JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
A LEFT MAIN CORONARY ARTERY THROMBUS PRESENTING AS A NON ST ELEVATION MI
Discussion: Spontaneous renal artery dissection is a rare cause of abdominal pain and often presents a diagnostic and therapeutic challenge. This case highlights the importance of considering alternate etiologies of localized abdominal pain when other common pathologies have been excluded.
U. Ezema, MD; D. Daberkow, MD; T. Delord, MD Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA Introduction: Left main coronary artery (LMCA) thrombus with an acutemyocardial infarction identifiedwith coronary angiography is a clinically rare conditionwith an extremely highmortality rate. We present a case of LMCA thrombus that presented as a non-ST elevation myocardial infarction (NSTEMI). Case: A 45-year-old woman with a history of tobacco use and hyperlipidemia presented with a complaint of 10/10 “hard pain” across her chest radiating to her left shoulder and breast which woke her from sleep. The pain was constant and severe, with no alleviation with rest. She had not experienced anything like this before. Workup revealed an upward trending troponin (1.9 8.98 9.79), and an EKG with some tachycardia but no ST elevation or T wave changes. Her CBC, CMP and coagulation studies were unremarkable. A toxicology screen was positive for opiates and benzodiazepines, medications she was on for pain and anxiety respectively. ACS protocol was started with DAPT, LMWH, Statin, ACEi, and Beta-blocker. An angiogram revealed a large thrombus in the LM coronary artery extending into the aorta with concomitant 99% stenosis of distal LAD. 2D Echo w/ bubble contrast was significant for PFO, akinetic apical inferior and anterior wall. Themid antero-septum and apical lateral wall were hypokinetic. Interventional Cardiology and CTS recommended conservative management with medical optimization (Continue DAPT, heparin), watchful waiting for the thrombus to resorb. Discussion: Left main coronary artery thrombosis (LMCAT) identified during coronary angiography is a rare and challenging condition. It is a life threatening condition with an approximate incidence rate of 0.8%. It is thought to be secondary to plaque rupture with subsequent thrombus formation that is associated with persistent hypercoagulable state, cocaine induced plaque rupture or coronary vasospasm, post-partum state and embolization of intra-cardiac masses. The patient presentation can vary from sudden cardiac death to STEMI, NSTEMI, unstable angina and cardiogenic shock. Standardized therapy has not been developed due to the small number of reported cases. RECURRENT HYPERTRIGLYCERIDEMIC PANCREATITIS (HTGP) AND THE USE OF INSULIN DRIP AS TREATMENT T. Tran, MD; N. Lee, MD Department of Internal Medicine, Ochsner Medical Center, New Orleans, LA Introduction: Chronic pancreatitis by definition is a recurrent episode of acute pancreatitis and is commonly associated with alcoholism in the US. Another cause of chronic pancreatitis is hypertriglyceridemia (HTGP), occurring in 1-5% of cases. The incidence of HTGP is higher in patients with diabetes and HIV, usually requiring triglyceride levels > 1000 mg/dL.
WHAT CAN ERODE THROUGH LUNGS, BONE AND SKIN?
J. Manalac, MD; D. Shankaranayanan, MD; J. Paul-Olivier, MD; L. Guidry, MD; NR Sells, MD Department of Internal Medicine, University Hospital and Clinics, LSU Health, Lafayette Case: A 51 year old African American Man without significant past history presented with three weeks of persistent cough productive of copious yellow sputum. He denied fevers, chills, hemoptysis, dyspnea, weight or appetite changes, sick contacts, recent travel. On physical examination, the patient was afebrile and appeared comfortable. He had decreased air entry of the left lower lobe with dullness to percussion. A 5x3 cm fluctuant mass was incidentally found on the left anterior chest wall at the level of the 11th rib with yellow expressible exudate at which time the patient reported a minor trauma sustained 3 weeks prior. WBC count was 17,300/mcL. CT chest identified a peripherally enhancing fluid-attenuation structure in the left lower lung measuring 11.8 cm x 11.3 cm x 9.6 cm. The collection appeared to be tracking out from the pleural space to the exterior skin that corresponded to the site of the chest wall swelling. Therewas also a focal lytic lesion of the adjacent ribs. He was empirically started on Vancomycin, clindamycin and piperacillin-tazobactam. CT- guided aspiration failed because the material was too viscous to be aspirated; a chest tube drained copious yellow exudate. Blood cultures and respiratory cultures were negative. Gram stain of the purulent material demonstrated clusters of branching gram positive rods. Pathology showed necrotic debris with clusters of filamentous gram negative organism. Acid fast and Kinyoun stains were negative. He was started on empiric Penicillin G for empyema necessitans with a presumed etiology of actinomyces. Due to development of hypersensitivity drug eruption from PCN, intravenous doxycycline was started for total of 14 days followed by 6 months of oral therapy. Imaging four weeks after treatment showed significant reduction in size of the lesion. Culture confirmed Actinomyces israelii. Discussion: Actinomyces are anaerobic grampositive commensals of the oral cavity notorious to breach though tissue planes. Thoracic manifestations are varied and can mimic malignancy. Astute microbiology and pathology tests are necessary to make an early diagnosis and prevent invasive surgery as the organism is a slow growing anaerobic bacteria. Excellent clinical and radiologic response were noted in our case following treatment with chest wall drainage and antibiotics thus avoiding invasive thoracic surgery.
J La State Med Soc VOL 169 MARCH/APRIL 2017 55
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