Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Cronkhite-Canada Syndrome: A Rare Cause of Chronic Diarrhoea in a Young Man Thu, 28 Jan 2016 13:23:25 +0000 A young Indian man presented with nine-month history of chronic diarrhea, occasionally mixed with blood and intermittent colicky abdominal pain. He also complained of generalized body swelling for the last three months. On examination, he had diffuse hyperpigmentation of the skin and dystrophic nail changes. Upper and lower gastrointestinal endoscopy revealed multiple sessile polyps in the stomach, small bowel, and colon and rectum. Biopsy of polyps showed adenomatous changes with stromal edema and dilated glands. Cronkhite-Canada syndrome (CCS) was diagnosed and treated with glucocorticoids and enteral nutritional supplementation. There was an associated small intestinal bacterial overgrowth (SIBO) and stool was positive for clostridium difficile toxin. After 12 weeks of treatment, the patient achieved remission. Close correlation with clinical findings, including pertinent ectodermal abnormalities, endoscopic studies, and careful examination of biopsies will ensure a timely and correct diagnosis of CCS. Dhrubajyoti Bandyopadhyay, Adrija Hajra, Vijayan Ganesan, Suvrendu Sankar Kar, Debarati Bhar, Manas Layek, Sabyasachi Mukhopadhyay, Cankatika Choudhury, Vivek Choudhary, and Prasun Banerjee Copyright © 2016 Dhrubajyoti Bandyopadhyay et al. All rights reserved. DAS181 Treatment of Severe Parainfluenza Virus 3 Pneumonia in Allogeneic Hematopoietic Stem Cell Transplant Recipients Requiring Mechanical Ventilation Thu, 28 Jan 2016 08:32:38 +0000 Parainfluenza virus (PIV) may cause life-threatening pneumonia in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Currently, there are no proven effective therapies. We report the use of inhaled DAS181, a novel sialidase fusion protein, for treatment of PIV type 3 pneumonia in two allogeneic hematopoietic SCT recipients with respiratory failure. B. Dhakal, A. D’Souza, M. Pasquini, W. Saber, T. S. Fenske, R. B. Moss, W. R. Drobyski, P. Hari, and M. Z. Abidi Copyright © 2016 B. Dhakal et al. All rights reserved. Imaging Findings of Plasmacytoma of Both Breasts as a Preceding Manifestation of Multiple Myeloma Wed, 27 Jan 2016 09:44:39 +0000 Breast plasmacytoma is an extremely rare tumor. It can occur as a primary isolated tumor or as an extramedullary manifestation in multiple myeloma. This report describes the unusual case of a primary extramedullary plasmacytoma that progressed to multiple myeloma within 15 months in a 35-year-old woman. The patient had been initially diagnosed with a primary extramedullary plasmacytoma of the epidural soft tissue at the cervical 6-thoracic 1 spine level and the stomach. The patient had received chemotherapy and the disease had been in remission. One year later, the disease recurred, affecting both breasts, right clavicle, and orbit. Three months later, the disease had progressed to multiple myeloma. I report this case, focusing on the findings of mammography, ultrasonography, magnetic resonance imaging, and positron emission tomography of bilateral breast plasmacytoma, and provide a review of the literature. Young Mi Park Copyright © 2016 Young Mi Park. All rights reserved. Angioimmunoblastic T Cell Lymphoma Mimicking Chronic Urticaria Tue, 26 Jan 2016 13:24:19 +0000 Angioimmunoblastic T cell lymphoma (AITL) is a rare but distinct type of T cell lymphoma with an aggressive course and high mortality. Most patients are diagnosed late in the disease and usually present with generalized lymphadenopathy. A minority have skin lesions at the time of diagnosis, more commonly in the form of nonspecific maculopapular rash with or without pruritus. We report a rare case of AITL presenting with chronic, recurrent angioedema and urticaria-like lesions and no palpable peripheral adenopathy. Primary Care physicians, dermatologists, and allergists must maintain a high index of suspicion for cutaneous manifestations of lymphoma, especially if the skin lesions are refractory to standard treatment. Timely diagnosis is essential to improve survival. Mohleen Kang, Nitasha Bhatia, Adrienne Sauder, and Mirela Feurdean Copyright © 2016 Mohleen Kang et al. All rights reserved. Rare Intracardiac Tumor: Primary Cardiac Lymphoma Presenting as Atypical Angina Tue, 19 Jan 2016 12:36:35 +0000 Primary lymphomas of the heart are extremely rare, accounting for 2% of all primary cardiac tumors. Due to the rare presentation, there is no proper consensus available on treatment strategy. Preoperative confirmation of the pathology is fundamental in guiding an early treatment plan, which allows for improved prognosis. Unfortunately, in most cases, primary cardiac lymphoma is only identified on postoperative histopathological analyses, which affect the treatment plan and outcome. Here, we report a unique case of primary cardiac lymphoma presented with dyspnea and reduced effort tolerance. Young age, rapid onset of symptom, and absence of cardiac risk factors prompted us towards further imaging and emergency resection. The patient received a course of postoperative chemotherapy and was disease-free on six months of follow-up. Karthigesu Aimanan, K. Saravana Kumar, M. N. Mohd Arif, Md Noor Zuraini, Md Jamil Ramdzan, and L. Hamdan Copyright © 2016 Karthigesu Aimanan et al. All rights reserved. Interventricular Septal Hematoma after Retrograde Intervention for a Chronic Total Occlusion of a Right Coronary Artery: Echocardiographic and Magnetic Resonance Imaging—Diagnosis and Follow-Up Thu, 14 Jan 2016 16:11:31 +0000 The reverse CART technique provides the potential to modify the retrograde procedure by improving the controlled movement of the retrograde wire and improve the success rates of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Development of interventricular hematoma is a rare complication of CTO PCI. A 63-year-old man with effort angina with a right coronary artery CTO lesion underwent PCI by retrograde approach from the LAD to a septal branch. A contrast “stain” was demonstrated surrounding the septal collateral channel used for the retrograde approach at the end of the procedure without symptom. Echocardiography indicated an increased interventricular septum thickness with low echo signals region and decreased contractility. Cardiac magnetic resonance (CMR) imaging using gadolinium showed a diffusely thickened septum with a low signal fusiform neocavitation delimited by an enhanced-signal ring suggesting intraventricular septal dissecting hematoma. After conservative treatment, follow-up echocardiogram and CMR showed the resolution of the hematoma without clinical events. This case highlights the potentially lethal complication of septal perforator dissection and hematoma that may cause severe myocardial injury caused by retrograde approach for CTO PCI. Makoto Araki, Tadashi Murai, Yoshihisa Kanaji, Junji Matsuda, Eisuke Usui, Takayuki Niida, Sadamitsu Ichijo, Rikuta Hamaya, and Tsunekazu Kakuta Copyright © 2016 Makoto Araki et al. All rights reserved. Probable Levofloxacin-Induced Thrombocytopenia in a Patient Previously on Ciprofloxacin: A Case Report and Literature Review Thu, 14 Jan 2016 15:57:28 +0000 Drug-induced thrombocytopenia is a poorly understood, yet common phenomenon widely encountered in clinical practice. We present a case of suspected levofloxacin-induced thrombocytopenia, a rare side effect of a ubiquitous antibiotic, in a patient without similar effect to ciprofloxacin. This report builds upon other isolated case reports of fluoroquinolone-induced thrombocytopenia and demonstrates our algorithmic approach to the issue as well as a literature review pertaining to fluoroquinolone-induced thrombocytopenia. A. Justine Landi and Robert Burkes Copyright © 2016 A. Justine Landi and Robert Burkes. All rights reserved. Nonthrombotic Pulmonary Embolism: A Potential Complication of Polyacrylamide Hydrogel Cosmetic Injection Thu, 14 Jan 2016 15:53:11 +0000 Context. Polyacrylamide hydrogel (PAAG) has gained importance as a synthetic soft tissue filling agent. It has been commonly employed by physicians in Europe for facial contouring and soft tissue augmentation. Previously, PAAG is considered nontoxic and well tolerated with a few mild procedural complications. Case Presentation. A 26-year-old female was hospitalized for dry cough, worsening dyspnea, and chest discomfort after 3 hours of multiple PAAG injections in buttocks. The patient’s condition deteriorated and rapidly advanced to acute respiratory failure. Therein, the diagnosis of nonthrombotic pulmonary embolism (NTPE) was established on standard set of investigations. She was intubated; corticosteroid and empiric antibiotic therapy was initiated resulting in improvement of her condition. Subsequently, extubation was done, and she was discharged from the hospital after an uneventful recovery. On 1-month follow-up, the patient had no previous symptoms. Conclusion. This report implicates clinicians to maintain a high index of suspicion for NTPE in patients presenting with respiratory symptoms following PAAG usage. Faisal Inayat, Ahmad R. Cheema, Hafeez Ul Hasan Virk, Daniel J. Yoon, Salman Farooq, and Abdul Manan Copyright © 2016 Faisal Inayat et al. All rights reserved. Pica for Uncooked Basmati Rice in Two Women with Iron Deficiency and a Review of Ryzophagia Mon, 04 Jan 2016 13:40:51 +0000 Reports of pica for uncooked rice (ryzophagia) in adults who reside in European and derivative countries are uncommon. We evaluated and treated two nonpregnant women with pica for uncooked basmati rice. Both women reported fatigue, abdominal discomfort after consuming large quantities of uncooked basmati rice, and hair loss. One woman was from India and the other was from Pakistan. Both women were vegetarians. Basmati was the local rice in their native countries and their usual rice in the USA. Both women had tooth damage due to eating uncooked rice and iron deficiency with microcytic anemia attributed to menorrhagia and multiparity. Ryzophagia and other manifestations (except tooth damage) resolved after iron dextran therapy. We review and discuss other reports of ryzophagia associated with iron deficiency, pregnancy, race/ethnicity, geographic origin, and local traditions. We conclude that adults with ryzophagia in European and derivative countries are likely to be non-Europeans. James C. Barton, J. Clayborn Barton, and Luigi F. Bertoli Copyright © 2016 James C. Barton et al. All rights reserved. Successful Treatment of Secondary Aortoenteric Fistula with a Special Graft Sun, 03 Jan 2016 11:18:59 +0000 Aortoenteric fistula is an uncommon but life-threatening cause of gastrointestinal blood loss. We report a case of a 70-year-old man who presented to the emergency department with an episode of melena and infection in the left inguinal region. Diagnosis of secondary aortoenteric fistula was made between the left limb of the aortobifemoral graft and the descending colon. We performed excision of the infected graft and in situ silver acetate coating of prosthetic vascular graft replacement (aortoleft femoral) on the patient. This study reports a rare type of secondary aortoenteric fistula to the left colon, and it describes an unusual and successful surgical treatment. Antimicrobial coating of prosthetic vascular grafts may be a good alternative in the presence of graft infection associated with aortoenteric fistula because in situ grafts may carry an increased risk of reinfection. Ömer Faruk Çiçek, Mustafa Cüneyt Çiçek, Ersin Kadiroğulları, Alper Uzun, and Mahmut Ulaş Copyright © 2016 Ömer Faruk Çiçek et al. All rights reserved. Erythema Ab Igne due to Heating Pad Use: A Case Report and Review of Clinical Presentation, Prevention, and Complications Sun, 03 Jan 2016 11:18:23 +0000 Erythema ab igne is an asymptomatic cutaneous condition caused by exposure to heat. Cases of erythema ab igne may prove to be diagnostically challenging due to lack of familiarity with the condition. While this dermatosis carries a favorable prognosis, nonmelanoma skin cancers have been reported to arise within lesions of erythema ab igne. Erythema ab igne is preventable, and, thus, clinicians should provide education regarding safe use of heating devices to patients using these products in both outpatient and inpatient settings. Marissa Milchak, Joanne Smucker, Catherine G. Chung, and Elizabeth V. Seiverling Copyright © 2016 Marissa Milchak et al. All rights reserved. Early Stage Relapsing Polychondritis Diagnosed by Nasal Septum Biopsy Wed, 30 Dec 2015 13:49:45 +0000 Relapsing polychondritis is a rare inflammation of cartilaginous tissues, the diagnosis of which is usually delayed by a mean period of 2.9 years from symptom onset. We present the case of a 36-year-old man with nasal pain and fever. Physical examination of the nose was grossly unremarkable, but there was significant tenderness of the nasal bridge. Acute sinusitis was initially diagnosed due to thickened left frontal sinus mucosa on computed tomography (CT); however, there was no improvement after antibiotic intake. Repeat CT showed edematous inflammation of the nasal septum; biopsy of this site demonstrated erosion and infiltration of lymphocytes, plasma cells, eosinophils, and neutrophils in the hyaline cartilage. Relapsing polychondritis was confirmed by the modified McAdam’s criteria and can be diagnosed at an early stage by nasal septum biopsy; it should be considered as a differential diagnosis in patients presenting with nasal symptoms alone or persistent sinus symptoms. Takaaki Kobayashi, Sandra Moody, Masafumi Komori, Akira Jibatake, and Makito Yaegashi Copyright © 2015 Takaaki Kobayashi et al. All rights reserved. Dabigatran Associated Leukocytoclastic Vasculitis Wed, 30 Dec 2015 09:32:20 +0000 Common side effects of dabigatran are bleeding, bruising, nausea, diarrhea, and abdomen discomfort. Skin reactions were not often noted (<0.1%). We report a case of 70-year-old male who developed dabigatran related skin reaction resistant to usual therapy. Skin biopsy revealed leukocytoclastic vasculitis. Evangelos Potolidis, Charalampos Mandros, Kalliopi Kotsa, Evdoxia Mitsiou, Dimitris Potolidis, and Panagiotis Fanourgiakis Copyright © 2015 Evangelos Potolidis et al. All rights reserved. A Case of Eosinophilic Gastroenteritis with Ascites Thu, 24 Dec 2015 12:22:46 +0000 Eosinophilic gastroenteritis is a rare disorder of unknown cause characterized by focal or diffuse eosinophilic infiltration of gastrointestinal tract, especially the stomach and duodenum. Its clinical presentation depends on which segment of gastrointestinal tract is affected and on the depth of eosinophilic infiltration in the affected segment. We present a case of a 35-year-old male with abdominal distention for six months. Laboratory testing revealed elevated eosinophil count and serum immunoglobulin E (IgE) levels. In abdominal tomography, ascites was observed, and eosinophilic infiltration was detected in duodenum biopsy samples, collected during endoscopic examination of upper gastrointestinal system. Clinical and pathologic findings of the patient responded to steroid dramatically. Even though their comorbidity is rare, eosinophilic gastroenteritis should be considered in differential diagnosis of patients with unspecified ascites. Erkan Caglar, Aslı Sezgin Caglar, Suut Gokturk, and Ahmet Dobrucali Copyright © 2015 Erkan Caglar et al. All rights reserved. Two Cases of Sarcoma Arising in Giant Cell Tumor of Bone Treated with Denosumab Tue, 22 Dec 2015 11:29:10 +0000 Giant cell tumor (GCT) of bone is a generally benign, but often locally aggressive, neoplasm of bone, with a propensity for recurrence. Sarcomatous transformation is rare and typically occurs with a history of recurrences and radiation treatment. Denosumab, an inhibitor of the RANK ligand involved in bone resorption in GCT, is increasingly used in treatment of recurrent or unresectable giant cell tumor of bone. We report two cases of sarcomatous transformation of GCT to osteosarcoma in patients receiving denosumab. One was a 59-year-old male with a 12-year history of GCT and multiple recurrences taking denosumab for 2.5 years. The second case was in a 56-year-old male with a seven-year history of GCT taking denosumab for six months. Review of the literature shows one case report of malignant transformation of GCT in a patient being treated with denosumab. As the use of denosumab for treatment of GCT will likely increase, larger, controlled studies are needed to ascertain whether denosumab may play a role in malignant transformation of giant cell tumor of bone. Cory Julian Broehm, Erika L. Garbrecht, Jeff Wood, and Therese Bocklage Copyright © 2015 Cory Julian Broehm et al. All rights reserved. Cowden Syndrome and Concomitant Pulmonary Neuroendocrine Tumor: A Presentation of Two Cases Tue, 22 Dec 2015 06:40:14 +0000 Cowden Syndrome is a rare autosomal dominantly inherited disorder. Patients with Cowden Syndrome are at increased risk of various benign and malignant neoplasms in breast, endometrium, thyroid, gastrointestinal tract, and genitourinary system. Neuroendocrine tumors are ubiquitous neoplasms that may occur anywhere in the human body. Bronchopulmonary neuroendocrine tumors include four different histological subtypes, among these, typical and atypical pulmonary carcinoids. No association between Cowden Syndrome and neuroendocrine tumors has previously been described. We present two cases of Cowden Syndrome that were diagnosed with pulmonary carcinoids. Seppo W. Langer, Lene Ringholm, Christine I. Dali, Rene Horsleben Petersen, Åse Krogh Rasmussen, Anne-Marie Gerdes, Birgitte Federspiel, and Ulrich Peter Knigge Copyright © 2015 Seppo W. Langer et al. All rights reserved. Allergy to Prolene Sutures in a Dural Graft for Chiari Decompression Mon, 21 Dec 2015 12:04:31 +0000 Allergy to Prolene suture is exceedingly rare with only 5 cases reported in the literature. There have been no such cases associated with neurosurgical procedures. Diagnosis is nearly always delayed in spite of persistent symptomatology. A 27-year-old girl with suspected Ehlers-Danlos, connective tissue disorder, underwent posterior fossa decompression for Chiari Type 1 malformation. One year later, the patient presented with urticarial rash from the neck to chest. Cerebrospinal fluid and blood testing, magnetic resonance imaging, and intraoperative exploration did not suggest allergic reaction. Eventually skin testing proved specific Prolene allergy. After suture material was removed, the patient no longer complained of pruritus or rash. This single case highlights the important entity of allergic reaction to suture material, namely, Prolene, which can present in a delayed basis. Symptomatology can be vague but has typical allergic characteristics. Multidisciplinary approach is helpful with confirmatory skin testing as a vital part of the workup. Iahn Cajigas, S. Shelby Burks, Joanna Gernsback, Lauren Fine, Baharak Moshiree, and Allan D. Levi Copyright © 2015 Iahn Cajigas et al. All rights reserved. Laparoscopic Excision of Large Intra-Abdominal Cysts in Children: Needle Hitch Technique Mon, 21 Dec 2015 12:03:30 +0000 Laparoscopic surgery has both diagnostic and therapeutic advantages in the management of intra-abdominal cysts in children. Large cysts in small children pose technical challenges during laparoscopic surgery, requiring multiple incisions and advanced laparoscopic skills. This paper describes a novel laparoscopic technique using minimal manipulation for both aspiration and excision of the cyst. This simple, safe, and effective approach was used to achieve traction and facilitate excision of a large intra-abdominal cyst in a neonate and a young child. Brice Antao, Jeffrey Tan, and Feargal Quinn Copyright © 2015 Brice Antao et al. All rights reserved. Pyoderma Gangrenosum Simulating Necrotizing Fasciitis Thu, 10 Dec 2015 07:12:54 +0000 Pyoderma gangrenosum received this name due to the notion that this disease was related to infections caused by bacteria in the genus Streptococcus. In contrast to this initial assumption, today the disease is thought to have an autoimmune origin. Necrotizing fasciitis was first mentioned around the fifth century AD, being referred to as a complication of erysipelas. It is a disease characterized by severe, rapidly progressing soft tissue infection, which causes necrosis of the subcutaneous tissue and the fascia. On the third day of hospitalization after antecubital venipuncture, a 59-year-old woman presented an erythematous and painful pustular lesion that quickly evolved into extensive ulceration circumvented by an erythematous halo and accompanied by toxemia. One of the proposed etiologies was necrotizing fasciitis. The microbiological results were all negative, while the histopathological analysis showed epidermal necrosis and inflammatory infiltrate composed predominantly of dermal neutrophils. Pyoderma gangrenosum was considered as a diagnosis. After 30 days, the patient was discharged with oral prednisone (60 mg/day), and the patient had complete healing of the initial injury in less than two months. This case was an unexpected event in the course of the hospitalization which was diagnosed as pyoderma gangrenosum associated with myelodysplastic syndrome. Erik Friedrich Alex de Souza, Guilherme Almeida Rosa da Silva, Gustavo Randow dos Santos, Heloisa Loureiro de Sá Neves Motta, Pedro Afonso Nogueira Moisés Cardoso, Marcelo Costa Velho Mendes de Azevedo, Karina Lebeis Pires, Rogerio Neves Motta, Walter de Araujo Eyer Silva, Fernando Raphael de Almeida Ferry, and Jorge Francisco da Cunha Pinto Copyright © 2015 Erik Friedrich Alex de Souza et al. All rights reserved. Facial Involuntary Movements and Respiratory Failure in CANOMAD, Responsive to IVIG Therapy Mon, 30 Nov 2015 06:15:25 +0000 CANOMAD is a rare chronic neuropathy, characterized by chronic sensory ataxia and intermittent brain stem symptoms due to antidisialosyl antibodies. The disorder results in significant morbidity but is poorly understood and often misdiagnosed. We describe a unique case of CANOMAD, associated with involuntary movements of the face; patient reported exacerbations with citrus and chocolate and respiratory muscle weakness. Our patient was initially misdiagnosed with Miller Fisher Syndrome, highlighting the need for vigilance should neurological symptoms recur in patients initially diagnosed with a Guillain Barre variant. Moreover, the optimal treatment is unknown. This patient responded remarkably to intravenous immunoglobulin and has been maintained on this treatment, without further exacerbations. Kate Johnson, Ashish Malkan, and Mohamed Shaffi Copyright © 2015 Kate Johnson et al. All rights reserved. Right Upper Lobe Shadow and Tracheobronchopathia Osteochondroplastica Confined to Right Main Bronchus: A Case Report and Literature Review Sun, 22 Nov 2015 12:16:55 +0000 Tracheobronchopathia osteochondroplastica (TO) is a well documented benign entity of endoscopic interest. We describe a case of 76-year-old patient who presented with fever, cough, purulent sputum during the past four days, and presence of an ovoid shadow in right upper zone of his chest X-ray. Medical history included diagnosis of colon diverticuli identified by colonoscopy 3 months ago. Chest CT revealed a compact elongated lesion containing air-bronchogram stripes. Bronchoscopy showed normal upper airways and trachea but presence of unequal sized mucosal nodules, protruding into the lumen, along the entire length of the right main bronchial mucosa. No other abnormal findings were detected. Moreover, brushing and washing smears from the apical segment of right upper lobe (RUL), where the compact lesion was located, were negative for malignancy. Biopsy from the mucosal nodules of right main bronchus showed presence of cartilaginous tissue in continuity through thin pedicles with submucosal cartilage. This finding posed the diagnosis of TO while RUL lesion was cleared by antibiotic treatment. Case is reported because, to our knowledge, it represents a unique anatomic location of TO which was confined exclusively in the right main bronchus mucosa without affecting trachea. Stylianos A. Michaelides, George D. Bablekos, George Ionas, Stephanie Vgenopoulou, and Maria Chorti Copyright © 2015 Stylianos A. Michaelides et al. All rights reserved. Primary Bilateral Non-Hodgkin’s Lymphoma of the Adrenal Gland Presenting as Incidental Adrenal Masses Sun, 22 Nov 2015 09:58:42 +0000 Although lymphoma may occasionally involve the adrenal glands as part of a generalized disease process, primary adrenal lymphoma (PAL) is a rare disease. We present a case of a 62-year-old woman with a history of mild/moderate hereditary spherocytosis with a well-compensated baseline haemoglobin, who presented with rapidly progressive symptomatic anaemia. During the diagnostic workup, imaging revealed bilateral large adrenal masses and she was later diagnosed with diffuse large B-cell non-Hodgkin’s lymphoma (DLBCL), with the adrenal glands being the dominant site of the disease. The patient was started on systemic chemotherapy, but her disease progressed with neurological involvement which responded to second-line therapy. Her adrenal disease however was refractory to further therapy. Christopher Rizzo, David James Camilleri, Alexandra Betts, Andre’ Gatt, and Stephen Fava Copyright © 2015 Christopher Rizzo et al. All rights reserved. Stabbing Yourself in the Heart: A Case of Autoimmunity Gone Awry Thu, 19 Nov 2015 09:53:20 +0000 Within internal medicine, cardiac and neurologic pathology comprises a vast majority of patient complaints. Physicians and advanced-care practitioners must be highly educated and comfortable in the evaluation, diagnosis, and management of these entities. Chest pain accounts for millions of annual visits to the emergency room with pericarditis diagnosed in approximately four percent of patients with nonischemic chest pain. Guillain-Barre Syndrome is autoimmune polyneuropathy that often results in transient paralysis. Simultaneous diagnosis of both entities is a rare but described phenomenon. Here, we present a clinical case of GBS associated pericarditis. A fifty-five-year-old man with history of renal transplant presented with lower extremity weakness and urinary incontinence. Physical exam and diagnostic studies confirmed Guillain-Barre Syndrome. Patient subsequently developed stabbing chest pain with clinical presentation and electrocardiogram consistent with pericarditis. The patient was successfully treated for both diseases. This case highlights that although infrequent, internal medicine care providers must be cognizant of this correlation to ensure timely diagnosis and treatment. Hari Vigneswaran, Leslie Parikh, and Athena Poppas Copyright © 2015 Hari Vigneswaran et al. All rights reserved. Allergic Interstitial Nephritis Manifesting as a Striated Nephrogram Wed, 18 Nov 2015 07:29:13 +0000 Allergic interstitial nephritis (AIN) is an underdiagnosed cause of acute kidney injury (AKI). Guidelines suggest that AIN should be suspected in a patient who presents with an elevated serum creatinine and a urinalysis that shows white cells, white cell casts, or eosinophiluria. Drug-induced AIN is suspected if AKI is temporally related to the initiation of a new drug. However, patients with bland sediment and normal urinalysis can also have AIN. Currently, a definitive diagnosis of AIN is made by renal biopsy which is invasive and fraught with risks such as bleeding, infection, and hematoma. Additionally, it is frequently unclear when a kidney biopsy should be undertaken. We describe a biopsy proven case of allergic interstitial nephritis which manifested on contrast enhanced Magnetic Resonance Imaging (MRI) as a striated nephrogram. Newer and more stable macrocyclic gadolinium contrast agents have a well-demonstrated safety profile. Additionally, in the presentation of AKI, gadolinium contrast agents are safe to administer in patients who demonstrate good urine output and a downtrending creatinine. We propose that the differential for a striated nephrogram may include AIN. In cases in which the suspicion for AIN is high, this diagnostic consideration may be further characterized by contrast enhanced MRI. Irfan Moinuddin, Erika Bracamonte, Bijin Thajudeen, Amy Sussman, Machaiah Madhrira, and James Costello Copyright © 2015 Irfan Moinuddin et al. All rights reserved. Dysuria, Urinary Retention, and Inguinal Pain as Manifestation of Sacral Bannwarth Syndrome Tue, 17 Nov 2015 07:02:29 +0000 Only few cases with sacral radiculitis due to infection with Borrelia burgdorferi leading to neurogenic urinary dysfunction have been reported. A 57-year-old male developed urethral pain and urinary retention, requiring permanent catheterization. Extensive urological investigations did not reveal a specific cause, which was why neurogenic bladder dysfunction was suspected. Neurologic exam revealed only mildly reduced tendon reflexes. Cerebral and spinal MRI were noninformative. CSF investigations, however, revealed pleocytosis, elevated protein, and antibodies against Borrelia burgdorferi. Intravenous ceftriaxone for three weeks resulted in immediate improvement of bladder dysfunction, with continuous decline of residual urine volume and continuous increase of spontaneous urine volume even after removal of the catheter and initiation of self-catheterization. Sacral radiculitis due to infection with Borrelia burgdorferi is a potential cause of detrusor areflexia and urethral, perineal, inguinal, and scrotal pain and may be misinterpreted as cystitis or urethritis. Ceftriaxone may result in progressive recovery of bladder dysfunction and pain. Neuroborreliosis may manifest exclusively as neurourological problem. Josef Finsterer, Johannes Dauth, Kurt Angel, and Mateusz Markowicz Copyright © 2015 Josef Finsterer et al. All rights reserved. Ceruminous Adenoma of the External Auditory Canal: A Case Report with Imaging and Pathologic Findings Mon, 16 Nov 2015 08:12:27 +0000 Ceruminous adenomas are benign tumors that are rare in humans and present with a nonspecific symptomatology. The treatment of choice is surgical excision. We present an 87-year-old woman who presented with a reddish, tender, round, soft mass of the outer third of the inferior wall of the left external auditory canal, discharging a yellowish fluid upon pressure. Coincidentally, due to her poor general condition, this patient also showed symptoms consistent with chronic otitis media, parotitis, and cervical lymphadenopathy, such as otorrhea, through a ruptured tympanic membrane and swelling of the parotid gland and cervical lymph nodes. The external auditory canal lesion was surgically excised under general anesthesia, utilizing a transmeatal approach. The pathological diagnosis was ceruminous gland adenoma. The tumor was made of tubular and cystic structures and embedded in a fibrous, focally hyalinized stroma. Immunohistochemistry confirmed the presence of two distinct cell populations. The luminal cells expressed keratin 7, while peripheral (basal) cells expressed keratins 5/6, S100 protein, and p63. The apocrine gland-related antigen GCDFP-15 was focally expressed by tumor cells. The postoperative course was uneventful and at the 2-year follow-up no recurrence of the ceruminous adenoma was noted. George Psillas, Argyrios Krommydas, Georgia Karayannopoulou, Kyriakos Chatzopoulos, Jean Kanitakis, and Konstantinos Markou Copyright © 2015 George Psillas et al. All rights reserved. A Rare Case of Nonsecretory Multiple Myeloma in Lagos, Nigeria: A Case Report and Literature Review Sun, 15 Nov 2015 09:03:43 +0000 Multiple myeloma (MM) is a plasma cell disorder associated with clonal proliferation of plasma cells. Nonsecretory multiple myeloma (NSMM) is a rare variant of MM and accounts for approximately 1% to 5% of all cases. It is defined as symptomatic myeloma without detectable monoclonal immunoglobulin on serum or urine electrophoresis. This variant usually poses a diagnostic challenge to the clinician. We present a 60-year-old Nigerian man who was investigated extensively for bone pain, weight loss, and anaemia. He was eventually diagnosed as having nonsecretory multiple myeloma based on histology and immunohistochemistry results of bone marrow trephine biopsy. He is currently being managed with bortezomib, doxorubicin, and thalidomide, as well as zoledronic acid. He is also on anticoagulation. He continues to show remarkable clinical improvement. We describe this case report and literature review for better awareness amongst medical practitioners and pathologists. Ebele Uche, Akinsegun Akinbami, Sarah John-Olabode, Adedoyin Dosunmu, and Majeed Odesanya Copyright © 2015 Ebele Uche et al. All rights reserved. Bilateral Malrotation and a Congenital Pelvic Kidney with Varied Vasculature and Altered Hilar Anatomy Tue, 10 Nov 2015 13:37:10 +0000 Variations of structure and position of the kidney along with variations of renal vessels are most frequently reported. Rotational variations form a rare entity that are not cited in most embryology textbooks. During an educational cadaveric dissection of a 42-year-old male, a complex picture of bilateral anatomical variants was encountered. Malrotation of both kidneys and a left lobulated ectopic kidney along with open hilum was observed. The left kidney showed a pelvic position in front of sacral promontory with three renal arteries retaining its embryological aortoiliac branches and two renal veins draining into right common iliac vein. These variations have an embryological base. Pelvic kidney with rotational variation though comparatively rare assumes great importance in view of present-day surgical procedures like laparoscopic radical nephrectomy, percutaneous nephrectomy, and renal transplantation. J. Singh, N. Singh, K. Kapoor, and M. Sharma Copyright © 2015 J. Singh et al. All rights reserved. Jugular Venous Catheterization: A Case of Knotting Sun, 08 Nov 2015 07:11:00 +0000 A 79-year-old woman, diagnosed for cancer of the ovary, had a central catheter that was placed with difficulty through the right internal jugular vein intraoperatively. After oophorectomy, it was realized that the catheter was knotted. Thus, the central venous catheter was removed successfully using a traction technique in the operating room. Central venous catheter use may result in various complications, although it has been used as an invasive method for hemodynamic monitoring and fluid and drug infusion. Here, we present catheter knotting in a case with solutions for this complication, under literature review. E. Erkılıç, M. Aksoy, T. Gümüş, S. Sarı, and E. Kesimci Copyright © 2015 E. Erkılıç et al. All rights reserved. Multiple Low Energy Long Bone Fractures in the Setting of Rothmund-Thomson Syndrome Thu, 05 Nov 2015 11:06:27 +0000 Rothmund-Thomson syndrome is a rare autosomal recessive genodermatosis characterized by a poikilodermatous rash starting in infancy as well as various skeletal anomalies, juvenile cataracts, and predisposition to certain cancers. Although Rothmund-Thomson syndrome is associated with diminished bone mineral density in addition to multiple skeletal abnormalities, there are few reports of the association with stress fractures or pathologic fractures in low energy trauma or delayed healing of fractures. Presented is a case of a young adult male with Rothmund-Thomson syndrome presenting with multiple episodes of long bone fractures caused by low energy trauma with one of the fractures exhibiting significantly delayed healing. The patient was also found to have an asymptomatic stress fracture of the lower extremity, another finding of Rothmund-Thomson syndrome rarely reported in the literature. A thorough review of the literature and comprehensive presentation of Rothmund-Thomson syndrome is provided in conjunction with our case. Nicholas Beckmann Copyright © 2015 Nicholas Beckmann. All rights reserved.