Pasteurella Endocarditis in a Patient with Rheumatic Mitral Valve Disease.

BACKGROUND As a common member of the oral bacterial flora of cats and dogs, Pasteurella multocida can cause skin and soft tissue infection in humans after bites, licks, or scratches from animals. Uncommonly, infection due to Pasteurella can cause sepsis in humans. Even more rare is the development of infectious endocarditis from a Pasteurella infection. CASE REPORT A 76-year-old woman presented with malaise and symptoms of fluid overload. Blood cultures were positive for Pasteurella multocida, and an echocardiogram was significant for mitral valve vegetation and severe biatrial enlargement. A diagnosis of Pasteurella endocarditis was made. Surgical intervention was recommended, but owing to the risk involved, the patient elected for conservative management involving long-term treatment with intravenous antibiotics. CONCLUSIONS While exceedingly rare, Pasteurella multocida can cause infectious endocarditis in patients with predisposing factors. This patient had a known history of rheumatic heart disease, which is believed to have caused the significant findings on imaging. To the best of our knowledge, our case is the only one to depict Pasteurella endocarditis in a patient with rheumatic heart disease and severe biatrial enlargement. It is the authors' belief that the rheumatic heart disease and remodeling of the heart increased her susceptibility to severe infection from Pasteurella. The purpose of this case is to describe the pathogenicity of an otherwise low-attack bacterial infection in an elderly patient with underlying structural acquired heart damage.

Methaemoglobinaemia from Vagisil creme in a 50-year-old woman.

Methaemoglobinaemia is a life-threatening condition that results from increased methaemoglobin production. As methaemoglobin is unable to reversibly bind to oxygen potentially lethal hypoxia and functional anaemia can occur. Benzocaine can be used as a topical anaesthetic and can be found in many nonprescription preparations marketed for self-application. It is known to cause methaemoglobinaemia in rare cases but most reports describe the complication occurring during endoscopy procedures. Methaemoglobinaemia occurring after topical benzocaine use on the perineum of a perimenopausal woman is exceedingly rare. A 50-year-old woman with methaemoglobinaemia secondary to the perineal application of over-the counter Vagisil (benzocaine 20% and resorcinol 3%- an antiseptic and disinfectant, respectively) presented to the emergency department. She had been using Vagisil for severe, chronic vaginal itching. While methaemoglobinaemia secondary to excessive use of over-the-counter medications such as Vagisil creme is exceedingly rare, it should be included in the differential diagnosis.

Acute Hepatitis E: A Rare Cause of Acute Liver Failure in a Patient With Acute Myeloid Leukemia.

Immunocompromised patients are particularly at risk to develop hepatitis E virus (HEV) infection and its related complications. We present a rare case of HEV infection in a 35-year-old Hispanic female with concomitant acute myeloid leukemia (AML). The patient presented with acute liver failure within a few weeks after receiving a blood transfusion. Our case likely represented an acute de novo HEV infection after chemotherapy in a patient with concurrent AML, evidenced by the presence of anti-HEV IgM antibodies as well as histological findings, and with a previous history of recent transfusions being one of the strongest risk factors for transmission. Liver failure from an acute de novo hepatitis E infection with concurrent AML can be catastrophic in the immunosuppressed patient. Our case is particularly unique due to the uncommon presentation of acute hepatitis E in a non-pregnant reproductive aged Hispanic female with recently diagnosed AML. Clinicians should maintain a low threshold to test serum HEV-RNA if a patient presents with signs and symptoms suggestive of acute hepatitis.

Case Report and Literature Review of Insulinoma in the Geriatric Population: An 86-Year-Old Female with Syncope of Unknown Origin.

Insulinomas are extremely rare pancreatic endocrine tumors. The tumor is characterized by endogenous hypersecretion of insulin and ensuing development of symptoms of neuroglycopenia and the catecholaminergic response. Symptoms may not always be present, particularly in patients compensating appropriately with increased appetites and caloric intake due to low glucose levels. Early localization of the disease is essential to prevent lethal hypoglycemia and timely treatment. This case report and literature review depict the case of a pancreatic insulinoma in an 86-year-old female, an exceptionally rare presentation based on age and absence of clinical symptoms for one or more years prior to hospitalization. Despite its rarity, similar presentations have been reported in the literature and are further outlined with characteristics and treatment plans. This case highlights a unique presentation of insulinoma and suggests the need for clinical vigilance and further study. It also discusses diagnosis, localization, and management of this uncommon disease in patients above the age of seventy-five.

Portal vein aneurysm with acute portal vein thrombosis masquerading as a pancreatic mass.

Portal vein aneurysm (PVA) with portal vein thrombosis (PVT) is an exceedingly rare vascular phenomenon with a limited number of reported cases in the medical literature. We describe a case of a 25-year-old man found to have a congenital PVA with PVT initially believed to be a pancreatic mass. While there remains some incongruity amongst clinicians with such a limited number of reported cases, herein, we describe the general consensus of the diagnostic approach and management of this vascular malformation.

Vaping-Induced Lung Injury: A Case of Lipoid Pneumonia Associated with E-Cigarettes Containing Cannabis.

Electronic cigarette, or vaping product use-associated lung injury (EVALI), is a group of lung disorders associated with vaping and e-cigarette products that has previously been categorized as a diagnosis of exclusion and best described as an exogenous lipoid pneumonia or chemical pneumonitis. Here, we describe the onset of an exogenous cause of lipoid pneumonia in an otherwise healthy patient using cannabis-containing electronic cigarettes. We explore similarities in the clinical case, define a common clinical presentation with progression of disease, characteristic radiographic findings along with pathological diagnosis and management.

Thrombocytopenia and endocarditis in a patient with Whipple's disease: case report.

BACKGROUND: Whipple's disease (WD) is a rare multisystem infectious disorder that is caused by the actinomycete Tropheryma whipplei. It presents with joint pain followed by abdominal pain, diarrhea, malabsorption and finally failure to thrive. Diagnosis requires tissue sampling and histology with periodic acid-Schiff [PAS] staining. Thrombocytopenia associated with endocarditis associated with WD has been reported twice. CASE PRESENTATION: A 56 year old Caucasian male presented with years of steroid treated joint pain and recent onset diarrhea, weight loss and abdominal pain. Ultimately he was found to have a platelet count of 4000 with concomitant endocarditis and embolic stroke. Small bowel biopsy confirmed the diagnosis of WD approximately 1 year after his first visit. His platelets improved with antibiotic treatment but he eventually expired 16 months after his initial consult and 5 months after his definitive diagnosis. CONCLUSION: WD can remain undiagnosed and untreated until late in the course of the illness. A high index of suspicion is recognized as necessary for early diagnosis to begin treatment. Critical thrombocytopenia associated with endocarditis is a rare and potentially poor prognostic sign in late stage Whipple's disease.

A Case of Thymic Carcinoma with Bone and Cerebral Metastases Treated with Stereotactic Radiosurgery and Chemotherapy.

BACKGROUND Thymic carcinoma is a rare malignant neoplasm. High-grade thymic carcinoma has a high recurrence rate following surgery, and a low 5-year survival rate. Approximately 30% of patients with thymic carcinoma will be asymptomatic at the time of diagnosis. Extrathoracic metastasis on presentation is uncommon. Treatment of the primary tumor includes surgery, chemotherapy, and fractionated radiation. A rare case of thymic carcinoma that presented with bone and cerebral metastases is reported in a patient who responded well to stereotactic radiosurgery and chemotherapy. CASE REPORT A 63-year-old woman presented to the hospital for evaluation of hip pain. She was diagnosed with a lytic bone lesion of the right femur and brain metastasis. Biopsies from the mediastinal mass and right femur showed histological features consistent with carcinoma. Immunohistochemistry showed positive immunostaining of the tumor cells for the c-kit receptor (CD117) and CD5, supporting a diagnosis of stage IVb thymic carcinoma. Treatment included stereotactic radiosurgery, which delivered multiple radiation beams to the tumor tissue from different directions to target the tumor without affecting normal tissues. She was treated as an outpatient with carboplatin and taxol after stereotactic radiosurgery. The patient recovered well following treatment. CONCLUSIONS A case of thymic carcinoma with bone and cerebral metastases was successfully treated with stereotactic radiosurgery and chemotherapy.

Plummer-Vinson Syndrome and Heart Failure: An Unusual Association in an African American Woman.

BACKGROUND Plummer-Vinson syndrome (PVS) is a rare disorder composed of the triad of dysphagia, iron-deficiency anemia (IDA), and esophageal webs. It is most prevalent in middle-aged white women, and the dysphagia often improves when the anemia is treated. It is well established that chronic hypertension can lead to congestive heart failure (CHF). While IDA is frequently found concomitantly with CHF, there have been no reported cases of new-onset CHF with anemia presenting as PVS. CASE REPORT We present the case of a 48-year-old African American woman with symptomatic anemia and new-onset congestive heart failure secondary to hypertension, who presented with the classic symptoms of PVS. CONCLUSIONS CHF with accompanying IDA may be an independent risk factor for the development of PVS. At the very least, there is an association between CHF-induced IDA and PVS. Patients presenting with CHF with symptoms of dysphagia should be considered at risk for the syndrome, and endoscopy may be warranted. Treatment for PVS includes iron replacement, and in some cases requires mechanical dilation.

Idiopathic Thrombocytopenic Purpura Induced by Synthetic Cannabinoid.

: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder defined as low platelet count with normal bone marrow in the absence of other causes of thrombocytopenia. It is caused by autoantibodies binding to several platelet surface antigens which lead to premature destruction of the platelet by the reticuloendothelial system. ITP can be primary or secondary, and it is known to be associated with various infections and drugs. K2/Spice, or synthetic marijuana, acts on cannabinoid receptors CB1 (cannabinoid type-1) and CB2 (cannabinoid type-2) with increased binding capacity compared to marijuana. A white male was brought to the emergency department with signs of acute drug toxicity. His urine drug test was negative but he admitted to a year long history of synthetic marijuana use. His platelet count was 12,000/mm and he was diagnosed with ITP. After receiving 2 doses of oral dexamethasone his platelets improved. Synthetic cannabinoids are widely available and used psychoactive drugs. Little is known about the complete chemical composition of the synthetic products thus there is relatively little information available on the pharmacodynamic and pharmacokinetic effects. A high index of suspicion is needed to diagnose toxicity to these drugs since there are no readily available on-site lab tests. Currently there exists 1 case report of ITP induced by K2/Spice. Here, we discuss another case of K2/Spice a as a potential cause of immune thrombocytopenia.

Malignant Peritoneal Mesothelioma Presenting as Mucinous Ascites.

We present a rare case of a 46-year-old man presenting with mucinous ascites secondary to malignant peritoneal mesothelioma (MPM) that was diagnosed via colonoscopy with biopsies. Both our findings and the clinical presentation were unique. While it is widely known that asbestos exposure is commonly associated with pleural mesothelioma, 6-10% of malignant mesotheliomas arise from the peritoneum. To date, only 4 cases of MPM with the primary tumor site in the colon have been described in the literature.

Black Esophagus: A Rare Case of Acute Esophageal Necrosis Induced by Diabetic Ketoacidosis in a Young Adult Female.

BACKGROUND: Acute esophageal necrosis is an uncommon clinical disorder diagnosed on endoscopy as a black esophagus. It has a multifactorial etiology that probably represents a combination of poor nutritional status, gastric outlet obstruction, and ischemia secondary to hypoperfusion of the distal esophagus. It typically occurs in older males with comorbidities. CASE: A 37-year-old woman presented with diabetic ketoacidosis and hematemesis. At esophagogastroduodenoscopy acute esophageal necrosis was diagnosed. The treatment included fluid and electrolyte management, insulin, and a proton pump inhibitor. She improved and left the hospital on day 3. CONCLUSION: Diabetic ketoacidosis can result in a profound osmotic diuresis, fluid loss, and hypoperfusion of the distal esophagus. This condition can then lead to ischemic injury and acute esophageal necrosis. Awareness of the possibility of its presence in young women with hematemesis and poorly controlled diabetes is important since early identification with esophagogastroduodenoscopy is necessary to prevent serious postnecrotic complications.