Hutchinsoncullen1194

We report a 50-year-old man with a possible stroke 3 months earlier, recurrent shingles outbreaks, and male-who-has-sex-with-men status who presented to the emergency department with worsening confusion, lower-extremity weakness, gait imbalance, and incontinence. Given his clinically immunocompromised state, the patient was started on intravenous acyclovir. A human immunodeficiency virus (HIV) test returned positive, magnetic resonance imaging of the brain showed a ring-enhancing lesion, and lumbar puncture was positive for varicella-zoster virus. Eventual brain biopsy of the ring-enhancing lesion confirmed vasculitis. This case highlights the broad differential of a ring-enhancing lesion and the importance of early HIV screening.This case describes a 60-year-old immunosuppressed man after renal transplant who presented to the emergency department with 1 week of generalized weakness, a 20-lb unintentional weight loss, sore throat, dysarthria, dysphagia, cough, and shortness of breath. Additionally, he developed tinnitus, headaches, photophobia, and neck stiffness. He underwent an extensive workup including a lumbar puncture with meningitis and encephalitis panel, which was positive for varicella zoster virus. He never developed a dermatomal vesicular rash but had persistent dysphagia and aspiration and was eventually diagnosed with Vernet syndrome. This case highlights theories for the increase in varicella zoster virus encephalitis cases causing neurologic symptoms and proposes that this trend is likely to continue.Mycobacterium chelonae can be difficult to treat because of inherent resistance to many available antimicrobials. We present a case of a multidrug-resistant M. chelonae skin infection in a 52-year-old woman who presented with a 3- to 4-week history of painful, erythematous nodules on the bilateral lower extremities. She demonstrated dramatic improvement at her 4-week follow-up on omadacycline.Kocuria kristinae is an aerobic gram-positive bacterium that is part of the normal skin flora and not a common cause of infection. Here, we present the first reported case of community-acquired pneumonia and bacteremia caused by K. kristinae. The pneumonia was complicated by acute on chronic diastolic heart failure, resulting in acute hypoxic respiratory failure requiring intubation and mechanical ventilation.Collapsing glomerulopathy is a distinct and aggressive clinicopathologic variant of focal segmental glomerulosclerosis (FSGS). Here we present a 46-year-old man with acute renal failure from biopsy-proven collapsing FSGS and nephrotic syndrome in the setting of a diagnosis of hemophagocytic lymphohistiocytosis secondary to acute Epstein-Barr virus infection. This rare association has not been well described previously.Langerhans cell histiocytosis (LCH), a disorder characterized by aberrant function and proliferation of mononuclear phagocytic cells called Langerhans cells, usually occurs in those less then 15 years of age. Adult-onset LCH is extremely rare. We present a case of a 35-year-old woman who presented with multiple episodes of confusion, rapidly progressive cognitive decline, and multiple endocrinopathies, including diabetes insipidus. Brain imaging showed a hypothalamic lesion, and biopsy results confirmed the diagnosis of LCH. Given the wide variety of presentations and the multiple differential diagnoses of hypothalamic lesions, it is essential to be aware of this uncommon condition, especially in adults, where it may be underdiagnosed.We present a rare case of severe ectopic Cushing's syndrome in a 39-year-old woman with a rapid onset of signs and symptoms and severe hypokalemia. Further workup demonstrated an adrenocorticotropic hormone-secreting metastatic high-grade neuroendocrine carcinoma.OnabotulinumtoxinA (ONA) is an injectable neurotoxin frequently used to temporarily halt the skin changes associated with aging. Side effects are rare and usually minor, such as bruising, injection site discomfort, and headaches. However, a true hypersensitivity reaction is a serious adverse effect, and clinicians should not attempt another trial if allergy is suspected. We present a case of a benign localized cutaneous reaction following ONA injections in the forehead without signs of an allergic reaction. The rash resolved with topical hydrocortisone, and the patient was able to undergo another trial of injections without recurrence.Alopecia universalis, the complete loss of body hair, during anti-tumor necrosis factor-alpha (TNF-α) biologic therapy is a rare occurrence that has infrequently been reported in the literature. In this case, a 50-year-old man with psoriatic arthritis exhibited alopecia universalis with concomitant onychodystrophy 3 months after initiation with adalimumab. Given the role of TNF-α in the pathogenesis of alopecia areata, it would seem unlikely for anti-TNF-α drugs to induce hair loss; however, it is hypothesized that alopecia areata and its variants may not be dependent on TNF-α and that other factors must be involved. It is important to be aware of such associated adverse effects given that many patients undergo therapy with TNF-α-blocking agents.Seborrheic dermatitis is a common multifactorial skin disorder favoring the scalp, ears, face, and central chest. We present a case of an elderly woman with new-onset severe seborrheic dermatitis with massive facial hyperkeratosis mimicking ichthyosis. Clinicians should be aware of rare presentations of common conditions and should screen for associated medical comorbidities in new-onset severe skin conditions.A 66-year-old man with a recent history of herpes zoster in the second division of the trigeminal nerve presented with hyperkeratotic plaques along his left cheek and temple. A shave biopsy was found to be consistent with postherpetic hyperkeratosis. This case represents a unique presentation of Wolf's postherpetic isotopic response a new skin disorder emerging at the site of a previously healed herpetic, predominantly zoster, infection. We aim to increase awareness of an unusual complication of herpes zoster and the importance of appropriate vaccination to help protect patients from these potential postinfection effects.Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory skin condition resulting in the formation of nodules, sinus tracts, and abscesses typically in intertriginous regions. HS management is often difficult and involves a multimodal approach, evaluating the benefit of both medical and surgical treatment options, along with treating associated pain and medical comorbidities that present concomitantly with the disease. In this article, we synthesize for the nondermatology clinician the evidence for various HS treatments, along with the diagnostic and therapeutic guidelines for HS published by the British Association of Dermatologists, US and Canadian HS Foundations, HS ALLIANCE, Canadian Dermatology Association, and Brazilian Society of Dermatology. Management of HS requires an individualized, patient-centered approach due to the lack of rigorous evidence for many interventions.Patients with complex chronic disorders, such as asthma, present clinicians with important management problems. The identification of a clinical syndrome usually leads to the diagnosis of the disease entity. The next concern involves classification and a choice as to whether to use a few inclusive categories or multiple exclusive categories. Patients with asthma have multiple clinical syndromes, and these can be described as phenotypes. The use of cluster analysis allows investigators to identify phenotypes with less clinical bias. However, the identification of a particular phenotype does not necessarily provide much insight into the underlying pathogenesis. In asthma, the pathogenetic events are complex and multiple and require a classification based on endotypes. This difficulty introduces the idea of causation and models for causation. Asthma probably does not have a single universal necessary cause. However, it does have multiple sufficient component causes. Understanding these components and their interactions potentially leads to better treatment trials and more focused drug therapy. Clinicians need to identify asthmatic patients and classify them into particular phenotypes; they should also wonder about causation. Clinical investigators need to use these phenotypes to identify more homogenous groups of patients to study the underlying pathogenesis and establish endotypes. Focusing on causation can improve our understanding of disease entities, disease classification, and disease causation. This review outlines ideas relevant to causation in nearly all diseases.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or novel coronavirus disease 2019 (COVID-19) emerged from China in December 2019 and progressed to become a global pandemic. Our understanding of its pathophysiology and potential management was initially extrapolated from previous epidemics of coronaviruses like SARS and MERS. SARS-CoV-2 is asymptomatic or minimally symptomatic in more than 80% of patients and requires no additional management; however, the remaining patients progress to pneumonia and hypoxemia with ranging severity, including a smaller group that requires intensive care unit admission. To date, there are no approved treatments for SARS-CoV-2, and current management is focused on supplemental oxygen and supportive care. The antiviral medication remdesivir recently received emergency use authorization by the US Food and Drug Administration for patients with severe disease. Multiple clinical trials evaluating different treatment modalities such as antivirals, immunomodulators, convalescent plasma, and monoclonal antibodies, among others, are still ongoing. We believe that patients present with clinical phenotypes that correlate with the spectrum of disease. Each phenotype may benefit from one or multiple interventions. We discuss treatments under evaluation in clinical trials and their potential application based on clinical phenotype presentation.Residents undergo professional identity formation during training, and the integration of a teacher identity into that of a clinician is part of this process. We aimed to measure the teacher identity of incoming interns of various specialties. In this cross-sectional, survey-based study, we modified a validated teacher identity scale and distributed it to residents attending orientation at a large, academic institution. A total of 297 residents took the survey, including 272 interns; 80% (218/272) of interns completed the survey and permitted use of their data. The mean score for global teacher identity was 4.16 (SD 0.67) on a 1 to 5 Likert scale. There were significant differences between interns' current self-assessed teaching abilities and their desired future performance as teachers (P less then 0.001 for all domains). Guanosine 5'-monophosphate concentration Male interns had higher global teacher identity scores (4.27) than female interns (4.05; P = 0.02). There were no differences in global teacher identity between interns in medical, surgical, and supportive specialties. Interns who had participated in a student-as-teacher program in medical school had higher global teacher identity (P less then 0.001) than those who had not. In conclusion, teacher identity is high in incoming interns, with higher scores in men and in those who completed student-as-teacher programs in medical school.