JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
MSSA. He was also found to have multiple other foci of infection including a left-sided pleural effusion and a perihepatic fluid collection, both of which were drained and also grew out MSSA. The patient initially improved on antibiotics after his pacemaker removal and drainage of the infected fluid collections. However, several days after the pacemaker removal he gradually became more bradycardic; due to his multiple comorbidities and active infection, he was not a candidate for a replacement implanted pacemaker. He became profoundly bradycardic and hypotensive overnight and died despite the use of multiple pressors to maintain his blood pressure as well as transcutaneous pacing to maintain his heart rate. Discussion: Purulent pericarditis has become a relatively uncommon occurrence since the development of effective antibiotics. This case illustrates a rare example of purulent pericarditis and cardiac tamponade secondary to the extension of an infected pacemaker wire through the pericardium and into the thoracic cavity. The presence of multiple other infected fluid collections in this case also illustrates the need to thoroughly assess for secondary foci of infection in cases of bacterial endocarditis.
shown to inhibit the inflammatory cascade and reduce thrombus formation in animal models. Clinical data is less clear. Interruption of TNF blockers has been shown to increase the risk of DVT in patients with rheumatoid arthritis undergoing orthopedic surgery. For patients with Bechet’s syndrome, anti-TNF agents appear help treat patients with pulmonary artery thrombosis. Further review of anti-TNF-α therapy in our general medicine patient population may disclose additional risks associated with discontinuation of these medications.
CASE REPORT OF SARCOIDOSIS AS A GREAT MIMICKER IN VARIOUS POPULATIONS
C. Bowe, MD; F. Jenssen, MD; A. Espinoza, MD. Department of Medicine, Leonard J Chabert Medical Center, Houma, LA Introduction: The prevalence of sarcoidosis varies as much as 1-40 cases per 100,000 depending on region and population. Sarcoid typically occurs in people younger than 50 years old, with a peak incidence with ages between 20 and 40 years old. African Americans are 3 times more likely to develop sarcoidosis than Caucasian Americans, and woman are more likely than men to develop sarcoidosis in any ethnic group; nonetheless, it remains a valid differential across any population. Case: A 32 year old Hispanic man presented to the Emergency Departmentwithnight sweats, fatigue, and35poundunintentional weight loss over the last several weeks. He also reported a sore throat, occasional cough w/ yellowish sputum, and new onset dyspnea with exertion. He moved from Mexico to the U.S. 20 years prior and last visited the country 7 yrs ago. He never smoked and denied any TB exposure. His vitals at admit demonstrated tachycardia (pulse 108) and temperature of 99.4 ᴼF. He had coarse bilateral breath sounds on exam. Serum chemistries were unremarkable. Chest radiograph demonstrated perihilar fullness. Chest CT revealed enlarged mediastinal and perihilar LAD and airspace consolidation in right middle and lower lobes bilaterally. The patient was admitted to a negative pressure roomw/ airborne precautions and RIPE therapy was initiated. PPD and AFB’s were negative. He underwent bronchoscopy and was discharged on RIPE. Lung biopsy showed non-caseating granulomas. RIPE therapy was stopped, and he was referred to ophthalmology to rule out uveitis. Cultures from the procedure were negative for fungal growth, and hewas started on prednisone 40mg dailywith taper 6weeks later as his weight returned, night sweats subsided, and dyspnea on exertion improved. Discussion: Sarcoidosis should be considered as a diagnosis in any gender of any racial or ethnic group. Sarcoid is a great mimicker of many serious illnesses including malignancies such as lymphomas, TB and atypical mycoplasma, fungal infections, and other granulomatous diseases, and other autoimmune disorders such a hypersensitivity pneumonitis. Diagnosis requires patient investigation and careful analysis of these differentials.
A CLOT (POSSIBLY) DUE TO LOSS OF TNF-α SUPPRESSION
J. Broussard, MD; M. Berlinger, MD; D. Lauret, MD Department of Medicine, LSU Health, Baton Rouge, LA
Introduction: Inflammation and venous thrombosis enjoy a close Relationship. We present a patient who had multiple DVTs following the discontinuation of anti- TNF-α therapy. Case: A 34 year old African American female with a history of multiple DVT’s, miscarriages, and reported Crohn’s disease presentedwithshortnessof breath. In theEmergencyDepartment, CTA showed bilateral pulmonary emboli. The patient had been off adalimumab for one year and reported abdominal pain with 6-7 non-bloody bowel movements daily. She had been prescribed lovenox for her unprovoked DVTs yet reported missing several doses prior to admission. Following admission, she developed severe abdominal pain prompting an emergent CT angiogram and she then developed a pulseless painful left lower extremity. CT revealed a partially occlusive thrombus in the infra-renal abdominal aorta, proximal left common iliac artery, and right renal arterywith subsequent right renal infarction. Following emergent vascular surgery to restore blood flow to the left lower extremity, the patient received four days of plasma exchange and high dose steroids for potential catastrophic antiphospholipid syndrome. Serology for APLAwas negative. The patient was dischargedwith lifelong anticoagulation. Discussion: The endothelial surface is a complex organ that works in concert with the surrounding environment. Inflammation and thrombus formation is closely associated. TNF-α can increase the expression of adhesionmolecules, specifically, tissue factor, on the surface endothelial cells and promote thrombosis. Suppression of TNF-α expression by low molecular weight heparin has been
52 J La State Med Soc VOL 169 MARCH/APRIL 2017
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