Among the pertinent differentials for hypercalcemia, milk-alkali syndrome remains a diagnosis of exclusion following a thorough workup of other severe causes. However, several key signs may increase a clinician's index of suspicion for possible milk-alkali syndrome, including a prolonged history of antacid ingestion. Milk-alkali syndrome commonly presents with a classic triad: hypercalcemia, metabolic alkalosis, and acute kidney injury. The diagnostic workup should include evaluation of both serum and urine calcium levels, serum phosphate levels, and other hormones (parathyroid hormone, vitamin D). In the case of a confirmed diagnosis of milk-alkali syndrome, rapid correction of calcium levels is of utmost importance. We present the case and workup of an individual presenting to the emergency room with hypercalcemia, acute kidney injury, and several key systemic symptoms. Given a significant history of antacid overuse, and a thorough diagnostic workup, a diagnosis of milk-alkali syndrome was made and the patient was treated accordingly, making a full recovery. We review this rare case and important clinical pearls regarding milk-alkali syndrome.
Purpose: To report the clinical presentation and outcomes in patients with Valsalva retinopathy. Methods: This was a retrospective case series of patients diagnosed with Valsalva retinopathy between June 1, 2010, and May 31, 2020. Clinical notes, operative reports, fundus photography, and optical coherence tomography images were reviewed. Results: This study comprised 58 eyes of 58 patients. The most common causes were lifting (34.4%), vomiting (20.6%), straining (20.6%), and coughing (17.2%). Mean best-corrected visual acuity at diagnosis was 20/163. The most frequently involved vitreoretinal compartment was the subhyaloid space (42.3%) followed by the intraretinal (32.7%), intravitreal (23.1%), and subretinal (13.4%) spaces. Mean best-corrected visual acuity of all patients was 20/59 at 3 months, 20/48 at 6 months, and 20/22 at 1 year. Mean time to clearance of hemorrhage on clinical examination was 99.0 ± 18.7 days in patients who underwent observation and 4.5 ± 3.5 days after surgery in patients who received pars plana vitrectomy. Conclusion: Valsalva retinopathy is generally associated with a favorable visual prognosis. Most eyes perform well with observation although pars plana vitrectomy may be indicated in patients requiring rapid resolution of hemorrhage.
We report two cases of fibroblast growth factor receptor (FGFR) inhibitor-associated retinopathy, including the first case of Debio 1347 associated retinopathy manifesting with bilateral serous retinal detachments along the superotemporal arcades and a case of erdafitinib associated retinopathy manifesting with classic foveal serous retinal detachments. Both cases demonstrate a clear dose-dependent and reversible class effect likely secondary to downstream effects of FGFR inhibition on the MEK pathway, resulting in retinal pigment epithelial cell dysfunction, and may also involve additional mechanisms of cellular injury through inhibition of the PI3K/AKT/mTOR pathway. FGFR inhibitor-associated retinopathy appears to manifest differently among patients. [ Ophthalmic Surg Lasers Imaging Retina 2023;54:xx–xx.]
Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin's lymphoma (NHL). This subtype can be present in various extranodal sites, including the brain, bones, intestines, kidneys, adrenal glands, and other soft tissues. As demonstrated in this case, one rare site of DLBCL is the nasal septum, which presents as a rapidly enlarging mass resistant to antibiotics and steroids. The definitive diagnosis for this case involved biopsy, but further workup, such as computed tomography (CT) and fluorescence in situ hybridization (FISH), helped support the diagnosis of DLBCL. While determining the stage of the lymphoma, treatment with R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) was initiated immediately. This case demonstrates a rare presentation of DLBCL in the nasal septum and describes the significance of urgent examination as well as treatment.
Vertebral osteomyelitis (VO) is an infection of the vertebral body, most often arising secondary to hematogenous spread or contiguous spread from local soft tissue infection. Establishing a diagnosis of VO requires a high index of suspicion as patients often present with nonspecific symptoms such as pain of the affected vertebral segments along with leukocytosis and elevated inflammatory markers. Magnetic resonance imaging (MRI) has high sensitivity and specificity for detecting VO, even in the early phases of infection. Diagnosis is generally confirmed with blood cultures or vertebral biopsy demonstrating a culprit organism and treatment is tailored to the identified organism. However, some patients may have culture-negative VO that still necessitates antimicrobial treatment. Imaging alone may be an acceptable form of diagnosis that can allow for prompt empiric antibiotic therapy, reducing the need for invasive diagnostic measures. We present a case of a 46-year-old male with a past medical history of type 2 diabetes mellitus, hyperlipidemia, and prior transient ischemic attack (TIA). The patient presented with signs and symptoms of another TIA as well as new-onset neck and upper back pain. MRI in the neurologic workup demonstrated findings consistent with osteomyelitis of the C5 and C6 cervical vertebrae. Previous imaging showed no evidence of vertebral dysfunction. This patient presented with new-onset VO in the absence of systemic symptoms or elevation of inflammatory markers and no identified source of infection. Based on imaging and clinical presentation, empiric antibiotic treatment was initiated resulting in clinical improvement and resolution of VO on imaging. This case demonstrates an atypical presentation of VO and describes the benefit of MRI in recognizing infection in the absence of concurrent typical findings, which allowed for the initiation of empiric therapy.
Private equity (PE) has grown rapidly in medicine. The reintroduction of PE in ophthalmology has necessitated a greater understanding of the potential contractual relationships with PE firms from both a practice owner and an employee physician perspective. There are contractual obligations that need to be met as PE agreements are designed to ensure clear investment patterns and abide by legal mandates. A practice owner entering into a PE contract needs to consider how the practice is being valued, what their obligations are to the PE entity after the sale has been completed to attain full compensation and understand their new role at the practice. On the other hand, employee ophthalmologists must carefully evaluate the compensation package being offered in terms of the type of equity, vesting of shares, obligations to the PE firm under the agreement such as a noncompete clause, and what occurs under a subsequent sale of the practice. Overall, contractual considerations in the private equity era need to be carefully evaluated in order to ensure the agreement is in the best interest for the clinician, practice, and their patients.
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