Poster Day 2021: Abstracts: Clinical Vignettes

Moyamoya disease is a rare vaso-occlusive disorder involving large intracranial arteries including the distal internal carotid artery and its branches, with resultant collateralization beyond the obstruction to improve cerebral perfusion.  This is frequently addressed with surgical revascularization, however postoperative courses may be complicated by the development of hyperperfusion syndromes.  Recognizing hyperperfusion related injury in such patients can be a daunting task.

This case highlights the consideration of hyperperfusion-related cognitive decline post revascularization in such patients after excluding other causes. Cognitive dysfunction is an uncommon sequelae of hyperperfusion syndrome.

Mohammed Akbar; Simran Kalsi; Florencia Anatelli; and Benjamin Lockshin

Drug-induced subacute cutaneous lupus erythematosus (DISCLE) is a lupus-like syndrome that can develop with long-term exposure to certain chemotherapeutic or biological agents including tumor necrosis factor (TNF) inhibitors.

We present the case of a patient with psoriasis and psoriatic arthritis who subsequently developed subacute cutaneous lupus erythematosus (SCLE) after 5 months of treatment with adalimumab, a fully human anti-TNF-α monoclonal antibody. Symptoms resolved within 3 weeks of discontinuing the drug.

Benjamin Buttars, OMS-IV; Gates Scott, OMS-II; Danielle Glinka, OMS-II; Katherine Oakley, OMS-III – Alabama College of Osteopathic Medicine; and Keoni Nguyen, DO, FAAD – Pine Belt Dermatology, Gulfport, MS

Molluscum Contagiosum and Verruca are common viral infections that are frequently seen in pediatric patients. Currently, available treatments include salicylic acid, cryotherapy, retinoic acid, and imiquimod, which are often painful and only marginally successful due to poor patient compliance. The application of ozone in the international community has been published since World War I as a treatment for various infectious processes. In its natural gaseous state, application of ozone to a skin lesion would be difficult. However, when infused into a lipid carrier, it creates reactive metabolites which are both bactericidal and virucidal.

The proposed case series demonstrates 5 pediatric patients: 3 with Molluscum Contagiosum and 2 with Verruca, all of whom had attempted various therapies but were unsuccessful in completely eradicating their lesions. These patients visited the clinic with the concern of pain intolerance to current treatment regimens.

These five cases illustrate that the application of ozonated olive oil to molluscum and verrucous lesions could serve as a viable alternative to current therapeutic regimens. Patients were instructed to follow a nightly process of bathing, application of ozonated olive oil to each lesion, and overnight occlusion with static cling-wrap where possible.

All cases showed resolution of the lesions within a 30-day period with nightly application. Ozonated olive oil may prove to be an effective and painless treatment modality, but further control studies need to be performed to increase the power of the study and account for other confounding factors.

Leah Grcevich OMS-IV; Maxwell Jabaay OMS-IV; Jordan Karroll OMS-IV; Dario Marotta OMS-IV; and Praful Patel, MD

Diverticulitis is an acute inflammation of diverticulosis, which is a group of acquired colonic outpouchings. Colonic diverticulum develops secondary to elevated intraluminal pressure from chronic constipation or weakened collagen or elastin in the colonic wall. Diverticulitis can usually be treated outpatient with antibiotics; however, treatment failure can lead to abscess formation or perforation..

A 28-year-old female with a history of cardiac tumor resection and recurrent diverticulitis unresponsive to conservative treatment was evaluated by general surgery for a pelvic abscess. The patient underwent definitive operative treatment of diverticulitis with pelvic abscess with a sigmoid colostomy. Surgery was complicated by distortion of pelvic anatomy by large bulky uterine masses. Following the procedure, the patient was referred to gynecology for myomectomy at the time of colostomy reversal. At this time the patient has been lost to follow up, and no additional screening or diagnostic tests have been performed.

The presentation of diverticulitis in a young female with multiple benign tumors raises suspicion for systemic congenital disease. A cooperative surgical approach contributes expertise in the technical elements of surgery to ensure a good outcome for this patient. However, a holistic perspective of the patient at her initial presentation may have established a definitive diagnosis prior to surgery.

This case highlights a multidisciplinary approach to the diagnosis and surgical management of a medically complex patient. Working in the isolation of a specific organ system is often sufficient but may fall short when identifying patients with multi-organ system disease involvement.

Liaqat, A.; Villareal, R.; Tangco, M.; Patak, P.; Barlas, A.; and Abdalsalam, B.

The neurologic complications of type 1 diabetes mellitus may involve dysregulation of the myenteric plexus resulting in esophageal dysmotility, gastroparesis and/or intestinal gastroparesis.  Together, these adverse effects can culminate into intractable gastroesophageal reflux disease with the resultant development of esophageal strictures.  We report the case of a type 1 diabetic patient with persistence of GI strictures refractory to repeated dilatation attempts.

A 25-year-old male with type 1 diabetes mellitus and recurrent esophageal strictures status post-recurrent esophagogastroduodenoscopy (EGD) dilatations who presented with reports of intractable nausea, vomiting, and an inability to tolerate oral intake. Repeat endoscopic evaluation revealed grade D esophagitis involving the mid and distal esophagus in addition to the presence of an esophageal stricture at approximately 35 cm of scope preventing further endoscope passage.  A scope balloon was then passed across the stricture and was inflated to 12 mm to dilate the affected segment.  Notable improvement was witnessed in the immediate postoperative setting. Thus far, the patient has been managed conservatively with empiric proton pump inhibitor therapy with further recommendations to undergo repeat EGD to assess disease progression.

Recurrent esophageal strictures can be evidence of advanced diabetic gastroparesis and result in worse outcomes.  Proton pump inhibitors remain the first-line therapy in the management of such events.  Other conservative strategies include esophageal dilation via EGD using push or balloon dilators.  Surgical options include subtotal esophagectomy involving the affected segments.

There should be a low threshold to perform endoscopic evaluation in a type 1 diabetic patient with persistent gastroparesis or GERD symptoms to evaluate for the presence of esophageal strictures if left untreated these structures can result in aspiration, rupture, perforation or malnutrition; therefore is important to identify this condition before such complications arise.

Jamie Kilpatrick Morrow, DO; Adnan Liaqat, MD; Sheila Hernandez, MD; and Dhaval Pau, MD

Refeeding syndrome (RS) is a well described clinical condition that is relatively rare in the developed world, and carries a high mortality.  The syndrome involves development of metabolic abnormalities after initiation of feeding, including: hypophosphatemia, hypokalemia, and hypomagnesemia. We present a case of acute respiratory failure related to respiratory muscle weakness and diaphragmatic paralysis as a consequence of severe refeeding hypophosphatemia.

A 56-year-old male patient with hypothyroidism, and rheumatoid arthritis was admitted to the hospital with severe constipation and minimal PO intake for several days. He required a nasogastric tube for decompression and repeated colonoscopies to relieve stool impaction. After improvement of his gastrointestinal issues, the patient was started on a diet. Subsequent to this, the patient developed acute hypoxic and hypercapnic respiratory failure requiring intubation and invasive mechanical ventilation. Workup for the usual causes of respiratory failure was unremarkable. Further investigation revealed drastically low levels of phosphorus (<1.0), along with hypomagnesemia. The diagnosis of respiratory muscle weakness and diaphragmatic paralysis was made. After optimization of his electrolytes and nutritional state, patient was successfully extubated. 

Refeeding syndrome is associated with a significant increase in mortality and morbidity particularly in critically ill patients. One predominant feature of RS is hypophosphatemia, which can impair diaphragmatic contractility. Even hypocaloric feeding in chronically malnourished patients can precipitate refeeding syndrome.

Physicians need to be mindful of refeeding hypophosphatemia in patients with minimal oral intake. Early recognition and prompt treatment can avoid worse outcomes.

Sheila Hernandez, Tariq Fateeha, and Abdalslam Bsmah

With the emergence of the COVID-19 pandemic and the subsequent formulation of a new vaccine with hundreds of millions doses administered world-wide, close surveillance for adverse effects have been monitored rigorously.  Although, mRNA vaccines produced by Pfizer and Moderna have been relatively safe, a new entity has surfaced related to the ChAdOx1 nCoV-19 adenoviral vector vaccine, known as Vaccine Induced Thrombotic Thrombocytopenia (VITT). Criteria for diagnosis has been proposed. Authors noticed similarities of this pathology to Heparin Induced Thrombocytopenia (HIT) as both are produced by antibodies against platelet factor 4 (PF-4), VITT however, is not associated with Heparin treatment.

We present the case the of a 22 year old Hispanic male farm worker who was brought to our Emergency Department with the chief complaint of left Lower extremity swelling found to have deep vein thrombosis and severe thrombocytopenia approximately 4-6 weeks after being vaccinated by the vaccine provided by his employer.  After extensive workup with findings of severe thrombocytopenia, thrombosis, a D-Dimer above 5,000 but a negative PF-4 antibody, the diagnosis of probable VITT was made.

In medicine, we often see diseases that can be diagnosed based on clinical evidence alone, but when faced with a negative biomarker necessary for the confirmation of the same, we are placed in a position of uncertainty and management becomes more challenging for which formulations of Criteria for the diagnosis of certain diseases are a useful tool for the clinician.

Mandyam S; Liaqat A; Foster B; Chaudary A; Villareal R; and Abdalsalam B

Limb girdle muscular dystrophy (LGMD) is a genetic disorder predominantly involving the proximal muscle groups. It rarely involves cardiac muscle; exhibiting as arrhythmia, conduction block, and cardiomyopathy. Here we report the case of a young female with underlying limb-girdle muscular dystrophy suffering from a rapidly progressive cardiomyopathy.

A 24-year-old female presented to the hospital with worsening dyspnea, decreased activity, and orthopnea. She was diagnosed with progressively worsening LGMD involving the pelvic, girdle, and shoulders at the age of 13. She denied any family history of similar disease. Physical exam revealed jugular venous distension, bibasilar crackles, and bilateral pedal edema. Laboratories were significant for a BNP elevated to 1402 with negative cardiac enzymes. EKG revealed normal sinus rhythm with presence of a few premature ventricular complexes. Echocardiogram was completed that revealed an ejection fraction (EF) of 10% visually. Upon further questioning, the patient reported a prior ejection fraction of 25-30%, noted on a prior echocardiogram completed at an outside facility. Nuclear stress test was negative for any definitive ischemia or infarct and findings were consistent with a severe dilated cardiomyopathy with EF of 12%. She was started on beta-blockers and diuretics with eventual plans for implantable cardioverter defibrillator (ICD) placement.

Our patient was diagnosed with severe ventricular dysfunction felt secondary to her underlying LGMD at the young age of 24. Considering lack of any family history of structural and electrophysiologic disease along with negative work up related to ischemic heart disease and absence of other risk factors, rapid progression of cardiac involvement was attributed to underlying LGMD.

Patients with LGMD require close cardiac monitoring in anticipation of a rapidly progressive cardiomyopathy that can lead to severe cardiopulmonary manifestations and fatal arrhythmias.

Tyler Finkenthal, Zackery Aldaher, and Salman Ahmed

The association between previously diagnosed autoimmune hemolytic anemia and exacerbations due to COVID-19 infection is a rare phenomenon that is not well understood.

In this case, we present a 68 year old female with a past medical history significant for systemic lupus erythematosus, splenectomy, and autoimmune hemolytic anemia since childhood that has been very well controlled with only one previous exacerbation. This patient’s chief complaint and clinical symptoms at admission were related to her hemolytic anemia and not her active COVID-19 infection.

This case report reveals a possible association between the cytokine storm caused by COVID-19 and the exacerbation of previously well controlled autoimmune diseases.

Sahar Baloch, Sagar Kulkarni, Paramjit Kaur, Pau Dhaval

Myonecrosis is a complication of carbon monoxide (CO) poisoning and few cases have been reported. It usually occurs in severe CO toxicity and symptoms vary from tachycardia, tachypnea and CNS depression. Pathophysiology of CO poisoning results in direct cellular toxicity with various mechanisms that leads to necrosis and other cellular injury.

Patient is a 28 year old male with a history of illicit substance use, mainly of amphetamines. He was transferred from an outside facility where he was found to be hyperthermic with a temperature of 105.0F, pinpoint pupils, hypoxic with SPO2 68. He was emergently intubated and transferred to ICU.  UDS positive for amphetamines.  Labs were suggestive of AKI due to possible myonecrosis. Patient was closely monitored in the ICU and remained intubated throughout his course. Neurology was consulted, MRI brain showed bilateral evidence of anoxic brain injury which correlated with the clinical suspicion of CO poisoning.  EEG showed slowing, concerning poor prognosis.  Over hospital course, palliative care was consulted and later transitioned patient to comfort care.

CO myonecrosis is a complication of severe CO toxicity. Our case is a significant contribution to existing data of case reports on CO induced myonecrosis as very few cases have been reported so far and literature is very limited. Timely presentation to the hospital and less exposure to offending agents would have changed the outcome. If within the time frame carboxyhemoglobin levels should be checked, as delay in treatment can result in poor outcome.

Sagar Kulkarni, Sahar Baloch, Sasha-Kay D'Aguilar, Pau Dhaval

Myxedema coma refers to a state of life-threatening and decompensated hypothyroidism in which thyroid hormone levels are dangerously low. Diagnosis appears to be more common in elderly women with long standing pre-existing hypothyroidism. Some precipitating factors may include infection, stroke, heart failure or use of certain medications. Typical presentation includes lethargy, altered mentation, bradycardia and hypothermia. Atypical presentation is rare and difficult to diagnose.

Patient is a 64 year old female with a past medical history of end-stage renal disease on hemodialysis, hypothyroidism, paroxysmal atrial fibrillation, and mechanical aortic valve who presented with bright red bleeding per rectum. Hospital course was complicated with hypotension while receiving blood transfusion for which she was transferred to ICU. Initial working diagnosis was septic shock requiring maximum vasopressor support. TSH was initially normal, however significantly elevated on later recheck. Home medications were reviewed and noted to be missing home levothyroxine. With trial of IV levothyroxine and IV hydrocortisone, her pressor requirements improved and were weaned off and later was able to be transferred out of ICU.

Cardiogenic shock in the setting of severe hypothyroidism is a rare complication of severe disease. Our case is a significant contribution to the existing data on case reports to thyroid related emergencies and complications. This case illustrates how proper diagnosis of an atypical presentation along with appropriate treatment can help to shorten the hospital stay and prevent complications.

Andrea Ollarves, OMS-III; Victoria Phillips, DO; Karen Terry, DO, Tahmina Zafar, MD, and Bsmah Abdalslam, MD

Cancer of Unknown Primary (CUP) defines those cancers where metastasis is found to be the primary manifestation and extensive imaging and laboratory studies do not reveal the origin of the disease. Without finding the source of metastatic disease, progression and treatment become murky at best. We hope to highlight a patient’s course from the unknown to diagnosis.

This case follows a 68-year-old African American female who presented with worsening chronic lower back pain that was poorly controlled with pain management. After extensive imaging, she was found to have innumerable osseous metastases spanning the entire spinal column. An initial diagnosis of multiple spinal and pelvic lesions concerning for metastatic disease with unknown primary was given, and a workup for Multiple Myeloma was started.  

Preliminary bone biopsy report of patient’s osteolytic metastases showed plasma cells which lead us to suspect Multiple Myeloma. CA 19-9, CEA, Immunofixation (Urine and Serum), Urine Protein Electrophoresis, and Serum Protein Electrophoresis were collected and returned negative. Final bone biopsy showed hypercellularity containing aggregate nests of atypical mononuclear cells. Immunohistochemistry showed cells positive for AE1/3, GATA3, and ER, indicating possible breast cancer as a primary source. Re-review of patient’s last mammogram, completed 2 months before hospital stay, shows a subtle soft tissue density hidden by heterogeneously dense fibrotic breast tissue.

This report illustrates a case of CUP that was able to be resolved with continuous testing. It is unusual to have such a small lesion lead to such a widespread metastatic disease.

Anthony Noll; Jaydip Desai; Sammy Dahan; and Kirkland Bradshaw

The purpose of this case is to highlight the patient safety risks that can occur with home rehabilitation after a Post-ORIF surgery. Specifically, this case will highlight potential risk factors for sepsis and prevention of these precipitators.

Mr. John Doe is a 90-year-old male presenting to the ICU with a severe complicated UTI secondary to obstructive nephrolithiasis. It is believed that this patient acquired an Escherichia Coli/Enterobacter spp. combination infection due to poor bathroom hygiene practices. Prior to this admission, the patient underwent an ORIF for a greater trochanteric fracture secondary to a fall. Multiple physical therapy, occupational therapy, and home healthcare members were unable to identify the increased risk of infection possibility in this patient.

Patient that suffers from complicated infections in the outpatient setting should be considered for constant screening and evaluation of potentiating factors that can lead to hospital readmissions. Multiple studies highlight the use of preventative practices to avoid the possibility of the transfer or self-inoculation of an infectious organism. These measures have been adjusted to protect against the transfer of the COVID-19 virus, but holes in screening are identified for other conditions/organisms.

Patients that are at an increased risk for acquiring an infection in the home setting should be evaluated and reevaluated for risk factors and preventative measure to avoid complications in their outpatient and home health care.

Sheila Hernandez; Erica Roman; and Krishnamohan Basarakodu

Chronic neutrophilic leukemia is an extremely rare entity that overlaps with some of the more common diseases such as CML, which is also diagnosed on the basis of neoplastic expansion of granulocytic cells, or infection identified by a left shift. The implementation of diagnostic criteria of CSF3R mutation has been the essential part of appropriately diagnosing this disease.

A 78-year-old Caucasian female without any significant past medical history presented to an outside facility with trauma on the right hand that was presumed to be infected and was treated as cellulitis. She was noted to have a WBC of 67,800 upon presentation. Further workup including blood cultures was negative. Peripheral blood smears showed leukocytosis suspicious for myeloproliferative neoplasm, however, she demonstrated a negative FISH for BCR/ABL1-ASS1, making CML unlikely. Further evaluation demonstrated a positive CSF3R mutation leading to the diagnosis of chronic neutrophilic leukemia.

Chronic neutrophilic leukemia is a rare and aggressive BCR-ABL negative myeloproliferative neoplasm that presents with predominant neutrophilic leukocytosis and hepatosplenomegaly. The discovery of the colony-stimulating factor 3-receptor  (CSF3R) oncogene in patients with CNL not only allowed for a better understanding of the pathogenesis of the disease, but it also facilitated its categorization as a separate entity from the well known CML.

Chronic neutrophilic leukemia can present with an incidental finding of leukocytosis with neutrophilic predominance. Therefore, in patients with clinical manifestations of poor wound healing despite antibiotic management and significant leukocytosis, further evaluation for an underlying malignant leukemia should be considered.

Bailee Keefe, OMS-I; Katherine Whalen, OMS-1; and Ariail Schmitz, DO

IgA Vasculitis is typically a pediatric illness that follows an upper respiratory or GI infection. While it is normally a self-limiting disease, in severe cases, it can result in renal failure, bowel perforation, and death. This small vessel vasculitis commonly manifests with a tetrad of arthralgias, palpable cutaneous purpura, abdominal pain, and nephritic syndrome.

A 19-year-old landscaper was bitten on his left lower leg by a non-venomous spider and then a non-venomous snake the next day. Four days after the initial bite, he developed a worsening rash and abscess at the bite site. The patient was prescribed antibiotics and ivermectin, for potential scabies. Six days after the initial bite, he presented to the ER with worsening rash and localized swelling. Patient denied any abdominal pain, arthralgias, hematuria, or hematochezia. Cultures of site showed a superimposed MRSA infection. A skin biopsy of the lower extremity rash confirmed concomitant IgA Vasculitis.

This patient’s lack of normal presenting tetrad and abnormal precipitating insults demonstrates an uncommon presentation of adult IgA vasculitis. Insect bites can induce IgA vasculitis but given that he also had a concomitant nonvenomous snake bite and resulting local MRSA infection it is difficult to assess which was the provoking agent.

In IgA Vasculitis, an early diagnosis can greatly reduce damage due to associated complications within multiple organ systems. Performing a skin biopsy is crucial to an accurate and timely diagnosis of IgA Vasculitis in patients who do not clearly exhibit the classic tetrad of IgA symptoms.

Katherine Whalen, OMS-I; Bailee Keefe, OMS-I; and Ariail Schmitz, DO

Pars planitis, also called intermediate uveitis, is an autoimmune process that causes macular edema and intra-vitreous inflammatory debris that can lead to insidious and possibly permanent vision loss. This disease process can be idiopathic or associated with multiple sclerosis and sarcoidosis. Rarely is it linked with spondyloarthropathies, inflammatory bowel disease, and psoriasis, as they typically induce anterior uveitis.

32-year-old G1P1 female, 3 months post-partum, presented with progressively worsening bilateral blurry vision. She was referred to ophthalmology and found to have pathognomonic “snowballs” in her retinal exam consistent with pars planitis. Autoimmune and neurological was overall unremarkable. On physical exam patient had slivery plaques consistent with psoriasis in her external auditory canal with no other skin involvement. Her review of systems was overall negative except of fleeting arthralgias, which were new since her delivery. She was treated with interocular steroid injections and adalimumab, resulting in remission.

Autoimmune disorders often affect women in their reproductive years. It is still unknown if pregnancy is causative or simply reveals these disorders in affected individuals. Similarly, psoriasis symptoms are sometimes reported to improve during pregnancy and worsen after delivery. This case also demonstrates that pars planitis can be induced by psoriasis with minimal disease burden, despite occurring more frequently with severe psoriasis.

A low threshold of suspicion should be maintained in postpartum patients to aid in the identification of new autoimmune processes or manifestations. Vision changes should especially be sent for prompt ophthalmology evaluation to mitigate permanent damages that could be caused by uveitis.

Leah Grcevich, OMS-IV; Fateeha Tariq, MD; Sheila Hernandez, MD; and Ariail Schmitz, DO

Statins are commonly prescribed due to robust evidence of cardioprotective effects.  Although rare, statins are linked to immune-mediated necrotizing myopathy (IMNM) which is characterized by symmetric proximal muscle weakness, frequently without myalgias, elevated creatine kinase levels, positive Anti-HMGCR, and muscle necrosis on muscle biopsy. Even rarer is the seronegative IMNM accounting for 25-40% of IMNM.

An 82-year-old female with a history of hypertension and osteoarthritis presented to the emergency department for evaluation of ambulation difficulties due to generalized weakness for a week and clonic movements of upper extremities with sustained positioning. The patient was found to have a creatinine level three times her baseline, nephrotic range proteinuria, and elevated creatine kinase. Her medications included meloxicam and hydrochlorothiazide with the addition of rosuvastatin three months prior. A muscle biopsy showed necrotizing myopathy, with MHC1 marker positivity. Anti-SRP and Anti-HMG CoA reductase levels were negative. The patient was started on oral prednisone for IMNM and showed clinical improvement over the following days with complete renal recovery.

Seronegative IMNM has a female predominance and can occur in statin naive patients. However, given this patient’s rapid improvement with steroids and discontinuation of her statin, this was likely statin induced. This case also demonstrates the value of limiting polypharmacy in geriatric patients, especially when perceived benefit is minimal.

IMNM should be considered in patients complaining of severe weakness without myalgias especially with the recent addition of statin therapy. Diagnosis is confirmed through muscle biopsy as seronegativity can occur occasionally.

Navid Leelani; Larry Stutts, Jr.; and Robert Bailey

Gastric perforation is a well-studied surgical emergency involving the formation of a passageway between the gastric lumen and the peritoneal cavity. The most common etiology of gastric perforations is full-thickness erosion of a peptic ulcer but other causes include interventional procedures, trauma or malignancy.

A 67-year-old male with past medical history of CVA, HTN, and HLD and no known abdominal surgical history who presented to the emergency department in an unresponsive state and severely distended abdomen. On examination the patient had a severely distended abdomen that was tympanic and mottled along with mottling of the skin of the bilateral lower extremities. Patient underwent computed tomography (CT) scan of the chest, abdomen, and pelvis with and without contrast which showed a massive amount of pneumoperitoneum. The small bowel and colon appeared normal and the inferior vena cava (IVC) was nearly completely compressed. In this case, nasogastric tube placement likely led to decompression of the gastric lumen and spontaneous sealing of the perforation.

Based on the patient’s medical history, clinical presentation and post-operative imaging the likely etiology of his perforation was barotrauma. Furthermore, the site of perforation at the lesser curvature of the stomach points toward an iatrogenic cause.

This case highlights an interesting presentation of a self-resolving gastric perforation. Although this was a unique presentation, evidence-based management led to a favorable outcome for the patient.

Jaydip Desai, OMS-III; and Saum A. Rahimi, MD

Abdominal aortic aneurysms occur due to a weakening in the aorta, most commonly infrarenal but above the iliac bifurcation. One rare complication that has known to develop before or after surgical repair is an aorto-enteric fistula, when communication between the arterial vessel bowel develops.

A 67-year-old male presented to the emergency room with an acute episode of lower abdominal pain and nausea. Physical exam was remarkable for a pulsatile mass the left of midline. CT w/ contrast of the abdomen showed a large infrarenal abdominal aortic aneurysm with circumferential mural thrombus measuring 10cmx9cm. The duodenum was wrapped around the anterior aspect of the aneurysm, placing the patient at risk for development of an aortoenteric fistula. The decision to perform an open repair versus endovascular was made, given the nature of the anatomy not being amendable with endovascular repair.

Primary aorto-enteric fistulas formations are rare with a .007 per million incidence rate and can be fatal almost up to 100% of the time if not managed. The most common predisposing condition for an aorto-enteric fistula is an atherosclerotic abdominal aortic aneurysm. A delay in identification can exacerbate underlying gastrointestinal bleeding.

This case highlights the importance of clinical suspicion for immediate surgical intervention when focal tethering of a bowel loop is immediately adjacent to the aorta. Early detection of complications with such given nature can help reduce morbidity and mortality associated with AAAs.

Abiotrophia defectiva is a nutritionally variant Streptococci (NVS) and a rare cause of endocarditis, representing less than 1 % of endocarditis cases. It can produce culture-negative endocarditis with diagnostic and treatment issues.

An 89 year-old man with a history of shingles and back pain initially presented to the ED for leg pain and was found to have a UTI on urinalysis with mild leukocytosis and low fever. He was stable and discharged with nitrofurantoin and gabapentin. However, he was readmitted due to two blood culture positive for A. defectiva, with concerns for endocarditis that possibly was dismissed by the patient as untreated tickborne illness in the past. He was started on IV vancomycin and piperacillin/tazobactam, and a TEE found mitral vegetation confirming native valve endocarditis. He was discharged to home health with 4 weeks IV penicillin and gentamicin, and cardiology follow-up.

Abiotrophia defectiva do not synthesize common media nutrients, requiring special media. A. defectiva is also pleomorphic based on media. Less than 150 cases of A. defectiva endocarditis have been documented. A. defectiva has a higher affinity for endocardium and increased extracellular matrix binding ability. This results in higher virulence, with higher rates of septic emboli, treatment failures, and mortality. Our case represents a rare microbiological finding and an important look its course.

Spinal cord hemorrhage is a rare condition typically caused by trauma, stroke, bleeding disorders and vascular malformations. There is established data for hypertensive emergency causing intracranial hemorrhages, however there are no cases with spontaneous spinal cord hemorrhages without underlying malformation.

66-year-old female presented with severe back pain. Initial blood pressure was found to be 240/160 mmHg which was treated with nicardipine drip. Despite adequate blood pressure control, severe back pain persisted. MRI of the spine revealed thoracic hematoma but was inconclusive for intradural or extradural hemorrhage. Lumbar puncture yielded grossly bloody fluid and CT of the head was negative for intracranial bleed. Subsequent cerebral and spinal angiogram showed no evidence of aneurysm, arteriovenous malformation, or fistula to explain the etiology of hematoma. She was treated medically for her back pain and did not require surgical decompression.

Work up revealed no malformation or coagulopathy that could have predisposed her to her spinal cord hemorrhage. Since spinal cord hemorrhage without vascular malformation is extremely rare, this leads us to believe the inciting factor to be her hypertensive emergency.

Hypertensive emergency is a common hospital admission diagnosis, however the occurrence of spinal cord hemorrhage is very rare in this setting. Severe back pain in the setting of hypertensive emergency should prompt imaging of the spine to rule out hemorrhage.

Henoch-Schönlein purpura (HSP) is a small vessel IgA vasculitis mainly affecting the capillaries of the skin, joints, kidneys, and gastrointestinal tract, common under 10 years of age; however, rarely can present in adulthood. Early data suggest that patients with specific HLA haplotypes show an increased susceptibility to HSP.

18 y/o male presented with intermittent, sharp and crampy, lower abdominal pain for 3 days associated with a rash and swollen and painful joints of the bilateral ankle, wrist, knees, and back for 7 days. Family history significant for HSP (brother) and lupus (maternal grandmother). Work up revealed urinalysis 3+ protein and 3+ blood, proteinuria > 1g/day, and 1.06 serum creatinine. He was started on course of ciprofloxacin, metronidazole, and prednisone in the setting of recently diagnosed colitis and possible HSP nephritis. Subsequently, kidney biopsy was consistent with IgA nephropathy with crescent formation present.

This patient presented in late adolescence with a positive family history for HSP. Although early studies suggest a potential link between HLA haplotype DQA1*01:01/DQB1*05:01/DRB1*01:01 and patient susceptibility to HSP, data does not show a potential link between the genetic component and the severity of renal involvement. In our patient the severity and consistency of renal involvement is instead, likely attributed to the late onset of HSP in this patient.

Rare adult onset HSP are associated with severe renal involvement and the ability to mimic other conditions it is critical for physicians to rule out HSP in the clinical settings.

Remdesivir is an antiviral, nucleotide analogue agent that has been extensively used during the SARS-CoV-2 (COVID 19) pandemic which has proven to reduce the duration of hospitalization in severely-ill COVID-19 patients. Commonly reported adverse effects of Remdesivir include nausea, vomiting, transaminase elevations, anemia, acute kidney injury, fever, and hyperglycemia. However, scant evidence exists regarding the cardio-toxic profile of Remdesivir more especially bradycardia and heart block.

In this case, we detail the clinical course of a 50-year-old female with a past medical history of atrial fibrillation, hypertension, coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD) who presented to the emergency room with worsening hypoxia and shortness of breath (SOB). She was subsequently diagnosed with COVID-19 and admitted for treatment. As the patient status continued to deteriorate, she met criteria for treatment with Remdesivir. The patient developed asymptomatic bradycardia with pulse 30-40 bpm.  Despite stopping patient’s home beta blocker medication and ensuring she was not on any other heart rate-limiting therapeutics, she developed a sinus pause for three seconds.  Remdesivir was discontinued and she did not develop any further sinus pauses.  There are recent reports of an association between Remdesivir and  AV nodal blockade, possibly attributed to an active metabolite; a nucleotide triphosphate derivative which is similar to adenosine triphosphate. The patient`s bradycardia started to improve gradually within 48 hours after discontinuation of remdesivir.

When considering the use of Remdesivir, the potential for its cardiotoxic adverse effects, most importantly bradycardia, should be acknowledged. Other efficacious agents may be considered in patients with increased risk for cardiovascular compromise who need antiviral therapy to treat COVID19. 

Remdesivir should be acknowledged for its arrythmia-producing cardiotoxic profile and should be employed tactically in the management of COVID-19 in patients with pre-existing comorbidities that affect the cardiac conduction system. Intensive cardiac surveillance is necessary for patients who develop Remdesivir-associated bradycardia.

SARS-COV-2 (COVID-19) predominantly involves lungs. However, there has been an increasing incidence of various arrhythmias presenting in patients with COVID-19. Atrial fibrillation (AF) has been classically noted to develop as a longstanding complication of chronic lung disease. However, here we present a case of particularly difficult to control atrial fibrillation with rapid ventricular response in a patient with COVID-19.

A 46-year-old female with stable coronary artery disease and hypertension presented with palpitations for a few hours. Initial EKG demonstrated AF with rapid ventricular response (RVR). Imaging studies revealed patchy opacities in her lungs bilaterally, suggestive of COVID-19 pneumonia. COVID-19 test returned positive although she did not require supplemental oxygen and was asymptomatic from a respiratory standpoint. Initially, rate with intravenous diltiazem bolus was unsuccessful. Subsequent chemical rhythm control with procainamide was also unsuccessful. Cardioversion was then attempted repeatedly without success. Eventually rate control was achieved with continuous diltiazem infusion. She was discharged on oral rate control medications and therapeutic anti-coagulation.

To our knowledge, this appears to be a rare case of refractory AF in an otherwise asymptomatic COVID-19 positive individual. Initially, beta-blockers and anti-arrhythmics were avoided due to risk of bronchospasm and potential drug-drug interactions between empiric antibiotics, anti-viral agents, and anti-arrhythmics; most notably QTc prolongation. Thus, clinicians must cautiously approach AF RVR treatment in patients with coexisting COVID-19 infection. Furthermore, the increased thromboembolic risk should be kept in consideration when anticoagulating patients with low CHA2DS2-VASc scores and active COVID-19 infection.

In patients with newly developed AF, COVID-19 testing should be considered as part of routine diagnostic workup despite the absence of respiratory complaints.

Fateeha Tariq, MD, Adnan Liaqat, MD, Qamar Gulzar, MD, Brian Foster, MD, Bsmah Abdalsalam, MD, Jose F. Ramirez, MD, Ramesh Swamiappan, MD 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can exhibit a wide range of clinical manifestations, from no symptoms to critical illness. Mild Thrombocytopenia is one of the commonly reported complications of COVID-19, but severe thrombocytopenia in the context of COVID-19 associated ITP is a rare complication.

72-year-old female with past medical history of coronary artery disease and COPD, who was recently admitted with COVID-19 pneumonia, presented with complaint of epistaxis, noted to have petechial rash with platelet count of 2000 after 26 days of COVID-19 diagnosis. Upon evaluation, her D-dimer was 674 ng/mL and LDH 765 U/L. She tested negative for HIT antibody, Serotonin release assay, Hepatitis C antibody, and HIV screen. Also, VIT B12 , folate levels, and ADAMTS13 activity were within normal range. Peripheral blood smear revealed morphologically normal appearing platelet however markedly reduced in number, absence of clumping, schistocytes or any findings suggestive of bone marrow failure.  Patient was treated with IVIG and high-dose steroids. She showed excellent response to treatment and platelet improved to 53,000 at the time of discharge.

ITP should be considered as late onset extra pulmonary complication of COVID-19.  Close follow-up of patients with COVID-19 after discharge is prudent and should be evaluated for ITP by primary care doctor if signs and symptoms are suggestive.

James Case, MD; Adnan Liaqat, MD; Fadi Bader, MD; Grant Gregory, OMS; and Yogesth Gujrati, MD

Iodinated-based contrast agents (IBCAs) are widely used in various imaging modalities including cerebral angiograms. Neurotoxicity is a rare adverse reaction to these agents resulting in temporary to permanent neurologic deficits. The aim of this case presentation is to highlight contrast-induced neurotoxicity that followed a cerebral angiogram in a 60 year old woman.

A 60-year-old woman with a history of recurrent strokes and cerebral aneurysm with primary coil embolization underwent elective cerebral angiogram to evaluate residual anterior communicating artery aneurysm. Post procedure she developed altered mental status, lethargy and weakness. CT revealed sulcal effacement with loss of gray-white matter differentiation involving the right cerebral hemisphere though MRI was without evidence of infarct. She was treated with high dose IV steroids for cerebral edema and levetiracetam as seizure prophylaxis. Repeat CT revealed restoration of the gray-white matter differentiation of the right cerebral hemisphere; neurological symptoms lagged though she clinically improved over time.

IBCAs can lead to diverse neurological sequalae, the pathophysiology of which remains controversial with theory surrounding breakdown of the blood-brain barrier leading to cerebral edema and chemotoxicity. Altered mental status, hemiparesis and visual changes are common findings alongside evidence of sulcal effacement.

IBCAs are an essential media though not without risk, the awareness of which may help understanding and prompt recognition of symptoms leading to appropriate treatment. Toxicity may be dose dependent or idiopathic, of which further research would help elucidate pathology and risk factors.

James Case, MD; Erin Park, OMS; Jose Fausto Ramirez Porres, MD; Dhaval Pau, MD; Shanna Killebrew, PA-C; and Ramesh Swamiappan, MD

Angioedema is characterized by swelling through dysregulation of histaminergic response or bradykinin leading to unchecked inflammatory cascade and vascular activation giving rise to vasodilation, increased permeability and hypotension. COVID-19 exhibits a similar mechanism by which des-arginine9-bradykinin(DABK), an analog of bradykinin acting on the same receptors, is left unchecked by depleted ACE2. Coincident activation of inflammatory pathways in an individual with both hereditary angioedema(HEA) and COVID-19 infection is described below.

51 year old female with C1 inhibitor deficiency was admitted for acute hypoxic respiratory failure due to COVID-19 pneumonia and was emergently intubated. Imaging revealed findings compatible with COVID-19 pneumonia. She was treated with dexamethasone, and continued on her home Haegarda, a C1 inhibitor. Firazyr, a bradykinin 2 receptor antagonist, was kept at bedside in case of emergent angioedema attack. She was continuously evaluated for laryngeal edema with cuff leak tests which were negative. She deteriorated, developing ARDS and worsening hypotension with unsuccessful spontaneous breathing trials.  

HAE is an autosomal dominant condition with deficient C1 inhibitor leading to a cascade of activating pathways. The involvement of bradykinin receptors through excess DABK in COVID-19 likely worsens or predisposes to exacerbation in individuals with HAE by loss of respiratory epithelial integrity and subsequent ARDS. 

The pathogenesis of HAE overlaps with that of COVID-19 thereby elucidating potential mechanisms which may be affected so as to alter the natural course of disease. Targeting inflammatory cascades and their constituents, such as bradykinin, may lead to a potent treatment for COVID.

James Case, MD; Jose Fausto Ramirez Porres, MD; Dhaval Pau, MD; Shanna Killebrew, PA-C; and Ramesh Swamiappan, MD

Idiopathic pulmonary fibrosis(IPF) is a progressive condition involving gradual, unrelenting fibrosis of the lungs through recurrent lung epithelial injury and abnormal repair with subsequent respiratory failure. COVID-19 pneumonia, through severe inflammation, leads to progressive fibrosis often lingering after resolution of infection. An individual with IPF infected with COVID-19 is at greater risk of exacerbation and worsening disease as subjected to an inflammatory environment with ongoing epithelial injury.

75 year old male with IPF was admitted for acute hypoxic respiratory failure in the setting of COVID-19 pneumonia. His imaging on presentation revealed bilateral ground-glass opacities superimposed on a pattern of usual interstitial pneumonia. His home medication, nintedanib, was continued during hospitalization, along with a COVID-19-directed regimen of dexamethasone. He continued to deteriorate, eventually requiring intubation and mechanical ventilation.

The pathophysiology of IPF involves abnormal lung epithelium predisposed to injury and subsequent abnormal repair attempts leading to progressive fibrosis. Two therapies have been identified in treating IPF, including pirfenidone and nintedanib, targeted at inhibiting fibrosis. COVID-19 pneumonia often leads to a prolonged secondary organizing pneumonia as evidenced by lingering fibrosis following infection similar to that of IPF, the pathophysiology of which involves inflammation and resultant fibrosis. COVID-19 therefore predisposes individuals with IPF to exacerbation and progression due to lung injury alongside an inflammatory cascade.

As the pathogenesis of both IPF and COVID-19 both involve lung damage and abnormal repair leading to extensive fibrosis, directed therapies towards inhibiting fibrotic changes may lead to an effective treatment.

James Case, MD; and Akinola Ayodeji, MD

Diabetic myonecrosis is a complication of uncontrolled diabetes with suspected pathophysiology involving microvascular damage with probable embolic phenomenon leading to tissue ischemia and necrosis. It may present as a unilateral lower extremity swelling and pain not dissimilar to cellulitis or other soft tissue infectious processes such as necrotizing fasciitis.

44 year old female with diabetes mellitus type 2 presented with right leg swelling and pain and admitted for sepsis secondary to cellulitis. A course of antibiotic treatment was initiated and MRI performed, revealing diffuse edema within the musculature consistent with myositis and concern of compartment syndrome for which surgery was consulted. Biopsy revealed findings consistent with diabetic myonecrosis. Antibiotics were withdrawn, and treatment was continued with analgesia and tight glucose control. Her pain and swelling improved prior to discharge.

Diabetic myonecrosis presents a difficult clinical scenario given it's rare occurrence and similarity with other disease processes though different management. MRI is the modality of choice revealing myonecrosis and edema within a muscle compartment, usually with unilateral involvement of a lower extremity. Antibiotics are not warranted and the natural history of the disease process is eventual, spontaneous resolution, however management with anti-inflammatory agents, pain control, and tight glucose control typically ensures quicker improvement.

Greater awareness of diabetic complications such as diabetic myonecrosis may lead to more apt diagnoses and prompt treatment of this painful condition. Patient education regarding disease presentation and glucose control may help lead to early diagnosis and prevent recurrence.

Matthew Mason, Adnan Liaqat, Awais Farooq, Brain Foster, Pooja Patak, Stephen Valle, and Arash Velayati

Pulmonary vein thrombosis (PVT) is a rare, life-threatening condition with an unknown incidence in patients with diffuse large B-cell lymphoma. PVT is exceedingly rare particularly in the absence of lung transplantation, lung lobectomy, or underlying lung malignancy. To our knowledge, there are no reported cases of pulmonary vein thrombosis in a patient with underlying diffuse large B-cell lymphoma.

A 63-year male with diffuse large B-cell lymphoma undergoing chemotherapy was admitted after routine laboratory findings revealed severe thrombocytopenia and neutropenia. At the time of admission, the patient met SIRS criteria, but further workup for potential sepsis was negative. Computed tomography (CT) scan of the chest incidentally revealed a left lower lobe pulmonary vein thrombus. After receiving platelet transfusion, our patient was started on therapeutic anti-coagulation with Apixaban.

The diagnosis of PVT can be established with imaging modalities such as transesophageal echocardiogram (TEE), magnetic radiation (MR) imaging and CT scan with contrast. Anticoagulation and thrombectomy are the most commonly used therapies for PVT whereas lobectomy has been reserved for severe cases of PVT with pulmonary necrosis and extensive hemoptysis. Notably, there is no expert consensus on treatment of PVT due to a paucity of data.

We report a rare case of PVT in a patient with diffuse large B-cell lymphoma. Early identification and prompt treatment with anti-coagulation can prevent further complications related to PVT. However, further studies on PVT are needed to provide clarity and consensus on management of this unique condition.

Nurbanu Selvi, MD; Barsbold Ganbat OMS, James Case, MD, and David Hewitt, MD

Drug reaction with eosinophilia and systemic symptoms (DRESS) Syndrome is a form of severe multisystem reaction to an offending drug. Nitrofurantoin is an antibiotic which is commonly prescribed for urinary tract infections and is a rare cause. This case report is to bring awareness to keep DRESS syndrome in the differential diagnosis for a patient presenting with rash and systemic symptoms.

59-year-old female was admitted to the hospital with fever, pancytopenia, eosinophilia, and rash after a week of nitrofurantoin prescribed for an UTI. On exam, the rash was found to be petechial, non-blanching vasculitis-like on bilateral extremities as well as blanching macular rash across her abdomen and back. Extrinsic hemolytic anemia was ruled out with a coombs test and peripheral smears. Free light chains ratio was within normal range and neoplastic causes were unlikely. Autoimmune conditions were unlikely. Her rash and lab values gradually improved after discontinuing nitrofurantoin. In conclusion, the transient aplastic crisis associated with a rash in our patient was due to nitrofurantoin.

DRESS syndrome is commonly caused by anticonvulsants and antibiotics. It is not commonly seen with Nitrofurantoin use. Skin eruption starts as maculopapular and progress to coalescing erythema. Although not common; skin reactions can be seen with Nitrofurantoin are maculopapular rash, erythema multiforme, Steven Johnson Syndrome. Presence of eosinophilia can be helpful in differentiation.

Nitrofurantoin is a rare cause of DRESS syndrome. Hence, detailed history including medication list and careful evaluation is important for the diagnosis.

Fateeha Tariq, MD, Leah Grcevich, OMS-IV, and Srikanth Paladugu, MD

Systemic lupus erythematosus is a complex multi-system inflammatory disease mediated by autoantibodies against cellular components [PMID: 18305268].  The 2019 American College of Rheumatology advises that the diagnosis of SLE be based on a validated scoring system based on clinical presentation, diagnostic imaging, and laboratory findings [PMID: 31385462]. However, this workup may impose significant cost on a patient a healthcare system.

A 25-year-old female with a past medical history of PCOS, portal vein and superior mesenteric vein thrombosis, idiopathic pancreatitis, recurrent SBO status-post laparotomy and partial resection presented to the emergency department for vomiting and sharp lower abdominal pain. She was currently undergoing outpatient workup for this problem. On further questioning the patient recalled one maternal and one paternal aunt both diagnosed with lupus. Laboratory studies were remarkable for a false positive pregnancy test and thrombocytopenia. Lupus workup was initiated and returned positive.

The workup of systemic lupus erythematosus in a community hospital setting may be limited by the available diagnostic testing. Preliminary testing (such as skin punch biopsy and bone marrow aspirate in this patient) may only reveal non-specific inflammatory changes, while send out anti-body testing may take days to weeks to return. Throughout this workup it is imperative to balance the value of a definitive diagnosis against the cost to the patient and healthcare system.

This case highlights a targeted approach to a rare multisystem illness in the inpatient setting starting with a thorough history and physical.

James Case, MD; and Mark Kalenian, MD

The thymus is stimulated by multiple neuroendocrine axes of which growth hormone has shown involvement in production and differentiation of T lymphocytes as well as thymulin, which contribute to adaptive immunity and inflammation suppression, respectively. Exogenous growth hormone may prolong thymus productivity and stall involution in individuals requiring supplementation as in pituitary dwarfism with subsequently affected immune response.

19 year old female with pituitary dwarfism having received supplemental growth hormone presented with mild symptoms and concern of COVID-19 infection. She had not received a COVID-19 vaccine. She was found to be positive by PCR. She maintained mild symptoms, resolving with symptomatic treatment.

Adaptive immunity involves the activity of T lymphocytes in mounting an immune response directed towards pathogens. Though the thymus involutes with aging, thymic epithelial cells remain which respond to growth hormone and promulgate immune response with thymulin. Thymulin acts to suppress inflammation. Therefore one with pituitary dwarfism subsequent growth hormone supplementation may have a unique adaptive immune response when encountering viral infections such as COVID-19.

An individual who had received supplemental growth hormone may have been uniquely poised to respond to COVID-19. Such a clinical scenario in which T lymphocyte and thymulin activity are upregulated by growth hormone highlights neuroendocrine involvement in suppression of inflammatory response and adaptive immunity. Further study into a thymulin analogue may lead to viable therapy for COVID-19 and other inflammatory processes. T lymphocyte response to mRNA vaccine as amplified by growth hormone may further develop vaccine technology.

Jennifer H. Ra; and Justin G. Hovey, MD

Amplified musculoskeletal pain syndrome (AMPS) is a rare diagnosis that is part of a broad spectrum of chronic pediatric musculoskeletal pain. Typically, females are more affected than males with an average age of onset of 9-15 years. The lower extremity is most often the primary site of injury and subsequent chronic pain. Labs and imaging studies are usually unrevealing. The various clinical presentations and psychosocial complexities of each patient commonly leads to delayed diagnosis.

In this article, we present a nine-year-old female with no significant medical history who sustained a Salter-Harris type I fracture to her left ankle. After removal of her cast, she subsequently developed swelling and pain along with a fever of unknown origin. The fever persisted for 115 days and led to a comprehensive work-up. Following consultation with pediatric rheumatology, a diagnosis of AMPS was made. After the diagnosis was made, the patient underwent intense physical therapy, and her symptoms resolved. This case highlights the complications that arise with diagnosing AMPS when affected by an autonomic component leading to fevers.

The prolonged nature of diagnosing AMPS stems from the complicated spectrum of clinical presentations and pathophysiological etiologies. The unique autonomic component of AMPS in this patient complicated and delayed the diagnosis. Future studies should focus on exploring the possible manifestations of AMPS when affected by seemingly unassociated symptoms, like fevers.

Increased knowledge and understanding of various clinical manifestations of AMPS can help physicians more quickly diagnose and treat the disease.

Liaqat, A.; Patak, P.; Gregory, G.; Skandhan, A; and Nallamouthu, R.

Tocilizumab is a monoclonal antibody that binds to the interleukin-6 (IL-6) receptor and inhibits the cytokine-receptor complex, thereby inhibiting IL-6’s pro-inflammatory effect. Tocilizumab is used in a host of autoimmune diseases including Giant Cell Arteritis (GCA) and Rheumatoid Arthritis (RA). It has also been utilized in the intensive care setting to reduce the inflammatory response to Coronavirus-disease 2019 (COVID-19). The immunosuppressive effects of Tocilizumab are beneficial in altering the inflammatory cytokine cascade, but believed to lead to an increased number of secondary infections due to its immunosuppressive mechanism of action.

Our study analyzed two cohorts of intensive care unit (ICU) patients receiving high flow oxygen. One cohort consisting of 50 patients ranging from February to June 2021. Another cohort of 43 patients ranging from July to September 2021 received high-flow oxygen and met criteria for Tocilizumab.

Of the 50 patients receiving high flow oxygen alone, 26 patients expired equating to a mortality rate of 52%. Comparatively, the cohort of 43 patients receiving high-flow oxygen in combination with Tocilizumab had 28 deaths, equating to a 65% mortality rate. The secondary infection rate of the high-flow oxygen group alone was 34%, compared to 26% in the high-flow oxygen plus Tocilizumab cohort. However, Secondary infection mortality rates were found to be 56% in the high-flow oxygen group alone, compared to 91% in the cohort of patients receiving Tocilizumab.

Patients in the ICU setting requiring high-flow oxygen, Tocilizumab use was associated with higher overall mortality rates and higher secondary infection mortality rates. One possible explanation of these results can be immunosuppressive action of Tocilizumab leading to increasingly virulent secondary infections and worse outcomes.

Erica M. Roman, MD; Sasha-Kay D'Aguilar, MD;Arial Schmitz, MD, and Mammatha Kondapalli, MD

Thrombotic thrombocytopenic purpura is an acute rare blood disorder that results in thrombocytopenia and hemolytic anemia. Its thrombotic effects have the potential to cause multi-organ system failure and even death.

A male in his 60s with past medical history of ischemic heart disease and a recent abdominal aorta repair on clopidogrel who presented with acute lower abdominal pain, elevated blood pressure, and bilateral lower extremity rash. Physical exam yielded abdominal tenderness and a purplish lacy rash over the lower extremities. Initial lab work showed hemoglobin of 12, platelets of 16, d-dimer of  >5,250, LDH of 1,081, haptoglobin < 30 and creatinine of 1.84. Peripheral smear showed schistocytes, confirming the diagnosis of TTP. Plasmapharesis was started by Nephrology, steroids were started by Oncology and clopidogrel was discontinued. Patient successfully recovered, was discharged home on a steroid taper, and is currently being managed at the Hematology Oncology clinic.

TTP can be inherited, based on a deficiency in the ADAMTS13 enzyme, or acquired, which is immune mediated and has been associated with the use of clopidogrel. Diagnosis is based on clinical evaluation and identification of schistocytes on peripheral smear and thrombocytopenia. Immediate treatment with plasma exchange and steroids in the immune mediated TTP is essential for patient outcomes.

Acquired forms of TTP can occur as a result of clopidogrel, which is used in many of our cardiac patients. Identifying the correct diagnosis as well as the association with these medications can be life saving in these patients.

Grant Gregory, Mohammed Zaman MD, and Hannah Gregory

Cellulitis, a localized infection of the deep dermis and subcutaneous tissue, is a common medical diagnosis resulting in thousands of hospital admissions and billions of dollars in treatment costs annually. Cellulitis is most commonly caused by the organism Streptococcus pyogenes, or Group A Strep (GAS). The organism species of nontuberculous Mycobacteria include all Mycobacterium other than M. tuberculosis or M. leprae. M. chelonae is a rare species of nontuberculous Mycobacterium and is sparsely identified in 0.08 to 0.2 cases per 100,000 people.

This case report details the clinical course and treatment of a 43-year-old immunocompetent female with lower-extremity cellulitis with worsening symptoms despite extensive workup, culture, and empiric treatment for typical causative organisms. After an extended series of hospital stays utilizing ceftriaxone, piperacillin/tazobactam, vancomycin, and doxycycline, progress was not evident in treating the cellulitis. M. chelonae was eventually identified as the causative organism and successfully treated with clarithromycin thereafter.

M. chelonae should be considered as a potential causative organism in patients with long-term intractable skin lesions whose symptoms do not improve with standard treatment. 

Although exceedingly rare, M. chelonae is an etiologic agent of cellulitis in both immunocompetent and immunocompromised patients. Consideration is warranted in atypical cases and treatment should be initiated based on culture sensitivities.

Eugene Wyzynski and Somesh Singh

Myelofibrosis is a myelo-proliferative disease characterized by overt deposition of collagen in the marrow by nonneoplastic fibroblasts. The factors come from fibrogenic factors released from neoplastic megakaryocytes. In about 30-50% of cases, the classic JAK V617F mutation can be observed on FISH analysis.

A 47 yr old female presented with a history of Essential thrombocytosis with secondary Myelofibrosis. FISH analysis did NOT show presence of a JAK V617F mutation. The patient underwent a allogenic bone marrow transplant and signed informed consent for treatment using  Busulfan, Fludarabine, and Thiotepa and post-transplant Cyclophosphamide (Cytoxin) conditioning regimen. For 28 days, she often received prophylactic medications for infection and GVhD along with GM-CSF drugs. The patient was discharged 28 days layer in stable condition. At a 1 year post-op evaluation, she is in remission, with the latest FLOW cytometry report showing NO CLONAL B CELLS AND NO CIRCULATING BLAST CELLS!

BMT in the appropriate patients and extensive GvHD and infection prophylaxis along with GM-CSF medications given as inpatient management is a powerful method to combat Myeloproliferative disorders.

Tyler Finkenthal, Zackery Aldaher, and Salman Ahmed

The association between previously diagnosed autoimmune hemolytic anemia and exacerbations due to COVID-19 infection is a rare phenomenon that is not well understood.

In this case, we present a 68-year-old female with a past medical history significant for systemic lupus erythematosus, splenectomy, and autoimmune hemolytic anemia since childhood that has been very well controlled with only one previous exacerbation. The patient's chief complaint and clinical symptoms at admission were related to her hemolytic anemia and not active COVID-19 infection.

This case report reveals a possible association between the hyperinflammatory syndrome caused by COVID-19 and the exacerbation of previously well controlled autoimmune diseases.