Journal of the Louisiana State Medical Society
Native Valve Legionella Endocarditis as a Cause of Arterial Embolization J. Domercant, S.R. Charpentier, K. Siddarth, and S.M. Gupta Leonard J. Chabert Medical Center, Houma Introduction: Legionella Endocarditis is an extremely rare condition even among patients with prosthetic valves. Even more infrequent in patients who have native valves, only a handful of cases have been reported. Case: A 43-year-old Caucasianmale with no past medi- cal history presented to the emergency department with dif- fuse abdominal pain. Associated symptoms included 20- to 30-poundweight loss, nausea, constipation fevers, and night sweats. Physical exam was significant for cachexia, acute distress secondary to abdominal pain and tenderness, and hepatosplenomegally. Labs revealed leukocytosis with a left shift, and abdominal and pelvic CTwith IV contrast showed infarcts within the spleen and in the lower pole of the right kidney. The differential diagnosis after admission to the hospital included endocarditis and hypercoagulable states secondary to malignancy. The former was confirmed with a Transesophageal Echocardiogram (TEE), which revealed an aortic valve that appeared to be bicuspid and a 0.9 cm x 0.7 cm calcified mass with adherent vegetations measuring less than 2 mm in length. Blood and urine cultures were negative, therefore empiric treatment for endocarditis with vancomycin, gentamycin, ciprofloxacin, and ampicillin/ sulbactam was continued. Per Infectious Disease recom- mendations, acute convalescent IgM for rare etiologies such as Q fever, mycoplasma, and Legionella were ordered for culture negative endocarditis. The final diagnosis of Legio- nella endocarditis with embolic phenomenawas madewhen IgM for Legionella was detected. The antibiotic regimenwas de-escalated to ciprofloxacin, and his symptoms continued to significantly improve. He was subsequently discharged symptom-free with outpatient follow-up for further evalu- ation and treatment. Discussion: This case underscores an atypical presenta- tion of endocarditis and the importance of TEE in evaluation of such cases. The patient had two minor criteria of fever and vascular phenomena on presentation with no known predisposing factors. Moreover, this case illustrates the ability of rare etiologies such as Legionella to present on native valves.
one month. On the first incident, she admitted recent heavy drinking and had an elevated ethanol level. Lipase was normal, and neither CT nor ultrasound showed evidence of acute pancreatitis. She was managed conservatively with bowel rest, IV hydration, and pain medication, and discharged home after three days. Two weeks later, she presentedwith epigastric pain, subjective fever, nausea, and vomiting. She denied alcohol use or abdominal trauma since the prior admission but reported heavy cannabis usage. Sur- gical history included cholecystectomy. She tookmetoprolol for hypertension. Abdominal exam revealed hypoactive bowel sounds, tenderness to palpation in the epigastrium, and guarding. Lipase, AST, and ALP were 3,784 U/L, 101 U/L, and 156 U/L, respectively. Lipid panel was normal. She was againmanaged supportively and discharged home after three days. Four days later, she presented again with abdominal pain and noted continued marijuana use. She responded well to conservative management. Discussion: As the most popular illicit drug in the world, the effects of cannabis are well-known. The mecha- nism behind cannabis-induced pancreatitis is not well understood, but one study suggests agonism of the CB1 receptor may play a role. Another possibility is that mari- juana often has chemical additives, commonly known as “lacing”. If marijuana was “laced” with a chemical or other additive known to cause pancreatitis, this too could result in pancreatitis. Cannabis-induced pancreatitis is a rare but reported entity in the literature. This diagnosis should be arrived at after other causes have been ruled out in a patient with history of cannabis usage. With the already-present popularity of cannabis, and the growing popularity of le- galization of marijuana, cannabis-induced pancreatitis is a condition that may become more common. Neutropenia and Splenomegaly After the Discontinuation of Methotrexate: A Case of Felty Syndrome W. Penn and Z. Bruce Earl K. Long Medical Center, Baton Rouge Introduction: Felty syndrome (FS) is the rare triad of rheumatoid arthritis (RA), neutropenia, and splenomegaly. RA occurs in about 1% of the population, while FS mani- fests in just 1%-3% of those with RA. It is important to dif- ferentiate FS from other life-threatening diseases such as lymphoma, leukemia, and HIV as treatments are markedly different. Case: A 52-year-old white female with long-standing seropositive RA treated with methotrexate, plaquenil, and adalimumab presented to clinic with chronic bilateral lower extremity neuropathy and significant weight loss. Physical examination revealed tender, deformed joints in the hands and feet bilaterally, with multiple rheumatoid nodules over the extensor surfaces of both forearms. Abdominal exam was significant for mild splenomegaly confirmed by ultrasound. Routine lab work revealed pancytopenia with an absolute neutrophil count (ANC) of 200/mm3. Peripheral blood smear was negative for blasts and large
Cannabis-Induced Pancreatitis: A Case Report M.C. Raley, M. Bouquet, and G. Kahlon LSU-Health Sciences Center, Shreveport
Introduction: Acute pancreatitis is a common cause of hospitalization in the United States. One study noted almost 275,000 admissions in a single year. Common etiologies are cholelithiasis, alcoholism, and medications. Cannabis- induced pancreatitis has been seldom reported in literature prior to this case. Case: A 54-year-old white female presented to the emergency department for abdominal pain three times in
J La State Med Soc VOL 166 March/April 2014 83
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