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ABSTRACTS FROM THE 2023 LOUISIANA ANNUAL ACP MEETING
CONTENTS
JOURNAL EDITORIAL STAFF ASSOCIATE EDITOR L.W. Johnson, MD CHIEF EXECUTIVE OFFICER Jeff Williams JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD L.W. Johnson, MD Fred A. Lopez, MD LSMS 2023W BOARD OF GOVERNORS OFFICERS President, John Noble, Jr., MD Past President, William Freeman, MD President-Elect, Richard Paddock, MD Speaker Of The House, Thomas Trawick, Jr., MD Vice Speaker, Robert Newsome, MD Secretary/Treasurer, Amberly Nunez, MD Chair, Col, David Broussard, MD COUNCILORS District 1 Member, Myra Kleinpeter, MD District 2 Member, Luis Arencibia, MD District 3 Member, Allen Vander, MD District 4 Member, VACANCY
Resident/Fellow abstracts, pages 6 -40 6 Extranodal Natural Killer T-Cell Lymphoma, Nasal Type in a Veteran with Endemic Exposure 6 Vascular-Esophageal fistula after distal esophageal botulinum toxin injection for esophageal achalasia 7 Acute Lung Herniation: An Unusual complication of COPD exacerbation 7 A Case Study of Secondary Hemophagocytic Lymphohistiocytosis 8 An Unusual Case of Hymenoptera Venom-Induced Angioedema 8 Head and Neck Paraganglioma: A rare presentation of a rare condition 9 Acute Unilateral Anterior Uveitis as A Presenting Manifestation of Tertiary Syphilis in A Young Caucasian Male 9 Renal Tubular Acidosis Secondary to Rheumatoid Arthritis 10 A rare case of hyperparathyroidism secondary to mediastinal parathyroid carcinoma 11 BRASH Syndrome: A Close “BRASH” with Death? 11 Pneumonitis presenting as late-onset Systemic Lupus Erythematosus 12 A 42-year-old male from Honduras presented with worsening left elbow, wrist, and knee pain: Disseminated Mycobacterium Tuberculosis Complex in a Patient Diagnosed with Dermatomyositis. 13 A 33-year-old male with a history of non-Hodgkin’s lymphoma presented to the hospital with a non-productive cough and fever: Lipoid Pneumonia in Context of Cosmetic Oils 13 TB or Not TB, That Is The Question 14 Never Turn a Blind Eye in DKA 14 Right Atrial Mass 15 Persistence may not be the key to success: a common risk of hemopericardium from ICD placement 16 A rare presentation of Adult Onset Stills Disease with Thrombotic Thrombocytopenic Purpura 16 Hypercalcemic Crisis from a Massive Benign Parathyroid Adenoma 17 A rare case of reverse Takutsubo in an elderly man who presented with new acute onset heart failure and Afib with RVR 17 Non-traumatic hemothorax in a 43-year-old woman 18 Double catastrophe: Spontaneous tumor lysis syndrome and large pericardial effusion in a patient with myelofibrosis. 19 Polycythemia Vera Presenting as Atypical Covid 19 infection related thrombosis 2
District 5 Member, Gwenn Jackson, MD District 6 Member, Michael Roppolo, MD District 7 Member, Brian Gamborg, MD District 8 Member, Lance Templeton, MD District 9 Member, Andy Blalock, MD District 10 Member, Nicholas Viviano, MD SECTION REPRESENTATIVES Senior Physician Member, Marcus Pittman, III, MD Senior Physician Alternate, Donnie Batie, MD Young Physician Member, Matthew Giglia, MD Resident/Fellow Member, Omar Leonards, MD Medical Student Member, Shavani Jain Employed Physician Member, John Bruchhaus, MD Private Practice Physician Member, Katherine Williams, MD
CONTENTS CONTINUED
19 A Rare Case of Extrapulmonary Small Cell Carcinoma Presenting as Abdominal Pain 20 A Case of Plasmodium Falciparum (P. falciparum) Infection 20 Severe Generalized Myositis After COVID-19 21 Sarcoidosis and Worsening Lymphadenopathy- Sarcoidosis Flare? Think Again!! 22 Pulmonary Hypertension during Pregnancy: A Critical Time 22 Acute Respiratory Failure Secondary to Endometrial Carcinosarcoma 23 Severe statin induced rhabdomyolysis: Does the Dose Make the Poison? 23 Parched for Pulmonary Embolism: Rare case of malignancy associated central diabetes insipidus with concurrent venous thrombosis. 24 Emergent Non-Operative Endoscopic Decompression Therapy in a Case of Ogilvie’s Syndrome 25 Seronegative Immune-mediated Necrotizing Myopathy 25 Recurrent Aortic Dissection in Young Patient with Systemic Lupus Erythematosus 26 A Fatal Case of Kaposi Sarcoma Immune Reconstitution Inflammatory Syndrome (KS-IRIS) 26 Utility of Fructosamine to Assess Glycemic Control 27 An Unusual Presentation of Diabetes Mellitus 28 A Curious case of Pericardial Effusion in Metastatic Clear Cell Renal Carcinoma 28 A Roundabout way to Gastric Adenocarcinoma Diagnosis after Roux-en-Y Bypass 29 Posterior Papillary Rupture following Inferior STEMI 29 Tuberculous Pericardial Effusion with Tamponade Medical student abstracts, pages 41 - 55 42 Rare Adult Granulosa Cell Tumor (AGCT) presenting with symptoms of a benign ovarian fibroma 42 Stroke and COVID-19: a review of case report trends 43 Development and Implementation of a Rapid PrEP Initiative at a Sexual Health Center in New Orleans, Louisiana 43 Pulmonary Septic Emboli and Hepatic Collections in
in Patient with Newly Diagnosed HIV 30 An Unflagged Red Flag: Severe Diabetic Ketoacidosis with Apparent Normokalemia 30 Fake It ‘til You Make It: Simulation-based Procedural Training for New Residents 31 Sjögren’s and Valvular Endocarditis: Caries and Cardiovascular Risk 32 Hallucinations in an Immunocompromised Patient 32 Drug Eruption Masquerading as Mastocytosis 33 The Link Between Bananas and Rhinitis 33 A Case of Systemic Thrombosis in Culture Negative Bacterial Meningitis 34 Checkpoint Inhibitor induced Myopericarditis presenting as Tamponade 34 Use of corticosteroid therapy in a case of West Nile virus encephalitis 35 Anti-MDA5 dermatomyositis: A winded rash 36 A rare presentation of retroperitoneal primary extragonadal seminoma 36 The Great Imitator: Disseminated Intravascular Coagulation (DIC) 37 Advanced Care Planning in the Outpatient Setting 37 TNF-a inhibitor-induced pericardial effusion in the setting of seronegative rheumatoid arthritis 38 Killian-Jamieson Diverticulum Presenting Simultaneously with Zenker’s Diverticulum 39 Multiple Myeloma Presenting as Fluid Overload 39 Aplastic anemia within few months of receiving a solid organ transplant Setting of Streptococcus Anginosus Facial Abscesses 44 The case for essential hypertension 45 Are you cereus? An Atypical Presentation of Bacillus cereus: Endocarditis Complicated by Stroke 45 A Case of Cryptococcal Meningoencephalitis in an Immunocompetent Patient with Chiari I Malformation
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CONTENTS CONTINUED
46 Chronic Lymphocytic Leukemia Disguised as Cholecystitis 46 Late Onset Immune Reconstitution Inflammatory Syndrome Following Cryptococcal Meningitis 47 One Viral Reactivation After the Next: Case Study in HCV-positive Renal Allograft Transplantation 47 Intravenous Immunoglobulin Therapy in a Case of Suspected Viral Meningoencephalitis 48 H2S donors as radiosensitizers for glioblastoma multiforme (GBM) 49 A Rare Biochemical Variant of Primary Hyperparathyroidism: Normohormonal Primary Hyperparathyroidism as a cause of Hypercalcemia 49 Discerning Fever of Infectious and Autoimmune Origins in the Setting of VEXAS Syndrome 50 A Long Way from Home: An Interesting Case of MSSA Bacteremia from an Unknown Source 50 Workup and Management of Behcet’s Disease Associated with Seronegative Arthritis
51 Case of Viable Intraparenchymal Neurocysticercosis 52 When Inflammation Begets Inflammation 52 Translational Investigation of Sex Differences in Alcohol Analgesic Efficacy: Comparison Across Preclinical and Clinical Domains 53 Understanding patient perspective on institutional speech and swallowing rehabilitation outcomes in total laryngectomy with tracheostomy 53 Successful Treatment of Cutaneous Leishmaniasis with Cryotherapy: Case Report 54 TJA Patient demographics before and after COVID-19 elective surgery restrictions 55 Fusobacterium nucleatum: A Rare Cause of Cryptogenic Abdominal and Hepatic Abscesses in an Immunocompetent Teenager 55 Genitourinary and Sexual Health Care for Women with Cancer: Overlooked Quality of Life Indicators
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Abstracts from the 2023 Annual Louisiana American College of Physicians (ACP) Associates Meeting
Each year residents from the nine Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual American College of Physicians (ACP) Meeting of the Louisiana Chapter. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to physician judges. This year a total of 96 abstracts were submitted for the meeting. Each judge scores each abstract independently and then the scores from all judges are averaged and ranked. This year we are excited to be able to publish the most highly ranked resident (13) abstracts presented at this year’s competition that were selected for oral presentations. An additional selection of resident (45) abstracts presented as posters were selected by judges for publication. All abstracts were presented at the Associates Meeting held at The Louisiana Cancer Research Center in New Orleans on February 4, 2023. We would like to thank the resident council for helping score the abstracts selected for presentation: Syed Hussain, Ochsner Medical Center; Elise Abdalla, LSU New Orleans, Matthew Perkins, LSU Lafayette; Jordan Nuss, LSU Baton Rouge; Priyanka Patel, Chabert Medical Center. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees.
Shane Sanne, DO, FACP Co-Chair, Louisiana Associates Liaison Committee Miranda Mitchell, MD Co-Chair, Louisiana Associates Liaison Committee
Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP
Abstract Winners
ORAL PRESENTATIONS – RESIDENTS SESSION 1 1st place - Acute Lung Herniation: An Unusual Complication of COPD Exacerbation
Lipoid Pneumonia in Context of Cosmetic Oils Hirrah Sajjad, Michael Almquist, Brad Broussard; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Syed Hussain, Maximillian Morvant; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
POSTER PRESENTATIONS – RESIDENTS 1st place - A Roundabout way to Gastric
ORAL PRESENTATIONS – RESIDENTS SESSION 2 1st place - BRASH Syndrome: A Close “BRASH” with Death? Fernanda Correa, David Beyer, Supraja Sridhar, Munraj Singh, Jasmine Nikdast, Kristi Boudreaux, Lee Engel; Department of Medicine, LSU Health Sciences Center, New Orleans, LA. MYSTERY CASE PRESENTATIONS – RESIDENTS 1st place - A 33-year-old male with a history of non- Hodgkin’s lymphoma presented to the hospital with a non-productive cough and fever…..
Adenocarcinoma diagnosis after Roux-en-Y bypass Ebiai Ruona, William Song; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
2nd place - Utility of Fructosamine to Assess Glycemic Control
Ashley Misky, Betty Lo, Lee Engel; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
3rd place - TB or Not TB, That Is The Question Trac Le, Sofia Beg; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
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ORAL PRESENTATIONS – RESIDENTS SESSION 1
EXTRANODAL NATURAL KILLER T-CELL LYMPHOMA, NASAL TYPE IN A VETERAN WITH ENDEMIC EXPOSURE Michelle Livitz, Kyle Hoppens, Stephen Kantrow; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: Extranodal Natural Killer T- Cell Lymphoma, nasal type (ENKL-NT) is a rare and aggressive subtype of non-Hodgkin’s Lymphoma within the United States. There does appear to be a genetic predisposition for this type of lymphoma, most commonly presenting in Asia and native populations of Central and South America. Case: A 47-year-old man with HTN and HLD was transferred to our care for 5 months of progressive dysphagia, odynophagia, nasal obstruction, and palatal necrotic ulceration. Associated symptoms included fever, subcutaneous nodules with excoriations of the head and neck, lung nodules, night sweats, an unintentional 40 lb. weight loss, epistaxis, and hypotension. During his hospital admission, multiple biopsies were taken of his cutaneous nodules and necrotic palatal ulceration. His hospital stay was complicated by fever, hypotension, tachycardia, tachypnea, profuse anterior epistaxis that was poorly clotting, anemia, thrombocytopenia, and neutropenia. A full infectious work up was negative. The surgical pathology of the
ulcerating palatal lesion was positive for extranodal NK/T-cell lymphoma, nasal type. This was confirmed on other biopsies of the cutaneous nodules and later a tap of the patient’s chronic pleural effusions. Prior to diagnosis, the initial flow cytometry showed normal levels of CD19, which were helpful in ruling out some subtypes of B-cell lymphoma (e.g. follicular, Hodgkin’s) with a reduced level in CD56+ cells (NK cells) since they were collecting in various portions of the body. The patient was found to have positive EBV IgG and EBV Capsid Ab IgM/IgG antibodies. Discussion: Our patient is an army veteran who spent one year deployed in South Korea when he was 19 years old. Although it is closely associated with latent EBV, there seems to be more epigenetic factors that play a role rather than direct cause and effect. While EBV is strongly correlated with this indolent disease course, it would be interesting to investigate any differences in the viral genome of EBV that is predominantly in these endemic regions and in the United States.
VASCULAR-ESOPHAGEAL FISTULA AFTER DISTAL ESOPHAGEAL BOTULINUM TOXIN INJECTION FOR ESOPHAGEAL ACHALASIA Sana Badar, Department of Medicine, Willis Knighton Health System, Shreveport, LA.
Introduction: Endoscopic injection of botulinum toxin is a common method to treat esophageal dysmotility and achalasia. Patients undergoing this procedure who subsequently present with hematemesis should be evaluated for possible complications of the procedure, including esophageal perforation and an aorto/ vascular- esophageal fistula. Case: A 73 year old female with HTN, HLD, ocular myasthenia gravis, bilateral mastectomies for intraductal carcinoma, hysterectomy, partial thyroidectomy for recurrent cyst and carotid body tumor removal in the past was scheduled for a per- oral endo myotomy (POEM) at a tertiary care center in a nearby city, however during the interim she was
admitted for severe vomiting, dehydration, inability for oral intake and aspiration pneumonia. She had a CT scan which showed 5cm aneurysm in the distal aorta and diffuse lymphadenopathy. After a 2 week hospital stay she was injected with 4 quadrant BTX injections in distal esophagus and discharged. She presented 8 days later with hematemesis and shock. Mass transfusion protocol was initiated and she had an urgent EGD showing brisk bleeding. 4 Hemostatic clips and a bear claw was applied to control the bleed. CT angiogram showed a 6mm blush from an artery at T6 with connection to the esophagus. The 5 cm distal aortic aneurysm was again noted. Coil embolization of the bleeding artery could not be done due to difficulty in visualization and 6
Discussion: The case described herein illustrates the importance of high vigilance and suspicion in a patient with hematemesis after botulinum toxin injection for a vascular-esophageal fistula. In unstable patients, minimally invasive approaches to control bleeding from the esophagus through endoscopy with application of hemostatic clips and TEVAR are viable options.
the patient was taken urgently for a TEVAR. Right femoral access was achieved, however after initial angiogram the iliacs were noted to be stenotic and too small for anterograde graft deployment. An emergent subclavian cutdown was done and 2 GORE TAG thoracic stent grafts were inserted through the innominate starting from 1.5 cm distal to the left subclavian to 1.5 cm above the celiac axis. The patient was taken to the ICU and extubated the following day.
ACUTE LUNG HERNIATION: AN UNUSUAL COMPLICATION OF COPD EXACERBATION Syed Hussain, Maximillian Morvant; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: We herein report a patient who developed acute lung herniation, a relatively rare complication associated with the forceful cough experienced during COPD exacerbations. Case: A 64 year-old male with HFpEF, pulmonary HTN, HTN, COPD, DVT presented with worsening two-week history of cough and shortness of breath. Over the past few days prior, along with worsening cough he noted bruising and pain in right flank without any associated trauma. Initial read of CXR only noted concerns for bibasilar reticular opacities concerning for edema vs atelectasis. There were concerns for retroperitoneal hemorrhage which were addressed with CT abdomen/pelvis that incidentally noted intercostal herniation of the right lung between the 7th and 8th ribs with associated partially visualized hematoma in the right lateral and posterior chest wall soft tissues, most significant deep to the right latissimus dorsi muscle. Due to elevated perioperative risk and high risk of repair failure secondary to active COPD exacerbation, Cardiothoracic surgery was unable to intervene. Pulmonology consult noted high risk of strangulation, hemorrhage, further decompensation
and recommended against chest tube insertion with hopes that pleural effusion may tamponade off bleeding. There were concerns for poor prognosis. He continued to decompensate with increasing oxygen support and updated Xray showing collapsed right lung, so he underwent intubation. Fortunately, his lung herniation spontaneously resolved, but imaging still showed persistence of complicated pleural effusions which was ultimately able to be addressed with chest tube placement. Discussion: This case highlights importance of early diagnosis and consideration of acute lung herniation, a rare complication of COPD exacerbation, which carries a risk of pulmonary parenchymal necrosis, strangulation, incarceration or pneumothorax. It can be a diagnostic challenge as it can be easily missed on plain film X-rays. This complication is rarely seen in patients without the typical risk factors of recent trauma or prior surgery. In our patient, perioperative risk factors limited any interventions such as thoracotomy with chest wall reconstruction. Fortunately, early identification and multimodal regimen for cough control allowed for spontaneous recovery.
A CASE STUDY OF SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Benjamin Horn; Department of Medicine, Louisiana State University, Shreveport, LA.
Introduction: Hemophagocytic Lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation with diagnostic criteria utilizing the H-score for scoring of symptomatology. Median survival for patients with HLH is approximately 50% with treatment of Etoposide and Dexamethasone taper for 8 weeks under the HLH-94 treatment protocol.
Case: 74-year-old male with diabetes mellitus was admitted for possible sepsis. A presumptive diagnosis of HLH was made based on clinical picture and lab results as they met 5/9 criteria for diagnosis. Additional labs were sent for HLH including soluble CD25, TGs, CXCL9, NK cell activity, which did not return in time of management. Treatment was begun with Dexamethasone as the patient was not a candidate for Etoposide or Alemtuzumab. 7
Patient’s condition worsened with multiorgan failure. A mutual discussion was held and ultimately patient transitioned to comfort measures only. Discussion: HLH is a rare disease (1 in 800,000 cases) with a mean survival with untreated HLH of only 3-4 months. Treatment is often delayed while awaiting
diagnosis, leading to prolonged hospital course stays that present with multiorgan dysfunction before a diagnosis may be considered for HLH. Lymphoma associated HLH (LAHS) is a rare finding, but it is the most common underlying condition of malignancy- associated HPS, commonly seen with NK/T-cell Lymphoma as compared to other subtypes.
AN UNUSUAL CASE OF HYMENOPTERA VENOM-INDUCED ANGIOEDEMA Hirrah Sajjad, Saifullah M. Shahid, Samiullah M. Shahid, Jody Rosson: Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: Angioedema is a localized submucosal reaction that can be part of a systemic anaphylactic response. The etiology can be difficult to diagnose but is commonly mast-cell or bradykinin mediated. Case: A 58-year-old male presented with a 12-hour history of progressive oral angioedema advancing to glossitis. His medical history included hypertension and hyperlipidemia, with reported use of lisinopril 3 years ago, which was discontinued due to coughing. Current home medications include losartan (initiated 3 months prior), aspirin, amlodipine, and rosuvastatin. He did not recall any enticing events such as insect bites, or stings so there was high suspicion for losartan-induced angioedema. Upon further questioning, he reported working as an electrician and had recently been underneath a house 1-hour prior to the onset of symptoms and did recall seeing a “wasp”. There was also a questionable history of his mother requiring hospitalization for oral edema raising concern for hereditary angioedema (HAE). The patient denied any rashes, dysphagia, drooling, hoarseness, stridor, shortness of breath, or abdominal pain. Physical exam was notable for profound lip and tongue base swelling with slight
blunting of the epiglottis evidenced on flexible bronchoscopy. There was a mild area of localized, raised, non-pruritic, erythematous left forearm rash. He was administered IV Solu-Medrol 125mg, IV Benadryl 25mg, and IV Pepcid with improvement in symptoms. ENT recommended monitoring for 24 hours for signs of anaphylaxis. Lab testing revealed normal ESR, CRP, and tryptase levels with borderline elevations in C3 and C4 complements. His hospital course remained uneventful, and he was discharged home with prednisone, Benadryl, EpiPens, and an allergy/immunology follow-up for further allergen testing. Send-out labs returned with normal C1 esterase inhibitor antigen level and elevated wasp venom IgE > 1300 (normal < 214). Discussion: Hymenoptera (a large order of insects) stings can lead to IgE-mediated effects that are more commonly localized to cutaneous or submucosal reactions including angioedema. Prompt recognition and management can prevent further progression to anaphylaxis. This case emphasizes the importance of clinical history and highlights the lab workup to differentiate ARB vs. HAE vs. venom-induced angioedema.
HEAD AND NECK PARAGANGLIOMA: A RARE PRESENTATION OF A RARE CONDITION Tanmayi Gadre, Catalina Negulescu; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Head and neck paragangliomas (PGL)/ glomus tumors are slow growing hypervascular neuroendocrine tumors originating from the autonomic paravertebral ganglia, most of them being nonfunctional and benign. The symptomatology is mostly related to mass effect and is usually gradual. A head and neck paraganglioma was an unexpected discovery in the work up of an acute cranial polyneuropathies presentation.
Case: A 65-year-old female, with HTN, Meniere disease, and depression presented after she woke up with “heavy tongue” and slurred speech. The previous two days she noted left upper lid drooping. Her symptoms would fluctuate but not resolve. She had no history of similar deficits in the past. Patient reported having mild COVID-19 infection two weeks prior and was treated symptomatically at home. She denied facial cosmetic procedures. Physical examination revealed left-sided ptosis 8
without miosis, left side tongue deviation and slightly slurred speech. CT scan of the head without contrast was unremarkable. Suspecting cranial neuropathies, possibly related to COVID-19 infection, head MRI and subsequently neck MRI were ordered and they revealed an avidly enhancing lesion at the jugular foramen with inferior extent in the left neck area (5.5 x 1.5 cm), demonstrating complete encasement of the left internal carotid artery with preserved flow. On further questioning, patient reported occasional dysphonia, pulsatile tinnitus, ear fullness, and chronic hearing loss, presumed to be related
Meniere disease. The patient was discharged with Endocrinology and ENT outpatient follow-up for evaluation of functional status and treatment options. Discussion: The case reflects an atypical presentation of head and neck paraganglioma with suspected acute Horner’s syndrome and hypoglossal nerve palsy (CN XII), presumed to be secondary to tumor engorgement and mass effect. Signs of jugular foramen syndrome (CN IX, X, XI dysfunction) would have been more expected.
ORAL PRESENTATIONS – RESIDENTS SESSION 2
ACUTE UNILATERAL ANTERIOR UVEITIS AS A PRESENTING MANIFESTATION OF TERTIARY SYPHILIS IN A YOUNG CAUCASIAN MALE Dhruvkumar Patel, Suyog Patel, Anuj Thakre, Shivani Sharma, Nitesh Gandhi; Department of Medicine, Louisiana State University, Shreveport, LA.
Introduction: Secondary and tertiary syphilis may have atypical and complex presentations. It can rarely present with isolated ophthalmic manifestations. Case: A 37-year-old male with Hepatitis C presented with left eye pain, redness, blurry vision, and photosensitivity of 5 days duration. Symptoms were associated with episodes of unilateral, squeezing, occipital-frontal headache. He denied any fever, chills, rash or injury to the eye. He consumed alcohol (1-2 glasses/day) and is also a non-IV drug user. He reported multiple male sexual partners. He was initially prescribed polymyxin B-trimethoprim eye drops by urgent care with no improvement in symptoms. He was later seen at the ophthalmology clinic where he was diagnosed with anterior uveitis of the left eye. A full uveitis workup was done which showed ESR 78 mm/hr, reactive RPR (1:256), positive Treponema Pallidum IgG and positive HIV 1 serology with a CD4 count of 255. Autoimmune work-up was unremarkable. The lumbar puncture was performed which showed elevated CSF protein (46 mg/dl) but
was otherwise unremarkable. He also tested positive for HBsAg, HBeAg, HBcAb (IgM), and hepatitis C antibody with a HepC viral load of 6,331,526. AST and ALT were mildly elevated. Other infectious workups for Histoplasma, Blastomyces, Toxoplasma, and IGRA were negative. He was treated with IV penicillin (24 million units daily) for 14 days total along with topical steroid and cycloplegics which improved ocular symptoms and visual acuity significantly. He was initiated on bictegravir-emtricitabine-tenofovir at the time of discharge with follow up with Infectious Disease and Ophthalmology as an outpatient. Discussion: Diagnosing syphilitic uveitis can be difficult as it lacks any pathognomonic signs. One should have a high index of suspicion in high-risk groups like men who have sex with men and HIV- positive patients. Its identification is important as it is easily treatable. It can lead to vision loss and many long-term complications if left untreated. Every patient with ocular syphilis should be tested for HIV and neurosyphilis as concurrence is high.
RENAL TUBULAR ACIDOSIS SECONDARY TO RHEUMATOID ARTHRITIS Suzanne Cooper, Ibrahim Shenawi, George Guidry; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: Renal tubular acidosis (RTA) is an impairment in the urinary acidification mechanism that often presents as a non-anion gap metabolic
acidosis. Distal RTA, also known as type 1 RTA, is commonly associated with autoimmune disorders. The pathophysiological mechanisms are not fully
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understood and very few studies have reported an association between RTA and rheumatoid arthritis.
gap metabolic acidosis with pH 7.20, PaO2 120, and PaCO2 25 on room air. She was transferred to the ICU for closer monitoring with concern for possible RTA. Her previous sedimentation rate had never been elevated above 28 so there was some concern for a rheumatoid flare. Nephrology was consulted and further labs were performed showing hypokalemia with an elevated urine pH and an elevated urine anion gap consistent with distal RTA. She was placed on a bicarbonate drip and her potassium was repleted appropriately. Her respiratory status improved significantly, and she was transferred out of the ICU. Discussion: This case further illustrates the association between RTA and autoimmune disorders. It also demonstrates the importance of monitoring inflammatory markers in patients with rheumatoid arthritis ensuring prompt diagnosis and early treatment of complications to avoid further comorbidities.
Case: A 75-year-old women with rheumatoid arthritis who presented with complaints of new- onset dyspnea on exertion. The patient had recently been discharged from the hospital 1 month prior after receiving a left total knee arthroplasty. She was found to have an elevated D-dimer of 1.2 and an acute kidney injury with a BUN/creatinine level of 29/1.58. Her other inflammatory markers were also found to be elevated with a sedimentation rate of 116 and a CRP of 63.01. She was admitted to the hospital for fluid resuscitation and to rule-out a pulmonary embolism. She received a V/Q scan which was negative for PE. She was placed on 5L nasal canula and continued to have increased oxygen requirements throughout her stay with continued complaints of shortness of breath. Pulmonology was consulted for further workup and an arterial blood gas was obtained which showed a non-anion
A RARE CASE OF HYPERPARATHYROIDISM SECONDARY TO MEDIASTINAL PARATHYROID CARCINOMA Chukwunoso Ezeani, Gift Echefu, Ifeoluwa Stowe, Shatha Murad; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Parathyroid carcinoma (PC) is rare with a reported prevalence of 0.005% of all tumors. Ectopic parathyroid glands localized to the mediastinum are even rarer and have similar pathophysiologic presentation as parathyroid adenomas (PA) making diagnosis arduous. We present a patient with recurrent hyperparathyroidism initially from PA but then had recurrence of his symptoms with a diagnosis of mediastinal parathyroid carcinoma. Case: A 73-year-old male presented with nervousness and generalized weakness of 2 weeks duration. He also had polyuria, polydipsia and bone pain. Medical history includes stage IV CKD and primary hyperparathyroidism with cervical parathyroid adenoma diagnosed a year prior for which he had subtotal parathyroidectomy, with benign histology. At presentation, his vital signs were stable. Strength was 3/5 in all extremities while other systemic examination was unremarkable. Labs revealed hypercalcemia (14.8mg/dL), elevated parathyroid hormone (1173pg/mL), normal phosphorus and Vitamin D. A diagnosis of primary hyperparathyroidism was made. The source was
initially thought to be the implanted gland in his arm, but ultrasound of the implantation site showed normal subcutaneous tissue. Nuclear medicine/ Sesatimibi parathyroid scan revealed persistent oblong uptake in the mediastinum suspicious for parathyroid adenoma. Chest CT showed 4.1 x 1.9cm soft tissue density in the anterior aspect of the superior mediastinum. He was managed with aggressive IV hydration with isotonic fluid, calcitonin x48 hours, Cinacalcet and one-time pamidronate. He underwent robotic mediastinal tumor resection with redo neck exploration, total parathyroidectomy and thymectomy. Histopathology revealed parathyroid carcinoma positive for chromogranin, GATA3 and PTH. Postoperatively, he was managed with calcium carbonate, Vit-D and calcitriol with improvement in his symptoms and biochemical parameters. Discussion: The extreme rarity of this condition poses diagnostic and therapeutic challenges for clinicians. Clinical and biochemical parameters may help in the differential diagnosis. The average diameter, weight, serum calcium (>14.2 mg/dl), parathyroid hormone (>1,000 pg/ml), and rates of 10
hypercalcemic crisis (>50%) are markedly higher in mediastinal PCs compared to parathyroid adenomas. Conducting appropriate preoperative localization
studies is crucial to effective management. The precision of CT and MRI imaging in detecting PC are 90–100% and 100% respectively.
BRASH SYNDROME: A CLOSE “BRASH” WITH DEATH? Fernanda Correa, David Beyer, Supraja Sridhar, Munraj Singh, Jasmine Nikdast, Kristi Boudreaux, Lee Engel; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: BRASH Syndrome is an underrecognized entity defined by bradycardia, renal failure, atrioventricular nodal blockade, shock and hyperkalemia. This constellation may occur when hyperkalemia and AV nodal blockade combine to produce a vicious cycle of shock, renal failure and resistant hyperkalemia that can be life-threatening and requires urgent provider recognition. Case: An 87-year-old woman with decompensated cirrhosis due to untreated hepatitis B & C on nadolol and spironolactone and CKD3 presented with progressive encephalopathy and decreased oral intake over three weeks accompanied by increasing dyspnea and a fall. Upon presentation, the patient was bradycardic (HR 30), hypotensive, and hypoxic with bilateral crackles on auscultation and pitting edema in her lower extremities. Initial laboratory evaluation showed hyperkalemia with an acute kidney injury. Her bradycardia did not improve after atropine administration. She was admitted to the ICU and placed on non-invasive positive pressure ventilation and continuous infusion of epinephrine to maintain adequate end-organ
perfusion. The patient underwent diuresis and frequent potassium shifting over the course of her admission. Hemodialysis was offered but due to chronic comorbidities and declining functional status, her family decided to defer dialysis and enter the patient into inpatient hospice care. Supportive care continued until the day of transfer when she was found to be euvolemic without pressor requirement or supplemental oxygen and a normal potassium level. She was able to be discharged home with home hospice with family support. Discussion: BRASH syndrome is an important and underrecognized entity in critical care medicine that requires urgent recognition. This constellation of symptoms may be difficult to differentiate between pure hyperkalemia and pure AV nodal blockade. The differences in these syndromes relate to the degree of hyperkalemia and the use of prescribed medications, respectively. Treatment involves addressing each component simultaneously, including immediate treatment of hyperkalemia, adequate resuscitation for hypotension or shock, and vasopressors to address AV nodal blockade & improve renal perfusion.
PNEUMONITIS PRESENTING AS LATE-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS Ishrat Gillani, Adrianne Melanthiou, Jasleen Hora; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease with significant heterogeneity on presentation. SLE occurs primarily in young women of childbearing age with clinical features ranging from mild joint and skin involvement to life-threatening kidney, hematologic and/or central nervous system involvement. Early detection and treatment is important as Lupus Nephritis is a major cause of morbidity and mortality in patients with SLE. Case: A 43 year-old female with hypertension, hyperlipidemia, and hypothyroidism presented with complaints of progressively worsening shortness of breath over two months with pain on
inspiration, increased dyspnea on exertion, bilateral lower extremity swelling, productive cough and fevers. Of note, the patient had multiple ED visits for polyarthralgias and recurrent URI’s over the past 2 years. The patient reported having worked in a shipyard and endorsed several pets at home including dogs, cats, and birds. The patient was a former smoker and had quit smoking one month prior to the current presentation. On arrival to the ED, the patient afebrile, tachycardic, tachypneic, and hypoxic requiring 4L supplemental oxygen. Admit labs with leukopenia, anemia, elevated ESR/CRP, and elevated IgE levels. CXR is notable for cardiomegaly. D-Dimer elevated, and CTA negative for pulmonary 11
embolism, for small-moderate pericardial effusion, and loculated pleural effusion. Echocardiography showed an EF of 60% and pericardial effusion. Physical exam with decreased breath sounds, no rales, (+1) pitting edema in bilateral lower extremity, no jugular venous distention appreciated. Patient with a constellation of symptoms including polyarthralgias, pleural effusion, and shortness of breath and an isolated finding of pericardial effusion, autoimmune workup was initiated. Workup revealed ANA positivity (1:2560, homogenous), Anti-DsDNA (+), Anti- Histone (+). Patient not on any offending agents to indicate drug induced lupus. Low C4 levels, and Rheumatology consulted and with findings consistent with acute lupus flare. Patient was started on hydroxychloroquine and prednisone. Thoracentesis was performed due to no improvement in shortness of breath and labs were consistent with
exudative effusion thus furthering confirmation of lupus diagnosis. Inpatient bronchoscopy was completed to rule out pneumonitis workup which revealed erythema throughout the tracheobronchial tree. Additional work up for HIV, hepatitis panel, fungitell and fungal immunodiffusion, and respiratory infection panel were negative. Over the course of hospital stay patient showed significant improvement in symptoms. Pt was discharged on hydroxychloroquine and prednisone with a follow up to rheumatology clinic. Discussion: Acute lupus pneumonitis is often described as being a rare manifestation of SLE, affecting 1%–4% of cases, with poor prognosis. Its clinical presentation is similar to pneumonia. Diagnosis is typically with imaging and treatment of acute lupus pneumonitis is systemic corticosteroids.
MYSTERY CASE PRESENTATIONS – RESIDENTS A 42-YEAR-OLD MALE FROM HONDURAS PRESENTED WITH WORSENING LEFT ELBOW, WRIST, AND KNEE PAIN: DISSEMINATED MYCOBACTERIUM TUBERCULOSIS
COMPLEX IN A PATIENT DIAGNOSED WITH DERMATOMYOSITIS. Carl Haupt, Danielle Aliano, Austin Tutor, Andrew Guthrie; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Disseminated tuberculosis is the clinical syndrome that results from hematogenous or lymphatic spreading and accounts for 15- 20% of cases. Biologic agents and existing immunocompromised can result in increased prevalence. Age, underlying medical conditions such as malignancy, alcohol abuse, renal disease, diabetes, pregnancy, connective tissue disease, and corticosteroid use can also increase prevalence. Case: A 42-year-old male from Honduras presented with worsening left elbow, wrist, and knee pain associated with fever and fatigue which had been intermittent for 9 months. Prior rheumatologic workup showed positive MDA5, ANA, and anti- smooth muscle antibodies. Muscle biopsy showed myopathy with necrotizing granulomas, denervation atrophy, and mitochondrial dysfunction. GMS, Gram, and AFB stains were negative. Quantiferon gold, fungitell, bartonella, brucella, and toxoplasma were negative. The patient was being treated with steroids at the time of presentation. On examination, the patient was febrile to 103°F, tachycardic to 142, and exquisitely tender in the left wrist, forearm,
and knee. X-ray of the knee showed a suprapatellar effusion. MRI of the forearm showed extensive soft tissue inflammation concerning for necrosis. Labs were notable for ALT 62 U/L (reference range, 10-44 U/L), lactate 3.2 mmol/L (reference range, 0.5-2.4 mmol/L), CRP 66.9 mg/L (reference range, 0-8.2 mg/L), ESR 57 (reference range, 0-23 mg/L), and CK 244 U/L (reference range, 20-200 U/L). Joint tap was unremarkable. Muscle biopsy showed no pathologic abnormality. Karius test was positive for mycobacterium tuberculosis complex. AFB showed mycobacterium tuberculosis complex. After a 14- day hospitalization, the patient was discharged to home isolation on rifampin, isoniazid, pyridoxine, and ethambutol with follow-up at infectious disease and tuberculosis clinics. Unfortunately, the patient has been unable to tolerate therapy resulting in repeat hospital admissions. Discussion: Disseminated TB is exceedingly rare in immunocompetent patients and accounts for 1-2% of cases.
Treatment consists of a 6-9 month regimen; generally
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two months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4-7 months of isoniazid and rifampin. Side effects are common and can complicate efficacious treatment. Although rare, disseminated tuberculosis is an important
consideration when treating patients from countries with high tuberculosis incidences. Prompt recognition of symptoms, particularly those which manifest late, is crucial for a timely diagnosis and appropriate care.
A 33-YEAR-OLD MALE WITH A HISTORY OF NON-HODGKIN’S LYMPHOMA PRESENTED TO THE HOSPITAL WITH A NON-PRODUCTIVE COUGH AND FEVER: LIPOID PNEUMONIA IN CONTEXT OF COSMETIC OILS Hirrah Sajjad, Michael Almquist, Brad Broussard; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: Lipoid pneumonia is a rare lung disease caused by lipid collections in the bronchial tree which induce an inflammatory response within the alveolar sacs due to lipid accumulation. Etiology of lipoid pneumonia is usually exogenous and is associated with a variety of cosmetic oils, vaping, and certain medications such as amiodarone. The diagnosis of exogenous lipoid pneumonia is based on a history of exposure to oil, characteristic radiological findings, and the presence of lipid- laden macrophages on sputum or BAL analysis. The incidence of lipoid pneumonia is the United States is increasing, which is thought to be due to an increase prevalence in vaping and cosmetic oils. Case: A 33-year-old male with non-Hodgkin’s lymphoma presented with a non-productive cough and fever. The patient had recently been hospitalized for similar symptoms. On this admission, he endorsed worsening shortness of breath and increased frequency of cough. Initial laboratory work-up was largely unremarkable. A CTA of the thorax was performed for further evaluation of his shortness of breath which showed ground
glass and air space opacities seen in left and right lower lobe. A bronchoscopy was performed with BAL and the pathology specimen showed intra- alveolar foamy macrophages and lipoid droplets favoring lipoid pneumonia. Patient’s history was thoroughly reviewed and it was noted that the patient used a large amount of beard oil sprays and conditioners daily on his face. Patient reported at times inhalation of aerosolized oils when conditioning his facial hair. The patient’s lipoid pneumonia was likely due to aspiration of the facial oils. Patient was started on high dose steroids with improvement of his cough and shortness of breath. Discussion: In this case, we discuss an uncommon form of pneumonia. Currently, there is no standard of care for the treatment of lipoid pneumonia. Treatment is largely supportive with some evidence for high dose steroids to reduce inflammation. In all cases of exogenous lipoid pneumonia, stopping the offending agent is imperative to prevent further damage. This case report demonstrates the importance of considering uncommon types of pneumonia.
POSTER PRESENTATIONS – RESIDENTS
TB OR NOT TB, THAT IS THE QUESTION Trac Le, Sofia Beg; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Tuberculosis (TB) is one of the leading causes of adrenal insufficiency worldwide, but conversely adrenal insufficiency is less frequently found in active TB. Case: A 27 year old male with no prior medical history presented with two days of fatigue, muscle cramps, and excessive sweating. He was noted to have biapical airspace disease on initial CXR which was confirmed on CT Chest, though he did not have
any respiratory symptoms. Due to his risk of living in an endemic area, TB was strongly considered however the patient’s PPD skin testing and serial AFB smears returned negative. The patient was admitted to the hospital for treatment of acute renal failure and rhabdomyolysis. He symptomatically improved with intravenous fluids but remained hyponatremic, hyperkalemic, and with non-anion gap metabolic acidosis in the setting of persistent hypotension. These electrolyte abnormalities and
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acid-base disorder were concerning for adrenal insufficiency and hypoaldosteronism. Workup of aldosterone, cortisol, and renin labs revealed significantly low cortisol and aldosterone with elevated renin and ACTH. Subsequent ACTH stimulation tests confirmed a primary adrenal insufficiency. A CT abdomen/pelvis was obtained which showed small bilateral adrenal glands with calcifications showing prior granulomatous infiltration. Considering biapical disease in the setting of granulomatous infiltration, an infectious etiology was pursued despite initial negative testing. Patient was eventually found to be TB positive via QuantiFERON gold testing. Given the imaging
findings with his active infection, the etiology of his adrenal insufficiency and hypoaldosteronism was believed to be secondary to TB infection. The patient was ultimately treated with RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) therapy in addition to steroid replacement with hydrocortisone and fludrocortisone for primary adrenal insufficiency (PAI). Discussion: Though there is a common association between TB and PAI, this case illustrates how TB can be difficult to diagnose, particularly if the first presentation manifests as extrapulmonary disease instead of the classic pulmonary symptoms that are usually seen in active TB infection.
NEVER TURN A BLIND EYE IN DKA Sofia Beg, Rohan Lal, Nadish Ravindran; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: Diabetic ketoacidosis is commonly treated in the critical care setting, however mucormycosis is a rare infectious complication of uncontrolled disease that is less frequently diagnosed. Case: A 42 year old female with bipolar disorder, depression, and schizophrenia presented with two weeks of worsening lethargy, altered mentation, and eventual syncope. Patient was found to be hyperglycemic in the setting of metabolic anion gap metabolic acidosis and elevated beta-hydroxybutyrate consistent with Diabetic Ketoacidosis (DKA). She was initially treated for DKA associated with coma with insulin and intravenous fluids, which improved her hyperglycemia and metabolic acidosis. During her admission, leukocytosis was persistently worsening, prompting evaluation of an infectious etiology. Despite broad spectrum antibiotics and antifungal treatment, the leukocytosis continued to increase. As the patient’s mentation improved, she complained of isolated right eyelid swelling, but denied other complaints. Symptoms did not improve with conservative measures. The case was discussed with the
ophthalmology team, who recommended an MRI head/orbit which showed paranasal sinus mucosal thickening with fluid in bilateral sphenoid and right maxillary sinuses, in addition to multiple small infarcts in the right cerebral hemisphere and occlusion of the right internal carotid artery. This raised high concern for extensive rhinoorbital mucormycosis infection therefore treatment with Amphotericin B was initiated. Patient continued to have declining unilateral vision loss while on therapy. She was transferred to a facility with ENT services available, however deemed a poor candidate for debridement due to extent of infection at time of discovery. Given the aggressive nature of her infection, the decision was made to discharge the patient to hospice care. Discussion: This case demonstrates the rapidly progressive nature of a rare but commonly associated complication of uncontrolled diabetes and the importance of a multimodal specialist approach to diabetes management. Prompt diagnosis and management in this case required assistance from ophthalmology, endocrinology, and ENT specialists.
RIGHT ATRIAL MASS Ishrat Gillani, Gurjit Brar, Vishal Vyas; Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA.
Introduction: In patients with atrial fibrillation the most common finding is a left atrial thrombus, however in 3-6% of cases we often see right atrial appendage thrombi.
Case: A 69-year-old male lost to follow up presented with complaints of dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and bilateral lower extremity edema. History is significant for persistent atrial fibrillation with restoration to normal sinus 14
rhythm, chronic heart failure with preserved ejection fraction, and non-obstructive coronary artery disease. Physical exam was noted for jugular venous distention, irregularly irregular tachycardia, laterally displaced PMI, high-pitched holo-systolic blowing apical murmur, tachypnea with mild use of accessory muscles, and 2+ bilateral pretibial edema. His chest X-ray showed a mildly enlarged cardiac silhouette. Electrocardiogram demonstrated atrial fibrillation with rapid ventricular rate of 122 and right axis deviation. He was admitted for management of acute decompensated heart failure. He was started on IV furosemide with adequate response. Transthoracic echocardiogram showed global left-ventricular hypokinesis with an ejection fraction of 40%, severe bileaflet mitral valve prolapse with resultant severe mitral valve regurgitation. Transesophageal echocardiogram prior to planned cardioversion revealed a 45mm x 25mm right atrial mass adherent to the right atrial appendage (non-enhancing with perflutren contrast and no color flow doppler signals)
and severe eccentric mitral regurgitation. Differentials were broad of right atrial mass and included concern for thrombus, benign myxoma and primary versus metastatic carcinoma. CT pulmonary angiogram excluded pulmonary embolism. Once his heart failure and atrial fibrillation were medically optimized, preoperative angiography confirmed non-obstructive coronary artery disease. Shortly after, he underwent surgical mitral valve replacement, Cox Maze to restore sinus rhythm, left atrial appendage resection and right atrial mass resection. Pathological analysis of mass revealed findings of large mural thrombus. Discussion: Right atrial thrombi are less common due to the shallow anatomy of the right atrial appendage. Some other conditions which can predispose to right atrial thrombus formation include tricuspid stenosis or a tricuspid valve prosthesis. The majority of patients with right atrial thrombi also have left atrial thrombi, thus cardioversion should be deferred even if patients have isolated right atrial thrombi.
PERSISTENCE MAY NOT BE THE KEY TO SUCCESS: A COMMON RISK OF HEMOPERICARDIUM FROM ICD PLACEMENT Michelle Livitiz, Logan Gold, Ian Denys, Ashley Misky, Trent Davidge, Panicker Renni Robinson, Eduardo Venegas, Neeraj Jain; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: A persistent left superior vena cava (PLSVC) is a congenital vascular anomaly where the left superior cardinal vein caudal to the innominate vein fails to regress and is present in about 0.5% of the population. Implantable cardiac defibrillator (ICD) placement is especially challenging in these patients. In this population, hemopericardium following ICD placement is likely a result of direct injury to the coronary sinus. Case: 48-year-old male with severe nonischemic cardiomyopathy with LBBB status post elective dual chamber ICD placement five days prior presented for persistent globus pharyngeus several hours after eating pizza. Patient had chest tightness and diaphoresis in the ED, with marked improvement of both after an emetic episode. A bedside echo incidentally found a pericardial effusion (PE), and CT imaging noted its density was similar to blood. The ICD placement op note described a failed attempt to place a CRT “given lack of lateral coronary sinus branches due to a congenital anomaly (PLSVC).” During the procedure, there was difficulty maneuvering in the coronary sinus.
Formal echo showed a moderate PE with coagulum. Cardiac CTA revealed no contrast extravasation into the pericardium. Serial imaging studies showed minimal interval changes in effusion volume, likely from a microtear causing a venous bleed from the coronary sinus during ICD placement. Throughout the patient’s hospital course, he was asymptomatic aside from his presenting symptom of dysphagia. Discussion: ICD placement in patients with congenital cardiovascular anomalies requires care and a planned approach to minimize complications. In this patient, there was no bridging vein connecting the bilateral super vena cavae, so the PLSVC was utilized for left pectoral device placement. During ICD placement, this patient did not have the lateral branches of the coronary sinus suitable for LV lead location. Coronary sinus dilatation associated with PLSVC and repeated attempts to deliver the LV lead is speculatively associated with microperforation and hemopericardium in this case. If PLSVC is diagnosed prior to device implantation, CT venography may be of high utility to guide procedural planning and minimize the risk of adverse procedural outcomes. 15
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