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
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