Cultures from the blister aspiration and tissue from the debridement grew Nocardia on hospital day 4 and antibiotics were changed to trimethoprim/ sulfamethoxazole and meropenem. After treatment with 4 days of trimethoprim/sulfamethoxazole, the patient was switched to linezolid PO due to acute kidney injury and continued on meropenem for a total of 2 weeks. The patient was transferred to a skilled nursing facility to continue antibiotics. Nocardia was eventually speciated as Nocardia
brasiliensis with sensitivity to linezolid.
Discussion: Most cases of Nocardia brasiliensis are limited to superficial infection or chronic mycetoma. Our case of Nocardia brasiliensis in an immunocompetent patient progressed to necrotizing fasciitis warranting surgical debridement and extended antibiotic use. This case demonstrates that primary cutaneous Nocardiosis can cause potentially life-threatening skin and soft tissue infection.
UNMASKING A RARE DUAL THREAT: BI-PHENOTYPIC COMPINED HEPATOCELLULAR CARCINOMA AND CHOLANGIOCARCINOMA WITH PORTAL VEIN THROMBOSIS Asad Mussarat MD, Nikki Arceneaux MD, Catherine Loehr, MD, Zacary Stielper MD, PhD, Christopher Hayden MD, Peyton Hopkins MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Bi-phenotypic combined hepatocellular carcinoma and cholangiocarcinoma (C-HCC/CC) is a rare and diagnostically challenging malignancy. We present a unique case of C-HCC/CC that initially manifested as ascites with portal vein thrombosis (PVT). Case: A 63-year-old male with non-alcoholic cirrhosis presented with one week of abdominal pain and distension. He was recently hospitalized for hematemesis secondary to esophageal varices which involved esophagogastroduodenoscopy with band ligation, and subsequent discharge on oral antibiotics for spontaneous bacterial peritonitis prophylaxis. The night of his discharge he developed diffuse aching abdominal pain. He described his stomach as being “hard as a rock.” The physical exam was significant for diffuse abdominal distension. A contrast-enhanced computer tomography (CT) scan of the abdomen and pelvis revealed the extension of a portal vein thrombus into the splenic and superior mesenteric veins, a significant change from a previous CT scan 11 days prior. Elevated alpha- fetoprotein and cancer antigen levels raised concerns for malignant thrombosis. Portal vein fine needle
aspiration biopsy was performed and was positive for high-grade carcinoma cells, but no discrete parenchymal masses were visualized on magnetic resonance imaging or CT scans of the liver. Further evaluation with a CT chest ruled out metastases. Y90 radioembolization mapping demonstrated less than 10% lung shunt and uptake in multiple liver segments. The plan was to hold off on additional locoregional therapy given that the angiogram revealed an arterioportal shunt that could not be effectively targeted with Y90 radioembolization. Given this unique presentation, we recommended oncology referral for systemic therapy. The patient also expressed interest in obtaining a second opinion, particularly exploring potential eligibility for clinical trials related to the management of bi-phenotypic tumors with portal vein invasion. Discussion: This case highlights the diagnostic challenges and therapeutic considerations for rare hepatic malignancies, emphasizing the importance of a multidisciplinary approach to patient care and the potential role of clinical trials in advancing our understanding and management of such complex tumors.
A CASE OF COCCIDIOMYCOSIS CONFOUNDING A SYSTEMIC LUPUS ERYTHEMATOSUS DIAGNOSIS Lily Chen MD, Sidney Mejia MD, Lydia Rewerts BS, Seema Walvekar MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Systemic Lupus Erythematosis (SLE) is a rare autoimmune disease with prevalence of 20-150 cases per 100,000 in the United States. Despite increased awareness among physicians and improvements in serologic testing, the time to
diagnosis from symptom onset is still delayed for many patients. One significant cause of diagnostic delay is due to the heterogeneity in the disease presentation, with symptoms that can present similarly to many other autoimmune, infectious, or 19
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