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ABSTRACTS FROM THE 2022 LOUISIANA ANNUAL ACP MEETING
CONTENTS
JOURNAL EDITORIAL STAFF
ASSOCIATE EDITOR L.W. Johnson, MD
CHIEF EXECUTIVE OFFICER Jeff Williams
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RESIDENT ABSTRACTS
JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD
5 BILATERAL THALAMIC GLIOBLASTOMA MULTIFORME PRESENTING WITH APHASIA 6 SEVERE NONCIRRHOTIC HYPERAMMONEMIA: WHAT UREA-LLY SHOULD CONSIDER 7 MASQUERADING AS TTP: AN INSIDIOUS PRESENTATION OF B12 DEFICIENCY 8 LEUKEMIA CUTIS: AN UNCOMMON PRESENTATION OF ACUTE MYELOID LEUKEMIA 9 ANORECTAL MUCOSAL MELANOMA: A RARE BUT POTENTIALLY FATAL CAUSE OF RECTAL BLEEDING 10 KSHV INFLAMMATORY CYTOKINE SYNDROME (KICS) 11 A PRESING NEUROLOGIC SEQUELA OF COVID-19 INFECTION 12 CNS NOCARDIOSIS IN AIDS PATIENT 13 A CURIOUS CASE OF THE “POX” STROKE 14 HERPETIC COLITIS CAUSING LOWER GI BLEEDING IN A PATIENT UNDERGOING CHEMOTHERAPY 15 A CURIOUS CASE OF MEIGS-LIKE SYNDROME 16 SYSTEMIC LUPUS ERYTHEMATOUS AS A MIMICKER OF LYMPHOPROLIFERATIVE DISEASE 17 AN OMINOUS PRESENTATION OF STAPHYLOCOCCUS HOMINIS 18 A CURIOUS CASE OF SPONTANEOUS WATERHOUSE-FRIDERICHSEN SYNDROME 19 PENILE CALCIPHYLAXIS 20 FUNGAL PETROCLIVAL OSTEOMYELITIS DUE TO ASPERGILLUS IN AN IMMUNOCOMPETENT PATIENT 21 REVERSE TAKUTSUBO CARDIOMYOPATHY ASSOCIATED WITH PHLEGMASIA CERULEA DOLENS 22 A CASE REPORT OF NEURO SARCOIDOSIS. 23 THE CROWN OF MISFORTUNE: A CASE OF AN UNDER- DIAGNOSED RHEUMATOLOGIC RARITY 24 DROOLING, STIFF, AND MUTE! 25 GLEICH SYNDROME 26 ADULT INTUSSUSCEPTION: FINDING A LEAD ON A RARE CASE 27 BREAST CANCER METASTASIS TO BONE MARROW, INITIALLY DIAGNOSED AS MYELOFIBROSIS 28 YOU DON'T WANT TO MISS THIS RASH 29 STUDENT ABSTRACTS 30 THE CURIOUS CASE OF NEUROMYELITIS OPTICA. 31 ADDRESSING DISRUPTIONS IN CARE: A STUDY OF CHRONIC DISEASE EXACERBATIONS IN AN UNDERSERVED COMMUNITY FOLLOWING HURRICANE IDA 32 DON’T| BE SO LITTORAL: FALSE-POSITIVE ECHINOCOCCUS ANTIBODY TESTING MASKS A CASE OF LITTORAL CELL ANGIOMA 33 INTERPRETING PATIENT PERCEPTION OF BANKART REPAIR VIA SOCIAL MEDIA 34 ASSESSING CLINICAL, DEMOGRAPHIC, AND EPIDEMIOLOGICAL VARIABLES AMONG THE FIRST 500 COVID-19 PATIENTS IN AN URBAN EMERGENCY DEPARTMENT 35 DETECTION OF LATENT AUTOIMMUNE DIABETES IN ADULTS IN A 40-YEAR-OLD WITH RHEUMATOID ARTHRITIS AND HASHIMOTO’S HYPOTHYROIDISM. 36 WONDERING ABOUT WUNDERLICH SYNDROME: A RARE CASE OF SPONTANEOUS RENAL HEMORRHAGE 37 OSMOTIC CENTRAL PONTINE DEMYELINATION SYNDROME IN A EUNATREMIC ELDERLY MAN 38 SWALLOW SYNCOPE ASSOCIATED WITH INTERMITTENT SINUS PAUSE AND HIGH DEGREE AV BLOCK 2
Anthony Blalock, MD D. Luke Glancy, MD L.W. Johnson, MD Fred A. Lopez, MD
LSMS 2021 BOARD OF GOVERNORS OFFICERS President, William Freeman, MD Past President, Katherine Williams, MD President-Elect, John Noble, Jr., MD Vice President, George Ellis, Jr., MD Speaker of the House, T. Steen Trawick, MD Vice Speaker, R. Reece Newsome, MD Secretary/Treasurer, Richard Paddock, MD Chair, COL, David Broussard, MD COUNCILORS District 1 Member, Myra Kleinpeter, MD District 1 Alternate, Maurice Sholas, MD District 2 Member, Robert Chugden, MD District 3 Member, Allen Vander, MD District 4 Member, Richard “Rick” Michael, MD District 5 Member, Gwenn Jackson, MD District 6 Member, Michael Roppolo, MD District 7 Member, Brian Gamborg, MD District 8 Member, Lance Templeton, MD District 9 Member, Andy Blalock, MD District 10 Member, Nicholas Viviano, MD District 10 Alternate, James Connolly, MD SECTION REPRESENTATIVES Senior Physician Member, Marcus Pittman, III, MD Senior Physician Alternate, Donnie Batie, MD Young Physician Member, Amberly Nunez, MD Resident/Fellow Member, Blake Denley, MD Medical Student Member, Brittany Wagner Employed Physician Member, Matt Giglia, MD Private Practice Physician Member, Vicki Steen, MD
Each year medical students from the five medical schools and residents from the eight Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual American College of Physicians (ACP) Resident and Student Meeting of the Louisiana Chapter. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to resident council judges. This year a total of 117 abstracts were submitted for the meeting. Each judge scores each abstract independently and then the scores from all judges are averaged and ranked. This year we are excited to be able to publish the most highly ranked resident (24) and student (9) abstracts presented at this year’s competition that were selected for oral presentations. All abstracts were presented at the Associates Meeting held virtually due to the COVID-19
pandemic on January 22, 2022. We would like to thank the Resident Council for helping score the top abstracts for presentation: Katherine Oakden, LSU New Orleans, Jacob Peoples, LSU Baton Rouge, Priyanka Patel, Chabert Medical Center, Chad Kaplan, Baton Rouge General, Paula Cacioppo, Ochsner Medical Center and Rebecca Prechter, LSU Lafayette. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees.
Shane Sanne, DO, FACP Co-Chair , Louisiana Associates Liaison Committee
Miranda Mitchell, MD Co-Chair , Louisiana Associates Liaison Committee
Shahzeem Bhayani, MD Co-chair, Louisiana Student Liaison Committee
Catherine Hebert, MD, FACP Co-Chai r, Louisiana Student Liaison Committee
Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP
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RESIDENT ABSTRACTS
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BILATERAL THALAMIC GLIOBLASTOMA MULTIFORME PRESENTING WITH APHASIA G Unis MD, E Philon DO Department of Medicine, Ochsner Medical Center, New Orleans, LA INTRODUCTION Bilateral thalamic lesions on brain Magnetic Resonance Imaging (MRI) represent a unique and unusual radiographic pattern. While unique, the differential for bilateral thalamic lesions is broad and can include cerebrovascular disease, toxin or metabolic syndromes, posterior reversible encephalopathy syndrome, viral infections, and neo- and paraneoplastic processes. CASE A 55-year-old male with hypertension and type 2 diabetes presented with an acute aphasia of 5 hours in duration and general malaise prior to admission but denied other significant symptoms. Physical examination at the time of admission was negative for neurological abnormalities including cranial nerve testing, as well as being fully alert and oriented with appropriate mentation. He was afebrile, slightly hypertensive with a blood pressure of 149/96, and without oxygen requirements. Laboratory studies were within normal limits on admission however, computed tomography of the head demonstrated subtle diminished density within the left thalamus. MRI imaging of the brain demonstrated bilateral thalamic enlargement with diffuse T2/FLAIR signal hyperintensity. Lumbar puncture was obtained and routine cerebral spinal fluid (CSF) studies in addition to viral, bacterial cultures, and autoimmune studies were ordered. The patient was found to be positive for West Nile Virus (WNV) but with a negative WNV polymerase chain reaction (PCR) and toxoplasmosis IgG positive results. The patient was treated empirically for toxoplasmosis but failed to improve. Repeat MRI was obtained and demonstrated new enhancement which prompted a brain biopsy of the temporal lobe. Pathology showed WHO Grade IV glioblastoma multiforme and the patient was referred to oncology. DISCUSSION This rare and unusual disease, while previously described in the literature highlights the broad differential for bilateral thalamic lesions found on brain MRI and represents a unique learning case.
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SEVERE NONCIRRHOTIC HYPERAMMONEMIA: WHAT UREA- LLY SHOULD CONSIDER S Wu, C Basilio MD, MPH Department of Medicine, Tulane Health Sciences Center, New Orleans, LA
INTRODUCTION Hyperammonemia is often the result of liver pathology. When hyperammonemia is not the result of liver disease, an occult disorder of metabolism must be on the differential for unexplained hyperammonemia, such as a urea cycle disorder.
CASE A 57-year-old man with recovered systolic heart failure, atrial fibrillation, hypertension, and cervical neck fracture status post recent cervical spine corpectomy and fusion presented with worsening dysphagia and neck discomfort and was found to have a cervical fluid collection. He had no known underlying liver disease and denied significant alcohol history. He received a dexamethasone taper and a lumbar drain. He was later admitted to the intensive care unit (ICU) for unstable atrial fibrillation with rapid ventricular rates. In the ICU, the patient became more somnolent and was unable to follow commands. Encephalopathy workup revealed elevated BUN with normal creatinine, ammonia of 772, and mildly elevated transaminases. Liver workup was normal. Workup for inborn errors of metabolism showed mildly decreased citrulline. Urine and plasma amino acids were otherwise normal. His hyperammonemia resolved and his mentation improved with lactulose three times daily and rifaximin twice daily. Urea cycle disorder gene panel and further genetic workup is ongoing. Patient will follow up with genetics after discharge. DISCUSSION Patients with elevations of ammonia present with encephalopathy, which may progress quickly to cerebral herniation. Survival requires immediate reduction of ammonia levels. Although the differential for hyperammonemia is broad, inborn errors of metabolism (IEM), like a urea cycle disorder, should be considered when hyperammonemia is of unclear etiology. Although IEMs often have early age of onset, urea cycle disorders have multiple modes of inheritance and can present at later stages. IEMs may also be unmasked by steroid therapy, which is plausible in this patient who was on a steroid taper prior to his hyperammonemic state. Treatment for a potential IEM begins prior to confirmation of an etiology. Geneticists should be consulted early on for evaluation and management.
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MASQUERADING AS TTP: AN INSIDIOUS PRESENTATION OF B12 DEFICIENCY M Zoya MD, M N Salloum MD Department of Medicine, Louisiana State University, Shreveport, LA INTRODUCTION Pseudothrombotic microangiopathy is a rare presentation of B12 (cobalamin) deficiency. Patients appear ill with elevated reticulocyte count, lactate dehydrogenase (LDH), and total bilirubin with low haptoglobin, platelet count, and anemia - deceivingly suggestive of thrombotic thrombocytopenic purpura (TTP), a type of true and deadly microangiopathic hemolytic anemia. CASE: A 36-year-old female with hypothyroidism presented for anemia with a hemoglobin of 5.1 g/dL and symptoms of fatigue, shortness of breath, palpitations, sweats, chills, vomiting, 54 lb weight loss, easy bruising and tingling in her fingertips and toes for one month. Exam was unremarkable other than pallor. She was found to have an LDH >4,000, haptoglobin <4, platelets as low as 13,000 k/ul, and peripheral smears showing hyper segmented neutrophils and schistocytes. B12 level was normal (295 mg/mL) and methylmalonic acid (MMA) was 1.56 μmol/mmol. Thyroid function panel was near normal. With fear of TTP, she received high dose IV steroids and three days of plasma exchange with minimal improvement in condition. ADAMTS13 is surprisingly found to be negative. Suspicious of B12 deficiency, Hematology recommends daily B12 injections and her symptoms improve. Intrinsic factor (IF) antibody is found to be positive and pernicious anemia is uncovered. DISCUSSION: Malabsorption, not diet, is oftentimes the culprit of B12 deficiency. Most of the absorbed form is done by binding to IF produced by gastric parietal cells, which enhances absorption of B12 in the terminal ileum. Pernicious anemia causes malabsorption via antibodies that impede the B12-IF complex - either targeted at gastric parietal cells or IF itself. In severe cases, it can present with tissue hypoxia symptoms such as shortness of breath in the setting of elevated LDH, reticulocyte count, total bilirubin with low haptoglobin, hemoglobin and platelets. Unlike TTP, the reticulocyte production index (RPI) is <2.0% (reflects inadequate bone marrow response), will not improve with plasmapheresis, MMA will be elevated and median LDH is 3000 (median 1400 in TTP). B12 levels may appear falsely normal in pernicious anemia because of buildup of homocysteine and MMA as a consequence of high levels of IF-Ab, which alters the lab assay.
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LEUKEMIA CUTIS: AN UNCOMMON PRESENTATION OF ACUTE MYELOID LEUKEMIA D Beyer MD2, M Lieux BS1, B Van Court BS1, C Pham BS1, C Van Dreumel MD2, R Foret MD2, N Nebeluk MD/Ph.D1, S Sanne DO2
1Department of Internal Medicine, LSU Health, New Orleans, LA 2School of Medicine, LSU Health Sciences, New Orleans, LA
INTRODUCTION: Leukemia Cutis is a rare condition characterized by infiltration of neoplastic cells into the epidermis and dermis with a characteristic dermatologic appearance. Leukemia cutis generally portends a poor prognosis in the setting of newly diagnosed blood cancers.
CASE: A 31-year-old man without a past medical history presented after 1 month of progressive dyspnea on exertion, worsening fevers, thirty-pound unintentional weight loss and diffuse rash on all extremities and trunk. Physical exam was significant for fever, tachycardia and scattered petechia and erythematous papules on his bilateral upper and lower extremities. Initial laboratory findings were significant for leukocytosis (222,000 k/uL) with 94% immature mononuclear cells and thrombocytopenia (8,000 k/ul). Punch biopsy was performed and pathology returned leukemia cutis with myeloid features. Bone marrow biopsy was significant for acute myeloid leukemia with 86% large blastoid cells. Patient was started on induction chemotherapy with cytarabine and idarubicin resulting in slow resolution of rash. DISCUSSION: Leukemia cutis is a challenging diagnosis and rare presentation of leukemia. When coupled with a new diagnosis of acute myeloid leukemia, as in this patient, portends a worse prognosis. This patient presented in blast crisis with cutaneous involvement and new diagnosis of acute myeloid leukemia was made promptly based on bone marrow biopsy results. Prompt dermatologic consultation resulted in diagnosis of leukemia cutis based on punch biopsy. After initiation of induction chemotherapy (cytarabine and idarubicin), his cutaneous lesions subsided significantly.
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ANORECTAL MUCOSAL MELANOMA: A RARE BUT POTENTIALLY FATAL CAUSE OF RECTAL BLEEDING R Mahat MD, G Echefu MD, D Kantamani MD, MP Stagg MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA
INTRODUCTION: Rectal bleeding is a common complaint with many relatively benign causes including hemorrhoids, anal fissures, and colonic diverticula. However, there are more insidious causes of rectal bleeding that can potentially prove to be fatal without early intervention.
CASE: A 71-year-old male presented to the gastroenterology office for 1-2 years history of bright red blood per rectum three to four times a week. Bleeding was associated with rectal pain and itching. He denied abdominal pain, weight loss, anorexia, altered bowel habit, or change in stool caliber. He was evaluated by his PCP in the past and was treated for hemorrhoids. Screening colonoscopy done 6 months earlier revealed nonbleeding thrombosed external and internal hemorrhoids, and sessile polyp in the rectum. The polyp was completely resected, and biopsy revealed tubular adenoma. Digital rectal examination showed grade II internal hemorrhoids. Flexible sigmoidoscopy showed 14 mm oozing, polypoid, semi pedunculated lesion in the distal rectum. Initial Computed Tomography scan of abdomen and pelvis showed ill-defined soft tissue thickening of the inferior rectum. The patient underwent trans anal resection of the mass and biopsy with histopathology revealed nodular malignant melanoma. Immunohistochemical stain was positive for S100 and Sox 10. Staging Positron Emission Tomography (PET) scan revealed metastasis in the left internal iliac chain lymph nodes without evidence of distal metastasis. He was staged as stage II ARM. After multidisciplinary discussion in a tumor board the patient was discharged home with a plan of outpatient immunotherapy. He completed a total of 3 cycles of immunotherapy with pembrolizumab. Follow up PET scan after 5 months showed multiple lung and liver metastasis. DISCUSSION: Anorectal mucosal melanoma (ARM) is rare, accounting for less than 1% of all melanomas, 24% of all mucosal melanomas. Unlike other subset of mucosal melanomas, ARM is increasing. Patients presents with rectal bleeding, a mass, anorectal pain, or a change in bowel habits. Approximately 20–30% of ARMMs are amelanotic, resembling benign polypoid lesions endoscopically. Pathology with immunohistochemistry is the gold standard for diagnosis. By the time of diagnosis, the majority of cases (61%) are locally progressed or have distant metastasis. Surgical excision remains the cornerstone of therapy. The prognosis is often dismal, with a 5-year survival rate of only 20%.
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KSHV INFLAMMATORY CYTOKINE SYNDROME (KICS) S. Sridhar MD1, V. Silver DO2, T. Davidge MD1, N Patel MD 3 1 Department of Internal Medicine, LSU Health, New Orleans, LA 2 Department of Emergency Medicine-Internal Medicine, LSU Health, New Orleans, LA 3 Section of Infectious Diseases and Pulmonary Critical Care, University Medical Center in New Orleans, New Orleans, LA
INTRODUCTION: KICS is a newly-described complication of Kaposi sarcoma-associated herpesvirus (KSHV) infections that is poorly described due to its high mortality rate. Most available data on KICS is derived from case reports.
CASE: A 33-year-old man with newly diagnosed HIV (CD4 332 cells/mm3), recent renal failure, thrombocytopenia, ocular syphilis, and Kaposi sarcoma presented with progressive dyspnea, productive cough, and pleuritic chest pain. On initial evaluation, the patient was tachypneic, tachycardic, and hypotensive. He had coarse crackles with poor air movement. Violaceous oral lesions were noted on the hard palate along with cervical and axillary lymphadenopathy. Several violaceous lesions covered the patient’s arms. He was admitted to the MICU for continuous BiPAP but he quickly decompensated and was intubated a few hours later. The next day, his abdomen became distended in the setting of poor urine output. Bedside ultrasound showed abdominal fluid and a right pleural effusion. A chest tube was placed that drained serosanguinous fluid. He became hypotensive and did not improve with vasopressors. The etiology of patient’s condition was through to be from inflammatory cytokine syndrome secondary to Kaposi sarcoma, but the patient was too unstable to tolerate chemotherapy with doxorubicin and rituximab. He remained anuric and CRRT was initiated and then discontinued on day 4 as the patient was persistently hypotensive despite maximal therapy. With the patient’s progressing multiorgan failure, his family chose to pursue comfort care. A cytokine panel, that had been sent out to an outside lab, demonstrated elevated IL-2, IL-2R, interferon gamma, IL-10, IL-13, and IL-6, which supports KSHV Inflammatory Cytokine Syndrome (KICS) as the etiology of the patient’s presentation. Although, KICS was suspected early, the disease process progressed too quickly for treatment to have been initiated. DISCUSSION: KICS typically presents in patients with a low CD4 count even if the patient is being treated with ART. Clinical presentation often resembles sepsis, but these patients will not respond to antibiotic therapy. Mortality rate is 60% with better outcomes in cases with early diagnosis and chemotherapy.
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A PRESING NEUROLOGIC SEQUELA OF COVID-19 INFECTION A Say MD, C Griffin MD Department of Medicine, LSU Health Sciences Center, Baton Rouge, LA
INTRODUCTION: Delirium is a common complication of acute illness that is associated with substantial morbidity and mortality. A crucial component of the management of delirium is to identify the underlying cause, particularly reversible causes, which requires maintaining a broad differential. In this case, we discuss a rare cause of delirium, Posterior Reversible Encephalopathy Syndrome (PRES), that is nevertheless important to recognize as it can be intervened upon successfully with rapid, aggressive blood pressure control. CASE: A 29-year-old woman developed COVID-19 at 30 weeks of gestation. She was admitted at an outside facility and developed a uterine rupture prompting emergency caesarean section, with subsequent concern for an intrabdominal infection. She completed a course of antibiotics and was discharged home, but later returned with wound dehiscence as well as ascending weakness which caused multiple falls and hyperalgesia. Initial workup was notable for lumbar puncture with cerebral spinal fluid WBC of 6. She was transferred for additional neurologic evaluation after there was concern for seizure- like activity and she developed worsening encephalopathy. Vitals at admission were notable for blood pressure 158/87 mmHg, (previously 101/72 mmHg as an outpatient). Exam was notable for profound weakness of both the upper and lower extremities with diffuse hyporeflexia. Shortly after admission she again developed seizure-like activity. Urgent Magnetic Resonance Imaging of the brain noted diffuse, edematous changes bilaterally with diffusion restriction in the parietal and occipital lobes consistent with PRES. Her mental status rapidly improved with intravenous antihypertensives and she ultimately required five oral antihypertensive agents to discontinue parenteral therapy. Her strength slowly improved over the next three weeks following aggressive physical therapy, supportive care, and a trial of IVIG. DISCUSSION: This case demonstrates a rare cause of delirium, likely triggered by a cascade of events following COVID-19 infection. We suspect she developed acute inflammatory demyelinating polyneuropathy (AIDP) in the aftermath of COVID-19 during her pregnancy. In addition to causing motor and sensory changes, AIDP has also been known to cause autonomic dysfunction. We believe this dysautonomia then precipitated her rapid elevation of blood pressure, leading to PRES.
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CNS NOCARDIOSIS IN AIDS PATIENT V Jaber MD 1 , L Ledet MD2, V Burke MD 2 1 Department of Internal Medicine, LSU Health, New Orleans, LA 2 Department of Medicine, Section of Infectious Disease, LSU Health, New Orleans, LA
INTRODUCTION: Nocardia is frequently an opportunistic pathogen, occurring in patients with depressed cell-mediated immunity such as those with lymphoma, other selected malignancies, human immunodeficiency virus infection, solid-organ or hematopoietic stem cell transplant and those receiving long-term treatment with steroids or other medications that suppress cell-mediated immunity. Pulmonary nocardiosis is the most common clinical presentation. The central nervous system (CNS) is the most common extrapulmonary location for nocardiosis. HIV patients with very low CD4 and high viral load are especially vulnerable to nocardia and disseminated disease. CASE: A 36-year-old man with a history of HIV/AIDS [absolute CD4 count 13 and Viral load of > 1 million while non-adherent with antiretroviral therapy (ART)] and previously treated pulmonary nocardiosis (July 2021), presented in November 2021 with progressive fever, sweats, and chills and new onset altered mental status, urinary incontinence, and seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head showed multiple ring enhancing lesions concerning for CNS nocardiosis especially in the setting of antibiotics and ART non-adherence. In addition, brain lesions were concerning for CNS toxoplasmosis especially in the setting of non-adherence to prophylactic trimethoprim-sulfamethoxazole (TMP- SMX). MRI brain demonstrated a 6 mm midline shift and lumbar puncture (LP) was deferred. The patient was started on steroids due to brain lesions, trimethoprim-sulfamethoxazole and imipenem, which was later transitioned to ceftriaxone based on previous lung culture susceptibility data. On day two after initiating treatment, the patient became more alert. Repeat brain imaging after 14 days of initiating treatment was planned to monitor disease progression, adequacy of current therapy, and to determine the possibility of obtaining an LP or biopsy to confirm diagnosis. DISCUSSION: Differentiating between CNS nocardiosis and CNS toxoplasmosis is difficult in patients who are vulnerable to both, such as in HIV infected patients with CD4 count < 50. LP and even lesion biopsy might confirm the diagnosis but may not be easy to obtain in patient with extensive brain lesion especially in the setting of high ICP with midline shift. Fortunately, tailoring treatment to cover both pathogens is not problematic.
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A CURIOUS CASE OF THE “POX” STROKE R Panicker MD, H Sajjad MD, A Ajit MD, JK Khera DO, S Shahid MD, N Sells MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: There has been an increasing incidence of strokes caused by reactivation of varicella-zoster virus (VZV) in both immunocompetent and immunocompromised hosts. Multiple case reports have demonstrated a link between stroke and zoster virus. Recent studies have emerged which reveal that VZV infection of the cerebral arteries directly causes pathological vascular remodeling and stroke (VZV vasculopathy). CASE: A 60-year-old man with uncontrolled diabetes, hypertension, and herpes zoster ophthalmicus (HZO) presented with right sided weakness. He was initially diagnosed with HZO six months prior and was treated with oral acyclovir for seven days. During his current admission his main deficits included right sided upper and lower extremity weakness along with right sided facial drooping. Contrast tomography of the head and angiography of the head and neck did not reveal any acute intracranial abnormality or large vessel occlusion. Of note, he was hospitalized two weeks prior to his current presentation with similar symptoms. Magnetic resonance imaging demonstrated a left pontine ischemic stroke and a lumbar puncture was positive for VZV IgG in the cerebrospinal fluid (CSF). He was treated with intravenous (IV) acyclovir 800 milligrams three times a day (TID) for fourteen days and afterwards was discharged. Infectious diseases and neurology services were consulted. Neurology recommended treating as a primary small vessel vasculitis with Methylprednisolone 1000 milligrams for five days without a taper. Infectious disease recommended acyclovir 800 milligrams TID as inpatient with an additional 14 days on discharge. He had significant improvement in his right sided weakness following treatment and was discharged to inpatient rehabilitation for further physical therapy and outpatient follow up with ophthalmology for his HZO. DISCUSSION: Several meta-analyses showed stroke risk is significantly increased shortly after acute zoster infection and remains elevated for up to one year. Herpes zoster ophthalmicus increases stroke risk by a larger magnitude. There is a growing consensus that VZV stroke presents as a small vessel vasculitis which necessitates treatment with pulse dose steroids as in such cases treatment with antivirals alone may not be enough.
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HERPETIC COLITIS CAUSING LOWER GI BLEEDING IN A PATIENT UNDERGOING CHEMOTHERAPY P Oakes MD, M Modica MD Department of Internal Medicine, LSU Health, New Orleans, LA
INTRODUCTION: Herpes simplex virus (HSV) is a ubiquitous double-stranded DNA virus that can cause a multitude of pathological manifestations. Herpetic colitis is a rare manifestation of the herpes simplex virus that has been mostly documented in patients suffering from inflammatory bowel disease who are being treated with immunosuppressive therapies. Use of these medications cause an exogenous immunosuppression that can lead to reactivation of a latent infection. CASE: A 66-year-old male with a past medical history of colorectal cancer treated with resection and chemotherapy presents with acute encephalopathy. On admission, the patient was febrile and tachypneic. The patient was treated with antibiotics for a Candida albicans urinary tract infection (UTI) and Staphylococcus epidermidis bacteremia. During the hospitalization, the patient experienced bloody output in his colostomy bag and a decrease in hemoglobin requiring a blood transfusion. The patient underwent an esophagogastroduodenoscopy and had two angioectasias cauterized. Approximately two weeks later, the patient experienced another episode of bloody ostomy output. The patient underwent a small bowel enteroscopy and had a duodenal angioectasia treated. Unfortunately, the patient continued to express blood-tinged stool via his ostomy and underwent a video capsule endoscopy. After eight hours, the capsule failed to advance further than the esophagus and was deemed inconclusive. The patient then underwent a colonoscopy. During the procedure, multiple areas of nodularity, friability, and ulceration were biopsied. The specimens demonstrated ulcerated mucosa with enlarged amorphous inflammatory cells suggestive of a cytopathic effect that was positive for HSV. This finding was consistent with herpetic colitis. The patient was treated with valacyclovir twice daily for fourteen days and did not suffer any more episodes of bloody ostomy output. He was eventually discharged to a skilled nursing facility. DISCUSSION: Herpetic colitis is a rare condition that has a small presence in the literature. Symptoms are variable, and can include bloody diarrhea, abdominal discomfort, fever, arthralgias, and weight loss. Immunofluorescence staining or PCR is the method of diagnosis. Treatment consists of administration of an antiviral nucleoside analog such as valacyclovir. As herpetic colitis is a rare cause of lower gastrointestinal bleeding, healthcare providers should familiarize themselves with the visceral manifestations of HSV, susceptible populations, diagnosis, and management.
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A CURIOUS CASE OF MEIGS-LIKE SYNDROME R Chan MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: Though it has long been a documented diagnosis, there are not many case reports involving Meigs syndrome. Defined as a benign ovarian tumor associated with ascites and pleural effusion, this syndrome must be considered once malignancy is ruled out. Even more rare is the association of Meigs syndrome with pericardial effusion. CASE: A 42-year-old female with recurring pleural effusions presented with a complaint of shortness of breath and tachycardia. On previous admissions for similar symptoms, she was noted to have moderate bilateral pleural effusions in the setting of community-acquired pneumonia. At that time, thoracentesis revealed exudative effusion, with reactive mesothelial and inflammatory cells, for which she underwent video-assisted thoracoscopy with chest tube placement and Talc pleurodesis. Additionally, Magnetic Resonance Imaging of the pelvis was significant for a 15mm right ovarian mass with mild ascites. CA-125 level was elevated (88) with negative autoimmune and infectious workup. The patient was started on Provera on discharge with plans for outpatient surgical intervention due to concern for endometriosis. On current presentation, Computed Tomography of the thorax without contrast showed reoccurrence of bilateral pleural effusions and new-onset pericardial effusion, confirmed by echocardiogram. Cardiology was consulted and a left and right heart catherization was performed without evidence of coronary obstruction or pericardial constriction. She then underwent a laparoscopic right salpingo-oophorectomy. Pathology was consistent with a paratubal cyst and no evidence of malignancy. Her symptoms improved post-operatively and eventually CA-125 normalized. She was discharged with close follow up with repeat chest x-rays confirming resolution of pericardial and pleural effusions. DISCUSSION: The presence of pericardial effusion in the setting of Meigs syndrome is extremely rare; our literature review revealed roughly three known cases. The diagnosis of Meigs syndrome in association with pericardial effusion is questionable. However, the resolution of the pericardial effusion following the removal of the ovarian mass does point to a link. In the setting of unexplained pericardial effusion, the possibility of Meigs Syndrome should be considered.
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SYSTEMIC LUPUS ERYTHEMATOUS AS A MIMICKER OF LYMPHOPROLIFERATIVE DISEASE
M Bank MD 1 , AS Ito MD 1 , SA Chaudhary MD 2 , S Sanne DO 1 1 Department of Medicine, LSU Health, New Orleans, LA 2 Department of Medicine, Section of Infectious Diseases, LSU Health, New Orleans, LA
INTRODUCTION: Systemic lupus erythematous (SLE) is a known mimicker of many other conditions because of its diverse multi-system presentation. Especially when evaluating for a lymphoproliferative disease, consider SLE as a coexisting or alternative diagnosis.
CASE: A 42-year female with no known past medical or family history presented to the hospital with three days of chest pressure, shortness of breath, fever, and five days of throat pain. The patient also reported weakness, arthralgias, myalgias, fatigue, night sweats, and a 20lb weight loss over the prior two months. Infectious workup was negative; however, patient was noted to have pancytopenia with a white blood cell count of 2.0 K/uL, hemoglobin of 7.6 gm/dL, and platelets of 120 k/uL. Imaging showed enlarged lymph nodes in both sides of neck, supraclavicular region, axilla, mediastinum, and scattered enlarged lymph nodes in periportal and peri-splenic area, retroperitoneum, pelvis, and groin. The patient had an elevated serum creatinine of 1.27 mg/dL with nephrotic range proteinuria and mild elevation in transaminases. Other relevant labs included an elevated ESR and a positive EBV IgG. Oncology was consulted due to concern for lymphoma and the patient underwent excisional lymph node and bone marrow biopsy. Lymph node biopsy revealed reactive lymphoid hyperplasia, but was negative for malignancy, as was the bone marrow biopsy. A concurrent autoimmune workup revealed a positive ANA and low complement levels. Further autoimmune workup was positive for anti-ds DNA, as well as anti-SSA, anti- SSB, anti-Sm, anti-chromatin, anti-ribosomal P, and anti-RNP. Rheumatology diagnosed the patient with SLE at that time. Nephrology was consulted for help with renal biopsy which showed lupus nephritis class IV. The patient’s symptoms improved with prednisone and she has been managed outpatient by rheumatology and nephrology on a regimen of hydroxychloroquine and mycophenolate. Follow-up labs revealed significant improvement in her anemia and renal function. DISCUSSION: This case highlights the importance of keeping a broad differential when approaching a patient to ensure a prompt and accurate diagnosis. While this patient’s B symptoms, pancytopenia and diffuse lymphadenopathy were suggestive of a hematologic malignancy such as lymphoma, she also exhibited many classic symptoms of SLE.
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AN OMINOUS PRESENTATION OF STAPHYLOCOCCUS HOMINIS
H Mir MD 1 , L Dartez BS 2 , T Roussel MD 1 , D Mickey MD 1 , C Giffin MD 1 1 Department of Medicine, LSU Health Sciences Center, Baton Rouge, LA 2 School of Medicine, LSU Health Sciences Center, New Orleans, LA
INTRODUCTION This case describes acute aortic valve insufficiency caused by infectious endocarditis secondary to an unlikely pathogen in a patient who’s only known risk factor was a spinal epidural injection. Coagulase-negative staphylococci cause less than 5% of native valve infectious endocarditis (NVE) cases. The majority of those infections are due to Staphylococcus epidermidis, making Staphylococcus Hominis NVE exceedingly rare. CASE: A 79-year-old woman with chronic obstructive lung disease, tobacco abuse, acid reflux, hyperlipidemia, osteoporosis, lumbar radiculopathy, anxiety/depression, and Schatzki’s ring presented for several months of progressive dyspnea, orthopnea, nonproductive cough, and weight loss. She associated her symptom onset with a transforaminal epidural steroid injection four months prior for chronic lower back pain with radiculopathy. She had experienced chest pain, anorexia, chills, and night sweats. Vitals were notable for a widened pulse pressure (BP 119/31mmHg), tachycardia (107 bpm), and afebrile. On exam, she had a diastolic decrescendo murmur at the left 3rd intercostal space and bounding symmetrical radial pulses. These signs and symptoms led to suspicion for aortic valve insufficiency. A transthoracic echocardiogram demonstrated severe aortic valve regurgitation and moderate mitral valve regurgitation. Subsequently, blood cultures revealed growth in three of four bottles for coagulase negative staphylococci and transesophageal echocardiogram demonstrated a 0.5-1cm vegetation of the native aortic valve. Cultures speciated as Staphylococcus hominis, a common noninvasive bacteria of normal skin flora. She denied any prior abrasions, skin lesions, or IV drug use that could have introduced Staphylococcus hominis besides the steroid injection. She underwent urgent aortic and mitral valve replacement surgery and received six additional weeks of antibiotic therapy. DISCUSSION: This case demonstrates the importance of considering infectious causes (endocarditis) in the differential for acute aortic valve insufficiency. Despite remaining afebrile and undergoing a relatively safe, common procedure of spinal epidural steroid injection, she developed an infectious complication. A review of adverse events from 11,980 intra-articular facet joint injection procedures performed from 2007-2017 found only one incident of infective endocarditis. While rare, it’s important to recognize this possible complication as these procedures become more commonplace.
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A CURIOUS CASE OF SPONTANEOUS WATERHOUSE-FRIDERICHSEN SYNDROME A Vaughn-Allen MD, M Fashho MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: Waterhouse-Friderichsen syndrome is uncommon, but it is especially rare when it is acquired in the absence of bacterial sepsis, i.e. fulminant meningococcemia. However, other causes can include anticoagulants, antiphospholipid syndrome, physiologic stress, tumor metastasis, and postoperative hemorrhage. This is a case of spontaneous bilateral Waterhouse- Friderichsen syndrome in a post-knee replacement patient on Eliquis. CASE: A 59 y/o female presented with fevers, hypoglycemia, and hypotension complaining of shortness of breath, nausea, abdominal pain, headache, myalgia, fatigue, and dizziness. Per chart review, patient recently had left knee replacement approximately one week prior to presentation and was placed on Eliquis for deep venous thrombosis prophylaxis. Two days prior to presentation, she was seen for right upper quadrant abdominal pain and hyperglycemia. Computed Tomography (CT) of the abdomen showed minimal non-specific stranding surrounding her adrenal glands. She refused treatment was discharged with instructions to return if symptoms worsened. On current admission, repeat CT of the abdomen and pelvis revealed new bilateral adrenal hematomas. The patient’s family denied recent trauma or falls. No abdominal or retroperitoneal bruising was noted on physical exam. Other significant labs revealed leukocytosis, lactic acidosis, acute kidney injury, and thrombocytopenia. Patient was initiated on intravenous fluids (IV), vasopressors, and antibiotics for possible septic shock secondary to a urinary tract infection. Anticoagulation was held and patient was started on IV hydrocortisone 100mg every eight hours out of concern for adrenal insufficiency secondary to spontaneous adrenal hemorrhages. Eventually, the patient did become more alert and oriented. Antibiotics were discontinued as final blood and urine cultures were negative. She remained hemodynamically stable and was able to be downgraded from the intensive care unit. She was discharged home on oral hydrocortisone 25mg daily. DISCUSSION: In this patient, it was highly suspected that Eliquis was the culprit of her bilateral adrenal hemorrhages in the absence of trauma or infection. It is important to be able to recognize that symptoms in these patients are relatively non-specific and can often mimic septic shock. However, with appropriate and timely management, patients often recover – possibly without even requiring long term glucocorticoid and mineralocorticoid replacement.
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PENILE CALCIPHYLAXIS C Rathore MD 1 , C Bruins, MD 1 , S Rimmer BS 2 , A Loghmani DO 1 , J Larrazolo MD 1 , S Walvekar MD 1
1 Department of Internal Medicine, LSU Health, New Orleans, LA 2 School of Medicine, LSU Health Sciences Center, New Orleans, LA
INTRODUCTION: Calciphylaxis, calcific uremic arteriolopathy, is a rare skin disorder that presents as intensely painful areas of skin ischemia and necrosis and carries a high morbidity and mortality. The skin lesions of calciphylaxis normally involve adipose-rich areas such as abdomen and thighs, though in much rarer cases have involved the penis. Calciphylaxis is most commonly associated with end-stage renal disease (ESRD). Other associated risk factors include hyperphosphatemia, hypercoagulable states, long-term dialysis use, and warfarin use. CASE: A 50-year-old man with ESRD on HD and mechanical mitral valve replacement on warfarin presented with one month of progressive penile pain and swelling, which worsened to an ulcerated lesion at the glans penis and phimosis. CT scan of the pelvis demonstrated marked diffuse atherosclerotic disease with wall calcification of all major vessels, as well as questionable mild soft tissue edema and skin thickening of the penis. Infectious workup was negative. Urology took the patient to the operating room for circumcision and penile biopsy given concern for malignancy. Surgical pathology results revealed necrotic ulcer with thrombosis and intravascular calcification at the ulcer base. Dermatology felt the biopsy was most consistent with calciphylaxis. The treatment plan was coordinated with nephrology to begin sodium thiosulfate with dialysis. The patient continued to complain of intense pain despite pain medications with palliative care and wound care input. The patient was offered penectomy given refractory pain, however he declined. Although it is recommended to discontinue warfarin in the setting of calciphylaxis as it can worsen skin necrosis, the decision was made to continue warfarin given the presence of his mechanical valve and limited options with ESRD. DISCUSSION: Penile calciphylaxis is particularly rare because of the rich vascular network in the area. Microvascular calcification leads to a cascade of vascular endothelial injury and consequent narrowing and thrombosis of the vessels, which ultimately leads to tissue necrosis from reduced blood flow. There is no approved treatment for calciphylaxis. A collaborative approach involving nephrology, dermatology, wound care, and palliative care is necessary to try and reduce risk factors.
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FUNGAL PETROCLIVAL OSTEOMYELITIS DUE TO ASPERGILLUS IN AN IMMUNOCOMPETENT PATIENT A Malik MD, S Thotamgari MD, S Kulkarni MD Department of Medicine, Louisiana State University, Shreveport, LA INTRODUCTION: Skull base osteomyelitis (SBO) is a rare entity with severe life-threatening consequences. Fungal SBO is uncommon and is usually seen in immunocompromised patients and is mostly caused by Aspergillus and Candida species. The overall mortality in SBO is around 9.5% and can go up to 50% in fungal SBO due to Aspergillus. CASE: A 62-year-old man with hypertension and well controlled type 2 diabetes (HgA1c 6.4%) presented with progressive worsening of left ear pain, neck pain and double vision for two months. About two months ago, he reported having pain in the left ear, a tympanostomy tube was placed and he was started on oral antibiotics at an outside hospital. However, he reported continuing to have left ear pain which progressed to left neck pain along with double vision. Physical examination revealed erythematous tympanic membrane and minimal purulent drainage in left ear. Left lateral gaze palsy was present on neurologic examination. Nasal endoscopy showed normal nasal mucosa. Computed Tomography scan of the temporal bone showed left petroclival hypodensity and cortical erosion. Magnetic Resonance Imaging further confirmed findings suggestive of petroclival osteomyelitis. The patient underwent left sided mastoidectomy and intraoperative cultures from left ear grew Aspergillus species. At the time of case submission, the patient was currently admitted in the hospital; being treated with intravenous voriconazole and the plan was to continue long-term intravenous antifungal treatment. Conclusion: SBO is a rare but life-threatening infection which usually starts from infection of either external ear canal or paranasal sinuses. PetroClival osteomyelitis due to Aspergillus species is a serious condition with high mortality rate and treatment includes aggressive surgical debridement, long-term culture-directed systemic antimicrobial therapy. Although the infection is very rare in immunocompetent patients, it can have significant morbidity and mortality rates up to 50%. Early diagnostic sampling along with high suspicion towards fungal infection should be considered in diabetic patients who do not improve with empirical antibiotics.
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REVERSE TAKUTSUBO CARDIOMYOPATHY ASSOCIATED WITH PHLEGMASIA CERULEA DOLENS F Echefu MD, D Hammett MD, C Forrester MD, A Ausef MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA INTRODUCTION: Phlegmasia cerulea dolens is a rare but potentially fatal complication of acute massive deep venous thrombosis characterized by severe pain and swelling of the extremities with cyanosis. It is rarely associated with reverse takotsubo syndrome (TTS). Takotsubo syndrome is a sudden onset, but reversible acute heart failure syndrome commonly associated with intense emotional or physical stress with higher incidence in postmenopausal women. CASE: A 56-year-old male presented with lower extremity pain, swelling and bluish discoloration of left leg that began the previous week. At presentation, he was tachycardic and hypotensive with no palpable left distal pulses. Lower extremity venous duplex showed completely occluded unilateral left proximal superficial and deep venous thrombi. He was admitted to the hospital and underwent urgent ultrasonic catheter directed thrombolysis and heparin drip under close supervision in the intensive care unit. On day 3, he complained of chest pain and atrial fibrillation with rapid ventricular response was noted on cardiac monitor. EKG revealed anterior ST-elevation myocardial infarction, absent on prior EKG. Transthoracic echocardiogram revealed left ventricular ejection fraction of 20% with apical hypokinesis. He underwent cardiac catheterization (CC) revealing basal hypokinesis with hyperdynamic left ventricular apex, left ventricular ejection fraction of 35%, and no obstructive coronary artery lesion. A diagnosis of reverse Takotsubo syndrome was made. DISCUSSION: We report the reverse variant of TTS, a rarer form, in which there is hyperdynamic apex and hypokinesis of the basal segments of the left ventricle observed on echocardiography and left cardiac catheterization. It has similar presentation as acute coronary syndrome, confusing and delaying its diagnosis. The hallmark differences are non-obstructive coronary vasculature and reversibility seen in TTS. Several etiologies have been reported in the pathogenesis of reverse takotsubo cardiomyopathy such as catecholamine excess, coronary artery spasm and microvascular dysfunction. Venous thromboembolism specifically pulmonary embolism is a rare but important etiology. To date no known case of phlegmasia cerulean dolens has been associated with TTS in literature.
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A CASE REPORT OF NEURO SARCOIDOSIS P Sakhamuri MD, T Dao MD, M Matthew DO, A. Chauffe DO Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: Neuro sarcoidosis is an uncommon manifestation of sarcoidosis seen in only 3% of patients. Cranial neuropathy, meningitis, and peripheral neuropathy are the most common types of neurological diseases. CASE: 31-year-old male presented with chief complaints of double vision and binocular diplopia for one day. He also reported that his left eye was pulled inwards one day prior. He denied any headaches, dizziness, lightheadedness, balance issues, and had no other cranial nerve or motor/sensory deficits. The patient was seen in pulmonology clinic a few months prior for ongoing worsening shortness of breath with nonproductive cough for over 2 years. Computed Tomography of the thorax revealed bilateral hilar opacification with scattered nodules throughout the lungs. An extensive autoimmune and infectious work-up along with a bronchoscopy and subsequent biopsy revealed chronic granulomatous inflammation suggestive of pulmonary sarcoidosis. He was prescribed prednisone 40 mg; however, the prescription was never filled. In the background of pulmonary sarcoid his new symptoms of binocular diplopia with left lateral rectus palsy was concerning for neuro-sarcoid prompting an Magnetic Resonance Imaging of the brain revealing multifocal cerebral cortex nodules, scattered leptomeningeal enhancement, optic chiasm distal optic nerve enhancement along with chronic appearing non- enhancing T2 hyperintense foci of cerebellar white matter consistent with neuro sarcoid. Neurology and Rheumatology recommended that he receive Solumedrol 1000 mg for 5 days. He was discharged home on an oral prednisone taper with plans to eventually start on biologic disease-modifying anti-rheumatic drugs (DMARDs) as an outpatient. His symptom’s slowly but steadily improved. DISCUSSION: Sarcoidosis most commonly presents with lung disease or hilar lymphadenopathy, affecting 90–95 % of patients. The diagnosis of neuro sarcoidosis is always a challenge. For this reason, a definitive diagnosis requires the exclusion of other causes of neuropathy. Imaging findings in neuro sarcoid include dural thickening or leptomeningeal involvement, enhancing and non-enhancing parenchymal lesions, cranial nerve involvement (most commonly facial, optic however any nerve can be involved) and spinal or nerve root enhancement. Recognizing and correctly diagnosing neuro sarcoid leads to proper treatment and decreased morbidity in patients.
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