Page 39 - Delaware Medical Journal - July-August 2018
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CASE REPORT
negative can be avoided by performing dilutions on the assay, but this is challenging logistically. For other immunoassays, run less commonly, there is no way to estimate the rate of false negative testing. While urinary and blood testing for histoplasmosis are pathology that makes the diagnosis. If clinical suspicion remains high enough based on patient’s clinical presentation, physicians should be aware of the limitations of laboratory testing and potentially pursue additional testing.
RESIDENT POSTER SECOND PRIZE
From Observation Status to the OR:
A Case of Mesenteric Ischemia Presenting
in an Unsuspecting Manner
By Bryan Haimes, MD/MPH and Joseph Deutsch, MD
Introduction
Mesenteric ischemia is a rare occurrence in younger persons, but
Case Presentation
A 31-year-old male with no prior medical history presented to the
Patient was called for admission from the emergency department count and hemoglobin, glucose 221, mild metabolic acidosis with anion gap of 13, mild transaminitis, and lactate of 1.7), continued pneumatosis to suggest ischemia. Upon initial evaluation, he had
no peritoneal signs but was still complaining of 10/10 abdominal pain, minimally worsened with examination, despite several doses During history and examination, the patient developed worsening tachycardia. His heart rate continued to climb into the 150s, despite a bolus of normal saline. On re-examination 30 minutes later, the patient had developed peritoneal signs, stat blood gas showed pH of 7.03 with a repeat lactate of 10.7. Patient was immediately brought
to the OR for exploratory laparotomy, where they found 160 cm of hemorrhagic necrosis of jejunum and ileum without perforation.
The patient required resection of 200 cm of his distal jejunum and proximal ileum. After surgical intervention, it is critical to identify condition versus heritable, or acquired thrombophilia) to inform appropriate treatment.
Discussion
The ED triaged this patient to the internal medicine service, as there
was minimal indication that this was a surgical issue. The historical presentation had classic characteristics of mesenteric ischemia —
pointed away from this diagnosis. Without a high index of suspicion based on history, this diagnosis would have been missed for minutes to hours, as the patient would have likely been instead treated for septic shock.
Internists do not often expect to encounter a primarily surgical diagnosis while admitting a new patient; however, patients are not always triaged correctly, and surgical emergencies should not be ruled out. Mesenteric ischemia is a tough diagnosis in someone
in the typically presenting age range. As early diagnosis and surgical intervention are key to survival, this case underscores the importance of retaining mesenteric ischemia within a differential diagnosis even in the absence of common epidemiologic presentation.
RESIDENT POSTER HONORABLE MENTION 1
‘Chasing the Dragon:’ A Case
of Drug-Induced Leukoencephalopathy By Nikita Donti, DO; Hammad Sattar, DO; Max Oran, MD; Shannon E. Barrow, MD
and Jennifer Goldstein, MD
Introduction
Toxic leukoencephalopathy (TLE) is a rare condition characterized by progressive damage to white-matter tracts in the brain from exposure to drugs, environmental toxins, or chemotherapy. The
Case Presentation
A 30-year-old man with a history of polysubstance abuse who presented comatose after being found down by his family. Upon arrival, the patient was obtunded, febrile, diaphoretic, tachypneic, and tachycardic, with non-reactive pinpoint pupils. Labs revealed leukocytosis (17,000), elevated creatinine (2.0), elevated CPK (6908), transaminitis, and UDS positive for benzodiazepines, cocaine, opiates, and amphetamines. He was intubated and transferred to the ICU. MRI revealed bilateral symmetric T2 hyperintensities of the cerebellar hemispheres and extensive symmetric restricted diffusion involving white matter on diffusion-weighted imaging. This
pattern was characteristic of a toxic leukoencephalopathy related to heroin inhalation, better known as “chasing the dragon.” His hospital course was complicated by sympathetic storm manifesting as fever, tachypnea, tachycardia, posturing, and diaphoresis.
He also developed language impairment, bilateral decerebrate posturing, and spastic paresis requiring extensive speech, physical,
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