A Common Infection in a Highly Atypical Patient: Hematochezia From a Cytomegalovirus Colonic Ulcer in a Young and Healthy Immunocompetent Patient.

Gastrointestinal (GI) cytomegalovirus (CMV) infections are far more common in immunocompromised as opposed to immunocompetent patients. Immunocompetent patients who develop GI tract CMV infections are typically older with medical comorbidities. As such, descriptions of GI CMV infections in younger immunocompetent patients are lacking. Here, we present a case of a GI CMV infection in a young and healthy immunocompetent patient. A 41-year-old male with hyperlipidemia and hypothyroidism presented with painless, intermittent hematochezia. He denied changes in bowel habits or appetite, abdominal pain, fevers, chills, fatigue, or weight loss. His history was pertinent for insertive and receptive intercourse with one male partner. Medications were emtricitabine/tenofovir for pre-exposure prophylaxis, levothyroxine, and atorvastatin. A colonoscopy revealed a cecal ulcer surrounded by nodular-appearing mucosa that felt firm and friable when biopsied. The remaining colon and terminal ileum were normal. There was no diverticulosis or hemorrhoids. Pathology was positive for CMV. A subsequent serological evaluation revealed a normal complete blood count and comprehensive metabolic panel. Tests for human immunodeficiency virus, syphilis, viral hepatitis, chlamydia, and gonorrhea were negative. He was treated with valganciclovir 900 mg twice daily for 21 days. A subsequent test for CMV deoxyribonucleic acid polymerase chain was negative. Hematochezia resolved. A repeat colonoscopy revealed normal mucosa in the cecum. GI CMV infections in immunocompetent patients are rare and typically occur in older patients with medical comorbidities. Further, such case reports are needed to inform clinicians about risk factors and the presentation of GI CMV infections in young healthy immunocompetent patients.

Icteric Leptospirosis Leading to Multiorgan Failure and Concomitant Pancreatitis.

Leptospirosis is a zoonotic disease caused by the spirochete Leptospira interrogans with a majority of cases occurring in the tropics. Diagnosing leptospirosis is challenging due to the variable and non-specific clinical presentation. While severe leptospirosis may present with renal failure, liver failure, and pulmonary hemorrhage, there are few described cases of renal failure and liver failure accompanied by pancreatitis and dysrhythmias, particularly in temperate climates. We present a case of severe leptospirosis presenting with bilateral calf pain, acute oliguric renal failure, acute liver failure, dysrhythmias, and pancreatitis. Clinicians must consider this diagnosis in temperate climates and consider testing and empirically treating for leptospirosis in patients with similar symptom constellations, vague symptoms, and lab abnormalities of unknown etiology.

Pre-Operative Predictors of Concurrent Choledocholithiasis in Patients With Acute Calculus Cholecystitis: An External Validity Analysis.

Introduction Patients that are presented with acute calculus cholecystitis (AC) and elevated liver enzymes markers (LEM), often require evaluation for concurrent choledocholithiasis (CDL). Currently, evaluation guidelines follow the American Society of Gastroenterology Endoscopy (ASGE) recommendations. Objectives The aim of the study was to externally validate both ASGE and the Chisholm predictors in a community hospital patient cohort. Methods We conducted a retrospective study of patients who presented to Ascension Saint John hospital with AC and elevated LEM over a period of two years. Sensitivity (SEN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were used to test the external validity of ASGE and Chisholm algorithms. Results A total of 132 patients' charts were reviewed, and 87 patients included. Chisholm predictors SEN, SP, PPV and NPV were 50%, 82%, 18%, and 95% respectively versus 100%, 19%, 8%, 100% for the ASGE predictors model. In the ASGE module, SP and PPV can be significantly improved to 60% and 13%, respectively, by changing a few risk categories including age and LEM range. Conclusions External validation of the Chisholm module in our patient cohort showed that it would lead to a low referral rate for unnecessary imaging and thus might be more cost-effective, especially when compared to current ASGE recommendations which would have a higher referral rate. On the other hand, current ASGE recommendations successively labeled all the patients with CDL, while the Chisholm module missed around 50 percent. We also observed that with the current ASGE module, the referral rate for further imaging and diagnostic tests can be possibly improved by adjusting a few of the predictors including the age and the abnormal liver transaminases range, but this observation is arbitrary and will need to be validated in a larger cohort study.

Violence against health workers in Family Medicine Centers.

BACKGROUND: Health care violence is a significant worldwide problem with negative consequences on both the safety and well-being of health care workers as well as workplace activities. Reports examining health care violence in Saudi Arabia are limited and the results are conflicting. OBJECTIVE: To estimate the prevalence and determine the demographic and occupational characteristics associated with workplace violence in primary care centers in Riyadh, Saudi Arabia. METHODS: A cross-sectional study included 270 health care workers in 12 family medicine centers in Riyadh during November and December 2014. A structured self-administered questionnaire was used to estimate the frequency, timing, causes, reactions, and consequences of workplace violence plus participants' demographic and occupational data. RESULTS: A total 123 health care workers (45.6%) experienced some kind of violence over 12 months prior to the study. These included physical (6.5%) and nonphysical violence (99.2%), including verbal violence (94.3%) and intimidation (22.0%). Offenders were patients (71.5%) in the majority of cases, companions (20.3%), or both (3.3%). Almost half (48.0%) of health care workers who experienced violence did nothing, 38.2% actively reported the event, and 13.8% consulted a colleague. A significant association of workplace violence was found with working multiple shifts, evening or night shift, and lack of an encouraging environment to report violence. CONCLUSION: Workplace violence is still a significant problem in primary care centers. The high frequency of violence together with underreporting may indicate the inefficiency of the current safety program. More safety programs and training activities for health care workers, efficient reporting system, and zero tolerance policies need to be implemented to minimize workplace violence against health workers.