An Atypical Presentation of Cystic Echinococcosis

Cystic echinococcosis (CE) is an infection caused by the Echinococcus granulosus tapeworm. CE generally manifests in the liver, but it may present in any organ. These patients often first present to the emergency department. Mortality over 10 years is significant for those who go undiagnosed. We report the case of a 34-year-old patient who immigrated from Yemen six years earlier. She presented with acute onset dysuria, suprapubic pain, and fever. Imaging revealed a primary multicystic mass on the right renal pole with a secondary lesion in the right hepatic lobe. On further investigation, the patient’s serum was positive for echinococcus antibodies

Renal Cysts in an Immigrant Patient: An Atypical Presentation of Echinococcosis

Introduction: Cystic echinococcosis (CE) is an infection caused by the Echinococcus tapeworm that results in the creation of cysts within a range of visceral organs. Ninety percent of these cysts are in the liver or lungs. In the United States, cases are quite rare and most are found in immigrants from endemic countries. Patients with CE may remain asymptomatic for years. If left undiagnosed and untreated, mortality from CE is estimated to be 90% by ten years. In this case, we discuss a patient who presented to the emergency department with genitourinary complaints and was diagnosed with CE of primary renal involvement, a rare anatomic location. Case Description: A previously healthy 34-year-old female presented to the emergency department with dysuria, suprapubic pain, myalgias and fever of one day duration. The patient had immigrated from Yemen 6 years prior. On presentation, she was febrile to 38.8C and tachycardic to 133. Complete blood count and lactic acid were within normal limits and urinalysis was not consistent with a urinary tract infection. Ultrasound revealed a mass on the right kidney and computerized tomography (CT) showed a subcapsular right renal cystic mass with septations as well as a secondary liver lesion. Further imaging by magnetic resonance confirmed the subscapular multi-cystic mass along the right kidney measuring 7 x 5.2 x 6.1 cm consistent with CE stage III and a 1.7 cm cystic lesion in the right hepatic lobe also consistent with CE. Serum IgG for echinococcus was positive. The patient was diagnosed with echinococcal disease and was initiated on albendazole 200mg BID for 3-4 months with future plans for surgical intervention. Discussion: Echinococcal disease is a parasitic infection with the majority of cases originating in the Middle East, South and Central America and sub-Saharan Africa. The clinical presentation of Echinococcus infection is largely dependent on the location and size of the cysts. Small cysts may be asymptomatic whereas larger cysts may cause mass effect or may present with toxic appearance with rupture. Some cysts present with symptoms up to several decades after initial infection or remain asymptomatic indefinitely. The most common sites of involvement are the liver (approximately 66%) followed by the lungs (25%). Less commonly reported sites include the brain, kidneys, muscle, bone and heart. Our patient’s primary renal cyst was large enough to cause mass effect, leading to dysuria and suprapubic pain. Generally, diagnosis of echinococcal disease is made with both imaging and serology. With regards to imaging, ultrasonography is 90-95% sensitive for CE and CT is only moderately better with 95-100% sensitivity; however, CT is superior to ultrasonography for evaluation of extrahepatic cysts. MRI offers no major advantage over CT. When considering serology, antibody detection has greater sensitivity than antigen detection. Our patient tested positive for echinococcal IgG. IgE and IgM were not pursued as IgG has better sensitivity. Management of these cysts are based on the WHO classification criteria and typically use a combination of observation, albendazole, PAIR (percutaneous puncture, aspiration, injection, re-aspiration) and surgery. Our patient’s renal cyst was classified as WHO stage III, for which the recommended treatment is albendazole followed by either PAIR or surgery. Conclusion: Although CE is uncommon in the United States, careful attention should be paid in individuals who have immigrated from endemic countries. While the liver and lungs are most commonly involved, cysts can be found in any organ and symptoms are often specific to the affected system. The best imaging modality for extrahepatic cysts in particular is by CT. The majority of these patients should be started on albendazole initially with definitive treatment often requiring evaluation by several subspecialists including Infectious Disease, Interventional Radiology and Surgery.https://scholarlycommons.henryford.com/merf2020caserpt/1123/thumbnail.jp

An Atypical Presentation of Cystic Echinococcosis

Cystic echinococcosis (CE) is an infection caused by the Echinococcus granulosus tapeworm. CE generally manifests in the liver, but it may present in any organ. These patients often first present to the emergency department. Mortality over 10 years is significant for those who go undiagnosed. We report the case of a 34-year-old patient who immigrated from Yemen six years earlier. She presented with acute onset dysuria, suprapubic pain, and fever. Imaging revealed a primary multicystic mass on the right renal pole with a secondary lesion in the right hepatic lobe. On further investigation, the patient’s serum was positive for echinococcus antibodies

Health care provider absences and intervenable areas during a COVID-19 surge

Background and Objectives: Health care provider (HCP) absenteeism during the initial phase of an epidemic or pandemic can lead to significant understaffing during a critical time. There is a paucity of literature that describes the effect that the initial phases of a pandemic have on emergency department (ED) HCP absences, or possible interventions that may curb the number of absences. This lack of data places frontline departments at undue risk for inadequate HCP staffing at a time when patient care needs are greatest. This study aimed to quantify HCP absenteeism in the ED during the initial Coronavirus Disease 2019 (COVID-19) surge and to identify potential interventions that may mitigate absences. Methods: This was a retrospective, descriptive record review that included 82 resident physicians, physician assistants, and staff physicians who were scheduled to work more than 3 clinical shifts during March 2020 in an urban, academic ED that received a high number of COVID-19 patients in March. The department created an external database during the pandemic to assist with staffing given the sudden increase in HCP absenteeism. This database included date of COVID-19 exposure, symptom onset, absence from and return to work, testing with result, age, gender, travel history, and admission history. Descriptive statistics and graphical representations superimposed with dated institutional policy changes were used in framing the progression of dependent variables. Results: During March 2020, of 82 ED HCPs, 28 (34%) required an absence from clinical duties, totaling 152 absentee calendar days (n = 13 women [46%]; n = 15 men [54%]). Median age was 32 years (interquartile range 28-39). Median number of days absent was 4 (interquartile range 3-7). While 16 (57%) of the total absences were secondary to a known exposure, 12 (43%) were symptomatic without a known exposure. A total of 25 (89%) absent HCPs received COVID-19 testing (n = 5 positive [20%]; n = 20 negative [80%]) with test results returning in 1 to 10 days. Eleven (39%) symptomatic HCPs had traveled domestically or internationally in the past 30 days. Conclusion: EDs should anticipate substantial HCP absenteeism during the initial surge of a pandemic. Possible interventions to mitigate absences include early and broad use of personal protective equipment, planning for many asymptomatic HCP absences secondary to exposures, prioritizing HCP testing, and mandating early travel restrictions

Thiamine Deficiency Is Common Among Emergency Department Oncology Patients

Background: Thiamine deficiency is associated with significant morbidity that may be precipitated by acute illness. Due to metabolic demands of cancer and difficulty maintaining adequate nutrition, oncology patients may be at higher risk of thiamine deficiency when acutely ill. Our primary objective was to quantify the prevalence of thiamine deficiency among ED oncology patients. Methods: This was a prospective, single center observational study. Inclusion criteria were adult patients with active malignancy presenting to the ED. We excluded patients with known cirrhosis or liver cancer due to known alterations in thiamine metabolism. Data collection included demographic and clinical information, including cancer type and albumin as a marker of nutritional status. We sent whole blood for thiamine levels (Warde Laboratories, Ann Arbor, MI). Analysis was descriptive but also included univariate analysis to test risk factors for thiamine deficiency. Results: There were 55 patients. The mean age was 63 ± 14 years, 53% were female, and 64% African American. The most common malignancies were lung (26%), colon (11%) and breast (11%) cancer. Metastatic disease was present in 43% of patients, and 52% of patients were undergoing current chemotherapy. Mean body mass index (BMI) and albumin were 26.7 ± 6.1 kg/m2 and 3.4 ± 0.8 g/dL, respectively. The rate of thiamine deficiency was 31% (95% CI 19 - 45%). There was no statistical difference in age (p=0.99), BMI (p=0.17), albumin (p=0.91), or gender (p=0.36) between patients with or without thiamine deficiency. 39% of patients with metastatic disease had thiamine deficiency compared to 23% without metastatic disease but the difference did not reach statistical significance (p=0.19). Conclusion: In this cohort of ED oncology patients, there was a surprisingly high rate of thiamine deficiency. Further work is indicated to delineate risk factors and attributable morbidity