JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
MUDBUG COLITIS
AN INTERESTING CASE OF CHEST PAIN
J. Landreneau, MD; J. Anderson, MD Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge
N. Turaga, MD; S. Gavini, DO; A. Konde, MD; A. Chaufe, DO; R. Chauffe, DO Department of Internal Medicine, LSU Health Sciences Center - Lafayette Introduction: Coronary Artery disease (CAD) is the most common cardiac etiology for chest pain. Atherosclerosis accounts for almost 95% cases of CAD, while autoimmune vasculitis is very rare. We present here an interesting case of chest pain which lead us to the diagnosis of Polyarteritis Nodosa (PAN). Case: A 36-year-old man presented with midsternal chest pain, dyspnea, epigastric pain, nausea and 50-pound weight loss. Vitals were stable except for blood pressure of 228/144 mm Hg and physical exam was unremarkable. Labs showed BUN 45 mg/dl, creatinine 4.28 mg/dl and normal troponin. ECG showed sinus tachycardia, frequent PVCs and incomplete left bundle branch block. Echocardiogram revealed 40% ejection fraction, moderate mitral and tricuspid regurgitation. Cardiac nuclear stress test revealed fixed medium defect in inferior region and small partially reversible defect in inferolateral region. Coronary angiography showed 100% stenosis of proximal right coronary artery (RCA), ectatic and aneurysmal changes in distal RCA, left mainstem coronary artery, proximal left anterior descending artery, proximal lateral circumflex artery, left subclavian artery and right femoral artery branches. Workup for all etiologies of vasculitis and hepatitis panel was negative. 4/10 ACR criteria for classification of PAN were met: weight loss >4kg, diastolic blood pressure >90 mm Hg, BUN >40 mg/dl or creatinine >1.5 mg/dl and arteriographic abnormalities. Medical management for CAD along with hemodialysis, pulse dose steroids followed by cyclophosphamide therapy was initiated. At 3-month clinic follow up, he remained chest pain free. Discussion: PAN is a systemic necrotizing vasculitis which routinely involves small to medium-sized arteries. Coronary artery involvement is very rare. There are no clear-cut guidelines or common consensus regarding management of coronary vasculitis with severe luminal narrowing in patients with PAN. A few published cases illustrate the utility of coronary artery bypass grafting and percutaneous coronary intervention (PCI) after initial treatment with immunotherapy. Cardiac transplantation may also be considered in patients with poor response to immunosuppressive therapy. Alternatively, initial medical management with close follow-up and interventions as necessary is a reasonable approach.
Introduction: Plesiomonas shigelloides and Vibrio mimicus are rare bacterial infections causing diarrhea, severe abdominal pain, and vomiting. Both bacteria live in water environments, flourish in warmer climates, and typically affect patients who consume raw or undercooked shellfish or drink contaminated water. Clinical manifestations of infection with either vary in length and in character often mimicking other gastrointestinal diseases, making these infections a diagnostic dilemma. Case: A previously healthy 24-year-old man presented with new onset generalized abdominal cramping, watery diarrhea and one-day of vomiting. Symptoms began intermittently six weeks ago and acutely worsened about one week prior to presentation afterconsumingboiledcrawfish. Familyhistorywassignificant for Crohn’s disease in his mother. Exam revealed diffuse hyperactive bowel sounds and tenderness to palpation across suprapubic/ epigastric regions of abdomen. Initial laboratory studies revealed a leukocytosis with a left shift and mild hypokalemia. There were few white blood cells seen in stool. FOBT was positive. HIV was negative. CT with contrast showed mild diffuse wall thickening of distal small bowel, cecum, and ascending colon with air-fluid levels in the small bowel. Esophagogastroduodenoscopy was negative. Colonoscopy revealed a 1 cm sigmoid polyp which was hot snared, otherwise normal. All biopsies taken during both diagnostic procedures were benign and without evidence of granulomas or lymphocytic changes. Clostridium difficile, stool-eosinophils, stool ova and parasites, Giardia antigen, and Rotavirus were all negative. Stool cultures later resulted with moderate growth of Vibriomimicus and Plesiomonas shigelloides . The patient was prescribed ciprofloxacin (500mg PO BID) for five days of treatment. Discussion: This case illustrates the nebulous presentation of Plesiomonas shigelloides and Vibrio mimicus coinfection in addition to the challenges of diagnosing inflammatory versus infectious colitis. The patient’s prolonged gastrointestinal symptoms along with family history of Crohn’s disease favored inflammatory bowel disease over infrequent causes of bacterial colitis. However, during this season when eating boiled crawfish is common, he may have had multiple exposures. Early recognition of patient risk factors and appreciation of atypical bacteria in certain regions of the country are important in reducing healthcare costs and unnecessary treatment for patients with ambiguous GI symptoms.
J La State Med Soc VOL 170 MARCH/APRIL 2018 57
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