Peritoneal Dialysis-Related Peritonitis With Acinetobacter Pittii: A Case Report.

We demonstrate the first reported case of peritoneal dialysis (PD)-related peritonitis with Acinetobacter pittii. Although previous reports have reported the uncommon similar infection in the larger Acinetobacter calcoaceticus-baumannii complex group of organisms, none have particularly focused on A pittii. Furthermore, we present a case of a young man with end-stage renal disease on PD who had a severe infection with A pittii. Although the organism was sensitive to ceftazidime, and despite a 4-week extended course of intraperitoneal antibiotics, the patient had a worsening infection leading to the removal of the PD catheter. Furthermore, the case illustrates the importance of proper sterile technique and hand hygiene, as this may have been the nidus of infection for this case.

Artificial Intelligence in Acute Kidney Injury Prediction.

The use of artificial intelligence (AI) in nephrology and its associated clinical research is growing. Recent years have seen increased interest in utilizing AI to predict the development of hospital-based acute kidney injury (AKI). Several AI techniques have been employed to improve the ability to detect AKI across a variety of hospitalized settings. This review discusses the evolutions of AKI risk prediction discussing the static risk assessment models of yesteryear as well as the more recent trend toward AI and advanced learning techniques. We discuss the relative improvement in AKI detection as well as the relative dearth of data around the clinical implementation and patient outcomes using these models. The use of AI for AKI detection and clinical care is in its infancy, and this review describes how we arrived at our current position and hints at the promise of the future.

Colonic Adenocarcinoma Presenting as Splenic Abscess Secondary to Suspected Microperforation.

Splenic abscesses are a rare infection that usually requires seeding from another primary source; however, direct contact of bacteria can occur with microperforation secondary to colon cancer leading to abscess formation. This occurrence is rare, and through literature review only 12 previous cases have been reported with associated bacteremia. Our patient is a 62-year-old female who presented with left upper quadrant pain with a history of tobacco and alcohol abuse that was febrile and hypoxic. Blood cultures were obtained that eventually grew Fusobacterium mortiferum. Computed tomography of the abdomen and the pelvis revealed 2 splenic abscesses that were cultured to grow Escherichia coli and ß-hemolytic Streptococcus group C. Colonoscopy was performed, which identified 2 masses that were biopsied, and histopathology confirmed well-differentiated adenocarcinoma with possible muscular invasion. The patient had no other identifiable risk factors for bacterial seeding from another primary source. We present the first reported case report of splenic abscess secondary to colonic adenocarcinoma suspected microperforation associated with Fusobacterium mortiferum bacteremia.

Tension Bullae With Peripheral Pneumothorax.

The differentiation between tension bullae, chronic tension pneumothorax, and atypical pneumothorax is difficult just from history and physical examination alone. A chest X-ray may help determine the underlying etiology; however, further imaging with computed tomography in stable patients may be necessary for accurate assessment of size, number, and location before considering any interventions. In this article, we present a rare case report of tension bullae with peripheral pneumothorax and recommend against needle thoracostomy in stable patients with tension bullae in order to obtain further imaging that may result in a change in the standard management.

Idiopathic Left Ovarian Vein Thrombosis.

Ovarian vein thrombosis (OVT) was first described in 1956 and is well known for its association with gynecological malignancy, pregnancy, postpartum, pelvic diseases, surgeries, and other thrombophilic etiologies. Most commonly OVT presents on the right ovarian vein. We report a rare case of a 47-year-old Caucasian female G7P7 with no significant past medical history who presented to the emergency room for acute nonspecific back pain and left lower quadrant pain of 1 day. Imaging with a computed tomography with contrast demonstrated a new left OVT. After a thorough literature review, this is presumed to be the third reported case of idiopathic left OVT.

Single Tertiary Care Center Outcomes After Lower Extremity Cadaveric Vein Bypass for Limb Salvage.

OBJECTIVE: Cadaveric saphenous vein (CV) conduits are used in rare instances for limb salvage in patients without autogenous veins although long-term outcome data are scarce. This study was designed to evaluate the outcomes of CV bypass in patients with threatened limbs. METHODS: We retrospectively reviewed the charts from 2010 to 2017 of 25 patients who underwent 30 CV allografts for critical limb ischemia and acute limb ischemia. Patient charts were reviewed for demographics, comorbidities, smoking status, indications for bypass, and outcomes. Primary outcomes included graft patency, major amputation rates, and mortality. Secondary outcomes measured included infection rates, 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE). Statistical analysis was performed using time series and Kaplan-Meier survival curves. RESULTS: A total of 30 limbs received CV lower extremity bypasses (20 males, 10 female), and the average age was 68 ± 4 years. Primary patency rates were 71%, 42%, and 28% at 3, 6, and 12 months, respectively. Assisted primary patency rates were 78%, 56%, and 37% at 3, 6, and 12 months, respectively. Secondary patency rates were 77%, 59%, and 28% at 3, 6, and 12 months, respectively. Minor amputations, defined as amputations below the transmetatarsal level occurred in 5 (20%) patients. Wound infection occurred in 8 (32%) patients which was managed with local wound care and no patients required an extraanatomic bypass for limb salvage. Thirty-day MALE occurred in 7 (23.3%) patients. We had no 30-day mortality or MACE. The average graft length was 64.2 ± 8 cm with an average graft diameter of 3.9 ± 2 mm. Amputation-free survival and overall survival at 12 months were 20 (68%) and 21 (84%), respectively. CONCLUSIONS: Cadaveric saphenous vein allograft may be used as a bypass conduit as a viable surgical option before limb amputation. Despite the poor patency rates, the limb salvage rates of cadaveric vein grafts demonstrate that this alternate conduit may be considered when no autogenous vein is available.

A Rare Case of Spontaneous Bilateral Subcapsular Renal Hematoma.

Spontaneous bilateral renal subcapsular hematoma is a rare condition. On literature review, only 2 case reports have elucidated possible etiologies for such a presentation; however, no definite conclusions have been made. We present a rare case of a 52-year-old female with diabetes mellitus type 2, chronic kidney disease stage 4, hypertension, hyperlipidemia, prior traumatic brain injury via motor vehicle accident, who presented to our hospital with diabetic ketoacidosis and clinical signs of pyelonephritis; subsequently, imaging demonstrated spontaneous bilateral renal subcapsular hematoma. Risk factors for the rare presentation in this patient included pyelonephritis, history of bilateral ureteral stent placement, and a remote history of a mild unilateral renal laceration secondary to a motor vehicle accident. Typically, patients with this condition achieve spontaneous resolution with conservative management. Our patient initially presented with diabetic ketoacidosis and pyelonephritis but gradually developed retroperitoneal bleeding and hemorrhagic shock. Our patient's critical condition required close monitoring in an intensive care unit and a more invasive approach including unilateral left renal artery embolization followed by a unilateral left nephrectomy. The patient ultimately recovered and continued to be followed outpatient without any serious long-term complications.

Methicillin resistant Staphylococcus aureus infective endocarditis presenting as neutrophilic meningoencephalitis.

Infective endocarditis (IE) with Staphylococcus aureus is associated with intravenous drug abuse or infected cardiac devices and commonly presents with non-specific constitutional symptoms. A 53-year-old female presented to the hospital with back pain, altered mental status, fever, and tachycardia. Due to patient's lethargy and decline in respiratory effort, she was intubated and lumbar puncture was performed that revealed neutrophil-predominant leukocytosis of the cerebrospinal fluid. The patient was empirically started on ceftriaxone and vancomycin, and blood cultures were positive for methicillin resistant Staphylococcus aureus (MRSA). A chest X-ray demonstrated pulmonary congestion and an implanted pacemaker; furthermore, a transesophageal echocardiogram (TEE) revealed a vegetation on the atrial lead of the pacemaker. As the patient's condition improved after a few days, she was extubated and was able to provide a clear history. The source of her infection was a pus pocket around her pacemaker which was placed two months prior to her admission. As expected, the infection resolved with proper source control and antibiotic therapy.

Disseminated Coccidioidomycosis to the Gallbladder.

Coccidioidomycosis is an infection caused by inhalation of arthroconidia produced by dimorphic fungi in the genus Coccidioides. Forty percent of patients will develop an influenza-like illness with symptoms suggestive of a mild and self-limited respiratory infection; however, 5% of these individuals will develop extrapulmonary disseminated disease. An immunocompromised patient presented with right upper quadrant pain, ultrasound with pericholecystic fluid, in which a percutaneous cholecystostomy contained biliary fluid that grew the fungus Coccidioides immitis. Patient was initiated on intravenous amphotericin therapy and was followed closely with postoperative bile drainage with eventual laparoscopic cholecystectomy. We present a very rare case of disseminated coccidioidomycosis to the gallbladder.

Successful body flossing via indwelling nephrostomy allowing for primary realignment of bladder rupture and placement of a foley catheter into the urinary bladder.

Vesicourethral anastomosis leaks are one of the most common short-term complications following radical prostatectomy. We present a case of a 67-year-old Caucasian male who presented to our Emergency Department (ED) with abdominal pain and urinary incontinence 10 days after a robotic-assisted laparoscopic prostatectomy. Interventional radiology initially performed successful nephrostomy placement for bilateral hydronephrosis. Vesicourethral disruption was managed via a multidisciplinary approach with urology and interventional radiology in which a novel approach to realign a bladder rupture and appropriately place a foley catheter in the bladder. Vesicourethral leaks are often managed conservatively. In a few cases, such as this one, mini-invasive intervention is often required to repair the disruption.

A rare case of acute pancreatitis due to very severe hypertriglyceridemia treated with subcutaneous insulin and lipid lowering drugs.

The diagnosis of acute pancreatitis in a patient requires the presence of two of the following three criteria: (I) acute onset of persistent, severe; (II) epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal; (III) characteristic radiographic evidence hypertriglyceridemia is a potential cause of acute pancreatitis when levels are greater than 1,000 mg/dL. Very severe hypertriglyceridemia is classified as levels above 2,000 mg/dL. Management includes targeting pancreatitis with intravenous fluids, pain control, and nutritional support. While apheresis with therapeutic plasma exchange is a known option for severe hypertriglyceridemia, we present a rare case with management with intravenous fluids, subcutaneous insulin, statins, and fibrates in a patient with a triglyceride level of 12,234 mg/dL who presented with severe epigastric pain radiating to her back.

A Rare Case of Multiple Myeloma Presenting as Evan's Syndrome.

Multiple myeloma is defined as the neoplastic proliferation of plasma cells resulting in a monoclonal gammopathy. The classic presentation of a patient is someone who presents with bone pain, osteopenia, or new onset fractures. We present a case of multiple myeloma presenting as Evan's syndrome (ES). Evan's syndrome is autoimmune hemolytic anaemia with autoimmune thrombocytopenia. A 44-year-old female was referred from her primary physician to the hospital as laboratory testing revealed haemoglobin of 5 gm/dL. The patient reported a two-month history of fatigue and a sixty-pound weight loss. Laboratory results demonstrated autoimmune hemolytic anaemia, C3 positivity, elevated immunoglobulin (Ig)G, elevated lactate dehydrogenase (LDH), low haptoglobin, elevated reticulocyte count, elevated RDW-CV (red blood cell distribution width-corpuscular volume), positive direct Coombs test, thrombocytopenia, and proteinuria, all of which led to an underlying ES. The patient was started on intravenous steroids followed by oral steroids. A flow cytometry, serum protein electrophoresis, and cytogenetics were obtained. A bone marrow biopsy revealed multiple myeloma and she was started on Bortezomib treatment. We present the fifth reported case of Evan's syndrome and multiple myeloma.

Recurrent Episodes of Diffuse Alveolar Hemorrhage in Systemic Sclerosis 30 Days Apart.

Diffuse alveolar hemorrhage (DAH) is a life-threatening clinicopathologic condition caused by accumulation of intra-alveolar red blood cells (RBCs) after disruption of the alveolar-capillary basement membrane that is often seen as a complication of various diseases, but is rare in systemic sclerosis. A 46-year-old female with systemic sclerosis presented to the emergency department complaining of right-sided chest pain. Initially, her electrocardiogram and chest X-ray (CXR) were unremarkable; however, she progressively decompensated into acute respiratory failure resulting in intubation. Repeat CXR and computed tomography scan showed diffuse bilateral alveolar infiltrates and pleural effusions. Video bronchoscopy with bronchoalveolar lavage showed numerous RBCs, neutrophils, macrophages, and respiratory epithelial cells consistent with acute DAH. She was started on intravenous pulse-dosing Solu-Medrol 1 g daily for 5 days. One month later, the patient returned with intractable nausea and vomiting. Again, she went into acute respiratory distress with a PaO2 of 59 while on a 10-L non-rebreather mask. CXR revealed development of alveolar infiltrates in the right lung. A bronchoscopy with bronchoalveolar lavage again showed numerous RBCs and neutrophils along with staining positive for hemosiderin-laden macrophages. Systemic sclerosis with alveolar hemorrhage is a rare occurrence; however, most cases are single episodes of hemorrhage, whereas we present a case with 2 confirmed episodes within 30 days. Its life-threatening nature makes a systemic approach and aggressive treatment crucial to decreasing morbidity and mortality-making it a diagnosis that should not be overlooked, especially in patients with nonspecific symptoms.

A Rare Case of Stage IV Basaloid Squamous Cell Cancer with Intrapulmonary and Brain Metastases.

BACKGROUND Metastatic basaloid squamous cell carcinoma is a fatal, high-grade variant of squamous cell carcinoma that is extremely rare in the oral cavity. We present a rare case of metastatic basaloid squamous cell carcinoma arising from the hypopharynx with pulmonary and brain metastases. Recognizing this diagnostic subtype is of critical importance due to the aggressive nature and high incidence of recurrence, lymph node metastases, and mortality. CASE REPORT A 42-year-old male arrived at the Emergency Department reporting a 1-week headache. Six months prior, he reported throat pain and neck swelling. Triple endoscopy revealed a large ulcerative tumor. A carbon dioxide laser procedure debulked and removed the mass. Incisional biopsy with histopathology was consistent with invasive basaloid squamous cell carcinoma. Computed tomography (CT) of the neck with contrast demonstrated bilateral cervical level II/III necrotic adenopathy, and CT chest with contrast demonstrated bilateral pulmonary nodules. The patient completed chemoradiation therapy with cisplatin; however, repeat CT chest revealed enlarging intrapulmonary metastases. CT brain without contrast demonstrated a central brainstem lesion. The patient started treatment with pembrolizumab. On day 14 of treatment, he presented to the Emergency Department again for headache. MRI of brain with contrast demonstrated a new lesion with vasogenic edema. Intravenous dexamethasone was started and the decision to pursue stereotactic radiosurgery was made. CONCLUSIONS The diagnosis of basaloid squamous cell carcinoma in the setting of intrapulmonary and brain metastases is an extremely rare, high-grade bimorphic aggressive variant of squamous cell carcinoma that needs to be histopathologically differentiated from other tumors. Given its high mortality rate and poor prognosis the decision to pursue further treatment versus aggressive palliative care should be discussed.

The Natural History of Gastrointestinal Bleeding in Patients without an Obvious Source.

With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma "the most common cause of lower GI bleeding is upper GI bleeding" may no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and their clinical outcomes. We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious sources such as hematemesis or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena, or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required, and types of interventions performed. Ninety-three patients were admitted with GI bleeding as defined previously: mean age was 74 years and mean hemoglobin was 8.2. Seventy-four per cent received blood transfusions with an average of 2 units transfused per patient; 22 per cent received 3 or more units of blood. The etiology of bleeding was 17 per cent upper GI source, 15 per cent lower GI source, and in 68 per cent, the source remained unknown. Bleeding stopped spontaneously in 86 per cent of patients and 9 per cent died. Endoscopy was performed in 71 per cent, but only 6 per cent underwent therapeutic endoscopic intervention. No patient had surgical or interventional radiologic procedures related to their GI bleed. Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative intervention or interventional radiologic procedure. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6 per cent of patients.

Ramsay Hunt Syndrome with Multiple Cranial Neuropathy in an Human Immunodeficiency Virus (HIV) Patient.

BACKGROUND Ramsay Hunt syndrome is a rare otologic complication resulting from varicella zoster virus reactivation that can present with a myriad of clinical presentations. Most common being triad of ear pain, vesicles at auricle, and ear canal with same side facial palsy. CASE REPORT We report a case of a 29-year-old male with a human immunodeficiency virus (HIV) infection who presented with left facial palsy, vesicles, pain in the left ear, dysphagia, dizziness, and headache resulting from multiple cranial nerves involvement such as cranial nerve V, VII, VIII, IX, and X. CONCLUSIONS This case report raises awareness among general practitioners to investigate for Ramsay Hunt syndrome in HIV patients presenting with ear pain with a thorough neurological exam and emphasize on the interplay of different specialties in managing these patients.

Rare imaging of a known entity: fat embolism seen on CT in lower extremity vein after trauma.

Fat embolism occurs in the vast majority of patients who have had trauma (approximately 90%). The most common occurrence is after long bone fracture. It has also been noted in cases after orthopedic surgery. Fat embolism is most often diagnosed when the clinical manifestations of fat embolism syndrome become apparent. Reported cases of fat emboli in transit are unusual. In our case, we present the rare finding of fat embolism seen on computed tomography in the lower extremity after a trauma.