Mirtazapine Therapy for a Patient With Weight Loss and Gastroparesis Associated With Limited Systemic Sclerosis.

Objective: Gastroparesis may be present in individuals with systemic sclerosis. In the United States, metoclopramide is the only medication approved for treating gastroparesis. Our case involves using mirtazapine therapy to help with weight loss and gastroparesis associated with systemic sclerosis. Case: A 70-year-old female with limited systemic sclerosis and sicca syndrome began experiencing weight loss, dysphagia, nausea, and abdominal fullness. Neither an esophageal dilation procedure nor six weeks of metoclopramide therapy alleviated her symptoms. However, 15 mg of mirtazapine once daily provided some symptomatic relief. A gastric emptying scan confirmed gastroparesis. The dose of mirtazapine was later increased to 30 mg once daily. With the mirtazapine therapy, the patient experienced both symptomatic improvement and weight gain benefits. Discussion/Conclusion: Mirtazapine therapy has anti depressive, appetite stimulating, anti-emetic, and prokinetic benefits. Consideration of mirtazapine therapy for patients with weight loss and gastroparesis associated with systemic sclerosis may be beneficial.

Takotsubo Cardiomyopathy Associated With Influenza A and a Ground-Level Fall.

Our case involves a 92-year-old female who presented to the emergency department due to a ground-level fall and difficulty breathing. She was found to have influenza A, elevated troponin, and decreased left ventricular ejection fraction. However, cardiac catheterization did not reveal any coronary artery stenosis, supporting a diagnosis of takotsubo cardiomyopathy (TC). The patient's ejection fraction was normal after nine months. This case highlights the importance of considering TC in elderly female patients who have reduced ejection fraction and elevated troponin in the setting of infection and a recent fall.

Disseminated Histoplasmosis Mimicking Macrophage Activation Syndrome in a Patient With Rheumatoid Arthritis.

Infections caused by Histoplasma capsulatum typically do not produce symptoms. However, in individuals who are immunocompromised, progressive disseminated histoplasmosis may occur. A 67-year-old female, with lengthy history of immunosuppression due to management of rheumatoid arthritis, reported a two-month history of fatigue, headaches, and intermittent fevers following hip surgery. Due to the concern for macrophage activation syndrome and hemophagocytic lymphohistiocytosis, a bone marrow biopsy was performed. However, the results indicated the presence of Histoplasma, which was supported by the presence of Histoplasma antigens in the serum and urine, Histoplasma antibodies in the serum, positive (1,3)-beta-D-glucan results, and fungal blood cultures. The patient initially received amphotericin B, but it was switched to itraconazole due to adverse effects. The patient remains on itraconazole therapy and follows as an outpatient with an infectious diseases specialist.

A Case of Saphenous Vein Graft Aneurysm Treated With Percutaneous Coiling.

In adults, coronary artery bypass grafting (CABG) is a commonly performed surgery. Oftentimes, saphenous veins from the lower extremity are used as the graft vessels. A rare complication of this procedure is the formation of saphenous vein graft (SVG) aneurysms. We present the case of a 63-year-old male who presented to a referring emergency department with left-sided chest pain after falling off a ladder. The patient's initial chest X-ray revealed a suprahilar mass that was suspicious for being an aneurysm. A computerized tomography coronary angiogram indicated a large aneurysm. The patient was transferred to our facility for specialist evaluation. The patient's history was positive for two CABG procedures and a sternal wound infection, so a repeat sternotomy was not advisable. The SVG aneurysm was treated with percutaneous coiling. The patient tolerated the procedure well and was discharged home the next day.

A Case of Ceftaroline-Associated Thrombocytopenia.

Ceftaroline is a fifth-generation cephalosporin that can be used for the treatment of serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA). A rare adverse effect of ceftaroline therapy is thrombocytopenia. Our case involves a 45-year-old male with active intravenous drug usage who presented with persistent fever, lower back pain, and left elbow pain. His bloodcultures were found to be positive for MRSA. He was initially started on vancomycin; subsequently, the antibiotic was changed to daptomycin and ceftaroline, as vancomycin failed to clear the bacteremia. Seven days after initiation of ceftaroline, it was unintentionally discontinued by the electronic health record. Following its resumption two days later, the patient started having epistaxis accompanied by an acute drop in his platelet count from 422,000 cells/µL to less than 2,000 cells/µL. The ceftaroline therapy was discontinued, and he received a platelet transfusion. However, daptomycin was continued, resulting in successful resolution of his bacteremia. The patient's platelet count at discharge improved to 582,000 cells/µL. The patient was diagnosed with ceftaroline-induced thrombocytopenia, and it was added to his list of allergies.

A Case of Multiple Vein Thrombosis Following Pacemaker Implantation.

Pacemakers are implanted as part of the treatment process of conditions including symptomatic bradycardia and certain types of heart block. One complication associated with pacemaker implantation is upper extremity deep venous thrombosis (UEDVT), which can subsequently lead to pulmonary embolism, limb loss, or death. We present the case of an 88-year-old male who developed UEDVT in his left subclavian, axillary, brachial, and basilic veins shortly after dual chamber pacemaker implantation for treating symptomatic heart block. The patient received anticoagulation with intravenous heparin while inpatient but was switched to oral apixaban prior to discharge. This case highlights the importance of detecting and treating UEDVT in patients who recently underwent pacemaker placement.

A Case of Hand-Foot-and-Mouth Disease in an Adult Male.

Hand-foot-and-mouth disease (HFMD) is commonly seen in infants and children; less frequently, it may be seen in adults as well. The disease is usually associated with viral infections, including many variants of enteroviruses and coxsackieviruses. We discuss the case of a 39-year-old male who presented with constitutional symptoms, fever, and lesions on his hands, feet, and mouth. His children, who had been recently diagnosed with HFMD, were likely the source of his infection. A comprehensive history and physical examination enabled us to identify the lesions, some of which were faint and difficult to visualize. Viral panel testing indicated positive results for human rhinovirus/enterovirus. Treatment and testing associated with the patient's condition were supportive, largely based on the history and physical findings which helped us narrow down our differential diagnoses. Complete resolution of the symptoms within one to two weeks is generally expected in these patients.

A Unique Presentation of 3-Methylcrotonyl-CoA Carboxylase Deficiency.

3-methylcrotonyl-CoA carboxylase deficiency is an autosomal recessive disorder resulting in impaired leucine metabolism. The condition is typically diagnosed with newborn screening; patients diagnosed at a later stage generally present with symptoms including metabolic disturbances, seizures, failure to thrive, or delayed development. We present the case of a child diagnosed at 12 months of age who was noted to have recurrent viral infections and nonspecific gastrointestinal symptoms of vomiting, hematochezia, and gaseous distention of the abdomen. Newborn screening did not reveal any abnormalities. Evaluation for underlying immunodeficiency was unremarkable; genetic testing revealed bi-allelic mutations in MCCC2, a known association of 3-methylcrotonyl-CoA carboxylase deficiency. It is important to consider genetic disorders when evaluating patients even if the newborn screening is unremarkable.

Global Pseudo-Atrial Flutter on Electrocardiogram and the Importance of Clinical Correlation.

Parkinson's disease is a condition in which tremors, rigidity, bradykinesia, difficulties with sleep, autonomic symptoms, and mood disturbances can be present. We present an intriguing case in which such tremors appear as a global pseudo-atrial flutter on electrocardiogram (ECG). A 73-year-old Caucasian female presented to the cardiology clinic for management of atrial flutter diagnosed by ECG in a primary care setting. In the cardiology clinic, the physical examination of the patient revealed bilateral upper extremity resting tremors. The ECG machine initially read the findings as "atrial flutter." However, immobilization of the patient's arms bilaterally resulted in a normal sinus rhythm. Repeated ECGs when the arms were relaxed and when the arms were immobilized resulted in findings consistent with pseudo-atrial flutter and normal sinus rhythm, respectively. Considering tremors as a source of artifact on electrocardiogram in patients with tremors and using corrective measures are critically important to prevent misdiagnosis, unnecessary testing, and potentially harmful treatments. This case underscores the importance of educating healthcare team members about tremor-induced artifacts in patients with tremors to avoid misdiagnosis based on ECG readings.

Fibrillary Glomerulonephritis in a Patient With Vulvar Squamous Cell Carcinoma.

Fibrillary glomerulonephritis is a rare condition characterized by glomerular accumulation of non-branching fibrils, leading to hematuria, proteinuria, and hypertension. It is often associated with malignancy but has no known cause. A 66-year-old Caucasian female with a history of vulvar squamous cell carcinoma presented with one month of painless hematuria in the setting of new-onset progressive renal dysfunction and nephrotic range proteinuria. Comprehensive evaluation, including renal biopsy with staining for DnaJ heat shock protein family member B9 (DNAJB9), provided a definitive diagnosis of fibrillary glomerulonephritis. The patient initially received rituximab and prednisone therapy. Unfortunately, her renal function continued to decline over the next month, requiring re-hospitalization with initiation of hemodialysis. To our knowledge, this is the first case describing an association between vulvar squamous cell carcinoma and fibrillary glomerulonephritis.

Liver Hydatid Cyst Masquerading as a Liver Abscess.

Hydatid cyst of the liver is a rare zoonotic disease in the United States. It is caused by Echinococcus granulosus. This disease is mainly seen among immigrants from countries where this parasite is endemic. Differential diagnoses of such lesions can include pyogenic or amebic abscesses, in addition to other benign or malignant lesions. We report the case of a 47-year-old woman who presented with symptoms of abdominal pain and was diagnosed with a hydatid cyst of the liver masquerading as a liver abscess. Microscopic and parasitological tests confirmed this diagnosis. The patient was treated and discharged without further complications during follow-up.

A Case of Pasteurella Bacteremia in a Patient With Hepatocellular Carcinoma.

Pasteurella multocida is a Gram-negative coccobacillus commonly associated with soft tissue and skin infections. On rare occasions, it may result in systemic bacteremia and sepsis. Our case describes a 59-year-old male who presented to the emergency department with septic shock. Physical examination was remarkable for bilateral lower extremity wounds which were in recent contact with feline oral secretions. Blood cultures were obtained and resulted in the growth of P. multocida after 48 hours. His treatment involved intravenous antibiotics and supportive care. After finishing his two-week course of antibiotics, he was placed on inpatient hospice care due to his clinical course involving other comorbidities and expired shortly after. This case highlights the importance of early recognition and treatment of P. multocida infection in patients with comorbid conditions such as hepatocellular carcinoma.