Poster Day 2022: Abstracts: Clinical Vignettes

Sarah J. Inbornone, M.S., Timothy N. Holbrook, Shyam K. Patel, M.S., M.B.A, Edsel Holden, M.D., James Lamb, M.D. 

Autoimmune encephalitis is an insidious neurological disease that can present with an array of neuropsychiatric symptoms. The literature demonstrates that patients continue receiving refractory care due to a delay in appropriate diagnosis and work up of autoimmune encephalitis. The acute manifestation of neuropsychiatric symptoms should signal prompt follow up with neurology. 

A 50-year-old Caucasian female presented to the neurology clinic with a four-month history of acute onset insomnia causing anxiety, poor concentration, memory loss, paranoia, as well as a 13-pound weight loss. Constant anxiety forced her to quit both her daily activities and job. Cerebrospinal fluid analysis (CSF) exhibited an elevated protein of 50.6 mg/dL (normal 15 – 45) and an elevated albumin of 28.1 mg/dL (normal <27.0). A comprehensive autoimmune and paraneoplastic encephalitis panel was performed on serum and CSF, which was positive for CASPR2 (1:10 dilution) antibodies in the serum. The patient’s insomnia and mood began to improve after initiation of IVIG infusions and prednisone.

CASPR2 is a voltage gated potassium channel that is found throughout the nervous system and is involved in regulating areas around the nodes of Ranvier. Anti-CASPR2 can also be associated with limbic encephalitis or Morvan syndrome with symptoms ranging from seizures, cerebellar dysfunction, hyper-excitability, dysautonomia, insomnia, neuropathic pain, and weight loss.

This case report examines the presentation and workup of a 50-year-old female with a four- month history of acute onset insomnia and mood disturbances. She was seen multiple providers before arriving at the neurology clinic where we discovered anti-CASPR2 antibodies in her serum. This case review attempts to elucidate the delay in treatment for patients presenting with acute or subacute onset mood disturbances with insomnia.

Andrew D. Vogel, M.S., Michelle Sindoni, M.S., Benjamin Comora, M.D., John Hochhold, M.D.  

Cor Triatriatum Sinistrum (CTS) is a rare congenital heart defect characterized by a fibromuscular membrane within the left atrium. CTS accounts for less than 0.4% of all congenital heart defects. The severity of clinical symptoms depends on the degree of membrane obstruction.  

A 38-year-old male from Guatemala presented to the emergency department with one week of worsening cough, dyspnea, and right-sided chest pain. He denied significant past medical history besides a remote diagnosis of Chagas disease. On physical examination, lungs were clear to auscultation bilaterally with non-labored respirations and regular heart rate and rhythm. A SARS-COV-2 test and workup for acute coronary syndrome were performed, and both produced negative results. Echocardiogram demonstrated a structurally normal mitral valve, mild to moderate tricuspid regurgitation, and ejection fraction of 40-45%. Chest computed tomography angiogram (CTA) displayed a thin fibromuscular membrane in the left atrium as well as marked dilation of the main pulmonary artery and partial anomalous pulmonary venous return (PAPVR).

In adulthood, patients can be asymptomatic although some may present with symptoms related to fibrosis and calcification of the membrane fenestrations. CTS may be associated with other abnormalities including persistent left-sided superior vena cava, PAPVR, mitral valve regurgitation, and septal defects.

Echocardiography is typically used to diagnose CTS, but it may not be able to visualize additional anatomic variants commonly present in CTS. A chest CTA may be necessary to precisely classify the membrane morphology, decipher complex cardiac anomalies, and determine the need for surgical intervention.

Andrew D. Vogel, M.S., Gabriela M. Galan, B.S., David Gregg, IV, M.D., Arman Kilic, M.D., Taufiek K. Rajab, M.D.  

Less than two percent of all congenital heart defects are univentricular anomalies with a double inlet left ventricle (DILV) being the most common presentation. DILV is often diagnosed after birth or in early childhood with two atrioventricular valves entering one ventricular chamber.  

A 58-year-old male with class III heart failure was referred for surgical evaluation. On physical examination he did not appear cyanosed (inset) as his systemic oxygen saturation was 80%. Echocardiography and computed tomography angiography (CTA) showed the left and right atrium draining into a DILV, a non-restrictive ventricular septal defect straddling the tricuspid valve, a diminutive right ventricle, levo-transposition of the aorta and pulmonary artery, and severe pulmonary stenosis. Cardiac catheterization revealed blood pressures of 125/10 in the DILV, 50/20 in the PA, and 125/60 in the aorta, pulmonary vascular resistance 4.3 Wood Units m², and the ratio of total pulmonary blood flow to systemic blood flow (Qp:Qs) was 1:1. He received orthotopic heart transplantation and subsequently died from surgical complications.

Unrestricted blood flow to the pulmonary system present at birth may result in heart failure and must be corrected immediately with pulmonary artery banding (PB) followed by the three stages of the Fontan surgery. Congenital pulmonary stenosis may mimic the PB procedure completed in neonates and allow for adequate pulmonary blood flow.

With just the right degree of pulmonary stenosis for sufficient blood distribution to the pulmonic and systemic circulations, long-term survival without surgery may be possible.

Malvika Chaudhary, B.S.1, Devam Parghi, M.D. 2, Meagan Hoggle, D.O.3, Saikiran Mandyam M.D.4 Carlos Sequera-Sanchez, M.D.5 

Euglycemic Diabetic Ketoacidosis is a commonly missed diagnosis due to its unusual presentation. As the use of sodium-glucose cotransporter 2 (SLGT2) inhibitors rises, there is a higher incidence of euglycemic DKA.1  

In our case, a 69-year-old female with past medical history of Type 2 Diabetes, CAD, and Gastroparesis presented with increasing weakness, nausea, vomiting, dyspnea on exertion and myalgias, with onset 3 weeks prior alongside a 5 lb weight loss. She was seen in multiple ERs for the same complaints without a definitive diagnosis. Patient again had severe acidemia in the ER with normal blood glucose levels; after home medication review, she was diagnosed with euglycemic DKA due to canagliflozin. She was initially started on insulin drip along with D10 while frequently checking CBGs and BMP. Her anion gap closed and bicarbonate levels normalized within the next 24 hours. She was then transitioned to sliding-scale insulin therapy and instructed to follow up with her primary care provider. Symptomatic resolution on discharge was noted.

Euglycemic DKA can has an abnormal presentation when compared to Diabetic Ketoacidosis (DKA) due to blood glucose levels being relatively in range or lower. 2 DKA is characterized by blood glucose >250mg/dL, bicarbonate level <18 mEq/L, and blood pH <7.30 with ketonemia and ketonuria.3 Timely management generally results in better outcomes.

There has been an increase in the use of SGLT2 inhibitors especially with new guidelines for HFrEF and CKD; hence, this will be a more common complication, which if diagnosed early can prevent morbid outcomes.

Andrew Horton DO, Daniel Radwanski MD, Bhoomi Shah MD, Muhammad Qureshi MD, Maria Kewish MD 

Diffuse large b-cell lymphoma (DLBCL) accounts for the majority of the cases of NHL and can affect various organ systems including the heart. In this case presentation, we will discuss a pleural effusion secondary to DLBCL in a young age group.  

A 30-year-old female with no significant past medical history presented to the ED with shortness of breath, generalized chest and neck pressure/fullness, and weight loss. A CT scan of her chest revealed an anterior mediastinal mass with associated moderate pleural effusion. Upon admission, she was incidentally found to be COVID-19 positive. Cardiovascular (CV) surgery recommended that the patient isolate for ten days before surgery or biopsy. During isolation, her symptoms worsened and her follow-up echocardiogram revealed near tamponade. A pericardial window (PW) and mass biopsy were performed the following day. Biopsy of the mass revealed diffuse large B-cell lymphoma with double protein overexpression of BCL-2 and C-MYC.

Patients with symptomatic PEf require drainage of pericardial fluid to prevent hemodynamic instability. PW is sometimes preferred to pericardiocentesis as the latter has a 38.3% reaccumulation rate, as well PW allows for a biopsy of the pericardium.

While the average age at the time of diagnosis for DLBCL is 64 years old, it is important to keep malignancy on one’s differential when a patient presents with PEf as malignancy accounts for 15 to 20 percent of moderate to large pericardial effusions.

Arsh Patel, Colby Kihara, Carter Gay, Katherine Oakley, and Dr. P.J. Reddy 

Foot drop is defined as an inability to dorsiflex and evert at the ankle joint due to weakness of the tibialis anterior muscle. Weakness is defined as a muscle strength test that results in anything less than 3/5. Most conditions of foot drop are related to chronic or progressive conditions rather than acute onset of presentation.  

An 84-year-old female presented to the outpatient clinic complaining of difficulty with ambulation due to bilateral lower extremity weakness. Incidentally, a popliteal DVT was discovered, and she was prompted for direct hospital admission.

Overall, there is limited data in current literature presenting acute bilateral foot drop. Like a case presented by Kertmen et al., we hypothesize that the T12-L1 compressed spinal cord found on our patient’s MRI may have led to bilateral compression of the L5 nerve root, causing acute bilateral foot drop. Treatment for the underlying cause of acute bilateral foot drop has been ill-defined in literature. The decision to pursue surgical intervention is dependent on the patient’s degree of impaired dorsiflexion, Surgical Risk Score, and willingness to undergo extensive surgery. There has been no clinical trial to date that specifically quantifies the efficacy of surgery versus conservative therapy using foot-ankle bracing orthosis for clinical improvement. Peroneus splints are the mainstay of conservative therapy, but they present with disadvantages.

Bilateral foot drop with acute onset is a unique and complex clinical presentation that requires a thorough approach to diagnosis and treatment due to their emergent nature. The decision of conservative or surgical management should follow the shared decision making model.

Mina Ghaly1, M.D. Malvika Chaudhary1, B.S., Bridget Budny1, M.S., Dominic Gigliotti2 M.S., Sahar Mazhar2, MD 

Mixed connective tissue disease (MCTD) is a subset of rheumatic overlap syndromes, characterized by anti-U1RNP antibodies and features of multiple inflammatory connective tissue diseases, including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).  

A 23-year-old female presented with abdominal pain, fatigue, subjective fevers, and generalized joint pain that was acutely worsening over the past 3 weeks. She had a recent medical history of new-onset colitis and urinary tract infection (UTI) not resolved with multiple courses of antibiotics. The patient was admitted for acute pyelonephritis and acute kidney injury due to a complicated UTI. However, her presenting symptoms in conjunction with the additional findings of normocytic anemia, bilateral pleural effusion, elevated inflammatory markers, and family history of RA also prompted further autoimmune evaluation. During her hospital course, the patient developed an oral ulcer and bilateral edema in the hands. The finding of U1RNP antibodies supported the diagnosis for MCTD. The patient’s condition subsequently improved with antibiotics, NSAIDs, and steroids. Following discharge, the patient was to follow up closely with her PCP, and specialists in GI and rheumatology.

Uncertainty in a MCTD diagnosis is commonly due to the changing nature of the disease and variability in case presentation with mixed support of differentiated disease. With U1RNP antibodies and features supporting an RA/SLE overlap syndrome in our patient, a MCTD diagnosis was made.

MCTD is a rare autoimmune disorder that predisposes patients to significant morbidity and mortality. It is imperative to recognize the clinical features of MCTD for adequate symptomatic treatment.

Robert D. Faccone, Arsh N. Patel, Dr. Hani A. Mayassi, Dr. Daniel J. Kaplan 

Distal femur fractures account for less than 1% of all fractures and about 3-6% of all femoral fractures. Most common mechanism involves direct trauma to a flexed knee, and caution must be placed in cases involving high-energy trauma as vascular injury is common. Fractures or dislocation which cause posterior translocation of any segment of the distal femur increases the risk of injuring the popliteal artery.  

67 year old male presented after being stuck by motor vehicle. Imaging revealed a displaced comminuted right distal femur fracture. In the OR the fracture was irreducible with external measures so a 5cm incision was made laterally and medially. Following dissection medially the popliteal artery and vein were entrapped anterior to the medial spike of the fractur. Following mobilization from the fracture site a small tear of the popliteal vein was noted. Repair of the tear was performed using a single simple interrupted 6-0 prolene suture. An intraoperative vascular consult was called. Vascular surgery evaluated the popliteal vein tear and dissected it out while further repairing the tear and ligating bridging veins.

A dilemma identified in major traumatic injuries that involve both the arterial and musculoskeletal system revolves around the initial order of which intervention to proceed with. The overall controversy weighs upon the clinical presentation to reduce arterial insufficiency. Enhancing patient outcomes should involve a multi-disciplinary approach to provide optimal care and increase the likelihood of patient outcomes.

Our goal is to emphasize the importance of recognizing these rare and potentially devastating vascular complications.

Lebnitz J. Charelus, MD, Bhoomi Shah , MD , Rafaela Basso, MD, Rakhee Reddy, MD, Amith Skandhan, MD.  

Ocular syphilis is a complication of syphilis, and it can affect almost any eye structure with the uvea being the most commonly affected. Patients with ocular syphilis often present with diminished visual acuity. Early Diagnosis and treatment can prevent complications.  

A 45 years-old male with no known medical problems presents with left eye swelling and periorbital pain for the past 3 days. He describes the pain as throbbing in nature, 5/10 in intensity, associated with photophobia, redness, and decreased vision of the left eye. Patient was found to have a maculopapular rash involving the extremities, palms, soles, and torso that has been present for 3 months. RPR was reactive, Treponema pallidum antibody index was 32.40 (N<0.9). A lumbar puncture revealed CSF pleocytosis concerning for neurosyphilis. Ophthalmologist evaluation confirmed ocular syphilitic uveitis and acute iridocyclitis. Patient was allergic to penicillin, and he was treated with Rocephin for 14 days.

A maculopapular rash involving palms and soles with ophthalmologic manifestations highly suggested ocular syphilis. Ocular manifestations can be seen without other neurologic manifestations or with neurosyphilis. If the latter is suspected, CSF analysis should be obtained before treatment which includes Penicillin G IV for 10-14 days. Individuals with Penicillin allergy may undergo desensitization or ceftriaxone for 14 days.

Ocular Syphilis should be a differential diagnosis in patients with ocular symptoms or those previously diagnosed with syphilis. Appropriate diagnosis and treatment can prevent the severity and progression of ocular manifestations which can lead to blindness.

Meghan J. Filson, Dakota C. Davis, and Dr. Claire G. Yother 

Usher Syndrome is a genetically inherited condition characterized by congenital sensorineural hearing loss as well as progressive vision loss secondary to retinitis pigmentosa. Patients may also display vestibular areflexia secondary to inner ear damage. Usher Syndrome is the most commonly diagnosed syndrome within the blind-deaf community, and it accounts for approximately 50% of hearing and visual deficit cases among patients younger than 65 years of age. Despite these impressive statistics, Usher Syndrome has an estimated prevalence of only 0.0044% in the United States, suggesting chronic underdiagnosis in clinical settings. A possible explanation for this is the visual deficits of Usher syndrome do not appear until later in life and thus inappropriately lower the index of suspicion for this diagnosis in young children with hearing deficits.  

This case study highlights a healthy newborn who failed the universal newborn hearing screening (UNHS) bilaterally as well as a follow-up hearing screening in a pediatrician's office. Auditory brainstem response (ABR) later confirmed bilateral severe-to-profound sensorineural hearing loss. Upon genetic testing, an abnormality in MYO7A was discovered and consistent with Usher syndrome.

For patients presenting with congenital hearing loss, Usher Syndrome should be considered on the differential.

Genetic counseling should be used if no other cause of sensorineural hearing loss is identified. Due to the progressive nature of this condition and the physical and developmental deficits that will transpire without treatment, a genetic panel for hearing loss should be prioritized to determine the presence of genetic mutations suggesting Usher syndrome.

Mohamad Jajeh MD, Marvin Sexton MD, Hamza Liaqat MD, Yousef Awad MD, and Riya Patel OMS  

Incidence of Pneumocystis Jirovecii pneumonia (PJP) is increasing among patients without Human immunodeficiency virus (HIV). PJP occasionally causes respiratory failure up to and including acute respiratory distress syndrome (ARDS) after initiation of an appropriate treatment. This report presents a unique case of PJP associated ARDS in a non-HIV patient.  

64-year-old male with history of Non-Hodgkin’s lymphoma status post chemotherapy 4 months prior with R-CHOP presented with worsening tachypnea, non-productive cough, and low-grade fever for seven days. On exam, patient’s vitals were stable with oxygen requirement of 5L on nasal cannula. Chest imaging revealed bilateral interstitial infiltrates. Other basic labs were normal. Work up for connective tissue related disorders returned negative. Subsequently, bronchoscopy was performed to obtain bronchoalveolar lavage and results returned positive for PJP. The patient was started on trimethoprim-sulfamethoxazole and steroids. After 48 hours of treatment, the patient worsened clinically and eventually, required mechanical ventilation. Repeat imaging and clinical course suggested development of ARDS. Patient’s clinical condition continued to worsen despite therapy. On day 28 of admission, the patient expired.

This case highlights findings of a relatively rare disease in non-HIV patients. This patient developed a catastrophic case of ARDS chronologically associated appropriate PJP therapy, despite concomitant therapy with steroids, presumed due to PJP lysis syndrome. Clinicians should be aware of this potentially catastrophic complication in such patient populations.

In immunocompromised patients, PJP is a potentially life-threatening infection. Patients should be monitored for possible complications of ARDS and lysis syndrome.

Danielle Glinka, OMS-III, Aneri Desai, OMS-III, Bobby Wrights, MD  

Pyoderma gangrenosum, PG, is a rare dermatologic disease predominated by cutaneous neutrophilic inflammation. While PG has been linked to inflammatory bowel disease and rheumatoid arthritis, only 75% of cases are associated with underlying disease, leaving a quarter of patients lacking associated risk factors. Thus, an approach to these patients relies on anecdotal and case series reports highlighting positive treatment outcomes.  

Here, we present a 54-year-old female with an atypical presentation of PG who responded well to a trial of topical corticosteroids.

Patient initially reported to the wound clinic status post cellulitis of the left posteromedial leg. She was previously admitted to the hospital and received IV and oral antibiotics. During the initial physical exam, patient had a serosanguineous draining blister. She was treated with silver alginate and foam dressings. At follow-ups, patient continued to demonstrate recurrent ulceration on the left lower extremity and was diagnosed with a chronic venous ulcer. Trials of an Unna boot and compression stockings were unsuccessful. Wound cultures were obtained, and the patient completed another round of oral antibiotics. Patient was referred to dermatology, where they performed a biopsy, revealing acanthosis and granulation tissue. Clinical history in conjunction with biopsy results was consistent with PG. Patient started betamethasone ointment and followed up at the wound clinic, where she demonstrated a reduction in erythema, blistering, and swelling with ultimate resolution. This patient’s case provides an example of PG in a patient lacking classical risk factors, a suggestive treatment approach, and a positive response to topical corticosteroids.

Aneri Desai, OMS-III, Daniella Glinka, OMS-III, Bobby Wrights, MD 

Leukocytoclastic vasculitis, LV, is an immune-complex mediated vasculitis affecting the small vessels of dermal capillaries and venules. While about half of all cases are idiopathic, it has been shown that infection, neoplasms, autoimmune disorders, and drugs are linked to the disease. Due to the many triggers associated with LV, it can be difficult to identify the inciting pathophysiology leading to the manifestation of the disease. Here, we present a 65-year-old female who reported the wound clinic with palpable purpura with a positive response to oral prednisone. 

The patient initially presented to with circumferential, papular, and dark purple lesions with surrounding mild erythema and tenderness on bilateral lower extremities. After a trial of antibiotics and subsequent negative wound cultures, arterial and venous studies were ordered, which demonstrated sufficient flow. Further history and work-up revealed an elevated CRP of 40mg/L. Punch biopsy confirmed the suspected diagnosis of LV and the patient was placed on oral prednisone 50mg, which led to a reduction in lesions and ultimate resolution.

Autoimmune diseases remain highly enigmatic to healthcare providers due to the rarity of cases and ambiguity of triggers, ultimately complicating early identification of the disease. This patient presented with a variety of possible LV risk factors, including Crohn’s disease, polypharmacy, recent allergic arthropod reaction, and COVID-19 infection. This case demonstrates the importance of highlighting further possible risk factors associated with LV for early identification, subsequent treatment of the disease, and decreased morbidity.

Mohamad El Sabbagh, OMS-I, Sarah Rifai, OMS-I, Zainalabedeen Sabah, OMS-I, Adam Tarakji, OMS-I, Ahmad Oussama Rifai, MD, Sally Dahan, OMS-I, Kristin M. Denig, PA-C 

Cutaneous leukocytoclasic vasculitis affects small blood vessels, particularly in the skin. Blood vessels affected may include microvasculature (capillaries), venules, lymphatics, or arterioles.  

A 45-year-old man presented with a rash on his left forearm as well as non-blanching palpable purpura on his right leg and foot, some of which have coalesced and ulcerated. The patient has a history of a hypercoagulable state and is chronically on anticoagulation. Symptoms began to appear a week after starting the patient on Apixaban, (Eliquis) 5 mg twice daily by mouth. Prior to that, he was on Rivaroxaban, (Xarelto). The rash was biopsied and demonstrated Cutaneous Leukocytoclastic Vasculitis (CLV). Anti-Nuclear Cytoplasmic Antibodies (ANCA) titers were negative. Complements, C3, C4 CH50 were normal. Hepatitis C antibodies were negative. Titers for Lyme Disease and Rocky Mountain Spotted Fever were not reactive. It is unusual for CLV to be induced by a drug and have negative titers for ANCA and it usually requires aggressive therapy. Our case resolved after the discontinuation of Eliquis and Xarelto and the initiation of warfarin for the hypercoagulable state in conjunction with a short course of steroids.

This case highlights findings of an unusual presentation of drug-induced cutaneous leukocytoclastic vasculitis and highlights the importance of a thorough workup.

Christopher Snow, MD; Juanita T. Heersink, M.D., FACP  

Subacute fever without defining infectious characteristics presents a diagnostic dilemma. Experienced clinicians will broaden their differential beyond infectious causes of fever to autoimmune and malignant etiology, particularly when the fever is not responsive to broad-spectrum antibiotics.  

A 54-year-old man with a history of non-insulin-dependent type 2 diabetes mellitus, hyperlipidemia, HFpEF (EF 55%) presented to the hospital with 2-week history of left-sided chest wall pain, generalized malaise, headache, myalgia, and nocturnal fevers. He had no leukocytosis, and chest imaging, EKG, and troponin were normal. Viral testing was negative. Inflammatory markers were mildly elevated, with D-dimer 953. Blood cultures were obtained, and the patient was started on Zosyn. Fevers persisted to Tm 102, and ID was consulted on day 5 of hospitalization when blood cultures grew Brucella suis. The patient reported a history of feral pig hunting. He slaughtered his own game and rendered his own sausage with exposure to feral pig blood during processing. Patient defervesced on Doxycycline, Gentamicin, and Rifampin.

Brucellosis is caused by an intracellular Gram-negative bacteria called Brucella. Clinical manifestations of brucellosis are variable, and the delay in symptom manifestation can often create a diagnostic challenge. Brucellosis commonly presents with fever and musculoskeletal symptoms but can also present with rarer cardiac and neurologic manifestations.

Cases like this one demonstrate the importance of bedside examination, and taking a thorough history that includes travel, hobbies, exposures, family history, and social history in the context of a patient presenting with subacute fever.

Bhoomi Shah MD, Priyanka Patel MD, Vidhi Patel MD, Hamza Liaqat, Osakpolor Ogbebor MD 

We present a case of multiple ring enhancing cerebral lesion that highlights the need to consider Human immunodeficiency virus (HIV) infection as a differential.  

A 58 year old woman with hypertension and hypothyroidism presented to the hospital with slurred speech and right-sided weakness. Magnetic resonance imaging (MRI) of the brain reported multiple ring-enhancing lesions in the left frontal and parietal lobe consistent with metastatic disease. Staging computed tomography (CT) scan showed no chest, abdominal or pelvic lesion. Furthermore, patient had dysphagia and weight loss for which she underwent Esophagogastroduodenoscopy (EGD) and a diagnosis of esophageal candidiasis was made. Initially, patient was reluctant to undergo brain biopsy and eventually was discharged on fluconazole, dexamethasone and Levetiracetam along with scheduled follow up. She was readmitted after she developed seizures and subsequently she had a brain biopsy with results consistent with Toxoplasma Gondii. Further workup confirmed a positive HIV test with a CD4 count of 1. The Toxoplasma IgG was also elevated. The patient was commenced on Trimethoprim sulfamethoxazole and Emtricitabine-Tenofovir-Dolutegravir. She continued to show clinical improvement.

In spite of advances in creating awareness about treatment of HIV, this case highlights the need not to be complacent and to consider HIV infection in a patient presenting with cerebral lesions, especially when they have additional constitutional symptoms such as weight loss.

Early recognition of HIV infection can lead to prompt intervention and better prognosis.

Dakota C. Davis, Meghan J. Filson, and Dr. Claire G. Yother 

Sjogren’s Syndrome is a chronic multisystem autoimmune condition where lymphocytes attack exocrine glands. Although this condition occurs in pediatric populations, it is often a missed diagnosis or diagnosis made after significant disease progression frequently leading to extensive investment of time and resources.  

This case study follows a 6-year-old African American female who, after an extensive medical course, was ultimately diagnosed with Sjogren’s Syndrome.

The intention of this case study is to increase awareness of the potential abnormal presentations of this connective tissue disease in specialty populations, specifically, school-aged pediatric patients.

Even with the rarity of this condition in the pediatric population, physicians should keep Sjogren’s Syndrome on their differential diagnosis when a patient is presenting with atypical or non-specific autoimmune-like symptoms. The presentation of children can be more severe than that anticipated in an adult. A rapid, multi-disciplinary approach needs to be implemented to improve the prognosis of pediatric patients with Sjogren’s Syndrome.

Muhammad Qureshi MD, Bhoomi Shah MD, Maria Kewish MD, Kristy Johnson-Pich DO 

Takotsubo cardiomyopathy is a condition during which acute transient left ventricular systolic dysfunction causes a patient to have chest pain mimicking an acute myocardial infarction; often with elevated cardiac biomarkers and ST-elevation on EKG. This presentation can make it difficult to distinguish Takotsubo cardiomyopathy from an acute coronary syndrome with ST-elevation. 

A 49 year old female with a past medical history of ADHD, GERD and current methamphetamine and tobacco use presented to the ER complaining of substernal chest pain, diaphoresis, nausea, and vomiting. Her symptoms started after she had an argument with her husband and was moving out of her house as she was going through a difficult divorce. Upon admission her troponins were elevated and her EKG was unremarkable. She was administered nitroglycerin which led to mild improvement in her symptoms. The following morning she had worsening chest pain and a repeat EKG demonstrated ST-elevations. Urgent cardiac catheterization was performed and demonstrated apical ballooning consistent with Takotsubo's cardiomyopathy.

Cardiac catheterization revealed features consistent with Takotsubo cardiomyopathy as the cause of the ST elevation myocardial infarction rather than coronary artery disease; thus, treatment plan was changed accordingly. Also it is important to know that methamphetamine use and emotional stress can both be causative of Takotsubo's cardiomyopathy.

STEMI is a common hospital admission diagnosis, however the occurrence of Takotsubo's cardiomyopathy is fairly rare in this setting. An emergent cardiac catheterization will help determine the cause of STEMI and deciding further treatment.

Jenny Jung MS, Muhammad Qureshi MD, Chang Hwan Park MD, Sanjida Jahan MD, Kristy Johnson-Pich DO 

Hyperhemolytic crisis is a rare but potentially deadly complication in patients with Sickle Cell disease (SCD). It is defined by a sudden exacerbation of hemolysis, worsening anemia and reticulocytosis usually after a transfusion 

A 32-year-old African-American male with a past medical history of SCD presented to the ER due to sickle cell pain crisis. His hemoglobin was 6.3 g/dL and he received 5 units of PRBC’s. The patient was discharged shortly after clinical improvement. He presented one week later with hematuria and hematemesis and was found to have a hemoglobin of 3.5 g/dL. His chest radiograph was unremarkable and his urinalysis demonstrated 3+ blood and leukocyte esterase. A CT of the abdomen demonstrated hepatomegaly, atretic spleen, osseous sequelae of SCD and an unremarkable urinary bladder. He was transfused with 2 units of PRBC due to concerns that this may be sickle cell crisis. However, due to findings of hemolysis out of proportion to SCD, Hematology was consulted and it was found that he was likely undergoing a delayed hyperhemolytic crisis due to previous transfusions. The patient was started on IVIG and his symptoms and hemoglobin level improved.

Hyperhemolytic crisis can be fatal if not promptly diagnosed and treated. Patients are generally treated with immunosuppressive therapy as this is secondary to an amnestic alloantibody response.

Serological testing should be considered for all SCD patients after each transfusion to look for new alloantibodies and keep records of any previously identified alloantibodies to reduce the risk of re-exposure.

Mashal Awais, Yogesh Gujrati, Holly Brown, Victoria Phillips 

Carotid artery dissection occurs when layers of the artery separate, compromising blood flow to the brain, leading to strokes.  

40 year old male with olivopontocerebellar atrophy (OPCA) and migraines presented with neck pain, worse on the left, left tongue swelling and dysphagia. Physical exam demonstrated hypoglossal nerve palsy, nystagmus and ataxia. Contrast CT neck showed bilateral subtotal occlusion of the ICAs, short segment dissection of the distal right cervical ICA, and areas of possible intraluminal thrombus. MRI brain revealed no evidence of acute infarct. Patient was placed on a heparin drip and underwent diagnostic angiogram showing extensive flow limiting bilateral extracranial ICA dissection, right more than left. The majority of intracranial right ICA circulation was supplied via retrograde flow from the reconstituted right ophthalmic artery and posterior communicating artery. Some antegrade flow to the left ICA intracranial vasculature was observed, but significant flow from the posterior circulation was appreciated. A pseudoaneurysm of the cervical segment of left ICA was noted. Flexible laryngoscopy revealed left-sided tongue and tonsillar swelling, attributed to abrupt shunting of the blood to the external carotid artery (ECA) circulation (lingual and facial branches). Patient was managed with dual antiplatelet therapy showing clinical improvement.

Spontaneous ICA dissection is uncommon, but is one of the most common causes of stroke in young patients. Abrupt shunting of blood to ECA circulation could manifest as oropharyngeal rather than stroke-like symptoms.

Early recognition and timely intervention is necessary in atypical presentations to prevent grave outcomes and decrease associated morbidity and mortality.

Katie Oakley OMS-III, Arsh Patel OMS-III, Carter Gay OMS-III, Colby Kihara OMS-III – Alabama College of Osteopathic Medicine, Elizabeth McCleskey DO, MS – Madison, AL 

Primary hyperparathyroidism is a relatively common cause of elevated serum calcium levels. Hypercalcemia caused by a parathyroid adenoma is often mild (less than 11). The high end of “normal” lab values varies among labs, ranging from approximately 10.2-10.6; however, these levels may vary with age and sex, which most labs do not account for when reporting results.  

The proposed case study discusses a patient with a history of chronic pain and other nonspecific symptoms who presented for OMT and was subsequently refractory to treatment. A lab workup was ordered, which showed slightly elevated calcium levels and a high-normal PTH level. Further workup revealed a history of intermittent, mild serum calcium elevations. This then led to the discovery of a parathyroid tumor, which was removed. As a result, she experienced symptom resolution and improved quality of life.

This presentation shows that symptom-inducing parathyroid tumors may present with high-normal or slightly elevated serum calcium levels. Currently, conflicting lab ranges for “normal” calcium make the determination of hypercalcemia difficult with sequential testing. Furthermore, calcium levels appear to vary with age and sex, which most labs do not adjust for when reporting lab values.

This case highlights the importance of considering primary hyperparathyroidism in patients who may have intermittent, mild elevations in serum calcium with normal PTH. Nonspecific symptoms should also raise the physician’s level of suspicion and lower their threshold for further testing. Finally, more research is needed regarding appropriate “normal” lab values and acceptable serum calcium levels based on age and sex.

Carter Gay, Arsh Patel, Colby Kihara, Katie Oakley, O.P. Akinsoto M.D.  

Myocardial bridging is an anomaly of the cardiac vasculature, specifically pertaining to the coronary arteries, which course along the wall of the epicardium before branching off to supply cardiac tissue. In cases of myocardial bridging, however, the coronary artery travels through the myocardium for a portion of its length. This may be problematic as the vessel is susceptible to compression during myocardial contraction.  

A 55-year-old male presented to the ER with complaints of acute onset chest pain. As part of the workup, EKG revealed ST-segment elevation in leads V2-V6. Upon cardiac catheterization, myocardial bridging of the left anterior descending (LAD) artery was discovered without evidence of any obstructive coronary artery disease.

While generally considered to be a benign pathology, there is increasing evidence to support risk of ischemia, infarction, arrhythmia, syncope and sudden cardiac death that stems from myocardial bridging. It requires special management through vasodilatory and heart rate control medications, namely beta blockers. Refractory cases may require surgical unroofing as part of the treatment process.

Myocardial bridging, although traditionally thought to be a benign pathology, can also present risk for ischemia and infarction, in addition to other adverse outcomes. This case highlights the importance of considering this etiology in patients with STEMI presentation or myocardial ischemia but negative cardiac enzyme and no evidence of CAD.

Yousef Awad MD, Riya Patel BS, Mohamad Jajeh MD 

Myxedema coma is a life-threatening rare condition that is challenging to diagnosis in dementia patients especially when presented with concurrent infections.  

79-year-old Caucasian female with history of congestive heart failure, atrial fibrillation, hypothyroidism, chronic kidney disease, and dementia presented with worsening confusion, decreased appetite, and deviation from her normal baseline from 4 days ago. Symptoms include bradycardia, hypotension, hyponatremia, and declining renal function. Her labs showed elevated troponins and lactate with urine analysis positive for leukocyte esterase. Chest x-ray was significant for possible underlying pneumonia. Due to unstable vital signs, she was admitted to the intensive care unit. Discussion with the family revealed patient was non-complaint with her medications for 5 months. Thyroid panel was obtained with initial thyroid stimulating hormone (TSH) of 331 µU/mL, free T4 less than 0.25 ng/dL, and free T3 18.33 pg/mL. She was started on thyroxine and corticosteroid with no improvement in her encephalopathy. On day 2, T3 received from an outside facility was administered leading to marked improvement in the clinical exam and dramatic corrections of thyroid panel. Three days later, she was in a stable condition with transition to oral thyroxine and medical floor for further management and discharge.

This case highlights effectiveness of treatment with T4 and later active T3 hormone for prompt management of myxedema in terms of quick onset of action and recovery.

Myxedema coma should be part of differential for patients with hypothyroidism especially with elderly dementia patients if presentation is suspicious.

Sahar Baloch, MD ; Paramjit Kaur, MD ; Zara Baloch, MBBS ; Sagar Kulkarni, MD 

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.

Nabeel Siddiqui, Mashal Awais, Christopher Snow, Fateeha Tariq 

Often due to an insidious onset and musculoskeletal symptoms that overlap with other disorders, polymyositis can be challenging to diagnose. Individuals may have vague symptoms such as myalgias and joint stiffness, arthralgias and diffuse muscle weakness. Specific weakness of the shoulder and pelvic girdle muscle groups are characterizing symptoms for polymyositis; however, these do not need to be found in the clinical picture for diagnosis.  

Our case is a typical presentation of polymyositis with initial symptoms of dysphagia which was thought to be caused by Achalasia. As symptoms progressed, workup for polymyositis was done however a muscle biopsy was not taken due to negative antibodies. This delay in diagnosis resulted in significant complications and healthcare costs.

Some individuals present with unusual symptoms including isolated dysphagia or early respiratory problems, which might delay diagnosis. A diagnosis of polymyositis is not excluded by a negative myositis panel and often a muscle biopsy is necessary to establish diagnosis. Any delay in diagnosis can result in severe complications such as aspiration pneumonia, hypoventilation, and interstitial lung disease. For decades, pulmonary complications have been recognized as important determinants regarding the clinical course.

Lack of early muscle biopsy can result in severe distress to patients and result in unnecessary healthcare costs. This case report demonstrates the significance of early muscle biopsy to establish diagnosis in patients with presentations of Polymyositis.

Sanjida Jahan, MD; Sahar Baloch, MD; Zara Baloch, MBBS; Amith Skandhan, MD 

Hidradenitis suppurativa (HS) is a chronic, recurrent, follicular occlusive disease. Clinical manifestations vary in types and areas. A variety of disorders, like metabolic syndrome and related comorbidities, Crohn's disease, inflammatory, neoplastic, and genetic disorders, have been associated with HS.  

The patient is a 27 year old male with a past medical history of HS since age of 9, who presented with complaints of fatigue for one week. On admission, pertinent labs showed Hemoglobin 4.9, MCV 53, and ferritin 7.2. He denied any melena or hematochezia, occult blood was negative. Blood was transfused. EGD and colonoscopy were normal with no evidence of a bleeding source. CT scan of the chest, abdomen, and pelvis revealed no evidence of cancer. A few abscess areas were identified and drained. He was started on antibiotics. Culture grew Proteus, S. aureus, and Streptococcus. He was discharged with oral iron, antibiotics- Augmentin and Levaquin, and a follow-up with dermatology.

Multiple studies suggest an association between HS and inflammatory bowel disease (IBD). Our patient had severe anemia but no signs of IBD. He had extensive, untreated HS with an early appearance. There are a few proposed contributors to HS including hormones, nicotine, obesity, dysregulation of the immune system, and genetic susceptibility. But it can be hypothesized that his extensive skin involvement may cause chronic microhemorrhages all over the skin, which may lead to severe iron deficiency anemia.

Paramjit Kaur, MD; Sahar Baloch, MD; Zara Baloch, MBBS; Tehmina Zafar, MD 

Acute Compartment syndrome (ACS) is caused by increased pressure in muscle compartments, which compromises circulation and function and damages the muscles and nerves. ACS is associated with trauma, fractures, thermal burns, crush injuries, immobilization and can also occur in non-traumatic circumstances. It may lead to a type of muscle necrosis called rhabdomyolysis. Rhabdomyolysis is characterized by the triad of myalgia, red-brown urine, and elevated CK.  

A 39-year-old male construction worker with no past medical history presented with complaints of back pain, generalized body aches, right leg numbness and pain. He denied any history of trauma. On admission, pertinent labs revealed potassium 6.7, creatinine 2.8, CK 10,000, and COVID-19 positive. Creatinine level continued trending up along with CK count, which peaked at 97,720. He initially received aggressive fluid resuscitation; however renal function didn’t improve and he was started on temporary dialysis. During the course, his right lower extremity started to worsen with neurological compromise. An ultrasound and CT scan of the right thigh showed fluid collection. Orthopedic surgery was consulted for concerns of compartment syndrome, and he underwent an open fasciotomy. Following fasciotomy, his CK level started trending down along with improvements in renal function.

COVID-19 infection is associated with a high inflammatory burden and may lead to myositis along with other complications. With our case presentation, we conclude that it can cause myositis and severe rhabdomyolysis, which leads to compartment syndrome. Early recognition of impending compartment syndrome and releasing the compartment improves the chances of saving the limb.

Sahar Baloch, MD; Paramjit Kaur, MD ; Maria Kewish MD; Sagar Kulkarni, MD 

Colorectal hemangiomas are rare but often misdiagnosed as a cause of GI bleeding. Patients with colorectal hemangiomas usually have a clinical triad of recurrent episodes of painless rectal bleeding, multiple ectopic phleboliths, and cutaneous hemangiomas.  

A 34-year-old African American male with a medical history of dextrocardia, hemorrhoids, ulcerative proctitis presented with complaints of syncope. Reported chronic rectal bleeding along with melena and hematochezia. Pertinent labs showed Hb/Hct of 7.4/24.3, and D-dimer of 767. CT of the chest, abdomen and pelvis revealed calcifications in the spleen and a small hemangioma or cyst in the liver.He was transfused with 1 PRBC, and GI was consulted. GI concluded that this presentation could be suggestive of ulcerative colitis, and findings suspicious for hemangiomatosis, which can be seen with dextrocardia. Colonoscopy showed normal colon, with the exception of the rectum from the anal verge and findings were suggestive of rectal cavernous hemangiomatosis. Case was discussed with radiology, who agreed with the same diagnosis.

Our case is interesting as hemangiomatosis is a rare diagnosis of rectal bleeding. Patient also had findings of phleboliths, which are associated with this condition. These tumors are important to diagnose, otherwise they can lead to massive hemorrhage. If a patient presents with a triad of intermittent hematochezia, multiple phleboliths and cutaneous hemangiomas this diagnosis should be considered.

Mina Ghaly, MD, Mousa Sagawed, MD, Hannah M. Gregory, Grant E. Gregory, Nawal Habib, MD, Nowoghomwenma Ibie, MD  

Mavyret (glecaprevir and pibrentasvir) is a highly efficacious antiviral agent used to treat chronic hepatitis C virus (HCV). This case report details the rare clinical association between Mavyret & drug-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, resulting in concomitant acute-on-chronic renal failure.  

A 53-year-old male with dyspnea & fatigue was admitted for workup of abnormal labs indicating a BUN of 65, creatinine of 6.89, BNP >3,500, K+ of 6, and H&H of 9.4. Past medical history was notable for HCV & recent 8-week therapy with Mavyret. Chest x-ray revealed pulmonary edema & bilateral pleural effusions indicative of volume overload, for which the patient received IV bumetanide. Urinalysis indicated 3+ proteinuria & hematuria, for which an ANCA-vasculitis screening panel was ordered, revealing a positive p-ANCA and myeloperoxidase antibody. Renal biopsy revealed a crescentic IgA nephropathy with significant chronicity as determined by 80% sclerosis. The patient was diagnosed with drug-induced ANCA-associated vasculitis & underlying primary IgA nephropathy. He was successfully treated with rituximab & methylprednisolone sodium succinate followed by daily prednisone.

Mavyret was identified as the causative agent of this patient’s ANCA-mediated disease as determined by symptom onset and histological & clinical findings. The goal of treatment is to achieve & maintain remission, which is accomplished with high dose corticosteroids & immunosuppressive medication, as demonstrated in this case.

Mavyret drug-induced ANCA-associated vasculitis is a rare, yet serious & potentially fatal condition. Prompt diagnosis should be made with a vasculitis workup & renal biopsy if indicated. Successful treatment includes the employment of high doses of corticosteroids & an immunosuppressive agent.

Ali Raza, M.S., Murtaza Shakir, M.D.  

Degloving Soft-Tissue Injuries (DSTIs) result from trauma sustained parallel to the body. Open DSTIs are more easily diagnosed, since muscle/tissue is exposed, granting direct visualization of the mechanism of injury. A variety of treatment methods are implemented, including debridement, skin grafts, and stem cell injections, protecting from any necrosis that may occur, further complicating the injury.  

Our patient presented as an 89-year-old-male post-MVA with a past medical history of BPH, HTN, and angina, complaining of an open wound on his R leg (15cmX10cm). Upon examination and radiology, pulses were 2+ bilaterally, intact vasculature, and no other significant injuries. Initial surgical debridement was carried out, and all bleeding points were coagulated with electrocautery. Upon discharge, the patient had dressings changed in-clinic, with weekly stem cell injections. Two months later, he underwent a skin graft to cover any remaining exposed tissue.

Surgical debridement and frequent dressing changes are the mainstay of treatment for open DSTIs. Ensuring vascular compliance is crucial in any substantial injury, providing adequate blood flow to stimulate healing. Membrane wraps and stem cell injections were utilized with this patient and proved to have substantial results.

Serious complications relating to DSTIs are very common, particularly when the patient is at an advanced age. Prompt clinical decisions and action, along with innovating treatment is crucial in providing patients with optimal outcomes.

Mina Ghaly, M.D., Bridget Budny, M.S., M.S., Jonathan Hardy M.S., Abdelrahman Shehata, M.D., Ramesh Swamiappan, M.D.  

Coronavirus OC43 is one of the major culprits responsible for causing the common cold in humans, though it has been documented to cause fulminant disease primarily in immunocompromised patients.  

Our case report details the clinical course of a 70-year-old female patient who developed acute respiratory distress syndrome (ARDS) with the only positive microbial suspect being the human coronavirus OC43. She had presented to the ED with acutely worsening weakness affecting her ability to ambulate with associated chills, non-productive cough, and nasal congestion. Other complicating features include a recent change in seizure medication management and recent diagnosis of bullous dermatitis. Upon admission for community acquired pneumonia, she received multiple courses of broad-spectrum antibiotics and failed multiple attempts to identify the source of infection. The patient’s condition progressively deteriorated, requiring intubation and pressor support. The patient developed end-stage fibrotic lung damage and was transitioned to palliative care.

While uncommon, there have been documented cases of severe neurologic and respiratory disease with an infection by HCoV-OC43. We draw parallels between our case and those that have been previously reported to further expand upon the disease potential for this endemic virus. Furthermore, we look towards current literature for guidance in treatment approaches for future patients with severe disease states.

Our findings add to the growing body of evidence detailing severe disease resulting from “mild” coronavirus infections, such as infections from variant OC43.

Alexis A Koch, Laurence Stolzenberg MSc.1, Alexis R. Penot MD 

Methemoglobinemia is a condition caused by increased methemoglobin, a reduced form of hemoglobin, in the blood. This causes the molecules to bind oxygen more tightly and decreases their ability to release that oxygen to tissue. Most cases of methemoglobinemia are acquired and occur either in pediatric populations or in individuals with predisposing conditions. This report illustrates a case of an otherwise healthy 31-year-old patient presenting to the emergency department with cyanosis of the hands and mouth and an O2 saturation of 78% after taking increased doses of the over-the-counter medication phenazopyridine. A “chocolate-brown” color of her arterial blood and increased methemoglobin levels of 20.2%, confirmed the diagnosis of methemoglobinemia. She was treated with both methylene blue and ascorbic acid and her oxygen saturation and serum chemistry returned to normal levels within a few hours. The case highlights the importance of discussing dosage of all over-the-counter medications with patients and recognizing the signs and symptoms of methemoglobinemia.

Daniel F. Leach III, MD, MEng, Michael Hall, MD, AH, Virgilio V. George, MD, David T. Marshall, MD, MS 

Rectal adenocarcinoma is treated with preoperative chemoradiation (CRT), termed total neoadjuvant therapy (TNT), followed by surgical resection. The CivaSheet is a biocompatible, implantable brachytherapy device used to improve local control following resection.  

We report the first documented use of the CivaSheet in conjunction with robot-assisted (RA) surgery in a 56-year-old male undergoing TNT for locally advanced rectal adenocarcinoma. The patient tolerated the procedure well without acute side effects.

Previously, the CivaSheet has been documented in the treatment of rectal cancer as well as axillary squamous cell carcinoma, pelvic and retroperitoneal sarcoma, retroperitoneal liposarcoma, gastric signet ring adenocarcinoma, and pancreatic adenocarcinoma. The CivaSheet represents a tailorable modality that could readily complement the TNT paradigm for rectal adenocarcinoma.

The German Rectal Cancer and RAPIDO trial showed that preoperative CRT, specifically structured as short-course RT followed by chemotherapy, is preferred over concurrent CRT prior to total mesorectal excision (TME). Thus, it would be interesting to study the effect of integrating the CivaSheet in the TNT algorithm at the time of TME on survival parameters, local control, toxicity, symptoms, and QOL. Management of Noninvasive Primary Cutaneous Leiomyosarcoma.

Aswin Sembu, Edward Wu, Riya Patel, Felicia Patel, Aasim Sebhai 

Primary cutaneous leiomyosarcoma are highly uncommon malignant lesions which are believed to arise from the arrector pili muscles and confined to the dermis. Due to inconsistent definitions and scarce literature, treatment algorithms and management are poorly defined. 

A 66-year-old male with a past medical history of follicular thyroid cancer status post radioactive iodine and resection presented with an enlarging mass on his left lateral distal thigh for the last year. Due to rapid growth, an emergent biopsy was performed demonstrating pathology consistent with leiomyosarcoma. MRI revealed a mushroom-shaped lesion with a central stalk extending into subcutaneous fat and investing fascia between vastus lateralis and biceps femoris without invasion of muscles or deep soft tissue. X-ray and positron emission tomography were negative for findings concerning for metastases. After discussion with a multidisciplinary tumor board, surgical resection without radiation was selected due to the noninvasive nature of the lesion.

Most tumors are low grade with a mean size of 1.3 centimeters. Treatment plans primarily consist of a combination of radiation and surgical resection. As the 4.2 cm lesion was not attached to fascia, radiation treatment was avoided, and surgical resection was completed. Postoperatively, the patient recovered with no further complications.

Most cases of leiomyosarcoma require treatment with both radiation and surgical resection. This case report demonstrates an uncommon presentation of leiomyosarcoma and serves as an example of successful treatment with only surgical resection.

Rohan Ghosh, Dr. David Preston Mitchell, MD 

Mesenteric ischemia is characterized by an interruption of blood supply to various portions of the small intestine leading to inflammation and eventually necrosis of a portion of the bowel. The overall incidence is 0.09%-0.2% of all acute surgical admissions. Ischemia to the duodenum makes up and even smaller fraction of this incidence rate, as very few cases have been reported postoperatively.  

This is a 84-year-old with a hx of valvular dysfunction and A fib who was initially admitted for a right hip fracture requiring operative repair. He presented to the medical ICU critically ill and was found to have a suspected gastroduodenal artery occlusion as evidenced by a black ischemic duodenum confirmed by an EGD. OG tube was placed, with 2.5L if dark fluid obtained. Surgery was consulted, discussions with the family on withdrawal of care were made, and the pt passed shortly after.

The duodenum is highly collateral with the foregut and midgut vessels, providing significant anastomoses that would discourage the likelihood of duodenal ischemia occurring. Other “watershed” areas are a much more common source of ischemia. Pt’s results confirmed by EGD.

It is extremely unusual for the duodenum to become ischemic due to the several collaterals and extensive blood supply to the area. Diagnosis can be made using an EGD, determining the extent of the necrosis.

Rohan Ghosh, Katie Sage Jordan, Jacob Gramacy 

Acute ischemic stroke can carry an increased number of lasting complications if left untreated or if not treated promptly enough. Accepted guidelines for administering tissue plasminogen activator (tPA) are within 3 hours since the last known onset of normal symptoms. With prompt administration, total function can be regained and the patient can resume nearly daily life. In addition, we wish to bring to light the considerations providers should take when removing blood thinners from a patient’s medical regimen.  

This 64-year-old presented to the cardiology with paroxysmal episodes of symptomatic Afib. Following these episodes, the pt was given a heart monitor to wear for 4 weeks, as well as a heart catheterization performed during this time. the pt was shortly taken off the blood-thinning medication he was prescribed prior to his heart catheterization. Following this, the pt was performing a routine laparoscopic cholecystectomy when the pt feel, complaining of right sided weakness. The pt was promptly take to the emergency department, where a head CT was taken and tPA was administered following confirmation that it was an ischemic stroke. Pt was back to performing surgeries within 2 weeks.

Prompt tPA administration is incredibly important in order to ensure rapid recovery from acute ischemic stroke. In addition, removal of a blood thinner from a pt’s medications list should be closely monitored and proceeded with caution to prevent such episodes from happening.

Prompt tPA administration for acute ischemic strokes benefits long term pt recovery. Anticoagulation therapy must be heavily monitored when discontinuing. 

Mina Ghaly, M.D., Monica Whaley, B.S., Kylie Besly, B.S., Jamie Morrow, D.O., Amith Skandhan, M.D 

Emphysematous cholecystitis is a deadly disguise of a common disease – acute cholecystitis. It occurs in about 1% of cases of acute cholecystitis and is more common in patients with diabetes mellitus and suppressed immune systems. It carries significantly higher morbidity and mortality. The most common organisms isolated from patients with this condition are gas-forming anaerobes such as Clostridium spp., and anaerobic streptococci.  

Our patient presented as a 72-year-old male with a past medical history of hypertension and diabetes mellitus complaining of nausea, vomiting, back pain, and shortness of breath. Upon examination and radiology, the patient was found in sepsis secondary to an emphysematous perforated gangrenous gallbladder. He was immediately started on empiric broad-spectrum antibiotics and underwent surgical intervention with laparoscopic cholecystectomy.

CT is the most sensitive investigation for the detection of the intraluminal or intramural gas in the gallbladder, and the demonstration of other associated complications like abscess formation and pericholecystic inflammatory changes. Broad-spectrum antibiotics and adequate surgical interventions should be taken into practice as soon as possible. Laparoscopic cholecystectomy is recommended as an effective and safe approach.

The mortality associated with emphysematous cholecystitis is 15%, compared with 4% for acute, non-emphysematous cholecystitis. Prompt clinical suspicion and appropriate abdominal imaging are crucial in making the correct diagnosis.

Mina Ghaly, M.D., Alyssa Zakala, M.S., Kavya Penmethsa, Mina Youssef, M.D., Kristy Johnson-Pich, D.O.  

Pantoea is a gram negative, anaerobic rod that causes rare nosocomial infections. In this case report, we present Pantoea cholecystitis with associated bacteremia in an immunocompromised patient with breast cancer.  

A 62-year-old immunocompromised female with stage three breast cancer arrived to the emergency department due to hypotension and tachycardia during routine chemotherapy. After workup, broad spectrum antibiotics were started due to sepsis thought to be secondary to acute cholecystitis. Peripheral and chemo port blood cultures revealed the presence of Pantoea. Laparoscopic cholecystectomy was performed, and the patient was switched to levofloxacin post-operatively after culture and sensitivities. The chemo port was thought to be the source of infection, and thus removed. Upon follow-up, she was reportedly recovering well and breast cancer free.

Pantoea species infect immunocompromised people and can be transmitted through medical devices. While Pantoea can demonstrate resistance to many antibiotics, the bacteria isolated in our patient revealed resistance to only cefazolin. Additionally, Pantoea produces an exopolysaccharide, known as Levan, which upregulates tumor suppressor genes like p53 and p27, preventing proliferation of breast cancer cell lines.

Pantoea bacteria is a rare opportunistic organism that mainly infects immunocompromised individuals. While the organism isolated from this case was treated without complications, there is a possibility that Pantoea can cause multiple-drug resistant infections which should be considered with future management. The patient was deemed cancer free shortly after her Pantoea infection, necessitating further exploration between Levan and its potential role in cancer therapy.

Rohan Ghosh 

Fecal impaction can present itself in a wide variety of ways and can step from a multitude of etiologies. In some cases they are hyper acute, while in others have been a lifelong chronic issue. Reasons can range from simply chronic constipation, to even a missed Hirschsprung’s diagnosis.  

This 64-year- old woman presented to the clinic complaining of abdominal pain and constipation. She reported that she has had constipation all throughout her life, noting that she has needed routine enemas to assist in bowel evacuation since she was born. She states that she finally decided to come in due to abdominal pain and discomfort. CT scan showed a large rectosigmoid fecal impaction measuring 20cm craniocaudad x 9cm AP x 12cm transverse. Following colon and rectal resection with permanent colostomy, pt reported resolution of her initial symptoms and markedly reduced fecal obstruction in abdominal cavity. Pt returned a week later for a transanal drainage of a pelvic fluid collection.

The importance of screening for bowel abnormalities cannot be understated. If this pt was indeed a missed diagnosis such as a Hirschsprung’s disease, many years of discomfort and eventual surgery could have been avoided all together. Early diagnosis and treatment is crucial, as with all conditions.

Mega colon and mega rectum secondary to chronic fecal impaction could have been preventable with early diagnoses and treatment of the patients underlying condition.

Britton Ethridge OMS-2, Michael Steadman OMS-2, Joseph H Sugg Jr MD 

Tolosa-Hunt Syndrome (THS) is a rare idiopathic inflammatory disorder affecting at least one oculomotor nerve, typically with associated granulomatous inflammation in the cavernous sinus, orbit, or superior orbital fissure. THS has not been linked to any racial, ethnic, or gender demographics.  

A 49-year-old male presented five days after onset of ptosis and ophthalmoplegia of the right eye. Patient denied headaches, autoimmune disease, recent illness, or other risk factors for neuro-ophthalmic disease. Denied any prescription or OTC medications. Pain reported (7/10) when attempting eye movement. PE: OD - Complete ptosis and frozen globe. Lid free of erythema or lesion. Pupils were round, brisk, with no RAPD. VA was 20/25 (lid retracted). CVF was full. No disc edema, pallor, or NFL defects. Remaining ophthalmic exam unremarkable. OS – Full EOM. Imaging: CT angiography of head and neck performed by ED three days prior to clinic visit was unremarkable without evidence of cavernous sinus thrombosis.

Differential diagnoses included orbital cellulitis, cerebrovascular accident, cranial nerve palsy, schwannoma, and THS. THS was most likely, based on the absence of systemic symptoms, radiologic findings, or signs of infection. Rapid improvement of symptoms with glucocorticoids – the mainstay of treatment – suggested THS, as palsies of CN-III and CN-IV normally take weeks to months to resolve.

This patient was prescribed prednisone 60mg daily and was reevaluated in two weeks. Follow-up exam showed moderate improvement in ptosis and minimal improvement in ocular mobility and pain.

Keana-Kelley D. Swanner MS, Riya Patel, Thuy Nguyen, Felicia Patel, and Raul Magadia MD 

Rhodococcus equi is an emerging opportunistic pathogen in immunocompromised patients. Due to its similarities to Mycobacterium, Nocardia, and Corynebacterium, R. equi is often misdiagnosed as a contaminant which may delay treatment. The purpose of this case report is to bring attention to the increasing prevalence of R. equi infection in rural communities and how to identify it quickly to prevent unfavorable health outcomes.  

A 65-year-old Caucasian man with a history of CABG and ESRD presented to the emergency department with pain and increased swelling on his right upper extremity. While in the waiting room, he developed respiratory distress and met sepsis criteria. Vancomycin was administered and blood cultures were collected. The cultures came back as Rhodococcus equi. He was managed in the ICU on Vancomycin, Azithromycin, and Rifampin with respiratory and cardiac monitoring until the cellulitis regressed and the patient became stable. The patient recovered without further complications and was discharged with follow-up with outpatient specialists.

R. equi is a partially acid fast actinomycete that is spread by animal contact and contaminated soil. It causes infection by invading macrophages as a survival tactic. As seen in this case, the patient worked on a farm taking care of goats. He was exposed after a fall where he sustained multiple lacerations to the right arm.

This case is unique because of the development of occult bacteremia and cardiopulmonary arrest in the setting of R. equi associated cellulitis in an immunocompromised patient.

Colby Kihara, Katie Oakley, Arsh Patel, Carter Gay, Jason Seale MD 

An ileal conduit is a form of urinary diversion that is often used in management of patients who have undergone a radical cystectomy. Although it is considered the gold standard in treatment, there can be a myriad of complications including herniation, bowel dysfunction, nutrient malabsorption, electrolyte abnormality, and renal dysfunction.  

A 91-year-old male with a history of prostate and bladder cancer status-post prostatectomy, cystectomy, and ileal conduit presented to the emergency department complaining of abdominal pain, nausea, and vomiting. A CT scan revealed a small bowel obstruction (SBO) secondary to a gallstone ileus. Laboratory testing also indicated a urinary tract infection (UTI) with acute kidney injury (AKI). Upon exploratory laparotomy, it was found that an internal hernia had incarcerated 36 cm of small bowel which became necrotic and ultimately lead to the SBO. Surgical resection and anastomosis resolved the bowel obstruction. After which a 3.3 cm calculus was found in the ileal conduit which may have caused the UTI and AKI.

A less well-known complication of ileal conduits are formation of calculi. Presence of calculi in the conduit can lead to urinary outlet obstruction with resultant UTI and AKI, both of which were seen in our patient.

Calculus formation in the conduit itself is an uncommon side effect of ileal conduits. In this instance, a large ileal conduit calculus was mistaken for a gallstone ileus and discovered incidentally in a patient who presented with a SBO. This report serves to highlight a rarely encountered cause of calcification that should be included in the differential diagnosis for gallstone ileus.

Jessica Cushing-murray, Ronda Carter, Julia Alexander 

Female collegiate athletes are among the highest at-risk population for eating disorders (EDs). Despite research demonstrating that one-third of Division I female athletes have symptoms of anorexia nervosa, the number clinically diagnosed remains low.  

We present a 19-year-old female NCAA DI Cross Country athlete, with no past medical history, who first presented with left thigh pain. Physical exam revealed a positive fulcrum test, and an MRI showed an area of edema within the medullary femur. Patient was diagnosed with a left femoral shaft stress fracture. Patient returned six months later with pain in the right thigh. A similar procedure was followed, and patient was diagnosed with a right femoral shaft stress fracture. Over the next year, the patient had three other stress-related bone injuries in the femur, tibia, and navicular.

The patient eventually saw a psychiatrist on her own accord, and was diagnosed with anorexia nervosa, specific to binging/purging subtype, with excessive exercise as method of purging. Throughout the patient’s athletic career, the team physician never investigated dietary habits as a possible cause of the continued stress fractures. Patient’s BMI was <18.5 during this time.

This report aims to raise awareness to the prevalence of eating disorders in the collegiate athlete population, highlight the physical consequences of an ED, and reiterate the difficulty of recognizing eating disorders for physicians outside the scope of psychiatry. Authors encourage future providers to broaden their differential diagnoses in collegiate athletes with repeat bone injuries.

Mina Ghaly M.D., Bridget Budny M.S., M.S., Grant Gregory M.S., Amith Skandhan M.D. FACP 

Eosinophilic esophagitis (EoE) is a rare immune-mediated condition characterized by the predominant eosinophilic infiltration of the esophagus. Inflammation isolated to the esophagus can cause dysphagia, reflux, and chest or abdominal pain. Dysphagia, and food impaction are the most common presentation. However, rarely, spontaneous tear or perforation (Boerhaave’s syndrome) may occur in association with eosinophilic esophagitis.  

In this case report, we discuss a 38-year-old male who presented to the ED with sharp chest pain and multiple, worsening episodes of hematemesis. Pertinent medical history included asthma, episodic dysphagia, and a previous bolus impaction 1.5 years ago. The patient was admitted for stabilization and further GI workup. An EGD was done and showed a large mucosal tear with an overlying blood clot. Biopsies were taken that later confirmed the diagnosis of EoE. The patient was monitored for several days and then discharged in stable condition with a PPI and inhaled corticosteroids.

First line therapy for EoE had been traditionally acid suppression, topical glucocorticoids, and diet modifications. However, this treatment regimen does not often work well for many patients. With FDA approval this year, the multiclonal antibody dupilumab offers a new hope for patients that do not respond to our current treatment options.

The diagnosis of EoE has become more prevalent over the last 20 years; however, the diagnosis is usually delayed by many years leading to progressive disease states. Current and developing therapies offer symptomatic relief with targeted immune-modulating medications and acid suppression.

Devam Parghi, Jocelyn Medal 

Varicella-zoster virus (VZV) can cause two distinct diseases. Primary infection causes varicella, which presents as vesicular lesions that develop diffusely on one’s body in different stages. It is postulated that, the virus infects nerve endings on the skin when vesicles develop(1). The virus then travels retrogradely to infect sensory axons and to establish long term latency(1). Reactivation can occur from weakened immunity caused by stress or immunocompromisation. When reactivation in the ganglion occurs, the virus can spread antegrade. Herpes zoster (HZ) will create a unilateral vesicular eruption that is concentrated within dermatomal lines. We present a case of cutaneous dissemination in an immunocompromised patient.  

A 28M with CVID and Hodgkin 3b s/p chemo rad who is not currently on IgG presented to the clinic with pain at the right thorax. He noticed a little bit of discomfort the day prior and his wife that noticed a rash on his chest upon wakening. The rash involved multiple dermatomes and was mildly tender to palpation.

Even though cutaneous manifestations could be treated as outpatient; immunocompromised patients should be considered for hospitalization. After all, HZ can have life threatening complications like aseptic meningitis, myelitis, stroke syndrome, visceral organ involvement, encephalitis, bacterial infections, and peripheral neuropathy(1). Therefore, it was necessary to admit the patient and to start a rapid initiation of IV acyclovir/valcyclovir.

Recognition is important in outpatient setting for immunocompromised patients. Younger individuals shouldn’t be ruled out from getting HZ. Specialized treatment should be used for complex cases.

Kristine Wong, B.A.1, Malvika Chaudhary 2, Raul Magadia, M.D.3 

Non-endemic cases of monkeypox infection have been increasingly reported worldwide, and this is the first reported case in Calhoun County, Alabama.  

A 52-year-old African-American MSM male presented to the emergency department with a one-week history of odynophagia, pharyngeal, and perianal pain. His past medical history was significant for hepatitis C and stable HIV with an undetectable viral load, CD4-count of 303, and he disclosed medication noncompliance. Sexual history was significant for recent oral and anal intercourse, and his partners reported exposure to monkeypox from another MSM partner, one week after which the patient’s symptoms developed.
Physical examination revealed tonsillar hypertrophy with exudate, four 2-5 mm ulcerated lesions with overlying eschar on the right buttocks, and surrounding erythema with tenderness to palpation. The patient was placed under contact and airborne isolation precautions, and two positive monkeypox DNA PCR tests confirmed the infection.
During his hospital stay, the patient restarted Biktarvy, and developed three new lesions. He experienced fever/chills, asthenia, and diaphoresis followed by pruritus at the tail end of the disease course and showed improvement with supportive care only.

Monkeypox is the currently most prominent orthopoxvirus impacting humans, and this patient’s presentation was consistent with the expected course of mild, self-limiting disease, and he had many notable risk factors his history.

Here, we report a case of mild, self-limited monkeypox disease that did not require additional treatment. As the monkeypox outbreak continues to evolve, it is vital for healthcare professionals to be aware of this disease’s spread, clinical presentation, and treatment.

Abdul Chaudry M.D.; Katherine Whalen, OMS-II; Bailee Keefe, OMS-II; Sai Avula, MD; Amith Skandhan, MD 

Osmotic demyelination syndrome is difficult to diagnose and is seen on MRI after tissue destruction has taken place. Although it is a known risk in the rapid fluctuation of sodium and patients receiving both IV saline and a lactulose enema should have their sodium levels carefully monitored to avoid hypernatremia and critically damaging cerebral edema. Only a few such cases have been reported to the best of our knowledge and this case provides a great teaching point, which otherwise can be easily overlooked and prove fatal to the patient.  

A 66-year-old female became noncompliant with home medications presented to the emergency room with altered mental status. She had an established diagnosis of decompensated cirrhosis on a recent discharge from hospital leading to metabolic encephalopathy. Five days into her hospital stay, the patient refused medications and nutrition leading to an IV saline treatment. Two days after initially refusing nutrition a lactulose enema was administered. The patient’s sodium levels changed from 148 to 172 overnight and she was admitted to the ICU. Sodium was corrected carefully between 7-8 meq/day but damage had already been done by rapid development of hyprenatremia.

The unusual presentation of this patient began with the refusal to comply with medications or nutrition which was treated with a lactulose enema. However, the patient was already being treated with normal saline for hydration. This combination led to severe hypernatremia in this patient which eventaully led to osmotic demyelination syndrome which was later diagnosed on MRI after the destruction had occurred. Monitoring the patient’s sodium levels aggressively in these patients and careful administation of lactulose enema should be a standard of care. Especially, a combination of normal saline and lactulose enema can prove fatal in patients. The proposed mechanism is the hyperosmolar nature of lactulose pulling fluids in the gut leading to increase concentration of sodium in blood causing fatal hyprenatremia.

Patients who initially present with metabolic encephalopathy can be at risk for osmotic demyelination syndrome when treated with saline and lactulose enema. Monitoring the patient’s sodium levels is a critically important step in avoiding demyelination.

Alexis A Koch, Laurence Stolzenberg, Katherine Oakley, Colby Kihara, Raphael Quansah 

Hypercalcemia is an electrolyte abnormality that may present with altered mental status, constipation, and, more concerningly, cardiac arrythmias. It has a variety of causes including primary hyperparathyroidism, malignancy, and medications. Routine outpatient screening can identify asymptomatic hypercalcemia and allow for early detection of malignancy.  

We present a case of a 60-year-old female who with a complaint of progressive intermittent confusion, slowed speech, facial droop, weakness, and arthralgia. Physical exam demonstrated supraclavicular chest wall mass and lymphadenopathy. Workup revealed an extremely elevated corrected blood calcium of 18.1 mg/dL, a low parathyroid hormone (PTH), and parathyroid hormone related peptide (PTHrP). Aggressive treatment with IV fluids, zoledronic acid, and denosumab was initiated and calcium levels stabilized a few days post-admission. Diagnostic studies revealed an advanced diffuse large B-cell lymphoma (DLBCL) with osteolytic tumor invasion and likely metastasis to the liver.

While hypercalcemia may occur with DLBCL, it is rarely the first presentation and does not usually cause such high levels. This patient had an extensive history of refusing primary care, which allowed for the development of a mediastinal mass that caused such significant bone destruction.

This case demonstrates the consequences of an undiagnosed hypercalcemia that progressed to an extreme level. Routine bloodwork by a physician would have likely identified this in a much earlier phase, highlighting the importance of preventative medicine. This successful treatment of severe hypercalcemia diminished the immediate threat to the patient’s life and allowed for further diagnostic measures and treatment of her non-Hodgkin lymphoma.