Rushikesh Shah

Infliximab-induced aseptic meningitis

Infliximab is a commonly used biologic agent in the treatment of various autoimmune diseases. Although it is generally well tolerated in most patients, infliximab has been associated with some rare but serious adverse events. Aseptic meningitis is one such distinctly uncommon side effect. We present the case of middle-aged white patient, who presented with fever and headache within a few days of starting the infliximab therapy and was diagnosed with infliximab-induced aseptic meningitis after a complete workup. To our knowledge, this is the fifth case of infliximab-induced aseptic meningitis reported in literature. Because of atypical presentation, the diagnosis can be easily missed. It is vital to increase awareness of this potentially severe side effect among internists and community physicians.

Esophageal dissecans: a rare life-threatening presentation of recurrent pemphigus vulgaris.

Esophagitis dissecans superficialis (EDS) is a rare condition characterized by sloughing of the mucosal layer of the esophageal lining, usually triggered by an environmental/immune insult. It is associated with blistering diseases such as pemphigus vulgaris (PV), bullous pemphigoid, and epidermolysis bullosa. Oral mucosa is the most commonly (50%) affected site in PV, but esophageal involvement has only been rarely reported. The most common presentation of EDS includes dysphagia and odynophagia, but overt gastrointestinal bleeding is a distinctly uncommon. We present a unique case of EDS presenting with melena in which diagnostic endoscopy enabled to diagnose and establish link with patients remote history of PV. Early suspicion and identification of this treatable condition can reduce morbidity and mortality in these patient populations by decreasing severity and recurrence of bleeding.

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 …

Cytomegalovirus Colitis Mimicking Rectal Carcinoma in a Young Immunocompetent Patient.

Cytomegalovirus (CMV) infection is often seen in immunocompromised patients. Rarely, immunocompetent patients may present with CMV as a self-limiting, flu-like illness, though a few cases of significant organ-specific complications have been reported in these patients. We report a case in which a previously healthy man presented with hematochezia and an obstructing rectal mass thought to be rectal adenocarcinoma. Biopsy was positive for CMV, which was treated with full resolution of rectal mass confirmed with colonoscopy and barium contrast enema. This is the first reported case of CMV colitis mimicking rectal adenocarcinoma in an immunocompetent patient.

An unusual complication of radioactive iodine therapy-stroke

Introduction: Grave’s disease is the most common cause of hyperthyroidism. Methimazole (MMI), radioactive iodine (RAI) therapy and surgery are currently the available therapies for Graves’s disease. Common side effects post RAI therapy include hypothyroidism and transient hyperthyroidism. Cerebrovascular accident (CVA) as a result of post RAI thyrotoxicosis is however a less reported side effect. Case: 75 year old female with history of Grave’s disease presented to our clinic with difficult to control hyperthyroidism on MMI as her thyroid function tests (TFTs) were fluctuating between hypo and hyperthyroidism (TSH from 0.01 to 51 uU/ml) and MMI dose was being adjusted every 1-2 months. She was treated with RAI therapy and received 15 millicuries dose of I-131. She continued MMI 30 mg daily until 5 days before RAI and restarted MMI same dose the next day and continued propranolol 80 mg twice daily. Three days post RAI, she presented to ER with right sided facial droop and slurred speech. On physical examination, she had tachycardia with irregularly irregular pulse, right facial weakness and flattening of right nasolabial fold. Complete blood count and complete metabolic panel were unremarkable. TFTs were consistent with post RAI thyrotoxicosis with TSH 0.090 uU/ml, free T4 2.42 ng/dl and free T3 6.08 pg/ml. CT angiogram of head and neck revealed acute infarction in the left insula. MRI Brain also showed acute infarction in the cortex and white matter of the left insular lobe. EKG showed atrial fibrillation. NIH stroke scale was 4 but tissue plasminogen activator (tPA) was not given due to guaiac positive stool. She was treated with epixaban, rosuvastatin and sotalol. Patient was finally diagnosed with acute CVA due to cardioembolic phenomenon in the setting of post RAI thyrotoxic exacerbation. She was discharged home with outpatient neurology and endocrine follow up. Her dysarthria continued to improve with no further focal deficits. Six weeks later, TFTs also improved with TSH 31.04 uU/mL and free T4 0.78 ng/dl and was started on low dose levothyroxine. Discussion: This case described a patient with Graves’ disease, who suffered atrial fibrillation and cardioembolic CVA in the setting of post RAI thyrotoxicosis. Thyrotoxicosis due to RAI in patients with hyperthyroidism is known complication but can be life threatening. This case highlights the rare complications like atrial fibrillation and stroke in post RAI thyrotoxicosis despite the appropriate use of MMI and Beta adrenergic blocker. Patients and treating physicians should be aware of this rare entity before procedure. Correspondence to: Sadia Ashraf, SUNY Upstate Medical University, Syracuse, NY, USA, E-mail: ashrafs@upstate.edu

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.

Refractory hypoglycaemia in patient with gastric outlet obstruction

A 68-year-old male with a longstanding history of severe gastric outlet obstruction secondary to peptic stricture was found unconscious at home with profound hypoglycaemia. He denied history of fasting, diabetes mellitus or use of hypoglycaemic agents. Systemic examination and metabolic profile were unremarkable. Hypoglycaemic episodes persisted during hospitalisation, requiring continuous intravenous dextrose and eventually diazoxide. Further investigative work up, including 72 h fasting study, revealed a hyperinsulinemic state. MRI and endoscopic ultrasound were unremarkable but mesenteric angiography with hepatic venous sampling revealed a subtle area of hypervascularity in the head of pancreas. An exploratory laparotomy was then performed and resulted in resection of a nodular lesion in the head of pancreas with retrocolic gastrojejunostomy for repair of pyloric stenosis. Histopathology of pancreatic nodule confirmed nesidioblastosis. Postoperatively the patient was weaned of parenteral dextrose and did not have any further episodes of hypoglycaemia.

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.