Community Hospital Internal Medicine Perspectives Research Articles

A CASE OF CRYPTOCOCCAL LAURENTII PNEUMONIA IN A PATIENT REQUIRING FREQUENT STEROID TAPERS

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal laurentii as a primary pathogen in infection is rare. The understanding of this non-neoformans species remains unclear as a rare virulent factor with high associated mortality or incidental finding in an at-risk immunocompromised populations. Here we present the case of a patient with chronic severe respiratory disease with acute pneumonia symptoms, found to have Cryptococcus laurentii pneumonia. CASE PRESENTATION: A 49-year-old woman with a 24 pack-year smoking history, COPD and uncontrolled severe persistent asthma, frequent hospitalizations for respiratory failure presented with acute dyspnea, wheezing and productive cough. She has previously responded to steroids, with several long tapers over the past year. A CT was performed revealing scattered ground-glass opacities, tree in bud pattern, hilar and mediastinal adenopathy, mucus plugging, and airway thickening. Initial labs were remarkable only for peripheral eosinophilia, a count of 640, with serum quantitative IgE of 33. Aspergillus testing, viral panel, COVID, and MRSA PCR were negative. Serum Quantiferon and autoimmune antibody panel were negative. The patient was started on broad-spectrum antibiotics but failed to improve. Bronchoscopy with BAL was performed, cytology showed growth of Cryptococcus Laurentii. Other respiratory samples were negative. The patient was started on a fluconazole regimen, with improvement in respiratory symptoms. DISCUSSION: Cryptococcal infection can be difficult to diagnose. Imaging and symptom presentation can be nonspecific. The most frequent symptoms are dyspnea, cough, and fever. Imaging findings can include pulmonary nodules, consolidations, nodular interstitial pattern, reticular interstitial pattern, ground glass opacities and pleural effusions. Severity can range from asymptomatic nodules to life-threatening illness. (3) There have been limited case reports of these species causing infection and pre-existing lung disease is a risk factor for pulmonary cryptococcal infection. There is a high associated risk of mortality (25-35%) (1). Due to an elevated risk of disseminated infection, diagnostic evaluation and workup should be broad and thorough. Standard cryptococcal antigen testing has worse sensitivity for non-neoformans species (3). The most appropriate treatment regimen remains contested as there has been poor correlation between in vitro antifungal susceptibility and treatment outcomes in patients (2). CONCLUSIONS: Cryptococcus laurentii remains a rare cause of infection. The symptoms may be non-specific; a high degree of suspicion is required for diagnosis. A better understanding of epidemiology and pathogenesis is crucial for improved recognition and treatment. REFERENCE #1: Shankar E. Pneumonia and pleural effusion due to Cryptococcus laurentii in a clinically proven case of AIDS. Canadian Respiratory Journal, 2006 Jul-Aug, 275-278. REFERENCE #2: Kabi S. Cryptococcus Laurentii: an unusual cause for atypical pneumonia in hematological malignancy. Journal of Mahatma Gandhi institute of medical sciences 25 (1): 45 REFERENCE #3: Smith N. Perspectives on non neoformans cryptococcal opportunistic infections. Journal of community hospital internal medicine perspectives. Oct 2017. 214-217 DISCLOSURES: No relevant relationships by Timothy Carroll, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response

A CASE OF FATAL INVASIVE PULMONARY ASPERGILLOSIS IN A PATIENT WITH ANTI-MDA5 DERMATOMYOSITIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is classically associated with solid/hematologic organ transplant, hematologic malignancy, and severe neutropenia. The presence of anti-melanoma differentiation-associated gene-5 (MDA-5) autoantibodies in dermatomyositis confers a higher risk of rapidly progressing interstitial lung disease (RP-ILD) resulting in high mortality. We present a case of a patient with a history of diagnosed anti-MDA5 dermatomyositis who developed acute fulminant IPA. CASE PRESENTATION: We report a case of a 65-year-old female with a history of MDA-5 positive dermatomyositis who presented to the hospital with symptoms of dyspnea, fever, and hypoxemia. A CT scan demonstrated bilateral peripheral patchy ground-glass opacities (image 1). The differential diagnosis was broad and included bacterial vs viral vs pneumocystis pneumonia. Upon presentation, she had been on 24 days of prednisone on a dose of 60mg for the first 14 days and 40mg daily for the last 10 for her recent diagnosis of dermatomyositis. Also on the differential was the possibility of RP-ILD. She was started on high-dose steroids at 60mg prednisone daily and broad-spectrum antibiotics. Given high clinical suspicion for RP-ILD, she was started on IVIG therapy. Bronchoscopy with bronchoalveolar lavage grew mold. A repeat CT days later demonstrated dramatically worsening bilateral pulmonary infiltrates with a consolidative pattern (image 2). The patient's clinical status worsened and required intubation for worsening respiratory failure. Eventually, galactomannan resulted positive on the initial and repeat BAL specimens (Ag Index 5.75, 3.62 respectively) with positive serum galactomannan (Ag index 3.33) making IPA the most likely diagnosis. She was started on voriconazole and micafungin with little clinical response and suffered from progressive respiratory decline leading to death. DISCUSSION: Our patient had anti-MDA-5 dermatomyositis with likely RP-ILD who experienced a rapid respiratory decline in the span of weeks. What makes this case interesting is the fulminant lung injury that occurred without a clear and early known diagnosis. Most notably the highest possibilities were RP-ILD and infection, now known to be from Aspergillus spp. The relationship between IPA in chronic respiratory diseases (CRD) particularly interstitial lung diseases is still unclear. There is some evidence to suggest even a short course of steroids may lead to substantial risk in those with underlying CRD such as dermatomyositis-related ILD. This may be the case in our patient who had been on high-dose prednisone before her presentation. CONCLUSIONS: There is the possibility that anti-MDA-5 positive dermatomyositis increases susceptibility to IPA, possibly through a mechanism related to RP-ILD. If characterized further, it may warrant more aggressive surveillance and treatment for invasive pulmonary fungal infections in these patients. REFERENCE #1: Naaraayan, A., Kavian, R., Lederman, J., Basak, P., & Jesmajian, S. (2015). Invasive pulmonary aspergillosis - case report and review of literature. Journal of community hospital internal medicine perspectives, 5(1), 26322. https://doi.org/10.3402/jchimp.v5.26322 REFERENCE #2: Sontheimer R. D. (2017). MDA5 autoantibody-another indicator of clinical diversity in dermatomyositis. Annals of translational medicine, 5(7), 160. https://doi.org/10.21037/atm.2017.03.94 DISCLOSURES: No relevant relationships by Merwise Baray, source=Web Response No relevant relationships by Deepa Lazarous, source=Web Response No relevant relationships by Robert Varipapa, source=Web Response No relevant relationships by Samuel Wopperer, source=Web Response

THROMBOTIC MICROANGIOPATHY: A RARE SEQUELAE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thrombotic microangiopathy (TMA) is characterized by many etiologies, however it is not often described as a complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). Failure to identify the relationship between TMA and ERCP may result in delay of diagnosis and poor patient outcomes. We present a case of a young healthy female who developed TMA after ERCP. CASE PRESENTATION: A 26-year-old woman presented to the hospital with complaints of abdominal pain, nausea and vomiting. An abdominal CT scan showed cholelithiasis and choledocholithiasis and the patient was scheduled for ERCP. She tolerated the procedure well with no immediate complications. However, a day after procedure, labs showed elevated serum lipase and amylase levels with renewed abdominal pain. Two days after ERCP she developed fever, severe thrombocytopenia, anemia and acute kidney injury (AKI) evidenced by elevated serum creatinine. A preliminary diagnosis of thrombotic thrombocytopenic purpura (TMA) was considered. Plasma exchange therapy with platelet transfusion and high dose steroids was initiated. She also received multiple packed red cell transfusion for severe anemia. ADAMTS13 antibody testing returned low at 53% with negative anti-ADAMTS13 IgG. After 7 daily sessions of plasma exchange platelets improved, AKI and anemia resolved, and the patient was discharged from the hospital. DISCUSSION: Literature review shows only about 4 cases of ERCP induced TMA. A well-known complication of ERCP is pancreatitis and a rare unfortunate sequela of this is TMA. There is a known correlation between TMA and pancreatitis, though the mechanism by which this occurs is still not well understood. Endothelial damage, cytokine release and platelet activation are thought to be the pathophysiological links between these two conditions (1). Cytokines cause release of ultra-large von-Willebrand factor (VWf) molecules that attach to activated platelets promoting aggregation, clumping and thrombus formation. There is concomitant reduction in serum ADAMTS13, which would normally cleave the ultra-large VWf, due to pancreatic enzyme degradation. CONCLUSIONS: This case illustrates how complicated the diagnosis of TMA can be, but also points out how clinical judgment is imperative to prompt early treatment and increase favorable outcomes. TMA caused by ERCP is rare, but recognizing this link is important for immediate initiation of life saving treatment. Reference #1: 1. Malik, F., Ali, N., Ahsan, I., Ghani, A. R., & Fidler, C. (2016). Eculizumab refractory thrombotic thrombocytopenic purpura secondary to post-endoscopic retrograde cholangiopancreatography pancreatitis in a patient. Journal of community hospital internal medicine perspectives, 6(6), 32310. DISCLOSURES: No relevant relationships by Kitson Deane, source=Web Response No relevant relationships by Abidemi Idowu, source=Web Response

STATIN-INDUCED DIAPHRAGMATIC MUSCLE WEAKNESS CAUSING HYPERCAPNIA AND SHORTNESS OF BREATH

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Statins are commonly used medications in medicine. One of their side effects is muscle injury. We present a case of a patient (PT) who presented with chronic shortness of breath (SOB) and hypercapnia secondary to statin therapy. CASE PRESENTATION: A 77 y/o male with history of DM, HTN, HLD and Asthma; no smoking or toxic exposures presented to the hospital due to SOB on exertion for the last 5-6 months. His SOB was relieved by rest, but noted hoarseness and weakness with discomfort of his legs. Upon admission PT had stable VS, physical exam was unremarkable with no muscle tenderness and clear lungs. Chest X-ray and CT scan (Fig. 1) showed only bibasilar atelectasis and small lung volumes. Cardiovascular work up was negative. Laboratory evaluation was significant for an elevated Creatinine Kinase of 470 U/L. He had been on Atorvastatin with increased dosage by his PCP a few months prior. Serum HCO3 level was elevated at 35 mmol/L without diuretic use. An arterial blood gas confirmed hypercapnia(pH 7.37, PCO2 58, PO2 67, O2 saturation at 92% at room air). Thyroid function test were normal and myositis work up was sent for ESR, Anti-Jo, Anti-Ro, Anti-La antibody, Lactate levels, ANA and were found to negative. BMI was calculated to 28. Aldolase was elevated at 21 U/L. Pulmonary Function testing (PFT) were performed showing a restrictive lung pattern with FEV1/FVC ratio of 89% with FVC 41% predicted, TLC was 3.39 L (68% predicted) (Fig.2), DLCO was 49% predicted with a normal DLCO/VA. Tidal-flow volume loop was almost completely shifted to the left suggesting that the PT couldn’t take a deeper breath as there was no airway obstructive pattern. After workup was completed, the statin was discontinued and the PT's SOB slowly improved over the course of a few days. He was successfully discharged without additional intervention. DISCUSSION: Statin induced myopathy is the most common side effect associated to statin therapy(1). Hypercapnia secondary to statin therapy causing diaphragmatic muscle weakness is uncommon in the literature.(2) Most people associate statin myopathies with skeletal muscle and diaphragmatic involvement is not routinely considered. In our PT any underlying lung pathology was ruled out by imaging studies along with central causes for hypoventilation. Autoimmune myositis work up was negative, thyroid function was normal and PFT were consistent with a restrictive lung defect suggesting muscle weakness given negative CT findings for interstitial lung disease or other extra-thoracic causes of restriction. Cognitive biases can frequently limit consideration of rarer causes of dyspnea. CONCLUSIONS: Hypercapnia in the hospital setting is mistakenly attributed to COPD without other causes being considered. We suggest statin induced myopathy causing diaphragmatic weakness to be considered as a differential on PTs on statin and unexplained SOB especially due to the frequency of their use. Reference #1: Upreti, Sunita, Beenish Fayyaz, and Ramchandran P. Bongu. "Anti-HMG-CoA reductase myopathy, an undesirable evolution of statin induced myopathy: a case report.” Journal of Community Hospital Internal Medicine Perspectives 9.1 (2019): 33-35 Reference #2: Biagioni, Bradly, et al. "Diaphragmatic Weakness Due to Statin Myopathy.” Chest 150.4 (2016): 1085A. DISCLOSURES: No relevant relationships by Walter Chua, source=Web Response No relevant relationships by Christian Lopez-Padilla, source=Web Response

SUCCESSFUL REMOVAL OF A DENTAL CROWN WITH CRYOTHERAPY AND RIGID BRONCHOSCOPY

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Aspiration of foreign bodies occurs most frequently in extremes of age, and these bodies are commonly lodged in the segment of the right middle lobe.1 Foreign body aspiration in adults is associated with such risk factors as alcoholism, drug abuse, mental retardation, and neuromuscular conditions. The most common foreign bodies aspirated are food and broken fragments of teeth.1,2 Foreign body aspiration can cause such complications as atelectasis, obstructive pneumonitis, bronchial stenosis, and endobronchial actinomycosis.3 CASE PRESENTATION: Our patient is a 47yo M with a known history of epilepsy who presented after his primary care physician found a foreign body on chest x-ray (CXR). One year prior to presentation he had a seizure and a dental crown was dislodged from his front tooth. He immediately experienced wheezing, and minor shortness of breath, but this resolved within days. Nine months later he began to have chest pain, worse in the mornings and with inspiration, moderate in severity, and associated with cough and fever. He was treated with multiple rounds of antibiotics as an outpatient for presumed bronchitis. CXR revealed what was believed to be his crown and a right upper lobe post-obstructive pneumonia. He underwent flexible bronchoscopy, which noted complete occlusion of the entrance of the right upper lobe with granulation tissue surrounding the crown. In order to facilitate the removal of the foreign body, rigid bronchoscopy was used. Forceps failed to grasp the crown, and it was successfully removed with the cryoprobe. During the retrieval the crown was dislodged and moved to the right lower lobe where it was finally removed from the patient. He was noted to have purulent drainage coming from the right upper lobe after removal of the foreign body. He did present to the emergency room three days later for pneumonia and acute hypoxemic respiratory failure. CXR noted diffuse interstitial infiltration and he was admitted for treatment. DISCUSSION: Cryoadhesion has been an effective means of removing foreign bodies, and this modality has been successful with various objects. The cryoprobe has been shown to be most useful with objects that have a high water content given to its ability to obtain sub-zero temperatures in a matter of seconds. CONCLUSIONS: Rigid bronchoscopy has benefit over flexible for centrally located foreign bodies, large amount of granulation tissue, or objects that require manipulation. Complications from rigid bronchoscopy include pneumothorax, bleeding, and hypoxia. Patient selection and the skill level of the operator are crucial in preventing adverse outcomes.2 Reference #1: Oke V., Vadde R., Munigikar P., et al. Use of flexible bronchoscopy in an adult for removal of an aspirated foreign body at a community hospital. Journal of Community Hospital Internal Medicine Perspectives. 2015;5(5):28589. Reference #2: Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO. Tracheobronchial foreign bodies: Presentation and management in children and adults. Chest. 1999;115:1357–62. Reference #3: Folch E, Mehta AC. Foreign body aspiration and flexible bronchoscopy. In: Flexible Bronchoscopy. 3rd edition: Wang KP, , Mehta AC, Turner JF. Chichester, Wiley-Blackwell. 2012, pp 238–49. DISCLOSURES: No relevant relationships by Benjamin Batson, source=Web Response No relevant relationships by Ximena Solis, source=Web Response No relevant relationships by Andres Yepes, source=Web Response

Clozapine-Induced Recurrent Pulmonary Thromboembolism

Clozapine-Induced Recurrent Pulmonary Thromboembolism

Journal of Community Hospital Internal Medicine Perspectives Second Anniversary

The Journal of Community Hospital Internal Medicine Perspectives (JCHIMP) was conceived in 2010. This was done in the context of the rapid expansion of Internet-based journals. The number of Internet journals had increased worldwide, including in the United States. There were a significant number of Internet medical journals published in the United States, but what was lacking was a journal aimed at scholarly activity and community hospital departments of medicine. Community hospitals constitute more than half of the training programs in the United States. (Published: 7 January 2013) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2 : 20218 - http://dx.doi.org/10.3402/jchimp.v2i4.20218

Images in clinical medicine: Popeye's sign

A72-year-old male with a history of bilateral rotator cuff tears presented to his primary care physician (PCP) with complaints of chronic shoulder pain and fatigue. Upon physical examination, a palpable mass was noted between his left shoulder and elbow, although he could not recall when the mass first appeared. Left arm cogwheel rigidity was also noted on physical examination. He denied any tenderness to the left shoulder, elbow, or previous mass palpation. The location of the mass is consistent with Popeye’s sign, a hallmark of biceps tendon rupture. He was referred to an orthopedic surgeon for evaluation but opted instead to strengthen his shoulder through physical therapy. (Published: 5 July 2013) Citation: Journal of Community Hospital Internal Medicine Perspectives 2013, 3 : 20688 - http://dx.doi.org/10.3402/jchimp.v3i2.20688

Pulmonary Thromboembolism Associated With Clozapine

Pulmonary Thromboembolism Associated With Clozapine

Anniversary issue of JCHIMP

This is the fourth quarterly publication of the Journal of Community Hospital Internal Medicine Perspectives (JCHIMP), www.JCHIMP.org. It could be looked at as the journal’s first birthday. It has the largest number of published manuscripts to date. The theme of this issue is case reports; it includes a perspective on case reports as well as numerous interesting cases that have been submitted by residents and faculty. (Published: 26 January 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 15885 - DOI: 10.3402/jchimp.v1i4.15885

Osborn waves in a hypothermic patient

A56-year-old man presented with hypothermia (rectal temperature of 30.1°C) and hypotension after being found by emergency medical services (EMS) on his basement floor. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with a rate of 62 bpm, right bundle branch block, prolonged QT interval (QTc of 564 ms), wide QRS (110 ms), and a prominent J wave in the precordial leads (Fig. 1). After the patient was warmed to a normal core body temperature, hydrated, and made normotensive, repeat ECG showed a normal sinus rhythm of 79 bpm, right bundle branch block, prolonged QT (QTc of 488), and resolution of the J waves (Fig. 2). (Published: 26 January 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 10742 - DOI: 10.3402/jchimp.v1i4.10742

CT scan for suspected acute appendicitis

Appendicitis is common with a 7% lifetime risk for an individual in the United States. Mean age at diagnosis is 22 years old. While frequently clinically obvious, by 2006, more than 90% of patients diagnosed with appendicitis had a CT scan of the abdomen and pelvis performed. Use of CT scans has allowed a decrease in false-negative rate at appendectomy to under 10% from a rate of approximately 20% before routine use of CT scan. In addition, the rate of perforation has decreased from nearly 30% to under 15%. In the pediatric population, initial ultrasound is often recommended, with CT utilized if the sonogram is inconclusive (Fig. 3). (Published: 26 January 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 10926 - DOI: 10.3402/jchimp.v1i4.10926

Imaging of carotid artery dissection

A32-year-old woman presented to the emergency room complaining of a headache and blurred vision in her left eye. Two weeks before presentation she felt ‘sinus pressure’ and heard a swishing sound in her left ear associated with pain and tightness on the left side of her head, face, and neck, most prominent at the angle of the jaw. She sought emergent attention when she felt a ‘gritty sensation’ in her left eye and noted that her left eyelid was red and droopy. On evaluation vitals were normal. Her forehead showed no vasomotor or sudomotor changes. She had an injected left conjunctiva with miotic pupil (left 3 mm, right 5 mm) which was reactive to light and accommodation. Corneal fluorescein uptake and fundoscopic exam were normal. Vision was 20/20 in both eyes. Extraocular movements were normal, but the patient complained of pain in the left eye. The higher cortical, other cranial nerve, motor, sensory, and cerebellar functions were normal. Imaging studies showed a left internal carotid artery dissection extending up to the base of the skull. (Published: 16 July 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2 : 18645 - http://dx.doi.org/10.3402/jchimp.v2i2.18645

Perspective on plagiarism

Plagiarism is the ‘action or practice of taking someone else’s work, ideas, etc and passing it off as one’s own’. The word plagiarism was first recorded in the seventeenth century, and it originated from the Latin word plagiarius, which means ‘kidnapping’. How close does a written piece have to be to another to be considered plagiarism? A match of more than 10% to other’s existing works is one. This can occur in certain situations, for example, according to Segal et al. and others, more than 5% of those applying to a prestigious Northeastern United States teaching hospital exceeded 10% similarities when writing personal statements. This appears particularly problematic for international medical graduates. In a recent survey of internal medicine community hospital programs that we conducted through the Community Hospital Education and Research Network (CHERN), more than one-half of the replying programs were dominated by English as a Second Language (ESL) residents 82%. (Published: 30 April 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2: 18048 - http://dx.doi.org/10.3402/jchimp.v2i1.18048

The value of reporting cases

When I wrote my first case report and it was published in a premiere medical journal (1), I was thrilled. The acceptance meant the world to me. It was a remarkable case with a unique combination of coexisting problems. Most importantly, we thought it was a one-of-a-kind case of cryptococcal infection emerging in a Cushingoid patient who had become adrenally excessive by virtue of an ACTHsecreting lung cancer. We thought it was the first case of disseminated cryptococcosis secondary to endogenous steroid excess. Previously, cryptococcal infections secondary to Cushing’s syndrome had been associated with exogenous steroids. Four months later, a letter to the editor in the same journal (2) pointed out that our literature review had missed a previous similar case published in the New England Journal of Medicine in 1959 (3). The respondent closed with ‘Does it matter who is first?’ (Published: 26 January 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 15884 - DOI: 10.3402/jchimp.v1i4.15884

In the SOAP: the Supplemental Offer and Acceptance Program (SOAP) from the perspective of a Community Hospital Residency

The Supplemental Offer and Acceptance Program (SOAP) was developed by the National Residency Matching Program (NRMP) as a way to modernize and streamline the ‘Scramble’ process for unfilled positions during Match Week of the Main Residency Match. As we all know, competition for residency spots is becoming more fierce, and the number of total unmatched applicants to PGY-1 positions (8,794 in 2010) continues to rise as unfilled PGY-1 positions (1,060 in 2010) continue to fall (1). Historically, the Scramble would begin on Tuesday at noon EST and conclude at noon on Thursday. The majority of spots were allotted within 4 hours, and over 90% were filled with 48 hours in 2009 and 2010 (2). In those hours, there was widespread panic, lots of wheeling and dealing and a huge disorganized influx of faxes, telephone calls, and emails. (Published: 16 July 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2 : 18712 - http://dx.doi.org/10.3402/jchimp.v2i2.18712

Splenic infarction associated with bacterial endocarditis and aortic valve vegetations

Of patients with left-sided endocarditis 20-47% have septic embolization to the spleen with varying degrees of clinical presentation. The natural history varies based on the size and location of the infarct. Larger and more peripheral infarctions are more prone to form abscesses and cause splenic rupture, whereas smaller infarcts may go largely unnoticed and only be detected on incidental imaging. Splenic abscesses are felt due to embolized septic material or secondary infection in a patient with bacteremia. (Published: 15 October 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2 : 19299 - http://dx.doi.org/10.3402/jchimp.v2i3.19299

Imaging diagnosis of aspergilloma

A 55-year-old man with Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS), has a history of noncompliance to antiretroviral therapy with recurrent opportunistic infections due to clostridium difficile and mycobacterium avium complex. He presented to the hospital with fever, diarrhea, weight loss and generalized weakness, and was diagnosed with clostridium difficile colitis and treated as such. His absolute CD4 count was 153 cells/microliter and HIV1-RNA 2,190 copies/mL. (Published: 30 April 2012) Citation: Journal of Community Hospital Internal Medicine Perspectives 2012, 2 : 17276 - http://dx.doi.org/10.3402/jchimp.v2i1.17276

Resident scholary work in the community hospital setting

The primary reason to develop the Journal of Community Hospital Internal Medicine Perspectives ( www.JCHIMP.org ) was to focus on and encourage the scholarly work of faculty and physicians in training (students, residents, and fellows) in community teaching hospitals. Our secondary focus was based on the belief that the presence of quality research is of itself a goal to strive for. Our third focus was to encourage compliance with the stated goals of the Internal Medicine Residency Review Committee regarding residency scholarly work. (Published: 17 October 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 8486 - DOI: 10.3402/jchimp.v1i3.8486

Open access, a revolution in scholarly publishing

Iwould like to thank Robert Ferguson, MD and the Editorial Team of the Journal of Community Hospital Internal Medicine Perspectives (JCHIMP) for the opportunity to write this commentary and congratulate them on the launch of the Journal which will serve as a valuable resource for physicians and other health professionals practicing in community settings. I am also very appreciative of their decision to publish JCHIMP as an open access (OA) journal which will add significantly to its value and impact. (Published: 9 May 2011) Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1 : 6350 - DOI: 10.3402/jchimp.v1i1.6350