Outbreak of Foodborne Botulism in an Immigrant Community: Overcoming Delayed Disease Recognition, Ambiguous Epidemiologic Links, and Cultural Barriers to Identify the Cause.

We describe a botulism outbreak involving 4 Middle Eastern men complicated by delayed diagnosis, ambiguous epidemiologic links among patients, and illness onset dates inconsistent with a point-source exposure. Homemade turshi, a fermented vegetable dish, was the likely cause. Patients ate turshi at 2 locations on different days over 1 month.

Gabapentin-induced delusions of parasitosis.

Delusions of parasitosis are a rare psychiatric disorder in which the patient has a fixed, false belief of being infested with parasites. The disorder is classified as primary if no cause is identified or secondary if associated with general organic conditions, psychiatric illnesses, and drugs (substance induced). Several medications have been reported in association with delusions of parasitosis, including anti-parkinsonian medications, ciprofloxacin, cetirizine, doxepin, and others. Delusions of parasitosis have not been previously reported to be associated with gabapentin use. We present the case of a patient who developed delusions of parasitosis after been initiated on gabapentin treatment for neuropathic pain and complete disappearance of symptoms after the medication was discontinued.

A wayward cyst.

CONTEXT: Pseudocysts are a common complication of acute and chronic pancreatitis. These are usually located within the pancreas but they can occur at other sites as well, including the mediastinum, neck, pelvis and rarely in the liver as in our case. The diagnosis of intrahepatic pancreatic pseudocyst relies on the demonstration of a high amylase level in the sampled cystic fluid in the absence of infection or neoplasm. CASE REPORT: A 60-year-old man with a history of chronic pancreatitis presents with a clinical and laboratory picture suggestive of acute exacerbation of his pancreatitis. A computed tomogram (CT) scan of the abdomen revealed a pancreatic pseudocyst and a cystic lesion involving both lobes of the liver. CT diagnostic aspiration of the intrahepatic cyst revealed high amylase level (greater than 20,000 U/L). The cyst was treated with percutaneous drainage with complete resolution of the cyst. CONCLUSION: In the setting of pancreatitis, intrahepatic pancreatic pseudocyst should be considered in the differential diagnosis of cystic lesion of the liver.

A bone to pick about chest pain.

Chest pain is an extremely common presenting symptom that is usually related to a cardiac cause. This case illustrates an unusual presentation of multiple myeloma as a cause of atypical chest pain. This case presentation shows the importance of having a broad differential diagnosis while evaluating patients with atypical chest pain. It also illustrates the potential role of Tc-99m sestamibi imaging as a diagnostic modality in patients with multiple myeloma.

Patient experiences with MedlinePlus.gov: a survey of internal medicine patients.

BACKGROUND: In 2004, the American College of Physicians joined with the National Library of Medicine in an effort to help patients find reliable health information free of commercial bias as the Web site MedlinePlus.gov. The aim of this study was to evaluate the usefulness of the MedlinePlus.gov site as perceived by patients who were referred to the site by their internist. MATERIALS AND METHODS: A 27-item questionnaire developed by the American College of Physicians Foundation was distributed between january and May 2005 to a convenience sample of 893 adult patient volunteers attending 34 internal medicine practices across the United States. RESULTS: The questionnaire revealed that although most patients (55%) routinely look up medical information, only 43% had used MedlinePlus.gov. Of those who had used the site, 95% were satisfied with the information they found there, and 94% said the information they found at MedlinePlus.gov would help them make better health decisions. DISCUSSION: Patients who used the MedlinePlus.gov site at the recommendation of their physician found it to use, informative, and felt it would help them make better health decisions. Directing patients to this high quality, noncommercial, educational resource online may be an important adjunct to patient education efforts by physicians.

Review of acute coronary syndrome diagnosis and management.

Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted. High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.

Cyanosis following transesophageal echocardiogram.

Topical anesthesia is routinely employed to facilitate diagnostic and therapeutic procedures that involve the oropharynx. Although this practice is usually safe, there is always the potential that methemoglobinemia might be induced by the topical anesthetic agent. The clinician should consider this possible complication when the patient experiences signs or symptoms of oxygen desaturation in the absence of another explanation. Because methemoglobinemia can be life-threatening, early recognition and treatment are extremely important.

'Bleeding Dilemma': The Story of a Periampullary Mass.

Periampullary malignancies arise in the vicinity of the ampulla of Vater, a common passage for biliary and pancreatic secretions. Determining the anatomical origin of these tumors represents a diagnostic challenge. This is especially true for large tumors due to the transitional nature of this region, proximity to different structures, anatomical variations, and overlapping features among constituting structures. This determination has significant prognostic and therapeutic implications. Among them, primary ampullary adenocarcinoma is a rare malignancy that has the best overall prognosis with high rates of potentially curative resection and possible survival even in advanced disease. Due to its rarity, it is also a vague territory with no definitive guidelines regarding management and surveillance currently available. Acute gastrointestinal hemorrhage is a rare presentation of ampullary carcinoma that occurs secondary to tumor ulceration. We report an elderly male with a previously known large, initially asymptomatic periampullary mass who came for evaluation of melena and was noted to be hypotensive secondary to acute blood loss from the large tumor, later determined to be adenocarcinoma of the ampulla of Vater.

When a good call leads to a bad connection: colovesical fistula in colorectal cancer treated with bevacizumab.

INTRODUCTION: Colorectal cancer is the third most common cancer in the United States. The use of bevacizumab (Avastin), a vascular endothelial growth factor (VEGF) inhibitor, has been increasing due to observed improvement in metastatic colon cancer survival, but so has the incidence of bowel perforation. We present one unusual complication of bowel perforation, a colovesical fistula in a colorectal cancer patient treated with bevacizumab. CASE PRESENTATION: A 54-year-old white male diagnosed with Stage IV colorectal cancer was treated with folinic acid, leucovorin, fluorouracil, oxaliplatin (FOLFOX) and bevacizumab. Two months later, he developed pneumaturia and fecaluria. CT showed a rectosigmoid colovesical fistula. A laparoscopic diverting colostomy was created to overcome the proximal retention of feces and the fecaluria. DISCUSSION: Colovesical fistulas more commonly result from diverticulitis, cancer, or Crohn's, but rarely can arise from radiation or chemotherapy. Our patient had two risk factors, colorectal carcinoma and bevacizumab use. Although colon cancer itself can cause a colovesical fistula, at the time of diagnosis, our patient had an intact fat pad between the colon and bladder on CT and did not have symptoms consistent with a fistula, suggesting that bevacizumab was the culprit. The exact mechanism of action leading to bowel perforation is not completely understood. Three theories include first, the idea that bevacizumab increases the risk of thrombosis, second, that tumor destruction creates an area of weakness more prone to perforation, or third, it slows down wound healing, causing leakage at the anastomotic site following surgery. CONCLUSION: Hospitalists encounter patients with colorectal cancer on a regular basis, so clinicians must be aware of the uncommon but potentially serious side effect of bowel perforation when bevacizumab is used. This case has illustrated an even more rare complication, the formation of a colovesical fistula that was treated with laparoscopic surgical intervention with a diverting colostomy.

Canagliflozin-Induced Diabetic Ketoacidosis: Case Report and Review of the Literature.

INTRODUCTION: Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are relatively new antihyperglycemic agents that lower renal glucose reabsorption. They are used as adjunctive therapy to standard diabetes treatment. CASE REPORT: We present the case of a 62-year-old woman with a past medical history of type 2 diabetes mellitus and sudden-onset diabetic ketoacidosis (DKA). Use of canagliflozin, a SGLT-2 inhibitor, was determined to be the cause of the DKA. The patient ultimately recovered after 5 days in the intensive care unit. She was changed to long- and short-acting insulins and instructed to avoid canagliflozin. CONCLUSION: Although SGLT-2 inhibitors are effective at lowering a patient's hemoglobin A1C, physicians must be aware of the rare but dangerous potential adverse effect of inducing DKA. This article reports an illustrative case and presents a review of the literature.

Visiting professorship in hospital medicine: An innovative twist for a growing specialty.

INTRODUCTION: As an emerging and rapidly growing specialty, academic hospitalists face unique challenges in career advancement. Key mentoring needs, especially developing reputation and relationships outside of their institution are often challenging. METHODS: We describe the structure of a novel Visiting Professorship in Hospital Medicine Program. It utilizes reciprocal exchanges of hospitalist faculty at the rank of late assistant to early associate professor. The program is designed explicitly to facilitate spread of innovation between institutions through a presentation by the visiting professor and exposure to an innovation at the host hospital medicine group. It provides a platform to advance the career success of both early- and midcareer hospitalist faculty through 1-on-1 coaching sessions between the visiting professor and early-career faculty at the host institution and commitment by visiting professors to engage in mentoring after the visit. RESULTS: Five academic hospitalist groups participated. Seven visiting professors met with 29 early-career faculty. Experience following faculty exchange visits demonstrates program effectiveness, as perceived by both early-career faculty and the visiting professors, in advancing the goals of mentorship and career advancement. One-year follow-up suggests that 62% of early-career faculty will engage in subsequent interactions with the visiting professor, and half report spread of innovation between academic hospital medicine groups. CONCLUSIONS: The Visiting Professorship in Hospital Medicine offers a low-cost framework to promote collaboration between academic hospital medicine groups and facilitate interinstitutional hospitalist mentoring. It is reported to be effective for the goal of professional development for midcareer hospitalists. Journal of Hospital Medicine 2016;11:714-718. © 2016 Society of Hospital Medicine.

Diabetic ketoacidosis as first presentation of latent autoimmune diabetes in adult.

A 54-year-old white female with hypothyroidism presented with abdominal pain, nausea, vomiting, and diarrhea. She was found to have diabetic ketoacidosis (DKA) and admitted to our hospital for treatment. Laboratory workup revealed positive antiglutamic acid decarboxylase antibodies and subsequently she was diagnosed with latent onset autoimmune diabetes in adult (LADA). She was successfully treated with insulin with clinical and laboratory improvement. Diagnosis of LADA has been based on three criteria as given by The Immunology of Diabetes Society: (1) adult age of onset (>30 years of age); (2) presence of at least one circulating autoantibody (GADA/ICA/IAA/IA-2); and (3) initial insulin independence for the first six months. The importance of this case is the unlikely presentation of LADA. We believe that more research is needed to determine the exact proportion of LADA patients who first present with DKA, since similar cases have only been seen in case reports. Adult patients who are obese and have high blood sugar may deserve screening for LADA, especially in the presence of other autoimmune diseases. Those patients once diagnosed with LADA need extensive diabetic education including potentially serious events such as diabetic ketoacidosis.

Review and practice guidelines for celiac disease in 2014.

Celiac disease, or gluten-sensitive enteropathy, is defined as a state of heightened immunologic responsiveness to ingested gluten (from wheat, barley, or rye) in genetically susceptible individuals. Ingestion of the offending proteins leads to inflammation and intestinal mucosal damage, which may result in a spectrum of gastrointestinal symptoms, nutritional abnormalities, and systemic complications ranging from anemia and osteoporosis to secondary autoimmunity and malignancy. The genetic influence in the pathogenesis of celiac disease is indicated by its familial occurrence. Celiac disease does not develop unless a person has alleles that encode for human leukocyte antigen DQ2 or DQ8 proteins. The clinical picture of celiac disease has changed considerably during the past 30 years. Diarrhea, which was the presenting symptom in > 90% of celiac disease patients before 1981, is now the chief complaint in < 40%. In contrast, the increased frequency of atypical celiac disease presentations, including anemia and bone disease, is revealed by the widespread availability of serologic testing. An association between celiac disease and autoimmune disorders, such as type 1 diabetes, autoimmune thyroid disease, and Sjögren's syndrome, has been well documented. The tissue transglutaminase immunoglobulin antibody and the endomysial immunoglobulin antibody are the most sensitive and specific serologic tests, respectively, for identifying individuals who need to undergo an intestinal biopsy. If the suspicion of celiac disease is high, intestinal biopsy should be pursued even if serologic tests are negative. The gold standard for the diagnosis of celiac disease is a small bowel biopsy showing villous atrophy. The treatment for celiac disease is lifelong adherence to a gluten-free diet (GFD). Despite the proven benefits of the GFD, it can be exceedingly difficult to completely avoid gluten-containing foods, and adherence to a GFD is estimated to be only 45% to 80%.

Cardiovascular Complications of HIV-Associated Immune Dysfunction.

Prolonged survival in HIV infection is accompanied by an increased frequency of non-HIV-related comorbidities. It is suggested that cardiovascular diseases (CVD) occur earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed which can be categorized into traditional and nontraditional risk factors. Immune dysfunction is a nontraditional risk factor that contributes significantly to cardiovascular pathology. Markers of inflammation are elevated in HIV-infected patients, and elevations in markers such as high-sensitivity C-reactive protein, D-dimer, and interleukin-6 (IL-6) have been associated with increased risk for cardiovascular disease. However, the data currently suggest the most practical advice is to start antiretroviral therapy early and to manage traditional risk factors for CVD aggressively. A better understanding of the mechanisms of CVD in this population and further efforts to modify chronic inflammation remain an important research area.

Ebola virus disease: The use of fluorescents as markers of contamination for personal protective equipment.

The recent Ebola virus disease (EVD) outbreak has created interest in personal protective equipment (PPE) content and usage. PPE testing has historically been done by individual component, rather than as a bundle for contact isolation. Fluorescent agents are commonly used in training for infection control techniques. The purpose of our study was to compare 2 PPE bundles and to evaluate the feasibility of fluorescent markers as an assessment tool for PPE effectiveness. Eight healthcare providers volunteered for this preliminary study. Participants were randomized to 1 of 2 PPE bundles that meet current (October 20, 2014) CDC recommendations. One PPE bundle utilized commercial EVD-recommended components. The other PPE bundle used components already available at local hospitals or retail stores. Participants were also randomized to standard or high volume exposures (HVE) to simulate fluid splash. Each participant was assisted in PPE donning and doffing by an experienced trainer. A training mannequin was contaminated with fluorescent agents to simulate bodily fluids. Participants were then given clinical tasks to care for the EVD "patient." De-gowned participants were examined under "black light" for fluorescence indicative of contamination. One participant in each PPE arm had evidence of contamination. One of the contamination events was suspected during the patient care exercise. The other contamination event was not suspected until black light examination. In spite of a large difference in cost of PPE, the two bundle arms performed similarly. Bundle testing using fluorescent markers could help identify optimal PPE systems.

Extramedullary plasmacytoma mimicking colon carcinoma: an unusual presentation and review of the literature.

A 72-year-old woman presented to outpatient clinic with fatigue, light-headedness, dyspnoea and dark stool suggestive of lower gastrointestinal bleeding. She was previously diagnosed with multiple myeloma and completed 9 cycles of chemotherapy with bortezomib, lenalidomide and dexamethasone. She had very good partial response. A CT scan of the abdomen revealed a 9 cm mass at the hepatic flexure of the large intestine with an apple core deformity causing a marked narrowing of the lumen. Colonoscopy confirmed a large, nearly obstructing ulcerative mass in the distal right colon. The patient underwent a right hemicolectomy, distal ileal resection and lymph node dissection. Histopathology confirmed the mass as a plasmacytoma. Postoperatively, the patient was started with bortezomib and liposomal doxorubicin followed by carfilzomib. She showed excellent response to the chemotherapy.