United States

Background
Hemosuccus pancreaticus is a rare form of upper gastrointestinal bleed with an incidence of 1 in 1500 cases that is defined as hemorrhage of the pancreatic duct, typically in the setting of a patient with chronic pancreatitis, vascular diseases, or pancreatic tumors. A common presentation occurs from pseudoaneurysm formation in the pancreatic circulation, which becomes prone to rupture, causing hemorrhage. Symptoms of epigastric abdominal pain radiating to the back that spontaneously resolve and are followed by melena are highly indicative of hemosuccus pancreaticus. CT angiography is the gold standard for identifying active hemorrhage, and coil embolization is a common and effective treatment once patients are hemodynamically stable.

Case Presentation
Here we present a case report of a 64 year-old male with a past medical history of a
mechanical mitral valve replacement, on warfarin, and without a history of acute or chronic pancreatitis, who presented to the E.D. with a chief complaint of 3 days of melena followed by an episode of a massive bright red bloody bowel movement causing persistent lightheadedness. He had a similar episode of bleeding months ago for which he underwent a push enteroscopy that revealed no abnormalities. He also endorsed a significant history of alcohol use, consuming 5-6 drinks a day. He was hypotensive to the 60s/40s with a hemoglobin (Hgb) of 5.0 and an INR of 12. He was volume resuscitated with fluids, packed red blood cells (pRBCs), vitamin K, and fresh frozen plasma, after which he became hemodynamically stable. An upper endoscopy revealed frank blood at the Ampulla of Vater. Subsequent CT angiogram revealed active contrast extravasation into the second portion of the duodenum from a gastroduodenal artery (GDA) segment, and he successfully underwent a GDA coil embolization with no further bleeding. He remained hemodynamically stable and was started on a Lovenox bridge to warfarin before discharge with a plan for outpatient follow-up.

Discussion
This case illustrates the point that hemosuccus pancreaticus should be considered in
patients with a history of alcohol abuse who present with a history of melena and a
significant acute gastrointestinal bleed, even in the absence of a history of chronic
pancreatitis.

AMA Research Challenge 2022

Hemosuccus Pancreaticus in the setting of a supra-therapeutic INR

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Hypercalcemia Secondary to B Cell Lymphoma – A Case Report

Background
Blastoschizomyces capitatus is an emerging opportunistic pathogen that can be found on the flora of the skin, gastrointestinal tract and upper respiratory tract. Invasive B. capitatus infection is more commonly seen in neutropenic patients, but can also be seen in immunocompetent hosts with COPD, in prolonged use of corticosteroids and/or broad-spectrum antibiotics and antifungals, intensive care unit patients, especially those on total parenteral nutrition or with central venous catheters in place. 


Case Presentation
38-year-old male with no past medical history who was admitted to the intensive care unit (ICU) for the management of diabetic ketoacidosis. Initial chest Xray, urinalysis, urine culture and blood cultures were all negative. On hospital day 2, he developed a fever with maximum temperature of 105°F and had leukocytosis with neutrophilia. He received 1 dose of piperacillin-tazobactam 2.25 g and was continued on cefepime 1 g twice daily for 9 days. Later, his blood cultures indicated Staphylococcus epidermidis and he was treated with 8 doses IV vancomycin. Due to persistent fever and leukocytosis, he was started on meropenem 500 mg daily and micafungin 100 mg daily, both for 7 days. He was placed on total parenteral nutrition for ileus and was given steroids for the treatment of thrombotic thrombocytopenic purpura. He also required the placement of a subclavian triple lumen catheter and a dialysis catheter. On day 29, his blood cultures were positive for blastoschizomyces capitatus. He completed treatment with Amphotericin B liposomal 500 mg daily for 8 days, Voriconazole 700 mg x 1 dose, then 400 mg twice daily x 13 days. His central triple lumen catheter and dialysis catheter were replaced. Repeated blood culture showed resolution of his bacteremia. 

Discussion
ICU patients have many of the risk factors for developing this opportunistic infection. Limiting the use of corticosteroids and broad-spectrum antibiotics, starting the patient on enteral nutrition early and removing central venous catheters when appropriate is critical in preventing invasive B. capitatus infection. Detection of capitatus in blood is associated with high mortality and early treatment with liposomal amphotericin B and voriconazole is paramount.

Isolated blastoschizomyces capitatus in an immunocompetent host

Lethal And Rare Side Effect Of Cyclosporin That Is Reversible If
Diagnosed Timely.
Introduction: Posterior Reversible Encephalopathy Syndrome-PRES, is a lethal but reversible condition that is caused due to impairment of cerebral perfusion autoregulatory mechanism. There are limited number PRES cases reported from Cyclosporine and hence wanted to alert the physician community to be more vigilant about closed surveillance of this population who presents with acute neurological changes.
Case Description: 22-year-old male with history of Cystic Fibrosis status post double lung and liver transplant, on cyclosporin presented to the ED after having a witnessed seizure. Patient reports of having severe headache upon waking up that morning, radiating from neck to his occipital area followed by nausea and vomiting which culminated in seizure. Patient also had another episode of seizure in the ED. Patient received Ativan and Keppra. Patient had fatigue but denies any other complains in ED. Vitals were BP-180/121, RR-20, HR-98, T-97.5F and SPO2 98% on 2L NC. On Physical Examination Patient appeared lethargic and had decreased breath sound bilaterally on auscultation of lungs. After the seizure at the hospital patient’s BP normalized. Neurologist and transplant team was contacted, and MRI was recommended along with continuation of Keppra and holding of cyclosporin.
Cyclosporine levels were checked and found to be normal. MRI showed hyperintense FLAIR and T2 signal within cortical/subcortical region of the bilateral occipital, frontal lobes and left cerebellum. The diagnosis of PRES was established. Due to lack of neurology service at our hospital, patient was transferred to another facility for further management. On further investigation it was found out that Patient had once developed PRES syndrome when he was initially on tacrolimus and was later changed to Cyclosporine 2 years back.
Discussion: PRES occurs when cerebral perfusion autoregulation is impaired
resulting in radiographic evidence of vasogenic edema. Presentation includes
neurological symptoms ranging from headache to seizures. Due to its vague
symptoms, PRES is occasionally missed. It is also commonly associated with
Tacrolimus, but we should be aware that any immunosuppressive or
cytotoxic medications can cause this. It is also to be noted that these patients
present with HTN emergency or labile BP but nitroglycerine should never be
used as it can aggravate cerebral edema. PRES is reversible and patients can
recover within weeks if diagnosed timely by rapid control of BP or withdrawal
of offending drug. If diagnosis is delayed or missed Patients can have
permanent neurological injury or even death due to high intracranial
pressure. Recognition of this syndrome is critical to institution of appropriate
therapy and prevention of this lethal outcome. This case illustrates that If a
patient presents with neurologic symptoms as mentioned above, and is
either in hypertensive emergency, has labile blood pressures and is on
cytotoxic agents or immunomodulators PRES should be in the differential
diagnosis.

Lethal And Rare Side Effect Of Cyclosporine That Is Reversible If Diagnosed Timely.

Mycobacterium abscessus complex (MABc) is part of the rapid-growing non-tuberculous mycobacteria group that usually resides in natural water sources. When it affects humans, it can be highly resistant and difficult to manage. The most common presentation is localized, mainly in the lungs and soft tissue, but can be generalized in immunocompromised patients. Here we present a case report of a 40-year-old female with a chronic infection of the abdominal wall after abdominoplasty.

A Rare Insidious Case Of Skin And Soft Tissue Infection Due To Mycobacterium Abscessus: A Case Report

Gastrointestinal stromal tumors (GIST) are the most common type of gastrointestinal tract mesenchymal tumors. They are typically characterized by activating mutations in the KIT or PDGFRA oncogenes. They usually present incidentally or with chronic and nonspecific symptoms like bloating, early satiety, fatigue, or anemia in patients over the age of 60 years. Approximately 5% of cases will present with an abdominal mass. Up to 10% of GISTs will present with advanced disease where the primary tumor is difficult to establish. We present a case here of a metastatic GIST with an unusual and late presentation, with a palpable abdominal mass, and without an obvious primary tumor on initial CT/ MRI imaging. 


Metastatic Gastrointestinal Stromal Tumour: A Rare Case

Nivolumab is a monoclonal antibody which blocks PD-1. It acts a checkpoint inhibitor and is used both alone and in combination to treat variety of cancers like melanoma, non-small cell lung cancer,squamous cell cancers of head and neck among others.Here we present a rare case of nivolumab induced hypothyroidism presenting as a case of severe hyponatremia.

Nivolumab induced hypothyroidism presenting as a case of severe hyponatremia

OMG, a Case Report

Posterior Reversible Encephalopathy Syndrome in the Setting of Uncontrolled Hypertension and Diabetes Mellitus

Role of Shoulder Injury Related to Vaccine Administration (SIRVA) in the COVID-19 Pandemic

Septic arthritis of the TMJ is a rare bacterial infection of the joint space, with a reported incidence of 2 to 10 cases per 100,000 patients. Its uncommonness in the clinical setting has led to a corresponding scarcity in the literature, and as a result, SATMJ has no definitive management guidelines in place. Owing to dangerous sequelae including abscess formation or total joint destruction, it is all the more essential to provide rapid therapeutic intervention. Here we present a case of a patient with a history of chronic mastoiditis and otitis media as well as skull base osteomyelitis, who presented with symptoms concerning for SATMJ. Our patient was a 62-year-old male who presented from a nursing facility with one week of progressive left-sided facial swelling and pain. Though the patient was afebrile and had a normal white blood cell count, CT imaging of the maxillofacial bones showed erosive changes at the left TMJ, most consistent with septic arthritis, and an adjacent multilocular abscess. The patient was placed on empiric vancomycin and zosyn; drainage of the abscess by ENT yielded 2 mL of purulent fluid, though culture was negative. The patient’s pain and swelling subsequently improved, and he was discharged with a four-week course of daptomycin and cefepime. Common etiologic factors in SATMJ include contiguous spread from nearby infectious sources. Our patient’s triad of oromaxillofacial pathologies appears to be unique in the literature, and further reflects the role that local infection can play in seeding the joint. Staphylococcus aureus is the most common offending organism, with Neisseria and H. flu also isolated on occasion. However, due to the prompt initiation of antibiotics in presenting patients, joint aspirate is often found to be sterile. Owing to the ambiguity of presenting symptoms and laboratory values, imaging via CT or MRI is considered the most accurate method of diagnosis. Treatment of SATMJ is accomplished through dual therapy of proper antibiotic coverage and drainage of the joint space. As seen in our patient, rapid detection and an equally timely treatment of his condition resulted in a positive clinical course and a successful outcome.

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Hypercalcemia Secondary to B Cell Lymphoma – A Case Report

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