Legionella pneumonia: A Case of Fever Prolonged for 10 Days.

Legionnaires' disease is a potentially severe type of pneumonia most often caused by the organism Legionella pneumophila. Exposure to this bacterial pathogen typically happens in the community but may also occur in the hospital setting. This report describes the case of a patient who presented due to 10 days of fever, shortness of breath, and diarrhea, with initial imaging demonstrating multifocal pneumonia. The patient was appropriately started on empiric antibiotics for community-acquired pneumonia and admitted to the medicine floor. The patient showed no meaningful improvement in his initial hospital course on empiric antibiotics with continued oxygen requirements. Meanwhile, urine Legionella antigen testing returned positive on hospital day four, and after tailoring antibiotics accordingly, the patient's clinical status improved significantly. This case report highlights the efficacy of broad testing in the initial admission and the need for constant re-evaluation in the context of a patient not improving with appropriate therapy.

Previously Untreated Ulcerative Colitis With Newly Diagnosed Primary Sclerosing Cholangitis: A Case Report.

Primary sclerosing cholangitis (PSC) is a rare type of autoimmune hepatic disease with unknown pathophysiology, often a sequela of ulcerative colitis (UC). Liver transplant, though curative, is inaccessible to many patients due to stringent organ availability and barriers to sufficient insurance coverage. Low health literacy and low socioeconomic class can significantly limit healthcare access and thus worsen overall healthcare outcomes. Here, we present the case of an uninsured 49-year-old man with untreated UC who was diagnosed with PSC and subsequently became lost to follow-up. It is critical for providers to identify barriers to acquiring appropriate medical care, such as financial instability and low health literacy, when identifying and treating conditions like PSC. Moreover, more research should be performed to investigate alternative treatments for PSC.

Carcinoid Tumor Presenting as Hemoptysis and Elevated Diaphragm.

A bronchial carcinoid tumor is a rare pulmonary neuroendocrine tumor. This report describes a case where a patient experienced multiple episodes of hemoptysis and dyspnea on exertion over the course of five months. An initial chest X-ray showed an elevated right hemidiaphragm with atelectasis, and a follow-up chest computed tomography (CT) scan was ordered to further assess this finding. The CT revealed a tumor occluding 90% of the right main stem bronchus lumen. A bronchoscopy with biopsy was then performed, confirming the diagnosis of a pulmonary carcinoid tumor. The patient underwent surgical resection of the tumor, a right upper lobe sleeve lobectomy, and a mediastinal lymph node dissection, resulting in full eradication of the tumor. This case highlights the need for physicians to maintain a broad differential when evaluating a patient with hemoptysis and an elevated diaphragm.

Bartonella Neuroretinitis: There Is More to Cat Scratch Disease than Meets the Eye.

BACKGROUND Cat scratch disease (CSD) is a self-limited infection caused by Bartonella henselae that causes lymphadenitis, fevers, skin changes at the inoculation site, headache, nausea, and ocular symptoms. Bartonella neuroretinitis is a form of CSD that presents with ocular symptoms, such as a central scotoma, rather than the typical lymphadenopathy of CSD. Bartonella neuroretinitis is the most common cause of infectious neuroretinitis leading to painless vision loss. Symptoms can mimic the more common optic neuritis, which can lead to under-diagnosis. Early diagnosis of Bartonella neuroretinitis and initiation of appropriate treatment is crucial to prevent vision loss and shorten recovery time. CASE REPORT A 47-year-old man presented to the Emergency Department with nonspecific symptoms of headache, fevers, and visual changes. He was noted to have adopted a cat 2 months prior to presentation. A dilated fundus examination revealed grade 3 optic disc edema with small disc hemorrhages bilaterally without lymphadenopathy, and Bartonella henselae serologies returned positive for the disease. The patient was treated with doxycycline and rifampin at discharge. At his follow-up outpatient ophthalmology visit, the patient had symptomatically improved vision, with dilated fundus examination supporting reduced optic disc edema in the right eye. CONCLUSIONS Early recognition and treatment of Bartonella neuroretinitis is essential to prevent vision loss and shorten recovery time. The current standard of treatment is doxycycline and rifampin for 4 to 6 weeks, and a growing body of literature indicates the supplementation of corticosteroids with these antibiotics.

Suprasellar Plasmacytoma Leading to the Diagnosis of Multiple Myeloma.

Plasmacytomas are a collection of plasma cells that occur as a solitary lesion or in conjunction with multiple myeloma. Intracranial location is uncommon but should be considered as management differs. Plasmacytomas in the suprasellar region are rare but should be considered in the differential diagnosis of suprasellar masses. Clinical presentation and imaging findings have similarities and overlap between pituitary adenomas and plasmacytomas, so the diagnosis depends on biopsy and pathological evaluation. Immunohistological staining is often necessary due to structural similarities to adenomas. Isolated cases may be treated with radiation alone and surgery is reserved for symptoms due to mass effect. Systemic therapy is given if there is evidence of multiple myeloma. In this case report, we present a 52-year-old male who presented with worsening blurry vision associated with headaches and epistaxis of four months duration. CT of the head showed a large mass involving the sella and skull base. Labs showed normal calcium, creatinine, and intact pituitary function. Biopsy of the mass was initially diagnosed as a pituitary adenoma but repeat pathology revealed plasmacytoma. Body imaging revealed diffuse lytic lesions. Bone marrow biopsy and serum electrophoresis were consistent with a diagnosis of multiple myeloma. The patient underwent radiation therapy to the suprasellar mass followed by systemic therapy for multiple myeloma with bortezomib, lenalidomide, and dexamethasone. The patient achieved a very good partial response.

His last breath.

Dying alone in a hospital bed is not what I envision when I think about my own death. As a third-year medical student, I have the honor of serving as leader for No One Dies Alone at my medical institution. I want to share my story to inspire others to participate in vigils with one who is dying or to assist in the efforts to contact family.

Native and Prosthetic Valve Staphylococcus capitis Endocarditis: A Review of the Literature.

Infective endocarditis (IE) is a rare but serious disease. Coagulase-negative staphylococci (CoNS) are among the least prevalent causes of IE. Staphylococcus capitis, a species of CoNS, although described in the literature before has only been seen in a few cases. Even with such few cases, complications and mortality have still been demonstrated. In our review, we look at the epidemiology, diagnosis, management, and literature prevalence of CoNS in native and prosthetic valve IE.

Immune Thrombocytopenic Purpura in a Patient With SARS-CoV-2 and Epstein-Barr Virus.

A 35-year-old female was admitted to the hospital for menorrhagia and fatigue. Initial labs revealed that the patient had severe thrombocytopenia and also tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main objective in this case is to describe the investigation that eventually led to a diagnosis of idiopathic thrombocytopenic purpura (ITP) in the setting of a SARS-CoV-2 coronavirus disease 2019 (COVID-19) infection and co-infection with Epstein-Barr virus (EBV). The majority of ITP cases are idiopathic and most are diagnosed and managed without hospital admission. Admission and careful management were warranted in this particular case. Interestingly, however, the patient did not have any respiratory complications associated with COVID-19. She was given 1 unit of platelets and subsequently received intravenous corticosteroids. Platelet counts improved and the patient was discharged with a course of oral prednisone. This case highlights the importance of understanding the differences between primary and secondary ITP.

Murine Typhus: A Life-Threatening Presentation of a Case in Galveston, Texas.

BACKGROUND Murine typhus is a rare bacterial infection caused by Rickettsia typhi, which is transmitted from rodents to humans through the infected Xenopsylla cheopis flea. The disease presentation is often non-specific, leading to unnecessary tests, and a delay in diagnosis and treatment. CASE REPORT A report is presented of a 22-year-old, previously healthy man, who presented with several symptoms and signs that increased in severity, requiring admission to the medical intensive care unit (MICU). After an extensive bacterial and viral laboratory workup, IgM and IgG titers confirmed the diagnosis of murine typhus due to infection by Rickettsia typhi. The patient was treated with doxycycline, which resulted in significant clinical improvement. CONCLUSIONS Murine typhus can present with a characteristic triad of fever, headache, and rash but also with other symptoms and signs and can vary in severity. Given its increasing prevalence in coastal cities, awareness of this infection and early diagnosis and treatment with doxycycline can reduce patient morbidity.

Concurrent Nontuberculous Mycobacteria Infection and High-Grade Anterior Mediastinal Extraskeletal Osteosarcoma (ESOS): Is There a Connection?

BACKGROUND Extraskeletal osteosarcomas (ESOS) of the mediastinum are extremely rare and may present with concurrent nontuberculous mycobacteria infection. CASE REPORT We present the second documented case of high-grade anterior mediastinal extraskeletal osteosarcoma in a 59-year-old man with a history of treated, latent tuberculosis (TB). Sputum samples grew Mycoplasma avium complex and Mycobacterium fortuitum. Imaging showed a right-sided 7.6 cm mass with compression of the main bronchus. Subsequent biopsy with vimentin staining established the diagnosis of ESOS. Due to the patient's rapidly declining performance status, he was not deemed a candidate for surgery or chemotherapy. He subsequently expired within one month of presentation. CONCLUSIONS We present a unique case of high-grade anterior mediastinum ESOS and a review of the literature regarding all documented cases of ESOS to date. We suggest there is a possible link between mediastinal masses and nontuberculous mycobacteria infection.

A fractured inferior vena cava filter strut migrating to the left pulmonary artery.

Inferior vena cava filters are increasingly used in patients with recurrent venous thromboembolism who are contraindicated to anticoagulation. Migration of a broken strut to the pulmonary artery is a very rare complication of these filters. We report the case of an 83-year-old female who experienced this complication with the migratory strut remaining in the same position for years. This case provides evidence that such filters probably have higher rates of complications than what has been thought that remain asymptomatic. The indications and the management of complications of such devices need to be studied further.

Multiple cutaneous nodules presenting as metastatic squamous cell carcinoma of the esophagus.

A 62-year-old man with weight loss and dysphagia developed 3 cutaneous nodules. Fine needle aspirate of one of the nodules identified squamous cell carcinoma, which was found to be a metastasis from esophageal cancer.

Paradoxical Immune Reconstitution Syndrome Presenting as Acute Respiratory Distress Syndrome in a Leukemia Patient during Neutrophil Recovery.

Immune reconstitution inflammatory syndrome (IRIS) in the setting of antiretroviral therapy is well described, but it is not as common in non-HIV patients; here, we present a case of immune reconstitution inflammatory syndrome presenting as acute respiratory distress syndrome in a leukemia patient who had neutropenic fever and septic shock after high-dose cytarabine. During neutropenia recovery, his chest X-ray showed progressive worsening despite being on adequate therapy, we started him on steroids which resulted in significant clinical improvement.

Next steps when BP won't come down.

A poor response to therapy should trigger a search for a secondary cause of hypertension. Use this review as your guide.

A Rare Case of Kikuchi Fujimoto's Disease with Subsequent Development of Systemic Lupus Erythematosus.

Kikuchi Fujimoto's disease (KFD) is a rare, immune-mediated, self-limiting disorder with unique histopathological features. KFD is usually seen in young Asian females; however, cases have been reported throughout the world and in all ethnicities. It has been recognized that there is a rare association between Systemic Lupus Erythematosus (SLE) and KFD via sporadic case reports. The exact pathophysiological relationship between these two diseases is still unclear. We report a case of a young Asian female who presented with persistent fever and lymphadenopathy and was diagnosed with Kikuchi Fujimoto's disease based on lymph node biopsy; although an SLE workup was done, she did not meet the American Rheumatology Association (ARA) diagnostic criteria for lupus, and the lymph node biopsy did not show features of SLE. She improved clinically with a short course of steroid therapy. Two months later, the patient presented with central facial rash and arthralgia. SLE workup was repeated, a skin biopsy was done, and the results at this time supported a diagnosis of SLE.