Patient: Female, 44Final Diagnosis: Post-cholecystectomy Mirizzi syndromeSymptoms: Abdominal pain • nausea • vomitingMedication: Tramadol • hydromorphone • prochlorperazineClinical Procedure: US • MRCP • ERCP• choledochoscopySpecialty: Gastroenterology and HepatologyObjective:Management of emergency careBackground:Mirizzi syndrome is biliary obstruction caused by extrinsic compression of the distal common hepatic duct by a gallstone in the adjacent cystic duct or infundibulum of the gallbladder. Post-cholecystectomy Mirizzi syndrome (PCMS) is Mirizzi syndrome in the post-surgical absence of a gallbladder. This case report of PCMS and review of the literature illustrates the diagnostic and therapeutic challenges in evaluating and managing Mirizzi syndrome.Case Report:A 44-year-old female with a remote history of laparoscopic cholecystectomy presented to a community teaching hospital with acute and severe upper abdominal pain and tenderness. Laboratory data revealed markedly elevated transaminases of a magnitude most often observed with hepatitis from acute viral infection, ischemia, or exposure to a hepatotoxin. PCMS was ultimately diagnosed at endoscopic retrograde cholangiopancreatography after being misdiagnosed as choledocholithiasis on magnetic resonance cholangiopancreatography. After transfer to an academic quaternary care referral hospital, the patient’s extrahepatic biliary tree was reportedly cleared of gallstones following endoscopically-directed shock-wave lithotripsy performed at repeat endoscopic retrograde cholangiography.Conclusions:Recognizing post-cholecystectomy syndrome, in general, and PCMS, in particular, is critical when caring for patients presenting with persistent or recurrent symptoms or signs of biliary obstruction following cholecystectomy. Expediently identifying and definitively relieving the biliary obstruction, while limiting the risk of iatrogenic complication, is the priority when caring for patients with PCMS.

Open Access Original Article

Sinus venosus atrial septal defect (SVASD) is a rare adult congenital heart disease which permits shunting of blood from the systemic to the pulmonary circulation and is commonly associated with anomalous pulmonary venous return.We report a case of a 27-year-old man with a history of premature birth and unilateral cryptorchidism who was admitted for syncope. Electrocardiogram (ECG) demonstrated atrial fibrillation (AF)and S1Q3T3 pattern along with an incomplete right bundle branch block. Transthoracic echocardiography (TTE) suggested the presence of right ventricular pressure and volume overload and severe right ventricular and right atrial enlargement. The agitated saline study was negative suggesting no inter-atrial communication. Transesophageal echocardiography (TEE) demonstrated a superior SVASD and raised the possibility of an anomalous pulmonary venous connection. Chest computed tomography identified the right superior pulmonary vein connection to the superior vena cava.The diagnosis of SVASD poses multiple challenges from the variety of symptoms to the selection of appropriate imaging and the complexity of surgical treatment.

Patient: Male, 74 Final Diagnosis: Rheumatoid arthritis (RA) Symptoms: Joint pain • joint swelling Medication: — Clinical Procedure: — Specialty: Rheumatology Objective: Rare co-existance of disease or pathology Background: Paget disease is a primary bone disease with adjacent joint involvement that commonly presents with degenerative arthritis. Rheumatoid arthritis (RA) is mainly an articular disease with symmetric synovitis of the peripheral joints and usually does not involve the lumbar spine. The coexistence of Rheumatoid Arthritis and Paget disease of bone is infrequently reported in the literature. Case Report: A 74-year-old African-American man was referred for the investigation of symmetrical polyarthritis, left upper arm joint deformity, and low back pain. X-ray imaging of the hands demonstrated bilateral erosions and deformities of the carpal bones, and the left arm showed mixed lytic and sclerotic bone lesions. Laboratory tests showed high levels of rheumatoid factor and alkaline phosphatase. Analysis of the synovial fluid from the left knee was consistent with inflammatory joint disease. Conclusions: The purpose of this article is to present the diagnostic challenges associated with the rare coexistence of Rheumatoid Arthritis and Paget disease of bone in the same patient. The correct diagnosis of both diseases has important consequences in preventing treatment delay.

Immunoglobulin D (IgD) monoclonal gammopathy is a rare subtype of multiple myeloma (MM) associated with a worse prognosis compared with other variants of MM. A 61-year-old man with no known past medical history presented with complaints of abdominal pain, nausea, and vomiting for three weeks. Physical examination revealed mild epigastric tenderness. Laboratory data demonstrated a significantly elevated creatinine with minimal proteinuria and small abnormality in the gamma fraction. Ultrasound of the kidneys described normal-sized kidneys. Serum-free light chains and immunofixation were consistent with IgD kappa monoclonal gammopathy. Kidney biopsy revealed cast nephropathy. Bone marrow biopsy was remarkable for sheets of CD 38+ plasma cells comprising approximately 80% of the marrow cells. Recognizing the atypical presentation of IgD MM is crucial to facilitate early diagnosis and management and improve the prognosis of this subtype of MM.