RESUMEN

Cryptococcus is a rare pathogenic fungus that is known primarily for causing meningeal and pulmonary disease in immunocompromised patients. There are scarce reports of other varieties of cryptococcal infections, such as disseminated and peritoneal disease. Here we present a very rare case of an elderly female patient with a history of non-alcoholic steatohepatitis (NASH) cirrhosis who presented with symptoms of dyspnea and abdominal distention and was found to have Cryptococcus neoformans pleuritis and peritonitis without evidence of disseminated disease. The patient was treated with antifungals consisting of amphotericin and flucytosine followed by fluconazole. This case describes a previously unknown pattern of disease spread and adds to the body of knowledge on Cryptococcus. Additionally, it reinforces growing evidence in the literature that cirrhosis is a risk factor for Cryptococcus.

RESUMEN

Identifying the etiology of aortic insufficiency (AI) is essential in the management of the patient with valvular heart disease. We report the case of a 34-year-old male who presented with New York Heart Association (NYHA) class IV symptoms. The physical exam was consistent with AI, which was confirmed on echocardiography. Interestingly, the trileaflet aortic valve (TAV) was comprised of three retracted cusps, a rarely cited anatomic abnormality yielding AI. The patient underwent an uncomplicated aortic valve replacement (AVR).

RESUMEN

Infective endocarditis (IE) is a rare complication in pregnancy that is associated with significant morbidity and mortality to both mother and fetus. We present a case of a 27-year-old female at 22-weeks gestation with a history of intravenous drug abuse (IVDA) who developed methicillin sensitive Staphylococcus aureus tricuspid valve endocarditis with persistent bacteremia and septic emboli necessitating tricuspid valve extirpation. Four days later, worsening decompensated heart failure required cesarean section at 23w5d. Although the patient's volume status and dyspnea improved significantly, fetal demise occurred 9 days after operative delivery.

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Context: Limited opportunities exist to practice technical skills and to be exposed to various surgical specialties during preclinical medical education. Objectives: To assess the value of workshop-based educational opportunities to medical students during preclinical training. Methods: One hundred and 75 medical and physician assistant students from 10 medical schools attended the 2019 Philadelphia Surgery Conference. All students received STOP THE BLEED® bleeding control training and participated in four workshops, chosen from a list of 23, that demonstrated a variety of surgical skills. Data collection was accomplished using both a pre- and postconference survey to assess changes in confidence of personal capabilities, knowledge base, and opinions regarding preclinical medical training. Results: Preconference survey results indicated low baseline confidence in personal surgical skills (mean [SD], 1.9 [1.0], on a Likert scale of 1-5), and knowledge of various surgical specialties (2.7 [1.0]). Students highly valued skill-building experiences (mean [SD], 4.2 [1.1]) and face-to-face interactions with resident and attending physicians (4.4 [0.9]). Postconference survey analysis demonstrated increased confidence in surgical ability by 52.6% (mean [SD], 2.9 [1.0]; p<0.001) and knowledge base by 34.6% (3.5 [0.8]; p<0.001). Value scores increased for both preclinical surgical skill-building opportunities (mean [SD], 4.4 [0.9]; p=0.014) and interactions with resident and attending physicians (4.7 [0.6]; p=0.002). Conclusions: The Philadelphia Surgery Conference provided a highly valuable experience to participating students, increasing confidence in personal knowledge base and surgical skills while facilitating a collaboration between students and resident and attending physicians from various surgical specialties.

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RESUMEN

Characterized by bone marrow dysplasia and peripheral blood monocytosis, chronic myelomonocytic leukemia (CMML) is one of the most aggressive chronic leukemias and has a propensity for progression to acute myeloid leukemia (AML). Patients with newly diagnosed AML generally present with symptoms related to complications of pancytopenia but can also present with renal insufficiency. We present a 79-year-old male with a past medical history of CMML and chronic kidney disease stage 3 (baseline creatinine 1.8 mg/dL) who presented with one day of inability to urinate and 20-lb unintentional weight loss, fatigue, and bone pain over 3 months. Laboratory evaluation revealed leukocytosis of 88.5 x 103/uL (normal 4.8-10.8 x 103/uL) with 24.0% monocytes on differential, creatinine 2.94 mg/dL (baseline creatinine 1.7-1.9 mg/dL), uric acid 19.8 mg/dL, potassium 4.0 mmol/L, phosphorus 4.0 mg/dL, calcium 9.2 mg/dL, and albumin 3.2 g/dL. Urinalysis was significant for protein 200 mg/dL, 20/LPF granular casts, and 7/LPF hyaline casts. Bone marrow biopsy revealed 20-30% blasts with monocytic features of differentiation consistent with acute myeloid leukemia. Computed tomography (CT) of the abdomen and pelvis appreciated splenomegaly with retroperitoneal, and pelvic lymphadenopathy. Kidney failure can complicate the presentation of AML but can be rapidly reversible with treatment. In patients with CMML who have progressive renal insufficiency and hyperuricemia, there should be a high index of suspicion for progression to AML.

RESUMEN

Priapism is a serious but rare side effect of psychiatric medications. We report the case of a 28-year-old male who has been mentally stable for a year on a combination of sertraline, olanzapine, and quetiapine. Two weeks after he was started on topiramate, the patient experienced priapism that led to a medical admission and surgical intervention. This case report suggests that topiramate might induce ischemic priapism, either directly or through interactions with other medications. Further studies are warranted to establish such a link.