JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
GONOCOCCAL ENDOCARDITIS: THE GIFT THAT STOPS GIVING! AN UNCOMMON PRESENTATION OF A COMMON DISEASE. G. Olayemi, MD; M. Oferczak, MD; A. Elagizi, MD; I. EL-Abbassi, MD; M. Eschete, MD; J. Crowe, MD Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA. Introduction: Gonorrhea is the 2nd most common sexually transmitted disease in the US with 800,000 cases of gonorrhea each year. Disseminated gonorrhea infection occurs in 0.5%- 3% of these patients and is more frequent in woman younger than 40 years of age. Case: A 36 year old woman with a history of polysubstance abuse presented with 10 day history of feeling generally unwell. At presentation, vitals were remarkable for tachycardia and hypotension. Physical exam was remarkable for conjunctival pallor, bibasilar crackles, and tachycardia with grade III/VI systolic murmur loudest over the 2nd inter-costal space and loudest with expiration. No skin lesions were noted. Labs demonstrated leukocytosis (WBC 20,200 with 84% neutrophils), anemia (Hb 6.7), thrombocytosis (platelets 423 k/uL), abnormal liver function tests (alkaline phosphatase 239 IU, AST 151 IU ALT 71 IU, albumin 2.5g/dL), PT/INR 17.1/1.5. Troponin 0.42, BNP 823, D-dimer 619, and a urine drug screen that was positive for benzodiazepines, opiates, barbiturates, amphetamine, and THC. Hep panel and HIV were negative. Chest radiograph showed mild cardiomegaly and early interstitial edema. The patient was placed on broad spectrum antibiotics and given adequate fluid resuscitation and blood products. Blood cultures grew Neisseria gonorrhoeae. 2D ECHO showed a large pedunculated/mobile echo density adherent to the non-coronary and lefts cusps of the aortic valve. Proximal aortic root and aorto-mitral continuity were thickened, consistent with aortitis and/or abscess formation. Initial EKG on arrival showed junctional tachycardia which progressed into complete heart block. Cardiologywas consulted and a pacemaker was placed emergently. However despite all aggressivemeasures the patient died of cardiac complications. Discussion: Endocarditis is a rare complication of disseminated gonorrhea, occurring in only 1-2%of patientswithgonoccocemia. The aortic valve is most commonly affected. Valve replacement is warranted in cases with severe dysfunction. Mortality remains around 19-20. Neisseria gonorrhoeae endocarditis should be included in the differential diagnosis in sexually active patients with endocarditis.
Leptospirosis diagnosed per year, most of which have been from southeast LA. This case illustrates the importance of considering the diagnosis of Leptospirosis and Weil’s Disease in patients in the southeast region of LA who present with multi-organ failure. In addition, our patient’s occupational exposure was key to her diagnosis which emphasizes the importance of a detailed history in clinical decision making and patient outcomes.
NOT ANOTHER ACS RULE OUT
S. Preston, BE 1 ; R. Nelson, MD 1 ; M. Watts, MD¹; D. Smith, MD²; T. Dewenter, MD³; D. Spruill, MD¹
1. Tulane University School of Medicine, Department of Internal Medicine; 2. LSU Health Sciences Center, Department of Radiology; 3. LSU Health Sciences Center, Department of Pathology, New Orleans, LA Case: A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell’s Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45% with antero- lateral hypokinesis. Shewas treated for NSTEMI, and an angiogram showed 95% stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. AnMRI Braindemonstrated scatteredT2/ FLAIR hyper-intense foci in the subcortical whitematter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. CardiacMRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogramdemonstrated recoveredejection fractionof 55% with improvedwall motion in the septumand apex. Additionally, her left-sided Bell’s Palsy and dysarthria improved after several days of therapy. Discussion: To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.
A CASE OF EARLY NEUROSYPHILIS
M. Walker, MD¹; R. Wisler, MD¹; J. Simmons, MD, MBA²; A. Johnson, MD¹
1. Department of Internal Medicine, LSU Health, Baton Rouge LA; 2. Dermatopathologist, Pathology Group of LA Baton Rouge
J La State Med Soc VOL 169 MARCH/APRIL 2017 47
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