ABSTRACTS FROM THE 2024 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
6 Beefing up! Fulminant Liver Failure Secondary to Anabolic Steroid Use 6 Abnormal Cardiac Conduction Abnormalities as the Presenting Sign of Pyrethroid Poisoning 7 The Importance of Recognizing BRASH with Mild Hyperkalemia 7 Invasive Mucormycosis in Patient with Acute Liver Failure 8 “Do I Have a Chance”—The Use of Angiovac System in a High Surgical Risk Patient with Aortic Valve Endocarditis. 9 A Bloody Lymphoma! 9 Decoding Sinusitis: Exploring the Complexities 10 Now You See Me, Now You Don’t: Transient Environmental Fungemia 10 “Why the Recurrence?”—Thoracic Endometriosis Presenting as Recurrent Hemothorax. 11 Switching to Long-Acting Injectables in Those with Hepatitis B and HIV Co-Infection: Good Intentions Gone Wrong 12 West Nile Virus Encephalitis: An Atypical Case Presentation 12 What Lies Beneath the Surface: A Case of Aquagenic Urticaria with IgG3 Subclass Deficiency 13 Pseudo-Thrombotic Microangiopathy Secondary to B12 Deficiency 13 Hemophagocytic Lymphohistiocytosis 14 A Rare Case of Fatal Drug Induced Hepatitis Secondary to Immune Checkpoint Inhibitor 15 A Unique Approach to Hybrid Extracorporeal Membrane Oxygenation: A Case Report 15 Pharmacy-Driven MRSA Nasal Swabs to Reduce Vancomycin Usage 16 Trends in the Most Common Chief Complaints in National Emergency Departments, with a Deeper Focus on Chest Pain, 2005-2021 16 A Novel Approach to Vegetation Aspiration in Native Valve Infective Endocarditis with the AlphaVac System 17 One in a Million: Ocular Manifestations and Parvimonas micra Infection in Lemierre Syndrome 18 Post-Operative Clostridium Difficile Infection in Inflammatory Bowel Disease Patients with Atypical Presentation 18 A Case of Nocardia brasilensis Causing Necrotizing Fasciitis in an Immunocompetent Patient 19 Unmasking a Rare Dual Threat: Bi-Phenotypic Compined Hepatocellular Carcinoma and Cholangiocarcinoma with Portal Vein Thrombosis 19 A Case of Coccidiomycosis Confounding a Systemic 2
L.W. Johnson, MD Fred A. Lopez, MD LSMS 2024 BOARD OF GOVERNORS OFFICERS OFFICERS
President, Richard Paddock, MD Past President, John Noble, Jr., 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, Matthew Giglia, MD COUNCILORS District 1 Member, Myra Kleinpeter, MD District 2 Member, Luis Arencibia, MD District 3 Member, Allen Vander, MD District 4 Member, Randall White, Jr., MD 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
Young Physician Member, Ken Ehrhardt, MD Resident/Fellow Member, Omar Leonards, MD Medical Student Member, Madison Thornton Employed Physician Member, John Bruchhaus, MD Private Practice Physician Member, Katherine Williams, MD
CONTENTS CONTINUED
Lupus Erythematosus Diagnosis 20 Systemic Lupus Erythematous Flare Presenting with Pericardial Tamponade 21 Could Be Chest Pain …But Wat About a Perforated Appendix? 21 Under the Collarbone: A Case of Primary Sternal and Clavicular Osteomyelitis 22 The Elusive Diagnosis of Systemic Lupus Erythematosus 23 An Incidental Case of Emphysematous Cystitis 23 P.O. to Pleural Potassium: A Case of Esophagopleural Fistula 24 Presentation of Biventricular Stress Induced Cardiomyopathy as Potential Severe Pathology Mimic 25 Autoimmune Encephalitis Secondary to embrolizumab in a Patient with Non-Small Cell Lung Cancer 25 Parkinsonism-Hyperpyrexia Syndrome: A Case Report Emphasizing Early Recognition and Management in Parkinson's Disease 26 A Rare Complication of Biliary Stent Migration: Choledochoduodenopyelo Fistula 27 Isolated Pituitary Mass: A Rare Multiple Myeloma Presentation 27 Acquired Amegakaryocytic Thrombocytopenia: A Precursor to Aplastic Anemia 28 An Unexpected Case of Neurosarcoidosis 28 Bilateral Cavernous Sinus Thrombosis and Skull Base Osteomyelitis in a 52-Year-Old Female 29 Acrodermatitis Enteropathica and Liver Cirrhosis 29 Chronic Troponin Elevation in a Patient in Absence of Identifiable Cardiac Pathology 30 A Case of Hemolytic Anemia in the Setting of Crotalid Envenomation 30 Unlocking the Potential: ChatGPT and the Quest for Reliable Blood Transfusion Information 31 Breast Adenocarcinoma Masquerading as Cold Agglutinin Disease: An Unusual Case 32 Burden of Chemotherapy-Related Myelodysplastic Syndrome/Acute Myeloid Leukemia in the
Chemotherapeutic Armamentarium 32 The Curious Case of Rhizobium Radiobacter 33 A rare case of nontyphoidal Salmonella cystitis 33 An Atypical Presentation of Exudative Effusion with elevated pH and LDH Suggestive of Rheumatoid Pleurisy 34 Transformation of Follicular B-cell Lymphoma into Diffuse Large B-cell Lymphoma in a Patient with Latent Tuberculosis 35 Violaceous Bullae: A Case of Vibrio Vulnificus (V. vulnificus) Necrotizing Fasciitis 35 What the H! is in my ear? 36 Short of Breath? Just Squat. A Case of Partial Anomalous Pulmonary Venous Return 36 Two is Company, Three is a Crowd: A Case of Cor Triatriatum 37 Sinus of Valsalva Aneurysm (SOVA) as Possible Etiology of Acute Heart Failure and Exertional Dyspnea 38 Gastric Xanthelasma 38 Meliodosis Presenting as Urinary Tract Infection: A Rare Presentation in a Non-Endemic Region Emphasizing the Role of Travel History 39 A Curious Case of Recurrent VTE – A New Diagnosis of Behcet Disease 40 Predictors and Impact of Acute Kidney Injury Among Hospitalized COVID-19 Patients. 40 A curious constellation of neurological signs 41 Peculiar Association of Two Uncommon Neurological Disorders—Neuromyelitis Optica and Myasthenia Gravis 42 Spontaneous Intracranial Hypotension 42 Retroperitoneal Malignant Mesothelioma 43 EMERGENCY! Really, Is It? - Superior Vena Cava Syndrome in T-Cell Lymphoblastic Lymphoma 44 An Interesting Case of Gram-Negative Bacteremia Due to Superior Mesenteric Vein (SMV) Thrombosis 44 Dual Diagnosis Dilemma: Kikuchi-Fujimoto Disease and Systemic Lupus Erythematosus 45 Fulminant Immune Checkpoint Inhibitor Myocarditis
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CONTENTS CONTINUED
Medical student abstracts, pages 46 - 61 47 What the BRASH? 47 Adenosine analogs have a dual immunomodulatory and antiviral function and are potential therapeutic agents against SARS-CoV-2 48 An Eye-Popping Twist: Unusual Ocular and Cerebral Manifestations of Lemierre Syndrome. 49 Actinomyces Empyema in an Immunocompetent Host with Dental Caries 49 The Perfect Storm: A Rare Case of Thyrotoxicosis Inciting Diabetic Ketoacidosis 50 Pseudo-Thrombotic Microangiopathy Secondary To B12 Deficiency 51 The Molecular Oligoastrocytoma 51 SGLT-2 Inhibitors: Wonder Drugs? Not So Fast 52 SARS-CoV-2 Decreases Neuronal Activity in Brainstem Respiratory Centers in C57BI6/J Mice 53 MRSE bacteremia via PICC line with AICD lead vegetation in a patient with heart failure on ambulatory Milrinone 53 Unilateral Pleural Effusion in the Setting of Severe Mitral Regurgitation
54 Crohn’s Disease in a patient with a history of Hemolytic Uremic Syndrome. 55 Exploring The Connection Between Brain Network
Connectivity And Cognitive Attention Acquired Brain Injury: A Systematic Review Of Structual And Functional Measures 56 Severe Abdominal Pain Secondary to Celiac Artery Stenosis. 56 A Case of Symptomatic Tachyarrhythmia of Unknown Etiology
57 MELAS syndrome as a predisposing factor to DKA 57 Early Onset Normal Pressure Hydrocephalus: Should we Expect the Unexpected 58 Labia Minora Hair Tourniquet Syndrome in an Adult Female: A Rare Presentation 59 Opportunistic Cutaneous Nocardiosis in a Patient with Advanced HIV. 59 Incidental Finding of Multiple, Enhancing Liver Lesions in the Setting of Mitochondrial Myopathy. 60 Promoting Resilience for Medicaid Members with Opioid Use Disorder. 61 Pickering Syndrome
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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 189 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 (14) abstracts presented at this year’s competition that were selected for oral presentations. An additional selection of resident (51) abstracts presented as posters were selected by judges for publication. All abstracts were presented at the Associates Meeting held at The Center for Advance Learning and Simulation on the LSU Health Sciences Center campus in New Orleans on January 27, 2024. We would like to thank the resident council for helping score the abstracts selected for presentation: James Gore, Ochsner Medical Center; Allison Pinner, LSU New Orleans, Amit Rajkarnikar, LSU Lafayette; Cassie Clark, LSU Baton Rouge; Simin Khan, LSU Shreveport; Besim Ademi, Tulane University; Chukwunoso Ezean, Baton Rouge General; Arpita Pawa, Willis Knighton. 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
POSTER PRESENTATIONS – RESIDENTS 1st place - Systemic Lupus Erythematous Flare Presenting with Pericardial Tamponade Edward Leonard MD , Mehnaz Rahman, MD, David Beyer, MD, Jacob Dubuc, MD, Fernanda Correa, MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA. 2nd place - Violaceous Bullae: A Case of Vibrio Vulnificus (V. vulnificus) Necrotizing Fasciitis Zui Keat Ng, DO, Heath Scott, MD , Youssef Bou- Mikael, MD, Joseph Hennig, MD, Amit Rajkarnikar, MD, Jacob Cunningham, MD, Benjamin Pickard, MD, Erica Jones, MD, George Gary Guidry, MD ; Department of Medicine, LSU Health, Lafayette, LA.
1st place - “Do I Have A Chance?” -The Use Of Angiovac System In A High Surgical Risk Patient With Aortic Valve Endocarditis Andikan Udoh MD , Kubiat Udoh MD, Akash Shah MD, Raja Saravanan MD, Sriveni Tangellapelli MD, Breanna Campbell MD; Baton Rouge General Internal Medicine Residency, Baton Rouge, LA. SESSION 2 1st place - Switching to Long-Acting Injectables in Those with Hepatitis B and HIV Co-Infection: Good Intentions Gone Wrong Jamie Tran MD, Nikki Seraji BS, Keionne Green BS, Alexander Fixler MD, Lauren Nunez MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA. MYSTERY CASE PRESENTATIONS – RESIDENTS 1st place - Pseudo-Thrombotic Microangiopathy Secondary To B12 Deficiency Karam Rahat, MD , Ricardo Vallejo-Calzada MD, Drishti Chawla MD; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
3rd place - A Rare Complication of Biliary Stent Migration: Choledochoduodenopyelo Fistula James Gore DO , Paula Cacioppo MD; Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA.
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ORAL PRESENTATIONS – RESIDENTS SESSION 1
BEEFING UP! FULMINANT LIVER FAILURE SECONDARY TO ANABOLIC STEROID USE Natasha Santosh, MD; Saloni Savani, MD; Srinivasa Iskapalli, MD- Willis Knighton Medical Center, Shreveport, LA.
Introduction: Trenbolone is an anabolic steroid used as a veterinary steroid in cattle and is often abused by fitness enthusiasts to increase muscle mass. Anabolic steroids have been known to cause psychological, neurological, endocrine, and cardiovascular disturbances. Here we present a case of fulminant hepatic failure in a young male with history of trenbolone and testosterone use who survived after receiving timely orthotopic liver transplantation. Case: A previously healthy, well developed, 30-year- old male presented with right upper quadrant pain, body aches for 2 days after he developed a fever of 103oF and petechial rash on his hands and feet. He consumed alcohol occasionally and denied smoking or recreational drug use. He admitted using trenbolone for bodybuilding. He was found to have thrombocytopenia, renal impairment, and markedly elevated liver function tests. Infectious, autoimmune, vascular, and other toxicological causes of fulminant liver failure were ruled out and his liver failure was attributed to his trenbolone use. He developed coffee ground emesis and altered mental status. He was intubated for airway protection, required vasopressor support, and received multiple units
of blood products. Continuous renal replacement therapy was initiated which helped stabilize his blood pressure. He received a liver transplant on day 6 of admission. Pathology of native liver revealed hepatocellular necrosis with a 2.5 cm benign hemangioma. Recovery was complicated by cerebral edema and continued bleeding at the surgical site which subsequently resolved. The patient was able to discontinue hemodialysis after 6 sessions. A polyuric phase of renal recovery was noted leading to suspicion of ATN secondary to bile cast nephropathy in addition to hepatorenal syndrome. The patient continued to recover with physical therapy and was able to walk independently upon discharge. Discussion: Previous case reports of acute liver disease associated with anabolic steroids describe a transient elevation of liver enzymes. This is the first reported case of fulminant hepatic failure secondary to anabolic steroid use treated successfully with orthotopic liver transplant. Awareness of recent fitness fads can help medical professionals educate patients about the risks of unauthorized drug use and offer safer alternatives.
ABNORMAL CARDIAC CONDUCTION ABNORMALITIES AS THE PRESENTING SIGN OF PYRETHROID POISONING Neha Bapatla MD, William Rothwell MD; Department of Medicine. Tulane University, New Orleans, LA.
Introduction: Pyrethroids are a type of synthetic insecticide seen in common household products. Toxicity with this agent mimics organophosphate poisoning and presents predominantly with neurologic and gastrointestinal manifestations. Cardiotoxicity associated with pyrethroid poisoning is an underreported phenomenon for which its mechanism of action is poorly understood. Case: The patient displayed nonspecific symptoms after experiencing dermal absorption of Raid. Initial EKG obtained revealed a T wave inversion in lead III but was otherwise unremarkable; however, the rhythm strip obtained indicated a premature atrial complex that degenerated into an irregular
tachycardia. Ultimately, this patient’s rhythm oscillated between normal sinus rhythm, sinus bradycardia, and atrial tachycardia with persistent hypotension. The diagnosis was nearly missed due to the abnormal presentation, but fortunately, the cardiac conduction abnormalities and history allowed the medicine team to facilitate a transfer of care to the medical intensive care unit. The patient was treated with a pralidoxime infusion with immediate resolution of cardiac conduction abnormalities. He was discharged in stable condition within a few days with complete resolution of all symptoms and laboratory abnormalities.
Discussion: Cases detailing cardiotoxicity because
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of pyrethroid poisoning is rare. When documented, rhythms are consistent with transient complete heart blocks or sinus arrest. The cardiac manifestations in our patient were uncommon and unexpected. We postulate that the EKG findings seen were reflective of
concomitant cocaine intoxication. This case highlights the importance of considering mixed toxicities and the effect of environmental toxicities in patients presenting with cardiac conduction abnormalities.
THE IMPORTANCE OF RECOGNIZING BRASH WITH MILD HYPERKALEMIA Chloe d’Aquin Spears, MD; Department of Medicine; LSU Health New Orleans, New Orleans, LA.
Introduction: BRASH is a clinical syndrome and acronym defined by bradycardia, renal dysfunction, AV nodal blockade, shock and hyperkalemia. It is often mistaken for beta blocker toxicity or undifferentiated shock in cases where hyperkalemia is mild.
evaluate for obstructive shock and found to have no pericardial effusion or signs of right heart strain. The cause of his shock is thought to be secondary to BRASH syndrome in the setting of hypovolemia due to decreased oral intake in response to uremic symptoms. AV nodal blockade from high dose beta blocker combined with poor renal reserve likely put him into a cycle of hyperkalemia and AV nodal block leading to worsening bradycardia, hypoperfusion, and shock. As the labetalol washed out of his system, his hemodynamics improved, and he was weaned off vasopressor support. His course was complicated by progression to end-stage renal disease, cardiac arrest during a tunneled line placement, and new atrial fibrillation diagnosis. He was discharged days later in stable condition. He unfortunately represented a month later with a STEMI leading to cardiac arrest and subsequently expired. Discussion: This case illustrates the importance of recognizing BRASH syndrome with mild hyperkalemia. Common precipitants of BRASH syndrome are hypovolemia, medications that increase serum potassium, and renal injury. It is important to recognize BRASH and correct even mild hyperkalemia to stop the cycle of worsening bradycardia and shock.
Case: A 77-year-old man with renal cell carcinoma status post nephrectomy, chronic kidney disease and hypertension presented with fatigue, shortness of breath, nausea, decreased appetite and decreased urinary output for one week. His medications were labetalol, amlodipine, calcitriol, patiromer, furosemide, and ferrous sulfate. He had no recent medication changes or dose adjustments. He was hypotensive despite fluid resuscitation and required vasopressors. He was bradycardic with initially borderline elevation in his potassium at K 5.1 mEq/L. His BUN and Cr were doubled compared to their baseline two months prior. He was initially managed for undifferentiated shock. He was covered with broad spectrum antibiotics, received glucagon and calcium for concern of beta blocker toxicity, and given albuterol, furosemide and potassium binders for hyperkalemia. An emergent transthoracic echocardiogram was obtained to
INVASIVE MUCORMYCOSIS IN PATIENT WITH ACUTE LIVER FAILURE Kierha Baker MD, Yanming Yang MD, Matthew Brown MD, Department of Medicine, Ochsner Clinic Foundation, New Orleans, LA.
Introduction: Rhinocerebral mucormycosis is a rare opportunistic infection caused by the inhalation of spores of either Rhizopus or Mucor species, affecting the paranasal sinuses and brain. The most important predisposing factors include immunocompromised individuals but even amongst high-risk patients, it accounts for only 8.3%-13% of all fungal infections. Due to the mucor species harboring a ketone reductase system, it grows aggressively in acidic conditions such as diabetic ketoacidosis, resulting in a fulminant and life-threatening disease, with
overall mortality 30-70% despite treatment. Early intervention is critical, however clinical signs of rhinocerebral mucormycosis are nonspecific. Case: A 33-year-old male with type 1 diabetes, hypertension, and alcohol abuse initially presented with jaundice and malaise. He had a distended abdomen, cognitive impairment, and right eyelid apraxia. Labs were consistent with diabetic ketoacidosis and acute liver failure with computed tomography (CT) of the abdomen/pelvis showing 7
Discussion: Rhinocerebral mucormycosis has the potential to be encountered in almost any immunocompromised individual presenting with altered mental status. In our patient, the differential diagnosis involved treatable causes including acute liver failure, diabetic ketoacidosis, Wernicke’s encephalopathy, and sepsis of unknown source. Because of nonspecific findings, a high index of suspicion should be made in the existence of risk factors. Management of rhinocerebral mucormycosis is a medical emergency requiring prompt treatment with amphotericin B and surgical debridement. Despite these measures, the survival of patients without brain involvement is between 50-80% and significantly drops to 20% with brain involvement.
an enlarged liver with mass effect on the inferior vena cava. Initial head imaging was unremarkable but despite appropriate treatment for diabetic ketoacidosis and hepatic encephalopathy, the patient continued to experience worsening encephalopathy and fevers. Repeat CT of the head showed bifrontal edema which was difficult to discern on prior imaging due to artifact. Given the patient's clinical course and imaging findings, a fungal etiology was suspected. Otorhinolaryngology confirmed the diagnosis of mucormycosis with nasal endoscopy. The patient was debrided and started on amphotericin b. Unfortunately, he continued to deteriorate and expired.
“DO I HAVE A CHANCE”—THE USE OF ANGIOVAC SYSTEM IN A HIGH SURGICAL RISK PATIENT WITH AORTIC VALVE ENDOCARDITIS. Andikan Udoh MD, Kubiat Udoh MD, Akash Shah MD, Raja Saravanan MD, Sriveni Tangellapelli MD, Breanna Campbell MD; Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Angiovac is a minimally invasive system approved for extraction of right-sided cardiac soft masses and embolic material in patients who are poor surgical candidates. Off-label use of the system has infrequently been prescribed in left-sided cardiac pathology and yielded encouraging results. Case: An 85-year-old male with refractory chronic lymphocytic leukemia not on chemotherapy, multiple episodes of bacteremia (methicillin-resistant staphylococcus aureus [MRSA], Streptococcus agalactiae and enterococcus faecalis), atrial fibrillation and bioprosthetic aortic valve replacement due to aortic stenosis presented with fever, weakness and erythematous rash that started after receiving the Respiratory Syncytial Virus and high-dose flu vaccines one day prior to presentation. He was febrile and tachycardic with an irregular rhythm. The cardiovascular examination was unremarkable and a diffuse urticarial rash over his torso was appreciated. Labs showed a WBC of 64 K/uL with lymphocytic predominance and no eosinophils. He was treated for presumed allergy to vaccines but started to spike fevers and he was empirically
started on broad spectrum antibiotics. Blood cultures grew MRSA. A transesophageal echocardiogram (TEE) was obtained because of inconclusive transthoracic echocardiogram (TTE), and it showed bioprosthetic aortic valve vegetations (largest-4cm). He was deemed a poor surgical candidate and he underwent a successful Angiovac debulking (90%) of the prosthetic AV vegetations eight days following admission. His procedure was complicated by post-op respiratory insufficiency and left common femoral artery injury that required angioplasty with endarterectomy. Post-procedure, he continued to spike fevers and repeat blood cultures grew coagulase positive staphylococcus. Post-procedure TTE had no evidence of aortic valvular dysfunction. Discussion: The primary goal of the Angiovac system in endocarditis is for vegetation debulking to allow reduction of microbic burden and reduce embolic risk. This procedure can paradoxically increase embolization risk intra-operatively and cause vascular access complications. Fiocco et al combined this procedure with a cerebral embolism protection device to mitigate the embolization risk.
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A BLOODY LYMPHOMA! Sneha Puvvada MD, Bhagya Challa MD, Maithri Vallabhaneni MD, Raja Saravanan MD, Sanjay Juneja MD; Department of Medicine, Baton Rouge General Medical Center; Baton Rouge, LA.
Introduction: Primary renal lymphoma (PRL) is a rare form of Non-Hodgkins Lymphoma with an incidence rate of less than 1% of all renal masses. As lymphoid tissue is absent in the kidneys, the genesis of PRL is uncertain. Our patient in this case study was incidentally diagnosed with PRL during a routine work up for iron deficiency anemia. Case: A 58-year-old post-menopausal woman with chronic cystitis with hematuria and recurrent UTIs presented for recurrent syncopal episodes and symptomatic iron deficiency anemia, that has been refractory to oral iron. She denied weight loss or anorexia but did have related night sweats. The patient did not have any signs of malabsorption, and evaluation with endoscopy was unrevealing. Flow cytometry and PNH were obtained for findings of worsening renal impairment with persistent lymphocytosis which produced negative results. Low levels of free light chains ruled out plasma cell dyscrasias. Renal ultrasound and follow up computed tomography confirmed a 3mm faint focus on the left lower pole. Her IgA levels and elevated inflammatory markers raised concerns for
immune complex glomerulonephritis for which a percutaneous kidney biopsy was obtained which unexpectedly revealed atypical lymphocytic infiltration. The diagnosis of PRL was validated by repeatedly negative results from subsequent PET scans and bone marrow biopsies. The patient was initiated on Bentamustine-Rituximab (BR) therapy and has shown to have favorable outcomes thus far. Discussion: Research indicates that PRL is more prevalent in men, organ transplant recipients, HIV patients, and individuals with unchecked Ebstein Barr Virus proliferation. PRL can easily be mistaken for renal cell carcinoma (RCC), particularly when it is a solitary lesion like this case. Nephrectomy is the usual course of treatment for RCC, while neoadjuvant chemotherapy would take precedence over nephrectomy in the case of PRL. This calls into doubt the long-held belief that in cases of renal masses, preoperative biopsies are not necessary before nephrectomy. Because of the aggressive nature of this disease, a delayed diagnosis results in poor prognosis; hence, an accurate diagnosis is crucial.
ORAL PRESENTATIONS – RESIDENTS SESSION 2
DECODING SINUSITIS: EXPLORING THE COMPLEXITIES Manush Sondhi, MD1; Chinedum Okafor, MD2; Samina Hayat, MD3, Department Medicine1, Department of Pathology2, Section of Rheumatology3, LSU Shreveport, Shreveport, LA.
Introduction: Aspirin-exacerbated respiratory disease (AERD) is defined as asthma, chronic rhinosinusitis with nasal polyposis, and hypersensitivity to cyclooxygenase 1 inhibitors. Immunoglobulin G4-related disease (IgG4-RD) is associated with reactive eosinophilia in one-third of patients. IgG4-RD and AERD can coexist in the sinonasal cavity, posing a diagnostic challenge. Case: A 52-year-old man with history of asthma and allergy to aspirin (confirmed by formal aspirin challenge) presented with chronic nasal congestion, thick yellow-green nasal discharge, post-nasal drip, and headaches for several months which worsened over the course of a week. He also experienced
intermittent shortness of breath, wheezing, coughing, and chest tightness. Lab results revealed elevated eosinophil levels (18.2%) and absolute eosinophil count (12.4). Computed tomography (CT) of the sinus revealed severe pansinusitis with opacification of all sinuses, while the CT of the chest showed diffuse patchy small airway disease. Otolaryngology identified bilateral nasal polyposis confined to the middle meatus (grade 4), but the patient declined invasive surgery. He was referred to Allergy and Immunology, where tests revealed elevated tryptase (33.4) and IgE levels (1470). He was treated with antihistamines and decongestants. Further evaluation by Hematology/Oncology showed normal flow cytometry, bone marrow findings, and negative
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genetic testing. He was started on hydroxyurea 1,000 mg daily. After a few months, he reported lower abdominal pain radiating to the back, diarrhea, flatulence, steatorrhea, and worsening sinusitis. CT abdomen revealed retroperitoneal mesenteric lymphadenopathy with multiple mesenteric lymph nodes. He was then referred to Rheumatology. All antibodies were negative, along with normal complement levels. Due to worsening sinusitis, he underwent polyp debulking, and a biopsy revealed acute and chronic lymphoplasmacytic inflammation with storiform fibrosis. IgG4 was elevated to 2413. He then was started on Prednisone 40 mg for a short interval period, followed by rituximab
infusions, on which he reported significant symptom improvement. Hydroxyurea was discontinued, and pancrelipase was started to improve digestion. Discussion: This instance highlights a unique occurrence of AERD/Samter's triad connected to IgG4, previously documented only once in literature. Considering the substantial increase in eosinophil levels and heightened interleukin (IL) 4 concentrations, type II inflammatory mechanism is at play, potentially responsible for the simultaneous presence observed in our patient. Timely identification and intervention are crucial to avert potentially harmful progression of IgG4-RD.
NOW YOU SEE ME, NOW YOU DON’T: TRANSIENT ENVIRONMENTAL FUNGEMIA Anthony Yeh DO, Kyle Stroda DO, Hoang Michael Nguyen MD, Roger Chang DO, Shantell Ford, MD; Department of Medicine, LSU Health, Lafayette, LA.
Introduction: Exophiala dermatitidis (previously Wangiella dermatitidis) is a dematiaceous dimorphic fungus known to cause a wide spectrum of human diseases. Melanin production is a core of all phaeoid fungi, which enables its survival in hostile environments. E. dermatitidis is especially known for creating biofilms. Case: A 29-year-old female with sickle cell disease, left hip avascular necrosis status post open reduction internal fixation and left shoulder avascular necrosis presented with complaints of sickle cell pain crisis. She denied chest pain but endorsed shortness of breath secondary to pain in her lower back and the posterior of her legs, in her usual distribution. She developed low grade fevers as high as 100.7oF, without leukocytosis, and she was pan-cultured. Without intervention, her low- grade fever resolved, and she was subsequently discharged while cultures were in process. Eventually, blood cultures grew Exophiala dermatitidis. She
was readmitted, had blood cultures drawn and received intravenous (IV) antifungals. The patient’s mediport was removed due to concern for seeding. A transesophageal echocardiogram was performed, which ruled out fungal endocarditis. She was treated with IV micafungin for 6 days and transitioned to diflucan for outpatient treatment after repeat blood cultures were negative. Discussion: Our patient who was initially admitted for sickle cell crisis subsequently developed transient fungemia that presented with fever without leukocytosis. E. dermatitidis is known to cause opportunistic infection and has the propensity to create a biofilm and can rarely cause fungal endocarditis. During her first hospitalization, the mediport was inappropriately accessed, which could have served as the source of initial infection. This case highlights the importance of only allowing implanted devices to be accessed by trained personnel and taking appropriate precautions during access.
“WHY THE RECURRENCE?”—THORACIC ENDOMETRIOSIS PRESENTING AS RECURRENT HEMOTHORAX. Kubiat Udoh MD, Andikan Udoh MD, Maithri Vallabhaneni MD, Vishal Busa MD, Shravani Surakanti MD. Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA.
Introduction: Extragenital endometriosis is an uncommon occurrence with an incidence of approximately 12% in reproductive-aged women. The thoracic cavity is the most common extragenital site and clinical presentation varies.
Diagnosis is often delayed which leads to further complications and recurrent hospitalizations.
Case: A 37-year-old female with dysmenorrhea with regular menstrual cycles presented with 2-weeks 10
duration of progressive shortness of breath. She had two successful vaginal deliveries previously. Labs were unremarkable besides iron deficiency anemia. Imaging showed a large right pleural effusion with right middle/lower lobe collapse and few sub- centimeter lymph nodes. A thoracocentesis yielded 1000cc of bloody fluid. Pleural fluid studies were consistent with an exudative process and cytology showed atypical cells. Given suspicion for malignancy, further abdominopelvic imaging was obtained that showed ascites, mixed solid/cystic mass (6.7 x 2.5 cm) in the left ovary, and a 1.5cm hepatic lobe mass with lymph nodes in the mesentery and right groin. CA- 125 was five times the upper limit of normal. She was referred to a gynecological oncologist after discharge who did a diagnostic laparoscopy that revealed endometriosis with a multicystic pelvic mass adhered to the sigmoid colon. Pre-operative PET/CT and colonoscopy were both normal. She subsequently underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, appendectomy, bilateral ureterolysis
with tumor debulking. Pathology was negative for malignancy. Post-surgery, she was readmitted for right hemothorax and apical pneumothorax with concern for lung entrapment. She underwent a right robotic-assisted pleurectomy, lysis of apical adhesions, mediastinal lymph node dissection. Pathology revealed endometrial tissue without malignant findings. Pathology re-reviewed her initial pleural cytology and found immunohistochemical patterns consistent with endometriosis but without any evidence of malignancy. Discussion: The diagnosis in this patient posed a dilemma as there was initial suspicion for ovarian cancer and Meig’s syndrome which can have similar presentations. The pathogenesis of thoracic endometriosis is not fully understood and different theories such as retrograde menstruation, lymphatic dissemination and pleural mesothelial metaplasia have been proposed. Surgical intervention is often necessary and postoperative hormonal suppression can prevent relapse.
SWITCHING TO LONG-ACTING INJECTABLES IN THOSE WITH HEPATITIS B AND HIV CO-INFECTION: GOOD INTENTIONS GONE WRONG Jamie Tran MD, Nikki Seraji BS, Keionne Green BS, Alexander Fixler MD, Lauren Nunez MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: For patients with HIV, there has been increased interest in transitioning from traditional daily anti-retroviral therapy (ART) to long-acting injectable medications which can be administered in 4-8 week intervals. Studies have shown that those that achieved viral suppression can safely transition to Cabenuva (cabotegravir and rilpivirine) with few side effects and maintain effective HIV suppression for at least 48 weeks. However, compared to ART, Cabenuva lacks an agent that targets Hepatitis B (HBV). Case: A 49 year-old female with HIV (diagnosed in 1990), hepatocellular carcinoma status post microwave ablation (diagnosed in 2015), and chronic hepatitis B (diagnosed in 2001) presented with chest pain and dyspnea for three weeks. Cardiac work up was unremarkable. Her CD4 count was 467 cells/ mm3 and she had an undetectable viral load. There was an incidental finding of severe elevation in her AST (2565 U/L) and ALT (1577 U/L). Alcohol levels and autoimmune workup was negative. Hepatitis-A IgM, Hepatitis-B surface antigen, Hepatitis-B IgM, Hepatitis-C antibody, and Hepatitis-D antibody
were also negative. Computed tomography of the abdomen and pelvis additionally had no significant findings. The patient denied taking any new medications besides Cabenuva which was recently switched from Symtuza (darunavir, cobicistat, emtricitabine, and tenofovir) 3 months prior. The gastrointestinal and infectious disease teams were in agreement that despite the negative hepatitis panel, confirmatory viral hepatitis labs should be obtained, and empiric HBV therapy should be initiated to treat a potential HBV flare given patient’s history and recent switch to a medication without an agent against HBV. AST and ALT down trended after initiation of Tenofovir so the patient was discharged with plans to transition back to Symtuza. The Hepatitis-B DNA PCR resulted a week later with a level of 4.7 million IU/mL confirming our suspicions.
Discussion: There are about 8-10% of people co-infected with HIV and HBV globally. HBV reactivation and hepatic failure are potential negative outcomes when switched to a regimen without activity against HBV. As a result, it is not 11
recommended at this time to switch to long-acting injectable medications for those with HIV and HBV.
More research needs to be done to create a long- acting injectable that has activity against HBV.
WEST NILE VIRUS ENCEPHALITIS: AN ATYPICAL CASE PRESENTATION Sepehr Sadeghi DO, Gurtaj Mahil BS, Oluwafemi Ajibola MD, Amita Krishnan MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: West Nile Virus (WNV) meningoencephalitis is typically associated with cerebrospinal fluid (CSF) studies consistent with lymphocytic predominance. Case: A 60-year-old male with hypertension, type 2 diabetes, stroke with left-sided hemiparesis, and epilepsy presented after being found unconscious in his backyard. He could not provide history due to a altered mental status, but his brother reported that the patient lived independently. Initially, he was only oriented to person, had a fixed rightward gaze, left hemineglect, increased muscle tone, and generalized tremors. He was hypertensive to 241/102 and febrile at 102.6o F. He was admitted to the intensive care unit for intubation and mechanical ventilation following a rapid deterioration in mental status. A computed tomography scan of his head without contrast ruled out any acute intracranial abnormalities. EEG results showed diffuse background slowing, consistent with widespread cerebral dysfunction and encephalopathy. A lumbar puncture was performed which revealed 528 white blood cells (WBC) with 82% neutrophils and 5% lymphocytes, no red blood cells (RBCs), protein of 165, and glucose of 83. Cerebral
spinal fluid (CSF) meningoencephalitis infectious studies were pan-negative, which prompted a second lumbar puncture for further evaluation. This subsequent CSF sample showed no RBCs, 84 WBCs with 87% lymphocytes, 5% neutrophils, protein 183, and glucose 46. Extensive autoimmune and paraneoplastic workup was negative. Notably, the patient experienced an unexplained renal impairment between the two CSF samples, with creatinine levels rising from 1.1 to 3.4 within two days, followed by a subsequent correction over the following two days. Serologic testing eventually confirmed the presence of an acute WNV infection given the presence of WNV IgM antibodies. The patient was subsequently transferred for neurocritical care at another facility. Discussion: This is a peculiar case of WNV encephalitis characterized by a biphasic pattern of leukocyte composition in the CSF, noted with a transition from neutrophilic to lymphocytic predominance. These findings underscore the importance of considering WNV encephalitis, even when the initial CSF analysis reveals a neutrophilic predominance, a finding typically considered to emanate from a bacterial infection.
WHAT LIES BENEATH THE SURFACE: A CASE OF AQUAGENIC URTICARIA WITH IGG3 SUBCLASS DEFICIENCY Nadjel Opamen MD, Erin Pratt MD; Department of Medicine, LSU Health, Lafayette, LA.
Introduction: Aquagenic urticaria is a rare condition with less than 100 cases documented in medical literature. This can significantly impair a patient’s quality of life. To our knowledge, there has never
ipratropium with minimal improvement. Further work-up revealed substantially low IgG with very low IgG3 subclass and 8 out of 23 positive pre- pneumococcal serotype-specific IgG antibodies. Prevnar was administered and resulted in a post- pneumococcal titer of 16 out of 23. Omalizumab was started with drastic improvement of symptoms. Repeat work-up showed persistently low IgG thus the decision was made to start monthly IVIG infusions. At this point, the patient was diagnosed with hypogammaglobulinemia with IgG3 subclass deficiency, aquagenic urticaria and vasomotor rhinitis. Since starting IVIG infusions, the patient can now tolerate rain exposure and showers 12
been a reported case of aquagenic urticaria in a patient with IgG3 subclass deficiency.
Case: A 75-year-old man with recurrent otitis media, sinusitis, and pneumonia presented with perennial pruritic urticaria and rhinitis particularly with rain exposure and during showers. He reported that he had been diagnosed with an allergy to water several years ago. The patient was initially treated symptomatically with oral antihistamines and
without significant pruritic urticaria and has reported a vast improvement in quality of life.
with sebaceous glands and transdermal migration of water-soluble antigens leading to mast cell release of histamine. IgG antibodies can inhibit IgE- mediated mast cell activation through direct allergen neutralization or through the inhibitory receptor FcγRIIb. This case raises questions of a potential mechanistic interaction, especially given the robust response to omalizumab and IVIG treatment.
Discussion: An association between IgG3 subclass deficiency and aquagenic urticaria has never been documented. The pathophysiology of aquagenic urticaria remains elusive, however proposed mechanisms include water antigens interacting
MYSTERY CASE PRESENTATIONS – RESIDENTS
PSEUDO-THROMBOTIC MICROANGIOPATHY SECONDARY TO B12 DEFICIENCY Karam Rahat MD, Ricardo Vallejo-Calzada MD, Graham Unis, MD, Drishti Chawla MD; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Pseudo-thrombotic microangiopathy (TMA), a rare presentation of vitamin B12 deficiency, shares many features with thrombotic thrombocytopenic purpura (TTP). TTP management
higher level of care due to concern for TTP given her altered mental status and concurrent renal impairment. Further evaluation revealed a vitamin B12 and folate deficiency and a PLASMIC score of 2. ADAMTS13 activity was normal. Intravenous vitamin B12 and folate repletion were initiated with improvements seen in her mental status and blood counts. An intrinsic blocking factor returned positive. The patient was discharged with monthly vitamin B12 injections and hematology follow-up. Discussion: Vitamin B12 deficiency has a variable presentation with a myriad of potential hematologic and neurologic sequelae. Pseudo-TMA represents a rare presentation of B12 deficiency often confused with TTP. Management of TTP involves plasma exchange and often requires specialized care. Therefore, recognition of factors that may distinguish Pseudo-TMA from TTP is critical.
often includes plasma exchange and other therapies that are neither therapeutic nor benign in regard to vitamin B12 deficiency.
Case: A 58-year-old female with no known history was brought by her family after being found on the bathroom floor with somnolence and confusion. Her initial workup was notable for a Hgb of 2.6 g/ dL, a MCV of 95fL, and platelets of 71k/µL. LDH 3500 Unit/L, Haptoglobin 19 mg/dL, negative direct Coomb’s test, elevated bilirubin with depressed reticulocyte index, reticulocyte 0.7%, reticulocyte index 0.06, elevated PT/aPTT and fibrinogen of 315 were also reported. Peripheral smear demonstrated schistocytes, teardrop cells, and hypersegmented neutrophils. The patient was transferred to a
HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Anastasia Graffagnini, MD, Andriane Melanthiou, MD, Jasleen Hora, MD, Jennings Field, MD, Shyam Mani, MD, Ibrahim El Abbassi, MD; Department of Medicine, Leonard J Chabert Medical Center, Houma, LA.
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome resulting from defective macrophages and cytotoxic T cells. HLH can be triggered by infections, malignancies, or autoimmune disorders. Patients can present with recurrent fevers, cytopenias, liver dysfunction, and a sepsis-like syndrome. Case: A 55-year-old male with atrial fibrillation, lung mass, hypertension, hyperlipidemia, diabetes, heart failure with a preserved ejection fraction, obstructive
sleep apnea, prior COVID-19 infection, and morbid obesity presented with four days of altered mental status, shortness of breath and a productive cough with clear sputum. In addition, the patient endorsed dysuria with malodorous urine and bilateral extremity swelling. Prior outpatient evaluation for her lung mass revealed atypical pneumocyte hyperplasia with background macrophages including vacuolated forms. Repeat biopsy performed to further evaluate the suspicious lung mass and adenopathy revealed predominantly lymphoplasmacytic inflammatory 13
cells including histiocytes, some of which contained cytoplasmic inclusions. Initial infectious workup was unremarkable. Ferritin was grossly elevated to >26,000 micrograms/L. Given patient’s lung biopsy findings, worsening clinical status, and progressive cytopenias, HLH was considered and worked up per HLH-94 guidelines. A bone marrow biopsy showed hypercellular marrow and erythrophagocytosis without underlying dysplasia. The IL-2 receptor was significantly elevated. H-score was calculated to be 284, which equates to >90% probability of hemophagocytic syndrome. This was deemed sufficient to begin treatment with Etoposide and Dexamethasone for HLH, and the
patient showed marked clinical improvement upon therapy initiation. Expanded workup for viral etiologies did reveal EBV positivity by PCR, which may have been the inciting factor. He will require further evaluation for malignancy. Discussion: The diagnosis of HLH remains challenging as patients initially present with non-specific findings, prompting clinicians to eliminate other differentials first. Timely diagnosis is of utmost importance due to HLH’s high mortality rate. This case exemplified the utility of HLH-94 guidelines in promptly diagnosing and initiating treatment in suspected HLH.
POSTER PRESENTATIONS – RESIDENTS
A RARE CASE OF FATAL DRUG INDUCED HEPATITIS SECONDARY TO IMMUNE CHECKPOINT INHIBITOR Jaahnavi Konidala MD, Natasha Santosh MD; Department of Medicine Willis-Knighton Medical Center, Shreveport, LA.
Introduction: Immunotherapy, including immune checkpoint inhibitors (ICPI), have presented new effective treatment modalities for various cancers. Durvalumab (PDL-1 inhibitor) is one such drug known to cause hepatitis in rare occasions managed successfully with corticosteroids or combination immunosuppression. In this report, we present a case of fatal grade 4 ICPI induced hepatitis failing monoclonal antibody therapy. Case: A 59-year-old female with hypertension, coronary artery disease, unresectable stage III non- small cell carcinoma without evidence of metastasis on PET scan, on durvalumab for 9 months, and a former smoker presented to oncology clinic with sudden onset worsening nausea and vomiting associated with diffuse abdominal pain radiating to the right shoulder and fatigue for 1 day. Examination was remarkable for generalized icterus without abdominal tenderness. An EKG showed no significant ST-T wave changes. Labs were significant for the ratio of ALT/ALP >5, an elevated PT/INR and an acute kidney injury. Infectious workup was negative. The serum acetaminophen level was normal. Autoimmune workup was negative. Ultrasound of the abdomen was negative for portal vein thrombosis. Durvalumab was determined to be the cause of her liver injury. The patient was treated with methylprednisolone 1mg/
kg with dramatic resolution of the derangements in her liver function tests. Her abnormal tests returned to baseline so she was discharged on oral prednisone. On follow up four days after discharge, labs showed recurrent elevation in liver function tests with a total bilirubin of 28 mg/dl. The patient was admitted, started on methylprednisolone, and required intubation for rapidly worsening mentation. Further immunosuppression was attempted with mycophenolate and then tocilizumab. Ultimately, she went on to develop hepatorenal syndrome requiring renal replacement therapy, multiorgan dysfunction and bleeding diathesis. She was not a suitable candidate for transplant due to malignancy and poor prognosis. The family opted for withdrawal of care in accordance with the patient’s wishes. Discussion: This is the first case ever reported with fatal grade 4 ICPI induced hepatitis despite use of monoclonal antibodies. Previous reports of ICPI hepatitis noted improvement with either corticosteroids or with combination of steroids and other immunosuppressants, rarely requiring monoclonal antibodies. With increasing use of immunotherapy, more such cases are likely to be reported. Early diagnosis and treatment of ICPI hepatitis is vital to improving patient outcomes.
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A UNIQUE APPROACH TO HYBRID EXTRACORPOREAL MEMBRANE OXYGENATION: A CASE REPORT Rakin Areef MD; Arpita Pawa MD, Ahmed Virani MD, Willis-Knighton Medical Center, Shreveport, LA.
Introduction: Extracorporeal membrane oxygenation (ECMO) is a life support system used in patients with severe cardiac or respiratory failure that is potentially reversible but is resistant to traditional medical management. Two major ECMO circuits are utilized throughout the country, Veno-Arterial (VA) and Veno-Venous (VV). Over the years, the concept of Hybrid ECMO using additional cannulas has come into existence for better hemodynamic support. Case: A 72-year-old male presented as a transfer post percutaneous intervention to the right coronary and left circumflex artery following an ST elevated myocardial infarction after a cardiac arrest. Upon arrival, the patient was in cardiogenic shock and was initiated on mechanical circulatory support using a percutaneous left ventricular assist device. An echocardiogram revealed severe aortic stenosis, severe mitral regurgitation, moderate tricuspid regurgitation and an ejection fraction of 30-35% with moderately depressed right ventricular
function. Given the degree of aortic stenosis, the patient was planned for a Transcatheter Aortic Valve Replacement (TAVR), however, he continued to decline hemodynamically and was not considered stable for the procedure. Given the severity of hemodynamic compromise and complexity of his condition, the patient was initiated on a hybrid ECMO with Veno-Veno-Arterial (VVA) configuration with dual venous drainage from the right atria and the pulmonary artery using a PROTEK cannula with femoral artery return. As hemodynamics improved, the patient was taken for TAVR procedure and transitioned to VV ECMO and finally explanted. Discussion: In conditions where severe hemodynamic compromise is noted, Hybrid ECMO circuits instead of traditional ECMO circuits should be considered to improve patient outcomes. Veno-Veno-Arterial ECMO using Pulmonary artery drainage is rarely mentioned in literature which makes its use unique.
PHARMACY-DRIVEN MRSA NASAL SWABS TO REDUCE VANCOMYCIN USAGE Besim Ademi, MD, Samuel Ficenec, MD, Joy Fesen, MD and Nicholas Tolat, MD; Department of Medicine, Tulane University, New Orleans, LA.
Introduction: Vancomycin is one of the most common antibiotic used in practice. This is problematic given rising resistance and inappropriate usage. De-escalation of antimicrobial therapy is paramount to avoid increased patient risks, costs, and growing resistance. However, de-escalation is a difficult choice for many physicians which may cause prolonged vancomycin therapy. A MRSA nasal swab is a minimally invasive clinical tool which has been helpful to guide therapy in cases of pneumonia. Study: This study implemented a pharmacy- driven MRSA nasal swab order after vancomycin prescription. The pharmacist would then review the result and make a recommendation to the primary team for either continuation or discontinuation of vancomycin. Data was collected retrospectively from all patients admitted to the hospital that received a confirmed dose of vancomycin for 1 month pre-and 2 months post-intervention. 129 and 185 patients respectively were included in the pre- and post-intervention groups. A significantly greater
proportion of patients that were admitted to the hospital during the post-intervention period had a MRSA nasal swab that was collected in comparison to the pre-intervention period (81% vs 67%, p =0.008). In the pre-intervention period, the mean duration of vancomycin therapy was 3.26 ±3.56 days. In comparison, during the post-intervention period the duration of vancomycin was significantly shorter with a median duration of 2.74 ±3.06 days (p =0.024). Discussion: The results of this study show that a pharmacy-driven MRSA nasal swab intervention reduces the total days of vancomycin therapy by about 12 hours. These results are similar to other studies examining MRSA nares interventions which demonstrated a reduction of vancomycin duration of 10 hours. However, our findings are unique, in that this is the first known study to demonstrate a significant reduction in vancomycin use in all infections. These findings are important as the growth of antimicrobial resistance is a major public health concern. The limited number of 15
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