Alpha-Gal Allergy: a new threat to Appalachia

Abstract Alpha-gal allergy, or mammalian meat allergy, is described as the development of IgE antibodies to the oligosaccharide galactose-a-1,3-galactose following a bite from the tick species Amblyomma americanum (Lone Star tick) or Dermacentor variabillis (Wood tick). Dermatologic or gastrointestinal symptoms are usually delayed by four to six hours after exposure, making the diagnosis difficult. Due to the use of mammalian proteins in many common medications, surgical equipment and prosthesis, unexpected reactions can occur. In the United States, this pathology is predominately seen in the southeast, but has been associated with other tick species on every continent except Antarctica. As the habitat for Amblyomma and Dermacentor continues to move further north due to changing patterns in deer population and weather, incidence of alpha-gal syndrome has increased in the states outside its normal southeastern locale, especially in people with occupations and hobbies that require time outdoors in wooded areas

Succenturiate Placental Lobe Abruption: a placental pathology complicating a dangerous delivery

The development of a placenta is a complex process that occurs without a clinically significant issue in most pregnancies. At times, however, the process develops in a way that isolates an island of placental tissue away from the main body, connected only by unprotected vasculature within the amniotic membranes. The vessels of this succenturiate lobe of the placenta are vulnerable both to compression or laceration, threatening the antepartum period with poor weight gain or the peripartum period with fetal distress, hemorrhage or retained products of conception. A majority of the time, this pathology is undiagnosed until recognized innocuously following delivery of the placenta. A placental abruption is a premature separation of the placenta from the uterus that can result in painful bleeding and fetal distress. This increased distress of mother or baby from continued blood loss usually necessitates delivery either vaginally, if stability is maintained, or by cesarean if it isn’t. The amount of distress correlates to where and how much of the placenta is affected. While succenturiate lobes of the placenta and placental abruptions are not routinely associated with each other, the abruption of only the succenturiate lobe of the placenta in this instance minimized the severity to the fetus, by allowing the main body of the placenta to remain intact. As the bleeding coagulated at the lobe, maternal well-being was maintained allowing enough time to complete a vaginal delivery

Pigmentary and Other Dermatologic Manifestations of Minocycline: a reminder of adverse effects

The applications of the tetracycline class of antibiotics extends beyond their antimicrobial activity to anti-inflammatory, immunosuppressive and neuroprotective applications making it a commonly used class of medication. Minocycline, a second generation tetracycline, has inherent characteristics that improve absorption and distribution. These benefits promote even more wide spread use. This familiarity of usage breeds prescriptive complacency toward the dermatologic complications including hyperpigmentation. The following case explores these adverse manifestations of Minocycline use

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in a Patient with Diabetes: a primary care perspective

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a recurrent and progressive disease that causes proximal, symmetrical extremity weakness. The disease is diagnosed using clinical features, electrophysiologic testing, albumino-cytological disassociation in the cerebrospinal fluid, and sural nerve plexus biopsy. However, because of the low sensitivity of diagnostic criteria and other similar neuropathies, including diabetic polyneuropathy (DPN), accurate diagnosis is difficult. Differentiating between these diseases is especially important as CIDP’s changes are reversible and DPN’s are not. Making this differentiation allows for symptomatic improvement in a patient’s quality of life that would not be achieved otherwise. Early recognition and treatment, with modalities including corticosteroids, plasmapheresis, and IVIG, demonstrate improvement in a majority of patients. Primary care physicians (PCP) encounter patients with diabetes daily. It is important for PCPs to have a level of familiarity with CIDP to best care for those patients

Diabetic Muscle Infarction: A Rare End-Organ Vascular Complication of Diabetes

Diabetic muscle infarction (DMI) is a rare microvascular complication of spontaneous ischemic necrosis of skeletal muscle in patients with poorly controlled diabetes. We herein describe the case of a 26-year-old woman with a history of type I diabetes and accompanying diabetic microvascular complications of neuropathy, nephropathy and retinopathy, who presented with sudden onset of swelling and sharp pain in her bilateral thighs. T2-weighted MRI imaging revealed subcutaneous edema and sub-fascial, hyper-intense enhancement of proximal thigh musculature. DMI has a relatively non-specific clinical presentation; therefore, physician awareness is key for early diagnosis, as aggressive management has been associated with poor patient outcomes. With poor long-term prognosis and high reoccurrence, DMI acts as an indicator of vascular end-organ damage

Chronic Exertional Compartment Syndrome: A Case Report about Claudication in a Healthy Adult

Claudication occurs when the blood supply is insufficient to service the musculature in the body with oxygen and metabolic waste management. A clinical complaint of claudication is commonly seen in primary care among older patients with vascular risk factors. A young and healthy patient presenting with claudication is less common and often results in delayed diagnosis with numerous extraneous diagnostic studies. This case discusses a young, healthy male patient with lower extremity symptoms that got worse with exercise and better with rest. He had normal physical exam findings leading to multiple diagnostic studies and over 12 months between the onset of symptoms and his return to full activity. Claudication can result from rare conditions, such as chronic exertional compartment syndrome, popliteal artery entrapment syndrome, fibromuscular dysplasia, and cystic adventitial disease. Symptomatic individuals with chronic exertional compartment syndrome experience reversible muscular pain from exercise-induced pressure, which increases within the finite spaces of any muscular compartment. Understanding the pathophysiology of exertional compartment syndrome and its related diagnoses allows for an organized diagnostic approach to young, healthy patients with claudication symptoms. This organized approach allows timely care, which is imperative for primary care physicians to reduce the number of tests performed, decrease the time to diagnosis, and reduce both the anxiety and cost for the patient. The approach presented herein can serve as a reminder of a proper work-up in similar patients and allow practitioners to identify the conditions that require intervention to improve outcomes

Analysis of Blood Borne Pathogen Exposure Monitoring Protocol Adherence in an Academic Medical Center: a seven year analysis and literature review

Background: Health care workers (HCW) are at risk for occupational blood borne pathogen exposures (BBPE). Effective prevention and management of BBPEs relies upon reporting and post-exposure follow-up protocol adherence. As post-exposure monitoring completion is largely unexplored, seven years of a university healthcare system’s BBPE exposure data was explored and compared to documented rates. Methods: The Marshall Health Occupational Health and Wellness division collected seven years (2012-2018) of BBPE follow-up monitoring adherence rates and demographic data. Data for HCW occupation, exposure incident, and source patient disease status were evaluated. Differences were analyzed with Chi square, Fischer Exact and logistic regression tests. Results: Of the HCWs (n =293), 31.7% completed follow-up monitoring. Completion rates of physicians and their learners (29.8%) trended lower than non-physician HCWs (43.9%; p \u3c 0.071). Similar completion rates were seen for all types of exposures (p = 0.470). Reported incidents had higher completion rates than unreported incidents (P = 0.001). Reported incidents (OR 6.906; 95% CI 1.936-24.637) and source patient status independently predicted completion, regardless of type of infection. Seropositive source patient status (67.2%) was associated with the highest HCW adherence rate (OR 4.747; 2.359-9.552), while unknown source patient status (17.1%) was the lowest (OR 0.423; 0.208-0.859). Conclusion: Current literature is limited regarding adherence rates to post-exposure monitoring protocols, favoring reporting rate analysis. Above results differ from some published reports potentially identifying unique demographic patterns in medical centers of differing size and governance. Understanding demographics associated with BBPEs may provide insight to institutional post-exposure monitoring adherence rates

Adult Pulmonary Langerhans Cell Histiocytosis with Osseous Involvement: understanding this rare mimic of malignancy

Langerhans cells are dendritic cells that form the antigenic barrier of the human body. They occur in nearly any tissue but are most prevalent in the skin, submucosa of the bronchial tree, and other mucosae. Langerhans Cell Histiocytosis (LCH) develops when these cells damage the tissues in which they reside through a combination of inflammatory and monoclonal stimulation. The pulmonary variant of LCH involves the lung parenchyma and creates a wide variety of disturbances: pulmonary hypertension and both obstructive and restrictive lung disease. Osseous involvement, in addition to the pulmonary variant, presents with pulmonary masses and lytic bone lesions, which sparks suspicion for malignancy. Early recognition of this rare pathology is important as early treatment is clinically beneficial. The following explores a case of adult Pulmonary Langerhans Cell Histiocytosis with osseous involvement

Nadolol in Pregnancy: A medical student’s reflection on her pregnancy

Hypertension is a common concern during pregnancy. Beta-blockers are one potential treatment, but third trimester exposure has correlated with an increased risk of perinatal events. Nadolol, a nonselective beta blocker, has properties that differ from those of its selective counterparts, including longer half-life, decreased protein binding, and renal excretion in the unchanged form. There is very limited data on the use of nadolol during pregnancy, and its safety has not been completely evaluated. This case study documents the perinatal outcomes of nadolol use throughout a medical student’s pregnancy and explores the experience in obtaining and undergoing medical care

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: a diagnosis obscured by concomitant recreational drug use

Anti-NMDA receptor encephalitis (aNMDAre) is a relatively newly discovered autoimmune and inflammatory disorder affecting the limbic system. It has a clinical course that includes Prodromal, Psychiatric, Unresponsive and Hyperkinetic stages. These stages are often confused with mental health issues in the medical literature, but they also share symptoms of various drug intoxication and withdrawal states. Implicit bias in physicians regarding substance use disorder and patient demographics can impair delivery of care and outcomes in patients with aNMDAre, especially in an environment of recreational drug use. When clinical presentation aligns, this diagnosis should be investigated as soon as possible, even in the case of atypical presentations or those with past or current substance use disorder. Early identification and treatment are essential to good outcomes and minimal sequalae at two years. Therefore, it is essential to consider aNMDAre with the symptom profile regardless of patient age, sex, race, or clinical disorder. Below is detailed the difficulty in diagnosing aNMDAre in a 32-year-old white male with a history of methamphetamine, opioid, benzodiazepine, and marijuana use