Stephen Jesmajian

Kounis syndrome secondary to ibuprofen use.

Kounis syndrome is the coincidental occurrence of acute coronary syndromes with allergic or hypersensitivity reactions. Clinicians should be aware that various mediators of allergy can cause coronary spasm and even plaque rupture and thrombus formation, thereby causing a serious impact on the course, prognosis and management of the allergic reaction. We report a case of a 20 year old female who developed acute coronary syndrome after anaphylactic reaction to ibuprofen.

Prevalence of use of advance directives, health care proxy, legal guardian, and living will in 512 patients hospitalized in a cardiac care unit/intensive care unit in 2 community hospitals.

Introduction The prevalence of use of any advance directives was 26% in 112 patients hospitalized in a cardiac care unit (CCU)/intensive care unit (ICU) in an academic medical center. Material and methods We investigated in 2 community hospitals the prevalence of use of advance directives (AD), health care proxy (HCP), legal guardian (LG), and living will (LW) in 512 patients hospitalized in a CCU/ ICU approached for AD and HCP. Results The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5%. Conclusions The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5% in patients hospitalized in a CCU/ICU. Educational programs on use of AD and of HCP need to be part of cardiovascular training programs and of cardiovascular continuing medical education.

Nephrogenic systemic fibrosis: Current concepts

Nephrogenic systemic fibrosis (NSF) was first described in 2000 as a scleromyxedema-like illness in patients on chronic hemodialysis. The relationship between NSF and gadolinium contrast during magnetic resonance imaging was postulated in 2006, and subsequently, virtually all published cases of NSF have had documented prior exposure to gadolinium-containing contrast agents. NSF has been reported in patients from a variety of ethnic backgrounds from America, Europe, Asia and Australia. Skin lesions may evolve into poorly demarcated thickened plaques that range from erythematous to hyperpigmented. With time, the skin becomes markedly indurated and tethered to the underlying fascia. Extracutaneous manifestations also occur. The diagnosis of NSF is based on the presence of characteristic clinical features in the setting of chronic kidney disease, and substantiated by skin histology. Differential diagnosis is with scleroderma, scleredema, scleromyxedema, graft-versus-host disease, etc. NSF has a relentlessly progressive course. While there is no consistently successful treatment for NSF, improving renal function seems to slow or arrest the progression of this condition. Because essentially all cases of NSF have developed following exposure to a gadolinium-containing contrast agent, prevention of this devastating condition involves the careful avoidance of administering these agents to individuals at risk.

Recurrent Lower Gastrointestinal Bleeding: Ileal GIST Diagnosed by Video Capsule Endoscopy—A Case Report and Literature Review

Introduction. Gastrointestinal stromal tumor (GIST) in the ileum is an extremely rare cause of recurrent lower gastrointestinal bleeding (GIB). Case Report. An 89-year-old man was admitted with melana. He had extensive PMH of CAD post-CABG/AICD, AAA repair, chronic anemia, myelodysplastic syndrome, lung cancer after resection, and recurrent GIB. Prior EGDs, colonoscopies, and upper device-assisted enteroscopy showed duodenal ulcer, A-V malformation s/p cauterization, and angioectasia. On admission, Hb was 6.0 g/dL. An endoscopic capsule study showed an ulcerated tumor in the ileum. CT showed no distant metastasis. The lesion was resected successfully and confirmed as a high-grade GIST. The patient was discharged with no further bleeding. Discussion. Early diagnosis for patients with ileal GIST is often challenging. Video capsule endoscopy and double balloon enteroscopy could be useful diagnostic tools. Surgical removal is the first line for a resectable GIST. Imatinib has become the standard therapy. Conclusion. This is a unique case of an ileal GIST in a patient with recurrent GIB which was diagnosed by video capsule. Complicated medical comorbidities often lead to a significant delay in diagnosis. Therefore, we recommend that if GIB does not resolve after appropriate treatments for known causes, the alternative diagnosis for occult GIB must be considered, including malignancy such as GIST.

Secondhand Smoke Exposure Among Community-Dwelling Adult Cancer Survivors in the United States: 1999–2012

Background: Little is known about the prevalence of secondhand smoke exposure (SHSe) among cancer survivors. We sought to determine the prevalence, trends, and correlates of SHSe among nonsmoking adult cancer survivors in the United States. Methods: Interview and serum cotinine data for nonsmoking adults, age 20 years and older, with a history of cancer (N = 686) were obtained from consecutive two-year cross-sectional cycles of the National Health and Nutrition Examination Survey from 1999 to 2012. SHSe was defined as serum cotinine 0.05–10 ng/mL among nonsmokers. We calculated and trended the prevalence of SHSe among nonsmoking cancer survivors. Multivariable logistic regression was used to examine the associations of SHSe with sociodemographic, smoking, and clinical characteristics. Survey weights were applied in estimating prevalence rates, adjusted ORs, and confidence intervals (CI). Results: The weighted aggregate SHSe and self-reported indoor SHSe prevalence rates over the study period were 28.26% (95% CI: 24.97%–31.55%) and 4.53% (95% CI: 3.48%–5.57%), respectively. SHS exposure declined from 39.61% (95% CI: 27.88%–51.34%) in 1999/2000 to 15.68% (95% CI: 9.38%–21.98%) in 2011/2012 (Ptrend < 0.001). Age ≥ 60 years was protective against SHSe, while being black, having less than high school education, poverty, and a smoking-related cancer history were associated with higher odds of SHSe. Conclusions: Fortunately, SHSe among nonsmoking cancer survivors in the United States is on the decline, although certain subgroups remain disproportionately burdened. Impact: These findings highlight clinical and public health imperatives to target socioeconomically disadvantaged nonsmoking cancer survivors to reduce their SHSe. Cancer Epidemiol Biomarkers Prev; 26(8); 1296–305. ©2017 AACR.

Dermatomyositis and HIV.

HIV has been linked to several autoimmune disorders since its emergence in the 1980s. By affecting different cells and pathways in the immune system, HIV induces the development of certain autoimmune diseases while prohibiting the emergence of others. Dermatomyositis has been rarely described in patients with HIV. We present a case of dermatomyositis in a patient with HIV and explore the pathogenesis of autoimmune disorders in HIV focusing on dermatomyositis.

Diffuse large B cell lymphoma with central pontine myelinolysis

Introduction: Diffuse large B cell lymphoma is the most common type of non-Hodgkin, lymphoma among adults, with an annual incidence of 7–8 cases per 100, 000 people per year. Case Report: We report a case of diffuse large B cell lymphoma with isolated splenomegaly, complicated by central pontine myelinolysis. Solitary splenic non-Hodgkin’s lymphoma is rare; with an incidence less than 1%. Treatment of diffuse large B cell lymphoma led to the resolution of the pontine lesion. The association of central pontine myelinolysis with diffuse large B cell lymphoma is exceedingly rare, with only one case report published till date. Conclusion: Diffuse large B cell lymphoma presenting as isolated splenomegaly is rare and can be a diagnostic challenge. The association of central pontine myelinolysis with diffuse large B cell lymphoma is rare and the possibility that central pontine myelinolysis could be an early manifestation of lymphoma or a paraneoplastic syndrome needs to be further explored.

A Case of Bacteremia and Meningitis Associated with Piperacillin-Tazobactam Nonsusceptible, Ceftriaxone Susceptible Escherichia coli during Strongyloides Hyperinfection in an Immunocompromised Host

Strongyloidiasis is an emerging parasitic infection with intriguing epidemiology, presentation, and clinical management. We report a case of hyperinfection syndrome complicated by E. coli bacteremia and meningitis with one of the isolates showing a unique resistance pattern recently being recognized. This report describes the aspect of invasive bacterial infections in strongyloidiasis and highlights the unique susceptibility pattern of the E. coli isolate and the extreme caution required during the antibiotic therapy.

Staphylococcus schleiferi Native Valve Endocarditis: A Case Report and Review of the Literature

Abstract Staphylococcus schleiferi is a recently described organism that infrequently causes disease in humans. To date, infections have included endocarditis in patients with prosthetic valves, pacemaker leads, or suppressed immunity. We present a case of an immunocompetent patient with native valve S. schleiferi subspecies coagulans endocarditis complicated by vertebral osteomyelitis. This case is of special interest both because of the rarity of the infectious agent and because of the paucity of associated clinical signs and symptoms.