Proton-Pump inhibitors related acute interstitial nephritis. A case report

Background: Acute Interstitial nephritis is a common and reversible cause of Acute Kidney Injury, accounting for 15-27% of renal biopsies performed because of this condition. Its incidence has been increasing worldwide. By and large, drug-induced AIN is currently the most common etiology, with antimicrobials and nonsteroidal anti-inflammatory drugs being the most frequent offending agents. The hallmark pathologic features are interstitial edema, interstitial inflammation, and tubulitis with a predominance of CD4+ T lymphocytes and mononuclear cells, with variable numbers of eosinophils. Patients with AIN typically present with nonspecific symptoms of acute renal failure, including oliguria, malaise, anorexia, nausea, and vomiting and a high-suspicious index is necessary. A case is described of a 29-year-old Hispanic obese and diabetic female, who developed AIN after an average period of 2 years of omeprazole. The symptoms were mostly fatigue and anorexia. She had non-nephrotic range proteinuria with pyuria with a mean serum creatinine of 4.72 mg/dl. Eosinophils in urine were normal. Patient also tested positive for ANA, and initially lupus nephritis was in the differentials along with Focal segemental glomerulo-sclerosis due to obestiry. Renal biopsy showed severe interstitial inflammation with lymphoid cells, scattered neutrophils, and very rate eosinophils, ruling out FSGS and lupus nephritis. Omeprazole was discontinued, and Prednisone 60 mg daily were started. Renal recovery was total in 6 weeks post-steroid therapy. Steroids were tapered as the kidney function improved. Conclusion: Prompt recognition, elimination of the offending source of antigen and use of a limited course of steroid therapy are the mainstay of the treatment. This will result in complete resolution in ~ 65% of cases, partial resolution in up to 20%, and irreversible damage in the rest. Recent studies strongly suggest that early steroid administration (within 7 days after diagnosis) improves the recovery of renal function, decreasing the risk of chronic renal impairment

A Rare Cause of Lymphadenopathy in a Young Hispanic Female: Unmasking Recurrent Nodal Rosai-Dorfman Disease

Rosai-Dorfman disease (RDD) is a rare histiocytic disorder that can present with painless bilateral symmetrical cervical lymphadenopathy, mimicking lymphomas. RDD is characterized by excessive tissue infiltration by dendritic cells, macrophages, or monocyte-derived cells, with a histopathologic diagnosis based on the presence of CD68+, CD163+, and S100+ histiocytes, which differentiate it from other histiocytic neoplasms. In this case report, we present a young Hispanic female with recurrent subcutaneous growths and lymphadenopathy, initially thought to be lymphoma, who was diagnosed with RDD after a significant diagnostic workup. Treatment initially consisted of surgical excision; however, due to recurrence, the patient was successfully treated with corticosteroids and a steroid-sparing agent, 6-mercaptopurine, with significant improvement in symptoms. RDD should be considered a differential diagnosis for patients with cervical lymphadenopathy, and an interdisciplinary approach is essential to managing this rare disorder effectively. The report highlights the need for an interdisciplinary approach to managing this rare disorder effectively and underscores the importance of multimodal treatment in disease suppression. As a rare disease with slow advancement of defined guidelines for diagnostic and treatment strategies, this case report adds to the existing literature on RDD

A Moyamoya Case Report On A Patient With Slurred Speech And Right-hand Weakness

Background: Moyamoya angiopathy (MMA) is a cerebrovascular disease affecting about one in a million people. It is characterized by progressive stenosis of the terminal portion of the internal carotid arteries leading to cerebral hypo-perfusion which in turn induces neo-angiogenesis in the deep parts of the brain. Patients are predisposed to ischemic and hemorrhagic strokes. Diagnosis is usually made with magnetic resonance imaging (MRI) and a magnetic resonance angiogram (MRA) to evaluate the brain and its blood vessels. Symptomatic patients should undergo surgical interventions. A few studies have shown that the superficial temporal artery to middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis (EDMS) can achieve a good therapeutic effect in the treatment of Moyamoya disease. Case Presentation: A 39-year-old right-handed lady with a history of chronic headaches, a lacunar infarct of the left basal ganglia, and recently diagnosed with Moyamoya disease presented to the ED due to slurred speech and right-hand weakness. On neurological evaluation, the patient was alert and oriented with a flat affect. Her cranial nerves were grossly intact, and sensory functions were preserved. She only had mild fine motor coordination deficits. Imaging showed no acute changes. The patient was already on maximum medical management with dual antiplatelet therapy and had an unsuccessful endovascular revascularization. Plastic surgery and Neurosurgery were consulted, and she underwent a left frontoparietal craniotomy for superficial temporal artery to middle cerebral artery bypass with concurrent EDMS. A post-surgical angiogram evaluating the carotid artery bypass showed good blood flow. A CT scan without contrast showed surgical changes from recent parietal craniotomy with a small amount of pneumocephalus on the left and minimal hemorrhage in the subdural space which was expected post-surgery. There was no evidence of mass-effect, midline shift, or parenchymal hemorrhage. The patient was stable and discharged to inpatient rehabilitation. Conclusion: Our patient showed how a joint bypass procedure and EDMS provided efficient revascularization and helped achieve a good therapeutic effect with very few complications. Moyamoya is a rare disease with small evidence published on effective treatments. This case highlights the surgical treatment protocol for Moyamoya disease as an effective way to improve the short- and long-term outcomes

A Whole CLOTTA Pain: A Case of IVC Thrombosis Presenting as Severe Abdominal Pain in a Patient with Anti-Phospholipid Syndrome

Background: Anti-phospholipid syndrome (APS) is an immune-mediated condition characterized by the presence of antiphospholipid antibodies in the setting of venous and arterial thrombosis and or pregnancy loss [1]. APS can be a primary syndrome or can be associated with connective tissue diseases such as systemic lupus erythematosus. The goal of treatment in patients with APS is to decrease the risk of thromboembolic events and the standard of care is warfarin therapy. We describe a case of a 42-year-old gentleman with a history of APS on anticoagulation with apixaban who presented to the hospital with severe abdominal pain secondary to infrarenal IVC thrombosis. This case highlights the importance of appropriate anticoagulation in patients with APS. Case Presentation: A 42-year-old man with a past medical history of APS presented to the hospital with a 7-day history of bilateral, dull, non-radiating, generalized abdominal pain. He denied any associated diarrhea, constipation, changes in urination, fever, nausea, or vomiting. Physical examination was notable for tachycardia with HR 110s, BP 150/100 mmHg, and a distended, tender abdomen with visible abdominal varicosities. Labs revealed a WBC 20,000 th/uL, creatinine of 2.0 mg/dL, AST 15 IU/L, ALT 20 IU/L, alkaline phosphatase 101gm/dL, INR of 1.12, and a PTT of 62.2 secs. CT abdomen and pelvis without contrast showed severe narrowing and occlusion of the infrarenal inferior vena cava over a length of 6-7 cm with dilated tortuous varices. Liver US demonstrated normal-appearing flow in hepatic veins and the intrahepatic IVC. The patient was evaluated by surgery however recommendations were made to treat the patient medically with a heparin drip with a bridge to warfarin. Discussion: Anticoagulation therapy in patients with APS is important as these patients can develop severe, life-threatening thrombotic events. Warfarin therapy is superior to direct oral anticoagulant (doac) therapy in preventing thrombotic events in these patients. Given the episode of thrombosis on doac therapy, our patient will be on lifelong warfarin therapy with an INR goal of 3.5. He has not had a recurrence of thrombotic events

At the Heart of the Diagnosis: A Case of Systemic Lupus Erythematosus Presenting as Cardiac Tamponade

Systemic lupus erythematosus (SLE) is a heterogenous, systemic disease characterized by the production of pathogenic autoantibodies against nuclear antigens. Although the most common cardiac manifestation of SLE is pericardial effusions, their progression to cardiac tamponade is rare and has an incidence between 1-3%. We describe a case of a 42-year-old Hispanic woman who presented with severe shortness of breath, vague chest pain, and hemodynamic compromise secondary to cardiac tamponade. The patient\u27s underlying etiology of cardiac tamponade was attributed to a new diagnosis of SLE based on the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification (EULAR/ACR) criteria for SLE. The patient\u27s treatment consisted of a pericardial window and immunosuppressive therapy with corticosteroids, Mycophenolate, and hydroxychloroquine. This case aims to increase awareness of SLE as a possible differential diagnosis of cardiac tamponade in the appropriate clinical setting

A Case of Hemorrhagic Myositis Associated With Prophylactic Heparin Use in Dermatomyositis

Dermatomyositis (DM) is a rare systemic autoimmune disease that is associated with inflammation of the skin and muscles. It typically presents with weakness of the proximal muscles along with characteristic skin lesions such as Gottron\u27s papules and heliotrope rash. One of the most feared complications of this disease is the appearance of spontaneous hemorrhagic myositis, as most reported cases are fatal. The mechanism or risk factors of this condition have not been elucidated; however, prophylactic anticoagulation has been correlated with it in previous case reports, although idiopathic hemorrhagic myositis may also be present. We present a case of spontaneous intramuscular hemorrhage (SIH) in a recently diagnosed DM patient. A 59-year-old Hispanic male with a medical history of recently diagnosed prostate cancer and DM presented to the emergency department (ED) due to worsening anemia. His previous hemoglobin (Hgb) was 9 g/dl, but repeated laboratory tests revealed a level of 6.5 g/dl and later 5.5 g/dl at the ED. On admission, the patient was afebrile, tachycardic, and normotensive, with no overt sign of gastrointestinal bleeding. The physical exam revealed an ecchymosis on the right medial aspect of the thigh, and a digital rectal exam was negative. Computer tomography (CT) of the abdomen and pelvis without contrast was ordered due to suspicion of a retroperitoneal hematoma, revealing an interval development of a right groin complex fluid collection of up to 6 cm, concerning a possible hematoma. The patient did not have any previous vascular procedures in the area but was exposed to deep vein thrombosis (DVT) prophylaxis during the previous admission. Vascular surgery was consulted, and the recommendation was made to proceed with conservative management. On the third day, the patient developed new-onset, left-sided pleuritic chest pain. Upon examination, significant swelling and tenderness were noted in his left pectoral region, which was not present on admission. A CT chest without contrast was ordered due to concerns of underlying hematomas, revealing bilateral thickening of the pectoralis muscles, more on the right side, with a fluid collection of 2.5 cm × 1.3 cm. In addition, there was thickening of the right lateral chest wall muscles in the posterior right trapezius or supraspinatus muscles, most likely from intramuscular hemorrhage. The patient was transferred to the step-down unit for close monitoring. Conservative management was continued with as-needed transfusions for three days until hemoglobin stabilized at 9.8 mg/dL. Once stable, the patient was resumed on steroids and immunosuppressive therapy with posterior resolution of the SIH. SIH has been reported in DM, particularly more prominent in those with anti-MDA-5 antibodies. A case series and literature review showed 60.9% mortality within six months in those presenting with SIH, with a poorer prognosis (80% mortality) in those with deep muscle bleeding versus superficial (25%). There is currently no consensus on the treatment approach, and arterial embolization has not been proven effective. In our patient, conservative management with close surveillance and frequent transfusions helped achieve hemodynamic stability. Clinicians should be more aware of these rare but life-threatening complications in patients presenting with DM

It Is Not Pneumocystis jiroveci (PCP), It Is Cyclophosphamide-Induced Pneumonitis

Cyclophosphamide (CYC) is an immunosuppressive medication used to treat life-threatening complications of various rheumatic diseases like vasculitis and systemic lupus erythematosus. A rare side effect of this medication is pneumonitis, which occurs in less than 1% of patients. We describe a case of an 83-year-old woman with a past medical history of microscopic polyangiitis, who presented with progressive dyspnea at rest, exacerbated on exertion, and associated with orthopnea that was attributed to CYC-induced pneumonitis. Three months before this presentation, the patient was diagnosed with antineutrophil cytoplasmic antibodies (ANCA)-positive pauci-immune crescentic and necrotizing glomerulonephritis and started on CYC. On admission, a computed tomography (CT) chest showed worsening bilateral ground-glass opacities in a mosaic distribution and inter and intralobular septal thickening, not present on the CT performed three months prior. The patient underwent an extensive workup, which included an echocardiogram, bronchoscopy with bronchoalveolar lavage, and viral respiratory panel to rule out infectious and cardiac pathologies. She was started on empiric treatment with antibiotics and diuretics, however, despite these interventions, she continued with respiratory distress. A multidisciplinary team convened, and the diagnosis of CYC-induced lung injury was entertained. The CYC was discontinued, and the patient was started on prednisone with significant improvement in symptoms. This case highlights the importance of recognizing CYC as a rare cause of interstitial pneumonitis. When considering CYC-induced lung toxicity, other etiologies, such as opportunistic infections, cardiac etiologies, and diffuse alveolar hemorrhage, should be ruled out

Deeper Seated Than Skin Deep: Report of a Rare Case of Follicular Occlusion Tetrad and a Literature Review

Follicular occlusion tetrad (FOT) is a clinical syndrome consisting of hidradenitis suppurativa (HS), acne conglobata (AC), dissecting cellulitis of the scalp (DCS), and pilonidal cyst (PC). These entities typically occur independently, but occasionally present simultaneously comprising FOT. The four components share similar pathophysiology affecting the apocrine glands, follicular hyperkeratinization being the hallmark of each entity.Understanding shared similarities of each disease is paramount for the treatment approach as the relapsing and chronic nature of this syndrome can be burdening to patients. We present the case of a 22- year-old obese Hispanic man with a history of tobacco use who presented with worsening skin lesions. The patient developed extensive facial cystic acne 5 years before presentation, followed by left axillary hidradenitis suppurativa lesions two years before the presentation and right axillary involvement one year after. Skin manifestations then expanded to include the lower back, gluteal and perineal areas. The patient was diagnosed with FOT and despite conservative medical management, his lesions failed to improve. He ultimately underwent multiple staged excisional debridement surgeries and skin grafts. Our case underlines the presence of a syndromic association of cutaneous lesions that share a common pathogenesis and emphasizes that this entity requires a multidisciplinary approach. New biologic therapies continue to emerge and may potentially prevent the need for surgical intervention and the burden associated with it

Improvement of diabetic retinopathy screening of diabetic patients seen at the Internal Medicine Clinic​​

Diabetic retinopathy (DR) is a leading cause of vision loss globally. The International Diabetes Federation (IDF) estimated the global population with diabetes to be 463 million in 2019 and 700 million in 2045. Retinopathy is a highly specific neurovascular complication of both type 1 and types 2 diabetes, and the prevalence strongly correlates to both the duration of diabetes and the level of glycemic control. Regular follow-up with early detection and treatment of vision-threatening retinopathy enables the prevention of up to 98% of visual loss due to diabetic retinopathy

Generalized Lymphadenopathy as the Initial Presentation of a Young Woman with Systemic Lupus Erythematous

Background: Generalized lymphadenopathy (LAP) refers to abnormal enlargement of more than two non-contiguous lymph node regions. There are various causes of LAP, including malignancy, infection, autoimmune disorders, medications, and iatrogenic causes. Obtaining a thorough history and physical examination is paramount in identifying the underlying etiology. Most of the time further investigation with laboratory and radiographic studies should be performed to identify the cause. Patients with high-risk features should undergo a biopsy for the diagnosis of malignancy. Case presentation: A 36-year-old lady with a remote history of COVID-19 presented with complaints of orthopnea, cough, arthralgia, and left-sided abdominal pain for the past two months. She denied associated B symptoms. On physical examination, her vitals were unremarkable; however, she had round, coin-shaped lesions over her MCPs and abdomen, alopecia, and generalized LAP. The initial workup was remarkable for anemia and leukopenia. CT scan of the abdomen and chest revealed bilateral inguinal, iliac, axillary, mediastinal, hilar, and retroperitoneal lymphadenopathy with bilateral pleural effusions. Due to malignancy suspicion a bone marrow biopsy was pursued, which demonstrated leukopenia, no circulating blasts, and moderate normocytic anemia. Then the patient underwent an excisional biopsy of 3 lymph nodes that showed reactive follicular hyperplasia without malignancy. Infectious workup including blood cultures, respiratory cultures, HIV, hepatitis panel, Bartonella, Brucella, and tuberculosis was negative. Due to the evidence of leukopenia, anemia, serositis, lymphadenopathies, and polyarthritis, a diagnosis of systemic lupus erythematosus (SLE) was entertained. Further workup revealed ANA by immunofluorescence of 1:1280, anti-dsDNA 38, ESR 75 mm/hr, anti-U1RNP 40, C-reactive protein 1.4, complement C3 48, and complement C4 less than 5. Based on these findings, a diagnosis of SLE was made. The patient was discharged on prednisone 40 mg and hydroxychloroquine 200 mg daily and had remarkable improvement. Conclusions: The prevalence of LAP in SLE ranges anywhere between 30-59% depending on the study. Although it is a common manifestation, it is not considered a criterion for the diagnosis of SLE. The presence of LAP typically correlates with a higher level of disease activity. This case highlights the importance of considering connective tissue diseases in the differential of patients presenting with LAP