Creutzfeldt-Jakob disease, a stroke masquerade case: Case report

Background: The first Creutzfeldt-Jakob disease (CJD) outbreak was in 1996 in the UK, where 10 cases of a new rare neurological disease were reported. CJD continues to be an unclear neurodegenerative disease. The disease is usually higher in the retina and the brain, which in the majority of cases results in neurological symptoms, including rapidly progressing dementia, extrapyramidal signs, myoclonus, and visual symptoms with a mean age of 67. There are 3 groups of human prion disease, sporadic CJD accounts for about 85% of the cases. Case presentation: A 66-year-old woman who presented with slurred speech and forgetfulness started in March 2020, in September the patient presented right leg limping and gait difficulties which progressed to right arm weakness and stiffness. MRI was read as a stroke. A month later, she lost vision in her right eye and progressive deterioration of her left eye. Later, the patient reported multiple jolts of electricity and sporadic jerking movements that worsened in 3 months. In January, an MRI was repeated and compared to the previous image, it showed patterns more consistent with an autoimmune disease. Lumbar Puncture with CSF analysis was negative for infection, but due to continued deterioration, a third lumbar puncture was performed, with a positive 14-3-3 protein in CSF, but with an EEG showing no clear triphasic waveforms of CJD. Conclusions: CJD is the most frequent of the human prion diseases, new sporadic CJD cases are found 1 in 1,000,000 individuals every year. No treatment has been identified at the moment, making the course of this disease fatal, with a survival time around the year. It is important to educate the worldwide population in order to attempt an early identification of its different presentations, avoiding unnecessary testing, and mostly focusing on the quality of life in this patient\u27s population

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

Enhancing appropriate statin therapy in Type 2 Diabetic patients aged between 40-75 years at Graduate Medical Education (GME) Internal Medicine clinic

Background: The prevalence of type 2 diabetes mellitus (T2DM) is significantly higher in Rio Grande Valley than the rest of the United States. T2DM patients have an elevated risk of Atherosclerotic cardiovascular disease (ASCVD), and clinical trials have demonstrated the beneficial effects of statin therapy on ASCVD. A quality-improvement project was implemented in the GME Internal Medicine (IM) Clinic at Doctors Hospital at Renaissance to improve statin therapy appropriateness. Methods: T2DM patients aged 40-75 were selected from the GME IM Clinic visits from July 2021 to October 2021 for baseline data and from January 2022 to April 2022 after implementing our interventions, which included education of the new practice guidelines of statin therapy in T2DM to the internal medicine residents, as well as development of a clinical decision support tool designed to assess the indication and intensity of statin therapy. Exclusion criteria included patients without T2DM, ages above 75/below 40 years of age, and missing information for ASCVD risk stratification. Statin appropriateness was determined according to the American Diabetes Association standards in diabetes management. Results: The number of patients in the four months after the exclusions pre-intervention and post-intervention were 153 and 207, respectively. Overall, 71.9% (n=110) of the patients pre-intervention were receiving an appropriate statin therapy; the number increased to 80% (n=166) post-intervention (p = 0.003), considered statistically significant using t-test analysis. Of the total patients (N=43) with inappropriate statin therapy, 37% (n=16) had inadequate dose, and 63% (n=27) were not receiving any statin in the pre-intervention cohort. This percentage of inadequate statin dose and no statin therapy decreased to 65% (n=27) and 35% (n=14), respectively post-intervention. Conclusion: Appropriate statin therapy has been shown to reduce all-cause mortality by 19% in T2DM. Appropriateness of statin therapy was increased by 10%, and more than 50% reduction of patients without receiving any statin therapy, after our intervention. Effective implementation of new guidelines regarding risk stratification and prevention of ASCVD in T2DM age 40-75 years of age may be challenging. Barriers such as physicians\u27 adoption and knowledge regarding new guidelines can be overcome with appropriate tools and education, such as those implemented in our project