Umair Masood

Colorectal Cancer Associated with Streptococcus anginosus Bacteremia and Liver Abscesses

Streptococcus anginosus is part of the normal flora of the human gastrointestinal tract. Their ability to cause abscesses is very unique and sets them apart from the rest of the streptococci groups. While an association of group D streptococcus bacteremia and endocarditis with colorectal carcinoma is well established, S. anginosus infections are rarely implicated with colonic malignancy. We present a case of a 62-year-old male who presented to the hospital with fatigue and generalized abdominal pain. Computed tomography of the abdomen revealed multiple liver abscesses and rectal thickening. Blood cultures were found to grow S. anginosus bacteria. Colonoscopy revealed a rectal mass which was later confirmed to be rectal adenocarcinoma. This case presents an association between S. anginosus bacteremia and presence of colorectal cancer which has been highlighted in only a few case reports in literature. This should prompt clinicians to screen for colorectal cancer in patients with S. anginosus bacteremia.

B-cell lymphoma, thiamine deficiency, and lactic acidosis.

Type B lactic acidosis is found in the absence of tissue hypoperfusion, can be associated with malignancies, and can be caused by thiamine deficiency. We present a patient who presented with an abdominal mass that biopsy disclosed to be a diffuse large B-cell lymphoma. Because thiamine deficiency is a rare cause of lactic acidosis in cancer, the patient was treated with intravenous thiamine with rapid normalization of the lactic acid level. The level prior to treatment was low. The case emphasizes a rare cause of lactic acidosis.

Unusual Case of an Alcoholic with Liver Injury from Sulfasalazine Use

A 57-year-old male with a history of alcoholism presented to the emergency room with abdominal pain, jaundice, transaminitis, and hyperbilirubinemia. Due to the history of alcoholism, it was initially presumed that the patient had alcoholic hepatitis but further investigation revealed that he was recently started on sulfasalazine for the treatment of rheumatoid arthritis. Upon cessation of the drug, the patient′s liver function tests significantly improved over a few days and eventually normalized within weeks. This case was interesting as the patient′s history of alcoholism disguised the actual diagnosis. Furthermore, the late presentation of sulfasalazine-induced liver injury is uncommon as it commonly presents 2-4 weeks after initiation of therapy.

A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit

Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was

Liver Toxicity From Solifenacin.

2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to

Pancreatitis with normal lipase and amylase in setting of end-stage renal disease

239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% (P < .001). Furthermore, we were able to decrease the costs by approximately

Bowel Ischemia from Heat Stroke: A Rare Presentation of an Uncommon Complication

2200/month.

Livedo Reticularis: A Rare Skin Manifestation of Pancreatitis

To the Editor:An 84-year-old woman with a history of end-stage renal disease presented to the hospital with abdominal pain and bilious vomiting. On admission, she was found to have significant elevation in serum aminotransferases (AST = 367 U/L and ALT = 639 U/L,) and marginal elevation in alkaline

A Successful Pharmacist based Quality Initiative to Reduce Inappropriate use of Stress Ulcer Prophylaxis in an Academic Medical Intensive Care Unit

Pancreatitis with normal lipase and amylase level is a rare phenomenon. This is especially true in patient with end-stage renal disease as lipase and amylase are renally excreted. Literature review reveals previous case report of pancreatitis with normal lipase and amylase level, however, none of them occurred in the setting of end-stage renal disease. Our case is the first such reported case of pancreatitis in such setting. Here we report a 30year old male with past medical history of end-stage renal disease who presented in emergency department with acute abdominal pain. Laboratory work up revealed normal lipase and amylase level. However, radiological work up was consistent with pancreatitis. This case report highlight the importance of taking the overall clinical picture rather than laboratory work up to rule in or rule out the diagnosis of pancreatitis. Furthermore, this should also serve an important reminder for clinicians to further investigate where clinical suspicion for pancreatitis is high.

Lamivudine-Associated Pancreatitis: Strongest Evidence to Date

A healthy 27-year-old female presented to the hospital after she collapsed an hour into her first marathon run on a hot humid day. On presentation, she was hyperthermic, encephalopathic, tachycardic, and hypotensive. On admission, she was found to have lactic acidosis, rhabdomyolysis, and acute kidney injury and was treated with cold normal saline and cooling blankets. She subsequently started having abdominal pain and bloody bowel movements. Computed tomography of the abdomen revealed ascending colon thickening. Furthermore, her lab findings showed transaminitis and elevated coagulation parameters. Due to the acute hypotensive state from the heat stroke, patient had developed bowel ischemia, ischemic hepatitis, and disseminated intravascular coagulation, all of which are uncommon complications of heat stroke. She was managed aggressively with intravenous fluid hydration with resolution of her symptoms over the course of 4 days. In addition to the uncommon complications, early presentation of this bowel ischemia despite adequate hydration in such a healthy individual is another unique aspect of the case.