Samer Al Hadidi

A rare case of Epstein-Barr virus mucocutaneous ulcer of the colon

Epstein-Barr virus mucocutaneous ulcer (EBVMCU) is a rare form of EBV lymphoproliferative disorder. The disease was recently described in 2010 for the first time in a case series and it was recently identified by the WHO classification of haematological malignancies as a separate category among the EBV lymphoproliferative disorders. We present a case of EBVMCU of the colon presenting as an ulcerating inflammatory mass in a female in her mid-60s who presented initially with abdominal pain and diarrhoea. The patient had extensive workup for her disease and due to progression of her symptoms, she was taken for an exploratory laparotomy. During the procedure, there was an inflammatory mass at the caecum and severe inflammation of the caecum and the terminal ileum and right hemicolectomy was performed. Diagnosis was confirmed by histopathology as EBV-positive lymphoproliferative disorder best classified as EBV-positive mucocutaneous ulcer.

Unusual presentation of uterine leiomyoma

Uterine leiomyoma is the most common pelvic tumour in women. The presentation of uterine leiomyoma varies. Symptoms may include abnormal uterine bleeding or abdominal pressure and heaviness; however, most cases are asymptomatic. We report a case with renal impairment as the first presentation of uterine leiomyoma in a patient who presented with extensive bilateral lower limb oedema and no menstrual symptoms. Imaging studies, a subsequent Papanicolaou test and uterine biopsy were suggestive of uterine leiomyoma, which was confirmed by pathological examination after hysterectomy. The patients kidney impairment resolved completely after the procedure.

Dystextia as a presentation of stroke

Cerebrovascular accident remains one of the major causes of morbidity and mortality worldwide. Understanding the presentation of this common disease will be of great benefit for early diagnosis and management. We report a newly recognised symptom of stroke where there is difficulty writing mobile phone texts, an entity called dystextia. This symptom was previously reported as a presentation of complex migraine and starts to be recognised in the symptomology of stroke. Our patient with this presentation was found to have ischaemic stroke secondary to carotid vascular disease which was operated and she had a complete resolution of her symptoms with returning to her baseline shortly after hospitalisation and before her vascular intervention.

Methicillin-resistant Staphylococcus aureus prostatic abscess after traumatic rectal injury.

Abstract Methicillin-resistant Staphylococcus aureus (MRSA) commonly causes infection of the skin, soft tissue, bones and heart. MRSA is a rarely reported organism of prostatic abscess (PA). We present a case of an intravenous drug user who presented with dyspareunia, dysuria and dyschezia after a traumatic injury to the rectum. He was diagnosed with PA, which was treated with transurethral resection of the prostate drainage and intravenous antibiotics. MRSA PA carries a low case fatality rate on early diagnosis and treatment with proper antibiotics with or without drainage of the abscess.

From a burn scar to malignancy! Marjolin’s ulcer, a disease of wound neglect

Abstract Marjolins ulcer is a rare and aggressive type of Squamous Cell Carcinoma (SCC) originating from previously chronic non-healing inflamed skin or trauma, and often after burns in up to 2% of cases. We are presenting a case of SCC secondary to a 30-year history of burn scar. Wound care and traumatic wound closure to prevent malignant degeneration is advisable and should be considered by medical providers.

PARP (Poly(ADP-Ribose) Polymerase) Inhibitors in Platinum-Sensitive Recurrent Ovarian Cancer: A Meta-Analysis of Randomized Controlled Trials

Background: PARP (poly(ADP-ribose) polymerase) inhibitors are used more frequently in platinum-sensitive recurrent ovarian cancer. Methods: We conducted a meta-analysis to check the strength of evidence on the use of PARP inhibitors for relapsed platinum-sensitive ovarian tumors. Results: A total of 4 randomized controlled trials were included in our analysis with a total of 1,264 patients (PARP n = 780). Progression-free survival (PFS) was significantly better in the PARP group in BRCA-positive patients (hazard ratio (HR) 0.24, 95% confidence interval (CI) 0.19-0.30; p < 0.00001). PFS was significantly better in the PARP group in BRCA-negative patients (HR 0.52, 95% CI 0.36-0.75; p < 0.00001). Similarly, we found a significant difference in overall survival (OS) between the two groups in BRCA-positive patients (HR 0.72, 95% CI 0.53-0.97, p= 0.03). Conclusion: PARP inhibitors in addition to standard platinum-based regimens along with subsequent maintenance therapy significantly improves PFS and OS with an acceptable side-effect profile in BRCA-positive women with recurrent, previously platinum-sensitive HGSOC.

Air in the portal vein: where computed tomography saved a patient's life

A 61-year-old African-American female patient presented with altered mental status. Medical history is significant for end stage renal disease on hemodialysis, hypertension, chronic obstructive pulmonary disease, history of intravenous drug abuse and left ankle fracture 1 week prior to presentation. Vital signs were significant for hypoxia and hypotension. Further history obtained from the family was remarkable for right lower abdominal pain that started 3 h prior to presentation. Computed tomography (CT) of the abdomen with intravenous contrast showed multiple air densities seen in left hepatic lobe (Figs 1 and 2). Also it showed evidence of pneumatosis intestinalis. Lactic acid was 0.9 (reference range 0.5–2.2mmol/l). Patient underwent emergent exploratory laparotomy with subtotal colectomy. Patient recovered after 10 days and was discharged home. Hepatic portal vein gas (HPVG), a radiologic sign first described in infants with necrotizing enterocolitis, is associated with numerous abdominal pathologies. Most commonly, bowel necrosis (72%) followed by ulcerative colitis (8%), intraabdominal abscess (6%), small bowel obstruction (3%) and gastric ulcer (3%) [1]. Although HPVG itself is no longer considered an ominous radiologic sign, the increased use of CT evidence in in-patient medicine has allowed for early detection of severe illnesses, and has influenced management [2]. HPVG in conjunction with the clinical context determines the degree of management. Aggressive management by way of emergent laparotomy is recommended in patients in whom CT evidence of HPVG is concurrent with clinical signs of bowel necrosis or ischemia [3]. Overall, prognosis and treatment are dependent on the underlying etiology of HPVG [4, 5]. Predictors of bowel necrosis were explored in recent study [5]. Mortality rate is highest in cases of HPVG associated with bowel necrosis, following scores from Acute Physiology and Chronic Health Evaluation (APACHE) II were helpful in guidance of management with higher scores predicting higher mortality [6].

A case of hypercalcemia with double pathology

ABSTRACT Hypercalcemia has many causes including primary hyperparathyroidism, malignancy, and other rare etiologies. In most of the cases, hypercalcemia is secondary to one etiology. In this case, we are reporting hypercalcemia with two causes. The initial workup showed primary hyperparathyroidism due to parathyroid adenoma. But because all features were not fully explained by primary hyperparathyroidism, further work-up revealed multiple myeloma. This case represents coexistence of two different diseases, which was rarely reported in the literature previously. Usually, the co-diagnosis was made subsequently after failure to correct hypercalcemia. In our case, both diagnoses were established at the same time of the patient’s presentation as of high suspicion. Establishing the diagnosis early will aid in the initiation of treatment in a timely fashion.

Use of dictation as a tool to decrease documentation errors in electronic health records

ABSTRACT Background: Use of Electronic Health Records is increasing. Copy-and-paste function is frequently used with higher rates of documentation errors. Studies to determine the nature of such errors are needed.Objectives: Determination of the effect of implementing a dictation system for completing notes on the quality of clinical documentation. We hypothesized that implementation of the dictation system for note writing would decrease the rate of errors in the progress notes as well as decrease the rate of copying and pasting. Design/Methods: A prospective interventional study in inpatient medical service for six months’ duration starting in July 2016. Resident physicians’ charts were reviewed by the attending physician on a daily basis. This study was done in a community based hospital affiliated to a university program. Residents’ physicians included Internal Medicine, Transitional year and Combined Internal Medicine Pediatrics residents. Charts reviewed for hospitalized patients. A total of 54 residents were offered a pre-intervention survey indicating their subjective use of copy/paste function. Response rate of 85.18%. Progress notes were reviewed on a daily basis for residents on their inpatient rotation. A total of 621 notes were reviewed. Results: Percentage of notes copied prior to the intervention was 92.73% which decreased to 49.71% post-intervention (RR of 0.54, 95% CI 0.48 0.60 Z statistic 11.005 with p-value <0.0001). Of the copied notes percentage of errors pre-intervention was 58% with no errors identified post-intervention (RR of 0.005, 95% CI 0.0003 0.0795 Z statistic 3.752 with p-value 0.0002). Most of the errors are from notes copied by the same author (85.8%). The most common documentation error was in the physical examination section. Conclusion: Implementing a dictation system eliminated documentation errors over our six months’ study. Further studies are needed to check long effects of using such systems on documentation errors

Seizure Associated Takotsubo Syndrome: A Rare Combination

Takotsubo cardiomyopathy (TC) is increasingly recognized in neurocritical care population especially in postmenopausal females. We are presenting a 61-year-old African American female with past medical history of epilepsy, bipolar disorder, and hypertension who presented with multiple episodes of seizures due to noncompliance with antiepileptic medications. She was on telemetry which showed ST alarm. Electrocardiogram (ECG) was ordered and showed ST elevation in anterolateral leads and troponins were positive. Subsequently Takotsubo cardiomyopathy was diagnosed by left ventriculography findings and absence of angiographic evidence of obstructive coronary artery disease. Echocardiogram showed apical hypokinesia, ejection fraction of 40%, and systolic anterior motion of mitral valve with hyperdynamic left ventricle, in the absence of intracoronary thrombus formation in the angiogram. Electroencephalography showed evidence of generalized tonic-clonic seizure. She was treated with supportive therapy. This case illustrates importance of ECG in all patients with seizure irrespective of cardiac symptoms as TC could be the cause of Sudden Unexpected Death in Epilepsy (SUDEP) and may be underdiagnosed and so undertreated.