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
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