnormal calcium deposition in vascular and extravascular structures. Calciphylaxis is well documented in the uremic population. Some cases in literature are reported in non-uremic patients, six of which are in patients with alcoholic cirrhosis. Our case demonstrates calciphylaxis successfully treated with bisphosphonates in a patient with alcoholic hepatitis without cirrhosis or kidney disease. Case Report: A 37-year-old Caucasian female was, recently hospitalized for alcoholic hepatitis, presented with a painful rash on the thighs. The patient underwent extensive evaluation which revealed an elevated calciumphosphorus product and slightly abnormal liver function tests. She underwent a biopsy of the rash which revealed evidence of calciphylaxis. The patient underwent topical wound care along with an aggressive pain regimen. She also received intravenous bisphosphonate therapy. Talal Alnabelsi1, Ramzi Mulki1, Corrado Minimo2, Janani Rangaswami3 Affiliations: 1MD, Resident, Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA; 2MD, Chief Anatomic Pathologist, Pathology, Einstein Medical Center, Philadelphia, PA, USA; 3MD Attending Physician, Nephrology, Einstein Medical Center, Philadelphia, PA, USA. Corresponding Author: Talal Alnabelsi, 5501 Old York Road, Einstein Medical Center, Philadelphia, PA 19141; E-mail: alnabelt@einstein.edu Received: 18 May 2016 Accepted: 13 July 2016 Published: 02 August 2016 The patient was subsequently discharged and on a follow-up visit demonstrated almost complete resolution of her symptoms. Conclusion: Calciphylaxis is a rare and life-threatening disorder of subcutaneous vascular calcification and necrosis. While reported in patients with chronic kidney disease, only few cases describe the occurrence of calciphylaxis in the presence of liver disease. The patient had evidence of alcoholic liver disease which was likely a culprit in the pathogenesis of this condition. Our case reports on a rare entity occurring in an unusual setting and illustrates the importance of perusing a tissue diagnosis.

Metastatic pancreatic cancer presenting as linitis plastica of the stomach

Metastatic disease from pancreatic carcinoma involving the stomach is an unusual event, and the pattern of spread in the form of linitis plastica, to our knowledge, has not been reported previously. Local recurrence after curative resection for pancreatic cancer is the most common pattern of disease. We report a case of metastatic pancreatic adenocarcinoma presenting as linitis plastica of the stomach 4 years after curative resection. A 52-year-old man presented with epigastric pain and melaena 4 years after undergoing a Whipples procedure for a poorly-differentiated pancreatic adenocarcinoma, stage IB; T2N0M0. CT imaging of the abdomen revealed thickening of the gastric wall, and subsequent oesophagogastroduodenoscopy (OGD) revealed diffuse friable erythaematous tissue. The biopsy specimen obtained during the OGD revealed a poorly differentiated adenocarcinoma, with similar appearance to the prior specimen obtained from the pancreas.