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ABSTRACTS FROM THE 2019 LOUISIANA ANNUAL ACP MEETING
CONTENTS
JOURNAL EDITORIAL STAFF
EDITOR D. Luke Glancy, MD
ASSOCIATE EDITOR L.W. Johnson, MD
3 METASTATIC EMBRYONIC CARCINOMA: AN ATYPICAL TRIGGER FOR ACUTE PANCREATITIS
CHIEF EXECUTIVE OFFICER JeffWilliams
4 ATYPICAL PRESENTATION OF SARCOIDOSIS: UNILATERAL SUPRACLAVICULAR LYMPHADENOPATHY 4 RARE CASE OF ACUTE ESOPHAGEAL NECROSIS SECONDARY TO DIABETIC KETOACIDOSIS GURVITS SYNDROME
JOURNAL EDITORIAL BOARD Vice Chair, K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD
5
A RARE CASE OF BLADDER CANCER
Anthony Blalock, MD D. Luke Glancy, MD L.W. Johnson, MD Fred A. Lopez, MD
6 WHY IT IS ESSENTIAL TO THINK TWO MOVES DOWN THE CHESS GAME
6 BLOOD, BILE, AND BLOCKAGE: AN ATYPICAL CAUSE OF PANCREATITIS
7
LUNG CANCER SCREENING IS 55 TOO LATE?
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
7 OCHROBACTRUM INTERMEDIUM : A CASE OF BACTEREMIA ASSOCIATED WITH DECOMPENSATED CIRRHOSIS 8 BILIARY CANDIDIASIS CAUSED BY CANDIDA GLABRATA IN PATIENT WITH PANCREATIC MALIGNANCY
9
METASTATIC HEMANGIOPERICYTOMA OF THE LUNG
9
AN UNKNOWN CASE OF STROKE
10 UTILIZATION OF NIVOLUMAB IN ADENOID CYSTIC CARCINOMA AFTER PROGRESSION ON PLATINUM BASED CHEMOTHERAPY
11
COCCIDIOIDOMYCOSIS
COUNCILORS District 1 Member, Vacant
11 RECURRENCE OF DIFFUSE LARGE B CELL LYMPHOMA PRESENTING AS ACUTE PANCREATITIS
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
12 THE ZEBRA OR THE HORSE: CHALLENGES IN DIAGNOSING PYLEPHLEBITIS
13
HYPONATREMIA SECONDARY TO PANHYPOPITUITARISM IN A PATIENT WITH A HISTORY OF SIADH
13
A CRYPTOGENIC CASE OF PNEUMONIA
14
NOT SO CLASSIC CORONARY CLOT: APLA SYNDROME PRESENTING AS ACUTE CORONARY SYNDROME
15 WHAT LIES BENEATH: A CASE OF DIFFUSE ALVEOLAR HEMORRHAGE SECONDARY TO SYSTEMIC LUPUS ERYTHEMATOSUS
15
PSEUDOPROGESSION OF BREAST CANCER WITH OLAPARIB
16
WHEN TO PERFORM ENDOSCOPY ON CASES OF SUSPECTED MAC
17
RARE CAUSE OF STEMI IN PROSTHETIC VALVE ENDOCARDITIS
17
MULTIPLE MYELOMA MASQUERADING AS AN AKI
18
SEVELAMER CRYSTALS: WREAKING HAVOC IN THE COLON
18 A CASE OF A SPLENIC ABSCESS THAT LIKELY SEEDED FROM A GASTROCNEMIUS ABSCESS
19
A CASE OF ORF VIRUS HUMAN ECTHYMA CONTAGIOSUM AFTER EID AL ADHA RELIGIOUS PRACTICES
19 WHEN TWO DRUGS ARE BETTER THAN DOUBLE OF ONE: A CASE OF PHENYTOIN TOXICITY
2
ABSTRACTS FROM THE 2019 ANNUAL LOUISIANA AMERICAN COLLEGE OF PHYSICIANS ASSOCIATES MEETING 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 Louisiana American College of Physicians (ACP) Associates Meeting. 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. 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 15 most highly ranked abstracts presented at this year’s competition that were selected for oral presentations. An Additional 12 abstracts presented as posters (out of 92 total) were selected by judges for publication. All abstracts (15 oral and 12 poster) were presented at the Associates Meeting held at The Louisiana Cancer Research Center in New Orleans on January 22, 2019. 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 Chair , Louisiana Associates Liaison Committee Lee S. Engel, MD, PhD, FACP Governor , Louisiana Chapter ACP
METASTATIC EMBRYONIC CARCINOMA: AN ATYPICAL TRIGGER FOR ACUTE PANCREATITIS J. Nguyen; C. Jones Department of Internal Medicine Tulane University Health Sciences Center, New Orleans *Presented as a mystery case Introduction: Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening. The usual causes include hypertriglyceridemia, alcohol abuse, and obstructing gallstones or pancreatic mass. Case: A 29 year old man with a past medical history of pancreatitis presented with abdominal pain, which began three days prior to admission. He complained of nausea, vomiting, dark color urine, and epigastric pain. Physical examination demonstrated diffuse abdominal tenderness and palpable right and left
patient included a total of 4 cycles Bleomycin, Etoposide and Cisplatin with follow up CT scans and possible surgical consultation if residual mass is present after chemotherapy. Discussion: In a young, otherwise healthy patient, it is tempting to ascribe pancreatitis to benign, common causes. However, if the history is unrevealing for these underlying causes, a thorough search is necessary. Unanticipated metastatic embryonic carcinoma causing obstructive lymphadenopathy is an extremely rare cause of pancreatitis, but malignancy of all causes deserves to be on the differential diagnosis.
inguinal lymph nodes. An abdominal CT revealed bulky retroperitoneal conglomerate masses and peritoneal lymphadenopathy. Fine needle aspiration and biopsy of the mass revealed reactive lymphadenopathy raising concerns for metastatic carcinoma. Furthermore, labs illustrated elevations in alpha fetoprotein, LDH, and BhCG. MRI/ MRCP then revealed a massive necrotic retroperitoneal mass that was impinging the proximal common bile duct. Gastroenterology was consulted and a biliary stent was placed by ERCP. Although testicular/ scrotal ultrasound revealed no masses, it is being considered as the primary source of the metastatic mass due to additional stain results. Pathology results showed that the mass was SALL4 (positive), and OCT3/4 (focally positive). These results were suggestive of a metastatic carcinoma with embryonic carcinoma and less likely of other extragonadal germ cell tumors. Per recommendations from Hematology/ Oncology, the treatment plane for the
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ATYPICAL PRESENTATION OF SARCOIDOSIS: UNILATERAL
RARE CASE OF ACUTE ESOPHAGEAL NECROSIS SECONDARY TO DIABETIC KETOACIDOSIS GURVITS SYNDROME T. Joshi; R. Gioe; J. Evans; D. Raines Department of Internal Medicine, LSU Health Sciences Center - New Orleans *Presented as a mystery case Introduction: Acute esophageal necrosis is a life-threatening condition. It is a rare disease with an incidence ranging from 0.01% to 0.28% of all upper GI endoscopies. Upon review of the English literature, only 14 cases of AEN associated with DKA have been published over the past 50 years. We present a case of AEN associated with DKA. Case: A 61 year old man with a history of hypertension, hyperlipidemia, type 2 diabetes, peptic ulcer disease, tobacco use, alcohol abuse, and obesity presented to the hospital with severe shortness of breath, worsening back pain and acid reflux symptoms. His vitals on admission were 97.8 F, blood pressure 183/85, heart rate 141 beats per minute, respiratory rate 31/min, and oxygen saturation at 99% on room air. On physical examination he had dry mucous membranes and tachycardia. His laboratory findings showed blood glucose of 833 mg/dL. ABG showed pH of 7.164, pCO2 of 11.1 mmHg, HCO3 of 4 mEq/L, and PO2 of 128 mmHg with an anion gap of 25. Serum Beta- Hydroxybutyrate of 4.9 mmol/L, 2+ urine ketones, (WBC) of 30.2 K/uL, Hb 13.5, potassium of 5.8, BUN 31 with Creatinine of 2.7. CXR was unremarkable and patient was started on an insulin drip. On day 2, he developed hematemesis without melena or hematochezia. On day 3, he continued having hematemesis and dysphagia. The next day Hb decreased from 12.8 to 10.7 g/dL and he had chest discomfort. Endoscopic evaluation revealed severe necrotic esophagitis along the entire esophagus with gastric and duodenal mucosa. Patient was started on oral (PPI) therapy and oral sucralfate therapy. The patient’s DKA resolved and he was discharged on 6 weeks of oral PPI and sucralfate therapy with plans for repeat EGD outpatient. Discussion: It is important to diagnose AEN in the settingof DKA as it is associated with increased disease-specific
based on the clinical presentation and demonstration of non caseating granulomas in the lymph nodes. This case highlights the presentation of sarcoidosis with supraclavicular lymphadenopathy and the possible environmental and occupational risk factors for sarcoidosis. Prompt recognition and management of anterior uveitis is important to prevent long term complications of uveitis.
SUPRACLAVICULAR LYMPHADENOPATHY
N. Patel; R. Singh; A. DeWitt; V. Tati Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge *Presented as a mystery case Introduction: Sarcoidosis is a systemic granulomatous disease of unknown etiology that can affect any organ system. Hilar and mediastinal lymphadenopathy is a common manifestation, however other causes of lymphadenopathy must be ruled out in a stepwise approach. Case: A 34 year old male quarry worker with significant exposure to granite for 15 years presented with a palpable non- tender mass on the left side of his neck for 2 months. During this time, he also had subjective fevers, drenching night sweats and a 30 lb. unintentional weight loss. The patientdenieddysphagia, dyspnea, cough or other upper respiratory symptoms. He endorsed occasional marijuana use and had tested negative for HIV within the past 2 years. He also reported intermittent redness and burning sensation in his eyes for the past 1 year. He stated that he used a surgical mask at work, but did not use a respirator. Physical examination revealed a mobile, non-tender, rubbery mass on the left side of his neck extending from the midclavicular line to the sternocleidomastoid muscle. Electrolytes and CBC were unremarkable, HIV and Quantiferon Gold were negative. His ACE level was elevated. Neck CT showed cervical, left supraclavicular and mediastinal lymphadenopathy with a mass effect on the left subclavian vein and numerous collaterals in the left neck and shoulder. It also showed bilateral ground glass nodular infiltrates. Excisional biopsy of the left cervical lymph node demonstrated noncaseating granulomas.
Discussion: inflammatory
Sarcoidosis
is
an
systemic
disease
characterized noncaseating granulomas. Cervical lymphadenopathy as the initial presentation of sarcoidosis is rare, adding to the difficulty in diagnosis. Furthermore, our patient presented with B symptoms increasing the possibility of malignancy. Sarcoidosis was diagnosed by
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A RARE CASE OF BLADDER CANCER
Discussion: Bladder cancer is often reported in Caucasians in their 7th or 8th decade of life and is often associated with tobacco abuse. This case discusses an aggressive lesion in a young man without tobacco use. <1% of cancers are described as Neuroendocrine in origin. Their occurrence in the bladder is rare and often diagnosed in an advanced stage with a poor prognoses. NET can be further subdivided into large and small cell carcinomas, neither of which are reported here.
mortality which could be decreased given appropriate precautions and treatment. Complications can include esophageal perforation, mediastinitis, and abscess formation which can be seen in up to 6% of cases. Late complications include esophageal strictures and stenosis which are seen in 10.2% of cases and may appear as early as 7-12 days after diagnosis. Mortality is as high as 32% with underlying co-morbidities and the mortality specific to AEN is closer to 6%.
B. Tymchuk; N.Silva; M. Eschete; G. Lacy Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma Introduction: Cancer with an unknown primary is common, accounting for 4 to 5 percent of all invasive cancers. Neuroendocrine tumor (NET) of the bladder is exceedingly rare, accounting for 0.5% of all bladder tumors. NET is classified into 2 subtypes: carcinoid tumor and neuroendocrine carcinoma. Neuroendocrine carcinoma is further subdivided into small cell carcinoma (SCC) and large cell neuroendocrine carcinoma, the latter of which is exceedingly rare in the bladder. Case: A 36 year old man without previous medical history who presented with gross hematuria for 2 days associated with urgency, frequency, hesitancy, dysuria, penile pain and left flank pain. He had no personal history of kidney disease nor occupational exposures. He was afebrile with normal vitals and liquid labs revealed a mild paraproteinemia with a gap of 4.3, a baseline BUN and Creatinine of 21 and 1.3 respectively. UA was red tinged, with 2+ protein, 3+ occult blood, trace ketones and micro revealed >100+ RBC’s. Urine and blood cultures were without organisms. CT abdomen/ pelvis revealed left hydronephrosis and hydroureter with renal cortical atrophy consistent with chronic obstruction. CT urogram revealed no pyelogram on the left, due to a 7.5 x 5.5 cm mass along the left posterolateral bladder wall separate from prostate obstructing the left distal ureter. Within a month his symptoms progressed to chronic hematuria and recurring obstruction, requiring nephrostomy tube placement, ureteral stenting, biopsy of bladder mass and subsequent TURBT with clot evacuation and fulguration. Further cancer screening did not reveal a primary source for his malignancy. Pathology demonstrated an invasive high-grade malignant neoplasm with a neuroendocrine differentiation, staining positive for synaptophysin, CD56 with a Ki67 proliferative index of ~70- 75%. Tumor was negative for CK7, CK20, CD 45PSA, PSAP, AE1/AE3 and RCC.
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WHY IT IS ESSENTIAL TO THINK TWO MOVES DOWN THE CHESS GAME
BLOOD, BILE, AND BLOCKAGE: AN ATYPICAL CAUSE OF PANCREATITIS
due the proximity of the intrahepatic bile duct, hepatic artery, and portal vein. Hemobilia can lead to thrombus formation and pancreatitis due to biliary tract obstruction. Classically this presents as Quincke’s triad of right upper quadrant pain, jaundice, and gastrointestinal hemorrhage. Removal of the obstruction and arterial embolization are regarded as the standard of care. This case represents the importance of understanding the diseases. While hemobilia pancreatitis is rare, the pathophysiology is similar to the common etiology of gallstones. Both are obstructive processes that initiate an inflammatory cascade within the pancreas. By recognizing that the patient had an obstructive process, she was able to receive proper evaluation and therapy.
C. Feng; A. Sutherland Department of Medicine, Tulane Health Sciences Center, New Orleans Case: A 64 year-old woman with a history of essential thrombocytosis presented with dyspnea. The clinical examination was consistent with a diagnosis of acute CHF. A peripheral smear revealed thrombocytosis with blasts, raising concern for acute myeloid leukemia with blast crisis. Given the risk for hyperuricemia secondary to tumor lysis, rasburicase was prescribed. On the next day, she developed hypoxia refractory to diuresis. Initially ascribed to worsening heart failure, however, an ABG revealed a PaO2 of 300 mmHg despite an arterial saturation of 80%. The discordance between the PaO2 and the arterial saturation combined with recent rasburicase exposure indicated methemoglobinemia. Methylene blue and ascorbic acid were administered. On hospital day three, an acute drop in her hemoglobin concentration suggested hemolytic anemia. G6PD deficiency was confirmed as the cause and was thought to be precipitated by methylene blue. Attempts were made to establish an exchange transfusion, but her condition deteriorated rapidly, resulting in cardiac arrest and death. Discussion: Tumor lysis is a common complication, especially for patients with high tumor burden or myeloproliferative disorder. Given the frequency that these patients are admitted to the hospital, the prophylactic administration of agents like rasburicase is often done without consideration for potential side effects. Methemoglobinemia occurs in less than one percent of patients who take rasburicase. The treatment for methemoglobinemia is methylene blue. Patients with G6PD deficiency are highly susceptible to acute hemolytic anemia post methylene blue administration.
M. Marak; L. Miles; R. Thibodaux Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge Introduction: Acute pancreatitis is a common clinical diagnosis that often presents with abdominal pain, systemic inflammatory symptoms, and an elevation inpancreaticdigestiveenzymes. Most cases are alcohol or gallstone related. However, there are numerous pathophysiological mechanisms that can contribute to pancreatitis including metabolic, infectious, obstructive, autoimmune, and toxic related processes. This case reviews a typical presentation of obstructive pancreatitis with an atypical etiology. Case: A 61-year-old woman with a past medical history of HIV and Hepatitis C presented with a chief complaint of right- upper-quadrant pain. Two days prior, she underwent a transjugular liver biopsy for cirrhosis staging. On initial presentation, she was afebrile with severe right- upper-quadrant tenderness. Laboratory evaluation revealed a lipase of 3174 U/L, total bilirubin of 3.4mg/dL, AST of 183 U/L, and ALT of 117 U/L. RUQ ultrasound was consistent with choledocholithiasis suggesting a diagnosis of gallstone pancreatitis. Subsequent ERCP revealed a thrombus extruding from the ampulla, and a sphincterotomy was performed and thrombus extracted. She clinically improved and was discharged with a diagnosis of hemobilia pancreatitis. Five days later she returned after a syncopal episode with a hemoglobin of 5.1 g/dL. Without a definitive source for bleeding, she underwent an interventional angiogram revealing a right hepatic artery to portal vein arteriovenous fistula that was subsequently coiled. The final diagnosis was hemobilia pancreatitis secondary to arteriovenous fistula leading to biliary tract obstruction. Discussion: Transjugular biopsy is a procedure that offers patients with coagulopathy or ascites an alternative to percutaneous liver biopsy. Benefits include avoiding peritoneal and liver capsule injury. Manipulation of the portal vein during biopsy is associated with hemobilia and fistula formation
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LUNG CANCER SCREENING IS 55 TOO LATE?
OCHROBACTRUM INTERMEDIUM : A CASE OF BACTEREMIA ASSOCIATED WITH DECOMPENSATED CIRRHOSIS G. Handley¹; D. Maslov² ¹Department of Medicine Ochsner Medical Center, New Orleans ²University of Queensland, Ochsner Clinical School, New Orleans Case: A 56-year-old woman with a history of alcohol abuse presented with 3 days of fevers, abdominal pain, and emesis. Exam was remarkable for generalized muscular tenderness. Labwork revealed white blood cell count 2.6, hemoglobin 9.9, platelets 27, albumin 1.8, bilirubin 4.6, AST 97, and ALT 28. Imaging demonstrated cirrhosis, peri-splenic varices, and an atrophic pancreas with a focus of gas in a dilated pancreatic duct. She was treated for alcohol withdrawal. She developed fever, tachycardia, became obtunded and was found to have leukocytosis to 18 with a lactate of 2.9. Vancomycin, ceftriaxone, piperacillin/ tazobactam and levetiracetam were given. Lumbar puncture, MRI brain, electroencephalogram, urine and respiratory cultures were unremarkable. Blood cultures from two sites grew Ochrobactrum intermedium sensitive to fluoroquinolones and aminoglycosides but resistant to beta-lactams except for carbapenems. Repeat abdominal imaging did not reveal an infectious nidus. She received ciprofloxacin at 750mg twice daily for two weeks with clinical cure. Discussion: Ochrobactrum are gram- negative rod-shaped flagellated bacteria most similar to Brucella species. O. anthropi was first described in 1988 as normal colonic flora, but is now as a recognized opportunistic pathogen. A decade later, O. intermedium was discovered. Cases are limited but include a patient with O. intermedium septicemia due to cholangitis a month after orthotopic liver transplant. Another case describes a man with end-stage renal disease on immunosuppression undergoing hemodialysis through a long- term catheter after a failed transplant developed endocarditis with a right atrial vegetation due to O. intermedium . A 6-week course of meropenem and minocycline achieved cure. Additional cases include endophthalmitis due to intraocular foreign body, and bacteremia
diagnosed/initially treated at UHC in 2017, if screening were to begin at age fifty, 57/58 of our patients would have been eligible for screening. This would have led to earlier diagnosis and potential better outcomes.
J. Patel; R. Patel; G. Jacob; C. Clark; T. Benoit-Clark Department of Internal Medicine, LSU Health Sciences Center- Lafayette Introduction: In 2014 24% of adults in Louisiana reported having had a history of smoking. Lung cancer was the most common cancer and the leading cause of cancer related deaths in Louisiana from 2010 to 2014. It has been estimated that 3510 new cases of lung cancer were diagnosed in Louisiana in 2017, with an estimated 2610 patients dying of lung cancer. The USPSTF recommends annual screening for lung cancer with low- dose computed tomography in adults between the ages of 55-80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. This study was designed to look at the age of patients initially diagnosed/treated at UHC in Lafayette, LA with lung cancer in 2017 and see if there was a statistically significant population that had lung cancer who did not meet lung cancer screening criteria. University Hospitals and Clinics in Lafayette, LA directly services the Louisiana parishes of Acadia, Iberia, Lafayette, St. Landry, St. Martin, and Vermillion. Methods: A retrospective analysis of the lung cancer patients that were diagnosed/ treated at UHC in2017 was performed. Charts of the patients were evaluated with the age of diagnosis of lung cancer documented. Results: In 2017, fifty-eight patients were diagnosed/initially treated at UHC for lung cancer. The age at the time of diagnosis ranged from 46-70 years. Fifteen of the 58 patients diagnosed were between the ages of 46-55 years. Following guidelines set by the USPSTF for lung cancer screening, 25.8% of the patients seen at UHC would not have been screened or screened early enough to diagnose lung cancer at a more treatable stage. Conclusions: The USPSTF has set the age to begin annual screening for lung cancer at 55 years. In the lung cancer patients
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BILIARY CANDIDIASIS CAUSED BY CANDIDA GLABRATA IN PATIENT WITH PANCREATIC MALIGNANCY S. Rashid; N. Hafiz; V. Nguyen Department of Internal Medicine, LSU Health Sciences Center – Shreveport Introduction: Acute cholangitis presents with fever, right upper quadrant pain and jaundice. Although many causes are due to bacterial translocation in biliary tree, fungal infections are also seen. Risk factors include immunocompromised state, malignancy, diabetes, and chemotherapy. We present here a case of a patient with biliary candidiasis from Candida glabrata . Case: A 68-year old man with history of type 2 diabetes, Hepatitis C, and tobacco use admitted for jaundice, intense pruritus, dark urine and weight loss of 30lbs over 1 month. Labs were significant for T bili 32.4, AST 61, ALT 62, ALP 201, lipase 3,300. CT showed a 2.5 x 3.6 cm pancreatic head mass, enlarged gallbladder and CBD diameter 1.1cm. ERCP showed distal CBD stricture 3-4cm in length with bile duct obstruction. Plastic stent placed, T bili trended down. Three days later, repeat ERCP performed with metal stent placement. EUS with FNA of pancreatic head confirmed malignancy. Patient was not surgical candidate. After second ERCP, T bili and LFT’s worsened, patient became oliguric with worsening creatinine function. Urinalysis confirmed large bilirubin crystals and blood. The patient became hypoxic, hypotensive, anuric and altered. He was started on vasopressors and CRRT, with improvement in creatinine. The patient went into acute liver failure with transaminitis and elevated INR. RUQ US findings were suggestive of a malpositioned stent. IR placed percutaneous cholecystostomy tube which drained thick dark bile. Despite aggressive management for septic shock, the patient’s condition deteriorated and he expired. Gallbladder aspirate grew Candida glabrata . Discussion: Systemic and localized candida infections are common in patients with certain predisposing factors such as neutropenia, malignancy, advanced diabetes mellitus, and immunocompromised status. Biliary
in a patient with bladder cancer. O. intermedium is susceptible to imipenem, ciprofloxacin, and trimethoprim- sulfamethoxazole, but resistant to penicillins and cephalosporins. Conclusion: There are few documented cases of O. intermedium . This is one of the first with bacteremia in the absence of malignancy or immunosuppressant medication. Many were likely classified as O. anthropi previously. Hospital Medicine physicians should recognize Ochrobactrum as an opportunistic pathogen which can cause life- threatening infection particularly in immunocompromised hosts.
candidiasis is very rare even in patients with systemic candidiasis. Patients typically present as acute cholangitis. According to Domargk et al, 29% of the patients present as biliary obstruction similar to our case presentation. Labs generally are remarkable for conjugated hyperbilirubinemia. Diagnosis is made via obtaining culture and sensitivity of biliary fluid sampled through ERCP, cholecystectomy and/or percutaneous cholecystostomy. Management includes source control and antifungal therapy. Unfortunately in our patient, diagnosis was confirmed after he expired due to worsening septic shock.
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METASTATIC HEMANGIOPERICYTOMA OF THE LUNG M. Mehmood; N. Siddiqui; R. Holladay Department of Internal Medicine, LSU Health Sciences Center - Shreveport Introduction: Hemangiopericytomas are a phenotype of solitary fibrous tumors which are considered malignant tumors of the central nervous system (CNS) and account for less than 1% of all CNS tumors. Patients often present with neurologic symptoms from the mass effect or edema within one year of tumor development due to the rapid onset of these biologically aggressive tumors. Treatment modalities generally include resection, radiation therapy, and adjuvant chemotherapy. However, these tumors have a high rate of local recurrence even after gross complete resection. Hemangiopericytomas also have a high propensity to metastasize along the neuraxis to extracranial structures (e.g. lung, bone) in about a quarter of the cases. Case: Here we describe an interesting case of a 52-year-old female, who was diagnosed with hemangiopericytoma and had a complete resection performed. She was found to have local CNS recurrence nine years after the initial surgery. She underwent repeat resection with adjuvant radiation therapy. At the same time, she was noted to have bilateral pulmonary nodules but was lost to follow up. She presented again with neurological symptoms two years later and was found to have enlarging pulmonary nodules. Navigational bronchoscopy was performed which was non-diagnostic for malignancy. One week after bronchoscopy, she presented with hemoptysis and underwent robot assisted right upper lobectomy as the mass was suspected to be the source. Surgical pathology revealed metastatic hemangiopericytoma with presence of NAB2-STAT6 fusion by immunohistochemistry. Discussion: This case highlights the aggressivenatureofhemangiopericytoma and the ability to metastasize. The rates of extracranial metastases are approximately 28% with about 18%
AN UNKNOWN CASE OF STROKE
of those to lung and pleura. This case was classified as WHO Grade III based on the pathology; however, there is no correlation to metastasis potential based on grade as metastasis is seen in all tumor grades. Despite the acceptance to long term follow up and high clinical suspicion for metastasis, there are no established protocols or guidelines for surveillance. Development of an established protocol is needed as there is currently a wide variation in clinical practice for follow up.
J. Hanawi-Heintze; Y. Ping Lin; J. Jaikishen Department of Internal Medicine, LSU Health Sciences Center - Lafayette Case: A 23-year-old woman with past medical history of bipolar disorder presented with complaints of left-sided weakness, headache, and numbness for 1 week. She initially presented to another facility where she was treated symptomatically. She then presented to our hospital because the above unrelenting symptoms. Left sided weakness was associated with ambulation difficulties. She reported falling several times. She also endorsed having throbbing, migraine-like headaches that began 1 month prior to admission, located in entire frontal region and top of her head with associated photosensitivity and vision changes. She was evaluated in the ED and noted to have left sided weakness, numbness, lethargy and headache. CT head excluded acute intracranial hemorrhage. Due to low grade fever, lethargy and headache, she was started on vancomycin, acyclovir, and ceftriaxone for empiric treatment of meningoencephalitis. MRI brain showed bilateral periventricular white matter foci suggestive of demyelinating disease, with active plaque formation in the area of enhancement on restricted diffusion images. Lumbar puncture showed the presence of oligo clonal bands. CSF cultures were negative at 48 hours. At this point, she was started on high dose steroids. All antimicrobials were rapidly deescalated. She then had complete resolution of symptoms over the next few days and she regained her ability to ambulate. She was discharged with a diagnosis of multiple sclerosis. Multiple Sclerosis (MS) is a heterogeneous disorder with an unknown cause that manifests itself in a variety of ways. Symptoms are often caused by inflammation, demyelination, and axonal degeneration. MS is associated with autoreactive lymphocytes, microglial activation and chronic Discussion: neurodegeneration. Initial manifestation is a clinically isolated symptom that can develop in an acute or subacute manner. However, as the disease can progress in various ways; MS is characterized into subtypes based on progression. This
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UTILIZATION OF NIVOLUMAB IN ADENOID CYSTIC CARCINOMA AFTER PROGRESSION ON PLATINUM BASED CHEMOTHERAPY D. Maslov¹; K. Thomas¹²; M. Matrana²³ ¹University of Queensland, Ochsner Clinical School, New Orleans ²Department of Internal Medicine and ³Department of Hematology and Oncology, Ochsner Medical Center, New Orleans Case: A 22-year-old man presented with a 6-month history of nasal congestion, epistaxis and rhinorrhea for which he had been seen multiple times. He received multiple doses of antibiotics and steroids with no improvement. Physical exam showed no abnormalities, except for sinus tenderness. Given his recurrent symptoms, a non-contrast CT of the sinuses revealed a mass with erosion of the lateral wall of the nasal cavity, lateral wall of the maxillary sinus and pterygoif plates. PET scan confirmed a metastatic disease in the right iliac crest and right cervical lymph node; biopsy was consistent with adenoid cystic carcinoma (ACC) nasopharynx. Patient received proton therapy to the main lesion and intensity-modulated radiotherapy (IMRT) to the iliac bone lesion with concurrent cisplatin. Four months later, a new metastasis in the right ischiumwas found, and stereotactic irradiation treatment was initiated. Genetic profiling located MDM2 mutation. He completed a Phase 1 Trial focusing on this targetable mutation but had progression of disease (PD) with new lung metastasis. He went onto a second trial utilizing DS3032b (a MDM2 inhibitor) but subsequently had PD. Patient was then started on Nivolumab and died twelve weeks later. Discussion: comprises approximately 10% of all neoplasms of the salivary glands. The rarity of this condition makes diagnosis challenging. High mortality rates in ACC is due to late distant metastases and local recurrences. ACC treatment is usually considered palliative, as there is no strong evidence that survival is extended by systemic chemotherapy. Immunotherapy has been utilized in the treatment of metastatic and recurrent head and neck cancers and have shown clinically significant activity in those who have progressed ACC
case exemplifies how Multiple Sclerosis can present acutely with neurological features that are consistent with other diseases such as an acute stroke. A high index of suspicion is needed in cases of unresolving symptoms of stroke to make a correct diagnosis with complete neurological recovery.
on platinum based chemotherapy. To date, no study has evaluated the efficacy of immunotherapy in ACC. Our patient demonstrated a survival of 3 month following the administration of Nivolumab after progressing on first line treatment. This case illustrates the difficulty in identifying ACC and the importance of a thorough workup. The use of Nivolumab may serve as an option to extend survival in patients with ACC.
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COCCIDIOIDOMYCOSIS
RECURRENCE OF DIFFUSE LARGE B CELL LYMPHOMA PRESENTING AS ACUTE PANCREATITIS N. Sahami; R. Poudel, B. Chandamuri; J. Kennedy Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma Introduction: Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma (NHL) accounting for nearly a third of all cases. Disease can arise in either nodal or extranodal tissues. Extranodal extramedullary tissue account for nearly 40% with the most common site being the primary extranodal disease of stomach/gastrointestinal tract. However diffuse large B cell lymphoma presenting as acute pancreatitis is quite uncommon. Case: A 36 year oldman with past medical history of treatment naïve Hepatitis C, and alcoholic induced cirrhosis, diffuse large B cell lymphoma GCB subtype presents to the Emergency Department for sharp epigastric pain with radiation to the back. Lipase was within normal limits but CT scan showed a soft tissue density mass in the region of the portacaval space measuring 4.6 x 2.8 cm in greatest dimension. Of note, the patient previously had CT scan that showed 11 cm mass in retriperitoneum anteriorly displacing the head of the pancreas. CT- guided biopsy of mass showed DLBCL of the GCB subtype. R-bendamustine chemotherapy was initiated followed by 5 cycles of R-CHOP and ISRT after which repeat CT did not show any evidence of disease. With these persistent symptoms and history of lymphoma, PET CT was performed and biopsy of recurrent mass showed recurrence. A decision was made to proceed with R-DHAP salvage therapy. Initially, the tumor showed some response to the therapy, however the patient was unable to tolerate the side effects with worsening hepatic function with increasing biliary and pancreatic duct dilatation. Subsequently biliary drain was placed to relieve the strictures and extrahepatic compression of the tumor with initial down trend of LFT’s and improvement in bilirubin. Shorty there after the drain became infected, requiring long term antibiotic therapy. Initial plans of auto-hematopoietic stem
symptoms are chest pain, cough and fever. Routine laboratory findings are frequently unremarkable. Common radiographic abnormalities include unilateral infiltrate and ipsilateral hilar adenopathy. In general, mild disease does not require antifungal therapy. Therapy with either fluconazole or itraconazole is recommended for patients who are at higher risk of developing severe disease.
M. Ziada; B. Morehead; M. Modica Department of Internal Medicine, LSU Health Sciences Center - New Orleans Case: A 28 year old man with who worked as a laborer and had a history of tobacco use presented with a 7 day course of intermittent high-grade fevers associated with sweats and generalized body aches which he described as “bone pain” and mild nausea without vomiting. He emigrated from Mexico 3 years prior and had no other recent travel. On physical exam, his vital signs were BP 123/51mmHg, pulse 123 bpm, Temp 100.5° F, Resp 22/min, SaO2 100% on room air. He was diaphoretic, with shallow breathing, but lungs were otherwise clear to auscultation. The remainder of his exam including neuro exam was unremarkable. Shortly after admission, he became hypotensive (88/49 mmHg) and he was not responsive to a 4L fluid bolus. He required presser support and was transferred to the ICU. Labs were significant for Leucopenia (26% bands, 63% neutrophils, 10% Lymp), thrombocytopenia, BUN 28 mg/dl, Cr 1.88mg/dl, transaminitis and elevated bilirubin. Computed tomographic imaging of the chest revealed a solitary necrotic nodule with fluid and gas. AFB smear and T.Spot were negative. He was treated for lung abscess and discharged. Further laboratory studies returned including Leptospira IgM which was positive but PCR was negative. Coccidioides antibodies IgM and IgG were positive. Repeat CT chest did not show improvement and lung biopsy was performed. Fungal culture from biopsy material grew Coccidioides immitis/ posadasii . Discussion: Coccidioidomycosis is an infection caused by the dimorphic fungi of genus Coccidioides. Most infections are caused by inhalation of spores. The clinical expression of disease ranges from self- limited acute pneumonia to disseminated disease, especially in immunosuppressed patients. In the United States, most cases are concentrated in southwest. Less than one-half of all infections come to medical attention because illness is often subclinical. Primary infection manifests as CAP approximately 7-21 days after exposure. Most common
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THE ZEBRA OR THE HORSE: CHALLENGES IN DIAGNOSING PYLEPHLEBITIS J. Marston; R. Thibodaux Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge Introduction: non-cirrhotic portal vein thrombosis is an uncommon condition which usually presents with abdominal pain as well as small volume ascites. While most cases are related to an underlying hypercoagulable state, it can also be associated with intraabdominal inflammatory conditions such as Acute pancreatitis, cholecystitis, appendicitis and diverticulitis. This case illustrates the difficulty of diagnosing pylephlebitis and the high degree of suspicion often required for diagnosis. Case: A 59 year old woman with CAD presented to the ED with RUQ abdominal pain for the past five days. She reported associated chills, dyspnea, nausea and emesis. On exam, she exhibited only mild right upper quadrant tenderness. Labs revealed mild leukocytosis, transaminitis, AKI, elevated alkaline phosphatase, and mild normocytic anemia. Abdominal CT scan revealed thrombosis of the intrahepaticportionof therightportalvein and anticoagulation initiated for acute non-cirrhotic portal vein thrombosis. She denied any personal or family history of thrombotic events, and a work up for hypercoagulable states including APLA, PNH, JAK-2 mutation was negative. She clinically improved and was discharged on rivaroxaban. She represented to the ED five days later complaining of subjective fever, chills, dyspnea, and near syncope, requiring a brief stay in the ICU as her blood pressure and heart rate remained labile despite aggressive volume resuscitation and empiric antibiotics. Given her symptoms along with persistently elevated transaminases and alkaline phosphatase, MRCP was obtained which revealed the previously identified portal vein thrombosis but suggested pylephlebitis with hepatic microabscesses. She clinically improved after modification of her antibiotics and remained hemodynamically stable with resolution of her transaminitis. Rivaroxaban was discontinued, and she was discharged to complete an extended course of antibiotics.
Discussion: Pylephlebitis, or infective suppurative thrombosis of the portal vein, is an uncommon complication of primary intraabdominal infection, occasionally with the source of infection being unapparent as in our case. It results from thrombophlebitis of surrounding small veins at the site of infection which ultimately propagates to involve the portal vein. Although pylephlebitis is a rare clinical entity, abdominal pain and fever are frequently encountered clinical symptoms. Modern imaging and microbiologic techniques have improved the detection rate of pylephlebitis, yet morbidity remains high. Therefore, prompt diagnosis and treatment is essential. Anticoagulation is recommended in certain circumstances. Clinicians should remain vigilant in suspecting the unusual while treating the usual.
cell transplantation were canceled as patient started to develop hepatic failure and renal failure, and became too weak to continue with the treatment plan. After discussion with the patient and his family, a decision was made to initiate hospice in accordance to patient’s wishes. Literature review revealed only a handful of cases with B-cell lymphoma presenting as acute Discussion: pancreatitis. This case is even more unique in that despite it being a Stage 1A lesion, the cancer initially responded to treatment, however recurred and ultimately resulted in the death of the patient.
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HYPONATREMIA SECONDARY TO PANHYPOPITUITARISM IN A PATIENT WITH A HISTORY OF SIADH M. Bilalis; T. Joshi; D. Matrana; S. Sanne Department of Internal Medicine, LSU Health Sciences Center - New Orleans Introduction: Non-pituitary intrasellar neoplasms, though less common than pituitary adenomas, can cause hypopituitarism via mass effect and compression of neighboring structures. Mass effect can also lead to panhypopituitarism. Hyponatremia secondary to panhypopituitarism mimics SIADH, but the hyponatremia is typically corrected after administering thyroxine and corticosteroids. We present a rare case of hyponatremia in a patient with a history of SIADH where a recurrent meningioma was the true culprit. Case: A 51 year old woman presented to the emergency department for tinnitus associated with her chronic headaches. She was found to have a Na of 116 and due to concern for hypovolemic hyponatremia was given 1 L of NS. Her Na decreased from 116 to 113 and she was admitted to the MICU. She had a PMH of SIADH with NA levels recorded in the 130’s, hypothyroidism, and meningioma resection. Head CT without contrast showed possible recurrence of meningioma. Patient was then given salt tablets, free water restricted, and started on her home dose of levothyroxine. She remained stable and was transferred to the floor. But, she was readmitted to the MICU the next day due to decreased level of consciousness, hypotension, increased somnolence. She was started on 3% hypertonic saline bolus, and her blood pressure increased. Considering differentials such as SIADH, hypothyroidism, adrenal insufficiency, or hypopituitarism, stress dose steroids were administered. Sodium initially dropped, but then started trending up. The dosage was decreased to 20mg AM/10mg PM once her sodium was around 120. The patient was found to have a high TSH, low free T4, FSH, IGF-1, and morning cortisol consistent with hypopituitarism. Brain MRI with contrast revealed invasion of sella and mass effect on pituitary gland as well as encasement of left cavernous internal carotid artery. Imaging and labs suggested panhypopituitarism as the
A CRYPTOGENIC CASE OF PNEUMONIA
cause for the patient’s hyponatremia.
Discussion: Hyponatremia secondary to a neoplasm is typically a diagnosis of exclusion. Initial symptoms of mass effect on the pituitary gland include irregular menstrual periods, infertility, decreased libido, and erectile dysfunction. As the tumor causes more compression, the more severe consequences include the effects of hypothyroidism and low cortisol (low blood pressure, confusion, nausea, vomiting, and fever) some visualizedwithout patient. Early detection via process of elimination taking all differentials into account is the key to ensuring a positive outcome.
E. Lee; J. Coe; K. Vaishnani; K. Curry; N. Sells Department of Internal Medicine, LSU Health Sciences Center - Lafayette Introduction: Pneumonia is one of the most common presentations in both the inpatient and outpatient settings. We present here a very interesting case of pneumonia caused by both Cryptococcus and Strep gordonii . Case: A 43 year old African-American woman with no significant past medical history presents with SOB, cough, and left-sided chest pain for 10 days. She presented to the ER 7 days prior to admission with bronchitis. She returned 5 days later with similar symptoms. CXR revealed left lower lobe pneumonia and she was discharged with oral Levaquin. She continued to endorse worsening of symptoms, which prompted her to return to the hospital. CT Chest revealed left basilar consolidation, moderate left pleural effusion, and fluid along the left fissureconcerning for possibledeveloping empyema. Pulmonology was consulted and recommended chest tube placement and obtaining cultures. IR placed a chest tube and sent pleural fluid samples for studies. She was treated empirically with Vancomycin, Pip-tazo, and Azithromycin. Blood and respiratory cultures were negative. Pleural fluid studies showed 30,836 WBC with 93% neutrophils and LDH of 2,227. Cytology showed reactive fluid with abundant acute inflammation but no evidence of malignancy. HIV was negative. Patient did well clinically throughout the hospitalization and eventually was discharged home with Linezolid. Pleural fluid later grew rare Strep gordonii and Cryptococcus . CSF was negative for meningitis. Cryptococcal antigen in the CSF and blood were both negative. Patient is currently being treated with fluconazole with a close outpatient follow-up. Discussion: We have a case of pneumonia with positive pleural cultures of two unusual causes of pneumonia. Strep gordonii is bacteria that resides primarily in oral flora in humans but is known to spread outside the oral cavity rarely. Cryptococcus is a yeast that usually
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NOT SO CLASSIC CORONARY CLOT: APLA SYNDROME PRESENTING AS ACUTE CORONARY SYNDROME L. Mile; M. Marak; M. Cannatella Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge Introduction: Antiphospholipid antibody (APLA) syndrome, diagnosed by clinical and laboratory criteria, is often considered after unusual or recurrent clots. APLA is also frequently suspected in females of reproductive age with underlying autoimmune disease or recurrent miscarriage. The following is an unusual case of an older woman with multiple risk factors for coronary artery disease whose acute coronary syndrome (ACS) etiology was thrombophilia. Case: A 68 year old woman with a past medical history significant for morbid obesity, hypertension, type 2 diabetes mellitus, right middle cerebral artery (MCA) stroke, and remote DVT presented with acute typical chest pain. She was admitted for chest pain evaluation after initial ECG was reassuring and troponin was 0.0. Her repeat troponins at 6 and 12 hours were 5.0 and 25.0 respectfully, and left heart catheterization was performed on hospital day two. Angiography showed occlusions both in the distal left anterior descending and left circumflex artery concerning for possible dissection or clot. Hypercoagulable workup ensued. Her lupus anticoagulant and phospholipid IgM were positive while inpatient, and she was discharged on anticoagulation and aspirin. She was then lost to follow up for 7 months, at which time she presented with a new left MCA stroke. Repeat APLA antibody testing was persistently positive (beta-2 glycoprotein, phospholipid, and lupus anticoagulant). She also had developed pancytopenia and nonscarring alopecia in the six-month interim. Immunologic testing for systemic lupus erythematosus (SLE) was positive, and she was diagnosed with SLE and APLA syndrome. Discussion: This case illustrates the unusual etiology of thrombophilia as the cause of a non-ST elevation myocardial infarction (NSTEMI) in a patient with multiple risk factors for coronary disease. Additionally, her clotting disorder was likely the initial manifestation of her
causes infection in immunocompromised individuals. Given that patient is at a low risk for aspiration and that she is currently known to be immunocompetent, it is unusual that patient presents with both Strepgordonii and Cryptococcus infections.
SLE, and she did not meet the clinical criteria (SLICC criteria) until seven months after her acute clotting event. There is a paucity of evidence for the role of immunomodulatory agents in APLA syndrome without SLE, and in the absence of clinical criteria of SLE there was not an indication for serologic SLE testing. Recognition of concomitant SLE and APLA is paramount to early initiation of immunomodulatory agents to control antibody production and decrease cardiovascular risk.
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