Isolated central nervous system Aspergillosis infection in a chronic lymphocytic leukemia patient on Ibrutinib: A case report.

BACKGROUND: In patients at high risk of opportunistic infections who present with isolated. neurological symptoms, it is lifesaving to consider Central Nervous System Aspergillosis (CNS-A). Ibrutinib use in chronic lymphocytic leukemia (CLL) has previously been associated with CNS-A. We provide a case report of a patient that presented with primary CNS-A on Ibrutinib therapy without any prior pulmonary or local paranasal signs of infection. CASE PRESENTATION: 74-year-old Caucasian male with CLL and no prior chemotherapy on ibrutinib for 6 months presented with three months of unsteady gait, occipital headache, and confusion. He has a history of pulmonary sarcoidosis on chronic prednisone 5 mg daily and chronic obstructive pulmonary disease (COPD). He was found to have a "brain abscess" on imaging. Emergent craniotomy confirmed Aspergillus and patient was treated with Voriconazole for 6 months. At six-month follow up, repeat magnetic resonance imaging (MRI) confirmed complete resolution of CNS lesion. CONCLUSIONS: Our case reinforces the importance of being vigilant for isolated CNS-A in CLL patients on ibrutinib who present with neurological symptoms and signs, without prior or co-infection of sino-pulmonary tissue.

Atrial Myxoma: Presenting as a Large Splenic Infarction.

Cardiac myxomas are the most common benign primary heart tumors, with the majority occurring in the left atrium. Clinical manifestations are a result of constitutional, obstructive, and/or embolic events. Complications include myocardial infarction and stroke, as well as renal and limb ischemia. Our unusual case is a middle-aged female who presented with a one-week history of progressively worsening abdominal pain and was found to have a large splenic infarction on a CT scan. There was no personal or family history of autoimmune diseases or hypercoagulable states. The evaluation revealed a large left atrial myxoma confirmed on biopsy after surgical resection. Our patient's clinical presentation was relatively benign compared to the size of her mass. Although her myxoma was very large, morphologically solid, and attached to the interatrial septum, she did not have any evidence of congestive heart failure. The tumor's irregular surface and mobility likely led to splenic embolization. Hence, the differential diagnosis of splenic infarction should include left atrial myxoma.

Inpatient Rheumatology Consultation Prompted by Positive Autoantibodies in Patients Receiving Intravenous Immunoglobulin Therapy: A Case Series and Literature Review.

Intravenous immunoglobulin (IVIG) is a therapeutic preparation used in the treatment of multiple diseases. Autoimmune testing with antinuclear antibody (ANA) screening is often obtained for some of these conditions, but only after initiation of IVIG treatment. This can present a diagnostic dilemma in hospitalized patients and may trigger a rheumatology consultation. We describe our consultative inpatient two-year experience with five such patients and review the pertinent literature. A retrospective chart review of rheumatology inpatient consultations between 6-2018 and 6-2020 at our academic tertiary care hospital for post-IVIG positive serologies was performed. A pertinent literature review was performed. Five patients had a positive ANA and other autoantibodies detected in their serum after they received IVIG for non-rheumatological conditions. None of these patients met the criteria for a connective tissue disease. The literature review identified a total of 58 patients from case reports and case series, several of whom tested positive for ANA and other antibodies after receiving IVIG. Studies assessing specific IVIG products detected multiple autoantibodies in the donor pool. Autoimmune testing is initiated on inpatients receiving IVIG for non-rheumatological conditions. If an autoantibody ANA screen is positive, a rheumatology consultation may be requested. In the absence of pre-IVIG antibody tests it is difficult to interpret post-IVIG-positive antibodies. Whether such positive antibodies are of clinicopathological significance is determined by clinical judgment and time.

Septic Shock From Pan-Spinal Epidural Abscess Attributed to Recent Acupuncture and Trigger Point Injections for Acute Lower Back Pain in a Previously Undiagnosed Diabetic Patient: A Case Report.

Epidural abscesses can lead to devastating neurological consequences if not diagnosed and managed in a timely manner, especially in immunocompromised patients. We report the case of a 60-year-old woman with undiagnosed diabetes mellitus who presented to the hospital with a complaint of progressive altered mental status for the past two days. Eight days prior to presentation, the patient tripped over a pillow at home and developed mildly nagging, acute lower back pain. Upon the recommendation of her friends, she underwent two sessions of acupuncture around the lumbar area on days six and five prior to being brought to the hospital. She also saw her primary care physician on day three prior to presentation, who performed a history and physical examination and, after feeling that she did not have any red flags, empirically administered lidocaine-based trigger point injections near the same lumbar areas with the patient's consent. On the day of presentation, the patient fell at home and was unable to walk, after which she was immediately brought to the hospital, where she demonstrated toxic metabolic encephalopathy due to diabetic ketoacidosis (DKA) and lower extremity paraplegia. Emergent imaging revealed a pan-spinal epidural abscess (PSEA) after an attempted lumbar puncture led to immediate pus in the syringe. Diagnosing an epidural abscess can be difficult as signs and symptoms can mimic other conditions such as meningitis, encephalitis, and stroke. High suspicion on the physician's end is needed when a patient presents with acute back pain, fevers, and neurological deterioration if the condition is otherwise unexplained, and especially in the presence of risk factors for PSEA that may be recognized only upon presentation.

Cardiac Papillary Fibroelastoma: Atypical Presentation Mimicking Infective Endocarditis With False Positive Commensal Blood Cultures.

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac neoplasms that carry a high risk of embolization if not diagnosed and managed in a timely manner. As most patients are asymptomatic, CPF may be incidentally detected on transthoracic echocardiography (TTE) when performed for other indications. Management of incidental CPF in asymptomatic patients is debatable. We report an unusual case of an incidental CPF in an asymptomatic patient admitted to the hospital for presumed infective endocarditis (IE). Two weeks following laser resection of laryngeal cancer (LC), a new pansystolic murmur was audible during a routine cardiology visit. Outpatient TTE revealed a "vegetation-like" lesion on the mitral valve (MV). Blood cultures (BC) with Gram-positive cocci in clusters (GPC) were reported within 24 hours. This prompted hospital admission for empiric antibiotics. A transesophageal echocardiogram (TEE) confirmed the lesion to be an echogenic mass attached to the MV consistent with CPF. Repeat BC, prior to empiric antibiotic initiation, were all negative. In the absence of all other signs and symptoms of IE, it was determined that the initial BC was false positive and IE was ruled out. Surgical resection was performed due to the potential risk of embolization. The pathology confirmed the diagnosis of CPF with negative tissue cultures.

A Patient's Six-Month Journey From Low Sodium to Blue Toes to Stroke: Non-infective Thrombotic Endocarditis Due to Non-small Cell Lung Cancer.

We report a patient's journey with a four-year history of hypertension (HTN) and hyperlipidemia (HLD), stable on beta-blocker and statin, monitored every six months by alternating visits between her cardiologist and primary care physician (PCP) in North Carolina (NC). Six months before relocating to New York (NY) she had been informed about incidental severe hyponatremia during her last outpatient visit, the need for repletion with sodium chloride tablets, and the critical importance of prompt follow-up to rule out malignancy by starting with a chest X-ray. She opted not to follow instructions, continued cigarettes, and decided to spend the summer season with her son in NY. Six months after being told of her low sodium, she presented to our NY hospital with an acute, painful right foot blue toe syndrome. During the ischemic right foot evaluation, she was discovered to have adenocarcinoma of the right lung (stage 4) and a normal transthoracic echocardiogram (TTE). Heparin was initiated and thromboembolectomy with an endovascular bovine patch to revascularize the foot was successful, and post-procedure apixaban was started. Hyponatremia was attributed to the syndrome of inappropriate antidiuretic hormone release (SIADH) secondary to non-small cell lung cancer (NSCLC). The serum sodium was stabilized, and the patient was discharged with a plan for outpatient follow-up with the cardiologist and oncologist within two weeks for hypertension, hyperlipidemia, hyponatremia, and management of stage 4 NSCLC. During her cardiology follow-up, 10 days after discharge, complaints of mild dyspnea on exertion (DOE) prompted an ECG (electrocardiogram) that revealed new T wave inversions in leads V3-6, and the patient was readmitted for non-ST elevation myocardial infarction (NSTEMI) evaluation. On day one of the readmission troponins were negative with normal ejection fraction (EF) on TTE and an acute 2 g/dl hemoglobin (Hb) drop with melena. This led to discontinuation of anticoagulation, initiation of intravenous (IV) pantoprazole, and endoscopy (EGD) which revealed gastritis. On the third day, she developed sudden expressive aphasia. Computed tomography (CT) of the head did not show any bleed but same-day magnetic resonance imaging (MRI) demonstrated multiple evolving acute infarcts. Transesophageal echocardiogram (TEE) demonstrated two large, mobile masses on the mitral valve consistent with vegetative endocarditis. Cultures for bacteria, fungi, and evaluation for organisms associated with culture-negative acute bacterial endocarditis/subacute bacterial endocarditis were unrevealing, thus confirming malignancy-associated non-infectious thrombotic endocarditis or non-bacterial thrombotic endocarditis (NBTE). Gastrointestinal (GI) bleeding ceased, and the patient initially started on a heparin drip and transitioned to enoxaparin as lifelong anticoagulation for malignancy-associated NBTE. She recovered neurologically and was given pembrolizumab. At her recent 15-month visit she continued to have no residual neurological impairments, however, new positron emission tomography (PET) detected metastasis to the liver, lung, and adrenals which prompted evaluation for hospice care. We, therefore, emphasize the need for timely diagnosis of NBTE and prompt initiation of anticoagulation in suitable patients to prevent complications such as in our patient. Additionally, hyponatremia secondary to SIADH in NSCLC is a poor prognostic indicator of overall survival.

Conversations With Individuals on the Fence about CV-19 Vaccination: Analysis of Lives Saved by Vaccine vs. Natural Infection Mortality and Other Reflections.

As of June 15, 2021, from 672,000 to 912,000 deaths have been averted through vaccination of 48% of the US population. Because 52% remain unvaccinated, 728,000 to 988,000 lives remain at risk. These deaths can be spared, and the pandemic stopped in its tracks provided a final national vaccination rate of 84% is achieved. We aim to demonstrate in our analysis the number of lives saved that can be attributed to CV-19 vaccination vs the mortality rate of natural infection seen in unvaccinated individuals. However, time is short given the recent exponential rise of the highly contagious SARS-CoV-2 Delta variant. Delta infection results in a thousand-fold increase in viral load and a transmissibility 2.25x that of the original SARS-CoV-2 strain. Predominance of the Delta variant has already resulted in Covid-19 surges in area with low vaccination rates. An aggressive and timely vaccination campaign is being attempted. We hope our analysis helps convince individuals 'on the fence' that vaccination is essential if the pandemic is to be ended in the United States.

Diagnosing and Managing Clinically Silent Lupus Nephritis and Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis Overlap Syndrome: A Clinical Challange.

Lupus nephritis is typically associated with anti-nuclear antibodies and anti-double-stranded DNA antibodies resulting in the intrarenal immune complex deposition. Levels of anti-double-stranded DNA antibodies reflect disease activity in these patients. With negative anti-double-stranded DNA antibodies, establishing a diagnosis of lupus nephritis is difficult. Lupus nephritis overlapped with anti-neutrophil cytoplasmic antibody-associated vasculitis is both a diagnostic and therapeutic dilemma. Herein, we describe a case of an asymptomatic 41-year-old female who had incidental findings of low hemoglobin and elevated serum creatinine. Making a clinical diagnosis of lupus nephritis and anti-neutrophil cytoplasmic antibody-associated vasculitis in an asymptomatic patient can be challenging and must be made based on the interpretation of evolving serology, imaging studies, and histopathology. Based on extensive workup, the patient was diagnosed with concurrent lupus nephritis and anti-neutrophil cytoplasmic antibody-associated vasculitis overlap syndrome warranting immediate immunosuppressive therapy.

Routine Screening Mammogram Leading to the Incidental Diagnosis of a Metastatic Neuroendocrine Breast Cancer (NEBC) from an Unrecognized Asymptomatic Small Bowel Neuroendocrine Tumor.

Neuroendocrine neoplasms (NENs) are epithelial neoplasms with predominant neuroendocrine differentiation that arise in the gastrointestinal tract, unique to the site of origin, such as the pancreas and small intestine. Neuroendocrine breast carcinoma (NEBC) is a rare tumor. Diagnosing NEBC is challenging because there is no specific clinical presentation, as it is usually presented as a breast lump. Therefore, diagnosing NEBC before biopsy is difficult. Another challenge in diagnosing NEBC is to know whether it is primary or metastatic. We present a case of a 60-year-old woman found to have a solid left breast nodule during routine screening mammography. Tissue biopsy was found to be consistent with metastatic NEBC. The patient was found to have primary small intestine asymptomatic NENs on further diagnostic tests. Eventually, she had a lumpectomy and started on lanreotide (Somatuline) intramuscular monthly injections. As per literature, metastatic NEBC is infrequent. It was considered a poor prognostic breast tumor, as it is usually presented as hormonally negative breast cancer. Management of metastatic versus primary NEBC is still more controversial. Gastroenteropancreatic NENs are treated with long-acting somatostatin analogs with good prognostic results.

Acute Myopericarditis in the Setting of Crohn's Colitis: Challenging Management Decisions.

Myopericarditis is a rare extraintestinal manifestation of Crohn's disease (CD). Myopericarditis has also been attributed to treatment with mesalamine and heart failure to tumor necrosis factor inhibitor (TNFi) use. When a patient with CD, controlled on these medications, presents with myopericarditis and/or heart failure, it can confound both the differential diagnosis and management of such patients. Our case is acute myopericarditis in a 34-year-old male, with a history of CD controlled with mesalamine and infliximab, who had been off TNFi therapy for over six months due to loss of insurance coverage and had been intermittently using leftover mesalamine. He presented to the ED complaining of a one-day history of abdominal pain with bloody diarrheal stools, chest discomfort, and fever. A colonoscopy performed two days back had demonstrated active colonic CD. Findings included ECG evidence of pericarditis, elevated cardiac biomarkers, and reduced left ventricular function on ventriculography consistent with myopericarditis. We present the differential, diagnostic and management challenges encountered in this situation, review the pertinent literature, and discuss decision making in what appears to be myopericarditis attributed to an extraintestinal manifestation of active GI Crohn's.

A Case Report of Anti-phospholipid Syndrome With Lower Extremity Arterial Thrombosis That Didn't Respond to Heparin and Direct Oral Anticoagulation: Ultimately, the Patient Agreed to Oral Warfarin.

In the absence of known thrombophilia or factors associated with thrombotic tendency, clinicians are more likely to think of antiphospholipid syndrome in patients presenting with venous thrombosis than in those with arterial thrombosis. We present a case of acute lower extremity arterial ischemia in a female smoker. Despite multiple surgical interventions and treatment with several different anticoagulants, our patient developed bilateral lower extremity thrombi. Ultimately, after developing a pulmonary embolism, she accepted to be on warfarin. She switched to warfarin without recurrence of her arterial thrombosis. We describe the challenging management of her critical limb ischemia and review the pertinent literature on the controversy surrounding optimal anticoagulation in such patients.

Posterior Reversible Encephalopathy Syndrome Onset Within 24 Hours Following Moderna mRNA Booster COVID-19 Vaccination: Vaccine Adverse Event Vs. Hypertension?

We present a case of a female who presented with the acute onset of neurological changes within 24 hours of receiving her third, or booster, dose of the mRNA Moderna (Cambridge, Massachusetts) coronavirus disease 2019 (COVID-19) vaccination. Her clinicoradiological findings were most consistent with posterior reversible encephalopathy syndrome (PRES). Although PRES has been reported with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this raised suspicion of a possible vaccine-induced PRES with her only confounder being hypertension managed with a beta-blocker. Extensive workup for other entities associated with PRES, including infection, autoimmune, paraneoplastic syndrome, and alcohol were unrevealing. Thus far, there have not been any reports of PRES post mRNA vaccination. We encourage providers to report similar cases with neurological manifestations post mRNA vaccination to the vaccine adverse event reporting system (VAERS). Timely diagnosis and treatment of PRES may help minimize any irreversible neurological sequelae.

Increasing Awareness of Palliative Medicine With the Emergency Department: A Quality Improvement Project.

Palliative medicine can be essential in helping to align patients' goals of care with their treatment team. Referrals for palliative medicine are more advantageous when initiated in the emergency department as this is the first point of contact for seriously ill patients being admitted to the hospital. This paper highlights a quality improvement project initiated to address knowledge gaps in palliative medicine with emergency department (ED) staff and to increase referrals for palliative medicine from the ED. The palliative medicine staff held an in-service training with the ED staff which focused on defining palliative medicine and the importance of early consults when the patient presents in the ED. Palliative medicine staff also highlighted the differences between palliative medicine and hospice care, when and how to initiate a consult for palliative medicine, as well as how to contact the palliative medicine division. The results showed that after this educational intervention the number of palliative medicine consults increased three-fold. Before the educational intervention, monthly averages for palliative medicine were 6 and after rose to 18.9 per month.

The use of the NEJM knowledge + online platform to supplement traditional pulmonary didactic: a resident-led educational quality improvement project at a community hospital IM GME program.

Introduction: Many internal medicine residents struggle to prepare for both the ITE and board test. Most existing resources are simply test question banks that are not linked to existing supporting literature from which they can study. Additionally, program directors are unable to track how much time residents are spending or performing on test preparation. We looked to evaluate the benefit of using this online platform to augment our pulmonary didactics and track time and performance on the pulmonary module and ITE pulmonary section. Method: During the month-long live didactic sessions, residents had free access to the pulmonology NEJM K+ platform. A platform-generated post-test was administered with new questions covering the same key elements, including the level of confidence meta-metric. An anonymous feedback survey was collected to assess the residents' feelings regarding using the NEJM Knowledge+ platform as compared to other prep resources. Results: 44 of 52 residents completed the pre-test. 51/52 completed the month-long didactic sessions and the post-test. Residents' score improvement from % correct pre-test (M = 46.90, SD = 15.31) to % correct post-test (M = 76.29, SD = 18.49) correlated with levels of mastery (t = 9.60, df = 41, p < .001). The % passing improved from 1/44 (2.3%) pre-test to 35/51 (68.6%) post-test, also correlating with levels of mastery. Accurate confidence correlated with improvement from pre to post test score (r = -51, p = .001). Survey feedback was favorable.

Myocarditis Post Moderna Vaccination: Review of Criteria for Diagnosis.

Case reports of myocarditis post-coronavirus disease 2019 (COVID-19) mRNA vaccination have not uniformly reported long-term follow-up beyond 90 days. We present a 23-year-old male who is typical of a patient presenting with myocarditis post-COVID-19 mRNA-1273 Moderna vaccination (young males, onset several days after second dose of the mRNA vaccine, and excellent short term complete recovery). Follow-up at 128 days revealed no residual sequelae in our patient. Although a definitive diagnosis of myocarditis requires an endomyocardial biopsy (EMB), diagnosis is usually made clinically and with imaging in most clinical settings unless part of an approved research protocol or if indicated clinically. We recommend active surveillance and reporting for myocarditis post mRNA vaccination and even consider reporting those with symptom onset beyond 90 days.

Educating Internal Medicine Residents on Palliative Medicine and Hospice Care at a Community Teaching Hospital.

BACKGROUND: The Accreditation Council of Graduate Medical Education (ACGME) currently requires Internal Medicine (IM) GME programs to incorporate educational opportunities for training and structured experiences in Palliative and Hospice Medicine. Miscomprehension of the differences between palliative medicine and hospice care is a barrier for IM residents ordering palliative consults as many residents may underutilize palliative medicine if a patient is not appropriate for hospice. OBJECTIVE: This educational performance improvement (PI) project assessed 3 domains, including Medical Knowledge (MK) of palliative versus hospice medicine at baseline and following a single didactic session. Additionally, the number of palliative consults ordered was used as a surrogate for interpersonal and communication skills (ICS) and patient care (PC) domains. METHODS: An 8-question survey and 30-minute didactic session were created based upon experientially-determined issues most confusing to IM residents. Participants included 33 IM residents (PGY-1s-3 s) from July 2018 (first cohort) and 32 (PGY-1 s and any PGY-2s-3 s who did not participate in the first cohort) from July 2019 (second cohort). RESULTS: 65 of a possible 73 residents participated (89% response rate) Pre-test Questions 5, 6, and 8 correct responses were <50% in both cohorts with average scores, respectively, of 43.1%, 35.4%, and 40%. Residents improved on the post-test for Q5, 6, 8 to, respectively, 80%, 86.7%, and 48.3% (t = 7.68, df = 59, p < 001). Correct Q1 responses declined in the first cohort, but clarification for the second cohort improved from pre-test (36.4%) to post-test (65.5%). The total number of palliative consults placed by IM residents increased as well. CONCLUSIONS: Baseline MK of palliative versus hospice medicine was <50% on 4/8 questions. A brief educational session significantly improved residents' short-term comprehension and increased the number of palliative consults.

The Risk of QTc Prolongation in Non-Diabetic and Diabetic Patients Taking Tyrosine Kinase Inhibitors (TKIs)- A Patient Safety Project at a Private Oncology Practice.

Objective: To assess the prevalence of QTc prolongation in both non-diabetic and diabetic patients on TKIs. Some TKIs have been reported to cause QTc prolongation, which is prevalent in diabetes. However, there is no Risk Evaluation and Mitigation Strategy using series ECG to monitor those patients. Methods: Patients taking TKIs, with two ECGs recorded between 1 January 2010 and 31 December 2017 were selected from the electronic database. The QTc duration >450 ms was determined as prolonged. Percentage of QTc prolongation on participants were compared using Chi-Square test. Results: This study included 313 patients (age 66.1 ± 0.8 years and 57.5% are female) taking TKIs. In non-Diabetic patients, the prevalence of QTc prolongation is 19.1% (n = 253) before and 34.8% (n = 253) after treatment with TKIs (p < 0.001), respectively. In diabetic patients, the prevalence of QTc prolongation is 21.7% (n = 60) before and 40% (n = 60) after treatment with TKIs (p = 0.03), respectively. In addition, we examined the effect of modifying risk factors for cardiovascular disease (CVD) on the prevalence of QTc prolongation caused by TKIs. In non-diabetic patients, the prevalence of QTc prolongation is 33.3% (n = 57) before and 34.2% (n = 196) after risk factors modification (p = 0.91), respectively. In diabetic patients, the prevalence of QTc prolongation is 50% (n = 24) before and 33.3% (n = 36) after risk factors modification (p = 0.20), respectively. Conclusion: Use of TKIs is associated with a significantly increased risk of QTc prolongation for patients, particularly when patients are diabetic. Modification of risk factors for CVD does not significantly affect the prevalence of QTc prolongation caused by TKIs.

Pleural fluid MYD88 L265P mutation supporting diagnosis and decision to treat extramedullary Waldenstrom's macroglobulinemia: a case report.

BACKGROUND: Our case of a patient with untreated lymphoplasmacytic lymphoma/Waldenstrom's macroglobulinemia with extramedullary pleural effusion is the first documented case of pleural fluid MYD88 L265P mutation status in a community hospital setting. Our patient was intolerant to 420 mg ibrutinib, but still achieved a lasting complete remission, as defined by National Comprehensive Cancer Network guidelines, with a dose reduction to 240 mg of ibrutinib. CASE PRESENTATION: A 72-year-old Caucasian (white) man diagnosed with monoclonal immunoglobin M kappa lymphoplasmacytic lymphoma/Waldenstrom's macroglobulinemia monitored without treatment for 2 years, presented with dyspnea and a left pleural effusion. At presentation, computed tomography scans of his chest, abdomen, and pelvis showed layering left pleural effusion and para-aortic lymphadenopathy. Pleural fluid cytology demonstrated B-cell lymphoma of the lymphoplasmacytic subtype, with monoclonal kappa B-cell population on flow and a positive MYD88 L265P mutation. The pleural effusion recurred post-thoracentesis and he achieved a lasting complete remission as defined by National Comprehensive Cancer Network guideline with 240 mg ibrutinib. CONCLUSIONS: Our discussion details a comprehensive literature review of extramedullary pulmonary involvement in Waldenstrom's macroglobulinemia. Establishing a malignant etiology for pleural effusion in Waldenstrom's macroglobulinemia can be challenging, as standard techniques may be insensitive. Allele-specific polymerase chain reaction for detecting MYD88 L265P mutations is more sensitive for confirming lymphoplasmacytic lymphoma/Waldenstrom's macroglobulinemia in pleural fluid. Extramedullary pulmonary involvement usually presents post-diagnosis of Waldenstrom's macroglobulinemia and responds well to Waldenstrom's macroglobulinemia-directed treatment regimens. Allele-specific polymerase chain reaction is a sensitive assay for detecting MYD88 L265P mutations in pleural fluid to support the diagnosis of malignant pleural effusion in the setting of Waldenstrom's macroglobulinemia and helps guide the treatment decision to use ibrutinib. Although intolerant of ibrutinib 420 mg, our patient achieved complete and sustained remission of pleural effusion with a dose of 240 mg with progression free survival of over 30 months.

Coronary Vasospasm-Induced Myocardial Infarction: An Uncommon Presentation of Unrecognized Hyperthyroidism.

Hyperthyroidism can present with cardiac issues, such as tachycardia, atrial fibrillation, and high output congestive heart failure. Rare case reports of coronary vasospasm leading to myocardial infarction (MI) are published. Of these cases, many are known to be hyperthyroid prior to cardiac presentation. We report a female patient with unrecognized thyrotoxicosis who presents with acute MI secondary to coronary vasospasm.

Hypercalcemia in a Patient Diagnosed with a Vasoactive Intestinal Peptide Tumor.

Hypercalcemia is a clinical problem that is commonly seen in both the inpatient and outpatient settings. Overall, most common causes of hypercalcemia include hyperparathyroidism and malignancy. Our case report is the presentation of hypercalcemia in a patient eventually diagnosed with a vasoactive intestinal peptide tumor, a type of neuroendocrine tumor, without associated hyperparathyroidism.