An 86-year-old male presented to the emergency department with fevers and tachycardia. Given concern for sepsis, a broad infectious workup was pursued. Though no source of infection was identified, the patient was found to have an elevated procalcitonin level. The patient subsequently developed painful joint effusions of the knees, which on arthrocentesis were consistent with calcium pyrophosphate deposition (CPPD) or "pseudogout". His symptoms of fevers and arthralgias resolved with anti-inflammatory agents. CPPD is a known cause of systemic inflammatory response syndrome (SIRS) in elderly patients. Procalcitonin has been studied as a biomarker for distinguishing infectious from non-infectious causes of SIRS, although its use in CPPD and other crystal arthropathies is not well-defined. The current case is the first to describe elevated procalcitonin specifically attributable to acute pseudogout flare and highlights the need for further study of this biomarker in non-infectious, pro-inflammatory states.

Patients returning from travel to a foreign country often present with atypical infections that can present as diagnostic challenges. Although rarely seen in the United States, Salmonella infections are commonly seen in Sub-Saharan Africa. The common clinical manifestations of Salmonella infection include fever and diarrhea; however, about 5% of cases of non-typhi Salmonella progress to bacteremia. Here, we present a case of a unique presentation of Salmonella infection manifesting as a prostatic abscess in an immunocompetent patient.

Central venous catheter (CVC) placement is a common medical intervention in hospitalized patients associated with a host of complications, including cardiac tamponade. Here, we describe a case of a 61-year-old male with end-stage renal disease on hemodialysis via a right internal jugular tunneled dialysis catheter who presented to the emergency room for hypoxia at his skilled nursing facility. He had been discharged three days prior for treatment of a Methicillin-resistant Staphylococcus aureus (MRSA) neck abscess, during which an uncomplicated right internal jugular tunneled dialysis catheter exchange was performed one day prior to discharge. On admission, bedside point-of-care ultrasound (POCUS) showed a pericardial effusion without tamponade physiology. While receiving hemodialysis on his second day of admission, he was noted to have new hypotension, and repeat POCUS was concerning for tamponade. An urgent pericardiocentesis was performed with 895 mLs of serosanguinous drainage, followed by an additional 1400 mLs of serosanguinous drainage over the next 48 hours. Interventional radiology noted a contrast leak at the distal superior vena cava at the cavoatrial junction and suspected that the etiology for hemopericardium was an endovascular injury from tunneled dialysis catheter placement.

The most common causes of tetany are hypocalcemia, hypomagnesemia, hypokalemia, and alkalosis. Most case reports of tetany in the literature include some combination of the above metabolic derangements leading to non-life-threatening symptoms. We present a unique case of severe life-threatening tetany in a 38-year-old female with a history of Crohn's disease. She was previously dependent on total parenteral nutrition (TPN) but discontinued TPN two weeks prior to presentation due to the improvement of her Crohn's symptoms with a new medication regimen. We propose that malabsorption led to multiple electrolyte abnormalities, resulting in acute tetany that subsequently caused rhabdomyolysis. This case reviews the most common causes of acute tetany and highlights the interaction between electrolytes implicated in both tetany and rhabdomyolysis. It also emphasizes the importance of considering tetany as a diagnosis in a patient with unstable vital signs and diffuse muscle spasms.

Administrative skills are essential tools for clinician educators to maximize success, however they are not considered a core component of a medical school or residency curriculum. This perspective describes domains of administrative skills that can be used with practical tools provided to increase productivity in clinical, academic, and leadership activities.

Hospitalist clinician-educators frequently work with medical students at the clinical level, but many early career educators may lack an understanding of how to effectively promote student learning and growth. We explore the role of hospitalists working with medical students in the clinical environment as it pertains to three overarching domains - clinical skills, systems-based healthcare, and career mentorship.

Steroid-induced psychosis is a known adverse effect of treatment with corticosteroids. On average, the time of onset is several days after exposure to the steroid. A 91-year-old man presented with left buttock pain with radicular features and was found to have severe left lateral recess spinal canal stenosis on MRI. He was started on a prednisone taper and developed steroid-induced psychosis one day later. He was treated with a short course of antipsychotic medication. This case discusses the unusually rapid onset of steroid-induced psychosis at a dose of prednisone that does not commonly cause this adverse effect. It emphasizes important considerations when starting steroids in patients with advanced age and comorbidities that may impact the metabolism of steroids.

Granulomatosis with polyangiitis (GPA) is one of three described anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Early diagnosis and treatment of GPA is paramount, as it may help prevent irreversible end-organ damage, especially renal and pulmonary failure. A 72-year-old male with a past medical history of lung adenocarcinoma in remission, chronic sinusitis status-post multiple sinus surgeries, and coronary artery disease presented with shortness of breath, dark urine, and asymmetric polyarthralgias. He had an acute kidney injury, leukocytosis, with urinalysis demonstrating pyuria and hematuria, without casts. Chest imaging showed cavitary nodular opacities in addition to interval increase of existing nodules compared to the most recent scan one month prior. His acute kidney injury progressed to renal failure requiring hemodialysis, and he developed an inflammatory polyarthritis. GPA was suspected clinically so he was started on high-dose intravenous corticosteroids, and subsequently plasmapheresis and rituximab. Serology returned with highly positive proteinase-3 antibodies, and cytoplasmic ANCA positivity on immunofluorescence. Renal biopsy demonstrated severely active pauci-immune glomerulonephritis. Several months after discharge, the patient passed away from gram positive bacteremia. This patient's recurrent sinusitis, pulmonary nodules, and subsequent renal failure were highly suggestive of GPA. A biopsy is recommended to confirm the diagnosis of GPA, but treatment should not be delayed if there is a high index of suspicion for the disease. Induction therapy with corticosteroids combined with rituximab or cyclophosphamide has significantly decreased the mortality of patients with GPA. Patients with GPA often have preceding history of nasopharyngeal and upper airway disease, and can present with fluctuating pulmonary infiltrates. Early recognition and treatment of patients with GPA can prevent life-threatening complications and reduce mortality.