Case Reports in Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Ulcerative Colitis Presented as Fever and Bloody Diarrhea at Initiation of Dialysis in an Elderly Patient with End-Stage Kidney Disease Wed, 04 Nov 2015 07:16:28 +0000 Ulcerative colitis (UC) is a chronic inflammatory bowel disorder that mainly affects the colon and rectum. Immunological derangements are associated with the pathogenesis of UC. Many patients with UC also have chronic kidney disease, associated with immunological disorders and/or pharmacotherapy for UC. Some patients with UC may develop end-stage renal disease (ESRD) and require renal replacement therapy. However, little is known clinically about ESRD patients who develop UC or about patients with UC who develop ESRD. This report describes an elderly patient with ESRD who presented with fever and bloody diarrhea and was finally diagnosed as UC (pancolitis type) at dialysis initiation. The patient was successfully treated with a series of immunosuppressive agents. This report highlights the importance of considering UC as a potential cause of bloody stool and fever in patients with ESRD. Shunsuke Yamada, Yuka Kanazawa, Noriko Nakamura, Kosuke Masutani, Motohiro Esaki, Takanari Kitazono, and Kazuhiko Tsuruya Copyright © 2015 Shunsuke Yamada et al. All rights reserved. A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman Tue, 03 Nov 2015 09:52:47 +0000 A 46-year-old woman presented to two emergency departments within 12 hours because of acute abdominal pain. Physical exam demonstrated tenderness and epigastric guarding. An ultrasound was interpreted as negative; she was discharged home. Later that evening, she was found dead. Postmortem exam revealed acute hemorrhagic necrosis of a segment of jejunum secondary to volvulus. Clinical clues suggesting presentations of small bowel volvulus are usually nonspecific; the diagnosis is typically confirmed at surgery. Her unremitting abdominal pain, persistent vomiting, and absolute neutrophilia were consistent with an acute process. The etiology of this volvulus was caused by an elastic fibrous band at the root of the jejunal mesentery. While congenital fibrous bands are rare in adults, this interpretation is favored for two reasons. First, the band was located 20 cm superior to postsurgical adhesions in the lower abdomen and pelvis. Second, there was no history of trauma or previous surgery involving the site of volvulus. Jared Klein, Kathryn Baxstrom, Stephen Donnelly, Patrick Feasel, and Paul Koles Copyright © 2015 Jared Klein et al. All rights reserved. Long-Lasting Fever and Lymphadenitis: Think about F. tularensis Tue, 03 Nov 2015 08:04:24 +0000 We report the case of glandular tularemia that developed in a man supposedly infected by a tick bite in Western Switzerland. Francisella tularensis (F. tularensis) was identified. In Europe tularemia most commonly manifests itself as ulcero-glandular or glandular disease; the diagnosis of tularemia may be delayed in glandular form where skin or mucous lesion is absent, particularly in areas which are assumed to have a low incidence of the disease. Maria Vittoria Longo, Katia Jaton, Paola Pilo, David Chabanel, and Véronique Erard Copyright © 2015 Maria Vittoria Longo et al. All rights reserved. Dual Effect of Ziconotide in Primary Erythromelalgia Mon, 02 Nov 2015 12:53:59 +0000 Erythromelalgia (EM) is a rare disabling clinical syndrome more commonly known to affect the lower extremities. There is no single effective treatment for this disease that often requires a multidisciplinary approach. Herein, we report the case of a 31-year-old woman affected by primary erythromelalgia who was successfully treated with intrathecal Ziconotide. We also observed an unexpected result following therapy with Ziconotide. The legs and feet of the patient that at the time of admission were swollen and tumefied dramatically improved after one week of the drug administration. Rosario Russo, Maria Cristina Caroleo, Erika Cione, Mariarita Perri, Maria Teresa Paparo, and Antonio Russo Copyright © 2015 Rosario Russo et al. All rights reserved. Association between Neurofibromatosis Type 1 and Breast Cancer: A Report of Two Cases with a Review of the Literature Thu, 29 Oct 2015 13:03:08 +0000 Neurofibromatosis type 1 (NF1) is one of the most common genetic diseases in humans and is associated with various benign and malignant tumors, including breast cancer. However, an increased risk of breast cancer in NF1 patients has not been widely recognized or accepted. Here, we report two cases of breast cancer in NF1 patients and review the literature on the association between NF1 and breast cancer. Yoon Nae Seo and Young Mi Park Copyright © 2015 Yoon Nae Seo and Young Mi Park. All rights reserved. Multisystemic Side Effects of an Indispensable Old Drug: A Case Report of Chronic Lithium Use (A Patient with Multiple Side Effects of Lithium) Wed, 28 Oct 2015 09:39:52 +0000 Presented here is a case of long-term lithium use, with multiple emerging lithium-associated side effects. An 82-year-old woman was brought into the emergency department because of loss of consciousness. According to the physical examination and laboratory analyses, patient was diagnosed with lithium-associated hypercalcemia, hyperparathyroidism, nephrogenic diabetes insipidus (NDI), symptomatic sinus bradycardia, and thyroid dysfunction. In the literature, there is a limited number of case reports with lithium induced multiple clinical conditions. Multiple clinical manifestations due to the side effects of chronic lithium use might be seen. Health care professionals should keep in mind that lithium-related side effects might trigger or exacerbate each other. To avoid toxicity, close follow-up and clinical supervision are important for the early diagnosis and treatment of these side effects, due to the narrow therapeutic index and obscure clinical signs and symptoms of toxicity. Levent Demirtas, Emin Murat Akbas, Husnu Degirmenci, Ali Gurel, and Eren Duzgun Copyright © 2015 Levent Demirtas et al. All rights reserved. Arthrogryposis Multiplex Congenita: Multiple Congenital Joint Contractures Wed, 28 Oct 2015 09:27:46 +0000 Arthrogryposis multiplex congenita (AMC) is a syndrome characterized by nonprogressive multiple congenital joint contractures. The etiology of disease is multifactorial; it is most commonly suspected from absent fetal movements and genetic defects. AMC affects mainly limbs; also it might present with other organs involvement. It is crucial that the diagnosis of AMC should be kept in mind by musculoskeletal physicians in newborns with multiple joint contractures and patients must begin rehabilitation in early stage after accurate diagnosis in terms of functional independence. We present the diagnosis, types, clinical features, and treatment approaches of this disease in our case with literature reviews. Hamza Sucuoglu, Nurettin Irem Ornek, and Cagkan Caglar Copyright © 2015 Hamza Sucuoglu et al. All rights reserved. Memory Profiles after Unilateral Paramedian Thalamic Stroke Infarction: A Comparative Study Mon, 26 Oct 2015 11:51:00 +0000 We performed extensive neuropsychological assessment of two male patients (matched for age and educational level) with similar (localization and size) unilateral paramedian ischemic thalamic lesions (AB on the left and SD on the right). Both patients showed severe memory impairments as well as other cognitive deficits. In comparison to SD, AB showed severe impairment of executive functions and a more severe deficit of episodic/anterograde memory, especially in the verbal modality. The findings of this single case study suggest the possibility that the profile and severity of the executive dysfunction are determinant for the memory deficits and depend on from the side of the lesion. In addition to a material-side-specific (verbal versus visual) deficit hypothesis, the differential diencephalo-prefrontal contributions in mnestic-processing, in case of paramedian thalamic stroke, might also be explained in terms of their stage-specificity (encoding versus retrieval). Antonio Carota, Herbert Neufeld, and Pasquale Calabrese Copyright © 2015 Antonio Carota et al. All rights reserved. Comment on “Trichobezoar Causing Airway Compromise during Esophagogastroduodenoscopy” Mon, 26 Oct 2015 11:09:09 +0000 Antonios Athanasiou, Demetrios Moris, and Eleftherios Spartalis Copyright © 2015 Antonios Athanasiou et al. All rights reserved. “The Great Mimicker”: An Unusual Etiology of Cytopenia, Diffuse Lymphadenopathy, and Massive Splenomegaly Thu, 22 Oct 2015 12:28:34 +0000 Sarcoidosis is an idiopathic multisystem disease characterized by the formation of noncaseating granulomas. It frequently presents with pulmonary infiltrates and bilateral hilar and mediastinal lymphadenopathy. Splenic involvement is common, but massive splenomegaly is a rare occurrence. Sarcoidosis is known as “the great mimicker” (or “the great imitator”) since it exhibits a myriad of symptoms, mimicking other inflammatory, infectious, and neoplastic conditions, including lymphoma. Herein, we report the case of a 44-year-old male patient who was found to have bicytopenia, hypercalcemia, diffuse lymphadenopathy, and massive splenomegaly, a constellation of findings suggestive of underlying lymphoma. Interestingly, lymph node biopsy showed noncaseating granulomas suggestive of sarcoidosis, without evidence of malignancy. Mazen Zaarour, Chanudi Weerasinghe, Elias Moussaly, Shafinaz Hussein, and Jean-Paul Atallah Copyright © 2015 Mazen Zaarour et al. All rights reserved. A Young Man Presenting with Pleuritic Chest Pain and Fever after Electrophysiological Study and Implantable Cardioverter-Defibrillator Placement: Diagnostic Difficulties and Value of Bedside Thoracic Sonography Wed, 21 Oct 2015 13:10:47 +0000 We describe the case of a 23-year-old man presenting with recurrent pleuritic chest pain and prolonged fever after electrophysiology testing and placement of an implantable cardioverter-defibrillator because of a suspected arrhythmogenic right ventricular dysplasia. The clinical suspicion was initially directed toward pneumonia with pleural effusion and later toward an infection of the cardiac device complicated by septic pulmonary embolism. The definitive diagnosis of pulmonary embolism and infarction was suggested by a point-of-care thoracic sonography, performed at the bedside by a clinician caring for the patient, and then confirmed by contrast enhanced computed tomography, which also showed thrombosis of the left iliofemoral vein, site of percutaneous puncture for cardiac catheterization. Prolonged fever was attributable to a concomitant Epstein-Barr virus primary infection that acted as confounding factor. The present report confirms the value of bedside thoracic sonography in the diagnostic evaluation of patients with nonspecific respiratory symptoms. Antonio Faraone and Alberto Fortini Copyright © 2015 Antonio Faraone and Alberto Fortini. All rights reserved. A Case of Special Complication following a Large Amount of Polyacrylamide Hydrogel Injected into the Epicranial Aponeurosis: Leukocytopenia Tue, 20 Oct 2015 06:39:20 +0000 Polyacrylamide hydrogel (PAAG) has been used as an injectable filler for soft tissue augmentation of different body parts, such as the face, breasts, and penis. However, this is the first report of leukocytopenia after injection of a large amount of PAAG in the epicranial aponeurosis. After receiving PAAG injection for craniofacial contouring, the female patient described herein experienced recurrent swelling, temporal pain (particularly with changes in ambient temperature and facial expression), and ultimately leukocytopenia due to widespread migration of the injected PAAG. We removed most of the PAAG from the affected tissues and the leukocytopenia disappeared 1 year after the operation. Based on this case, we hypothesize that injection of a large amount of PAAG into tissues that have ample blood supply, such as the epicranial aponeurosis, may induce leukocytopenia. Li Rong, Shi-Jie Lan, Ying Shao, Zhe Chen, and Duo Zhang Copyright © 2015 Li Rong et al. All rights reserved. Ongoing Pregnancies following Cosmetic Micromanipulation of Preimplantation Embryos in Patients with Implantation Failure Tue, 13 Oct 2015 17:02:28 +0000 Cosmetic micromanipulation is defined as fragment and coarse granulation removal from preimplantation embryos. We report two cases of pregnancies in patients with implantation failure following cosmetic micromanipulation. Iman Halvaei, Mohammad Ali Khalili, Somayyeh Safari, and Navid Esfandiari Copyright © 2015 Iman Halvaei et al. All rights reserved. Markedly Elevated Carbamazepine-10,11-epoxide/Carbamazepine Ratio in a Fatal Carbamazepine Ingestion Tue, 13 Oct 2015 12:19:06 +0000 Carbamazepine is a widely used anticonvulsant. Its metabolite, carbamazepine-10,11-epoxide, has been found to display similar anticonvulsant and neurotoxic properties. While the ratio of parent to metabolite concentration varies significantly, at therapeutic doses the epoxide concentration is generally about 20% of the parent. We report a case of fatal carbamazepine overdose in which the epoxide metabolite concentration was found to be 450% higher than the parent compound, suggesting a potential role for metabolite quantification in severe toxicity. Jason L. Russell, Henry A. Spiller, and Daniel D. Baker Copyright © 2015 Jason L. Russell et al. All rights reserved. Subdural Empyema Complicating Bacterial Meningitis: A Challenging Diagnosis in a Patient with Polysubstance Abuse Mon, 12 Oct 2015 08:14:50 +0000 Subdural empyema (SDE) and cerebrovascular accident (CVA) are uncommon life-threatening complications of bacterial meningitis, which require urgent neurosurgical intervention to prevent adverse outcomes. Clinicians must be vigilant of the onset of focal neurologic deficits or seizure activity to establish the diagnosis of SDE. Streptococcus pneumoniae accounts for <1% of pyogenic brain abscesses. This case describes a presentation of community acquired pneumococcal pneumonia in which the diagnosis of SDE with vasculitis induced CVA was confounded by concomitant substance abuse and sedation. Melissa Dakkak, William Russell Cullinane Jr., and Virin Rajiv Neil Ramoutar Copyright © 2015 Melissa Dakkak et al. All rights reserved. Acute Cyanide Poisoning: Hydroxocobalamin and Sodium Thiosulfate Treatments with Two Outcomes following One Exposure Event Mon, 12 Oct 2015 07:27:22 +0000 Cyanide is rapidly reacting and causes arrest of aerobic metabolism. The symptoms are diffuse and lethal and require high clinical suspicion. Remediation of symptoms and mortality is highly dependent on quick treatment with a cyanide antidote. Presently, there are two widely accepted antidotes: sodium thiosulfate and hydroxocobalamin. These treatments act on different components of cyanide’s metabolism. Here, we present two cases resulting from the same source of cyanide poisoning and the use of both antidotes separately used with differing outcomes. Andrew Meillier and Cara Heller Copyright © 2015 Andrew Meillier and Cara Heller. All rights reserved. Drug-Induced Rhabdomyolysis with Elevated Cardiac Troponin T Thu, 08 Oct 2015 12:19:20 +0000 The essential role of cardiac troponin in the diagnosis of acute myocardial infarction has led to the development of high-sensitivity assays, which are able to detect very small amounts of myocardial necrosis. The high-sensitivity cardiac troponin T assay, however, is not entirely specific for myocardial injury. This case report describes a 48-year-old woman, who, two years after cardiac transplantation, presented with rhabdomyolysis. During the course of the disease, her troponin T level was elevated on repeated occasions, but other definitive evidence of myocardial injury was not found. Asymptomatic cardiac troponin T elevations during rhabdomyolysis may be due to either cardiac involvement or false positive results stemming from skeletal muscle injury. Gro Egholm and Manan Pareek Copyright © 2015 Gro Egholm and Manan Pareek. All rights reserved. Systemic Levamisole-Induced Vasculitis in a Cocaine User without Cutaneous Findings: A Consideration in Diagnosis Thu, 08 Oct 2015 07:03:24 +0000 Levamisole is a known immunomodulating agent frequently used as a cutting agent in cocaine consumed in the United States today. Numerous cases of anti-neutrophil cytoplasmic antibody (ANCA) vasculitis connected with the use of levamisole-adulterated cocaine have previously been reported in the literature, classically characterized by a retiform purpuric rash. We report a case of a crack-cocaine user without cutaneous abnormalities who developed ANCA-associated glomerulonephritis that progressed to renal failure. This case demonstrates the difficulties in solidifying the diagnosis of levamisole-induced vasculitis in the absence of cutaneous findings and the need to pursue more testing to establish causality in ANCA-associated vasculitis that has potential for severe end-organ damage in patients who continue to use cocaine. Gillian G. Baptiste, Anastasia-Stefania Alexopoulos, Tahsin Masud, and Joanna M. Bonsall Copyright © 2015 Gillian G. Baptiste et al. All rights reserved. Atypical Presentation of Disseminated Zoster in a Patient with Rheumatoid Arthritis Mon, 05 Oct 2015 08:04:46 +0000 Patients with rheumatoid arthritis (RA) have 2-fold increased risk of herpes zoster. In literature, limited information exists about disseminated cutaneous zoster in RA patients. An 83-year-old African-American female with RA presented with generalized and widespread vesicular rash covering her entire body. Comorbidities include hypertension, type II diabetes, and dyslipidemia. Patient was on methotrexate 12.5 mg and was not receiving any corticosteroids, anti-TNF therapy, or other biological agents. The patient was afebrile (98 F) with no SIRS criteria. Multiple vesicular lesions were present covering patient’s entire body including face. Lesions were in different stages, some umbilicated with diameter of 2–7 cm. Many lesions have a rim of erythema with no discharge. On admission, patient was also pancytopenic with leukocyte count of 1.70 k/mm3. Biopsies of lesions were performed, which were positive for Varicella antigen. Subsequently, patient was started on Acyclovir. The patient’s clinical status improved and rash resolved. Our patient presented with “atypical” clinical picture of disseminated cutaneous zoster with no obvious dermatome involvement. Disseminated zoster is a potentially serious infection that can have an atypical presentation in patients with immunocompromised status. High index of suspicion is needed to make the diagnosis promptly and to initiate therapy to decrease mortality and morbidity. Nirav Patel, Davinder Singh, Krunal Patel, Shadab Ahmed, and Prachi Anand Copyright © 2015 Nirav Patel et al. All rights reserved. Asymptomatic Bacteriuria Caused by Chromobacterium violaceum in an Immunocompetent Adult Sun, 04 Oct 2015 16:39:20 +0000 Because of increasing antimicrobial resistance, the treatment of the asymptomatic bacteriuria is not considered except in specific circumstances like during pregnancy or before invasive urologic procedures. We are reporting a first case of asymptomatic bacteriuria caused by Chromobacterium violaceum in a 16-year-old male. With the reporting of the C. violaceum which is notorious for its high propensity for hematogenous dissemination causing fatal sepsis (with reported mortality rate up to 65–80%) if prompt proper treatment is not given, as causative agent of asymptomatic bacteriuria, it is recommended to treat the asymptomatic bacteriuria caused by this organism. Narayan Dutt Pant, Manisha Sharma, and Saroj Khatiwada Copyright © 2015 Narayan Dutt Pant et al. All rights reserved.