Scholar Commons @ Tower Health

Ortiz-Loubriel, Ricardo, MD

Cassella, Courtney, MD

Sigal, Adam, MD

Lymphoma diagnosis in the evaluation of lower leg pain.

Lalwani, Ayushi

Hariharan, Abishek

Moss, Caitlyn, MD

 
Introduction: 
Pulmonary infections are an important cause of morbidity and mortality in cancer patients on 
chemotherapy. These patients are immunosuppressed due to the underlying malignancy itself or due 
to the therapy. We present a challenging case of a 35-year-old immunocompromised patient 
presenting with multifocal pneumonia.  
 
Case description: 
35-year-old female with a history of right breast carcinoma stage IB post partial mastectomy on 
adjuvant dose-dense paclitaxel chemotherapy was admitted with worsening fevers and cough and 
was found to have sepsis secondary to multifocal pneumonia. COVID/RSV/influenza testing was 
negative. Lab studies were significant for CRP of 5.75 (normal <1) mg/dl, and white blood cell count 
of 4.8 (Normal: 4.8-10.8) 10E3/ uL, without evidence of neutropenia. Left-sided port appeared clean. 
She was initiated on broad-spectrum antibiotics including atypical coverage. She continued to spike 
fevers with a maximum temperature of 102.9⁰ Fahrenheit. Additional studies including HIV, 
galactomannan, and beta D glucan for Pneumocystis Jerovecii pneumonia (PJP) were ordered. She 
developed acute respiratory failure with hypoxemia requiring 4L of oxygen. Differential diagnosis 
was broadened to include chemotherapy-induced pneumonitis. She underwent bronchoscopy 
significant for 51% (Normal: 0-50%) lymphocytes, and Pneumocystis Jerovecii PCR and fungal 
cultures were sent. Beta D glucan returned positive, and treatment for presumed PJP with 21 days of 
IV trimethoprim-sulfamethoxazole (TMP-SMX) along with a prednisone taper was initiated. Rapid 
improvement was noted within 24 hours of therapy. She was discharged with oral TMP-SMX and 
prednisone. Ultimately, her PJP PCR testing returned positive. 
 
Discussion:  
 
There is evidence in the literature about PJP pneumonia occurring after dose-dense neoadjuvant 
chemotherapy. It is challenging to diagnose this condition as the presentation is similar to bacterial 
pneumonia, viral pneumonia in an immunocompromised host, and chemotherapy-induced 
interstitial pneumonitis. Interstitial pneumonitis presents similarly with low-grade fever, cough, 
tachypnea, and bilateral ground glass infiltrates. It is diagnosed through clinical history and the 
exclusion of other causes as it can be a relative contraindication to continued chemotherapy. In our 
case, it was challenging to identify interstitial pneumonitis versus PJP until confirmatory results. 
Lastly, since the onset of PJP can be life-threatening, careful consideration of prophylaxis for PJP is 
required. 
  
 
 
 


English

Chemotherapy-Induced Pneumocystis Jirovecii Pneumonia

Villa, Nicole Ann

Espiridion, Eduardo

Neuropsychiatric Manifestations of Arteriovenous Malformation: A Case of Acute Mania 
Nicole Ann Villa and Eduardo Espiridion, MD 
Abstract: 
Introduction: Organic mania is a well-described phenomenon that can be attributed to a variety 
of causes. In patients with acute mania, organic causes must be considered especially when they 
present atypically, such as a lack of previous psychiatric history or presentation above the age of 
40. Mania has been thoroughly researched, with lesions causing mania found to affect regions of 
the brain that regulate functional control of sleep, appetite, energy, and libido. There are various 
neurologic, toxic, and metabolic causes that have been associated with disrupting locations that 
normally play a vital role in maintaining neurological and psychological homeostasis. However, 
there is only scattered evidence of mania arising secondary to vascular lesions, and more 
specifically from patients with arteriovenous malformation (AVM). We report on a case of acute 
mania in a patient with an AVM and no prior reported psychiatric history. 
Case Presentation: The patient is a 46-year-old male with a history of a left AVM post-radiation 
treatment. He was also diagnosed with major depressive disorder and seizure disorder 
approximately a year before his AVM diagnosis. The patient was brought in by police to the 
emergency department of a local hospital due to a report of domestic disturbance at his 
residence. He presented with manic symptoms, including mood lability, impulsivity, insomnia, 
decreased appetite, jealous delusions, pressured speech, and suicidal ideations. In the ED, the 
patient's Escitalopram dose was reduced from 20 mg to 10 mg, and Divalproex was started. After 
a three-day hospital admission, his psychiatric symptoms improved. He was subsequently 
discharged home with an additional instruction to follow up with his neurologist. 
Discussion: In this report, we emphasize the importance of distinguishing between primary 
psychiatric conditions and those secondary to medical conditions as this can greatly dictate the 
acute care patients receive and can make a difference in their psychiatric and medical prognosis. 
In addition, we discuss the pathophysiology and treatments available for AVM’s, where this 
presents an opportunity for further research into long-term effects and patient prognosis. 
Keywords: Arteriovenous Malformation, Acute Mania, Neuropsychiatric Manifestations 


Neuropsychiatric Manifestations of Arteriovenous Malformation: A Case of Acute Mania

Ullah, Irfan

Moeed, Abdul

Waqar, Eisha

Ahmed, Muhammad

Zaidi, Farwa

Virwani, Vikash

Khan, Ejaz

Rehan, Syeda Tayyaba

Hussain, Hassan Ul

Irfan, Muhammad

yousaf, zohaib

Association of Non-Alcoholic Fatty Liver Disease with Risk of New-Onset Heart Failure: An Updated Systematic Review and Meta-analysis

Kumar, Mukesh

Ali, Syed Musadiq

Kumar, Vinod

Al-Sibai, Ahmad

Myositis with elevated creatinine Kinase in patient after Coxsackie B infection 
Mukesh Kumar (01) , Syed Musadiq Ali (01), Nivedita Jha (02), Al-Sibai Ahmed (03) 
Abstract: Viral myositis is rare but serious complication coxsackie B virus infection and often 
mistaken with idiopathic “polymyositis” or dermatomyositis. A severe form of viral myositis 
with extensive necrosis may mimic necrotizing myopathy and drug‐induced myopathy. We 
report a case of 47-year-old patient with history of decompensated alcoholic cirrhosis who was 
presented with bilateral upper and lower extremity weakness and diffuse body pain with motor 
deficit of extremities after Group B coxsackie virus infection. Neurological exam was 
unremarkable except some proximal weakness (4/5 shoulder abduction b/l, elbow flexion and 
extension 4+/5, hip flexion 2/5 b/l, hip abduction -4/5 b/l, knee flexion) and diminished sensation 
to cold temperature in length dependent pattern in lower extremities.  Activities significantly 
limited by tenderness in bilateral upper and lower extremities. Creatine kinase blood level rose to 
1678 U/L. Autoimmune, infectious and Inflammatory workup was negative including extended 
myositis panel, HMG Cao reductase antibodies, influenza panel, COVID, blood cultures, ascitic 
fluid cultures, viral hepatitis panel all negative.  
Coxsackie viral panel showed higher titers for Coxsackie B3 and B5 1:64. AST and ALT mildly 
elevated. 
Patient’s muscle biopsy was suggestive of immune mediated inflammatory myopathy with 
necrotizing features, antibody negative. Due to lack of spontaneous recovery for about a week, 
she was subsequently started on trial of IV Solu-Medrol 1 g for 5 days. All clinical and 
paraclinical abnormalities improved. 
This case illustrates the importance of Coxsackie B myositis specific to B3 and B5 which is rare 
cause of focal weakness and not reported well in literature before. It is very important to take 
comprehensive history to identify prodromal symptoms when working up weakness and 
myalgias, especially in patients with chronic problems like alcoholic liver cirrhosis. Clinicians 
should broaden serological testing for coxsackie panel as potential cause of weakness. 
Regardless of its influence on the treatment plan, awareness of potential complications like 
myositis will help direct clinicians to manage patients in an effective way and save time in 
similar situations. More cases need to be reported in patients who have muscle weakness due to 
coxsackie B and to determine whether use of steroid has any importance in management. 
 
 
 


Coxsackie B Associated Myositis: Elevated CK Following Infection

Ravi, Anjani

Pediatric Heart-Lung Transplantation Through the Decades at a High-Volume Institution

Millar, Benjamin

Stoker, Tyson

Taylor, Kenneth, MD

Publication Rates and Qualities of Abstracts Presented at the American Society for Surgery of the Hand Annual Meeting 2015-2019

Keck, Mei-Le

Schilken, Meghan M., M.S.

Beale, Emma

Guzolik, Hannah, M.S.

Gadegbeku, Annette, M.D.

Optimizing Community Health: Student-Driven Strategies for Vaccine Clinic Implementation

Nugent, Grant

Sigal, Adam

Cassella, Courtney

Authors: Nugent, Grant; Sigal, Adam; Cassella, Courtney 
Title: UTI With a New Renal Mass: Chicken or the Egg? Introduction: Here we present a case of a woman 
who presented with signs, symptoms, and a workup concerning for acute pyelonephritis. The case was 
complicated by bedside ultrasound and CT imaging revealing an enlarged left kidney with grossly 
distorted architecture which could be mistaken for malignancy by the clinician unfamiliar with this 
specific, rare pathology. Case Description: A 58-year-old female presented to the ED with lower 
abdominal pain for one month. Two days prior to presentation she developed left flank discomfort, 
fevers, and chills. Physical examination was notable for T 101.3F, HR 118, RR 27, lower abdomen and left 
flank tenderness. The patient’s urine was turbid with large leukocyte esterase, large blood, elevated 
WBC, and many bacteria. CBC revealed WBC 18.2 and platelets 582. BMP showed normal appearing 
renal function. Ultrasonography of the left kidney showed a “bear paw” sign, and CT showed perinephric 
inflammation, a diffusely enlarged upper pole with multiple fluid locules and a large stone in the 
infundibulum. An astute radiology read reported the findings could be consistent with 
xanthogranulomatous pyelonephritis. The patient was admitted and treated with IV ceftriaxone for 
acute sepsis. Urine cultures grew Proteus mirabilis. She was discharged on oral cefpodoxime and 
underwent a left total nephrectomy 6 weeks later with a surgical pathology report confirming the 
diagnosis. Discussion: Xanthogranulomatous pyelonephritis (XGP) is a rare and aggressive variant of 
chronic pyelonephritis, most commonly due to chronic nephrolithiasis and infection. Characteristic 
ultrasound findings include an enlarged kidney with grossly distorted architecture including dilated and 
multiloculated calyces indicating pyelitis, staghorn calculi seen as large amorphous echogenicities with 
posterior acoustic shadowing, and a “bear paw” sign similar to the CT finding created by multiple 
adjacent anechoic/hypoechoic masses which are xanthomatous conglomerates. Imaging characteristics 
can mimic malignancy creating a diagnostic dilemma. Urinary cytology and presence of staghorn calculi 
with perirenal inflammatory changes help differentiate from urothelial cell carcinoma. Diffusion 
weighted imaging can help differentiate from renal cell carcinoma (RCC) showing marked restricted 
diffusion in the cystic infiltrate of XGP compared to RCC. Acute infections are treated with antibiotics, 
however definitive management is nephrectomy. 
 
Keywords: “xanthogranulomatous pyelonephritis”; “chronic pyelonephritis”; “pyelonephritis”; “renal 
mass”; “renal imaging” 
 
Figure 1: Coronal CT of the abdomen and pelvis displaying a left kidney (white arrows) with multiple fluid filled locules and thick 
septations with a stone seen in the infundibulum. 


UTI With a New Renal Mass: Chicken or the Egg?

Takagi-Stewart, Julian

Prater, Laura C

Marts, Erika

Ayachit, Pooja

Jesus, Tiago S

Circumstantial variables preceding firearm suicide among females with and without mobility disability: comparative analysis using data from the National Violent Death Reporting System

Phoenixville Hospital

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