Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.
ABSTRACTS FROM THE 2017 LOUISIANA ANNUAL ACP MEETING
CONTENTS
JOURNAL EDITORIAL STAFF
EDITOR D. Luke Glancy, MD
ASSOCIATE EDITOR L.W. Johnson, MD
3 DELAYED PRESENTATION OF TUBEROUS SCLEROSIS COMPLEX IN AN ADULT WOMAN
CHIEF EXECUTIVE OFFICER JeffWilliams
3
WEIL’S DISEASE FROM A LOCAL NEW ORLEANS BAR
4
NOT ANOTHER ACS RULE OUT
JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD
4 GONOCOCCAL ENDOCARDITIS: THE GIFT THAT STOPS GIVING! AN UNCOMMON PRESENTATION OF A COMMON DISEASE.
Anthony Blalock, MD D. Luke Glancy, MD L.W. Johnson, MD Fred A. Lopez, MD
4
A CASE OF EARLY NEUROSYPHILIS
5
JUST A “PUFF OF SMOKE”
5
THE MYSTERIOUS CASE OF DYSPNEA
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
6 AUTOIMMUNE DIABETES PRESENTED WITH DIABETIC KETOACIDOSIS INDUCED BY IMMUNOTHERAPY IN AN ADULT WITH MELANOMA
6 SECOND REPORTED CASE OF CANDIDA CATENULATA FUNGEMIA
7 A CASE OF HEPATOSPLENIC T CELL LYMPHOMA-A RARE, AGGRESSIVE TUMOR OF THE YOUNG
7 DIULAFOY’S LESION – AN UNCANNY ETIOLOGY OF GASTROINTESTINAL BLEED
7 THREE’S A CROWD – AN EXTREMELY RARE CASE OF COR TRIATRIATUM DEXTER
8
A STRONG AND FORTUITOUS CASE OF DYSPNEA
8 PURULENT PERICARDITIS DUE TO AN INFECTED PACEMAKER LEAD
COUNCILORS District 1 Member, Vacant
9 A CLOT (POSSIBLY) DUE TO LOSS OF TNF-Α SUPPRESSION
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
9 CASE REPORT OF SARCOIDOSIS AS A GREAT MIMICKER IN VARIOUS POPULATIONSON
10 PHEOCHROMOCYTOMA OF THE ORGAN OF ZUCKERKANDL: A CASE REPORT
10 A RARE CASE OF TROPICAL PYOMYOSITIS ACQUIRED ON VACATION IN A HEALTHY MALE
10
WHAT THE EYES DON’T SEE, THE HEART DOES GRIEVE OVER
11
MISSED OPPORTUNITY: TOF DIAGNOSED IN 4TH DECADE OF LIFE
11
A RARE CAUSE OF ABDOMINAL PAIN
12
WHAT CAN ERODE THROUGH LUNGS, BONE AND SKIN?
12 LEFT MAIN CORONARY ARTERY THROMBUS PRESENTING AS A NON ST ELEVATION MI
12
RECURRENT HYPERTRIGLYCERIDEMIC PANCREATITIS (HTGP) AND THE USE OF INSULIN DRIP AS TREATMENT
13 WHO SHOT THE CANNONBALLS? EXTENSIVE LUNG METASTASES IN A 39 YEAR OLD MAN
13 ASSOCIATION OF STATE-MANDATED ABSTINENCEONLY SEXUALITY EDUCATION WITH RATES OF ADOLESCENT HIV INFECTION AND TEENAGE PREGNANCY
14
SEVERE SEPSIS AND SEPTIC SHOCK CASES MEETING GUIDELINES AMONG PATIENTS IN A UNIVERSITY HOSPITAL SETTING DISSEMINATED CRYPTOCOCCAL DISEASE WITH DIFFUSE PULMONARY INFILTRATES IN A NON-HIV HOST
14
2
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Abstracts from the 2017 Annual Louisiana American College of Physicians (ACP) Associates Meeting
Each yearmedical students in Louisiana and residents fromthe eight Internal Medicine trainingprograms in Louisiana are invited to submit abstracts for theAnnual LouisianaAmericanCollege of Physicians (ACP) AssociatesMeeting. 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 tophysician judges. Each judge scores eachabstract independently and then the scores fromall judges are averagedand ranked. This year we are excited to be able to publish the 28 most highly ranked abstracts presented at this year’s competition. These abstracts (15 oral; 13 poster) were presented at the Associates Meeting held at Ochsner Medical Center in New Orleans on January 24, 2017. We would like to thank the Journal of the Louisiana StateMedical Society and appreciate its efforts to publish the hardwork of these trainees.
Shane Sanne, DO Chair, Louisiana Associates Liaison Committee
Lee S. Engel, MD, PhD, FACP Governor, Louisiana Chapter ACP
DELAYED PRESENTATION OF TUBEROUS SCLEROSIS COMPLEX IN AN ADULT WOMAN J. Manalac, MD; S. Saad, MD; G. Akoghlanian, MD; T. Benoit-Clark, MD. Department of Internal Medicine, University Hospital and Clinics, LSU Health, Lafayette Introduction: Tuberous sclerosis complex (TSC) is an autosomal dominant disorder character ized by the format ion of hamartomatous lesions inmultiple organs, with a birth incidence of around one in 10,000. Although it usually manifests itself in early life, we present a case of an adult womanwhowe diagnosed with TSC. Case: A 27 year oldwoman presented to Emergency Department with worsening right flank pain and progressive dyspnea. Physical examination findings revealed Shagreen patches and multiple angiomyolipomas of the skin. Computed tomography scan of the chest and abdomen was remarkable for pulmonary lymphangioleiomyomatosis and renal angiomyolipomas. Brain imaging revealed multiple subependymal nodules and cortical dysplasias. Subsequent genetic testing later confirmed pathogenic mutation in the TSC2 gene and patient was referred for Genetic counseling and further management. Discussion: Clinical features of TSC continue to be the principal means of diagnosis, with the inclusion of identification of a pathogenic mutation in TSC1 and TSC2 as an independent diagnostic criterion. Affected patients may present early in life with the classic triad of seizures, intellectual disability, and cutaneous angiofibromas, but some findings, notably renal angiomyolipomas and pulmonary lymphangioleiomyomatosis (LAM), emerge later, placing adults with undiagnosed TSC at increased risk for morbidity and mortality. Recent advances in the treatment of TSC highlight the need to identify and follow affected patients.
WEIL’S DISEASE FROM A LOCAL NEW ORLEANS BAR
H.P. Kahn, MD; L. Bateman, MD Department of Medicine, Ochsner Clinic Foundation, New Orleans, LA
Introduction: Leptospirosis is a zoonotic infection that typically presents with fever, myalgias, nausea, and vomiting after contact with contaminated waters or infected animals (typically rodents) and their excrements. Conditions favorable to the transmission of leptospirosis are common in LA and, without treatment, leptospirosis can lead to both liver and renal failure, meningitis, pulmonary hemorrhage and ultimately death. Case: A 56 year oldwomanwith no pastmedical history presented to the Emergency Department withweakness, myalgias, jaundice anddecreasedurine output for oneweek. On arrival, she appeared septic with a heart rate of 130 and fever. Her examwas significant for significant jaundice and diffuse abdominal pain. Laboratory studies were notable for WBC 14, hemoglobin of 12 and platelet count of 63. Creatinine was 8.5mg/dL with a blood-urea nitrogen of 96mg/dl. Total bilirubinwas 19.4mg/dL and direct bilirubinwas 13.7mg/dL. AST/ALTwere 69/38 U/L, respectively and the alkaline phosphate was 160U/L. The patient was admitted to the hospital medicine wards for sepsis and multi-organ failure. She was started on broad spectrum antibiotics but her clinical condition continued toworsenwith progressive decline in her hemoglobin and thrombocytopenia and worsening liver failure. She quickly became anuric necessitating dialysis and developed respiratory distress with bilateral pulmonary infiltrates and hemoptysis. Additional historywas obtained fromher employer that sheworks at a local New Orleans bar and had been cleaning out rats from the kitchen. Leptospirosis antibody was sent, which returned as positive. Her antibiotics were de-escalated to IV Ceftriaxone. She made a slow recovery over the next two-week period.
Discussion: Since 1987, there has been an average of 3 cases of
46 J La State Med Soc VOL 169 MARCH/APRIL 2017
3
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
GONOCOCCAL ENDOCARDITIS: THE GIFT THAT STOPS GIVING! AN UNCOMMON PRESENTATION OF A COMMON DISEASE. G. Olayemi, MD; M. Oferczak, MD; A. Elagizi, MD; I. EL-Abbassi, MD; M. Eschete, MD; J. Crowe, MD Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA. Introduction: Gonorrhea is the 2nd most common sexually transmitted disease in the US with 800,000 cases of gonorrhea each year. Disseminated gonorrhea infection occurs in 0.5%- 3% of these patients and is more frequent in woman younger than 40 years of age. Case: A 36 year old woman with a history of polysubstance abuse presented with 10 day history of feeling generally unwell. At presentation, vitals were remarkable for tachycardia and hypotension. Physical exam was remarkable for conjunctival pallor, bibasilar crackles, and tachycardia with grade III/VI systolic murmur loudest over the 2nd inter-costal space and loudest with expiration. No skin lesions were noted. Labs demonstrated leukocytosis (WBC 20,200 with 84% neutrophils), anemia (Hb 6.7), thrombocytosis (platelets 423 k/uL), abnormal liver function tests (alkaline phosphatase 239 IU, AST 151 IU ALT 71 IU, albumin 2.5g/dL), PT/INR 17.1/1.5. Troponin 0.42, BNP 823, D-dimer 619, and a urine drug screen that was positive for benzodiazepines, opiates, barbiturates, amphetamine, and THC. Hep panel and HIV were negative. Chest radiograph showed mild cardiomegaly and early interstitial edema. The patient was placed on broad spectrum antibiotics and given adequate fluid resuscitation and blood products. Blood cultures grew Neisseria gonorrhoeae. 2D ECHO showed a large pedunculated/mobile echo density adherent to the non-coronary and lefts cusps of the aortic valve. Proximal aortic root and aorto-mitral continuity were thickened, consistent with aortitis and/or abscess formation. Initial EKG on arrival showed junctional tachycardia which progressed into complete heart block. Cardiologywas consulted and a pacemaker was placed emergently. However despite all aggressivemeasures the patient died of cardiac complications. Discussion: Endocarditis is a rare complication of disseminated gonorrhea, occurring in only 1-2%of patientswithgonoccocemia. The aortic valve is most commonly affected. Valve replacement is warranted in cases with severe dysfunction. Mortality remains around 19-20. Neisseria gonorrhoeae endocarditis should be included in the differential diagnosis in sexually active patients with endocarditis.
Leptospirosis diagnosed per year, most of which have been from southeast LA. This case illustrates the importance of considering the diagnosis of Leptospirosis and Weil’s Disease in patients in the southeast region of LA who present with multi-organ failure. In addition, our patient’s occupational exposure was key to her diagnosis which emphasizes the importance of a detailed history in clinical decision making and patient outcomes.
NOT ANOTHER ACS RULE OUT
S. Preston, BE 1 ; R. Nelson, MD 1 ; M. Watts, MD¹; D. Smith, MD²; T. Dewenter, MD³; D. Spruill, MD¹
1. Tulane University School of Medicine, Department of Internal Medicine; 2. LSU Health Sciences Center, Department of Radiology; 3. LSU Health Sciences Center, Department of Pathology, New Orleans, LA Case: A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell’s Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45% with antero- lateral hypokinesis. Shewas treated for NSTEMI, and an angiogram showed 95% stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. AnMRI Braindemonstrated scatteredT2/ FLAIR hyper-intense foci in the subcortical whitematter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. CardiacMRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogramdemonstrated recoveredejection fractionof 55% with improvedwall motion in the septumand apex. Additionally, her left-sided Bell’s Palsy and dysarthria improved after several days of therapy. Discussion: To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.
A CASE OF EARLY NEUROSYPHILIS
M. Walker, MD¹; R. Wisler, MD¹; J. Simmons, MD, MBA²; A. Johnson, MD¹
1. Department of Internal Medicine, LSU Health, Baton Rouge LA; 2. Dermatopathologist, Pathology Group of LA Baton Rouge
J La State Med Soc VOL 169 MARCH/APRIL 2017 47
4
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Introduction: Neurosyphilis is an infection of the central nervous system by Treponema pallidum, which can occur after the initial syphilis infection. Although commonly associatedwith late stage disease, patients with early neurosyphilis may present with acute syphilitic meningitis, meningovascular syphilis, or uveitis. Case: A 28 year old man with a past medical history of HIV (CD4 364), and recent diagnosis of uveitis presented to the Emergency Department with a positive RPR result. His visual acuity had been gradually declining over the past few months. He denied painless or painful ulcerating lesions on his penis, or scrotum, difficulty concentrating, dermatitis on the soles/palms, or difficulty with proprioception. Physical exam was notable for atrophic hyperpigmented polycyclic, annular plaques and patches along the hairline as well as several areas of confluent hyperpigmented polycyclic plaques and nodules on the patient’s face, back, left arm, and right posterior leg. Fundoscopic exam revealed bilateral posterior uveitis and chorioretinitis. Evaluation of cerebrospinal fluid revealed a lymphocytic pleocytosis with a positive VDRL and FTA-ABS. Aqueous crystalline penicillin G was initiated for treatment of early neurosyphilis. Within six hours of beginning the infusion, the patient had a documented temperature of 101.8°F, heart rate of 128 beats perminute, bloodpressure 142/84, with generalized malaise and headache. Fever and tachycardia resolved over the next 12 hours, with weakness and headache resolving within 1-2 days. His symptom complex was consistent with the Jarisch-Herxheimer reaction. Histopathology of skin biopsy of the back showed perivascular inflammation and rare spirochetes, consistent with secondary syphilis. The patient completed 14 days of aqueous crystalline penicillin G and was discharged after receiving the first of three benzathine penicillin injections. Discussion: The initial manifestations of syphilis in this patient were posterior uveitis and pruritic skin plaques. His diagnosis should be appropriately classified as secondary syphilis with concomitant symptomatic early neurosyphilis, requiring 14 days of aqueous crystalline penicillin G. This type of presentation is not specific to immunocompromised populations and must be considered even in the general population. Making the diagnosis of early neurosyphilis, regardless of stage, is critical, as it necessitates a longer duration of treatment. Furthermore, clinicians should be reminded of the profound immunologic reaction, Jarisch-Herxheimer, which may occur when treating any treponemal disease.
Her mother died of a stroke. On exam the patient was afebrile, normotensivewithmild tachycardia to 110. The patient moved all her extremities but was lethargic, agitated, responded to pain but would not follow commands and moaned nonsensical speech. Labs were unrevealingwithmild leukocytosis (WBC: 11.7 × 109/L), normal metabolic panel, ammonia, glucose, and a negative urine toxicology. Initial computed tomography (CT) of her head demonstrated atrophywith large area of encephalomalacia in Left middle cerebral artery (MCA) area. Repeat CT, 1 day later showed edema and sulcal effacement in the right occipital, posterior, temporal, and posterior parietal lobes with evolving infarct in right posterior cerebral artery (PCA) and right MCA territories. CT angiogram showed occlusion of the clinoid segments of both internal carotid arteries, consistent with Moyamoya pattern of collateral flow. Neurosurgery was consulted and recommended cerebral bypass. The patient was unable to consent for surgery and her closest relative refused surgery. The patient received supportive therapywithminimal improvements inword findings/ communication and no improvement in inability to perform daily activities. She was accepted to inpatient stroke rehab upon discharge. Discussion: Moyamoya disease is a rare vascular condition which leads to progressive stenosis of the internal carotid arteries through wall thickening of the associated arteries which leads to progressive strokes and the development of collateral vessels. Moyamoya is a Japanese term for a “puff of smoke” which describes the appearance on imaging of the small collateral vessels that develop around the progressively blocked arteries. There is a hereditary association and our patient’s mother likely had the disease as well. The prognosis is poor and the disease will lead to a cognitive decline with associated CVAs. Treatment includes cerebral revascularization or bypass. The case highlights the need for early diagnosis, as our patient was too debilitated to makemedical decisions for treatment at the time of her diagnosis.
THE MYSTERIOUS CASE OF DYSPNEA
S. Saad, MD¹; N. Turaga, MD¹; J. Grant, DO²; N. Jain MD²
1. Department of Internal Medicine, LSU Health - Lafayette; 2. Section of Cardiology, LSUHealth Sciences Center NewOrleans.
Introduction: Dehiscence of a mitral valve annuloplasty ring is a rare occurrence that often manifests as mitral regurgitation and heart failure. We present a case of mitral ring dehiscence which was initially unrecognized by standard 2-dimensional transthoracic echocardiography (2D TTE) and 2-dimensional transesophageal echocardiography (2D TEE). Case: A 65-year-old woman was referred to Cardiology clinic for evaluation of dyspnea. Her history included tobacco abuse, atrial fibrillation status post pulmonary vein isolation, nonischemic cardiomyopathy, and prior mitral valve repair with annuloplasty ring for rheumatic valvular disease. She had been asymptomatic post-surgery. Physical examination, cardiac rhythm and initial ischemic workup were unremarkable. Pulmonary function tests revealed moderate emphysematous type obstructive lung
JUST A“PUFF OF SMOKE”
A. Leonard, MD Department of Internal Medicine, LSU Health Sciences Center, New Orleans, LA Case: A 44 year old woman with a history of stroke s/p aneurysm clipping, seizure, and substance abusewas brought to the hospital after a family member received a call from her friend saying she was acting unusual and may have had a seizure while hanging out on the street. At her baseline, she needed modest assistance in daily activities after her CVA and conversed without issue.
48 J La State Med Soc VOL 169 MARCH/APRIL 2017
J La State Med Soc VOL 168 JULY/AUGUST 2016 48
5
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
disease. A 2D TTE demonstrated moderate mitral regurgitation withnormal left ventricular function. In right heart catheterization, large v waves were noted and 2D TEE also revealed severe mitral regurgitation. On 2D TEE, the mitral valve annuloplasty ring was visible above the native anterior mitral valve leaflet. Color Doppler flow estimated the effective regurgitation orifice area of 0.4cm2 using the proximal isovelocity surface area method and regurgitant volume of 58 cc, consistent with severe mitral regurgitation. A “floating mitral ring” and dehiscence measuring 1 cm in diameter were seen on high resolution three-dimensional reconstruction resulting fromthe detachment of the ring fromthe weakened posterior annulus. Based on these findings patient was referred to cardiothoracic surgeon for re-do mitral valve surgery. Discussion: This was a perplexing case as the patient’s dyspnea could be explained by many disease processes including atrial fibrillation, mitral regurgitation and chronic obstructive lung disease. The standard imaging modalities did not help us to formulate a diagnosis. 3D TEE provided invaluable and unparalleled information of mitral valve pathology. Annuloplasty ring dehiscence is a well described complication of mitral valve repair and should always be considered in symptomatic patients. AUTOIMMUNE DIABETES PRESENTEDWITH DIABETIC KETOACIDOSIS INDUCED BY IMMUNOTHERAPY IN AN ADULT WITH MELANOMA A.A. Alzenaidi, MD; J. Dendy, MD; L. Rejjal, MD Department of Internal Medicine, Ochsner Medical Center, New Orleans, LA Introduction: Immunotherapy has been approved for treatment of melanoma. Autoimmune endocrinopathies have been reported in trials involving immunotherapy but autoimmune diabetes has not been definitively linked to them. Here we describe a case of autoimmune diabetes presenting with DKA after receiving combined immunotherapy with anti-CTLA4 and anti-PD1 monoclonal antibodies. Case: A 47year old gentleman with metastatic melanoma presented to our institution with confusion, abdominal pain and decreased oral intake. The patient had a history of diabetes on metforminwhichwas discontinued two years prior. Hewas started on Novilumab/Iplimumab for metastatic melanoma. He had received two cycles of immunotherapy and treatment was initially well tolerated. However, eight days after the second cycle the patient developed lethargy, confusion, vomiting and abdominal pain. CT of the head was negative for intracranial abnormalities and without evidence of brain metastasis. His laboratory results included: serum sodium 126 mmol/L, potassium 6.7 mmol/L, BUN 55 mg/dL, creatinine 3.5, bicarbonate 5 mmol/L, chloride 94 mmol/L, albumin 3.2 g/dL. Serum beta-hydroxybuterate was elevated (4.7 mmol/L, N: 0.0-0.5 mmol/L) and the calculated anion gap was 43 mmol/L. Serum lipase elevated (535 u/L, N: 4-60 u/L). The diagnosis of diabetic ketoacidosis was made and he was started on intravenous fluids and insulin therapy. Given his history of metastaticmelanoma, his DKAwas initially thought to be secondary to pancreatic metastasis especially considering
the elevated lipase level. A non-contrast CT of the abdomen showed no evidence of pancreatic metastasis. Interestingly, further investigation identified high serum titers of anti-glutamic acid decarboxylase (anti-GAD) antibodies (0.43 nmol/L, N: <0.02 nmol/L), a low C-peptide level (0.2 ng/ml, N: 0.9-5.5 ng/ml), supporting an autoimmune etiology of the diabetes. Other islet autoantibodies were not elevated and his Hemoglobin A1C was 8.0%. Discussion: There are few case reports about diabetes and immunotherapy. Autoimmunemechanismwas suggested as the culprit, although not all cases reported with positive antibodies. Moreover, it is unlikely that patient developed latent autoimmune diabetes (LADA) and not related to immunotherapy due to the course of LADA is quite more gradual and our patient presented with acute DKA few days post the second cycle. Physicians and patients should be aware that autoimmune disorder such as DKA may be a rare but important immunotherapy related adverse events. SECOND REPORTED CASE OF CANDIDA CATENULATA FUNGEMIA
G. Garmon, MD¹; M. Hughes, MD¹; R. Arora, MD¹; V. Mekala, MD²; R. Washburn, MD²
1. LSUHSC Shreveport Department of Internal Medicine; 2. Overton Brooks VA Section of Infectious Disease
J La State Med Soc VOL 169 MARCH/APRIL 2017 49 Case: A 57 year-oldwhitemanwith a history of alcoholic cirrhosis, recurrent pancreatitis and pseudocysts, intra-abdominal abscess and prior partial small bowel obstruction, and prior extended courses of IV antibiotic therapy presented to the emergency department with fevers, malaise, and abdominal pain. The patient was initially admitted to the intensive care unit because of sepsis, placedonbroad spectrumantibiotics, and received image-guided drainage of the largest abscesses. His course was complicated by recurrent small bowel obstruction attributed to one abscess that was not amenable to drainage. The patient had poor oral intake, only liquids includingmilk. He eventually requiredPICCplacement for TPN. He subsequently experienced fever and altered mental status. Preliminary blood cultures from the PICC and periphery indicated“budding yeast species”. Micafunginwas added and the catheterwas removed. Blood cultures fromthe PICCandperiphery grew C. catenulata, while vancomycin-resistant Enterococcus grew only from the PICC line cultures. The patient improved, and follow-up cultures remained negative. The patient completed a two week course of micafungin and was eventually discharged to a long-term acute care facility for completion of antimicrobial therapy. 6 Introduction: There are over 20 species of Candida yeasts that can cause infection in humans, themost common of which is Candida albicans. This is the second reported case of Candida catenulata fungemia. Candida catenulata is not usually associated with invasive infection in humans. The previously reported case was in a patient with gastric cancer. Candida catenulata is a natural contaminant of dairy products. Cases of candidaemia with this species are uncommon.
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Discussion: This case highlights C. catenulate, a rare cause of fungemia. The previously reported case involved a gastric cancer patient and a presumed GI portal of entry. In our case although the organism may have entered through the GI tract the PICC line and TPN represented additional risk factors. Thus, this case underscores the importance of maintaining a high index of suspicion for fungal pathogens when risk factors are present as well as the need to promptly initiate antifungal therapy when fungemia is confirmed.
novel approach reportedby Hoss et.al with a non-CHOP induction therapy with or without splenectomy followed by autologous SCT may have better outcomes as demonstrated with our case.
DIULAFOY’S LESION – AN UNCANNY ETIOLOGY OF GASTROINTESTINAL BLEED
V. Gasia, MD; O. Lamendola, MD. Department of Medicine, Baton Rouge General Medical Center, Baton Rouge, LA Introduction: Dieulafoy’s lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1–2% of acute gastrointestinal (GI) bleeding. Case: A 99-year-old woman was initially admitted due to left lower extremity cellulitis related to chronic venous stasis ulcer andwas receiving broad-spectrum IV antibiotics. Upon admission to the medical floor, she had an episode of hematemesis and multiple bowel movements with black-tarry stools. The patient denied chronic non-steroidal anti-inflammatory drug use. Her past medical history was significant for dyslipidemia and remote history of colon cancer status post colon resection. Home medications included atorvastatin 20 mg and aspirin 81 mg. Digital rectal examdemonstratedmelenic stool in the rectal vault. Hemoglobin and hematocrit on admissionwere noted to be 12.1 g/dl and 40.7 % respectively which dropped to 8.1 g/dl and 28.3 % following her GI bleed. A rise on BUN was also noted from 14 mg/dl to 34 mg/dl. Platelets and INR were normal. She received fluid resuscitation with 2 liters of crystalloid and a total of 2 units of pack red blood cells. Emergent EGD revealed a protruding and oozing vessel surrounded by normal gastric mucosa located at the greater curvature of the stomach body. The lesion was covered by a prominent fresh clot, whichwas cleared. Endoscopic hemostasis was achieved with a combination of epinephrine injection followed by BI-CAP electrocautery. The patient had an uncomplicated post-operative course and hemoglobin remained stable. Discussion: Given this patient’s clinical presentation, an upper GI bleed was suspected. Based on the patient’s advanced age and history of previous history of colon cancer, the initial differential diagnosis included peptic ulcer disease versus a GI malignancy. However, her EGD findings were consistent with a Dieulafoy’s lesion. Dieulafoy’s lesions are twice as common in men as compared towomen. These lesions can occur in any age group are diagnosedmore frequently in the elderly population. Dieulafoy’s lesions should be included in the differential diagnosis of obscure GI bleeding in all age groups.
A CASE OF HEPATOSPLENIC T CELL LYMPHOMA-A RARE, AGGRESSIVE TUMOR OF THE YOUNG
S. Cingam, MD; S. Patel, MD; N. Koshy, MD Department of Medicine, LSU Health Sciences Center, Shreveport, LA Introduction: Hepatosplenic T-cell lymphoma (HSTCL) is an unusual entity first described in 1990 that predominantly affects middle-agedmen and is classified byWHOunder peripheral T-cell lymphomas. We present a 26-year-old man with HSCTL treated with a non-CHOP regimen. Case: A 26 year old immigrant fromCameroonwithout significant past medical history presented with abdominal discomfort that was first noted 1 month prior at which time he was elbowed in abdomen during a basketball game. His abdominal discomfort continued to gradually worsen and was associated with nausea, vomiting, early satiety and decreased appetite. He developed subjective fever, chills, night sweats, fatigue and epistaxis 3 days prior to presentation. CBC with differential revealed WBC 8 x 103/ul, RBC 4.50 x 103/ul, Hemoglobin 12.9 mg/dl, Hematocrit 38.2 %, Platelets 30 x 103/ul, elevated monocytes and nRBC’s. EBV serology was positive for VCA IgG and Nuclear-antigen Antibody IgG, indicating past infection. Abdominal CT revealed marked hepatosplenomegaly with displacement of abdominal viscera. PET revealed heterogeneously increased FDG uptake in liver and spleen. Bone marrow showed increased cellularity, increased atypical lymphocytes with clustering, and sinusoidal infiltration. Lymphoid cells mainly expressed CD2, CD3 and CD8. Cells were negative for TdT, CD1a, and increase in Ki-67 expression. Bonemarrowflowcytometry revealed predominance of atypical gamma/delta T cells. Cytogenetics revealed normal male karyotype. Based on imaging, bone marrow, and flow cytometry, diagnosis of HSCTLwasmade. The patient was treated with 4 cycles of Ifosfamide, Carboplatin and Etoposide (ICE). PET showed complete resolution of uptake in liver and spleen. Repeat bone marrow showed no residual disease. He underwent splenectomy and pathology revealed no evidence of residual T-cell lymphoma. The patient then underwent autologous SCT with BEAM (Carmustine-Etoposide-Cytarabine-Melphalan) conditioning. He remains in remission after transplantation. Discussion: Although HSTCL is rare, recognition is important as it is aggressive, refractory to conventional therapies, and carries a uniformly poor prognosis. Conventional therapy consists of CHOP (cyclophosphamide-doxorubicin-vincristine-prednisone) with or without autologous stem cell transplantation (SCT). A
THREE’S A CROWD – AN EXTREMELY RARE CASE OF COR TRIATRIATUM DEXTER
A. Elagizi, MD; R. Marvin, MD; G. O’Bryan MD; V. Vyas, MD; L. Arcement, MD. Department of Medicine, Leonard J. Chabert Medical Center, Houma, LA
50 J La State Med Soc VOL 169 MARCH/APRIL 2017
7
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Introduction: Cor triatriatum is a congenital cardiac anomaly in which the left (sinister) or right (dexter) atrium is divided into two compartments by residual embryonic tissue, resulting in a tri-atrial heart. As cor triatriatum dextrum can present clinically in various ways and have multiple associated cardiac anomalies, this report attempts to contribute to what is known about this exceedingly rare disorder. Case: A 40 year oldHispanicmanwith amedical history of gastritis presentedwith complaints of palpitations, dizziness and bilateral lower extremity edema. He was found to have atrial fibrillation and new onset heart failure. The patient was admitted for rate control and further evaluation, which revealed several cardiac anomalies. Initial 2D echocardiography demonstrated severe right atrial enlargement, right ventricular hypertrophy and an engorged coronary sinus, which prompted further assessment of the patient’s cardiovascular anatomy. Transesophageal echocardiography (TEE) revealed a severely enlarged, septated right atriumwith a possible unroofed coronary sinus and a small patent foramen ovale (PFO). Left- and right-heart catheterization established a coronary-cameral fistula between the right coronary artery (RCA) and right atrium, as well as left-to-right shunt. The patient improved clinically with conservative management including diet modification, furosemide and digoxin for fluid and rate control, and was referred to cardiothoracic surgery for further evaluation. Discussion: Cor triatriatum dextrum is an extremely rare cardiac condition: In high-volume echocardiographic laboratories, prevalence is <0.01%. This case highlights the association between cor triatriatum and other congenital cardiac anomalies, including persistent left superior vena cava with an unroofed coronary sinus, PFO and left-to-right shunt; all of which were found in this patient. While cases of cor-triatriatum sinistrum often require correction in infancy (due to left sided heart failure, pulmonary edema and cyanosis), cor-triatriatum dextrum is sometimes diagnosed in adulthood due to the lack of left heart and pulmonary involvement.
Transthoracic echocardiogram revealed a dilated left ventricle with global hypokinesis and severely depressed systolic function with an ejection fraction less than 15%. The patient was diuresed, and subsequent left and right heart catheterizations were normal. CT chest showed a small nodule in the right upper lobe. Tests for Coccidiosis, Trypanosoma cruzi, andMycobacterium tuberculosis were negative; however the acid fast bacilli culture grew Mycobacterium fortuitum. A Strongyloides stercoralis antibody test was positive, and the patient was treated with two doses of oral ivermectin with one dose of intravenous ceftriaxone, and discharged. Two months later, his eosinophilia resolved, but he remained symptomatic with productive cough and weight loss, andwas started on an outpatient course of oral ciprofloxacin and trimethoprim-sulfamethozole for M. fortuitum. Discussion: Strongyloides-infectedpatientsmay carry the parasite for years without prominent symptoms. Endemic throughout South America, Strongyloides persists in its hosts through a lifecycle of autoinfection, which, over time, increases parasite burden and can lead to a hyperinfection syndrome whereby filiariform larvae penetrate organ tissue, most commonly: heart, central nervous system, lungs and liver. We suspect chronic eosinophilia and disseminated filiaria to be the etiology of the non-ischemic dilated cardiomyopathy in this patient. Standard treatment of strongyloidiasis is ivermectin, however, mortality owing to transient bacteremia in the setting of hyperinfection syndrome is high. Therefore, bacteremia prophylaxis with gram negative rod coverage should be considered before antiparasitic agent initiation.
PURULENT PERICARDITIS DUE TO AN INFECTED PACEMAKER LEAD
Teresa Backes, MD Department of Internal Medicine, LSU Health Sciences Center, New Orleans, LA Introduction: Intravenous drug users have a substantially increased risk of infective endocarditis, especially in the setting of implanted cardiac devices. Purulent pericarditis is a rare occurrence that can occur iatrogenically or through direct or hematogenous spread. Case description: A 75 year old man with a past medical history significant for hepatitis C, IV drug abuse, and sick sinus syndrome status post pacemaker was brought in by EMS with a chief complaint of diaphoresis and chest pain. Initial EKG revealed atrial fibrillation with ST elevations in multiple leads. The patient was taken urgently to the cardiac catheterization lab due to concern for STEMI. Left heart catheterization revealed nonobstructive CAD; bedside echo was significant for a pericardial effusion and a pacemaker lead vegetation. CT of the chest revealed extension of the ventricular pacemaker lead through the anterior right ventricular wall and pericardium and into the pleural cavity. Cardiothoracic surgery performed a pacemaker removal as well as pericardial window due to early tamponade; approximately 900 mL of purulent fluid was drained from the pericardial space. The patient was septic with initial blood cultures growing
A STRONG AND FORTUITOUS CASE OF DYSPNEA
R. Hammer, MD; M. Sciaudone, MD. Department of Internal Medicine, Tulane Health Sciences Center, New Orleans, LA Case: A 48 year-old man with no past medical history was sent to our emergency department (ED) from a primary care clinic for hypertensive urgency of 200/130. The man reported an intermittent non-productive cough of approximately one year’s duration and worsening dyspnea on exertion and orthopnea over the last month with lower extremity swelling. Of note, he emigrated from Honduras twenty years ago. Blood pressure normalized with administration of Lasix in the ED. Physical exam revealed rales in lung bases bilaterally, jugular venous distension, lower extremity pitting edema with serpiginous patches of erythema and excoriation, and a cardiac gallop. Labs showed peripheral eosinophilia, thrombocytopenia, elevated creatinine, hyperbilirubinemia, hyperglycemia, and mild transaminitis.
J La State Med Soc VOL 169 MARCH/APRIL 2017 51
8
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
MSSA. He was also found to have multiple other foci of infection including a left-sided pleural effusion and a perihepatic fluid collection, both of which were drained and also grew out MSSA. The patient initially improved on antibiotics after his pacemaker removal and drainage of the infected fluid collections. However, several days after the pacemaker removal he gradually became more bradycardic; due to his multiple comorbidities and active infection, he was not a candidate for a replacement implanted pacemaker. He became profoundly bradycardic and hypotensive overnight and died despite the use of multiple pressors to maintain his blood pressure as well as transcutaneous pacing to maintain his heart rate. Discussion: Purulent pericarditis has become a relatively uncommon occurrence since the development of effective antibiotics. This case illustrates a rare example of purulent pericarditis and cardiac tamponade secondary to the extension of an infected pacemaker wire through the pericardium and into the thoracic cavity. The presence of multiple other infected fluid collections in this case also illustrates the need to thoroughly assess for secondary foci of infection in cases of bacterial endocarditis.
shown to inhibit the inflammatory cascade and reduce thrombus formation in animal models. Clinical data is less clear. Interruption of TNF blockers has been shown to increase the risk of DVT in patients with rheumatoid arthritis undergoing orthopedic surgery. For patients with Bechet’s syndrome, anti-TNF agents appear help treat patients with pulmonary artery thrombosis. Further review of anti-TNF-α therapy in our general medicine patient population may disclose additional risks associated with discontinuation of these medications.
CASE REPORT OF SARCOIDOSIS AS A GREAT MIMICKER IN VARIOUS POPULATIONS
C. Bowe, MD; F. Jenssen, MD; A. Espinoza, MD. Department of Medicine, Leonard J Chabert Medical Center, Houma, LA Introduction: The prevalence of sarcoidosis varies as much as 1-40 cases per 100,000 depending on region and population. Sarcoid typically occurs in people younger than 50 years old, with a peak incidence with ages between 20 and 40 years old. African Americans are 3 times more likely to develop sarcoidosis than Caucasian Americans, and woman are more likely than men to develop sarcoidosis in any ethnic group; nonetheless, it remains a valid differential across any population. Case: A 32 year old Hispanic man presented to the Emergency Departmentwithnight sweats, fatigue, and35poundunintentional weight loss over the last several weeks. He also reported a sore throat, occasional cough w/ yellowish sputum, and new onset dyspnea with exertion. He moved from Mexico to the U.S. 20 years prior and last visited the country 7 yrs ago. He never smoked and denied any TB exposure. His vitals at admit demonstrated tachycardia (pulse 108) and temperature of 99.4 ᴼF. He had coarse bilateral breath sounds on exam. Serum chemistries were unremarkable. Chest radiograph demonstrated perihilar fullness. Chest CT revealed enlarged mediastinal and perihilar LAD and airspace consolidation in right middle and lower lobes bilaterally. The patient was admitted to a negative pressure roomw/ airborne precautions and RIPE therapy was initiated. PPD and AFB’s were negative. He underwent bronchoscopy and was discharged on RIPE. Lung biopsy showed non-caseating granulomas. RIPE therapy was stopped, and he was referred to ophthalmology to rule out uveitis. Cultures from the procedure were negative for fungal growth, and hewas started on prednisone 40mg dailywith taper 6weeks later as his weight returned, night sweats subsided, and dyspnea on exertion improved. Discussion: Sarcoidosis should be considered as a diagnosis in any gender of any racial or ethnic group. Sarcoid is a great mimicker of many serious illnesses including malignancies such as lymphomas, TB and atypical mycoplasma, fungal infections, and other granulomatous diseases, and other autoimmune disorders such a hypersensitivity pneumonitis. Diagnosis requires patient investigation and careful analysis of these differentials.
A CLOT (POSSIBLY) DUE TO LOSS OF TNF-α SUPPRESSION
J. Broussard, MD; M. Berlinger, MD; D. Lauret, MD Department of Medicine, LSU Health, Baton Rouge, LA
Introduction: Inflammation and venous thrombosis enjoy a close Relationship. We present a patient who had multiple DVTs following the discontinuation of anti- TNF-α therapy. Case: A 34 year old African American female with a history of multiple DVT’s, miscarriages, and reported Crohn’s disease presentedwithshortnessof breath. In theEmergencyDepartment, CTA showed bilateral pulmonary emboli. The patient had been off adalimumab for one year and reported abdominal pain with 6-7 non-bloody bowel movements daily. She had been prescribed lovenox for her unprovoked DVTs yet reported missing several doses prior to admission. Following admission, she developed severe abdominal pain prompting an emergent CT angiogram and she then developed a pulseless painful left lower extremity. CT revealed a partially occlusive thrombus in the infra-renal abdominal aorta, proximal left common iliac artery, and right renal arterywith subsequent right renal infarction. Following emergent vascular surgery to restore blood flow to the left lower extremity, the patient received four days of plasma exchange and high dose steroids for potential catastrophic antiphospholipid syndrome. Serology for APLAwas negative. The patient was dischargedwith lifelong anticoagulation. Discussion: The endothelial surface is a complex organ that works in concert with the surrounding environment. Inflammation and thrombus formation is closely associated. TNF-α can increase the expression of adhesionmolecules, specifically, tissue factor, on the surface endothelial cells and promote thrombosis. Suppression of TNF-α expression by low molecular weight heparin has been
52 J La State Med Soc VOL 169 MARCH/APRIL 2017
9
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
PHEOCHROMOCYTOMA OF THE ORGAN OF ZUCKERKANDL: A CASE REPORT
more northern climates, especiallywithHIV, immunosuppression, and IV drug abuse as predisposing factors. Pyomyositis has the tendency to mimic other conditions, such as muscle contusion, necrotizing fasciitis, or septic arthritis. The rarity of this disease and non-specificity of its symptoms often lead to delay in appropriate diagnosis and treatment. Case: 24-year-oldman, seen 2 days prior in orthopedics clinic and the Emergency Department for persistent gluteal pain thought to be due to right-sided sciatica, was admitted followingworsening pain, diffuse generalized weakness with polyarthralgias and myalgias These symptoms were associated with night sweats, shaking chills, and difficulty walking. Prior to onset of symptoms, the patient vacationed in Cayman Islands and experienced a stingray bite on his right hand as well as numerous cuts on rocks in stagnant waters. He was febrile with WBC count of 18.7 K/ µL and was found to have methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Magnetic resonance imaging (MRI) of his lumbar spine on admission was unremarkable. Repeat MRI 4 days later showed extensive inflammation within musculature with multiple abscesses around right sciatic foramen and septic arthritis of the sacroiliac joint. The patient was subsequently diagnosed with MSSA septic polyarthritis and required several orthopedic procedures. Infectious and oncologic work up was unremarkable. Transesophageal echocardiogram showed 0.3 cm x 0.5 cm aortic valve vegetation, which was managed medically. Repeat MRI 11 days after initiation of appropriate antibiotics and surgeries showed improvement inmuscular edema. Based on the MSSA susceptibilities, the patient was treated with 6 weeks of intravenous cefazolin and 2 weeks of oral cephalexin thereafter. Discussion: Awareness of tropical pyomyositis in colder climates remains scarce, although cases have been reported in immunosuppressed patients. However, in healthy patients, accurate history of travel and trauma is important in evaluation for predisposing factors for pyomyositis. Early antibiotic and appropriate surgical interventions are imperative formanagement of this disease in order to prevent systemic toxicity, dissemination of infection, and long-term debility.
C. Lee, MD¹; E. Chang, MD²; J. Gimenez, MD³; and R. McCarron, MD 2
1. Department of Dermatology, 2. Department of Internal Medicine, 3. Department of Radiology, LSU Health Sciences Center, New Orleans, LA Introduction: Pheochromocytomas (PCCs), or intra-adrenal paragangliomas (PGLs), are neuroendocrine tumors arisingwithin the adrenal medulla. Extra-adrenal paragangliomas may arise in the sympathetic or parasympathetic paraganglia and more rarely in other organs. One of the most common extra-adrenal sites is in the organ of Zuckerkandl, a collection of chromaffin cells near the origin of the inferior mesenteric artery or near the aortic bifurcation. The following is a case of a patient with resistant hypertension secondary to an extra-adrenal paraganglioma in the organ of Zuckerkandl. Case: The patient is a 43 year oldmanwith a history of depression, type 2 diabetes mellitus, and hypertension who was sent to the emergency department by his primary care physician for severely elevatedbloodpressures. Patient alsohaddiaphoresis, tachycardia, and a new, fine tremor of his left hand. Upon presentation, the patient’s blood pressure was 260/120 mmHg with a heart rate of 140 beats per minute. Plasma fractionated metanephrines sent on admission revealed significantly elevated levels of total plasma metanephrines (2558 pg/mL), free metanephrine (74 pg/ml) and free normetanephrine (2484pg/mL). An I-123 metaiodobenzylguanidine (MIBG) scan showed abnormal uptake in the lower abdomen at the level of the aortic bifurcation. Patient was started on alpha-blockade, with subsequent addition of a beta-blocker prior to surgery. Patient underwent surgical removal of the tumor with pathology consistent with a paraganglioma. Discussion: Pheochromocytomas and paragangliomas are responsible for approximately 0.5% of cases of secondary hypertension. Many different biochemical markers have been used to aid in the diagnosis of PCC/PGL including plasma catecholamines, plasma metanephrines, urine fractionated metanephrines, urine catecholamines, total metanephrines and vanillymandellic acid. Definitive management of a PCC and PGL involves surgical removal of the tumor. Finally, there should be a discussion with each patient to determine if he or she should undergo genetic testing, as studies show that approximately 25% of catecholamine producing PCCs and PGLs are due to heritable genetic mutations. A RARE CASE OF TROPICAL PYOMYOSITIS ACQUIRED ON VACATION IN A HEALTHY MALE K. Poole, MD; T. Tran, MD Department of Internal Medicine, Ochsner Medical Center, New Orleans, LA
WHAT THE EYES DON’T SEE, THE HEART DOES GRIEVE OVER
M. Sciaudone, MD; M. Dery, MD Department of Internal Medicine, Tulane Health Sciences Center, New Orleans, LA Case: A 71 year old Peruvian woman presented with blurry vision and bilateral eye pain and had evidence of bilateral endophthalmitis on eye examination. Her past medical history was notable for multiple abdominal surgeries within the preceding months, including an incarcerated inguinal hernia repair which required an ileostomy placement, and cholecystitis requiring cholecystostomy tube placement. Over her multiple long hospitalizations, she developed bacteremia and fungemia on several occasions, with organisms including Enterobacter cloacae, Klebsiella pneumoniae, Bacteroides fragilis, Pseudomonas aeruginosa, Enterococcus faecium, and Candida
Introduction: Pyomyositis has traditionally been considered a tropical disease. Increasing prevalence has been observed in
J La State Med Soc VOL 169 MARCH/APRIL 2017 53
10
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15Made with FlippingBook Digital Publishing Software