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University of v irginiajoUrnal of medicineInside:Clinical Vignettes . 1 Falls and Gait Instability as the Presenting Symptoms of anExtramedullary Cervical Spinal MeningiomaJ. Genda, M. Williams Glucarpidase: A Novel Therapy for Methotrexate ToxicityS. Bhojwani, M. Douvas Extranodal Diffuse Large B-Cell Lymphoma Presentingwith Involvement of the Myocardium and Large IntestineC. Hudak, J. Prichard, M. Quesenberry A Case of Relapsing Sarcoidosis with MyopathyS. Kunaparaju, R. Krishna, I. Ipkan Invoking Occam’s Razor: A Case Report of CardiacSarcoidosisL. Mirch, M. Sartin, D. Henderson Minoxidil-Associated Pericardial EffusionJ.Huang, R. Schutt, P. Pollak, J. Dent Hypertensive Emergency after Mannitol Administrationfor Ciguatera Fish PoisoningR.Schutt, P. Monteleone, D. LawrenceImages in Medicine .27 An Unusual Presentation of Multiple MyelomaK. Peichert Aggressive Potassium Repletion Leading to Iatrogenic PillEsophagitisG. Moulder Identification of Massive Free Air on SupineRoentgenogram of the AbdomenR. Schutt, P. Jackson, D.Green, M. Indihar, C. Rose, Jr Swyer-James-MacLeod SyndromeA. Zandieh, R. Becker, S. Martinez, S. EricksonACP Abstracts .33October 2011 Volume 8
Editor-in-Chief:Managing Editors:Gerald R. Donowitz M.D.Edward W. Hook Professor ofInfectious DiseasesRichard Hall, MDPeter P. Monteleone, MDHeather Y. Hughes, MDChristopher J. Arnold, MDChief Medical ResidentsReview Board:Cynthia Brown, M.D.Assistant Professor, Pulmonary and Critical CareMichael Ragosta, III, M.D.Associate Professor, Cardiovascular MedicineSteven M. Cohn, M.D., Ph.D.Associate Professor, Gastroenterology and HepatologyC. Edward Rose, Jr., M.D.Professor, Pulmonary and Critical CareJohn J. Densmore, M.D., Ph.D.Associate Professor, Internal MedicineJoel M. Schectman, M.D.Professor, General MedicineRebecca Dillingham, M.D.Assistant Professor, Infectious DiseasesAmy L. Tucker, M.D.Professor, Cardiovascular MedicineMichael G. Douvas, M.D.Associate Professor, Hematology/OncologyBrian Uthlaut, M.D.Assistant Professor, General MedicineGeorge M. Hoke, M.D.Associate Professor, General MedicineGeoffrey R. Weiss, M.D.Professor and Chief, Hematology/OncologyLewis C. Lipson, M.D.Associate Professor, Cardiovascular MedicineMichael E. Williams, M.D.Byrd S. Leavell Professor of Medicineand Professor, Pathology, Hematology/OncologyPatrick G. Northup, M.D.Assistant Professor, GastroenterologyShetal H. Padia, M.D.Assistant Professor, Endocrinology and MetabolismManager: Terry L. BennettCopyeditor: Linda Sherman, ELSPermission to reprint articles may be granted.Please contact Terry L. Bennett for permission: tll2e@virginia.eduCOPYRIGHT 2011, RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA
U N I V E R S I T YO FV I R G I N I AJ O U R N A LInformation for Authors:o fM E D I C I N EPurposeThe mission of the University of Virginia Journal of Medicine is to provide residents, fellows, and facultymembers the opportunity to publish original materials generated from their experiences in patient care orpatient care–related research. The journal will give housestaff at the University of Virginia Health System theopportunity to work with the faculty in writing medical case reports, thus providing a forum for learningabout the process of journal article submission and revision. In addition, the journal offers referring physiciansin the state of Virginia; alumni of the medicine training programs, and healthcare providers associatedwith the University of Virginia Health System the opportunity to learn from the breadth of clinically basededucational experiences generated from patient care at the University of Virginia Health System.Article SubmissionOnly original, unpublished materials will be considered for publication. Submissions should be madeelectronically by e-mail to Terry Bennett (tll2e@hscmail.mcc.virginia.edu). When submitting a manuscript,authors should provide full disclosure of any duplicate publication of any content of the paper in a coverletter to the Editor. Funding sources and any potential conflicts of interest reported in the cover lettershould also be included in the manuscript text file.Manuscript Format Authors are encouraged to follow the AMA writing style as outlined in Writing and Publishing inMedicine, 3rd Edition, Edward J. Huth, MD. Accepted manuscripts are edited in accordance with theAmerican Medical Association Manual of Style: A Guide for Authors and Editors, 9th edition. Authors arealso encouraged to refer to this guide when preparing manuscripts for submission. All submissions should Include a title page, text, references, and as appropriate, figure legends, tables,and figures. For preparation of accepted manuscripts, a manuscript text file in Word must be submitted.Figure images should be submitted in separate files, with labels. Legends for all figures should beincluded at the end of the manuscript text file. Tables must be submitted as text, not images, andincluded in the manuscript text file. Abbreviations should not be used in the title or abstract, even commonly used abbreviations. Limitthe use of abbreviation in the text, and expand all abbreviations at first mention in the text. Allmeasurements should be expressed in SI units. Generic drug names are preferred. The manuscripts must be free of any identifying patient information in order to respect confidentiality. Include the full names, highest academic degrees, and affiliations of all authors, according to theseformats:UVA faculty and students:1. Thomas Jefferson, BS, Medical Student2. Edgar Poe, MD, MPH, Assistant Professor of Medicine, Division of General MedicineNon-UVA authors:1. Herbert West, MD, Miskatonic University School of Medicine, Department of Reanimation, Arkham,MA All correspondence for this journal is handled by Terry Bennett (tll2e@hscmail.mcc.virginia.edu), soauthor addresses and other contact information are not included.i
U N I V E R S I T YO FV I R G I N I AJ O U R N A Lo fM E D I C I N EAbstractsA structured abstract of no more than 300 words for reports of original data. Structured abstracts shouldinclude the following sections: Background, explaining the clinical (or other) importance of the study andstating the objective or question addressed. Methods, describing the basic design of the study, patient orparticipant characteristics, and interventions. Results, reporting and quantifying the main outcomes of thestudy. Conclusions, providing conclusions of the study supported by the results, along with implicationsfor clinical practice. For other manuscripts, include an unstructured abstract of no more than 200 words that summarizesthe objective, main points, and conclusions of the article. No information should be reported in theabstract that does not also appear in the text of the manuscript.References All information not considered statements of common knowledge must be supported by citation ofpublished articles in the medical scientific literature. Literature sources must be cited according to AMA guidelines. List all authors and/or editors up to 6; ifmore than 6, list the first 3 followed by “et al.” Number references in the order they appear in the text;do not alphabetize. In text, tables, and legends, identify references with superscript Arabic numerals.Abbreviate names of journals according to PubMed guidelines.Examples of Reference Style:Journal Article:1. Crusher BC, McCoy LH, Bashir JS, et al. Extraterrestrial transfusion methods. J Interplanetary Med.2800;13:53-65.Book:2. West H. Reanimation in Theory and Practice. Providence, RI: Miskatonic Universtiy Press; 1923.Guidelines for Article Review ProcessManuscripts will be blindly reviewed by two members of the review board. Decisions regarding acceptancefor publication will be based on the strength of the paper compared with other papers in the literature,the need for the University of Virginia Journal of Medicine to represent a balanced picture of importantadvances in internal medicine, and the number of accepted papers in the paper’s category and topic area.In addition, reviewers will score submissions based on the following criteria.i.Originality of case presentationii.Clarity of teaching pointsiii.Balanced and evidence-based representation of recommendationsiv.Quality of the writingii
U N I V E R S I T YO FV I R G I N I AJ O U R N A Lo fM E D I C I N EUVa Journal Article Categories:Clinical Vignettes: length - 800-1600 words Clinical vignettes describe patients with classic presentations of rare diseases or common diseases withunusual or interesting aspects. Authors are encouraged to present a brief review of pertinent literatureand discuss salient parts of the patient diagnosis. Clinical Vignettes are coauthored by the resident orfellow and the attending physician who supervised the care of the patient and focus on one or twoteaching points related to diagnosis, management, or treatment.UVa Images in Medicine: length - maximum 250 words Presentation of a radiographic image or digital photograph of an intriguing patient case accompaniedby a brief case report. Authors should focus on the diagnosis and management of underlyingpathophysiology related to the presented image and associated medical condition.Medical Grand Rounds: length - 1600-3200 words A review article written by an attending physician who recently presented during Medical GrandRounds at the University of Virginia. Specifically, this article should provide readers a thorough overviewof recent scientific and technologic advances, discussed during the Grand Rounds and developed atthe University of Virginia, which have contributed to the overall understanding and management ofspecific conditions.Clinical Review Article: length - 1600-3200 words A comprehensive review article written by an attending physician based on a thorough assessment ofthe literature with the goal of outlining the current understanding of the pathophysiology and up-todate practice guidelines for specific clinical topics.Clinical Commentary: length - 1600-3200 words The Clinical Commentary offers attending or resident physicians an opportunity to provide a uniqueclinical perspective on a component of patient care, education, or medical advancements. The scopeof this submission is quite broad and may incorporate discussion of controversial issues in the practiceof medicine, topics related to or examples of patient care that have affected the author’s personal orprofessional outlook, and/or commentaries about health care policy or public health.The Academic Hospitalist Corner: length - 1600-3200 words This section is dedicated to the emerging field of inpatient hospitalist medicine. Article submissionsmay be case reports, clinical reviews, perspective pieces, and/or commentaries on medical educationand training as related to hospitalist medicine.Chief Resident Clinical Medicine Conference: length - 1600-3200 words A report that describes a rare or unusual case, with an emphasis on processes of differential diagnosis,work-up, and management that are also applicable to commonly encountered medical conditions. Thearticle should include a thorough discussion of several diagnostic dilemmas with the goal of addressingboth the management of complex pathophysiology and the process of systematically arriving atdifficult diagnoses.Tutorials in Medicine: length - 1600-3200 words A classic presentation of a disease process with board-style questions about the case. This is followedby a discussion of one or more of the following: differential diagnosis, pathophysiology, management,or treatment. These should be authored by an attending physician with resident or fellow physiciancollaboration.Clinical Research : length - 1600-3200 words Presentation of original data from clinical research conducted wholly or in part at the University ofVirginia. Research accepted for publication must be current, well-executed, and applicable to patientcare.iii
U N I V E R S I T YO FV I R G I N I AJ O U R N A LClinical Vignetteo fM E D I C I N EFalls And Gait Instability as the Presenting Symptoms of anExtramedullary Cervical Spinal MeningiomaJeffrey Genda, Medical StudentMark E. Williams, MD, Ward K Ensminger Distinguished Professor of Geriatric MedicinePlease address all correspondence to Terry L. Bennett, tll2e@virginia.edu.Central nervous system neoplasms are categorizedon the basis of their location, either within thenervous tissue (intramedullary) or external to thetissue (extramedullary). Extramedullary tumorsare predominately nerve sheath tumors andmeningiomas and tend to produce symptoms byexerting a mass effect that compresses the brain orspinal cord.His medical history was significant for multileveldegenerative disk disease, including severe c-spinefacet arthropathy and L4-L5 radiculopathy andrecurrent episodes of isolated upper extremitymyoclonus, as well as suspected systemic amyloidosisas evidenced by previous frontal lobe hemorrhages,abnormal spinal fluid proteins, urinary kappa andlamda light chains and left anterior hemifascicularblock, and complete right bundle branch block onelectrocardiogram. He had declined biopsy or otherdiagnostic studies to confirm the diagnosis.Meningiomas usually have a broad dural attachmentand typically grow slowly and insidiously, oftenproducing a vague clinical picture that can beconfused with musculoskeletal disorders or otherlesions within the central and peripheral nervoussystems.1 We present an elderly patient witha multifaceted neurologic history and a chiefcomplaint of falls, whose previously known spinalpathology could explain a clinical picture of gaitinstability and radiculopathy. However, his rapidprogression of symptoms and key physical diagnosisfindings suggested an additional possibility.His family history was significant for a sister withsystemic amyloidosis. Social history and review ofsystems were noncontributory.Physical examination revealed an elderly gentlemanin no apparent distress, who walked into the clinicwith an antalgic gait, using a cane. His bloodpressure was 200/82 mm Hg, pulse 62 beats perminute and regular; respirations were 16 per minuteand unlabored and oxygen saturation was 99% onroom air.Case DescriptionA 90-year-old gentleman with a history ofdegenerative disk disease and gait instabilitypresented to his primary care physician withincreasing episodes of falling. Until recently,the patient had described his occasional fallsas mechanical, resulting from being tripped upon his walker. However, over the last 4 weeks heexperienced several episodes of sudden upper andlower extremity weakness resulting in ground levelfalls, after which he was able to regain most of hisstrength. The patient did not experience any visualchanges, dizziness, or lightheadedness prior to hisfalls.A significant finding was a 2/6 blowing holosystolicmurmur most consistent with mitral regurgitation.His range of motion in all 4 extremities was full,and was not limited by shoulder pain. There wasno tenderness to palpation of the spine or rightscapula. He had significant dextroscoliosis, aswell as an antalgic, wide-based gait. Neurologicalexamination showed normal cranial nerves.Strength was 5/5 in all 4 extremities, with spasticityin the upper extremities, without atrophy orfasciculations. A very fine postural tremor was notedin his upper extremities that persisted with point-topoint testing. Upper extremities were hyperreflexic,and lower extremities were normoreflexic. Jaw-jerkreflex was within normal limits. Further testingrevealed a hyperreflexic right pectoralis muscle.There was a mild stocking-glove distribution ofdiminished primary sensory modalities in the upperand lower extremities, as well as pain to palpation inhis lower extremities. Romberg testing results werenormal.The patient also complained of worsening urinaryincontinence, but attributed this to ambulatorydifficulties and his inability to get to the bathroomin time. He also complained of worsening occipitalheadaches and the onset of deep right shoulderpain unrelated to movement or activity, withradiation into the upper chest.1
U N I V E R S I T YO FV I R G I N I AJ O U R N A Lo fM E D I C I N EGenda, WilliamsNeuroimagingC4 and central canal stenosis with marked corddeformity and abnormal signal (Figure 2).Because of the clinical findings of peripheralhyperreflexia with a normal jaw jerk, the patientwas scheduled for neuroimaging of his head andcervical spine. A small subarachnoid hemorrhagewas identified, and the patient was subsequentlyhospitalized. Magnetic resonance imaging (MRI)of the cervical spine revealed a homogeneouslyenhancing, dural-based extramedullary mass at T1T2 that was causing a severe mass effect on thecord (Figure 1). The lesion filled the canal at thelevel of the right neural foramen, causing a severemass effect on the exiting T1 nerve root. Cervicalimaging revealed marked facet arthropathy at C3-Further neurologic examination during the patient’shospitalization revealed bilateral hyperactivereflexes in the upper extremities and weakness inboth upper and lower extremities, as well as a veryactive right-sided pectoralis reflex. The patient wasstarted on steroids and underwent a C3, C4, andpartial C5 laminectomy, as well as a T1 and partialT2 laminectomy with removal of the intraduralextramedullary lesion. Pathological analysis of thelesion revealed that it was a meningioma, WorldHealth Organization grade 1.The patient’s postoperative course was uneventful,and he was discharged home for rehabilitation. Onfollow-up evaluation in the outpatient clinic he waswalking normally, using a cane for confidence, andhis urinary incontinence was improved.DiscussionMeningiomas are most often intradural andextramedullary, and account for approximately25% of all primary spinal cord tumors.2 They arebelieved to arise from arachnoid cluster cells, andtherefore are often at the nerve root junction withthe spinal cord where the laterally positioned spinalarteries penetrate the cord.1 For this reason, lateralmeningiomas predominate over ventral or dorsalmeningiomas. These lesions are confined withinthe collagen-rich dural tissue and grow slowly andinsidiously within the spinal canal. As they grow,the adjacent medullary tissue is compressed anddisplaced, creating a widened subarachnoid spaceboth superior and inferior to the lesion.3Figure 1. Sagittal T2-weighted image showing anextramedullary mass at T1-T2 with spinal cord compressionin addition to marked cervical spine degeneration andmarked stenosis.Although schwannomas also tend to arise fromnerve root sheaths and can produce radiculopathy,meningiomas can be differentiated by theirextramedullary origin and myelopathic clinicalpicture. This presentation is often slow and gradual,and can be obscured by other primary neurologicdeficits, making the diagnosis elusive. As thetumor enlarges, symptoms frequently begin withregional paraspinal pain, most often at night. Thisis often followed by sensorimotor changes, notinfrequently of the Brown-Sequard type, includinga constellation of symptoms such as contralateralpain and temperature deficits, as well as ipsilateralparalysis and decreased sensation to tactile anddeep touch. As would be expected by their lateralposition, sensory and motor deficits are seenequally. As the tumor continues to grow, sphincterdysfunction can be seen as well.4Figure 2. Transverse T2-weighted image at T1-T2 showingright posterolateral tumor with mass effect and cordcompression.2
U N I V E R S I T YO FV I R G I N I AJ O U R N A Lo fM E D I C I N EFalls And Gait Instability as the Presenting Symptoms of an Extramedullary Cervical Spinal MeningiomaBefore the advent of MRI, spinal meningiomaswere confused with herniated disks, syringomyelia,pernicious anemia, and multiple sclerosis, l
Professor and Chief, Hematology/Oncology Michael E. Williams, M.D. Byrd S. Leavell Professor of Medicine and Professor, Pathology, Hematology/Oncology Manager: Terry L. Bennett Copyeditor: Linda Sherman, ELS Permission to reprint articles may be granted. Please co
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