Background: Septic arthritis is a rare but potentially fatal complication of intra-articular corticosteroid injection, commonly caused by Staphylococcus aureus. The risk is higher in older adults and those with diabetes, rheumatoid arthritis (RA), immunosuppression, or a history of recent joint procedures. Diagnostic delay is possible, as non-infectious arthritis can present with similar features. Although rituximab is generally considered safe, rituximab-associated hypogammaglobulinemia may increase susceptibility to severe infections. We report a case of methicillin-sensitive Staphylococcus aureus (MSSA) septic arthritis with hematogenous vertebral seeding following intra-articular corticosteroid injection in a patient receiving rituximab therapy. Case: A 73-year-old man with seropositive RA, treated with prednisone, methotrexate, hydroxychloroquine, and rituximab, presented with one week of progressive knee pain, swelling, and erythema following an intra-articular corticosteroid injection performed several days earlier. He met criteria for severe sepsis. Arthrocentesis revealed purulent fluid, and cultures grew MSSA, consistent with blood culture results. The patient underwent two surgical washouts and received intravenous cefazolin. During hospitalization he developed new thoracic back pain. Magnetic resonance imaging demonstrated T5-T6 osteomyelitis/discitis with early epidural phlegmon, consistent with hematogenous spread. Blood cultures cleared after six days of antibiotic treatment and source control, and he completed eight weeks of intravenous antibiotic therapy. Discussion: Intra-articular corticosteroid injections can precipitate rapidly progressive septic arthritis with potential for distant seeding, particularly in immunosuppressed individuals. Early arthrocentesis, prompt source control, and surveillance for secondary foci, including vertebral osteomyelitis, are critical. Infection risk assessment prior to rituximab initiation and judicious use of intra-articular injections in high-risk patients are recommended.
Background: Takotsubo Syndrome (TTS) is a transient, stress-induced cardiomyopathy that mimics acute myocardial infarction in the absence of obstructive coronary artery disease. Although often self-limiting, TTS may lead to serious complications, including left ventricular (LV) thrombus formation. Case Summary: A 73-year-old woman with a complex medical history was referred to the emergency department for an abnormal electrocardiogram. She reported transient dyspnea and indigestion but denied chest pain. Laboratory evaluation demonstrated elevated high-sensitivity troponin I and B-type natriuretic peptide. Electrocardiography showed new diffuse T-wave inversions. Coronary angiography revealed non-obstructive coronary artery disease. Transthoracic echocardiography demonstrated apical akinesis with a large LV thrombus and mildly reduced ejection fraction. The patient was treated with systemic anticoagulation and supportive therapy, resulting in complete recovery of ventricular function and thrombus resolution on follow-up imaging at five months. Discussion: LV thrombus is an uncommon but clinically important complication of TTS, occurring in approximately 2–3% of cases, likely related to apical hypokinesis and catecholamine-mediated endothelial injury. In the absence of definitive guidelines, anticoagulation for approximately three months is commonly recommended in patients with LV thrombus or severe systolic dysfunction. Conclusion: LV thrombus can complicate TTS even with only mildly reduced systolic function, underscoring the importance of early imaging and timely anticoagulation
Background: Pneumonia remains a major cause of morbidity and mortality among people living with HIV (PLHIV), particularly in low- and middle-income countries. Despite the availability of antiretroviral therapy (ART), early mortality after hospitalization for pneumonia remains high. Indian data on short-term mortality predictors in HIV-associated pneumonia are limited. Methods: We conducted a prospective observational study of HIV-positive adults admitted with pneumonia to a tertiary-care hospital in North India between April and December 2025. Clinical, laboratory, microbiological, and radiological parameters were recorded at admission. Patients were followed for 30 days. The primary outcome was all-cause 30-day mortality. Predictors of mortality were assessed using univariate analysis and multivariable logistic regression. Results: Fifty HIV-positive adults were included. The study flow is shown in Figure 1. Baseline characteristics are summarized in Table 1. Thirty-day mortality was 72%. Hypotension at admission and requirement of inotropic support were independently associated with mortality (Table 2). Disseminated tuberculosis was strongly associated with death. ROC analysis of laboratory predictors is presented in Table 3. Conclusions: Mortality among HIV-positive adults hospitalized with pneumonia remains alarmingly high. Hemodynamic instability and tuberculosis are dominant drivers of early mortality. Early recognition of shock and prompt tuberculosis management are essential to improve outcomes.
Ischemic colitis is the most common form of intestinal ischemia and is typically associated with acute hypoperfusion states such as shock or dehydration.1 Chronic low-flow states related to persistently low baseline blood pressure may represent an underrecognized contributor to recurrent disease in the absence of classic acute triggers.2 We present a case of a 54-year-old woman with recurrent, biopsy-proven ischemic colitis occurring in the setting of persistently low blood pressure documented across multiple clinical encounters. Unlike many patients with ischemic colitis, she lacked documented atherogenic, autoimmune, radiation-related, or vasospastic risk factors, and CT angiography showed patent mesenteric vasculature. Review of her longitudinal course demonstrated recurrent left-sided ischemic colitis over several years, patent mesenteric vasculature on CT angiography, and persistently low outpatient and periprocedural blood pressures. Blood pressure–directed therapy with midodrine and nonpharmacologic measures was associated with improved blood pressure control and decreased frequency of episodes. This case highlights chronic low-flow physiology related to persistently low baseline blood pressure as a plausible contributor to recurrent nonocclusive ischemic colitis and emphasizes the importance of reviewing longitudinal blood pressure patterns in patients without an obvious acute precipitant.
Thoracentesis is a commonly performed bedside procedure for diagnostic evaluation or symptomatic relief of pleural effusions. Although generally considered low risk, prior studies comparing complication rates between aspiration methods, particularly manual and vacuum-assisted aspiration, have reported mixed results. We therefore compared complication rates between these two methods among patients undergoing ultrasound-guided thoracentesis by a hospitalist-led procedure service at a community teaching hospital. Thoracentesis-related complications, including pneumothorax, hemothorax, procedure site bleeding, and re-expansion pulmonary edema were assessed. A total of 96 patients underwent manual aspiration and 97 underwent vacuum-assisted aspiration. Patient demographics and comorbidities were similar between groups with no statistically significant differences. Overall complication rates were low, with no statistically significant difference between manual and vacuum-assisted aspiration (1.0% vs 2.1%, P=1.00). These findings provide additional comparative safety data for bedside thoracentesis. The retrospective design and low event rates may have limited detection of small but clinically meaningful differences, which larger, prospective studies could better define.
Hidradenitis suppurativa (HS) is a chronic dermatologic condition characterized by painful inflammatory nodules, abscesses, and draining sinus tracts, predominantly affecting intertriginous regions and significantly impairing patients' quality of life. These lesions are prone to relapsing, with many patients experiencing painful recurring flares. HS patients frequently visit emergency departments during flares and often end up requiring hospitalization. This may be due to limited access to outpatient dermatologic care. Therefore, hospitalists must possess the knowledge and skills to effectively manage HS flares in the inpatient setting. Optimal management of HS involves a multimodal approach, including wound care, topical and systemic medications, and pain management. While systemic antibiotics are frequently used for their antiinflammatory effects, their selection is controversial due to concerns about resistance. This article provides an approach to HS in the acute setting.
Background: Spontaneous Coronary Artery Dissection (SCAD) is an important non-atherosclerotic cause of acute coronary syndrome (ACS), predominantly affecting younger females. Despite increasing recognition, data on gender-based differences in SCAD presentation and outcomes remain limited, particularly in South Asian populations. Methods: This retrospective case series included 24 patients diagnosed with SCAD at Abbas Institute of Medical Sciences (AIMS) between January 2022 and March 2025. Patient demographics, clinical presentation, angiographic findings, management strategies, and outcomes were analyzed with a focus on gender-based differences. Results: Of the 24 patients, 17 were female (70.8%) and 7 were male (29.2%). Females were younger and had fewer traditional cardiovascular risk factors. Chest pain was the most common symptom (91.7%), and NSTEMI was the predominant ACS type. Conservative management was favored in females, while PCI was significantly more common in males (71.4% vs 11.8%, p = 0.004). All patients survived the acute episode; two experienced recurrent SCAD. No 30-day mortality was observed. Conclusion: SCAD predominantly affects younger females with minimal risk factors and generally has favorable short-term outcomes. However, males may present with more severe forms requiring intervention. These gender differences highlight the need for individualized diagnostic and therapeutic approaches.
Cushing syndrome is a rare but life-threatening endocrine disorder associated with a classic constellation of physical exam findings (e.g. “moon facies”, abdominal striae, etc.). However, thorough biochemical testing is needed to confirm this diagnosis. We present the case of a 35-year-old male with multiple hospitalizations across a variety of healthcare institutions for heart failure, cellulitis, uncontrolled hypertension, and diabetes. While an adrenal mass was eventually identified on imaging, classic signs of Cushing syndrome – including violaceous striae, truncal obesity, and facial plethora – were missed during prior admissions. This case illustrates the diagnostic delay that can result from incomplete physical exams. It highlights the importance of maintaining a high index of clinical suspicion for Cushing syndrome in patients with suggestive features and unexplained cardiometabolic complications. Finally, it underscores how factors like the social determinants of health exponentially amplify the complexity of disease management even after diagnosis
Background/ Purpose: To analyze the sex distribution of physicians in a specific subspecialty, identify factors influencing subspecialty choice in internal medicine, assess job satisfaction, and evaluate burnout levels among Internal Medicine (IM) trainees and specialists. Methods: A questionnaire-based study was conducted using the Abridged Job Descriptive Index (AJDI) for job satisfaction and the Maslach Burnout Inventory (MBI) for burnout. Participants included IM residents, fellows, attendings, and hospitalists considering fellowship. Descriptive and statistical analyses, including Fisher's exact test, were performed using R to assess trends across subspecialties grouped by fellowship competitiveness. Results: A total of 162 IM physicians participated, with a male predominance in highly competitive subspecialties and female predominance in others. Clinical rotations were the most influential factor in subspecialty choice (64.2%, p=0.012), with most first exposures occurring during residency. Over half reported job satisfaction; depersonalization burnout was significantly higher in the least competitive fellowship group (p=0.023). Conclusion: This study highlights key gender disparities, the strong influence of clinical rotations, and moderate levels of job satisfaction across IM subspecialties, with higher depersonalization in less competitive fields. Declining interest in certain subspecialties reflects concerns about work-life balance, compensation, and limited exposure. Residency programs and policymakers should enhance early exposure, mentorship, and implement targeted incentives to improve recruitment into underserved but essential specialties.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have expanded beyond glycemic control to include cardiovascular and renal risk reduction, with recent approval for reducing major adverse cardiovascular events in individuals with obesity or overweight and established cardiovascular disease. Increasing attention has focused on their potential applications in neurodegenerative disorders and substance use disorders (SUDs), supported by mechanistic links to neuroinflammation, mitochondrial function, and central reward pathways. However, clinical evidence remains heterogeneous and disease-specific, with discordance between biological mechanisms, biomarker changes. In Alzheimer disease, phase 3 trials of oral semaglutide (EVOKE and EVOKE+) did not demonstrate slowing of clinical progression despite biomarker effects. In Parkinson disease, early-phase signals suggesting benefit have not been replicated in larger trials, arguing against a consistent class effect. In alcohol use disorder, randomized and observational studies suggest reductions in craving and alcohol-related outcomes, although residual confounding remains substantial. Current evidence does not support off-label use of GLP-1RAs for neurodegenerative disease or SUDs. For clinicians, their role remains within approved cardiometabolic indications, with emerging relevance in comorbidity recognition, safety monitoring, and consideration of clinical trial referral.These findings are particularly relevant for general internists managing patients with overlapping cardiometabolic disease, cognitive impairment, and substance use disorders.
Background: Pleural effusion is a common manifestation of autoimmune and connective tissue disorders, but large-scale data on its incidence, risk factors, and outcomes are limited. This study aimed to assess the clinical characteristics, hospital course, and outcomes of patients with pleural effusion associated with autoimmune diseases compared to those without autoimmune conditions. Methods: We conducted a single-center retrospective cohort study of adult patients admitted with pleural effusion. Patients were divided into two groups: those with autoimmune diseases (study group, n = 1,346) and those without autoimmune conditions (control group, n = 1,278). Data were extracted from electronic health records, and subgroup analyses were performed for rheumatoid arthritis and systemic lupus erythematosus. Statistical comparisons were made using t-tests and chi-square tests. Results: Patients with autoimmune diseases were slightly younger (61.4 vs. 64.1 years, p = 0.002) and had a higher prevalence of exudative effusions (50.9% vs. 44.2%, p = 0.01). Mean length of stay (LOS) was significantly longer in the autoimmune group (10.2 vs. 8.8 days, p < 0.001), with SLE patients experiencing the longest hospitalization (12.3 days). Thoracentesis was more frequent among autoimmune patients (39.2% vs. 31.5%, p < 0.001), whereas chest tube placement was more common in controls (22.9% vs. 15.8%, p < 0.001). Mechanical ventilation was required more often in autoimmune patients (14.0% vs. 5.5%, p < 0.001). Corticosteroid and antibiotic use were also higher in the autoimmune cohort. Conclusion: Autoimmune pleural effusions are usually exudative, require respiratory support, prolong hospitalization, and warrant prospective studies to improve risk assessment and management.
The rise in use of herbal and dietary supplements, which are regulated as food rather than as drugs by the Food and Drug Association, poses the risk of unknown and potentially severe side effects. We describe the case of acute liver injury, characterized by significant elevation in AST and ALT, likely induced by the consumption of an over-the-counter supplement containing alpha lipoic acid (ALA). Our patient trusted in a “natural” alternative to Western medicine for management of neuropathy, which was ultimately detrimental to her liver. An immediate and sustained improvement in liver enzyme levels was noted with discontinuation of the patient's daily supplements. Multiple studies have demonstrated the hepato-protective effects of ALA, however data on its adverse effects is limited and not readily available. This is the case for most over-the-counter dietary and herbal supplements available to consumers. In fact, certain animal studies have reported that in high doses, ALA can have negative effects on the liver. While safety and efficacy trials are limited and lag behind the industry’s growth, case reports are instrumental in sharing such information.
Lyme disease is the most common tick-borne disease in the United States. Lyme neuroborreliosis occurs when systemic infection leads to neurologic involvement. Neuroborreliosis presents with a wide spectrum of clinical manifestations but classically presents with facial nerve palsy. Here, we present a case with a rare constellation of symptoms including radicular back and abdominal pain, ileus, rash, and SIADH due to Lyme disease with suspected neuroborreliosis. This case highlights the importance of recognizing atypical presentations of Lyme disease, especially for patients in Lyme endemic areas.
Granulomatosis with polyangiitis (GPA) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis classically involving the respiratory tract and kidneys. Although musculoskeletal symptoms are common, they are rarely the initial or dominant presentation, which may lead to diagnostic delays. We present the case of a man in his 40s who initially presented with acute asymmetric oligoarthritis and constitutional symptoms. Initial evaluation for infectious and crystal-related etiologies was unrevealing. During hospitalization, he developed cutaneous vasculitic lesions, including punctate digital lesions and subungual hemorrhages, prompting further investigation. Imaging revealed bilateral pulmonary nodules, and serologic testing demonstrated markedly elevated PR3-ANCA levels. Lung and skin biopsies were compatible with early changes of granulomatosis with polyangiitis. The patient demonstrated rapid clinical response to high-dose glucocorticoid therapy. This case highlights the diagnostic challenges of GPA when presenting with predominant musculoskeletal symptoms. Early consideration of vasculitis, timely serologic testing, and tissue biopsy are essential to avoid delays in diagnosis and prevent disease progression.
Hospitalist medicine has grown considerably over the last 30 years. What began as internal medicine physicians filling the role of primary care physicians for their hospitalized patients has expanded to other specialties. This growth has created a need for both administrative and clinical support for these hospitalist specialties. To meet the needs of the adult Internal medicine-based group, a small community hospital created an administrative structure in order to facilitate clinical and administrative needs. As the administrative group began providing support to other specialties, this led to integration within the group. The program has grown to seven specialties and 56 physicians and 17 advanced practitioners. Benefits have included assistance in providing sufficient staffing, payroll, ensuring clinical quality, and interfacing with both other specialties and nursing. Challenges have included supporting vastly different needs of multiple specialties and the large number of physicians within the group.
Background: Eosinophilic esophagitis (EoE) frequently coexists with atopic conditions, but the impact of atopy on inpatient outcomes and health care utilization remains unclear. This study evaluated national trends, hospitalization characteristics, endoscopic intervention rates, and the association between atopic comorbidities and clinical outcomes among adults hospitalized with EoE from 2016–2022. Methods: A retrospective analysis was conducted using the Nationwide Inpatient Sample (NIS) 2016 to 2022. Survey-weighted descriptive statistics, trend analyses, and multivariable survey logistic and linear regression models assessed associations between atopy and inpatient outcomes, including length of stay (LOS), total hospital charges, in-hospital mortality, and need for esophageal dilation. Subgroup analyses were performed for primary diagnosis EoE encounters and sex-stratified cohorts. Results: Among 41 million U.S. adult hospitalizations, 6,561 involved EoE, 24% had at least one atopic comorbidity. Atopic patients were younger but had slightly higher comorbidity burden. Atopy prevalence, LOS, and mortality rates remained stable over time, while hospitalization costs increased by approximately $2,825 per year. In adjusted models, atopy was not associated with mortality or charges. Comorbidity burden was the strongest predictor of mortality. Atopy was independently associated with shorter LOS, with a dose-response effect with increasing atopy burden. Among all EoE hospitalizations, 32.1% underwent inpatient EGD and 5.2% required esophageal dilation; atopy was not associated with dilation risk, whereas older age, lower socioeconomic status, and geographic region were significant predictors even when EoE is the principal reason for hospitalization. Conclusion: These findings improve understanding of inpatient EoE care and point to socioeconomic and regional disparities in management.
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare ANCA-associated vasculitis characterized by asthma, eosinophilia, and small-vessel vasculitis. Cardiac involvement occurs in up to 62% of cases but is more commonly associated with ANCA-negative disease; MPO-ANCA positivity typically correlates with vasculitic manifestations such as neuropathy and glomerulonephritis rather than isolated cardiomyopathy. We present a 65-year-old man with adult-onset asthma who developed acute dyspnea, markedly elevated high-sensitivity troponin (peak 1980 ng/L), peripheral eosinophilia (peak 1550/mm³), and new left ventricular systolic dysfunction (LVEF 30–34%) with normal coronary angiography. He improved rapidly after intravenous corticosteroids, with LVEF normalization to 55–60% within six weeks. MPO-ANCA was positive (6.0 U; normal
Background: Mpox (formerly monkeypox) is a double-stranded DNA virus with increasing global prevalence, particularly among men who have sex with men (MSM) and individuals living with HIV. Co-infections with other viruses such as HSV and Varicella have been reported, but no documented cases with Coxsackievirus exist to date. Case: We report the first known case of co-infection with Mpox and Coxsackie B virus in a 30-year-old transgender female with well-controlled HIV. The patient presented with a diffuse painful rash, perianal lesions, rectal pain, and constitutional symptoms. Physical examination revealed characteristic vesiculopustular lesions of Mpox, and laboratory testing confirmed co-infection with Mpox by PCR and Coxsackie B virus by positive serology. The patient improved with supportive care and was discharged with isolation precautions, post-exposure prophylaxis for high-risk close contacts with the JYNNEOS vaccine, and appropriate follow-up recommendations. Discussion: Mpox and Coxsackievirus share overlapping clinical features, complicating early diagnosis, particularly in immunocompromised hosts. While the patient’s HIV was well controlled, her immune profile suggested underlying immune activation, potentially influencing disease severity and presentation. This case highlights the importance of maintaining a broad differential in MSM and HIV-positive populations presenting with a rash and systemic symptoms. Conclusion: This case underscores the need for comprehensive diagnostic evaluation in high-risk patients, including consideration of co-infections. Routine screening and preventive strategies, including vaccination, warrant further study in immunocompromised populations.
Contrast-associated acute kidney injury (CA-AKI) is a known complication following coronary angiographic procedures using iodinated contrast media (ICM). The risk of CA-AKI is multifactorial, dependent largely on estimated glomerular filtration rates. The most important and accepted hospital-based preventive strategy involves both a reduction of iodinated contrast and multi-hour pre- and post-intervention normal saline hydration. Because of time constraints, neither ambulatory surgical centers (ASC), nor outpatient-based laboratories (OBL) can provide similar degrees of pre- and post-intervention hydration. The utilization of carbon dioxide (CO2) imaging, intravascular ultrasonography, and limited iso-osmolar contrast agents may provide an alternative preventive strategy.
Introduction. Cryptococcal meningitis (CM) primarily affects immunocompromised individuals, but up to 20% of cases occur in immunocompetent patients. However, there are limited clinical comparisons between immunocompromised and immunocompetent patients. Methods. This is an IRB approved, single-centered retrospective chart review study. Patients aged >18 admitted between 2012 and 2022 with Cryptococcus neoformans meningitis were included. Demographic, associated conditions, clinical data, and clinical outcomes were obtained. Patients were categorized into immunocompromised and immunocompetent groups. Results. 37 patients with CM were identified, with 32 (86.5%) immunocompromised patients and 5 (13.5%) immunocompetent patients. The median time to first lumbar puncture was 1.07 days (IQR -0.43, 2.84) in immunocompromised versus 3.89 days (IQR 0.20, 12.1) in immunocompetent groups. ICU care was required in 7 (21.9%) immunocompromised patients and 2 (40.0%) immunocompetent patients. There were 8 readmissions (25.0%) within 30 days and 5 (15.6%) recurrences in the immunocompromised group while no readmission or recurrence among the immunocompetent group. Overall mortality was greater in the immunocompromised group than the immunocompetent group, with 13 deaths (40.6%) versus 1 death (20.0%), respectively. Conclusions. Based on our results, we speculate a greater delay in diagnostic lumbar puncture and greater disease severity requiring ICU level of care in the immunocompetent group compared to the immunocompromised counterpart. However, long-term outcomes such as mortality, recurrences, and readmissions were lower in the immunocompetent group. These findings may help guide future large dataset studies.
