Mary Washington Hospital

Introduction: In the absence of an immunocompromised state, a tetrad of fever, thrombocytopenia, leukopenia, and transaminitis, should prompt investigation for tick-borne illness in the appropriate season and geographic location. Our case highlights how pattern recognition and serial evaluation triggers decisive early treatment/diagnostics in life threatening Human Monocytic Ehrlichiosis (HME). Description: 61-year-old female with baseline history of anxiety/depression was hospitalized after 4 days of progressive lethargy, fevers, vomiting and diarrhea. Initial laboratory tests were significant for leukopenia, transaminitis (AST 440 U/L, ALT 340 U/L), and thrombocytopenia (platelets 68,000/µL). She was empirically started on Doxycycline and Piperacillin-Tazobactam. Further history elicited the removal of a tick 4 weeks prior without the presence of skin findings. Presentation evolved to acute hypoxic respiratory failure (P/F ratio 51mmHg) with bilateral opacities on chest x-ray (non-dependent, preserved costophrenic angles) resulting in intubation. Prior to intubation, she demonstrated lethargy, neck/back pain, and bilateral lower extremity jerking movements (normal deep tendon reflexes). Considering tick-borne illness as a highly likely cause, Doxycycline was continued, and Piperacillin-Tazobactam switched to Ceftriaxone. EEG and CT head w/o contrast were normal. CSF analysis was consistent with aseptic meningitis. Clinical improvement followed with vent liberation and she did not have residual neurologic deficits. Final disposition included 14 days of Doxycycline. The initial PCR confirmed the presence of HME (Ehrlichia Chafeensis) in the blood (without coinfection of other tick-borne disease). Discussion: Per CDC, 1,907 cases of Ehrlichiosis were reported in 2023 with highest incidence in the southeastern United States. Coinfection with Lyme and Babesiosis are common. Laboratory findings often mimic acute HIV, EBV, and acute hepatitis. E. Chafeensis species demonstrates findings for aseptic meningitis. PCR assays have the highest sensitivity/specificity within 1 week of symptom onset. Complications include seizures, coma, renal failure, and ARDS. Our case highlights how laboratory patterns, geography, and serial evaluations can streamline diagnostics leading to early treatment of Ehrlichiosis.

BackgroundCardiac rehabilitation (CR) is a key post-percutaneous coronary intervention (PCI) quality metric and is known to improve cardiovascular outcomes. Although referral rates after PCI have been described, far less is known about what occurs after a referral order is placed, specifically whether patients are successfully contacted, whether they enroll, and the barriers they encounter. This quality improvement (QI) project aimed to determine referral and enrollment rates following PCI, compare referral timing at discharge versus the first follow-up visit, and identify patient-reported and system-level barriers contributing to low CR participation.MethodsWe performed a retrospective chart review of 200 consecutive patients who were at least three months post-percutaneous coronary intervention. All patients not enrolled in the CR program at our center were prospectively contacted at home to confirm if they were referred to, and whether they were doing CR. If patients were not enrolled, reasons were explored.ResultsA total of 194 patients were discharged. The mean age was 68±11 years, and 34% (n=65) were female. The overall referral rate was 55% (n=107), including 21.6% (n=42) at hospital discharge and 33.5% (n=65) at the first outpatient clinic visit. After at least three months post-PCI, only 35 patients (18% of the entire group and 33% of those referred) were enrolled in CR. Of those with a referral order placed at discharge, only 10 (24%) were doing CR. The most common reason for non-enrollment in cardiac rehabilitation was lack of awareness of the need to enroll, reported by 58% (n=92) of respondents. In a multivariate analysis, PCI in an urgent setting and prior PCI were the only independent predictors of non-referral. Not private insurance and diabetes were independent predictors of lack of CR participation.ConclusionsReferral to, and especially enrollment in, the CR programs post-PCI remained markedly low. Enrollment tended to be lower when referrals were placed at discharge, highlighting limitations of current quality metrics that focus solely on referral placement. Improving patient and physician education and strengthening system-level processes may help support higher enrollment and more effective use of CR.

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that primarily affects joints and causes mobility problems. RA is associated with high mortality and morbidity as a result of the increased prevalence of cardiovascular disease (CVD) and cardiovascular (CV) risk factors, such as blood pressure (BP), in these patients. Exercise has a beneficial effect on CVD and CV risk factorsand improves the overall well-being of RA patients. This systematic review aims to investigate the effect of exercise on CVD and CV risk factors, specifically BP, in RA patients. We searched the relevant literature across databases such as PubMed, PubMed Central, Cochrane Library, ScienceDirect, and Google Scholar. In this study, we included English-language studies with full text and related information on the impact of exercise on CVD in RA patients. The study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. We used the Joanna Briggs Institute (JBI) appraisal method for evaluating non-randomized clinical trials (RCTs), pilot studies, and observational studies, the Assessment of Multiple Systematic Reviews (AMSTAR) checklist for systematic reviews, and the Narrative Review Checklist for the narrative review studies. Eight relevant studies were included in this systematic review. The study shows that different types of exercise, from low to high intensity, have a beneficial effect on CVD and CV risk factors such as BP in RA patients. Exercise improves mortality, morbidity, and overall quality of life in this patient population. The study strongly recommends incorporating physical activity into the management of RA patients.

Undifferentiated pleomorphic sarcoma (UPS) of the small intestine is an exceedingly rare malignancy associated with a poor prognosis, characterized by a high risk of recurrence and metastasis. The typical age of onset is between 61 and 70 years. Only a few cases of UPS in the terminal ileum have been successfully treated with complete surgical resection, followed by adjuvant chemotherapy, leading to favorable outcomes and prolonged disease-free survival. Currently, there are no standardized treatment guidelines for UPS due to the tumor’s rarity, and the role of adjuvant chemotherapy in the management of UPS in the small intestine remains inadequately explored in the literature. We present the case of a 40-year-old man diagnosed with high-grade UPS of the terminal ileum. The patient underwent successful surgical resection with negative margins, followed by adjuvant chemotherapy with the Adriamycin, ifosfamide, and mesna (AIM) regimen. At his 30-month follow-up, the patient remains disease-free. In conclusion, the complete surgical resection of UPS of the small intestine, combined with adjuvant chemotherapy, can lead to favorable outcomes and long-term disease-free survival.

Severe chronotropic insufficiency, while uncommon in psychiatric populations, presents unique challenges in patients with psychotic disorders because many antipsychotics can adversely affect cardiac rhythm by exacerbating bradycardia or prolonging the QT interval. This case report describes a young male with a complex psychiatric history, severe substance use disorder, and coexisting cardiac abnormalities, who presented with profound sinus bradycardia and a prolonged QT interval. The patient's psychiatric symptoms were compounded by medication nonadherence and illicit drug use. The patient had a history of profound sinus bradycardia (heart rates in the 20s to 30s) with a mean heart rate of 41 beats/min (SD = 4), yet remained asymptomatic from a cardiovascular perspective. Despite the presence of bradycardia and a prolonged QT interval (mean QT = 495 ms (66), QTcB = 427 (30) (Bazett), and QTcF = 448 (32) (Fridericia)), he was treated with oral olanzapine and valproate. His psychiatric symptoms improved significantly, with no exacerbation of bradycardia or QTc prolongation noted during treatment.This is a rare case of a hemodynamically stable young man treated with second-generation antipsychotics, without any notable effect on the length of the QT interval. QT prolongation is a side effect of many antipsychotics, and bradycardia tends to further prolong the QT interval, increasing the risk of adverse cardiac outcomes, such as torsades de pointes or sudden cardiac death, for patients taking antipsychotics. An interprofessional, interdisciplinary, and cohesive team can reduce the cardiac risk to the patient while effectively treating the underlying psychiatric disorders. Nonetheless, it is essential for psychiatrists to have a solid understanding of psychotropic medications and cardiac rhythms, particularly because many free-standing psychiatric facilities do not have direct access to a cardiology consult team. In this report, the authors will attempt to provide a structured framework for psychiatrists managing patients with bradycardia who require antipsychotic therapy.

The Roux-en-Y gastric bypass (RYGB) is a commonly performed bariatric surgery option for individuals with severe obesity. Although gastrointestinal (GI) bleeds are a well-recognized complication of RYGB, it is uncommon in the late postoperative period as the surgical sites heal. It can be challenging to diagnose and manage these GI bleeds due to their isolated location and, consequently, difficult accessibility via traditional endoscopy. Various approaches have been described for the management of this complication with different treatment options, and treatment can vary based on patient risk factors and presentation. We report a case of a patient with bleeding in the gastric remnant 18 years after bypass surgery. Traditional endoscopy and other imaging options were attempted before surgical intervention, with laparoscopy and intraoperative endoscopy being warranted. The patient was discharged in stable condition after spontaneous hemostasis following a complicated hospital course.

Legionella is an aerobic, intracellular, Gram-negative bacillus native to warm water sources and soils and is transmitted to humans via aerosols. While there are numerous different species of Legionella, the most commonly encountered is Legionella pneumophila, particularly serotype 1. This bacteriumnotably causes a mild, self-limited infection known as Pontiac fever, in addition to a more severe form of pneumonia calledLegionnaires' disease. Like any pneumonia, Legionnaires’ disease carries a mortality risk, making early and rapid detection crucial. This is of particular importance in immunosuppressed patients, as they possess a weakened cell-mediated defense. As with any intracellular organism, host immune defense plays a crucial role in the protection against the Legionella species, as cell-mediated immunity is vital in restricting intracellular growth. For detection, the least invasive and most commonly used test for Legionella is a urine antigen test (UAT). However, one major limitation of the UAT is that it only detects Legionella pneumophila serotype 1 antigen, which can lead to false negatives. Cultures, typically obtained from respiratory secretions, are usually the next diagnostic test used due to their ability to detect more species of Legionella than just Legionella ​​​​​​pneumophila serotype 1. However, while broader than UAT, cultures lack sensitivity and can take days to show any growth. Given the limitations of these first-line diagnostic tests, the following case report highlights that further testing with polymerase chain reaction (PCR) may be necessary to definitively rule out Legionnaires’ disease in already high-risk, immunosuppressed patients when clinical suspicion is strong.