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Know Your Colleagues, Know Yourself: Checking In on Mental HealthLiz Lawrence, MD, FACP

September 16, 2022

Individual and Organizational Resources That Give Agency and Provide Nurturing Safe Spaces and Supportive CommunitiesIf you or someone you know is in crisis, help is available 24/7. Text 741741 or call the National Suicide Prevention Lifeline (988 or 1-800-273-8255) or Disaster Distress Hotline (1-800-985-5990).

Patients Before Paperwork

Physician Well-being Call to Action Advocacy Toolkit: Modernize License and Credentialing Applications to Not Stigmatize Mental Health View Here! Ask Your Legislators to Expand Physician Workforce, Improve Patient Access, Promote Health Equity and Reduce Burden View Here!

Noteworthy Resources

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper Matthew DeCamp, MD, PhD, and Mark Levine, MD, for the ACP Ethics, Professionalism and Human Rights Committee

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Protective Equipment for Physicians' Mental Health By Mollie Frost ACP Internist

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After a Physician Dies by Suicide By Ryan DuBosar ACP Internist This article shares resources and discusses the multiple factors that contribute to physician death by suicide. Highlighted tools include advocating for systems changes, destigmatizing mental health help-seeking in the culture of medicine, and creating supportive communities for those associated with or affected by the tragic event. View here!

ACP Multimedia Education

Know Your Colleagues, Know Yourself: Checking In on Mental HealthLiz Lawrence, MD, FACP

September 15, 2023

Individual and Systems Resources That Give Agency and Provide Nurturing Safe Spaces and Supportive CommunitiesIf you or someone you know is in crisis, help is available 24/7. Text 741741 or call the National Suicide Prevention Lifeline (988 or 1-800-273-8255) or Disaster Disress Hotline (1-800-985-5990).

Professional Fulfillment Zone

Celebrating Over 5 Years of ACP Well-being Champions!In September, we held a special event that celebrated the history of ACP's Well-being Champion Program.

Patients Before Paperwork

Advocacy in ActionThese are scary times for public healthBy Shari M. Erickson, MPH, for I.M. Matters from ACPActions taken by leadership at the Department of Health and Human Services are creating confusion and slowly killing off the science and research that public health depends on.Read here!

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Displaying 261 - 270 of 499 in Annals of Internal Medicine: Clinical Cases

Partial Splenic Artery Embolization in the Management of Acute Immune Thrombocytopenia Refractory to Medical Treatment | Annals of Internal Medicine: Clinical Cases

Our case details a 60-year-old man with cirrhosis from hepatitis C referred to hematology for severe thrombocytopenia after right hemiglossectomy in the setting of squamous cell tongue cancer. Acute immune thrombocytopenia was diagnosed. Platelet transfusions, high-dose steroids, intravenous immunoglobulin ×2, romiplostim, and rituximab were administered without adequate platelet response (2000/µL), and patient developed gastrointestinal bleeding. Partial splenic artery embolization was performed urgently for refractory thrombocytopenia resulting in ∼60% splenic infarction. His platelet count increased in the next few days and was sustained. Our case demonstrates partial splenic artery embolization as an underused approach to severe thrombocytopenia in the setting of acute immune thrombocytopenia resistant to steroids and medications.

COVID-19–Mediated Electrical Storm Managed With Milrinone in a Vaccinated Patient | Annals of Internal Medicine: Clinical Cases

SARS-CoV-2 infection (COVID-19) can lead to an inflammatory response affecting multiple organs. Ventricular arrhythmias, including ventricular tachycardia and ventricular fibrillation (VF), have been reported in otherwise-healthy individuals who have not been vaccinated. A young, otherwise-healthy man who was vaccinated and recently diagnosed with COVID-19 was admitted for refractory VF. Common pharmaceutical agents for VF were given to no avail. VF resolved with use of low-dose milrinone infusion. An inotropic agent usually used in patients with heart failure, milrinone also possesses proven anti-inflammatory effects, which may have allowed it to succeed where the traditional agents failed.

Immune Checkpoint Inhibitor-Induced Polyarthritis: A Case Series | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors (ICIs) have revolutionized cancer care; however, they are associated with ICI-related adverse events (ICI-AEs). Polyarthritis is a rare ICI-AE. Here we describe 2 patient cases of ICI-induced polyarthritis, induced by nivolumab/ipilimumab and sasanlimab for melanoma and urothelial cancer, respectively. Both patients had a medical history of nonrheumatological autoimmune disease, developed symptoms within 8 weeks of ICI, and had negative autoantibodies. Symptoms resolved with glucocorticoids. Neither patient discontinued their anticancer therapy. These cases add to the literature on ICI-induced polyarthritis. As ICIs become the standard of care, clinicians should familiarize themselves with their adverse effects.

What and Where Else: Hypervirulent Klebsiella pneumoniae With Pyogenic Liver Abscess and Disseminated Multifocal Osteomyelitis | Annals of Internal Medicine: Clinical Cases

Hypervirulent Klebsiella pneumoniae (hvKp), a pathotype of Klebsiella pneumoniae presents many clinical challenges. hvKp often causes disseminated, invasive disease in immunocompetent hosts. It is primarily associated with pyogenic liver abscesses, but also causes osteomyelitis, necrotizing fasciitis, endophthalmitis, and meningitis. The diagnosis of hvKp is largely clinical because many laboratories lack the ability to test for the associated biomarkers. To emphasize the need to assess for disseminated invasive infection in such patients, we present a patient with hvKp who had bacteremic and tibial osteomyelitis, but also pyogenic liver abscess and multifocal osteomyelitis with a pathologic fracture.

An Atypical Presentation of Progressive Multifocal Leukoencephalopathy With Newly Diagnosed HIV Infection | Annals of Internal Medicine: Clinical Cases

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating infectious disease of the central nervous system that typically presents in immunosuppressed patients with history of AIDS, hematologic malignancies, or immunosuppressant drug treatment. We report a case that highlights the importance of differentiating PML from acute/chronic ischemic stroke. Distinction is made between acute ischemic stroke and demyelinating disease with the T2-gradient recalled-echo weighted imaging. Failure to test for HIV in patients with suspected chronic ischemic stroke can lead to increased morbidity, decreased highly active antiretroviral therapy efficacy, and poorer patient outcomes. Clinicians should strongly consider PML in immunocompromised patients with frequent, progressive neurologic symptoms.

ACTH-Dependent Cushing Syndrome in Metastatic Acinic Cell Carcinoma: A Poor Prognostic Factor | Annals of Internal Medicine: Clinical Cases

Acinic cell carcinoma (ACC) with high-grade transformation is an aggressive subtype of salivary gland neoplasm. Only a few cases of adrenocorticotropic hormone (ACTH) production in metastatic ACC have been documented. We present a patient case of ACTH-dependent Cushing syndrome (CS) that developed 18 months after surgical resection of ACC. The original tissue sample was found to stain positive for ACTH, and the development of CS coincided with aggressive progression of ACC. Our case highlights the potential significance of ACTH staining in ACC and the development of CS as a signal of dedifferentiation, disease progression, and a poorer prognosis.

Medical Management of Emphysematous Gastritis | Annals of Internal Medicine: Clinical Cases

A 95-year-old man presented to the hospital with altered mental status, sepsis, and coffee-ground emesis. His chest radiograph showed gas along the lesser curvature of the stomach, prompting abdominal computed tomography, which demonstrated intramural gastric air. This patient's clinical presentation and computed tomography findings were suggestive of emphysematous gastritis (EG). He was successfully managed with an intravenous proton-pump inhibitor and broad-spectrum antibiotics. Details of the case are presented to encourage the early diagnosis of EG, which may make conservative management more successful.

Chylothorax as the Initial Manifestation of Follicular Lymphoma | Annals of Internal Medicine: Clinical Cases

Chylothorax is the presence of chyle in the pleural space, which can occur with any disruption of the thoracic duct or its main tributaries. Here we describe the case of a 64-year-old nonsmoking woman who presented with shortness of breath and had findings of a massive right-sided chylous pleural effusion. She was subsequently diagnosed with high-grade follicular lymphoma and had chest tube placement and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone therapy with complete response.

A Case of Bilateral Subclavian Artery Stenosis Presenting as Refractory Hypotension | Annals of Internal Medicine: Clinical Cases

A 72-year-old woman presented with epigastric pain, hypotension, and tachycardia. Laboratory studies revealed anemia and lactic acidosis. Endoscopy showed gastric cancer without active bleeding. Although the tachycardia and lactic acidosis resolved shortly after a blood transfusion, her blood pressure (BP) remained low. BP measured in both her upper and lower extremities confirmed a discrepancy. Computed tomography revealed findings suggestive of bilateral subclavian artery stenosis. Bilateral subclavian artery stenosis should be suspected in a patient who presents with prolonged unexplained asymptomatic low BP measured in both upper extremities, noting the importance of also measuring the BP in all extremities.

Achromobacter Hepatic Abscess Several Months After Laparoscopic Cholecystectomy: A Case Report and Review of Literature | Annals of Internal Medicine: Clinical Cases

Achromobacter xylosoxidans is a rare pathogen that causes opportunistic and nosocomial infections in immune-compromised patients. After a cholecystectomy, dropped stones can serve as nidus for abscess formation. We describe a rare case of hepatic abscess caused by Achromobacter xylosoxidans in a 40-year-old immune-competent woman who had a laparoscopic cholecystectomy 9 months previously.

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