Canadian Journal of General Internal Medicine <p><strong>The Canadian Journal of General Internal Medicine (CJGIM) ISSN: 2369-1778</strong> is the official publication of the Canadian Society of Internal Medicine (CSIM). The journal has a well respected editorial board and provides a sharp focus on the topics and issues facing the profession of Internal Medicine with a combination of society news, clinical and scientific original articles. CJGIM is published four times a year and is distributed to all members of the Canadian Society of Internal Medicine along with physicians in various subspecialties of medicine.</p> The Dougmar Publishing Group en-US Canadian Journal of General Internal Medicine 1911-1606 <p>&nbsp;</p> <p>Articles are published under a <a href="">Creative Commons Attribution - Non Commercial 4.0 International License</a>.&nbsp; Authors and users are free to copy and redistribute the material in any medium or format, with proper attribution, for non-commercial purposes. Authors retain copyright to their article.</p> Health Promotion Heroes <p>N/A</p> James Douketis ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 4 4 10.22374/cjgim.v14i1.348 Heros de la promotion de la sante <p>N/A</p> James Douketis ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 5 5 10.22374/cjgim.v14i1.349 BMJ Rapid Recommendations: A Possible Revolution in Clinical Practice Guidelines <p>BMJ rapid recommendations hold the potential to revolutionize clinical practice guidelines, achieving both timeliness, trustworthiness, and usefulness to clinicians and patients to allow well informed decisions in clinical practice.</p> Gordon Guyatt Thomas Agoritsas Lyubov Lytvyn Reed Siemieniuk Per Vandvik ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 6 12 10.22374/cjgim.v14i1.318 Gender Equity in Academic Medicine: Why Should We Care? <p>Gender disparity exists generally in academia and specifically in research and education among academic medical specialists. Reasons for this disparity include overt and unconscious biases that result in women getting fewer opportunities to lead, receiving less compensation, being excluded from networking channels in which privileged positions are discussed, and facing bias in research, including in the peer review grant process. The recent spotlight on these disparities in other sectors pushes us to focus attention on the causes and consequences of gender disparity in academic medicine and to advocate for structural changes to ensure gender equity in academic departments of hospitals and universities.&nbsp;</p> Sonia S. Anand Anita I. Anand, BA, BA, LLB, LLM ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 13 15 10.22374/cjgim.v14i1.289 Not Every Low Back Pain is a Radiculopathy <p class="p7">A 66 year old man with a history of chronic low back pain and three previous spine surgical procedures presented with new onset, acute, excruciating low back pain with dysesthesias radiating to the left leg, left leg weakness, and difficulty walking.&nbsp;</p> Pankaj Bansal Laura Grennan Karthik Mahadevappa Emilia Semenov Shanker Nesathurai ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 16 16 10.22374/cjgim.v14i1.284 Metastatic Breast Cancer Presenting as Refractory Anemia <p>We will review the case of a 71-year-old woman with an atypical presentation of stage IV breast cancer. She presented with symptomatic normocytic anemia (Hb 85 to 100 g/L) for the past two years, with a normal extended laboratory evaluation. Due to deterioration of her anemia, a bone marrow biopsy was done and concluded to myelodysplastic syndrome. Treatment with Epoetin alfa and a trial of Lenalidomide didn’t improve her hemoglobin and she was still transfusion dependent. A second bone marrow biopsy revealed breast carcinoma infiltration, which was initially missed on the first biopsy. The patient was started on Letrozole and Palbociclib with good clinical response. Here, we present the clinical evolution, diagnosis and management of bone marrow micrometastasis due to breast cancer.&nbsp;</p> <p>&nbsp;</p> <p><strong>Résumé</strong></p> <p>Nous présentons l’étude de cas d’un cancer du sein de stade IV, chez une femme de 71 ans, ayant eu une présentation atypique. Elle s’est présentée avec une anémie normocytaire (Hb 85 à 100 g/L) symptomatique depuis deux ans, non explicable par un bilan biochimique approfondi. Suite à la dégradation de son anémie, une biopsie de moelle osseuse a été effectuée concluant à un syndrome myélodysplasique. Un traitement à l’epoetin alfa ainsi qu’un essai de lenalidomide ne permirent pas l’amélioration de son hémoglobine et elle est demeurée dépendante aux transfusions. Une seconde biopsie de moelle osseuse démontra une infiltration par un carcinome mammaire qui n’avait pas été constatée lors de la première biopsie. Un traitement avec du letrozole et du palbociclib a alors été débuté avec une réponse clinique satisfaisante. Nous passons en revue la présentation clinique, la démarche diagnostique ainsi que la prise en charge des micro métastases de la moelle osseuse dans le cancer du sein.</p> Julie Beaudoin-Maitre Chantal Vallée ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 17 20 10.22374/cjgim.v14i1.261 Liver Abscess Metastatic Syndrome Caused by Hypermucoviscous Klebsiella Pneumoniae in a Canadian Patient of Vietnamese Origin <p><span style="font-size: medium;"><span style="font-family: Times New Roman;"><em>Klebsiella pneumoniae</em> liver abscess syndrome (KLAS) is an emerging infection caused by hypermucoviscous strains (K1, rmpA, mgA) with a particular virulence at risk of metastatic dissemination. We describe a case of metastatic KLAS in a Canadian immunocompetent patient of Vietnamese origin who presented with fever and abnormal liver function tests. Imaging studies revealed unique liver and pulmonary abscesses. Blood and liver abscess cultures showed colonies of <em>K.pneumoniae</em> with hypermucoviscous phenotype, a K1 serotype and the presence of a rmpA gene confirming biomolecular features of the invasive syndrome. Mostly reported in patients of Asian origin, KLAS has been reported in Canada since 2007. Prompt identification and treatment prevents severe complications such as endophthalmitis, meningitis, lung abscess and spondylodiscitis. </span></span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><strong><span style="font-family: Times New Roman; font-size: medium;">Résumé:</span></strong></p><p><span style="font-family: Times New Roman; font-size: medium;">Le syndrome d’abcès hépatique à <em>Klebsiella pneumoniae</em> (KLAS en anglais) est une infection en émergence résultant d’une souche hypermuqueuse (K1, rmpA, mgA) d’une virulence accrue, à risque de dissémination. Nous décrivons un cas de KLAS métastatique chez un patient canadien d’origine vietnamienne, immunocompétent, qui présentait de la fièvre et des anomalies du bilan hépatique. Les imageries ont révélé des abcès hépatiques et pulmonaires uniques.  Les hémocultures et les cultures du drainage de l’abcès hépatique ont confirmé la présence d’une souche hypermuqueuse de <em>Klebsiella pneumoniae</em>, sérotype K1, génotype rmpA, caractéristiques biomoléculaires associées aux infections invasives. Principalement décrits chez des patients d’origine asiatique, des cas de KLAS sont rapportés au Canada depuis 2007. L’identification et le traitement rapide préviendront des complications sévères, dont l’endophtalmite, la méningite, l’abcès pulmonaire et la spondylodiscite.</span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><p><span style="font-family: Times New Roman; font-size: medium;"> </span></p><strong><br clear="all" /> </strong> Sandra Patricia Criales Doria Alexandre Lafleur Philippe Gervais ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 21 24 10.22374/cjgim.v14i1.279 A Challenging Case of Non-resolving Pneumonia: Keeping Antisynthetase Syndrome In the Differential Diagnosis <p>A 62-year-old Caucasian female ex-smoker presented to the emergency department with progressive shortness of breath with associated pleuritic chest pain, new arthralgias, and muscle weakness for two months.&nbsp;She had already been&nbsp;treated with two courses of antibiotics for suspected community acquired pneumonia (CAP) with no improvement in her respiratory symptoms. This is a case that illustrates the eventual diagnosis of antisynthetase syndrome, a subtype of the&nbsp;<span lang="EN-CA">idiopathic inflammatory myopathies. Current standard of diagnostic criteria and treatment for this autoimmune condition will also be discussed.&nbsp;</span></p> Stephanie Lapinsky, MD Jessica Leen, MD Jessica Mak, BSc. Pharm (Hons), RPh. MD Candidate  Mohammed A. Shafiee, MD ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 25 28 10.22374/cjgim.v14i1.278 Renal Limited Lupus-Like Nephritis <p>Biopsy diagnosis of lupus nephritis with no extra-renal features of SLE, normal complement levels, negative or weekly positive ANA and negative other serology is a rare entity known as “Renal Limited Lupus Like Nephritis”. So far, only 10 cases of RLLLN in adults have been reported in literature. The prognosis of these patients varied depending on their clinical presentation. Herein, we report a case of an elderly female with RLLLN who presented with massive proteinuria and acute kidney injury with crescents, however had a good outcome contrary to reported cases with similar presentations. We also reviewed all reported cases thus far.</p> Jumana Amir Salwa Sheikh Abdulrazack Amir ##submission.copyrightStatement## 2019-02-12 2019-02-12 14 1 29 34 10.22374/cjgim.v14i1.281