Persistent Relapsing Immune Thrombocytopenia Following COVID-19 Infection

Immune thrombocytopenia (ITP) is a rare autoimmune disease that presents along a spectrum of disease severity, ranging from asymptomatic thrombocytopenia to potentially life-threatening bleeding complications. Recent case reports and case series suggest that a COVID-19 infection can trigger secondary ITP and may be associated with higher rates of bleeding and lower nadir platelet counts compared to patients with ITP of other etiologies. Multiple ITP relapses have also been described in some COVID-19 patients. We report the case of a 30-year-old otherwise healthy woman who presented to the hospital with fatigue, easy bruising, and a platelet count of 11 x 10³/µL. She responded well to our initial treatment with prednisone and intravenous immunoglobulin (IVIG) but experienced a persistent disease course with nine ITP relapses (defined as platelet count <30 x 10³/µL) over the next 10.5 months, requiring six additional hospital admissions for acute management as well as long-term maintenance medication adjustments. It is important for clinicians to recognize ITP as a potential complication of a COVID-19 infection and to initiate early therapy to prevent serious bleeding in these patients. Further studies will be needed to understand the natural history, optimal treatment, and prognosis for patients with relapsing COVID-19-associated ITP.

False-Negative 18F-Fluorodeoxyglucose PET/CT in Malignant Pleural Mesothelioma

We report a diagnostically challenging case of a 77-year-old man who presented with shortness of breath and was found to have a large right hydropneumothorax with collapse of the right lung. A malignancy was suspected, but pleural fluid cytology and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging were negative. He then underwent video-assisted thoracoscopy with biopsies of the pleura and chest wall which revealed malignant pleural mesothelioma (MPM). Older patients with early stage MPM are more likely to have false-negative FDG PET/CT results. Pleural biopsy is essential when there is clinical suspicion for mesothelioma, even with negative initial FDG PET imaging.

Epistaxis Complicated by Hemolacria: A Case Report

Hemolacria is a rare complication of epistaxis treated with nasal compression or tamponade. We report the case of a man, aged 81 years, with end-stage renal disease who developed hemolacria after insertion of a "Rhino Rocket" nasal tamponade device to treat persistent epistaxis. The hemolacria resolved after treatment with intranasal oxymetazoline. In the setting of epistaxis with nasal tamponade, hemolacria is thought to be caused by retrograde flow from the inferior nasal turbinates via an anatomic connection with the lacrimal system, with passage through the valves of Hasner and Rosenmüller to the lacrimal ducts. Hemolacria is very rare even in severe cases of epistaxis; we postulate that only patients with either congenital absence or acquired incompetence of the lacrimal valves are predisposed to hemolacria after treatment of epistaxis with a tamponade device. Physicians should be aware that hemolacria in the setting of epistaxis is usually a self-limited condition that can be treated with conservative measures to control nasal hemorrhage.

Zinc Deficiency-induced Hypogeusia in a Patient with Refractory Iron-deficiency Anemia: A Case Report

Zinc deficiency is a relatively common condition in various American populations but is frequently unrecognized and under-diagnosed. It typically presents with nonspecific symptoms, including lethargy, immune dysfunction, dermatitis, diarrhea, and decreased taste sensation (hypogeusia). Zinc deficiency often occurs concurrently with iron deficiency and has been linked to more severe clinical manifestations of iron deficiency anemia. We describe a 66-year-old man who presented with weakness and fatigue and was found to have persistent iron-deficiency anemia attributable at least in part to malnutrition caused by zinc deficiency-induced hypogeusia. The hypogeusia rapidly improved and nutritional intake normalized with zinc supplementation.

Norovirus-induced Gastroparesis

Postviral gastroparesis can result from a variety of viral infections and may cause severe, persistent gastrointestinal symptoms. We report the case of an 85-year-old man with one year of persistent nausea, epigastric pain, early satiety, and 25-pound weight loss after an episode of viral gastroenteritis contracted on a cruise ship. The patient reported that he had tested positive for norovirus shortly after the onset of symptoms. Esophagogastroduodenoscopy revealed no abnormalities, and his symptoms persisted despite treatment for a positive serum H. pylori IgG antibody. Lab workup, including hemoglobin A1c, was otherwise normal, and computed tomography (CT) angiography was unremarkable. A gastric emptying study performed one year after the onset of illness revealed moderate gastroparesis. While most cases of postviral gastroparesis resolve within a year or less, there are a few reports of gastroparetic symptoms lasting two to three years or longer. The pathophysiology might involve a slowly reversible injury to gut neuromodulator cells. Antiviral treatment has not been shown to be effective; symptomatic treatment with antiemetic and prokinetic drugs may be helpful in some cases.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey

BACKGROUND

Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic.

OBJECTIVE

To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation.

DESIGN

National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey.

PARTICIPANTS

One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018.

MAIN MEASURES

The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons.

KEY RESULTS

The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%).

CONCLUSIONS

Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

Evaluation and Treatment of Severe Rhabdomyolysis in a Patient with Legionnaires' Disease

A 53-year-old man with alcoholism and a three-day history of diarrhea and abdominal pain was hospitalized with mild acute kidney injury (AKI) and rhabdomyolysis after a fall where he was down for a short duration. Subsequent testing revealed patchy right lower lobe infiltrates on chest X-ray and a positive urinary Legionella antigen test. Creatinine phosphokinase (CPK) peaked at 85,780 U/L (normal 0-250) on hospital day two and remained markedly elevated for five days despite aggressive intravenous (IV) hydration and appropriate antibiotic treatment. When the patient defervesced and showed clinical signs of resolution of pneumonia, the CPK level declined rapidly, and renal function returned to baseline. Rhabdomyolysis with AKI is a rare but serious complication of Legionella pneumonia, with most patients requiring dialysis. Our patient’s complete recovery without renal replacement therapy can probably be attributed to his normal baseline renal function, timely diagnosis of his Legionella-associated rhabdomyolysis, and prompt treatment with aggressive IV hydration and appropriate antibiotics. Legionella infection should be considered in acutely ill patients with rhabdomyolysis of unclear etiology.

Submassive Pulmonary Embolism: A Re-evaluation of Hemodynamic Instability

Current medical management of pulmonary embolism (PE) is driven by risk stratification, with thrombolytic treatment reserved for patients with hemodynamic instability. We describe a case of a man with acute submassive bilateral pulmonary emboli and a right popliteal deep vein thrombosis (DVT), who had persistent shortness of breath, tachycardia, and hypoxemia but remained normotensive and was therefore not treated with thrombolytics until he suffered a fatal cardiac arrest on hospital day six. We examine the indications, risks, and potential benefits of thrombolytic treatment in patients with submassive PE who exhibit signs of instability but do not meet current indications for thrombolytic treatment with persistent hypotension or shock.

Analysis of Medical Error Contributing to Missed Acute Myeloid Leukemia Diagnosis

Hospitals and physicians attempt to minimize medical error by putting systems checks and balances in place at multiple levels. The effectiveness of these hospital-specific strategies to thwart error is called into question, as medical error remains a leading cause of death in the United States. This case report outlines the course of a 62-year-old man with a history of non-small cell lung cancer and right tongue squamous cell carcinoma, who had been admitted to an outside hospital for possible pneumonia. On initial presentation, the patient was pancytopenic with an absolute neutrophil count of 598. As his counts continued to downtrend and his conditioned worsened, oncology saw the patient and attributed the pancytopenia to "transient myelosuppression from pneumonia”. This statement impacted the trajectory of the patient’s care, delaying his ultimate diagnosis and treatment for acute myeloid leukemia. This case emphasizes the power of framing and anchoring biases in medical decision making and the need to evolve practice models from the current method of closed-door inquiry towards a more inclusive system of error reporting and analysis.

Validity Evidence for a Brief Online Key Features Examination in the Internal Medicine Clerkship

PURPOSE

Medical educators use key features examinations (KFEs) to assess clinical decision making in many countries, but not in U.S. medical schools. The authors developed an online KFE to assess third-year medical students' decision-making abilities during internal medicine (IM) clerkships in the United States. They used Messick's unified validity framework to gather validity evidence regarding response process, internal structure, and relationship to other variables.

METHOD

From February 2012 through January 2013, 759 students (at eight U.S. medical schools) had 75 minutes to complete one of four KFE forms during their IM clerkship. They also completed a survey regarding their experiences. The authors performed item analyses and generalizability studies, comparing KFE scores with prior clinical experience and National Board of Medical Examiners Subject Examination (NBME-SE) scores.

RESULTS

Five hundred fifteen (67.9%) students consented to participate. Across KFE forms, mean scores ranged from 54.6% to 60.3% (standard deviation 8.4-9.6%), and Phi-coefficients ranged from 0.36 to 0.52. Adding five cases to the most reliable form would increase the Phi-coefficient to 0.59. Removing the least discriminating case from the two most reliable forms would increase the alpha coefficient to, respectively, 0.58 and 0.57. The main source of variance came from the interaction of students (nested in schools) and cases. Correlation between KFE and NBME-SE scores ranged from 0.24 to 0.47 (P < .01).

CONCLUSIONS

These results provide strong evidence for response-process and relationship-to-other-variables validity and moderate internal structure validity for using a KFE to complement other assessments in U.S. IM clerkships.

Staphylococcus caprae: A Skin Commensal with Pathogenic Potential

Staphylococcus caprae (S. caprae) is a catalase-positive, coagulase-negative organism that was first isolated from goat milk, and was later found to colonize healthy human skin, nails, and nasal mucosa. Rarely, this commensal organism can become pathogenic in humans. S. caprae has been implicated in a variety of human infections, with the highest incidence being in bone and joint infections. We describe a man who, after receiving facet joint injections for back pain, developed native vertebral discitis, vertebral osteomyelitis with phlegmon, and bilateral psoas abscesses, from which S. caprae was isolated.

Vancomycin-resistant Enterococcus faecium Empyema in an Asplenic Patient

Enterococcal empyema is a rare complication of pneumonia. We report the case of a 67-year-old asplenic man with pneumonia complicated by respiratory failure and empyema requiring decortication and prolonged chest tube drainage. Cultures of the empyema were initially negative, but later grew vancomycin-resistant Enterococcus faecium (VRE), which was successfully treated with linezolid. To our knowledge, this is only the second reported case of an empyema caused by VRE that was not associated with an intra-abdominal infection. We suspect superinfection due to airway or chest tube contamination as the most likely mechanism of infection. Physicians should consider multi-drug resistant organisms such as VRE in patients with empyema that fail to resolve with chest tube drainage and broad-spectrum antibiotics.

A Case Suspended in Time: The Educational Value of Case Reports

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.

Introduction

Writing case reports can provide many scholarly, clinical, and academic benefits. The inspiration for case reports can arise in unexpected places. Unlike randomized trials, which confirm and quantify the evidence, case reports provide inspiration, new ideas, and fresh hypotheses. When randomized trials are lacking, case reports may become the best available evidence for clinical decision-making. Case reports also function as “reports from the front line” with timely and critical information on emerging diseases, such as Zika and Ebola viruses. In the twenty first century, case reports have evolved new forms and functions that parallel the rapid growth of biometrics and computer technology. Today’s medical students and early-career physicians will help to determine the future of the case report.

SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve

Medical students must learn how to practice high-value, cost-conscious care. By modifying the traditional SOAP (Subjective-Objective-Assessment-Plan) presentation to include a discussion of value (SOAP-V), we developed a cognitive forcing function designed to promote discussion of high-value, cost-conscious care during patient delivery. The SOAP-V model prompts the student to consider (1) the evidence that supports a test or treatment, (2) the patient's preferences and values, and (3) the financial cost of a test or treatment compared to alternatives. Students report their findings to their teams during patient care rounds. This tool has been successfully used at 3 medical schools. Preliminary results find that students who have been trained in SOAP-V feel more empowered to address the economic healthcare crisis, are more comfortable in initiating discussions about value, and are more likely to consider potential costs to the healthcare system.

Trousseau's Syndrome in Cholangiocarcinoma: The Risk of Making the Diagnosis

We report a case of Trousseau's syndrome with cholangiocarcinoma complicated by a fatal pulmonary embolism after liver biopsy. A 69-year-old man who presented with right upper quadrant pain was found to have portal vein thrombosis and nonspecific liver hypodensities after imaging by computerized tomography. Following four days of anticoagulation, heparin was held for percutaneous liver biopsy. After the biopsy, he developed acute hepatic failure, acute kidney injury, lactic acidemia, and expired. Autopsy revealed intrahepatic cholangiocarcinoma and a pulmonary embolism. Trousseau's syndrome with cholangiocarcinoma is rarely reported and has a poor prognosis. This case highlights a fundamental challenge in the diagnosis and early management of intrahepatic cholangiocarcinoma with hypercoagulability. Diagnostic biopsy creates an imperative to reduce post-operative bleeding risk, but this conflicts with the need to reduce thrombotic risk in a hypercoagulable state. Considering the risk of withholding anticoagulation in patients with proven or suspected cholangiocarcinoma complicated by portal vein thrombosis, physicians should consider biopsy procedures with lesser bleeding risks, such as transjugular liver biopsy or plugged percutaneous liver biopsy, to minimize interruption of anticoagulation.

Type B Lactic Acidosis in a Patient with Gastric Adenocarcinoma and Extensive Hepatic Metastases

OBJECTIVE

We report the second case of gastric adenocarcinoma associated with type B lactic acidosis.

CLINICAL PRESENTATION AND INTERVENTION

An 81-year-old man presenting with upper gastrointestinal bleeding was found to have an advanced gastric adenocarcinoma. He had persistently elevated serum lactate attributed to malignancy-associated type B lactic acidosis as a diagnosis of exclusion. As he remained clinically stable with a near-normal pH, his elevated lactate was not specifically treated.

CONCLUSION

This patient had an unusual type B lactic acidosis associated with gastric cancer. In the absence of signs and symptoms of other etiologies of lactic acidosis, physicians should consider malignancy-associated type B lactic acidosis.

Severe Romiplostim-Induced Rebound Thrombocytopenia After Splenectomy for Refractory ITP

Objective: To report a case of severe rebound thrombocytopenia after temporary discontinuation of romiplostim during splenectomy in the context of refractory immune (idiopathic) thrombocytopenic purpura (ITP). Case Summary: A 65-year-old man with a history of severe refractory ITP failing multiple treatments was considered for romiplostim therapy. He was initiated on 1 µg/kg and titrated upward to 4 µg/kg to elevate and stabilize his platelet levels prior to splenectomy. On day 74 of his clinical course, his platelets increased to 434 × 109/L, and his scheduled dose of romiplostim was withheld on day 75 for fear of romiplostim-induced postsplenectomy rebound thrombocytosis. On day 78, his platelets dropped precipitously to 9 × 109/L, and he experienced multiple episodes of epistaxis. He was reinitiated at 5 µg/kg and soon recovered. He later missed a scheduled dose of romiplostim, and his platelets fell to 23 × 109/L. After resuming romiplostim at 8 µg/kg, his platelets continued to recover. Discussion: Romiplostim, a thrombopoietin mimetic is directly regulated by megakaryocytes and existing circulating platelets via a negative feedback mechanism. This explains the theoretical risk of rapid clearance of romiplostim caused by an increased platelet pool. Clinically, alternative causes of his severe postoperative thrombocytopenia were considered and deemed unlikely. The rebound effect was observed after romiplostim was withdrawn on 2 occasions, and platelet counts improved after restarting romiplostim. The Naranjo Adverse Drug Reaction Probability Score of 7 suggests a probable adverse drug reaction. Conclusion: Physicians using romiplostim as a bridge to splenectomy should be cautious about withholding a scheduled dose around the time of surgery.

Cannabinoid hyperemesis syndrome: a case report and review of pathophysiology

Cannabis is the most widely used illicit drug in the United States, with lifetime prevalence of use estimated at 42% to 46%. The antiemetic properties of cannabis are well-known by the medical community and the general public; however, less well-recognized is the paradoxical potential for certain chronic users to develop hyperemesis. We describe in this case a patient with prior extensive work-up for nausea and vomiting and previous diagnosis of cyclic vomiting syndrome who presented with characteristic features of cannabinoid hyperemesis syndrome. We review the current literature for this condition and highlight potential mechanisms for its pathogenesis.

Development of a four-day service-learning rotation for third-year medical students

BACKGROUND

Despite the proven benefits of service-learning, its use in medical school curricula has been inconsistent. The effect of service-learning on students' primary care residency choices is largely unknown.

DESCRIPTION

Fifty-three students completed a 4-day service-learning experience, which included homeless clinics, homeless shelter, and street outreach, then completed surveys and wrote reflection essays. The survey responses were tested for significant differences using an overall F test, and the responses of volunteer versus assigned students were compared. The essays were analyzed for thematic content using an inductive approach. Primary care residency rates of the students were compared with the class as a whole.

EVALUATION

Of the participating students, 94.3% agreed or strongly agreed that learning objectives were fulfilled, and 81.9% rated the educational experiences as outstanding or good. The best-achieved learning objectives were increased understanding of the role of poverty in disease and development of a sense of professional commitment as a physician. Of the essays, 74% discussed barriers to care, of which substance abuse (28%) and mental illness (19%) were the leading themes. Primary care residency rates of participants were not different from the class as a whole, but there was a nonsignificant trend toward primary care residencies in volunteer versus assigned students.

CONCLUSIONS

We present a brief service-learning experience that provides educational value to medical students and service to the community, fulfills Liaison Committee on Medical Education accreditation requirements, and has only a small cost in time taken from the clerkship curriculum.

Fatal hemolytic anemia associated with metformin: a case report

Introduction

Metformin is a widely prescribed biguanide antidiabetic drug that has been implicated as a cause of hemolytic anemia in three previous case reports. We report a case of rapidly fatal hemolysis that was temporally associated with the initiation of metformin treatment for diabetes. Clinicians need to be aware of this rare but potentially serious side effect of metformin.

Case presentation

A 56-year-old Caucasian man with type 2 diabetes mellitus was started on metformin to improve glycemic control. Shortly afterwards, he developed progressive fatigue, exertional dyspnea, cranberry-colored urine and jaundice. Laboratory studies showed severe hemolysis, with a drop in hemoglobin from 14.7 to 6.6 g/dl over 4 days, markedly elevated lactate dehydrogenase, bilirubin and reticulocyte counts, and a low haptoglobin level. A peripheral blood smear showed no schistocytes, and a direct Coombs test was positive for anti-IgG and negative for anti-C3. Despite corticosteroid treatment and transfusion of packed red blood cells, the patient developed increasing dyspnea, hypotension, further decline in hemoglobin to 3.3 g/dl, and fatal cardiorespiratory arrest 12 hours after admission.

Conclusion

The serologic findings in this case suggest an autoimmune hemolytic anemia, caused either by a drug-induced autoantibody or a warm autoantibody. Based on the temporal association with metformin and the lack of other clear precipitating causes, we propose that metformin-induced hemolysis with a drug-induced autoantibody is a strong possibility. This mechanism differs from a previously described case with a possible antibody to the erythrocyte-drug complex. It has been shown, however, that hemolysis may occur via multiple mechanisms from the same drug. Clinicians should consider the possibility of metformin-associated immune hemolytic anemia in patients with otherwise unexplained hemolysis.

Chronic hypokalemia due to excessive cola consumption: a case report

A 52-year-old man was noted to have severe chronic hypokalemia despite discontinuation of diuretic treatment for hypertension and aggressive oral potassium supplementation. His serum potassium normalized temporarily when he was hospitalized, but hypokalemia recurred after discharge. He complained of generalized weakness and fatigue, and occasional loose stools. Physical examination showed mild generalized muscle weakness. Laboratory testing ruled out renal potassium wasting. A dietary history revealed that he was consuming 4 liters of cola per day, with a calculated fructose load of 396 grams per day. Since fructose absorption in the small bowel is relatively inefficient, this probably led to an osmotic diarrhea and GI potassium wasting. Physicians should ask their patients about soft drink consumption when they encounter unexplained hypokalemia.

Vertebral sarcoidosis mimicking lytic osseous metastases: development 16 years after apparent resolution of thoracic sarcoidosis

Vertebral sarcoidosis is a rare condition that can present with persistent back pain, often with concurrent lung, lymph node, or skin involvement. It can produce lytic or blastic osseous lesions that are indistinguishable from metastatic cancer on bone scan and magnetic resonance imaging (MRI). It usually occurs at the time of initial diagnosis of sarcoidosis, but may in very rare cases appear many years after presumed resolution of thoracic sarcoidosis. We present the case of a 47-year-old man who developed persistent low back pain 16 years after spontaneous resolution of stage I pulmonary sarcoidosis. MRI of the spine showed lytic thoracic and lumbar vertebral lesions. Computed tomography of the chest showed a pleural-based lung mass, multiple pulmonary nodules, and hilar and mediastinal lymphadenopathy. Positron emission tomography with fluorodeoxyglucose was widely positive, including at the vertebral foci noted on MRI. Metastatic lymphoma was suspected, but mediastinal lymph node and vertebral body biopsies showed noncaseating granulomas with negative stains for acid-fast bacilli and fungi. After 1 month of treatment with prednisone, the angiotensin-converting enzyme level and erythrocyte sedimentation rate had normalized, and the back pain was substantially improved. We found only 1 case report of a longer interval between resolution of initial sarcoidosis and development of vertebral involvement.