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ABSTRACTS FROM THE 2021 LOUISIANA ANNUAL ACP MEETING
CONTENTS
JOURNAL EDITORIAL STAFF
EDITOR D. Luke Glancy, MD
ASSOCIATE EDITOR L.W. Johnson, MD
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AN ATYPICAL PRESENTATION: BELCHING AS A CHIEF COMPLAINT IN AORTIC STENOSIS-RELATED ANGINA NOT THE EXPECTED DIPLOCOCCI: A RARE CASE OF GONOCOCCAL INFECTIVE ENDOCARDITIS
CHIEF EXECUTIVE OFFICER JeffWilliams
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JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD
6 TICAGRELOR INDUCED DIFFUSE ALVEOLAR HEMORRHAGE AFTER PCI INTERVENTION 7 A RARE CASE OF ADULT TYPE ALCAPA SYNDROME: TEN YEARS AFTER SUCCESSFUL SURGICAL REPAIR 8 SUBCUTANEOUS PANNICULITIS LIKE T-CELL LYMPHOMA PRESENTING WITH HLH 9 CEFEPIME NEUROTOXICITY IN THE SETTING OF NORMAL RENAL FUNCTION 10 AVOIDING TEE AND INVASIVE INTERVENTION IN LOW RISK PFO IN A CASE OF PARADOXICAL STROKE B BUNOL MD, K KINGSTON DM, O SAQQA MD, H SHI MD 11 THE TRAVELLING TICK: NEUROLOGICAL MANIFESTATIONS IN LATE TICK-BORNE ILLNESS 12 A CASE OF COVID-19 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME RESULTING IN NEW ONSET HEART FAILURE IN AN ADULT 13 A PECULIAR ENCEPHALOPATHY: A RARE CASE OF PNEUMATOSIS INTESTINALIS SECONDARY TO CYTOMEGALOVIRUS 14 A CASE OF SYPHILITIC AORTIC DISSECTION 15 CYTOPENIAS TO POLYCYTHEMIA VERA: AN UNUSUAL CASE 16 A CASE OF TRANSFUSION RELATED BACTERIAL INFECTION 17 DIAGNOSIS AND MANAGEMENT OF CARDIAC HEMOCHROMATOSIS 18 RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB 19 CNS MIXED FUNGAL BALL IN AN IMMUNOCOMPETENT PATIENT - A RARE ENTITY! 20 ABNORMAL PRESENTATION OF ADVANCED GESTATIONAL TROPHOBLASTIC NEOPLASM (GTN) WITH PULMONARY ARTERY OBSTRUCTIVE SYMPTOMS AND PROFOUND ANEMIA 21 CENTRAL RETINAL ARTERY OCCLUSION AND NEW ONSET ATRIAL FIBRILLATION 22 TREATMENT RESISTANT PROLACTINOMA: REASONS BEYOND NON-COMPLIANCE 23 A CASE OF STRONGYLOIDES IN AN IMMUNOCOMPROMISED PATIENT 24 ADENOSQUAMOUS CARCINOMA: AN ABNORMAL PRESENTATION OF A RARE MALIGNANCY 25 EDWARDSIELLA TARDA: A PISCINE CULPRIT OF ACUTE CHOLANGITIS 26 A RARE CASE OF PSEUDO-TMA IN A PATIENT WITH COBALAMIN DEFICIENCY
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, Vacant
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, Bennett Schmidt, MD Private Practice Physician Member, Vicki Steen, MD
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Each year medical students from the four 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) 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 physician judges. This year a total of 119 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 23 most highly ranked 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 March 13, 2021. 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 Chair, Louisiana Associates Liaison Committee
Lee S. Engel, MD, PhD, FACP Past Governor, Louisiana Chapter ACP
Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP
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AN ATYPICAL PRESENTATION: BELCHING AS A CHIEF COMPLAINT IN AORTIC STENOSIS-RELATED ANGINA T Dao, MD; J Edavettal, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Angina pectoris classically presents as a substernal squeezing chest pain associated with exertion and often related to coronary atherosclerotic disease. Occasionally, there can be atypical presenting symptoms including nausea, vomiting, and diaphoresis. Although gastrointestinal symptoms have been described in angina pectoris, high suspicion for cardiac etiology must be maintained due to potentially detrimental outcomes due to delayed diagnosis. CASE A 69-year-old man with tobacco abuse presented to internal medicine clinic with a 6-month history of abdominal bloating and episodic belching. He denied nausea or vomiting, but reported a sensation of dysphagia without weight loss. He denied chest pain but reported discomfort with exertion and meals that were relieved with belching, causing some food aversion. EKG showed no conduction, rhythm, ST segment or T wave abnormalities. At the time he was started on esomeprazole for treatment of gastroesophageal reflux which initially provided relief but eventually did not resolve his symptoms. Esophagogastroduodenoscopy was showed no esophageal abnormalities. Biopsies were negative for H pylori. A systolic murmur was heard on exam prompting an echocardiogram which showed an ejection fraction of 65%, aortic stenosis with a dilated left atrium, an aortic valve area of 0.86 cm 2 and a peak velocity of 3.42m/s. He was referred to cardiology for surgical aortic valve replacement evaluation. Coronary angiogram showed 70% stenosis of an ostial lesion in the circumflex artery. He underwent a coronary artery bypass as well as a surgical bioprosthetic aortic valve replacement. At 6-week follow up, he reports that his symptoms have largely resolved including his belching symptoms. DISCUSSION Although uncommon, belching and dysphagia can be concerning for esophageal disease but cardiac pathology must be maintained on the differential. In a patient with cardiac risk factors and gastrointestinal symptoms that resolved with surgical intervention, belching may be observed as early symptom of angina warranting further investigation.
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NOT THE EXPECTED DIPLOCOCCI: A RARE CASE OF GONOCOCCAL INFECTIVE ENDOCARDITIS J Dubuc, D Montgomery, S Vignes Department of Internal Medicine, LSU Health Sciences Center, New Orleans, Louisiana
INTRODUCTION Neisseria gonorrhoeae is a gram-negative diplococci bacteria responsible for over 80 million cases of urethritis in men and women every year. Infections rarely spread to distant sites such as skin, brain, joints, and even heart valves. Gonococcal endocarditis has been described in the literature fewer than 150 times, yet it portends a 19% mortality with 50% of cases requiring surgical intervention. CASE: A 56-year-old Caucasian man with a history of nephrolithiasis, coronary artery disease, and hypertension presented to the emergency department for 5 months duration of chest pain, fever, and chills. The chest pain was described as sternal intermittent aching pain with associated fevers, night sweats and rigors. The patient denied penile lesions, dysuria, and urethral discharge. Other pertinent history includes recent multiple laser lithotripsy procedures to treat nephrolithiasis. Temperature upon arrival to the emergency department was 100.1 o F, physical exam was remarkable for a grade II/VI holosystolic murmur at the left mid-sternal border. Labs remarkable for WBC 8.4 10^3/uL ESR 77 mm/hr, CRP 9.7 mg/dL , and BNP 166 pg/mL On trans-thoracic echocardiogram a highly mobile 3.3x1.7cm vegetation on the septal leaflet of the tricuspid valve was visualized resulting in severe tricuspid regurgitation. On hospital day #2, blood cultures resulted positive for Neisseria gonorrhoeae . Empiric antibiotics were changed to Ceftriaxone 2g every 12 hours. On hospital day #8, the patient underwent tricuspid valve replacement with a mechanical valve. He was discharged on hospital day #14 with plans to complete a 6-week course of ceftriaxone. His course was later complicated by a pericardial effusion and supratherapeutic INR requiring emergent pericardiocentesis. DISCUSSION: Gonococcal Endocarditis will inherently become increasingly common due to rising cases of gonorrhea STIs and antibiotic resistance. Identification of genitourinary infections and early effective treatment is imperative to prevent serious sequelae. In this case, genitourinary manipulation for treatment of nephrolithiasis in the setting of active gonococcal infection was likely the nidus of hematogenous spread.
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TICAGRELOR INDUCED DIFFUSE ALVEOLAR HEMORRHAGE AFTER PCI INTERVENTION
H Sajjad, MD, R Chan, MD, R Panicker, MD, S Shahid, MD, WD Brown, MD, M Fashho, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA
INTRODUCTION Diffuse alveolar hemorrhage (DAH) is a medical emergency that must be immediately recognized and treated. DAH is characterized by bilateral pulmonary infiltrates, hypoxia, hemoptysis, and/or falling blood count. Treatment ranges from supportive measures, to withdrawal of offending agents, steroid administration, plasmapheresis, and/or direct immunosuppression. CASE A 56 -year-old woman with a history of hypertension, hyperlipidemia, diabetes, and tobacco abuse presented with one- week of episodic, sharp, pressure-like, substernal chest pain that worsened with activity. EKG at admission revealed sinus tachycardia with ST elevations in the infero-lateral leads and elevated troponin-I. She was given Aspirin, started on a heparin drip, and underwent emergent percutaneous coronary intervention with a drug eluding stent to the right coronary artery and the circumflex artery. Post-procedure she was bolused with tirofiban, loaded with ticagrelor, and transferred to the intensive care unit. The following day she was started on dual antiplatelet therapy (DAPT) with Aspirin and Brilinta, Lopressor, and Atorvastatin. Overnight she developed dyspnea and hemoptysis. CT Angiography revealed diffuse bilateral infiltrates. Labs revealed hyponatremia, elevated BNP, and hemoglobin decrease from 13.5 to 11.5. She became febrile, tachycardic, and tachypneic with leukocytosis. Broad spectrum antibiotics were started. Chest x-ray revealed worsening bilateral opacities concerning for DAH. Brilinta was immediately discontinued and replaced with Plavix. Exam was significant for bilateral rhonchi and coarse breath sounds. Ultimately, she was intubated for acute hypoxemic respiratory failure, DAPT was discontinued, and methylprednisolone administered. She was extubated after a bronchoalveolar lavage, which revealed blood-tinged aspirate without signs of active bleeding. Aspirin and Plavix were restarted once her hemoptysis resolved. Her dyspnea improved and she was discharged home with oxygen. She is awaiting pulmonology and cardiology follow-up. DISCUSSION This case highlights the need for immediate recognition of Ticagrelor induced DAH and discontinuation of therapy in preventing life threatening progression to acute hypoxic respiratory failure.
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A RARE CASE OF ADULT TYPE ALCAPA SYNDROME: TEN YEARS AFTER SUCCESSFUL SURGICAL REPAIR A Gaddam MD, B Swirsky MD Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA INTRODUCTION Anomalous left coronary artery from the pulmonary artery (ALCAPA) Syndrome is a very rare congenital heart disease where the left coronary artery (LCA) originates from the pulmonary artery. It affects 1 in every 300,000 live births in the USA and if left untreated, has a 90% mortality within the first year of life. CASE DESCRIPTION: A 32-year-old woman with a past medical history of hypertension, non-insulin-dependent type 2 diabetes mellitus, hyperlipidemia, with no family history of heart disease presented with complaints of exertional angina since 2 years and had a normal physical examination. Further work-up with coronary angiography showed an anomalous left coronary artery arising from the pulmonary artery. Coronary angiographic findings also revealed a large voluminous right coronary artery (8 mm in diameter) with extensive collaterals to the left coronary artery. Transthoracic Echocardiogram revealed an ejection fraction of 40%withmild left ventricular hypertrophy. EKG showed nonspecific T wave abnormality in lateral leads. Our patient underwent surgical repair with coronary button transfer procedure without any perioperative complications. After 10 years of post repair, our patient is asymptomatic with and ejection fraction of 45% on Transthoracic Echo. DISCUSSION: In extremely rare cases of adult type ALCAPA Syndrome, those who live to adulthood have extensive collateral circulation from the right coronary artery and develop chronic myocardial ischemia resulting in arrhythmias, congestive heart failure, and sudden cardiac death. The extent of myocardial ischemia is determined by the development of collaterals between the right and left coronary artery. Diagnosis is usually established with coronary angiography, cardiac MR imaging, multi detector CT angiogram. Surgical correction with coronary button transfer procedure has excellent long-term results.
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SUBCUTANEOUS PANNICULITIS LIKE T-CELL LYMPHOMA PRESENTING WITH HLH C Sullivan, MD MSc, A Loghmani, DO, A Abbas MD, K Thomas, MD MSc, H Hall MD, G Destin DO, S Guillory MD, S Walvekar MD, R Chowdry, MD Department of Internal Medicine, LSU Health Sciences Center, New Orleans, Louisiana CASE: A 34-year-old man with no past medical history presented with two months of a rash on his lower back and daily fevers up to 103°F. Additionally he had fatigue and loss of appetite resulting in an 18-pound weight loss. He had previously been treated with sulfamethoxazole-trimethoprim and clindamycin for presumed cellulitis. He had erythematous indurated dusky plaques on his right neck, bilateral lower back and hips, right upper abdomen and groin, which were not painful, or pruritic. He also had faint erythematous pink macules scattered on his trunk and bilateral upper extremities. His lab work revealed elevated liver enzymes, cytopenia, ferritinemia, hypertriglyceridemia, and increased levels of soluble IL-2 receptors. These findings along with fevers and hemophagocytosis seen on skin biopsy met criteria for hemophagocytic lymphohistiocytosis (HLH). Further evaluation of the skin biopsy led to a diagnosis of subcutaneous panniculitis like T-cell lymphoma (SPTCL) alpha/beta subtype. He was started on cyclosporine 5mg/kg/day and dexamethasone 20mg/day. The patient noted almost immediate improvement is his skin lesions and laboratory abnormalities trended towards patient’s baseline within two weeks. DISCUSSION: SPTCL typically presentswith erythematous painless plaques and nodules on the trunk and extremities. Systemic symptoms include fever, chills and weight loss. Cytopenia and elevated liver enzymes are common. The two types of SPTCL are alpha/ beta and gamma/delta with the former being the less aggressive. STPCL presenting with HLH portends worse outcomes. Historically, many of these cases were treated with aggressive cytotoxic chemotherapy including cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate and prednisone (CHOP) based regimens; however, patients frequently relapse. There is no standardized treatment for SPTCL but previous studies suggest successful treatment with systemic steroids and cyclosporine. CONCLUSION: Our findings suggest that HLH secondary to SPTCL may be treated with cyclosporine and dexamethasone to achieve rapid clinical and symptom management of this rare malignancy.
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CEFEPIME NEUROTOXICITY IN THE SETTING OF NORMAL RENAL FUNCTION Abigail H. Boudreaux, MD PGY-1 Department of Medicine, Ochsner Medical Center, New Orleans, LA INTRODUCTION Antibiotics are some of the most prescribed medications in the inpatient setting. Although the profound benefits of treating infections often outweigh the potential adverse effects of antimicrobial administration, it is important to be aware of iatrogenic causes of new problems in the hospital. Beta-lactams such as penicillins and cephalosporins have been known to cause neurotoxicity. CASE: An 81-year-old man with a cerebral vascular accident without residual deficits, newly diagnosed hepatocellular carcinoma, and alcohol use disorder with last drink 2 weeks ago presented with lower back pain. MRI was suspicious for lumbar osteomyelitis/discitis. Empiric treatment for osteomyelitis with vancomycin and piperacillin-tazobactam was initiated, whichwas narrowed to vancomycin and cefepime while awaiting biopsy. The patient’s mental status on admissionwas fully alert and orientedwhich progressively changed to complete disorientation by day five. Initial workup of his encephalopathy was significant only for hyponatremia of 131 (patient had been without good food intake). Vital signs, other electrolytes, renal function, complete blood count, lactate, ammonia were all within normal limits. Computed tomography of the head was without convincing evidence of large hemorrhage or midline shift. Electroencephalogram obtained was negative for seizures, but demonstrated frequent triphasic waves, suggestive of metabolic encephalopathy. Due to growing clinical suspicion for cefepime neurotoxicity and grossly negative workup for other causes of metabolic encephalopathy, the patient was transitioned to ceftriaxone. By 48 hours, he was completely back to his baseline. DISCUSSION: Cefepime neurotoxicity is thought to be due to concentration-dependent GABA receptor antagonism. While most commonly seen among patients with renal impairment, a systemic review suggested cefepime toxicity in the setting of normal renal function may be more likely to occur in patients with pre-existing brain damage, possibly due to increased blood-brain barrier permeation. Our patient had history of substance abuse and prior stroke. It may have been interesting to obtain a serum or CSF cefepime concentration before discontinuation of the drug as toxic trough levels have been proposed in literature. One paper proposed therapeutic drug monitoring targeting troughs of <7.5 mg/L in patients with risk factors for cefepime toxicity.
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AVOIDING TEE AND INVASIVE INTERVENTION IN LOW RISK PFO IN A CASE OF PARADOXICAL STROKE B BUNOL MD, K KINGSTON DM, O SAQQA MD, H SHI MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA BACKGROUND: Patent foramen ovales (PFO) can be incidentally found as part of a stroke work-up on a transthoracic echocardiogram (TTE) with bubble study. Transesophageal echocardiogram (TEE) is the standard for elucidating the size of the defect, however, is an invasive procedure with risk and cost. This case describes using PFO scoring systems and TTE to avoid overutilization. CASE: A 65-year-old man with hypertension initially presented after being found down at home. EKG showed sinus rhythm with premature atrial complexes. Magnetic resonance imaging (MRI) of the brain showed a new infarction in the superior left basal ganglia and posterior left hippocampus with old lacunar infarcts. A Transthoracic echocardiogram (TTE) showed an ejection fraction greater than 55%, with positive bubbles crossing the septal wall after 4-5 cycles concerning for a PFO. Venous doppler showed a left femoral and brachial thrombus. There was a concern for paradoxical embolus from the PFO and possible need for surgical closure. The Risk of Paradoxical Embolization (RoPE) score was calculated to be low at 3 (age, hypertension, previous stroke on imaging, subcortical infarcts). Although cryptogenic stroke was in two different territories, telemetry did not show any arrythmias, and the decision was made to treat with apixaban for deep venous thrombus’ and aspirin for secondary prevention. TEE was deferred. DISCUSSION: Although PFOs can be causally related to strokes, other processes such as atrial fibrillation, lacunar injury, hypercoagulable disease are more common. The RoPE score can be used to determine if TEE and repair can be beneficial. This scoring system was created due to the challenge of identifying which cryptogenic strokes bay be attributable to a PFO. This score can help give insight in how to separate from within a cryptogenic stroke population those PFO’s which are related to the stroke from those which are more likely incidental findings. The score will not directly predict who will or will not benefit from closure.
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THE TRAVELLING TICK: NEUROLOGICAL MANIFESTATIONS IN LATE TICK-BORNE ILLNESS P Devulapalli, MD, C Michael, MD, O Alawale, MD Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA
INTRODUCTION Infections caused by Borrelia burgdorferi, predominantly seen in the Northeast, are categorized into three main stages: early localized, early disseminated, and late. Depending on the stage, various organ involvements are seen, including the skin, joint, cardiac, and nervous systems. Specifically, Lyme meningitis can manifest as headaches, neck stiffness, and visual impairment. CASE: A 45-year-old woman with type II diabetes mellitus and hypertension initially presented for evaluation by Ophthalmology, given complaints of progressively worsening blurry vision for the past two years. The patient noted over the past few months, she had developed bilateral peripheral vision loss, intermittent headaches, lightheadedness, and photophobia. MRI of the Head-Orbits was obtained to investigate her painless vision loss and showed scattered punctate nonspecific T2 hyperintensities of the bifrontal subcortical white matter. Given the patient’s age this was less likely to be microvascular ischemic changes, and the distribution of the lesions was not typical of demyelinating disease. It was recommended that vasculitis and Lyme disease be ruled out, for which the workup included: ANA, ANCA, CBC, ESR, CRP, CMP, FTA- Abs, RPR, Echo, Carotid doppler, LP, and Lyme antibodies. Though the vasculitis workup was negative, the Lyme IgM western blot was positive. On referral to Infectious Disease, the patient admitted to a tick bite in 2016 while living in rural Shreveport, Louisiana, and was uncertain of treatment. Of note, physical findings were negative for Brudzinski and Kernig signs. Subsequently, the lumbar puncture was consistent with Lyme meningitis with pleocytosis. The patient was treated for four weeks with intravenous ceftriaxone. DISCUSSION: Despite Lyme disease being a rare condition in the Southern states, this case emphasizes the importance of keeping Lyme meningitis as a possibility. Given the majority of patients develop skin manifestations, rarely does Lyme meningitis present solely as a neurological manifestation. While symptoms can be very nonspecific, CSF findings can be just as variable, prompting focus on the less abrupt onset of symptoms and findings of pleocytosis in CSF.
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A CASE OF COVID-19 ASSOCIATED MULTISYSTEM INFLAMMATORY SYNDROME RESULTING IN NEW ONSET HEART FAILURE IN AN ADULT M Bulathsinghala, MD PhD, 2 R Samson, MD Department of Internal Medicine, LSU Health Sciences Center; New Orleans, LA Department of Internal Medicine, Section of Cardiology, Tulane University Health Sciences Center, New Orleans LA INTRODUCTION COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare complication seen 2 to 6 weeks after the resolution of an acute COVID-19 infection. There is only one previously described case of COVID-19 related hyperinflammatory syndrome in adults. Here we present a case of COVID-19 associated MIS causing myocarditis and new onset heart failure with reduced ejection fraction in an adult. CASE: A 23-year-old man presented with fever, fatigue, exercise intolerance, myalgias, headaches, and a positive COVID-19 PCR test approximately 5 weeks earlier. On admission, the patient was noted to be febrile to 102.2, tachycardic, and hypotensive. Physical exam was notable for bilateral conjunctival irritation and trace lower extremity edema. Labs on admit were significant for creatine of 1.67, mild transaminitis, BNP 262, Troponin 0.67, and WBC 12.8. Bedside echo performed in the Emergency Department was significant for a decreased LVEF 40-45%, global hypokinesis, and collapsible IVC. The patient was empirically treated with vancomycin and zosyn for possible sepsis however blood cultures remained clear and no source of infection was ever identified. Inflammatory markers were elevated with a LDH 252, D-Dimer 588, Ferritin 1,500, CPK 108, and CRP of 28. Angiogram of his chest showed no evidence of acute cardiopulmonary/airspace disease and no pulmonary embolism. Troponins peaked at 1.64 and CRP peaked at 37. DISCUSSION: The patient continued to worsen with no obvious source of infection with a pattern of inflammatory markers consistent with MIS in the setting of recent COVID-19 infection. The severity of his presentation prompted treating the patient according to MIS-C guidelines developed for children which included IVIG, IV steroids, and high dose aspirin which resulted in a quick resolution of his fever and improvement in his cardiac function and end-organ labs and markers. The patient was discharged home on aspirin and pantoprazole. Follow up echocardiogram one month later demonstrated a return of normal cardiac function.
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A PECULIAR ENCEPHALOPATHY: A RARE CASE OF PNEUMATOSIS INTESTINALIS SECONDARY TO CYTOMEGALOVIRUS C Parent MD, R Goel MD, L Bateman MD Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana INTRODUCTION Pneumatosis intestinalis (PI) is characterized by the formation of gas within the walls of the intestines. It has a poorly understood pathophysiology. The rarity of PI and the lack of defined treatment recommendations may present a challenge for clinicians both in terms of diagnosis and deciding on appropriate management. CASE: A 74-year-old man renal transplant patient presented with a two-month duration of decreased appetite and progressively worsening altered mental status associated with new short-term memory deficits and intermittent confusion. His physical examwas significant for encephalopathy but with an unremarkable abdominal exam. His initial laboratory work-up showed an elevated creatinine with normal electrolytes, thyroid function, and ammonia levels. He tested negative for BK virus, HIV, and syphilis. Computed tomography of the head and magnetic resonance imaging of the brain were unremarkable. Chest X-ray ordered to rule out infectious etiology of encephalopathy incidentally detected air within the wall of the colon at the hepatic flexure. A follow-up CT of the abdomen confirmed air within the wall of the ascending colon and proximal transverse colon consistent with PI. The patient underwent right sided hemicolectomy and ileostomy creation. Pathology of the resected colon was negative for malignancy but ultimately revealed evidence of cytomegalovirus. In addition, blood cultures later revealed disseminated Candida albicans felt secondary to possible bowel micro-perforation. He was treated and improved following a two-week course of Ganciclovir and a prolonged course of Micafungin. DISCUSSION: PI has been linked to a wide variety of etiologies from the rupture of COPD blebs to ischemic bowel to fungal overgrowth. Because it represents such a wide spectrum of diseases, rapid evaluation may be difficult and requires the involvement of a multidisciplinary team in conjunction with targeted imaging modalities to make the diagnosis.
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A CASE OF SYPHILITIC AORTIC DISSECTION R Panicker MD, S Acosta MD, C Clark MD, B Shaik MD, N Salagundla MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Aortic dissection is a rare complication of syphilis in the antibiotic era which makes diagnostic assumption even more difficult. CASE: A 46-year-oldWoman with hypertension, Crohn's disease, chronic hepatitis B and latent syphilis presented with complaints of acute onset left arm numbness, pain and weakness when walking her dog. She initially presented five days prior for a Crohn's exacerbation and was incidentally found to have positive syphilis antibody diagnosed as untreated latent syphilis of unknown duration. Infectious disease was consulted and recommended 2.4 million units benzathine penicillin G weekly for three weeks with first dose given. During her current presentation, she was significantly hypertensive with systolic pressures in the 220’s. Physical examination was significant for decreased distal pulses in the left upper extremity (LUE) and labs were only significant for mild leukocytosis. LUE arterial ultrasound showed distal subclavian versus proximal axillary artery thrombus with high bifurcation of the brachial artery and minimal distal ulnar artery flow. Computed tomography (CT) angiography of the LUE confirmed the findings. A heparin drip was initiated, and vascular surgery consulted. She underwent an open embolectomy of the left distal axillary artery. On postop day 1, CT angiography of thorax revealed filling defect within the distal descending aortic arch with early dissection suspected. The patient did not have any prior CT scans of the thorax. A transthoracic echocardiogram showed mild left ventricular hypertrophy and an ejection fraction of 60%. She was transferred to an outlying facility where she underwent thoracic endovascular aortic repair with stent placement successfully and was discharged on chronic anticoagulation. DISCUSSION: Reports of aortic dissection secondary to syphilis is uncommon in literature. In untreated syphilis, aortitis/aneurysm may manifest after 15-30 years from initial infection. This case highlights the potential complication of untreated syphilis and raises a question of whether we should consider ordering a CT thorax in patients with untreated syphilis of unknown duration.
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CYTOPENIAS TO POLYCYTHEMIA VERA: AN UNUSUAL CASE R Shaukat MD, T Benzar MD, P Ramadas MD. Department of Medicine, LSU Health Sciences Center, Shreveport, Louisiana
INTRODUCTION Hematological malignancies can take years to develop and may be preceded by clonal mutations. We describe an interesting case of evolution of a hematological disorder from cytopenias requiring growth factor support to polycythemia vera requiring disease specific therapy to secondary myelofibrosis.
CASE: An 81-year-old woman, who was referred to hematology in 2006 at the age of 67 for leukopenia. CBC showed WBC 2600/ uL with ANC 620/uL, hemoglobin 14.9 g/dL and platelets 156,000/uL. Bone marrow biopsy showed mild dysplasia with normal cytogenetics, not diagnostic of myelodysplastic syndrome. Testing for clonal mutations were not performed at that time. Over time, she developed worsening leukopenia with anemia and decision made to initiate granulocyte colony- stimulating factor along with darbepoetin alfa. This was continued for a decade with stable counts. In early 2019, she developed thrombocytosis and erythrocytosis. Workup revealed JAK2 V617F mutation. She was started on phlebotomy and hydroxyurea. As she developed mucositis, hydroxyurea was switched to ruxolitinib. Over the next few months, she was noted to develop a leukoerythroblastic blood picture. Flow cytometry of blood showed increased myeloblasts of 6.5% of total cells. Bone marrow biopsy showed hypercellular marrow with atypical megakaryocytic hyperplasia, erythroid hypoplasiawithmoderate to severe reticulin fibrosis, consistent with secondarymyelofibrosis given history of polycythemia vera. Cytogenetics showed normal karyotype. Next generation sequencing showed ASXL1 mutation along with JAK2 mutation. Ultrasound of the abdomen showed splenomegaly. Given that the blast count was less than 10%, decision made to continue ruxolitinib with the plan of initiating a hypomethylating agent if disease progression. She is currently doing well with stable counts and is being closely monitored. DISCUSSION: This is an unusual case where a patient with cytopenias, either idiopathic cytopenia of undetermined significance or clonal cytopenia of undetermined significance requiring growth factor support, acquired a JAK2 mutation requiring reversal of the treatment goal to phlebotomy and cytoreduction and eventually developed secondary myelofibrosis. It is unknown whether the JAK2 mutation occurred rather by chance or if the use of G-CSF contributed.
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A CASE OF TRANSFUSION RELATED BACTERIAL INFECTION M. Germain MD, J. Lollazolo MD, S. Saito MD Department of Medicine, LSU Health Sciences Center, New Orleans, LA CASE:
A 32-year-old woman with a history of myelodysplastic syndrome with multiple transfusions presented with a 7-day course of increasing shortness of breath, fatigue, dyspnea on exertion, pallor and chest pain. The patient was alert and cooperative, tired appearing, had generalize pallor with pale conjunctiva. She was also noted to bemildly tachycardic. Labs were positive for a hemoglobin of 4.2 and a hematocrit of 11. She was started on an infusion of packed red blood cells. About 20 minutes into the infusion, she began to complain of increased SOB and chest pain and felt ill, having multiple episodes of emesis and diarrhea. She then developed rigors and spiked a fever of 105.1, became profoundly tachycardic and hypotensive and was given epinephrine, diphenhydramine and solu-medrol. Repeat labs included CBC, LDH, haptoglovin, d-diner, fribrinogen, Direct Antiglobulin Test, and procalcitonin. She had a hemoglobin of 3.9, WBC count of 0.4 with absolute neutrophil count of 300, and pro-cal of 524. She was started on epinephrine infusion, then switched to levophed and started on antibiotics. The transfused blood was tested again for compatibility and it was thought that patient could safely resume transfusions and tolerated them well. Gram stain on the transfused blood demonstrated Gram-negative rods in addition to Gram-positive cocci, and cultures of the transfused blood grew Rahnella aquatilis and Pseudomonas fluroesence . The patient’s blood cultures never grew. DISCUSSION: Transfusion reactions are a relatively common occurrence; they can range from mild to severe and life threatening. Transfusion emergencies include TACO and TRALI, as well as hemolytic reactions. Transfusion related sepsis is a rare but documented adverse reaction (~1:5million). In immunocompetent patients, Rahnella aquatilis is a relatively weak pathogen found in fresh water. There are, however, other documented cases of patients who become septic from this microorganism. Pseudomonas fluroesence is also a relatively weak pathogen, but case reports illustrate that this organism can be a source of bacteremia in patients who received contaminated infusions.
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DIAGNOSIS AND MANAGEMENT OF CARDIAC HEMOCHROMATOSIS F Shariati MD, M Sultan MD, H Field MD. Department of Medicine, Ochsner Medical Center, New Orleans, LA
INTRODUCTION Cardiac hemochromatosis is an important and preventable cause of heart failure. It often starts in adults ages 30-50 with hiddenprogression tocardiacdysfunction. It is characterizedbydilatedcardiomyopathywithdilatedventricles, and reduced ejection fraction. Unfortunately, once heart failure develops, there is a rapid deterioration. Therapeutic phlebotomy is the treatment of choice in nonanemic patients with cardiac hemochromatosis. CASE: A51-year-old-manwas admittedwith acutedecompensatedheart failure andnewonset atrial fibrillation. He had a history of hereditary hemochromatosis, however, was non-compliant with medical follow up and with phlebotomy. On examination he appeared to have bronze skin and yellow eyes along with significant peripheral edema. Iron metabolism markers were obtained and were highly elevated. Echocardiography was significant for dilated ventricles, reduced ejection fraction, and reduced fractional shortening. Cardiac magnetic resonance (CMR) was consistent with diagnosis of myocardial siderosis. Standard heart failure treatment along with chelation therapy and regular phlebotomies were initiated. DISCUSSION: Cardiac hemochromatosis should be considered in any patient with new onset heart failure and treatment should be started in a timelymanner as if left untreated the average survival is less than a year in thosewith severe cardiac impairment. However, if diagnosed and treated early, the survival rate can approach that of the regular heart failure population.
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RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB V Bolgiano, DO, D Cohen MD, S Walker MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) which may have distinctive mucocutaneous manifestations. Up to 33% of IBD patients have at least one extraintestinal disease manifestation. To our knowledge, this is the first case to describe success in treating MCD with certolizumab alone. CASE: A 63-year-old woman with a previous history of Crohn’s disease presented to the dermatology clinic for evaluation of a rash located on her right upper lip. She reported that the rash appeared two years prior. It was associated with pruritus and moderate swelling. Histopathological findings from a 4.0 mm punch biopsy revealed multiple nodular granulomatous infiltrates extending from the superficial reticular to deep reticular dermis. The granulomas were composed of numerous histiocytes as well as a moderately dense inflammatory infiltrate made up predominantly of lymphocytes with scattered plasma cells and eosinophils. S-100 staining was negative. PAS and Fite stains were negative for infectious organisms. The patient had tried Humira, Imuran, Remicade, Plaquenil, Minocycline, and intralesional Kenalogwithminimal improvements. This patient ultimately responded to the induction dose of 400mg certolizumab (2 injections of 200mg) andwas prescribed a maintenance dose of 400 mg every other week that will require long-term follow up. DISCUSSION: Metastatic Crohn’s disease is a rare, non-contiguous cutaneous manifestation of primary CD, being the least common presentation of extra-intestinal CD. Most cases of MCD occur on the lower extremities, intertriginous areas, face, and genital area. No clear correlation between the development of MCD and luminal disease activity has been established. Adalimumab, infliximab, antibiotics, systemic & topical corticosteroids, methotrexate, and azathioprine have demonstrated benefit in MCD. Certolizumab (certolizumab pegol) is a PEGylated anti-tumor necrosis factor biologic therapy approved for use in Crohn’s disease among other diseases.
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CNS MIXED FUNGAL BALL IN AN IMMUNOCOMPETENT PATIENT - A RARE ENTITY!
S Chennapragad MD, A Netzel MD, C Graham MD, R Mansour MD. Department of Medicine, Louisiana State University, Shreveport, LA
INTRODUCTION Aspergillus species are ubiquitous fungi in the environment and readily acquired through inhalation. Immunocompromised individuals are at particularly high risk of progressing to invasive fungal infections following inhalation. It can present with deep-seated invasive infections in immunocompromised hosts such as HIV/AIDS and acute leukemias.
CASE: A 64-year-oldmanwith acutemyeloid leukemia (AML), currently in remissionwho presented fromhis ophthalmologist with left sided visual disturbances and facial numbness. He was found to have retinal hemorrhages and left sided hemianopia. A magnetic resonance imaging (MRI) of the brain showed an enhancing right occipital mass measuring 2.5x2.1x1.8cm with surrounding vasogenic edema. The initial differential diagnosis was broad, ranging from infectious, benign to malignant causes. Of note, he had a history of invasive pulmonary aspergillosis during his induction phase of chemotherapy for AML which was promptly treated. This time, he was empirically started on liposomal amphotericin B while awaiting results of the biopsy, but steroids were held. The biopsy showed extensive angio-invasive fungal organisms. Some appeared as septate hyphae with 45 angle branching, with features of aspergillosis, while other hyphae were non-septate with 90 angle branching, demonstrating features of phycomycosis such as Mucorales. The mass was completely removed during surgery and the patient was continued on Amphotericin B which was later shifted to Isavuconazole due to renal failure. Post treatment MRI of the brain and aspergillus antigen were negative for residual disease. DISCUSSION: Central nervous system (CNS) aspergilloma is a rare form of invasive aspergillosis associated with high morbidity that can be difficult to diagnose and treat. The gold standard for diagnosis remains direct histopathology as most forms of imaging poorly differentiate between CNS aspergilloma and alternative infections or neoplasms. The combination of aspergillosis and mucormycosis in the same fungal element is exceedingly rare with only one other case published. This case shows that both diseases can be treated with surgical excision with Isavuconazole treatment.
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ABNORMAL PRESENTATION OF ADVANCED GESTATIONAL TROPHOBLASTIC NEOPLASM (GTN) WITH PULMONARY ARTERY OBSTRUCTIVE SYMPTOMS AND PROFOUND ANEMIA P Lowery MD, C Gregg, MD, M Modica MD, Department of Internal Medicine, LSU Health Sciences Center; New Orleans, LA CASE: A 42-year-old woman with a history of untreated Hepatitis C, Pre-diabetes, anxiety, and polysubstance abuse presented withbilateral lower extremity swelling andworseningdyspnea on exertion for 6 days. Initial chest radiographwas consistent with a large right sided pleural effusion. Her hemoglobin was 5.4, RDW was 24.8, and she had 11% nucleated RBCs on the differential. Other labs included LDH 946 and haptoglobin <1, however her direct antiglobulin test was negative. Her HbA1c was <2.9 which was thought to be due to an abnormally high RBC turnover. Her serum BhCG of 180,000 was at the upper limit of normal for a 6-8 week intrauterine pregnancy. Pelvic ultrasound did not reveal intra-uterine gestation. Computed tomographic scan of her chest revealed that the right sided pleural effusion as in fact a large mass incasing the R lung and invading into the mediastinum and abdomen. She also had multiple metastasis in both lungs and diffuse lymphadenopathy. Imaging findings along with such elevated BhCG was consistent with a GTN. DISCUSSION: Gestational Trophoblastic Neoplasm refers to a group of malignant neoplasms that consist of abnormal proliferation of trophoblastic tissue, and may follow a hydatidiform mole or a nonmolar pregnancy. Four histologic subtypes include invasive mole, choriocarcinoma (more aggressive, metastasize early, and secret high levels of BhCG), placental site trophoblastic tumor, and epithelioid trophoblastic tumor (less aggressive, generally remain localized, and do not secrete high levels of BhCG). Approximately 50 percent of cases of GTN arise from molar pregnancy, 25 percent from miscarriages or tubal pregnancy, and 25 percent from term or preterm pregnancy. Estimated incidence of GTN after a term pregnancy is 1 per 150,000 and after a spontaneous miscarriage is 1 in 15,000. Tissue diagnosis is not necessary and often avoided due to high risk of hemorrhage. Highly responsive to chemotherapy agents due to aggressive growth but also likely to develop resistance.
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CENTRAL RETINAL ARTERY OCCLUSION AND NEW ONSET ATRIAL FIBRILLATION H Baldawi MD, K Obi MD. Department of Medicine, Ochsner Medical Center, New Orleans, LA INTRODUCTION Central Retinal Artery Occlusion (CRAO) is an ocular emergency, in which patients usually present with painless acute monocular blindness. Most cases are associated with an embolic ipsilateral carotid artery atherosclerosis. Other etiologies have also been identified such as valvular disease and giant cell arteritis. Atrial fibrillation (AF) is not well associated with CRAO. CASE: A 65-year-old man with coronary artery disease, hyperlipidemia, diabetes mellitus, hypertension presents with a 1-day historyof painless acute left eye vision loss. Thepatient deniedany recent heador eye trauma. In theemergencydepartment, the patient had pressure of 15 mmHg on tonometry and was noted to have hyperechoic strip concerning for possible retinal detachment. He had a cherry red spot and retina whitening on exam pointing to the diagnosis of central retinal artery occlusion (CRAO). The patient was noted to be in atrial fibrillation (AF) with rapid ventricular rate. He denied previous history of arrhythmias or AF. The patient was managed with Apixaban and Metoprolol and remained in sinus rhythm. Complete metabolic panel and complete blood count were unremarkable. Hemoglobin A1c was 6.1 and lipid panel were unremarkable. Transthoracic echocardiogram revealed a preserved ejection fraction (55 %), mild ventricular and bi-atrial enlargement, mitral valve with normal leaflets, and aortic valve with mild sclerosis. Carotid ultrasound revealed sluggish flow within right carotid artery only. Magnetic resonance imaging of the brain and neck were without hemodynamically significant stenosis of the neck vessel. AF was recognized as the possible culprit for CRAO in this case after ruling out common etiologies. DISCUSSION: This review emphasizes the importance of a thorough workup required in patients with retinal artery occlusions. The increase risk of incidental AF in patients with CRAO has been documented in different case reports and some cohort studies. Further investigation is needed to establish AF as one underlying cause of CRAO. Also, given that retinal vascular disease increases the risk for embolic disease in AF, incidental AF should be considered in some CRAO cases.
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TREATMENT RESISTANT PROLACTINOMA: REASONS BEYOND NON-COMPLIANCE G Farrish MD, J Hinkle MD Department of Medicine, LSU Health Sciences Center, Baton Rouge, LA INTRODUCTION Prolactinomas are the most frequently occurring pituitary tumor. Hypersecretion of prolactin from these adenomas suppresses gonadotropin function leading to deficiencies in sex hormones. Larger tumors can also suppress TSH and ACTH by mass effect. In most cases, Cabergoline therapy leads to normoprolactinemia and significant tumor shrinkage. Treatment-resistant prolactinomas require more invasive approaches like surgery and radiation which greatly increase morbidity and mortality. The Ki-67 index is a burgeoning metric that could be used to identify prolactinomas which are more likely to resist treatment and recur. CASE: A 21-year-old man with a one-year history of seizure and prolactinoma presented with a new seizure. His first and only seizure was one year prior, and brain magnetic resonance (MRI) imaging discovered a large 6 cm macroadenoma filling his pituitary fossa. Prolactin at that time was >2,000 ng/mL. He was diagnosed with prolactinoma and discharged on Cabergline, Keppra and Synthroid with regular follow-up scheduled with Endocrinology. At this present hospitalization, repeat MRI showed increased growth of the prolactinoma that was now invading the clivus, cavernous sinus and orbital apex. His prolactin level remained >2,000 ng/mL. The patient affirmed compliance with Cabergoline therapy, and past Endocrinology clinic notes corroborated his year-long usage. Because the patient failed maximum dose Cabergoline therapy, he was scheduled for endoscopic transsphenoidal resection followed by craniotomy if necessary. A tissue biopsy obtained perioperatively was sent to pathology lab and revealed a Ki-67 proliferation index of 15%. DISCUSSION: The Ki-67 index could be a useful tool to explain prolactinomas which do not respond to traditional pharmacologic or surgical treatments. Cabergoline therapy has demonstrated success in achieving normal prolactin levels and decreased tumor burden in the vast majority of patients. However, the average Ki-67 index for prolactin-secreting adenomas was measured to be 3.37 +/- 1.8%. This patient’s Ki-67 index of 15% might explain why his adenoma resisted maximum dose Cabergoline therapy, and the need for close monitoring for recurrence even after surgical resection.
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A CASE OF STRONGYLOIDES IN AN IMMUNOCOMPROMISED PATIENT P Soto Justiniano MD, C Michael MD, M Eschete MD Department of Internal Medicine, Leonard J Chabert Medical Center, Houma, LA
INTRODUCTION Infections due to Strongyloides stercoralis are prevalent in rural areas of tropical and subtropical regions, and cases in the United States are more common in the Southeast. Immunocompromised hosts with HTLV-1, HIV/AIDS, malignancy, congenital immunodeficiency, or alcoholism are at an increased risk of developing disseminated disease, and are more prone to atypical presentations. CASE: A 44-year-old man with HIV presented with arthralgias, myalgias, and fevers. He reported pain in his knuckles and toes that started one day after re-initiating antiretroviral therapy (ART) (Dolutegravir/Lamivudine), and concomitantly noted a cough and sore throat. Computed Tomography (CT) chest showed focal consolidations in bilateral lobes, mediastinal lymphadenopathy, and splenomegaly. Studies were negative for Legionella and Streptococcal antigens and Mycoplasma antibodies. The patient was treated for community acquired pneumonia, and his antiretroviral medication was held. As he continued to have polyarthralgia despite holding ART, the medication was then resumed. Two weeks post discharge, and four days after resuming ART, the patient developed fever, chills, fatigue, and a productive cough with brown-grey sputum. Labs were significant for: ESR 42, CRP 86.1, and a positive ANA screen; however the ANA profile/pattern/titers, Rheumatoid factor, Fungal immunodiffusion test, Quantiferon Gold, and AFB sputum cultures were negative. The patient was transitioned from his ART to Biktarvy, and was referred to Pulmonology. The patient was noted to have a peripheral eosinophilia. Workup included: CCP, ANCA, Aspergillus IgE, and stool O&P, which were negative. Bronchoscopy showed a Staphlococcus aureus infection, but despite appropriate treatment, his cough and debilitating arthralgias persisted. The last study was Strongyloides IgG antibody which was positive. Treatment was initiated with Ivermectin for disseminated strongyloidiasis. Within four weeks, the patient’s symptoms resolved, eosinophilia trended down, and Chest CT improved. DISCUSSION: With a mortality rate of 70-100%, higher rates being in disseminated disease, Strongyloidiasis is not to be overlooked. While eosinophilia can be observed, it is often absent in disseminated disease. Patients often present with gastrointestinal, pulmonary, and cutaneous manifestations. Less commonly, nephrotic syndrome, GI bleeding, ascites, hepatic lesions, and arthritis can be seen. Early treatment ensures the highest chances for survival.
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