JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
albicans. On exam, she was febrile and tachycardic. She had bilateral conjunctival injection, hypopyon, and severely decreased visual acuity. She also had a III/VI harsh holosystolic murmur at the apex. Her lungs were clear to auscultation. Transesophageal echocardiogramrevealed severemitral regurgitation and a 16 x 15 mmmitral valve vegetationandaperforatedaneurysmal posterior mitral valve leaflet. The patient underwent bilateral vitrectomy and was treated with flucytosine and ambisome. Blood and vitreous humor cultures were obtained, but remained negative, likely due to being drawn after the patient had been empirically treated with antifungals and antibiotics. She continued to spike fevers and developed heart failure, but refused valve replacement surgery as she wished to return to her home country. Discussion: A systemic source of infection should be sought in the presence of bilateral endophthalmitis. In our case, we suspected seeding from endocarditis or an intra-abdominal infection, given the patient history of multiple complicated abdominal surgeries and recurrent bacteremia and candidemia. Based on the vegetation’s large size andbilateral endophthalmitis, we believed Candida was the most likely culprit. Additionally, eye lesions observed during surgery appeared consistent with fungal endophthalmitis. Candida is a rare but very morbid cause of infective endocarditis. Arterial embolization and metastatic infections such as endophthalmitis aremore frequent in candidal endocarditis, likely due to the generally larger vegetation size. Valve replacement should be strongly considered regardless of other factors, as some studies have shown a mortality benefit for antifungals and surgery compared to antifungals alone. In cases in which valve replacement is not feasible, the patient should be kept on lifelong suppressive antifungal therapy.
lower extremities. The patient related lifelong knowledge of a congenital heart defect, but had not been seen by a cardiologist as an adult. She was asymptomatic, yet sedentary until one year ago when she had the first of multiple hospitalizations for acute decompensated heart failure. A chest x-ray showed massive cardiomegaly with right-sided calcified aortic arch and patchy bilateral infiltrates. Transthoracic echocardiogram revealed severe right ventricular hypertrophy, ventricular septal defect, overriding aorta, and ejection fraction of 50%, consistent with unrepaired ToF. We utilized multimodality imaging techniques including CT angiography and CardiacMRI which further defined her cardiac anatomy. Findings were consistent with unrepaired ToFwith pulmonary atresia. The pulmonary arteries arose directly from the aorta in a confluent fashion via a large patent ductus arteriosus, major aortopulmonary collateral artery. The arterialized pulmonary arteries were aneurysmal with dissection and mural thrombus formation. Discussion: This case illustrates how a patient with a rare presentation of unrepaired ToF with pulmonary atresia can go undiagnosed into adulthood. Early recognition utilizing a multimodality imaging approach can lead to proper diagnosing and hopeful surgical repair which can provide considerable improvement in functional status and long-term survival.
A RARE CAUSE OF ABDOMINAL PAIN
E.M. Dauchy, DO; M. Modica, MD; N. Masri, MD Department of Medicine, LSU Health Sciences Center, New Orleans, LA
Case: A 54 year old woman with hypothyroidism presented with right flank pain that began acutely oneweek prior topresentation. She was told initially she had a urinary tract infection and treatment resulted in mild symptomatic improvement. The pain returned and she presented to another Emergency Department (ED) and was told the pain was due to constipation. She returned to the ED the next day when her pain worsened and her labs were notable for WBC of 19,000/uL, BUN/Cr of 28/0.75 mg/dL, AST of 31 U/L, ALT of 92 U/L and total bilirubin of 0.6 mg/dL. RUQ ultrasound was notable for dilation of the common bile duct. Given concern for choledocholithiasis, she was started on cefepime and metronidazole. MRCP demonstrated a distended gallbladder without stones and a small amount of pericholecystic fluid. Also noted were two areas of increased signal in the right kidney, concerning for neoplasia or infarction. Contrasted abdominal Computed tomography showed amoderate size area of hypodensity, consistent with renal infarct.Workup for embolic source of the infarctionwas unrevealing. Renal artery angiogram demonstrated a spontaneous dissection of the superior branch of the right renal artery. PCI was not performed due to risk of jeopardizing the other vessels and so shewasmanagedmedically with rivaroxaban alongwith hydrochlorothiazide andmetoprolol succinate to keep her systolic blood pressure below 140 mmHg. The morning after the procedure, the patient told the treatment teamthat her grandson liked to jump froma height and shewould catch him on her right side. This was felt to be a likely etiology of her spontaneous dissection. At the time of discharge, her pain was improved and repeat angiogram performed eight weeks later noted healing of the dissection. 11
MISSED OPPORTUNITY: TOF DIAGNOSED IN 4TH DECADE OF LIFE
O. Baniahmad, MD¹; T. Jarreau, MD²; A. Johnson, MD¹
1. Department of Internal Medicine, LSU Health, Baton Rouge, LA 2. LA Cardiology Associates, Baton Rouge, LA
Introduction: Tetralogy of Fallot (ToF), themost common cyanotic heart disease after infancy, has a 3% survival rate at 40 years without surgical intervention. Althoughmost cases are diagnosed in infancy, patients can less commonly go undiagnosed into adulthood. Clinicians in theprimary care settingmay unknowingly encounter these patients while caring for their other chronic illnesses. Case: A 40 year old woman with a history of HIV, congestive heart failure secondary to an unknown congenital heart defect, and hypertension presented to our emergency department with worsening edema. On roomair, oxygen saturationwas 55%. On 5L of oxygen via nasal cannula, oxygen saturationwas 88%. Physical examinationwas notable for central cyanosis, facial and lid edema, a II/VI holosystolic murmur across right chest radiating to entire right back hemithorax, decreased breath sounds at bases with pulmonary crackles, clubbing of fingers and edema of bilateral
54 J La State Med Soc VOL 169 MARCH/APRIL 2017
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