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
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