Bold and Brash: A Case of Unstable Bradycardia

Gabriel Monti, MD

Resident Collaborator: Michael Wright, MD

Faculty Mentor: David Shim, MD PhD

BRASH syndrome, characterized by Bradycardia, Renal dysfunction, AV nodal blockage, Shock, and Hyperkalemia, is an important cause of symptomatic bradycardia in which bradycardia leads to shock, leading to renal dysfunction, leading to hyperkalemia and AV nodal agent buildup, leading to worsened bradycardia. Treatment necessitates rapid correction of this vicious cycle in order to restore renal perfusion and induce kaliuresis and AV nodal blocker clearance. Accomplishing this may necessitate fluid resuscitation if hypovolemic, a catecholamine to address shock, prompt correction of hyperkalemia, and temporary pacing to address bradycardia if the prior interventions are insufficient.

Recurrent Metastatic Breast Cancer Presenting as Hydronephrosis

Emmanuella Oyogoa, MD

Faculty Mentor: Evie Hobbs, MD

Patients with early stage hormone receptor positive (HR+) breast cancer remain at risk of metastatic relapse for the remainder of their life. Roughly 20% of patients experience a late recurrence 15 years or more after initial diagnosis.  Current guidelines support the detection of metastatic recurrence by physical exam and symptoms as systemic surveillance imaging, tumor markers or routine bloodwork have not been shown to improve overall survival.  Spatiotemporal patterns of metastatic spread are well known with common sites being the axial skeleton, liver, lungs, and lymph nodes.  When a patient has achieved remission, diagnosis of recurrent metastatic breast cancer is challenging.  

B-HCG Elevation in Primary Lung Malignancy

Neha Agrawal, MD

Resident Collaborator: Ajay Mohinani, MD

Faculty Mentor: Jeremy Cetnar, MD

This case illustrates that ectopic secretion of B-hCG can be associated with primary lung malignancy in the absence of gynecologic malignancy. Although it is a rare finding in lung malignancy, prompt recognition of this association can further expedite oncologic diagnosis and treatment.   

Vancomycin Induced Linear IgA Bullous Dermatosis

Neha Agrawal, MD

Faculty Mentor: Kelsi Manley. MD

Linear IgA Bullous Dermatosis (LABD) is a rare autoimmune vesiculobullous disease that typically presents idiopathically and rarely presents as drug induced disease. We describe a presentation of Vancomycin induced LABD in a clinical and histopathologic context. The infrequency and variable severity of this disease state makes prompt diagnosis and treatment an important clinical challenge to recognize.  

Cushing Syndrome: A Continuing Conundrum

Erynn Beeson, MD

Faculty Mentors: Simone Dekker, MD PhD; Sima Desai, MD

Cushing’s Syndrome, a product of hypercortisolism, presents with subtle signs and symptoms including fatigue, depression, diabetes, hypertension, and obesity. More pronounced findings of bruising, weakness, and striae may also be present. The incidence of Cushing’s Syndrome is 2-5 cases per million per year. Importantly, discovering the etiology of a patient’s hypercortisolism is critical in treatment.  Here, we present a severe case of Cushing’s Syndrome with an elusive cause. 

Disseminated Central Nervous System Coccidioidomycosis – The Fungus Among-us

Phillip Blatt, MD

Resident collaborators: Michael Wright, MD; MJ Rice; MD

Faculty Mentors: Peter Sullivan, MD

Disseminated CNS coccidioidomycosis is an unusual cause of rim-enhancing lesions and is fatal if untreated. Typically, these lesions present in immunocompromised patients with subtle symptoms: headaches, altered mental status, and rarely hydrocephalus. Clinically, these lesions pose a diagnostic challenge as the symptoms and imaging are rarely suggestive of a diagnosis and fungal cultures are typically negative.  

Family (Hyper)Tensions

KerriAnn Boanca, MD

Faculty Mentor: Wayne Kang, MD

Von Hippel-Lindau (VHL) disease is an autosomal dominant hereditary syndrome caused by germline loss-of-function mutation in the VHL tumor suppressor gene, and characterized by the development of various benign and malignant tumors associated with unregulated Hypoxia-Inducible Factor (HIF) complex activity. Due to the wide spectrum of tumors in VHL disease and their different presentations, multidisciplinary management and careful surveillance are crucial to prevent increased morbidity and mortality.

Dissecting the Etiology of Postpartum Chest Discomfort

Claire Cambron, MD

Faculty Mentor: Pranav Chandrashekar, MD

Cardiovascular disease (CVD) is not only the leading cause of death in women, but also the most common underlying etiology of pregnancy-related death. Despite advances in the field of cardio-obstetrics, peripartum CVD complications such as acute myocardial infarction and arterial dissection have increased 100-175% in recent decades. Reasons for disparate cardiac outcomes among women are multifactorial but include unfamiliarity with sex-specific manifestations and delayed diagnosis due to overlooking CVD as an etiology of their symptoms.  

Sudden Cardiac Death in a Young Runner

Claire Cambron, MD

Faculty Mentor: Lidija McGrath, MD

Sudden cardiac death (SCD) represents up to 50% of all cardiovascular deaths and a quarter of the time, SCD is a tragic first manifestation of undiagnosed cardiac disease. Because SCD most often occurs due to underlying ischemic heart disease, targeting modifiable risk factors for coronary artery disease (CAD) offers an opportunity for primary prevention. However, in individuals <35 y.o., SCD more commonly occurs due to coronary artery anomalies, structural heart disease, non-ischemic cardiomyopathies, and inherited arrhythmogenic syndromes. Because screening for these etiologies is not standard practice, it is only after an individual succumbs to SCD that the search for etiologies and secondary prevention measures begin.

Breast Cancer and Acute Hypoxic Respiratory Failure--A Diagnostic Mystery

Melissa Chai, MD

Resident collaborators: Emmanuella Oyogoa, MD; Selinam Norgbe, MD

Faculty Mentor: Shewit Giovanni, MD

There are many treatment options available for hormone receptor positive breast cancer including ado-trastuzumab, which is an antibody-drug conjugate targeted against HER-2 covalently linked to a microtubule inhibitor DM1. Some of these therapies can rarely cause interstitial lung disease with a wide array of presentations leading to acute hypoxemic respiratory failure. The manifestations of lung injury in patients on chemotherapeutic treatments for breast cancer can be multifactorial making diagnosis and targeted treatment difficult.  

Posterior Reversible Encephalopathy Syndrome Masked by Hepatic Encephalopathy

Jacqueline Chang, MD

Faculty Mentor: Gita Gelfer, DO

Posterior Reversible Encephalopathy Syndrome (PRES) is a rare neuroradiologic diagnosis associated with various clinical conditions. Patients with PRES may present with neurologic symptoms such as altered mentation, visual disturbances, headaches, or seizures.1 We present a case of PRES that was found on imaging in a patient with encephalopathy originally attributed to hepatic encephalopathy (HE).

A Mystery Block, or Two

Ellen Clark, MD

Resident collaborator: Phillip Blatt, MD

Faculty Mentor:  Vishnu Manoranjan, MD 

The incidence of acute pancreatitis is very high in the US and continues to increase, with alcohol and gallstones accounting for approximately two thirds of the cases. In addition, most cases deemed “idiopathic” are likely to have a genetic risk, particularly in younger patients. In the same vein, the etiology of complete heart block in a younger patient without a clear acquired or structural cause may be genetic, although it is uncommon.

To be SBP or To Not Be SBP

Ellen Clark, MD

Resident collaborator: Grant Coan, MD

Faculty Mentor: Sarah Diamond, MD

A variant of spontaneous bacterial peritonitis (SBP) known as culture negative neutrocytic ascites (CNNA) was originally identified in 1984 and presents similarly to SBP. There is limited literature discussing the prevalence and management of CNNA.

When Air Clouds Oxygen--A Case of Pneumomediastinum and Hypoxemia

Ryan Friedman, MD

Resident Collaborator: Emma DeLoughery, MD

Faculty Mentor: Kelsi Manley, MD; Alan Hunter, MD

In medicine one is constantly seeking unifying diagnoses to explain clinical presentations, which can be challenging when presented with apparently disparate syndromes. The following case of hypoxemia and pneumomediastinum presents an opportunity to engage in analytic decision making that ultimately led to the final diagnosis.

Thinking Twice About Benzodiazepines: Treatment of Progressive Dementia in a Hospitalized Patient

Mallika Lal, MD

Resident collaborators: Brian McGarry, MD; Arinea Salas, MD

Faculty Mentor: Katie Drago, MD; Rebecca Harrison, MD, FACP

Catatonia is a psychomotor disorder involving changes in movement and speech. The main causes include psychiatric and neurologic diseases including dementia, metabolic abnormalities, and medications (1,2). Recognition is important because the mainstay treatment is lorazepam which works by binding GABA receptors and is generally harmful in the elderly. Overlap with depression, dementia, and delirium make it important to recognize early and avoid harmful effects such as immobility and malnutrition.

An Unsuspecting Source: The Cause of Three Pressor Mixed Shock

Carley Little, MD

Faculty Mentor: Elly Karamooz, MD

While there are multiple case reports of septic shock requiring pressors and multi-organ failure from Pasteurella bacteremia in the literature, almost every report encountered included an elderly patient (>75 y.o.) with cirrhosis or an underlying immunosuppressive condition. While this patient has several comorbidities, he is much younger than and not immunocompromised like most known cases. The case exemplifies how something so simple and innocuous as cat saliva in a long-standing chronic wound can lead to a life-threatening severe illness.

Metastatic MRSA: Seek and You Will Find

Liat Litwin, MD

Faculty Mentor: Amy Kwon, MD

Multifocal infection arising from a single source can be defined as metastatic MRSA. This case is notable for the sheer number of sites of infection, involving eight organ systems and requiring nine different procedures in attempt at source control. The importance of a multidisciplinary approach with multiple specialists in such disseminated disease is highlighted in this case. Furthermore, the significance of intensive diagnostics and repeat monitoring to isolate sites of infection is a crucial component in the management of MRSA endocarditis. A low threshold for imaging and immediate intervention can positively alter the course of disease.

Scurvy--Not Just a Pirate's Disease

Alexandra Malesz, DO, MPH

Resident Collaborator: Emma DeLoughery, MD

Faculty Mentor: Kevin Landefeld, MD

This case illustrates an occurrence of scurvy along with other nutritional deficiencies in a patient on an unusual formulation of TPN with rapid improvement in skin rash with optimization of nutrition, including vitamin C supplementation. This emphasizes the importance of checking nutritional labs on patients receiving TPN and ensuring supplementation of all necessary vitamins and minerals. 

The Adult Neck Mass: a Diagnostic Dilemma and Occasional Distractor

Caroline McCormick, MD

Resident Collaborator: Apoorva Bhaskara, MD

Faculty Mentor: Simone Dekker, MD PhD

As imaging technology becomes less expensive and more available, so do the number of incidental findings. Of those, masses of the neck can cause a diagnostic dilemma as the underlying etiology is not easily identifiable and clinical practice guidelines for evaluation are suboptimal. Here, we present a case of an incidentally found neck mass, and review the associated differential diagnosis and diagnostic evaluation.

Perioperative Cardiac Arrhythmias After COVID-19: A Case Series

Brian McGarry, MD

Faculty Mentors: Katie Schenning, MD; Avital O'Glasser, MD

COVID-19 is associated with increased post-operative risk of pulmonary complications, venous thromboembolism, and mortality that persists up to four weeks after resolution of symptoms. Acute COVID-19 is associated with cardiac complications and while it is hypothesized that recent COVID-19 increases perioperative cardiac risk, data evaluating these outcomes are relatively lacking from the literature. We present cases of new onset cardiac arrhythmia in the peri- and post-operative period in patients undergoing elective surgery after COVID-19.

Perioperative Venous Thromboembolism Risk after Large Joint Arthroplasty: What Role Does Prior COVID Infection Play? A Case Study

Brian McGarry, MD

Faculty Mentors: Katie Schenning, MD; Avital O'Glasser, MD

COVID-19 infection produces a hypercoagulable state that has been associated with venous thromboembolism, endothelial injury, arterial thrombosis, among other vascular complications. Existing literature has also demonstrated an increase in peri- and post-operative risk for VTE for at least four weeks following COVID-19. Lower extremity total joint arthroplasty carries known risk for post-operative VTE. Optimal post-operative VTE prophylaxis strategy after COVID-19 infection is unknown and should be the subject of future work.

HSV-2 or Monkeypox or Both?

Pristine Mei, MD

Resident Collaborator: Corbin Edmonson, MD

Faculty Mentors: Martha Gerrity, MD

This case illustrates the importance of considering hMPXV when there is a high clinical suspicion, especially in a patient with relevant risk factors in the appropriate clinical context. hMPXV can be easily transmitted during sexual or intimate contact, thus should be considered as a possible coinfection with other STIs. Diagnosis and management of hMPXV requires a coordinated multidisciplinary approach involving the state health department, Infectious Disease, Nutrition, Infection Control, to name a few.  

The Great Masquerader: Sarcoidosis

Ajay Mohinani, MD

Resident Collaborators: Lyndsey Sandow, MD; Reed Nerness, MD

Faculty Mentors: Mary Brooks, MD

Lofgren syndrome is an acute sarcoid arthropathy characterized by bilateral hilar adenopathy, pulmonary opacities, and skin/joint or eye lesions. This was a challenging case as sarcoidosis is typically more prevalent in 20–40-year-olds, has a greater prevalence in women, and African Americans/Caucasians. Our patient did not fit that presentation and the absence of his pulmonary and ocular symptoms was confounding along with no notable findings of chest radiograph to suggest sarcoid on initial screening.

Acute Decompensation in a Patient with Miliary Tuberculosis

Marcella Muysson, MD

Faculty Mentor: Sara Schwanke Khilji, MD MPH

Miliary tuberculosis is caused by hematogenous dissemination of Mycobacterium tuberculosis (TB). It can result from primary infection or reactivation of latent disease and may result in multiorgan failure, with CNS, liver, and adrenal gland involvement particularly common.

A Curious Case of Colitis

Thuy-Duyen Nguyen, MD

Faculty Mentor: David Lieberman, MD

This case illustrates an occurrence of scurvy along with other nutritional deficiencies in a patient on an unusual formulation of TPN with rapid improvement in skin rash with optimization of nutrition, including vitamin C supplementation. This emphasizes the importance of checking nutritional labs on patients receiving TPN and ensuring supplementation of all necessary vitamins and minerals. 

To Treat or Not to Treat?

Shira Peress, MD

Faculty Mentor: Harsha Tathireddy, MD

Lemierre syndrome is a condition where a septic thrombophlebitis develops in the internal jugular vein, usually secondary to a Fusobacterium infection. This condition can be complicated by septic emboli, hematogenous spread, or even direct  extension of the thrombophlebitis, which can rarely present as a cavernous vein thrombosis (CVT). COVID-19 is another infection that predisposes to higher rates of thromboses, including a cavernous vein thrombosis. Depending on the etiology, treatment of cavernous vein thrombosis sometimes varies. 

Allergic Bronchopulmonary Aspergillosis: Learning from a Missed Diagnosis

Mara Peterson, MD

Resident Collaborator: Michelle Beam, MD

Faculty Mentor: Joel Burnett, MD

This case highlights key clinical features that should raise suspicion for ABPA and demonstrates the importance of close post-hospital follow up. Clinically, it is difficult to distinguish ABPA from pneumonia with asthma exacerbation. Clinicians should have a high degree of suspicion for ABPA when patients with asthma or CF experience frequent, recurrent symptoms.

You’ve Got to be Kidney’ing Me

Arinea Salas, MD

Faculty Mentor: Alan Hunter, MD

Ascites can be classified as related to portal hypertension or nonportal hypertension based on the SAAG, with a low gradient (<1.1) representing nonportal hypertension. Non-portal hypertension is either protein-poor or protein rich, with this case being the former. One standard etiology of low albumin ascites is nephrotic syndrome.  The proposed mechanism of ascites accumulation in these patients is decreased oncotic pressure in the portal capillaries resulting in the movement of low protein fluid into the peritoneum. However, the role of hypoalbuminemia and/or nephrotic syndrome alone resulting in ascites is controversial.

Recurrent Hypotension and Syncope in Severe Aortic Stenosis and ESRD: The Role of Balloon Aortic Valvuloplasty

Abharika Sapru, MD

Faculty Mentor: Brian Davidson, MD

Patient’s with end-stage renal disease (ESRD) and aortic stenosis (AS) have generally worse outcomes following transcatheter-aortic valve intervention (TAVR) compared to non-ESRD  patients. Management of chronic hypotension and symptomatic orthostasis in ESRD patients is challenging as the etiology is often multifactorial and requires integrating complex mechanisms that mediate blood pressure regulation often with competing solutions.    

Autoimmune Hemolytic Anemia Leading to a Workup for Lymphoproliferative Disorders

Virginia Tan, MD

Resident Collaborator: Emmanuella Oyogoa, MD

Faculty Mentor: Derek Galligan, MD

The initial presentation of hematologic malignancies can vary, ranging from constitutional symptoms to lymphadenopathy and pancytopenia and can present a diagnostic challenge. We present a case concerning for cold agglutinin disease, resulting in a further workup for lymphoproliferative disorders.

No Vitriol for Calcitriol: Hypercalcemia Due to 1,25-Vitamin D Excess

Michael Wright, MD

Faculty Mentor: Rebecca Harrison, MD

Hypercalcemia in an elderly patient should be assumed secondary to malignancy until proven otherwise, and patients with cancer histories presenting with hypercalcemia should undergo an exhaustive workup to exclude complication of previous malignancy.

Food as Fuel: Investigation of the Flammability and Heat Produced of Household Foodstuff

Emma DeLoughery, MD

Faculty Mentor: Thomas DeLoughery, MD

Fuel for the body, food can also represent fuel in the more traditional sense. Whether trapped at home in winter without power or lost in the wilderness, hypothermia poses a greater threat to human life than dehydration or starvation under certain environmental conditions. Therefore starting a fire using available resources, including food, is a reasonable survival strategy. This project’s goal was to determine the ideal foodstuff for starting a fire. 

Social, Behavioral, and Medical Risk Factors and Health Outcomes Among Oregon Counties

Emma DeLoughery, MD

Faculty Mentor: Katie Iossi, MD

It is well-known that a person’s social environment influences their health, however most healthcare interventions focus on the individual with little if any intervention directed towards the community in which an individual lives. This study examined data from the Oregon Health Authority (OHA) to identify associations between subjective and objective outcomes and potential social, behavioral and medical risk factors. 

Fecal Immunohistochemistry Testing as Focus - FIT AF at the Portland VA

Gabriel Monti, MD

Resident collaborator: Colin Bartz-Overman, MD; Kristopher Van Huss, MD

Faculty Mentor: David Lieberman, MD

Colorectal cancer (CRC) remains the third leading cause of death amongst all cancers in the United States. The US Preventative Services Task Force (USPSTF) and U.S. Multi-Society Task Force on Colorectal Cancer (MSTF) recommend screening with fecal immunohistochemical testing (FIT) annually or colonoscopy every 10 years as comparable means of screening. Adherence to these recommendations is both inadequate and highly variable in the US. Our aim was to determine the rate of adherence to annual FIT completion after a prior negative FIT in an organized health care system, the Portland Department of Veterans Affairs (PVAMC).  

Clinical Outcomes of Patients Referred for Asymptomatic Neutropenia: A Focus on Racial Disparities

Emmanuella Oyogoa, MD

Faculty Mentors: Kylee Martens, MD; Sven Olson, MD; Thomas DeLoughery, MD; Joseph J Shatzel, MD

Asymptomatic neutropenia is a common referral to Hematology. In the following study, we aim to describe the demographic characteristics, laboratory and clinical outcomes of patients referred for asymptomatic neutropenia.