Vitamin B12 deficiency presenting as neck pain and cervical radiculopathy.

Vitamin B12 is required for the formation of haematopoietic cells and the synthesis of myelin. Deficiency typically presents with fatigue and megaloblastic anaemia. Prolonged deficiency can cause neurological symptoms such as paresthesia, which can progress to subacute combined degeneration of the spinal cord. We describe an unusual presentation of B12 deficiency in a young man who was initially diagnosed and treated for cervical radiculopathy. This case highlights the challenges of diagnosing B12 deficiency in patients with neurologic but without haematologic, abnormalities. While the current incidence of B12 deficiency in developed countries is low, cases are likely to rise with the increased adoption of veganism. Clinicians should be aware of the variable presentations of B12 deficiency because delayed diagnosis and treatment increases morbidity and can cause irreversible neurological deficits.

Follmann Balanitis: An Unusual Case of Syphilis.

A 33-year-old man presented with suprapubic abdominal pain and small vesicular lesions on the foreskin of the penis. Based on the presentation, he was empirically treated for genital herpes, although the herpes simplex virus swab was negative. He returned to the emergency department 4 months after his initial presentation with worsening symptoms that were consistent with balanoposthitis and cystitis. He was tachycardic and febrile on presentation. He denied any sexual contact for the last 3 months, with previous negative screening tests for sexually transmitted infections. Syphilis was eventually diagnosed during this admission. The incidence rates of syphilis have increased in recent years, and the infection is often undiagnosed given atypical manifestations. Here we present an atypical manifestation of syphilis that was initially misdiagnosed as herpes simplex virus.

Strategies to promote scholarship among academic hospitalists.

Academic hospitalists play an integral role in the day-to-day care of hospitalized patients, education and research. They are well-positioned to engage in scholarly and research activities and inform clinical practice. Hospital medicine also offers a compelling career path for those seeking to maintain a broad clinical focus while also pursuing opportunities in quality improvement (QI), clinical research, and medical education (MedEd) projects. Participation in these endeavors not only foster scholarly growth but also enhances career satisfaction for hospitalists. Therefore, there is a need to explore and implement feasible strategies to equip hospitalists with the knowledge and resources necessary to generate scholarship and promote academic growth within the field.

Severe Thrombocytopenia in Decompensated Liver Disease: An Example of Accelerated Intravascular Coagulation and Fibrinolysis.

INTRODUCTION: Advanced liver disease can present with severe thrombocytopenia that can be difficult to delineate and manage. Here we describe a unique entity of accelerated intravascular coagulation and fibrinolysis (AICF) in a patient with decompensated liver disease. CASE PRESENTATION: A 56-year-old male with a history of alcoholic cirrhosis was admitted for weakness, nausea, metabolic derangement, and acute kidney injury determined to be secondary to decompensated liver disease. During admission, his platelet count declined to <10 000/µL requiring 8 total platelet transfusions. Laboratory and clinical evaluation supported a diagnosis of AICF, and the patient gradually improved with supportive management. DISCUSSION: AICF can present similarly to disseminated intravascular coagulation, and careful evaluation of specific laboratory values is required for accurate diagnosis. Appropriate management minimizes the associated increased risk of bleeding and prevents delay in procedural intervention. CONCLUSIONS: This case highlights the importance of early clinical and laboratory correlation, multidisciplinary care, and supportive treatment in the management of AICF.

Granulomatosis With Polyangiitis Presenting As Orbital Apex Syndrome.

Granulomatosis with polyangiitis (GPA) is a rare small-vessel vasculitis that typically presents with a triad of sinonasal, pulmonary, and renal symptoms. Here, we present the case of a 43-year-old female with a history of substance use disorder who presented with vision changes and worsening left eye pain over five days. Previous evaluations raised concerns about GPA versus cocaine-induced vasculitis, but diagnostic confirmation was hindered by a lack of medical follow-up. Prompt multidisciplinary intervention led to significant improvement following steroid therapy and IV antibiotics, and the patient was ultimately diagnosed with a high GPA. This case highlights the complexities involved in diagnosing and managing GPA presenting as orbital apex syndrome, particularly in patients with comorbidities and non-adherence to medical follow-up.

Interaction of Semaglutide and Ziprasidone in a Patient With Schizophrenia: A Case Report.

Semaglutide (Ozempic), a GLP-1 receptor agonist effective in weight management, and ziprasidone (Geodon), an antipsychotic with a lower risk of metabolic side effects, are well-established in treating type 2 diabetes and schizophrenia, respectively. However, their interactions and effects on psychiatric symptoms are less understood. In this study, we report a case of a 43-year-old male with schizophrenia and diabetes with exacerbated paranoid delusions upon semaglutide administration for weight loss; symptoms peaked at higher doses and subsided after dose reduction. Concurrently, serum ziprasidone levels were significantly elevated at the dose reduction, suggesting a pharmacokinetic interaction likely due to semaglutide-induced slowed gastric emptying affecting ziprasidone's absorption and metabolism. This study illustrates the need for careful monitoring of psychiatric symptoms and drug levels when these medications are used together. Additionally, further research into their interactions to optimize treatment for patients with coexisting metabolic and psychiatric conditions is warranted.

A Case of Disseminated Mycobacterium Haemophilum in a Kidney Transplant Recipient Presenting With Subcutaneous Nodules.

INTRODUCTION: Dermatologic manifestations of diseases in solid organ transplant recipients are common due to long-term immunosuppression. CASE PRESENTATION: We present the case of a 63-year-old man with a kidney transplant who exhibited subcutaneous nodules on lower extremities, cytopenia, and asymptomatic pulmonary infiltrate. Through a skin biopsy and 16S ribosomal RNA (rRNA) sequencing, Mycobacterium haemophilum was identified. His clinical course was complicated by empyema, septic arthritis, and recurrence of his skin manifestations, despite ongoing antimicrobial treatment. DISCUSSION: This case emphasizes the challenges and potential complications associated with M haemophilum infections in solid organ transplant recipients receiving long-term immunosuppressive therapy. It highlights the importance of employing advanced diagnostic techniques when evaluating dermatologic manifestations in these patients. The patient's complex clinical course also underscores the difficulties involved in effectively addressing and managing complications that may arise even after initiating therapy.

Double Trouble: COVID-19 Pneumonia Concurrent With COVID-19-Associated Pulmonary Aspergillosis.

INTRODUCTION: Severe complications due to COVID-19 are a growing concern. We present a case of COVID-19 pneumonia with development of a superimposed COVID-19-associated pulmonary aspergillosis. CASE PRESENTATION: A 52-year-old unvaccinated male with a history of asthma and sleep apnea presented with progressive dyspnea 10 days after COVID-19 diagnosis. Worsening respiratory function despite broad-spectrum antibiotics and negative cultures prompted a repeat respiratory culture that revealed Aspergillus; voriconazole was initiated. DISCUSSION: The risk of COVID-19-associated pulmonary aspergillosis is highest in patients who are immunosuppressed or who receive corticosteroids to treat COVID-19 infection. Subtle and atypical presentations can be seen; our patient had only mild leukocytosis and progressive dyspnea with a negative initial respiratory culture. COVID-19-associated pulmonary aspergillosis is associated with high morbidity and mortality; thus, prompt diagnosis and treatment may confer a survival benefit. CONCLUSIONS: Despite the subtle presentation and variable radiographic findings in COVID-19- associated pulmonary aspergillosis, a low clinical threshold for workup is crucial to a timely diagnosis and treatment.

A Case of COVID Cholangiopathy and Literature Review.

INTRODUCTION: With cholangiopathy, the bile ducts become inflamed and have a "beads on string appearance" with elevated bilirubin. It is typically associated with primary sclerosing cholangitis but is now being reported as a post-COVID complication. CASE PRESENTATION: A 65-year-old White male presented with resolved respiratory failure from COVID-19 pneumonia, jaundice, and likely subacute kidney injury. He was diagnosed with COVID-19 cholangiopathy due to clinical picture and magnetic resonance cholangiopancreatography imaging. Unfortunately, due to a massive refractory gastrointestinal bleed, he was transitioned to hospice care. DISCUSSION: COVID-19 has been shown to have both short- and long-term effects on multiple organ systems. Cholangiopathy is a rare complication of COVID-19. Most of these cases result in severe liver failure and require liver transplant, similar to primary sclerosing cholangitis. CONCLUSIONS: We report this case to increase awareness among clinicians to consider COVID-19 cholangiopathy in patients with unexplained jaundice and a history of severe COVID-19 infection.

Perception of Burnout and Its Impact on Academic Hospitalists During COVID-19 and Institutional Strategies to Combat Burnout and Improve Wellness.

INTRODUCTION: Physician burnout has been alarmingly high, particularly among general internal medicine, which displays some of the highest rates. A recent study of academic hospitalists reported a higher level of burnout (62%) than the rates found in similar studies, but with agreement about factors leading to burnout, consequences of burnout, and importance of steps to prevent burnout. This study seeks to expand upon these results by investigating the impact of COVID-19 on burnout among hospitalists and uncovering the perspectives of frontline clinicians to formulate effective mitigation strategies. METHODS: Academic hospitalists were recruited to participate in a series of focus group interviews. The questions focused on contributors to burnout, the impact of COVID-19, and strategies to improve wellness and reduce burnout. The focus groups were audio-recorded, transcribed, and coded for emergent themes using Taguette, an open-source qualitative data analysis software. RESULTS: Burnout-inducing themes included workload, bureaucratic hurdles, and lack of control. COVID-19-specific themes included fear of exposing family and social isolation. The most common mitigation strategy was to increase social interactions to foster a sense of community. Additional solutions included adhering to a census cap of patients, streamlining clinical work, and providing avenues for two-way communication between leadership and clinicians to share concerns and elicit feedback. CONCLUSIONS: Streamlining clinical work allows more time for patient care. Enhancing community and fostering collaboration in decision-making allows clinicians to feel more empowered. A crucial first step to combat burnout is to encourage a work environment that values clinician well-being and proactively works to increase job satisfaction.