complication of an acute lupus flare. Widespread inflammation can lead to rapid fluid shifts with accumulation of pericardial fluid, leading to tamponade physiology and rapid deterioration of an otherwise healthy patient. Glucocorticoid abrupt cessation and younger age of patient
have also been shown to be risk factors for SLE flare. Caution and a multidisciplinary approach to these patients with prompt recognition of tamponade physiology and emergent evaluation for pericardiocentesis is required in these patients.
COULD BE CHEST PAIN …BUT WAT ABOUT A PERFORATED APPENDIX? Allison Derise MD, Amanda Ritchie MD, Seth Vignes MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: It is well described that there can be atypical presentations of acute coronary syndrome, especially within the female population, but what about other pathologies that can present as chest pain? Acute appendicitis is known to present as right lower quadrant abdominal pain, but there can be a variety of signs and symptoms that are usually located within the abdomen or pelvic regions. Rarely is the presenting complaint of appendicitis chest pain. Case: A 94-year-old female with hypertension, hyperlipidemia, coronary artery disease and mild aortic stenosis presented with shortness of breath, intermittent, substernal chest pain, and acute encephalopathy present for several days. Work up for acute coronary syndrome showed non-elevated high-sensitivity troponin levels and an ECG with left ventricular hypertrophy and non-specific T wave inversions in leads III and aVF. Physical exam on admission was notable for abdominal fullness with hypoactive bowel sounds but no tenderness, tympany, or guarding. Other admission labs were remarkable for leukocytosis with neutrophilic predominance, significantly elevated D-dimer, and lactic acidosis. A Computed tomography (CT) angiogram of the chest was performed, which was negative for pulmonary embolism, but
showed a mildly distended small bowel loop in the anterior mid abdomen. An upright abdominal x-ray showed air throughout small and large bowel loops without focal transition point noted. A CT abdomen and pelvis showed acute appendicitis with phlegmon changes and microperforations surrounding a fluid-filled appendix and partial small bowel obstruction with gastric outlet obstruction likely secondary to the inflammatory process. The patient was taken for an emergent exploratory laparotomy, which converted to open after discovery of an appendiceal rupture, purulent peritonitis, and partial small bowel obstruction. Discussion: Due to its ability to lie in different positions, an inflamed appendix can present with various abdominal, flank, and pelvic complaints; however, there are rarely presentations that are similar to acute coronary syndrome. Atypical presentations of acute appendicitis can be challenging and may lead to delayed diagnoses putting patients at risk for serious decompensation and increasing the possibility of morbidity and mortality. This case highlights the importance of maintaining a broad differential diagnosis and awareness of atypical presentations of diseases to prevent delay in critical diagnoses.
UNDER THE COLLARBONE: A CASE OF PRIMARY STERNAL AND CLAVICULAR OSTEOMYELITIS Nikki Arceneaux MD, Vivek Patel DO, Ross McCarron MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Primary sternal osteomyelitis (PSO) is a rare but life-threatening condition. This case underscores the diagnostic challenges of PSO, highlighting the significance of early culture-based pathogen identification and the potential success of conservative management when patients respond well to antibiotics.
Case: A 41-year-old female with uncontrolled type 2 diabetes, hypertension, obesity and intravenous drug use complicated by necrotizing fasciitis of the left forearm presented with acute left chest pain and purulence of left forearm wounds for two days. Her exam was significant for tenderness to palpation to the anterior chest, left shoulder, and purulence of the left forearm. The patient was started 21
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