cipitated transfer to a tertiary referral center. Thyrotoxicosis was treated with propylthiouracil, propranolol, iodine, and steroids with clinical improvement. Lower extremity spas- ticity and muscle stiffness persisted; however, brain MRI was unrevealing. GADA elevations (1,612 [<0.02 nmol/L]) confirmed clinical suspicions of SPS. She responded to a combination of baclofen and intravenous immunoglobulin (IVIG). Her Graves’ hyperthyroidismwas eventually treated with I 131 ablation; subsequent hypothyroidism required levothyroxine therapy. GADA has been as high as 44,147 [<0.5 U/mL] during worsening SPS symptoms, requiring further IVIG infusions. She achieved clinical stability of her SPS symptoms with a combination of baclofen, intermittent IVIG infusions, and clonazepam. Recent GADA was 528 [<0.02 nmol/L]. Discussion: This case of SPS highlights the importance of clinical suspicion for other autoimmune conditions. Muscle spasticity and stiffness are atypical of thyrotoxico- sis. Early recognition of an uncharacteristic presentation of Graves’ hyperthyroidism resulted in expedient diagnosis and therapy in this patient, and combination therapy has resulted in favorable SPS symptom control. Solid Pseudo-Papillary Tumor of the Pancreas S. Mani, G. Grewal, K. Dalmau, J. Crowe, and S.M. Gupta Leonard J. Chabert Medical Center, Houma Case: A 21-year-old African-American woman with a past medical history of pancreatitis andmorbid obesity was initially admitted with pancreatitis with intractable nausea and vomiting for pain control and IV hydration. Shortly after discharge, she again presentedwith pancreatitis symptoms, with an elevated lipase level of 575, and was transferred to our medical center. The patients’ epigastric pain continued to persist, rated as a 9/10 constant sharp/stabbing with radiation to her back, and worsened with oral intake. There were no alleviating factors noted. On admit to our facility, the patient was afebrile and hypertensive (157/107) and had a BMI of 49. Labs on admit showed slightly elevated lipase level of 67 and anemia (hemoglobin 9.7 hematocrit 31.7). Treatment was started with intravenous fluids and pain medication, a CT scan of her abdomen showed a 4.5 cm circumferential mass in the body of the pancreas without pancreatic ductal dilatation. Endoscopic ultrasound and fine needle aspiration of this mass showed scattered clusters of cells with variation in size and shape and papillary struc- tures seen in some clusters. These findings were consistent with solid pseudopapillary tumor of the pancreas. The patient was subsequently scheduled for a distal pancreatec- tomy and splenectomy. On follow-up, the patient remained pain symptoms free. Discussion: Solid pseudo-papillary tumor of the pan- creas, also known as Frantz’s tumor, is a rare previously misdiagnosed neoplasm affecting young females with a 10:1 predilection toward females and a mean age of 24. This tumor typically carries a better prognosis compared to adenocarcinoma and has a low likelihood of metastatic
disease; however, it does have the ability to invade local structures. Most patients present with vague abdominal pain, nausea, and vomiting, mostly due to the mass effect of the neoplasm on surrounding structures. Diagnosis can usually be confirmed by biopsy and cytology, leading to visualization of solid and pseudo-papillary in sheets of uniform, epitheloid cells situated around a microvascular stalk. Treatment includes distal pancreatectomy and ag- gressive surgical approach for possible metastatic disease. Following resection of the neoplasm, survival is 95% at a five-year interval. Scratch Me If You Can: A Case of Peliosis Hepatitis and Splentis N. Gupta and P.C. Porada Ochsner Clinic Foundation, New Orleans Introduction: Peliosis Hepatitis is a rare vascular condi- tion characterized by multiple blood-filled cysts within the liver parenchyma. Due to multiple etiologies and a vague presentation, this diagnosis requires a thorough history and complete diagnostic workup. Case: A 23-year-old African-Americanmale with a past medical history of HIV (CD4 = 650 cells/mm 3 ) presented to the emergency department with a chief complaint of left upper quadrant abdominal pain for seven days. The pain was described as acute, intermittent, sharp, worse with inspiration, and radiating to his left shoulder. His other symptoms included fever; four to five episodes per day of non-bloody, non-bilious emesis; and four to five episodes per day of non-bloody loose stools. On physical exam, the patient was febrile, tachycardic, tender to palpation at the LUQ, and had palpable hepatosplenomegaly. Abdominal CT scan revealed multiple small hypodensities in the liver and spleen that were concerning for micro-abscesses and a large area of hypoattenuation in the spleen extending to the periphery. Upon further investigation of patient’s exposure history, he revealed that several months prior to admission he began to care for a stray kitten. He denied any sick con- tacts, recent travel, or any other exposure history. Serology for Bartonella henselae and ultrasound-guided biopsy of his liver lesions were obtained. Serology titers for Bartonella henselae IgMwere positive (1:80), and liver biopsy revealed a mixed inflammatory infiltrate including neutrophils and eosinophils with adjacent fibrosis. In addition, there were nonspecific findings in the setting of positive serology sug- gestive of Bacillary Peliosis. Subsequently, therapy was transitioned to Doxycycline twice daily for eight weeks. Repeat imaging seven months later demonstrated resolu- tion of his lesions. Discussion: The fastidious nature of these organisms of- ten precludes them from being found on cultures and tissue samples. Peliosis hepatitis is often an incidental finding on abdominal imaging. Thus, this case illustrates an occurrence of peliosis hepatitis caused by Bartonella henselae , elucidating the imperativeness of obtaining a detailed history in HIV positive patients.
J La State Med Soc VOL 166 March/April 2014 91
Made with FlippingBook - Online catalogs