Monday, August 10, 2015

Joint pains in a heavy smoker

By Jason Hew, MD; Dat Pham, MD
Department of Internal Medicine and Division of Medical Oncology
University of Florida Health, Jacksonville


A 52 year old male with a past medical history of Hypertension, osteoarthritis and 40 pack years of cigarette smoking came to the emergency department with an episode of acute onset left-sided chest pain and dyspnea. The chest pain was described as severe, sharp in quality and not reproducible with physical exertion. He denied any associated cough, fever, anorexia or weight loss. He also complained of worsening symmetrical joint and limb pains and stiffness involving his elbows, hands, knees, legs and feet over the past 6 months, which impaired his ability to function as a construction worker and subsequently resulted in the loss of his job. He was medically evaluated for his musculoskeletal pains prior to this presentation and was being treated for osteoarthritis.  On physical exam he was noted to have marked clubbing of the digits of his hands and feet. The remainder of his exam was unremarkable. A thorough cardiac evaluation was performed including an EKG and serial cardiac enzymes, followed by an exercise stress test and echocardiogram which were unrevealing for cardiac pathology. A CT of his chest revealed a 3 cm left upper lobe lung mass. This mass was later biopsied and found to be adenocarcinoma of the lung. This case highlighted secondary hypertrophic osteoarthropathy and its association with lung cancer. This will hopefully be useful in improving clinical awareness of this relationship.

Figure 1: Clubbing of the toes

Figure 2A: Clubbing of the fingers


Figure 2B: Clubbing of the fingers

Figure 3: CT Chest without contrast showing a 3 cm left lung lass (adenocarcinoma of the lung)

Wednesday, April 22, 2015

Bubble trouble – Undiagnosed gastric adenocarcinoma noted on a chest radiograph

By William C. Palmer, MD; Kayin B. Jeffers, MD; Rene D. Gomez-Esquivel, MD

A 62 year old male with no previous medical problems presented to our emergency department with two weeks of progressive exertional shortness of breath and six weeks of progressive esophageal dysphagia for solids. Hemodynamics were found to be stable, but melena was noted on rectal examination. A chest radiograph was performed which demonstrated clear lung fields, but was notable for a round opacification in the gastric bubble (A). Serum labs demonstrated a hemoglobin level of 5.1mg/dL. Volume resuscitation, intravenous proton pump inhibitor therapy, and blood transfusion were initiated.

Endoscopic gastroduodenoscopy visualized a bleeding and friable mass filling the gastric fundus and extending up into the cardia and across the gastroesophageal junction (B). Biopsy and histological exam with hematoxylin and eosin demonstrated invasive gastric adenocarcinoma (C). Immediate referral was made to consultants in Gastrointestinal Oncology and Foregut Surgery.
Figure A

Figure B


Figure C




FIGURE LEGEND:A: Chest radiograph with opacity in gastric bubble highlightedB: Endoscopic images of large gastric adenocarcinomaC: Histological exam (hematoxylin and eosin stain; 10x and 20x)

Thursday, November 13, 2014

Apical Hypertrophic Cardiomyopathy

By: Jacob I. Lewis, M.D., Jordan Ray, M.D., Brian P. Shapiro, M.D., Patricia J. Mergo, M.D. Department of Internal Medicine and Division of Cardiology Mayo Clinic, Jacksonville, FL

A 69 year old female presents to the cardiology clinic after being told she has an “enlarged heart” after undergoing a pre-operative ECG for cataract surgery. On presentation, she is asymptomatic without any exercise limitations, shortness of breath, chest pain, palpitations, orthopnea, or pedal edema.




Thursday, September 11, 2014

Colonic Ulceration from Metastatic Breast Cancer

By William C. Palmer1, MD; Raouf E. Nakhleh2, MD; Andrew Keaveny, MD1

1Division of Gastroenterology and Hepatology and 2Department of Pathology
Mayo Clinic
Jacksonville, Florida

A female in her 50’s with a history of mastectomy who subsequently received adjuvant chemotherapy for ER/PR+, HER2- metastatic breast cancer presented with abdominal pain. She underwent colonoscopy for further evaluation. At colonoscopy, diffuse ulceration and contact bleeding from the rectum to the cecum were observed, the most prominent changes being noted in the proximal colon. The findings were suspicious for an inflammatory or infectious etiology (Figure 1a and 1b). 


Wednesday, July 23, 2014

Pericarditis in a 13 year-old male

Fernando Bula-Rudas, MD, Fellow, Pediatric Infectious Diseases, University of Florida - Jacksonville and Mobeen H. Rathore, MD, Chief, Pediatric Infectious Diseases and Immunology Wolfson Children’s Hospital
A 13 year-old male presented with complaint of acute chest pain and throbbing pain in both shoulders. Pain worsened and then it localized in the sternal area. There was no history of fever, upper respiratory tract or GI complaints, trauma or excessive physical activity. Evaluation included EKG, chest x-ray (Figure 1) and CBC that yielded normal results. Patient was discharged on NSAIDs and rest with a diagnosis. Chest pain did not improve and now he had rapid breathing. Patient returned and a repeat chest x-ray (Figure 2) showed cardiomegaly. An echocardiogram showed pericardial effusion with normal systolic function. He underwent pericardiocenthesis and fluid sample had 10,235 WBCs/mm3 with 97% neutrophils and 1% lymphocytes and LDH of 394 IU/L. Patient was started on vancomycin and ceftriaxone because of these results. Antibiotics were stopped after 48 hours of sterile pericardial fluid cultures. Patient improved clinically and was discharged. Serology for Coxsackie virus reported IgM positive for serotype A7 and A16.

Saturday, May 31, 2014

Diffuse Neurofibromas

Nolan Caldwell, MD Stanford University, Department of Emergency Medicine

A 47 year old female with severe aortic stenosis and dilated cardiomyopathy was evaluated for aortic valve repair. She had a normal childhood followed by development of large cutaneous masses in her 20’s.

Eventually diagnosed with Neurofibromatosis type 1 (an autosomal dominant disease), she did not undergo medical evaluation until her current presentation. Although patients with NF-1 have increased rates of pulmonic stenosis, aortic stenosis is not more frequent in NF-1.

Congenital Cardiomyopathy Presenting as Palpitations and Heart Failure in an Otherwise Healthy Adult

Christopher Austin M.D, Brian Shaprio M.D., Patricia Mergo M.D., Majdi Aschi D.O. and Fred Kusumoto M.D. 

A 48-year-old female was referred to our facility for an electrophysiology evaluation for placement of a prophylactic automated implantable cardioverter-defibrillator (AICD) due to decreased left ventricular ejection fraction (LVEF) in the setting of non-ischemic cardiomyopathy.

The patient was an otherwise healthy female despite a prior history of long-standing palpitations, which were rare, self-limited, and not associated with syncopal episodes. She denied dyspnea, chest pain, edema, and exercise intolerance. Prior echocardiography revealed a LVEF of 35%, and a diagnosis of non-ischemic cardiomyopathy was established with a normal coronary angiogram. Over the past ten years, the patient received excellent management for asymptomatic LV dysfunction including maximal-dose beta blocker and angiotensin converting enzyme inhibitor.

More recently the patient’s LVEF normalized to 55% based on echocardiogram, however there was concern over hypertrabeculated myocardium. An electrocardiogram-gated cardiac magnetic resonance imaging (MRI) exam was performed which revealed low-normal LVEF in the setting of myocardial non-compaction. This was characterized by severely non-compacted myocardium with deep recesses and trabeculations ranging from the apex to the mid-myocardial wall [Figure 1].

Figure 1. Long axis four chamber cardiac MRI at end-diastole. Trabeculated myocardium (a) extends from mid left ventricle (LV) to the apex. Compacted myocardium (b); right ventricle (RV); left atrium (LA).