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Volume 9, Issue 11, 2021

Recurrent Syncopal Episode and Undetectable Vitamin B12
Case Report
Syncope is a common cause of hospital admissions, with a high prevalence found in people 10-30 years of age, and in those 70 years and older. The condition often requires an extensive yet unrevealing workup. Vitamin B12 deficiency, however, is rarely thought to be the primary root of recurrent syncope. We had a case of vitamin B12 deficiency without findings of anemia, which presented as a recurrent syncope in an otherwise relatively young healthy man.
American Journal of Medical Case Reports. 2021, 9(11), 667-668. DOI: 10.12691/ajmcr-9-11-13
Pub. Date: August 19, 2021
Severe Refractory Hypocalcemia after Parathyroidectomy for Hyperparathyroidism and Parathyroid Adenoma in a Patient with Prior Bariatric Surgery: A Rare Case Report
Case Report
Hypocalcaemia is a common but transient complication post Parathyroid surgery. In patients who have gone through bariatric surgery including Roux-En-Y the risk increases further. We present a challenging case report of a patient with history of RYGB who underwent parathyroidectomy and consequently developed refractory hypocalcaemia. Hypocalcaemia was managed conservatively initially but subsequently required higher doses of both intravenous and oral calcium along with teriparatide. Patients post Bariatric surgery including those who have undergone Roux-en-Y who are proceeding with Parathyroid procedures should be followed up closely for hypocalcaemia.
American Journal of Medical Case Reports. 2021, 9(11), 664-666. DOI: 10.12691/ajmcr-9-11-12
Pub. Date: August 17, 2021
Ehrlichia chaffeensis-associated Hemophagocytic Lymphohistiocytosis: A Case Series and Literature Review
Original Research
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition characterized by abnormal, excessive immune activation resulting in severe cytopenias from an uncontrolled inflammatory response. It can be primary/ familial or secondary/sporadic. Infections, particularly viral infections are a common cause of secondary HLH. HLH due to Human monocytic ehrlichiosis (HME) is very rare, hence we are reporting our cases. Objective: To review cases of Ehrlichia-associated HLH at our institution and perform a literature review regarding this entity. Methods: We reviewed cases of Ehrlichia-associated HLH for the previous two years at our institution (Carilion Clinic). We then performed a review of the published literature on it, using Pubmed. Results: Over the past two years, five cases of Ehrlichia-associated HLH were diagnosed at our hospital. The average age of the patients was 67 years with predominantly males. All the patients were pancytopenic, and a majority had abnormal liver function tests. Diagnosis of ehrlichiosis was made by serum polymerase chain reaction (PCR) assay on blood. Patients had further testing done because of lack of clinical improvement. All patients had significantly elevated ferritin levels. Bone marrow biopsy samples of all patients showed findings of hemophagocytosis. All, but one, patients were treated with doxycycline and a combination of etoposide and dexamethasone. Three patients recovered while two died. On review of medical literature, we found a total of only 36 cases of Ehrlichia-associated HLH, including our five cases. There were 19 adults and 17 children. Both population groups showed varying degrees of pancytopenia. Splenomegaly was relatively uncommon, seen in less than one-third of the patients. Ferritin and triglyceride levels were routinely elevated. Bone marrow biopsy showing hemophagocytosis was the confirmatory test in all patients. A significant number of patients, both adults and children, required a combination of doxycycline and chemotherapy (etoposide and dexamethasone) to achieve clinical cure. Children had a better prognosis than adults, with one child and four adults succumbing to their illness. Conclusions: Ehrlichia-associated HLH is a rare but emerging disease entity. In endemic areas, a high degree of suspicion is required to diagnose ehrlichiosis and HLH resulting from it. Early diagnosis and prompt initiation of treatment for HLH is key to a favorable outcome.
American Journal of Medical Case Reports. 2021, 9(11), 557-563. DOI: 10.12691/ajmcr-9-11-11
Pub. Date: August 17, 2021
Reperfusion Injury Following Catheter Directed Thrombolysis of Pulmonary Embolism
Case Report
Catheter directed thrombolysis (CDT) is a growing field of intervention to treat pulmonary embolism (PE) and restore physiologic circulation. Reperfusion injury (RI) is a well-documented phenomenon seen post-thrombolysis. To date there are no reported cases of this phenomena following CDT. We present a patient with bilateral PE treated with CDT who subsequently developed RI.
American Journal of Medical Case Reports. 2021, 9(11), 554-556. DOI: 10.12691/ajmcr-9-11-10
Pub. Date: August 16, 2021
Reassessing Combining Real-time Elastography with Fine-needle Aspiration Biopsy to Identify Malignant Thyroid Nodules
Letter To Editor
Debate is still ongoing in the thyroid gland with indeterminate cytology w/wo suspicious clinics and sonographic features, besides their size selection criteria, in Endocrine Pathology, Endocrine Surgery, and Thyroidology, till today. Real-time elastography (RTE) still have been utilized for this purpose though it remains a controversial determinant. We postulate that the so-called RTE diagnostic tool selectively is enriched by considering nondiagnostic, Category I, and indeterminate cytology, Category III, IV, and V, of The Bethesda System for Reporting Thyroid Cytopathology, TBSRTC, 2nd ed., individually and separately, regarding noninvasive follicular thyroid neoplasm with papillary-like nuclear features, NIFTP, all of which a wide range of implied risk of malignancies.
American Journal of Medical Case Reports. 2021, 9(11), 552-553. DOI: 10.12691/ajmcr-9-11-9
Pub. Date: August 16, 2021
A Case Report of Recurrent Spontaneous Pneumothorax Secondary to Thoracic Endometriosis Syndrome
Case Report
Endometriosis is a benign condition in which ectopic endometrial glands and stroma are present outside of the uterine cavity. It commonly affects the pelvic organs but can also spread throughout the entirety of the body, including the thoracic cavity. The ectopic presence of endometrial glands and stroma in lung or pleura can produce a range of clinical and radiological manifestations – catamenial pneumothorax, catemenial hemothorax, catamenial hemoptysis, and pulmonary nodules – collectively referred to as “thoracic endometrial syndrome.” Thoracic endometriosis constitutes an uncommon cause of spontaneous pneumothorax in nonsmoking women of childbearing age. Symptoms are often non-specific and the diagnosis is often delayed. A thorough menstrual history and its temporal relationship to pneumothorax onset should be assessed in every women presenting with recurrent pneumothorax. Thoracic endometriosis syndrome is very manageable with the advancements of VATS and hormonal therapy, but we as clinicians should have this on our differential diagnosis when a young, reproductive-aged female presents with a spontaneous pneumothorax to expedite appropriate care. Here we present a case of a 44 year old female with recurrent spontaneous pneumothorax that was attributed to thoracic endometriosis that will hopefully educate providers to have a high clinical suspicion in patients to obtain an accurate diagnosis and initiate proper treatment.
American Journal of Medical Case Reports. 2021, 9(11), 548-551. DOI: 10.12691/ajmcr-9-11-8
Pub. Date: August 03, 2021
Calciphylaxis in a Young Adult with Acute Kidney Injury and Recently Diagnosed End-stage Liver Disease
Case Report
Calciphylaxis is a rare condition in which calcification of medium blood vessels in the skin results in the purpura and painful, necrotic skin ulcers. Although most commonly seen in adults with end-stage kidney disease and long-term dialysis use, reports of nonuremic calciphylaxis exist. We present the case of a 29-year old woman with recently diagnosed end-stage liver disease who presented with an acute kidney injury and painful lower extremity purpura and ulcers with biopsy-confirmed calciphylaxis. The patient had been receiving dialysis for less than one month. Treatment with sodium thiosulfate was provided but was unsuccessful. The patient ultimately pursued palliative care.
American Journal of Medical Case Reports. 2021, 9(11), 544-547. DOI: 10.12691/ajmcr-9-11-7
Pub. Date: July 18, 2021
Amputation of the Bilateral Legs due to the Lower Limbs Continuously Hanging Upside down after Becoming Trapped in a Chest of Drawers
Case Report
An 81-year-old woman was trying to reach something up high by stepping on the highest drawer of a chest of drawers. However, she fell off, and both of her both legs became trapped between the chest and the drawer. Her lower limbs and hips were stuck in an upside-down position, with her head and upper back on the floor. She was found in this awkward position by another person two days later. As the patient was hemodynamically unstable, she underwent venous infusion and bilateral tourniquets before rescue. On arrival, she was still in a shock state with hypoxia. Initially, she underwent tracheal intubation, and then the tourniquets were released one by one. She received a diagnosis of bilateral leg infections, ischemic left leg and multiple organ failure due to sepsis and unstable circulation, pulmonary embolism, and ischemic colitis with anemia. She underwent infusion of antibiotics, transfusion, noradrenaline, left lower limb amputation, renal replacement therapy, and then delayed right leg amputation. She was complicated with ischemia-reperfusion injury, ulcerative colitis and urosepsis during the hospital course, but she ultimately obtained a survival outcome after intensive care. This unique case adds another item to the list of documented etiologies of drawer-related injury and ischemia-reperfusion injury.
American Journal of Medical Case Reports. 2021, 9(11), 540-543. DOI: 10.12691/ajmcr-9-11-6
Pub. Date: July 18, 2021
Hermeneutics for Evaluation of the Diagnostic Value of Ultrasound Elastography in TIRADS 4 Categories of Thyroid Nodules
Letter To Editor
The accurate size cutoff of thyroid nodules for interventional diagnostic purposes still remains a major challenge in Thyroidology like thyroid nodules with indeterminate cytology and/or suspicious sonography, to date. The size cutoff of 10 mm has been well-stablished by recommendations of some guidelines for the thyroid nodules for the purposes of US-guided fine-needle aspiration (US-FNA). Nevertheless, some authors emphasized the “epidemic” of papillary thyroid carcinoma under 10 mm in the largest diameter of the thyroid nodules. In addition, The American Thyroid Association, ATA, Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer recommended US-FNA procedure for thyroid nodules under 5 mm in case of simultaneous existence of lateral cervical lymph node (LCLN) metastasis. Herein, some authors consider the size cutoff of 5 mm for developing LCLN metastases and extrathyroidal extensions. Of note, LCLN metastasis is reported as being more closely observed in papillary thyroid microcarcinomas ≥7 mm than in those under 7 mm. Furthermore, some other studies stated the size cutoff of >7 mm or 8 mm as an independent factor for LCLN metastasis. Herewith, we postulate that so-called thyroid nodules under 10 mm concept selectively might enrich accurate diagnostic purposes of malignancies in Thyroidology.
American Journal of Medical Case Reports. 2021, 9(11), 538-539. DOI: 10.12691/ajmcr-9-11-5
Pub. Date: July 18, 2021
A Case of Pulmonary Alveolar Hemorrhage Mimicking Community Acquired Pneumonia
Original Research
Granulomatosis with polyangiitis is a vasculitis that affects small to medium sized blood vessels in the lungs and kidneys. Alveolar hemorrhage is often initially misdiagnosed as pneumonia and treated incorrectly, leading to higher adverse outcomes in patients with undiagnosed vasculitis. We describe a case of a 68-year-old female who presented to our institution and was initially diagnosed and treated for community acquired pneumonia, however, after a protracted clinical course with no improvement in her respiratory status, she underwent a bronchoscopy that revealed pulmonary alveolar hemorrhage, a manifestation of underlying granulomatosis with polyangiitis.
American Journal of Medical Case Reports. 2021, 9(11), 535-537. DOI: 10.12691/ajmcr-9-11-4
Pub. Date: July 12, 2021
Life-threatening Pseudo-thrombotic Microangiopathy Caused by Severe Vitamin B12 Deficiency
Case Report
Vitamin B12 deficiency is a common cause of macrocytic anemia. Life-threatening hematologic complications including immune and non-immune hemolytic anemia are present in about 10% of the cases. Pseudo-thrombotic microangiopathy is an extremely rare presentation found in around 2.5% of patients with vitamin B12 deficiency. We present a case of a 70-year-old male patient who presented with progressive fatigue and syncope. He was found to severe macrocytic anemia with hemoglobin of 4.1 g/dL. Further workup showed very low serum vitamin B12 level at 22 pg/mL (normal 180-914), methylmalonic acid of 93.23 umol/L (normal 0-0.4) and homocysteine of 93 umol/L (normal 4-12). Anti-parietal cell and intrinsic factor blocking antibodies were positive. He was noted as well to have thrombocytopenia, low haptoglobin, increased lactate dehydrogenase and increased serum creatinine. Peripheral blood smear showed schistocytes, hyper-segmented neutrophils, and marked dimorphic anemia. His presentation was concerning for thrombotic thrombocytopenic purpura; however, PLASMIC score was intermediate. He was monitored in the intensive care unit. He received supportive treatment with intravenous hydration and packed red blood cells transfusion. He was started on daily intramuscular cyanocobalamin supplements. Significant improvement in his symptoms with near normalization of complete blood count after one month of treatment was noted. His condition improved without the need for plasmapheresis.
American Journal of Medical Case Reports. 2021, 9(11), 532-534. DOI: 10.12691/ajmcr-9-11-3
Pub. Date: July 11, 2021
COVID-19 Vaccine and Potentially Related Thromboembolic Events: Case Series
Case Report
The advent of multiple COVID vaccinations over the past year through an accelerated vaccine development process has led to concerns over its safety. The United States approved for emergency use the BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), ChAdOx1 nCoV-19 (Oxford-AstraZeneca), and the Ad26.COV2.S (Janssen/Johnson & Johnson) vaccines. Although these vaccines have had a high safety profile, rare but serious adverse events have been reported including pulmonary embolism (PE) and cerebrovascular thrombosis. In this case series, we identified three patients admitted to Beaumont Hospital with new onset of pulmonary thromboembolism shortly after receiving the Pfizer-BioNTech vaccine. Clinical and laboratory data were obtained and reviewed from the Epic charting system. The three patients included two male and one female patient. All were older than the age of 40, obese with a BMI > 30 kg/m2, and had underlying vascular disorders including hypertension, coronary artery disease, and/or a history of a cerebrovascular accident. One patient was a current cigarette smoker, one had quit over 27 years ago, and the third patient never smoked. Two patients developed pulmonary embolism after the second dose of the Pfizer-BioNTech vaccine, while the third patient developed pulmonary embolism after the first dose. This case series illustrates a possible association between the Pfizer-BioNTech vaccine and the potential development of pulmonary thromboembolism, particularly in middle-aged, obese adults with underlying vascular disease. This is not surprising as recent research has seen higher incidence of thrombosis with other COVID-19 vaccinations including Moderna, Oxford-AstraZeneca, and Janssen/Johnson & Johnson. Identifying this possible association is crucial in early diagnosis and patient management, but more importantly in educating higher risk adults to avoid modifiable risk factors for venous thromboembolism including immobility, certain medications, and possibly postponing elective surgeries. Further prospective or retrospective cohort studies are warranted to assess this association.
American Journal of Medical Case Reports. 2021, 9(11), 527-531. DOI: 10.12691/ajmcr-9-11-2
Pub. Date: July 08, 2021
Clickbait: A Rare Case of Monomorphic Ventricular Tachycardia and Clicking Sensation without Infectious Presentation Revealed as Infective Endocarditis with Aortic Root Abscess
Case Report
Presenting symptoms of infective endocarditis (IE) typically includes infectious signs such as diaphoresis, fever, and malaise. Pathogenic microorganisms implicated in IE may form vegetations, collection of debris that may subsequently embolize. Notable complications and concomitant sequelae of systemic embolization from resulting from valvular vegetations include stroke, acute renal failure, and cutaneous manifestations. Valvular dysfunction warranting surgical repair does not preclude redo-repairs from subsequent emboli, highlighting the extensive propensity of IE to cause acute decompensation across multiple domains. A presenting feature of arrhythmia stemming from valvular dysfunction have been appreciated in the literature. However, literary accounts of ventricular tachycardia (VT) as the resultant arrhythmia are scant. Moreover, these accounts usually include concomitant infectious presentation. We report the case of a 36-year-old male with a past medical history of Bartonella spp. endocarditis and aortic valve repair who appeared to the emergency department with acute onset monomorphic VT. Complicating his presentation was a reported sensation of clicking in his surgically repaired valve while lacking infectious symptoms. Arrhythmia was treated with further workup delineating S. epidermidis vegetations and aortic root abscess successfully treated with antibiotics and ICD placement.
American Journal of Medical Case Reports. 2021, 9(11), 522-526. DOI: 10.12691/ajmcr-9-11-1
Pub. Date: July 07, 2021